Community Acquired Pneumonia (CAP) - Assure Measure Information

Discharge Months: July 2015 onwards 

Document History

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Pathway: Community Acquired Pneumonia (CAP)
Document Publication Date: 22.07.15
Applicable to: July 2015 discharge patients onwards
This document is designed to provide detailed information on the individual measures within the Community Acquired Pneumonia pathway. This information includes the population criteria, exclusions, Assure questions and system flowcharts.  
Further support is available on the Assure Wiki including detailed guidance on answering Assure questions and a list of Frequently Asked Questions (FAQs).
Users have the ability to download the document to their PC should they wish to do so. However, it is the responsibility of the user to ensure that they have the latest version of the Measure Information document as published within the data dictionary handbooks on the Assure Wiki.
Why are we measuring quality of care in Community Acquired Pneumonia?

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These measures are designed to ensure that high quality care is delivered for all eligible patients. Research has shown that passing these measures is associated with a 3% reduction in mortality.

Assure CAP Measures

CAP-1: Chest X-Ray within 4 hours of hospital arrival
CAP-2: Oxygen assessed within 1 hour of hospital arrival
CAP-3: Oxygen prescribed within 1 hour of hospital arrival
CAP-4: Initial antibiotic received within 4 hours of hospital arrival
CAP-5: Appropriate antibiotic regimen received
CAP-6: CURB-65 score recorded
CAP-7: Critical care referral

Populations included in the Community Acquired Pneumonia pathway

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CAP-1: Chest X-Ray within 4 hours of hospital arrival

Measure numerator statement: Number of community Acquired Pneumonia patients who receive a chest X-Ray or CT scan of thorax within 4 hours of hospital arrival
Measure denominator statement: All patients includes in the Assure CAP population minus exclusions
Patients excluded from the denominator population of CAP-1:

• Patients receiving palliative care only
• Patients involved in clinical trials directly affecting CAP measures
• Patients received in transfer from an A&E department of another Trust
• Patients who refused a chest x-ray or CT scan of thorax on arrival
• Patients who were not clinically indicated to receive a chest x-ray or CT scan of thorax on arrival
• Patients with the following SUS Source of admission codes:
• 0: Data not supplied
• 52: NHS other hospital provider-ward for maternity patients or neonates
• 79: Babies born in or on the way to hospital
• 98: Not applicable
• 99: Not known: a validation error

Measure numerator question(s): Chest X-Ray or CT scan of thorax date/time on arrival
Measure denominator and exclusion questions:

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• Is there documentation within the clinical record that the patient received palliative care only?
• Is there documentation within the clinical record that the patient was involved in clinical trials directly affecting Community Acquired Pneumonia measures?
• Is there documentation within the clinical record that the patient was received as a transfer from the A&E department of another Trust?
• Arrival date/time
• Is there documentation within the clinical record that the patient received a chest X-Ray or CT scan of thorax on arrival?
• Chest X-Ray or CT scan of thorax date/time on arrival

CAP-2: Oxygen assessed within 1 hour of hospital arrival

Measure numerator statement: Number of Community Acquired Pneumonia patients who receive oxygen assessment within 1 hour of hospital arrival.
Measure denominator statement: All patients included in the Assure CAP population minus exclusions.
Patients excluded from the denominator population of CAP-2:

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• Is there documentation within the clinical record that the patient received palliative care only?
• Is there documentation within the clinical record that the patient was involved in clinical trials directly affecting Community Acquired Pneumonia measures?
• Is there documentation within the clinical record that the patient was received as a transfer from the A&E department of another Trust?
• Arrival date/time
• Is there documentation within the clinical record that the patient received a chest X-Ray or CT scan of thorax on arrival?
• Is there documentation within the clinical record that the chest X-Ray or CT scan of thorax received on arrival was consistent with Community Acquired Pneumonia?
• Is there documentation within the clinical record that the patient received a pulse oximetry or arterial blood gas (ABG) assessment on arrival?
• Pulse oximetry/arterial blood gas analysis date/time on arrival

CAP-3: Oxygen prescribed within 1 hour of hospital arrival

Measure numerator statement: Number of Community Acquired Pneumonia patients who are given oxygen within 1 hour of hospital arrival.
Measure denominator statement: All patients included in the Assure CAP population minus exclusions.
Patients excluded from the denominator population of CAP-3:

• Patients receiving palliative care only
• Patients involved in clinical trials directly affecting CAP measures
• Patients received in transfer from an A&E department of another Trust
• Patients who did not receive a chest x-ray or CT scan of thorax on arrival
• Patients who refused a chest x-ray or CT scan of thorax on arrival
• Patients who were not clinically indicated to receive a chest x-ray or CT scan of thorax on arrival
• Patients whose chest x-ray or CT scan of thorax on arrival was not consistent with CAP
• Patients who did not receive pulse oximetry or ABG on arrival
• Patients who refused pulse oximetry or ABG on arrival
• Patients who were not clinically indicated to receive pulse oximetry or ABG on arrival
• Patients who were not clinically indicated to receive oxygen
• Patients with the following SUS Source of admission codes:
  • 
    
    • 0: Data not supplied
    • 52: NHS other hospital provider-ward for maternity patients or neonates
    • 79: Babies born in or on the way to hospital
    • 98: Not applicable
    • 99: Not known: a validation error

Measure numerator question(s): If oxygen was clinically indicated, please detail the given date/time
Measure denominator and exclusion questions:

• Is there documentation within the clinical record that the patient received palliative care only?
• Is there documentation within the clinical record that the patient was involved in clinical trials directly affecting Community Acquired Pneumonia measures?
• Is there documentation within the clinical record that the patient was received as a transfer from the A&E department of another Trust?
• Arrival date/time
• Is there documentation within the clinical record that the patient received a chest X-Ray or CT scan of thorax on arrival?
• Is there documentation within the clinical record that the chest X-Ray or CT scan of thorax received on arrival was consistent with Community Acquired Pneumonia?
• Is there documentation within the clinical record that the patient received a pulse oximetry or arterial blood gas (ABG) assessment on arrival? Is there documentation within the clinical record that the patient was clinically indicated to receive oxygen, following initial oxygen assessments on arrival? If oxygen was clinically indicated, please detail the given date/time

CAP-4: Initial antibiotic received within 4 hours of hospital arrival

Measure numerator statement: Number of Community Acquired Pneumonia patients who receive initial antibiotics within 4 hours of hospital arrival.
Measure denominator statement: All patients included in the Assure CAP population minus exclusions.
Patients excluded from the denominator population of CAP-4:

• Patients receiving palliative care only
• Patients involved in clinical trials directly affecting CAP measures
• Patients received in transfer from an A&E department of another Trust
• Patients who did not receive a chest x-ray or CT scan of thorax on arrival
• Patients who refused a chest x-ray or CT scan of thorax on arrival
• Patients who were not clinically indicated to receive a chest x-ray or CT scan of thorax on arrival
• Patients whose chest x-ray or CT scan of thorax on arrival was not consistent with CAP
• Patients who had a prior hospitalisation within the last 10 days
• Patients who were immunocompromised
• Patients with another suspected source of infection
• Patients who refused antibiotics
• Patients who were already receiving antibiotics on arrival
• Patients with the following SUS Source of admission codes:
  • 
    
    • 0: Data not supplied
    • 52: NHS other hospital provider-ward for maternity patients or neonates
    • 79: Babies born in or on the way to hospital
    • 98: Not applicable
    • 99: Not known: a validation error

Measure numerator question(s): Please enter the details of the antibiotic(s) given which were specific to the patient's Community Acquired Pneumonia treatment: substance; route; date of administration; time of administration (if date and time are unable to be determined from the medical record select 'UTD')
Measure denominator and exclusion questions:

• Is there documentation within the clinical record that the patient received palliative care only?
• Is there documentation within the clinical record that the patient was involved in clinical trials directly affecting Community Acquired Pneumonia measures?
• Is there documentation within the clinical record that the patient was received as a transfer from the A&E department of another Trust?
• Arrival date/time
• Is there documentation within the clinical record that the patient received a chest X-Ray or CT scan of thorax on arrival?
• Is there documentation within the clinical record that the chest X-Ray or CT scan of thorax received on arrival was consistent with Community Acquired Pneumonia?
• Is there documentation within the clinical record that the patient has been admitted to hospital within the last 10 days?
• Is there documentation within the clinical record that the patient was immunocompromised (as defined by the data dictionary)?
• Is there documentation within the clinical record that the patient had another suspected source of infection in addition to Community Acquired Pneumonia upon arrival?
• Is there documentation within the clinical record that the patient was already receiving antibiotics upon arrival?
• Is there documentation within the clinical record that the patient refused antibiotics?
• Please enter the details of the antibiotic(s) given which were specific to the patient's Community Acquired Pneumonia treatment: substance; route; date of administration; time of administration (if date and time are unable to be determined from the medical record select 'UTD')

CAP-5: Appropriate antibiotic regimen received

Measure numerator statement: Number of Community Acquired Pneumonia patients who receive an appropriate antibiotic regimen.
Measure denominator statement: All patients included in the Assure CAP population minus exclusions.
Patients excluded from the denominator population of CAP-5:

• Patients receiving palliative care only
• Patients involved in clinical trials directly affecting CAP measures
• Patients received in transfer from an A&E department of another Trust
• Patients who did not receive a chest x-ray or CT scan of thorax on arrival
• Patients who refused a chest x-ray or CT scan of thorax on arrival
• Patients who were not clinically indicated to receive a chest x-ray or CT scan of thorax on arrival
• Patients whose chest x-ray or CT scan of thorax on arrival was not consistent with CAP
• Patients who had a prior hospitalisation within the last 10 days
• Patients who were immunocompromised
• Patients with another suspected source of infection
• Patients who were already receiving antibiotics on arrival
• Patients who refused antibiotics
• Patients with the following SUS Source of admission codes:
  • 
    
    • 0: Data not supplied
    • 52: NHS other hospital provider-ward for maternity patients or neonates
    • 79: Babies born in or on the way to hospital
    • 98: Not applicable
    • 99: Not known: a validation error

Measure numerator question(s): Is there documentation within the clinical record that the patient received the appropriate antibiotic regimen according to current local guidelines?
Measure denominator and exclusion questions:

• Is there documentation within the clinical record that the patient received palliative care only?
• Is there documentation within the clinical record that the patient was involved in clinical trials directly affecting Community Acquired Pneumonia measures?
• Is there documentation within the clinical record that the patient was received as a transfer from the A&E department of another Trust?
• Is there documentation within the clinical record that the patient received a chest X-Ray or CT scan of thorax on arrival?
• Is there documentation within the clinical record that the chest X-Ray or CT scan of thorax received on arrival was consistent with Community Acquired Pneumonia?
• Is there documentation within the clinical record that the patient has been admitted to hospital within the last 10 days?
• Is there documentation within the clinical record that the patient was immunocompromised (as defined by the data dictionary)?
• Is there documentation within the clinical record that the patient had another suspected source of infection in addition to Community Acquired Pneumonia upon arrival?
• Is there documentation within the clinical record that the patient was already receiving antibiotics upon arrival?
• Is there documentation within the clinical record that the patient refused antibiotics?
• Please enter the details of the antibiotic(s) given which were specific to the patient's Community Acquired Pneumonia treatment: substance; route; date of administration; time of administration (if date and time are unable to be determined from the medical record select 'UTD')
• Is there documentation within the clinical record that the patient received the appropriate antibiotic regimen according to current local guidelines?

CAP-6: CURB-65 score recorded

Measure numerator statement: Community Acquired Pneumonia patients who have a CURB-65 OR CRB-65 score recorded within 4 hours of arrival
Measure denominator statement: All patients included in the Assure CAP population minus exclusions.
Patients excluded from the denominator population of CAP-6:

• Patients receiving palliative care only
• Patients involved in clinical trials directly affecting CAP measures
• Patients received in transfer from an A&E department of another Trust
• Patients who did not receive a chest x-ray or CT scan of thorax on arrival
• Patients who refused a chest x-ray or CT scan of thorax on arrival
• Patients who were not clinically indicated to receive a chest x-ray or CT scan of thorax on arrival
• Patients whose chest x-ray or CT scan of thorax on arrival was not consistent with CAP
• Patients who refused a CURB-65 score
• Patients who were not clinically indicated to receive a CURB-65 score
• Patients with the following SUS Source of admission codes:
  • 
    
    • 0: Data not supplied
    • 52: NHS other hospital provider-ward for maternity patients or neonates
    • 79: Babies born in or on the way to hospital
    • 98: Not applicable
    • 99: Not known: a validation error

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Measure denominator and exclusion questions:

• Is there documentation within the clinical record that the patient received palliative care only?
• Is there documentation within the clinical record that the patient was involved in clinical trials directly affecting Community Acquired Pneumonia measures?
• Is there documentation within the clinical record that the patient was received as a transfer from the A&E department of another Trust?
• Is there documentation within the clinical record that the patient received a chest X-Ray or CT scan of thorax on arrival?
• Is there documentation within the clinical record that the chest X-Ray or CT scan of thorax received on arrival was consistent with Community Acquired Pneumonia?
• Is there documentation within the clinical record that the patient received a CURB-65 assessment within 4 hours of arrival?
• What is the CURB-65 score documented within the patient's clinical record within 4 hours of arrival?
• What is the CRB-65 score documented within the patient's clinical record within 4 hours of arrival?

CAP-7: Critical care referral

Measure numerator statement: Community Acquired Pneumonia patients who were appropriately escalated to critical care.
 Measure denominator statement: All patients included in the Assure CAP population minus exclusions.
 Patients excluded from the denominator population of CAP-7:

• Patients receiving palliative care only
• Patients involved in clinical trials directly affecting CAP measures
• Patients received in transfer from an A&E department of another Trust
• Patients who did not receive a chest x-ray or CT scan of thorax on arrival
• Patients who refused a chest x-ray or CT scan of thorax on arrival
• Patients who were not clinically indicated to receive a chest x-ray or CT scan of thorax on arrival
• Patients whose chest x-ray or CT scan of thorax on arrival was not consistent with CAP
• Patients who did not require or were not clinically indicated to receive critical care referral
• Patients with the following SUS Source of admission codes:
  • 
    
    • 0: Data not supplied
    • 52: NHS other hospital provider-ward for maternity patients or neonates
    • 79: Babies born in or on the way to hospital
    • 98: Not applicable
    • 99: Not known: a validation error

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Measure numerator question(s): Is there documentation within the clinical record that the patient was escalated appropriately to critical care?
Measure denominator and exclusion questions:

• Is there documentation within the clinical record that the patient received palliative care only?
• Is there documentation within the clinical record that the patient was involved in clinical trials directly affecting Community Acquired Pneumonia measures?
• Is there documentation within the clinical record that the patient was received as a transfer from the A&E department of another Trust?
• Is there documentation within the clinical record that the patient received a chest X-Ray or CT scan of thorax on arrival?
• Is there documentation within the clinical record that the chest X-Ray or CT scan of thorax received on arrival was consistent with Community Acquired Pneumonia?
• Is there documentation within the clinical record that the patient required a critical care referral?
• Is there documentation within the clinical record that the patient was escalated appropriately to critical care?

Assure Questions

The questions listed below contain all questions included in the Community Acquired Pneumonia measure set

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