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The Joint Commission(TJC) and the Centers for Medicare and MedicaidServices (CMS) require accredited hospitals to collect and submit performance data so that they can review clinical trends that have a significant effect on patient outcomes. The core measure data requirement was established to allow TJC to use collected informationto work with hospitals to improve patient safety and quality of care and to support performance improvement.

Listed are the TJC instituted core measures for ensuring better outcomes for patients suffering from pneumonia. Adherence to these guidelines will assist physicians to achieve positive patient outcomes and maintain compliance with TJC and CMS regulations.

1) Oxygenation Assessment

Pneumonia patients must recieve an assessment of arterial oxygenation by arterial blood gas measurement or pulse oximetry within 24 hours prior to or after arrival at the hospital.

2) Pneumococcal Screening and/or Vaccination

Pneumonia patients age 65 and older who were screened for pneumococcal vaccine status and were administered the vaccine prior to discharge, if indicated.

3.1) Blood Cultures Performed Within 24 Hours Prior to or 24 Hours After Hospital Arrival for Pneumonia Patients Who Were Transferred or Admitted to the ICU Within 24 Hours of Hospital.

3.2) Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital

Pneumonia patients whose initial emergency department blood culture specimen was collected prior to first hospital dose of antibiotics.

4) Adult Smoking Cessation Advice/Counseling

Pneumonia patients with a history of smoking cigarettes who are given smoking cessation advice or counseling during hospital stay.

5) Antibiotic Timing

Initial antibiotic received within 4 hours of hospital arrival.

6) Immunocompetent ICU and non-ICU Patients with Community Acquired Pneumonia

Patients mustreceive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines.

7) Influenza Vaccination

Pneumonia patients age 50 years and older, hospitalized during October, November, December, January, February, or March who were screened for influenza vaccine status and were vaccinated prior to discharge, if indicated.

If you have any questions, contact Raquel Schwankhart Margulis, Pharmacy Clinical Manager, at (504) 897-8070, or at Raquel.Margulis@Touro.com.

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Touro Infirmary, 1401 Foucher Street, New Orleans, Louisiana 70115
Phone: 504-897-7011 Pencil
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