Measure Title: Prevention of Arterial Line-Related Bloodstream Infections
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 three 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
Note: The overall measure score will be calculated as an average of the total cases of part A (rate 2) and part B (rate 3). The overall measure score is rate 1.
Denominator:
4a: Brachial, Radial, Posterior Tibial, or Dorsalis Pedis Arterial Lines
DENOMINATOR:
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
DENOMINATOR EXCLUSION:
None
4b: Femoral and Axillary Arterial Lines
DENOMINATOR:
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: 4a.
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
4b.
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
Denominator Exclusions: None
Denominator Exceptions: 4a. 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) 11A75
4b. 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) 11A78
National Quality Forum (NQF) number, if applicable
N/A
Care setting(s)
Hospital
Telehealth, if applicable
No
Number of performance rates required for measures
3
Traditional vs. inverse measure
Traditional
Proportional, continuous variable, and/or ratio measure indicator
Proportional
Risk adjustment, if applicable
No
Submission pathway
Traditional MIPS