| Title |
Hospital Harm – Falls with Injury
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| CMS eCQM ID |
CMS1017v1
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| Short Name |
HH-FI
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| CBE ID* |
4120e
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| Measure Steward |
Centers for Medicare & Medicaid Services (CMS)
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| Description |
This ratio measure assesses the number of inpatient hospitalizations where at least one fall with a major or moderate injury occurs among the total qualifying inpatient hospital days for patients age 18 years and older
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| Measure Scoring |
Ratio measure
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| Measure Type |
Outcome
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| Stratification |
None
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| Risk Adjustment |
Variables being collected for the development of baseline risk adjustment model include encounters with: Medications active on admission such as: - anticoagulants - antidepressants - antihypertensives - central nervous system depressant medications - diuretics - opioids Medications administered... during the hospitalization, such as anticoagulants. Diagnoses present on admission which may increase the risk for a fall with injury, such as: - abnormal weight loss or malnutrition - coagulation disorders - delirium, dementia, or other psychosis - depression - epilepsy - leukemia or lymphoma - liver disease (moderate to severe) - malignant bone disease - neurologic movement and related disorders - obesity - osteoporosis - peripheral neuropathy - stroke - suicide attempt Physical traits, such as body mass index (BMI) during the hospital encounter. All encounter diagnoses along with their rank (e.g., 1, 2, 3) and present on admission (POA) indicators are being collected for the development of baseline risk adjustment model. Please see the Hospital Harm - Falls with Injury Risk Adjustment Methodology Report on the eCQM-specific page on the eCQI Resource Center website: https://ecqi.healthit.gov/
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Variables being collected for the development of baseline risk adjustment model include encounters with: Medications active on admission such as: - anticoagulants - antidepressants - antihypertensives - central nervous system depressant medications - diuretics - opioids Medications administered during the hospitalization, such as anticoagulants. Diagnoses present on admission which may increase the risk for a fall with injury, such as: - abnormal weight loss or malnutrition - coagulation disorders - delirium, dementia, or other psychosis - depression - epilepsy - leukemia or lymphoma - liver disease (moderate to severe) - malignant bone disease - neurologic movement and related disorders - obesity - osteoporosis - peripheral neuropathy - stroke - suicide attempt Physical traits, such as body mass index (BMI) during the hospital encounter. All encounter diagnoses along with their rank (e.g., 1, 2, 3) and present on admission (POA) indicators are being collected for the development of baseline risk adjustment model. Please see the Hospital Harm - Falls with Injury Risk Adjustment Methodology Report on the eCQM-specific page on the eCQI Resource Center website: https://ecqi.healthit.gov/
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| Rationale |
Inpatient falls are among the most common incidents reported in hospitals and can increase length of stay and patient costs. Due to the potential for serious harm associated with patient falls, “patient death or serious injury associated with a fall while being cared for in a health care... setting” is considered a Serious Reportable Event by the National Quality Forum (NQF, 2019). Falls (including unplanned or unintended descents to the floor) can result in patient injury ranging from minor abrasion or bruising to death as a result of injuries sustained from a fall. While major injuries (e.g., fractures, closed head injuries, internal bleeding) (Mintz et al., 2022) have the biggest impact on patient outcomes, 2008-2021 data findings from The 2022 Network of Patient Safety Databases (NPSD) demonstrated that 41.8 % of falls resulted in moderate injuries such as skin tear, avulsion, hematoma, significant bruising, dislocations and lacerations requiring suturing (NPSD, 2022). Moderate injury is, as defined by the National Database of Nursing Quality Indicators (NDNQI), that resulted in suturing, application of steri-strips or skin glue, splinting, or muscle/joint strain (Ganey, 2020). NPSD findings also demonstrated that mild to moderate level of harm represent 24.2.%, 0.4% - severe harm, and 0.1% - death (NPSD, 2022; WHO, 2009). By focusing on falls with major and moderate injuries, the goal of this hospital harm eCQM is to raise awareness of fall rates and, ultimately, to improve patient safety by preventing falls with injury in all hospital patients. The purpose of measuring the rate of falls with major and moderate injury events is to improve hospitals’ practices for monitoring patients at high risk for falls with injury and, in so doing, to reduce the frequency of patient falls with injury.
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Inpatient falls are among the most common incidents reported in hospitals and can increase length of stay and patient costs. Due to the potential for serious harm associated with patient falls, “patient death or serious injury associated with a fall while being cared for in a health care setting” is considered a Serious Reportable Event by the National Quality Forum (NQF, 2019). Falls (including unplanned or unintended descents to the floor) can result in patient injury ranging from minor abrasion or bruising to death as a result of injuries sustained from a fall. While major injuries (e.g., fractures, closed head injuries, internal bleeding) (Mintz et al., 2022) have the biggest impact on patient outcomes, 2008-2021 data findings from The 2022 Network of Patient Safety Databases (NPSD) demonstrated that 41.8 % of falls resulted in moderate injuries such as skin tear, avulsion, hematoma, significant bruising, dislocations and lacerations requiring suturing (NPSD, 2022). Moderate injury is, as defined by the National Database of Nursing Quality Indicators (NDNQI), that resulted in suturing, application of steri-strips or skin glue, splinting, or muscle/joint strain (Ganey, 2020). NPSD findings also demonstrated that mild to moderate level of harm represent 24.2.%, 0.4% - severe harm, and 0.1% - death (NPSD, 2022; WHO, 2009). By focusing on falls with major and moderate injuries, the goal of this hospital harm eCQM is to raise awareness of fall rates and, ultimately, to improve patient safety by preventing falls with injury in all hospital patients. The purpose of measuring the rate of falls with major and moderate injury events is to improve hospitals’ practices for monitoring patients at high risk for falls with injury and, in so doing, to reduce the frequency of patient falls with injury.
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| Clinical Recommendation Statement |
Certain protocols and prevention measures to reduce patient falls with injury include using fall risk assessment tools to gauge individual patient risk, implementing fall prevention protocols directed at individual patient risk factors, and implementing environmental rounds to assess and... correct environmental fall hazards. Recommended clinical guidelines and practices to reduce falls and injuries from falls in hospitals support many prevention activities including implementing multifactorial interventions and tailoring interventions to individual patient's conditions and needs. The intent and desired outcome for this eCQM is to work with existing and recommended falls prevention processes to track falls with injury, and aim to reduce rates of inpatient falls resulting in major injury. Recommended falls prevention guidelines are: - Mohanty, et al. Optimal Perioperative Management of the Geriatric Patient: Best Practices Guideline from ACS NSQIP/AGS, 2016 - National Institute for Health and Care Excellence (NICE) Falls in older people: assessing risk and prevention, 2013 - Registered Nurses’ Association of Ontario (RNAO). Preventing falls and reducing injury from falls (4th edition), 2017 - Schoberer et al. Fall prevention in hospitals and nursing homes: Clinical practice guideline, 2022 - World Falls Guidelines (WFG) Task Force, 2022
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Certain protocols and prevention measures to reduce patient falls with injury include using fall risk assessment tools to gauge individual patient risk, implementing fall prevention protocols directed at individual patient risk factors, and implementing environmental rounds to assess and correct environmental fall hazards. Recommended clinical guidelines and practices to reduce falls and injuries from falls in hospitals support many prevention activities including implementing multifactorial interventions and tailoring interventions to individual patient's conditions and needs. The intent and desired outcome for this eCQM is to work with existing and recommended falls prevention processes to track falls with injury, and aim to reduce rates of inpatient falls resulting in major injury. Recommended falls prevention guidelines are: - Mohanty, et al. Optimal Perioperative Management of the Geriatric Patient: Best Practices Guideline from ACS NSQIP/AGS, 2016 - National Institute for Health and Care Excellence (NICE) Falls in older people: assessing risk and prevention, 2013 - Registered Nurses’ Association of Ontario (RNAO). Preventing falls and reducing injury from falls (4th edition), 2017 - Schoberer et al. Fall prevention in hospitals and nursing homes: Clinical practice guideline, 2022 - World Falls Guidelines (WFG) Task Force, 2022
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| Improvement Notation |
A lower measure score indicates higher quality
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| Definition |
A fall is defined as: A sudden, unintentional descent, with or without injury to the patient, that results in the patient coming to rest on the floor, on or against some other surface (e.g., a counter), on another person, or on an object (e.g., a trash can). A fall with moderate or major... injury is defined as: A fall and a diagnosis of moderate or major injury during the inpatient hospitalization. Examples of moderate injuries include lacerations, open wounds, dislocations, sprains, and muscle strains. Examples of major injuries include fractures, closed head injuries, and internal bleeding. Inpatient hospitalizations: Includes time in the emergency department and observation when the transition between these encounters (if they exist) and the inpatient encounter are within an hour or less of each other. Present on admission (POA) is defined as the conditions present at the time the order for inpatient admission occurs. The POA Indicator is intended to differentiate conditions present at the time of admission from those conditions that develop during the inpatient admission. A POA Indicator of Y = yes (Diagnosis was present at time of inpatient admission). A POA Indicator of N = no (Diagnosis was not present at time of inpatient admission.) A POA Indicator of W = clinically undetermined. A POA Indicator of U = documentation insufficient to determine if the condition was present at the time of inpatient admission. Per CMS and the Agency for Healthcare Research and Quality (AHRQ) convention, POA indicators of Y and W are accepted indicators of a diagnosis present on admission. POA indicators of N and U are accepted indicators of a diagnosis that is not present on admission.
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A fall is defined as: A sudden, unintentional descent, with or without injury to the patient, that results in the patient coming to rest on the floor, on or against some other surface (e.g., a counter), on another person, or on an object (e.g., a trash can). A fall with moderate or major injury is defined as: A fall and a diagnosis of moderate or major injury during the inpatient hospitalization. Examples of moderate injuries include lacerations, open wounds, dislocations, sprains, and muscle strains. Examples of major injuries include fractures, closed head injuries, and internal bleeding. Inpatient hospitalizations: Includes time in the emergency department and observation when the transition between these encounters (if they exist) and the inpatient encounter are within an hour or less of each other. Present on admission (POA) is defined as the conditions present at the time the order for inpatient admission occurs. The POA Indicator is intended to differentiate conditions present at the time of admission from those conditions that develop during the inpatient admission. A POA Indicator of Y = yes (Diagnosis was present at time of inpatient admission). A POA Indicator of N = no (Diagnosis was not present at time of inpatient admission.) A POA Indicator of W = clinically undetermined. A POA Indicator of U = documentation insufficient to determine if the condition was present at the time of inpatient admission. Per CMS and the Agency for Healthcare Research and Quality (AHRQ) convention, POA indicators of Y and W are accepted indicators of a diagnosis present on admission. POA indicators of N and U are accepted indicators of a diagnosis that is not present on admission.
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| Guidance |
Hospital days are measured in 24-hour periods starting from the time of arrival at the hospital (including time in the Emergency Department and or Observation.) The number of days will be counted as whole numbers; any fractional periods are dropped. For example, an eligible encounter... with a length of stay of 75 hours will be measured as 3 days (72 hours). Reported as the number of inpatient hospitalizations with falls with moderate or major injury per 1000 patient days. To express the rate of inpatient hospitalizations with falls with moderate or major injury per 1,000 patient days, the following calculation is applied post-production during implementation: (Total number of encounters with falls with moderate or major injury / Total number of eligible hospital days) x 1000 = rate. Example: 1 eligible encounter with a patient fall with moderate or major injury over 120 eligible days (1/120) x 1000 = 8.33. In ratio measures, both the Denominator and Numerator populations flow separately from the same Initial Population. Therefore, the same exclusion criteria must be applied to both the Denominator and Numerator to prevent excluded cases from being considered. This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period. This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.
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Hospital days are measured in 24-hour periods starting from the time of arrival at the hospital (including time in the Emergency Department and or Observation.) The number of days will be counted as whole numbers; any fractional periods are dropped. For example, an eligible encounter with a length of stay of 75 hours will be measured as 3 days (72 hours). Reported as the number of inpatient hospitalizations with falls with moderate or major injury per 1000 patient days. To express the rate of inpatient hospitalizations with falls with moderate or major injury per 1,000 patient days, the following calculation is applied post-production during implementation: (Total number of encounters with falls with moderate or major injury / Total number of eligible hospital days) x 1000 = rate. Example: 1 eligible encounter with a patient fall with moderate or major injury over 120 eligible days (1/120) x 1000 = 8.33. In ratio measures, both the Denominator and Numerator populations flow separately from the same Initial Population. Therefore, the same exclusion criteria must be applied to both the Denominator and Numerator to prevent excluded cases from being considered. This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period. This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.
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| Initial Population |
Inpatient hospitalizations for patients age 18 and older with a length of stay less than or equal to 120 days that ends during the measurement period
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| Denominator |
Equals Initial Population
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| Denominator Exclusions |
Inpatient hospitalizations where the patient has a fall diagnosis present on admission
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| Numerator |
Inpatient hospitalizations where the patient has a fall that results in a major or moderate injury during the encounter. The diagnosis of a major or moderate injury must not be present on admission.
|
| Numerator Exclusions |
Inpatient hospitalizations where the patient has a fall diagnosis present on admission
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