Measure Description
Percentage of Adult Patients Who Had a Risk Assessment for C. difficile Infection and, If High-Risk, Had a Plan of Care for C. difficile Completed on the Day Of or Day After Hospital Admission
Denominator
- Any patient ≥ 18 years of age evaluated by the Eligible Professional (E/M Codes 99221- 99223, 99231- 99233, & 99291-99292 AND Place of Service Indicator: 21)
- Transferred, eloped or AMA patients are excluded
Numerator
Patients that had a risk assessment for C. difficile infection and, if high-risk, a plan of care documented on the day of or day after hospital admission
Definitions:
- Risk assessment (e.g., IDSA score, SHEA score, ZAR criteria):
- Previous C. difficile infection
- Recent antibiotic use (60-90 days prior to current admission)
- Recent contact with healthcare facility (60-90 days prior to current admission)
- Age ≥ 65
- Recent use of proton pump inhibitor (PPI) or histamine receptor 2 antagonists (H2RA)
- Diagnosis and procedure history (e.g., IBD, immunosuppression or hemodialysis)
- Plan of Care
- Contact precautions if diarrhea is present
- Stool assay
- Initiation of antibiotics if indicated
Numerator Options:
- Performance Met (PRO13): Patients who did have a C. difficile infection risk assessment, AND if high-risk, a plan of care for C. difficile documented on the day of or day after hospital admission
- Medical Performance Exclusion (Denominator Exception) (PRO16): Patients who did not have a C. difficile infection risk assessment, AND if high risk, a plan of care for C. difficile for medical reasons documented by the Eligible Professional (e.g., C. difficile infection already documented prior to hospital admission, patients unable to provide history, patients on comfort measures)
- Performance Not Met (PRO14): Patients who did not have a C. difficile infection risk assessment, AND if high risk, a plan of care for C. difficile documented on the day of or day after hospital admission, no reason specified
Numerator Exclusions
None
NQF ID Number
N/A
NQS Domain
Patient Safety
High Priority Measure
Yes
Includes Telehealth?
Yes
Inverse Measure
No
Proportional Measure
Yes
Continuous Variable Measure
No
Ratio Measure
No
Number of performance rates to be calculated and submitted
1
Risk-Adjusted Status?
No
Meaningful Measure
Healthcare-associated Infections
Measure Type
Process
Care Settings
Hospital Inpatient