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Hospital Harm - Severe Hyperglycemia

General eCQM Information

CMS Measure ID CMS871v1
Short Name HH-02
NQF Number 03533e
Measure Description

This measure assesses the number of inpatient hospital days with a hyperglycemic event (harm) per the total qualifying inpatient hospital days for patients 18 years of age or older at admission.

Initial Population Inpatient hospitalizations where the patient is 18 years or older at the start of the admission with a discharge during the measurement period, as well as either: 1. a diagnosis of diabetes that starts before or during the encounter; or 2. administration of at least one dose of insulin or any hypoglycemic medication during the encounter; or 3. presence of at least one blood glucose value >=200 mg/dL at any time during the encounter. The measure includes inpatient hospitalizations that began in the emergency department or in observational status.
Measure Steward Centers for Medicare & Medicaid Services (CMS)
Measure Scoring Ratio
Measure Type Outcome
Improvement Notation

A lower measure score indicates higher quality.

Guidance

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

To calculate a hospital-level measure result, total the number of hyperglycemic days (numerator events) across the total number of eligible days (denominator) which match the initial population/denominator criteria.

To create the Measure Observation associated with the numerator, include all hyperglycemic days meeting the follow criteria:

1) All 24-hour periods with a blood glucose level >300 mg/dL (except those occurring in the first 24-hour period after admission to the hospital (including the emergency department and observation)),

Or,

2) All days where a blood glucose was not measured, and it was preceded by two consecutive days where at least one glucose value during each of the two days is >=200 mg/dL.

Do not count the first 24-hour period after inpatient admission to the hospital (including the emergency department and observation) for >300 mg/dL events in order to exclude hyperglycemic events potentially due to poor glucose control outside of the hospital setting or that preceded the start of hospital care.

Remove the last time period before discharge, if it was less than 24-hours, to avoid counting a period of time that was less than 24-hours, on the day of discharge, as a full day.

Blood glucose levels are determined by laboratory or point-of-care (POC) tests, including capillary/glucometer blood glucose tests.

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