Measure Description
Percentage of patients, regardless of age, who undergo placement of a peripheral intra-arterial catheter for whom the arterial line was inserted with all indicated elements of sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed.
This measure will consist of two performance rates:
a. Percentage of patients, regardless of age, who undergo placement of a peripheral intra-arterial line in the brachial, radial, posterior tibial or dorsalis pedis artery for whom the arterial line was inserted with all indicated elements of sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed
b. Percentage of patients, regardless of age, who undergo placement of a peripheral intra-arterial line in the femoral or axillary artery for whom the arterial line was inserted with all indicated elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound technique is followed
The overall measure score will be calculated as an average of the performance rates of part A and part B.
Denominator
a. All patients, regardless of age, who undergo placement of an intra-arterial catheter in the brachial, radial, posterior tibial or dorsalis pedis artery
Denominator Criteria (Eligible Cases):
All patients, regardless of age
AND
Patient encounter during the reporting period (CPT): 36620
AND
Intra-arterial catheter placed in brachial, radial, posterior tibial, or dorsalis pedis artery: 11A71
b.All patients, regardless of age, who undergo placement of an intra-arterial catheter in the femoral or axillary
artery
Denominator Criteria (Eligible Cases):
All patients, regardless of age
AND
Patient encounter during the reporting period (CPT): 36620
AND
Intra-arterial catheter placed in femoral or axillary artery: 11A72
Numerator
a. Patients for whom intra-arterial catheter was inserted with all indicated elements of sterile barrier technique, hand hygiene, skin preparation (including >0.5% chlorhexidine with alcohol, unless there is a contraindication to chlorhexidine), and, if ultrasound is used, sterile ultrasound techniques followed
Numerator Definitions:
Sterile Barrier Technique: Includes all of the following elements: Cap AND mask AND sterile gloves AND sterile draping. Sterile Ultrasound Techniques: Require sterile gel and sterile probe covers Numerator Quality-Data Coding Options for Reporting Satisfactorily
Performance Met:
11A74 All indicated elements of sterile barrier technique, hand hygiene, skin preparation, and, if ultrasound is used, sterile ultrasound techniques followed
OR
Denominator Exception:
11A75 Documentation of medical reason(s) for not following all indicated elements of sterile barrier technique, hand hygiene, skin preparation, and, if ultrasound is used, sterile ultrasound techniques during intra-arterial catheter insertion (e.g. An emergency surgical, therapeutic, or diagnostic procedure or an unanticipated worsening of the patient’s clinical condition so that adherence would cause delay in arterial line insertion resulting in increased risk of harm to patient)
OR
Performance Not Met:
11A76 All indicated elements of sterile barrier technique, hand hygiene, skin preparation, and if ultrasound is used, sterile ultrasound techniques not followed, reason not otherwise specified
b. Patients for whom intra-arterial catheter was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation (including >0.5% chlorhexidine with alcohol, unless there is a contraindication to chlorhexidine), and, if ultrasound is used, sterile ultrasound techniques followed
Numerator Definitions:
Maximal Sterile Barrier Technique – includes all of the following elements: Cap AND mask AND sterile gloves AND sterile gown AND sterile full body draping Sterile Ultrasound Techniques- Require sterile gel and sterile probe covers
Numerator Quality-Data Coding Options for Reporting Satisfactorily
Performance Met:
11A77 All elements of maximal sterile barrier technique, hand hygiene, skin preparation, and, if ultrasound is used, sterile ultrasound techniques followed.
OR
Denominator Exception:
11A78 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 intra-arterial catheter insertion (e.g. An emergency surgical, therapeutic, or diagnostic procedure or an unanticipated worsening of the patient’s clinical condition so that adherence would cause delay in arterial line insertion resulting in increased risk of harm to patient).
OR
Performance Not Met:
11A79 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.
Numerator Exclusions
None
NQF ID Number
N/A
NQS Domain
Patient Safety
High Priority Measure
Yes
Includes Telehealth?
No
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