#076: Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections

Quality ID

076

High Priority Measure

Yes

Specifications

Registry

Measure Type

Process

Specialty

Anesthesiology Hospitalists Interventional Radiology

Measure description

Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed

 

Instructions

This measure is to be submitted each time a CVC insertion is performed during the performance period. There is no diagnosis associated with this measure. It is anticipated that eligible clinicians who perform CVC insertion will submit this measure.

Measure Submission:

The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry submissions; however, these codes may be submitted for those registries that utilize claims data.

 

Denominator

All patients, regardless of age, who undergo CVC insertion

Denominator Criteria (Eligible Cases):

Patient procedure during the performance period (CPT): 36555, 36556, 36557, 36558, 36560, 36561, 36563, 36565, 36566, 36568, 36569, 36570, 36571, 36578, 36580, 36581, 36582, 36583, 36584, 36585, 93503

 

Numerator

Patients for whom central venous catheter (CVC) was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed

Definitions:

Maximal Sterile Barrier Technique – includes all of the following elements: Cap AND mask AND sterile gown AND sterile gloves AND sterile full body drape.

Sterile Ultrasound Techniques – require sterile gel and sterile probe covers.

Numerator Options:

Performance Met: All elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed (6030F)

OR

Denominator Exception: Documentation of medical reason(s) for not following all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques during CVC insertion (including increased risk of harm to patient if adherence to aseptic technique would cause delay in CVC insertion) (6030F with 1P)

OR

Performance Not Met: All elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques not followed, reason not otherwise specified (6030F with 8P)

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