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Hospital Harm - Severe Hypoglycemia

General eCQM Information

CMS Measure ID CMS816v1
Short Name HH-01
NQF Number 3503e
Measure Description

The proportion of inpatient hospitalizations for patients 18 years of age or older at admission, who were administered at least one hypoglycemic medication during the encounter, who suffer the harm of a severe hypoglycemic event during the encounter.

Harm (numerator) is defined as a laboratory or point-of-care (POC) test for blood glucose with a result less than 40 mg/dL, where the hypoglycemic medication was given within the 24 hours prior to the start of the low blood glucose event (and administered during the encounter). Only one severe hypoglycemic event is counted per inpatient hospitalization encounter.

Initial Population Inpatient hospitalizations where the patient is 18 years of age or older at the start of the encounter, and at least one hypoglycemic medication was administered during the encounter. The measure includes instances of administration of hypoglycemic medications in the emergency department or in observation status at the start of an inpatient hospitalization when assessing inclusion of encounters in the measure denominator.
Denominator Statement

Equals Initial Population

Denominator Exclusions

None

Numerator Statement

Inpatient hospitalizations which include:

1. A severe hypoglycemic event during the encounter, defined as a test (laboratory or point-of-care (POC)) for blood glucose with a result less than 40 mg/dL;

AND

2. A hypoglycemic medication administered within 24 hours prior to the start of the severe hypoglycemic event (and that was during the encounter);

AND

3. No subsequent repeat test for blood glucose with a result greater than 80 mg/dL within five minutes of the start of the initial low blood glucose test.

Only the first qualifying severe hypoglycemic event is counted in the numerator, and only one severe hypoglycemic event is counted per encounter. The 24-hour and 5-minute timeframes are based on the time the blood glucose was drawn, as this reflects the time the patient was experiencing that specific blood glucose level.

Numerator Exclusions

Not Applicable

Denominator Exceptions

None

Measure Steward Centers for Medicare & Medicaid Services (CMS)
Measure Scoring Proportion
Measure Type Outcome
Improvement Notation

A lower proportion indicates better quality.

Guidance

Note the measure is currently confined to using mg/dL as the unit of measurement for glucose results.

To calculate the hospital-level measure result, divide the total numerator events by the total number of qualifying inpatient hospitalizations (denominator).

Qualifying inpatient hospitalizations (denominator) include all patients 18 years of age or older at the start of the encounter, who had at least one hypoglycemic medication administered during the encounter.

To create the numerator, for each encounter identify:

1. Any instance of a test for blood glucose with a result less than 40 mg/dL during the encounter (severe hypoglycemic event), with a hypoglycemic medication administered within 24 hours preceding the event and during the encounter (including emergency department and observation stays contiguous with the admission).

A severe hypoglycemic event is defined as a test (laboratory or point-of-care (POC)) for blood glucose with a result less than 40 mg/dL. The 24-hour timeframe extends from the end of the medication administration to the start of the blood glucose test.

2. Do not include any severe hypoglycemic events (identified in Step 1) which were followed by a repeat test for blood glucose with a result greater than 80 mg/dL within five minutes of the start of the initial low blood glucose test.

Rationale: This is done to remove false positives that can occur in POC testing. The 5-minute timeframe extends from the start of the severe hypoglycemic test to the start of the repeat hypoglycemic test.

Only the first qualifying severe hypoglycemic event is counted in the numerator, and only one severe hypoglycemic event is counted per encounter.

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 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

Meaningful Measure Preventable Healthcare Harm
Last Updated: May 05, 2021