National Healthcare Safety Network (NHSN) Facility-wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure

NQF ENDORSEMENT STATUS: Endorsed  |  NQF ID: 1717  |  MEASURE TYPE: Outcome  |  INFO AS OF: Not available  |  CMIT ID: 831  |  REVISION: 9
This measure calculates the total number of observed hospital-onset CDI LabID events among all inpatients in the facility, excluding well baby-nurseries and NICUs, from the total number of expected hospital-onset CDI LabID events, determined through the facility's number of inpatient days, bed size, affiliation with a medical school, microbiological test used to identify C. difficile, and community onset CDI admission prevalence rate.
Info As Of Not available
Description This measure calculates the total number of observed hospital-onset CDI LabID events among all inpatients in the facility, excluding well baby-nurseries and NICUs, from the total number of expected hospital-onset CDI LabID events, determined through the facility's number of inpatient days, bed size, affiliation with a medical school, microbiological test used to identify C. difficile, and community onset CDI admission prevalence rate.
Numerator Total number of observed hospital-onset CDI LabID events among all inpatients in the facility, excluding well baby-nurseries and NICUs
Denominator Total number of predicted hospital-onset CDI LabID events, calculated using the facility's number of inpatient days, facility type, CDI event reporting from Emergency Department and 24 hour observation units, bed size, ICU bed size, affiliation with medical school, microbiological test method used to identify C. difficile, and community-onset CDI admission prevalence rate.
Denominator Exclusions Data from patients who are not assigned to an inpatient bed are excluded from the denominator counts, including outpatient clinics, 24-hour observation units, and emergency department visits. Inpatient rehab locations and inpatient psychiatric locations that have their own Centers for Medicare and Medicaid Services (CMS) Certification Number (CCN) are excluded. Additionally, data from well-baby nurseries and NICUs are excluded from the denominator count.
Rationale Clostridium difficile (C. diff) infection can cause fever diarrhea, fever, appetite loss, nausea, and abdominal pain. Most cases of C. diff infection occur in patients taking antibiotics. C. diff. Infections may be prevented or stopped from spreading to other patients when inpatient rehabilitation facilities use infection control steps recommended by CDC. The measure can then be used to drive prevention practices that will lead to improved outcomes, including the reduction of patient morbidity and mortality
Evidence Clostridium difficile is responsible for a spectrum of C. difficile infections (CDI), including uncomplicated diarrhea, pseudomembranous colitis, and toxic megacolon which can, in some instances, lead to sepsis and even death. In recent years, a previously unrecognized strain of C. difficile with increased virulence and high levels of antimicrobial resistance has resulted in outbreaks in healthcare facilities in the United States. Additionally, CDI has become more common in the community setting, with increased risk in those with a recent inpatient stay in a healthcare facility. Significant increases in cost of inpatient care and post-hospitalization care have been seen in cases of CDI.
Steward Centers for Disease Control and Prevention (CDC)
Contact MMSSupport@Battelle.org
Measure Developer Centers for Disease Control and Prevention NHSN
Development Stage Fully Developed
Measure Type Outcome
Meaningful Measure Area Healthcare-Associated Infections
Healthcare Priority Make Care Safer by Reducing Harm Caused in the Delivery of Care
eCQM Spec Available Not Available
NQF Endorsement Status Endorsed
NQF ID 1717  (NQF Website )
Last NQF Update 2019-06-11
Target Population Age Not specified
Target Population Age (High) Not available
Target Population Age (Low) Not available
Reporting Level Facility
Conditions Infection
Subconditions Clostridium Difficile Infection (CDI)
Care Settings Hospital Inpatient , Emergency Department and Services , Emergency Department , Other , Dialysis Facility , Long-term Care Hospital , Hospital/Acute Care Facility , Hospice , Home Care , Nursing Home , Inpatient Rehabilitation Facility , Behavioral Health/Psychiatric: Inpatient , Post Acute/Long Term Care Facility: Nursing Home/Skilled Nursing Facility

  Core Measure Set  :   Not available


Measure Group Group Identifier Actions
CDI Not available
HAI 6
There are no relationships associated with the measure at this time.
Info As Of Not Available
Program / Model Notes
Data Sources Not available
Purposes Not available
Quality Domain Patient Safety
Reporting Frequency Not available
Impacts Payment Not available
Reporting Status Active
Data Reporting Begin Date 2016-01-01
Data Reporting End Date Not Available
Milestone Effective Date Comments Links Other Data Actions
Implemented 2016-10-01 Not available

https://www.federalregister.gov/articles/2013/08/19/2013-18956/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the#p-2676

Finalized 2013-08-19 Not available

https://www.gpo.gov/fdsys/pkg/FR-2016-08-22/pdf/2016-18476.pdf

Considered 2012-12-01 Not available
MUC ID 474
Info As Of Not Available
Program / Model Notes
Data Sources Not available
Purposes Not available
Quality Domain Not available
Reporting Frequency Not available
Impacts Payment Not available
Reporting Status Unknown
Data Reporting Begin Date Not Available
Data Reporting End Date Not Available
Links
Links Actions
Milestone Effective Date Comments Links Other Data Actions
Implemented 2016-10-01 Not available

http://www.gpo.gov/fdsys/pkg/FR-2014-08-06/pdf/2014-18447.pdf

Finalized 2014-08-06 Not available

http://www.gpo.gov/fdsys/pkg/FR-2015-08-06/pdf/2015-18973.pdf

Reference 1900-01-01 Not available

http://www.qualityforum.org/QPS/QPSTool.aspx?tID=9:690&Exact=False&Keyword=inpatient+rehabilitation+facilities#qpsPageState=%7B%22TabType%22%3A1,%22TabContentType%22%3A2,%22SearchCriteriaForStandard%22%3A%7B%22TaxonomyIDs%22%3A%5B%5D,%22SelectedTypeAheadFilterOption%22%3A%7B%22FilterOptionLabel%22%3A%22inpatient+rehabilitation+facilities%22,%22SearchType%22%3A0,%22TaxonomyId%22%3A0,%22SortWeight%22%3A0,%22TypeOfTypeAheadFilterOption%22%3A1,%22ID%22%3A21603,%22IsNew%22%3Afalse,%22IsActive%22%3Afalse,%22IsDeleted%22%3Afalse,%22IsLocked%22%3Afalse,%22IsLoading%22%3Afalse%7D,%22Keyword%22%3A%22inpatient+rehabilitation+facilities%22,%22PageSize%22%3A%2225%22,%22OrderType%22%3A%2210%22,%22OrderBy%22%3A%22ASC%22,%22PageNo%22%3A2,%22IsExactMatch%22%3Atrue,%22QueryStringType%22%3A%22%22,%22ProjectActivityId%22%3A%220%22,%22FederalProgramYear%22%3A%220%22,%22FederalFiscalYear%22%3A%220%22,%22FilterTypes%22%3A2%7D,%22SearchCriteriaForForPortfolio%22%3A%7B%22Tags%22%3A%5B%5D,%22FilterTypes%22%3A0,%22PageStartIndex%22%3A1,%22PageEndIndex%22%3A25,%22PageNumber%22%3Anull,%22PageSize%22%3A%2225%22,%22SortBy%22%3A%22Title%22,%22SortOrder%22%3A%22ASC%22,%22SearchTerm%22%3A%22%22%7D,%22ItemsToCompare%22%3A%5B%5D,%22SelectedStandardIdList%22%3A%5B%5D,%22StandardID%22%3A1717,%22EntityTypeID%22%3A1%7D

https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/hospitalqualityinits/hospitalcompare.html

Info As Of Not Available
Program / Model Notes
Data Sources Not available
Purposes Not available
Quality Domain Not specified
Reporting Frequency Not available
Impacts Payment Not available
Reporting Status Inactive
Data Reporting Begin Date 2014-01-01
Data Reporting End Date 2020-01-01
Milestone Effective Date Comments Links Other Data Actions
Removed 2021-10-01 Not available

https://www.gpo.gov/fdsys/pkg/FR-2018-08-17/pdf/2018-16766.pdf

Implemented 2014-10-01 Not available
Info As Of Not Available
Program / Model Notes
Data Sources Not available
Purposes Not available
Quality Domain Safety
Reporting Frequency Not available
Impacts Payment No
Reporting Status Active
Data Reporting Begin Date 2016-01-01
Data Reporting End Date Not Available
Info As Of Not Available
Program / Model Notes
Data Sources Not available
Purposes Not available
Quality Domain Not available
Reporting Frequency Not available
Impacts Payment Not available
Reporting Status Unknown
Data Reporting Begin Date Not Available
Data Reporting End Date Not Available
Links
Links Actions
Milestone Effective Date Comments Links Other Data Actions
Implemented 2014-10-01 Not available

https://www.medicare.gov/inpatientrehabilitationfacilitycompare/

Info As Of Not Available
Program / Model Notes
Data Sources Not available
Purposes Not available
Quality Domain Making care safe through timeliness and responsiveness of care
Reporting Frequency Not available
Impacts Payment Not available
Reporting Status Active
Data Reporting Begin Date 2015-01-01
Data Reporting End Date Not Available
Milestone Effective Date Comments Links Other Data Actions
Implemented 2016-10-01 Not available

http://www.gpo.gov/fdsys/pkg/FR-2014-08-06/pdf/2014-18447.pdf

Finalized 2014-08-06 Not available

http://www.gpo.gov/fdsys/pkg/FR-2015-08-06/pdf/2015-18973.pdf

Considered 2013-12-01 Not available
MUC ID E1717
Reference 1900-01-01 Not available

http://www.qualityforum.org/QPS/QPSTool.aspx?tID=9:690&Exact=False&Keyword=inpatient+rehabilitation+facilities#qpsPageState=%7B%22TabType%22%3A1,%22TabContentType%22%3A2,%22SearchCriteriaForStandard%22%3A%7B%22TaxonomyIDs%22%3A%5B%5D,%22SelectedTypeAheadFilterOption%22%3A%7B%22FilterOptionLabel%22%3A%22inpatient+rehabilitation+facilities%22,%22SearchType%22%3A0,%22TaxonomyId%22%3A0,%22SortWeight%22%3A0,%22TypeOfTypeAheadFilterOption%22%3A1,%22ID%22%3A21603,%22IsNew%22%3Afalse,%22IsActive%22%3Afalse,%22IsDeleted%22%3Afalse,%22IsLocked%22%3Afalse,%22IsLoading%22%3Afalse%7D,%22Keyword%22%3A%22inpatient+rehabilitation+facilities%22,%22PageSize%22%3A%2225%22,%22OrderType%22%3A%2210%22,%22OrderBy%22%3A%22ASC%22,%22PageNo%22%3A2,%22IsExactMatch%22%3Atrue,%22QueryStringType%22%3A%22%22,%22ProjectActivityId%22%3A%220%22,%22FederalProgramYear%22%3A%220%22,%22FederalFiscalYear%22%3A%220%22,%22FilterTypes%22%3A2%7D,%22SearchCriteriaForForPortfolio%22%3A%7B%22Tags%22%3A%5B%5D,%22FilterTypes%22%3A0,%22PageStartIndex%22%3A1,%22PageEndIndex%22%3A25,%22PageNumber%22%3Anull,%22PageSize%22%3A%2225%22,%22SortBy%22%3A%22Title%22,%22SortOrder%22%3A%22ASC%22,%22SearchTerm%22%3A%22%22%7D,%22ItemsToCompare%22%3A%5B%5D,%22SelectedStandardIdList%22%3A%5B%5D,%22StandardID%22%3A1717,%22EntityTypeID%22%3A1%7D

Info As Of Not Available
Program / Model Notes
Data Sources Not available
Purposes Not available
Quality Domain Not available
Reporting Frequency Not available
Impacts Payment Not available
Reporting Status Unknown
Data Reporting Begin Date Not Available
Data Reporting End Date Not Available
Links
Links Actions
Milestone Effective Date Comments Links Other Data Actions
Implemented 2013-10-01 Not available

https://www.medicare.gov/longtermcarehospitalcompare/

Info As Of Not Available
Program / Model Notes
Data Sources Not available
Purposes Not available
Quality Domain Patient Safety
Reporting Frequency Not available
Impacts Payment Not available
Reporting Status Active
Data Reporting Begin Date 2015-01-01
Data Reporting End Date Not Available
Milestone Effective Date Comments Links Other Data Actions
Implemented 2016-10-01 Not available

http://www.gpo.gov/fdsys/pkg/FR-2013-08-19/pdf/2013-18956.pdf

Finalized 2013-08-19 Not available

https://www.gpo.gov/fdsys/pkg/FR-2016-08-22/pdf/2016-18476.pdf

Info As Of Not Available
Program / Model Notes
Data Sources Not available
Purposes Not available
Quality Domain Patient Safety
Reporting Frequency Not available
Impacts Payment Not available
Reporting Status Active
Data Reporting Begin Date 2016-01-01
Data Reporting End Date 2022-01-01
Milestone Effective Date Comments Links Other Data Actions
Implemented 2017-10-01 Not available
Finalized 2015-08-17 Not available
Proposed 2015-04-30 Not available
There are no links associated with the measure at this time.