| Valid Data Submission Method(s) | Measure Type | High Priority Measure? | NQS Domain | Specialty Measure Sets |
|---|---|---|---|---|
| Claims, Registry | Process | Yes | Patient Safety | Anesthesiology, Hospitalists |
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
Instruction
This measure is to be reported 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.
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) (6030 with 1P)
OR
Performance Not Met: All elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is not used, sterile ultrasound techniques followed, reason not otherwise specified (6030 with 8P)