Hospital Harm - Opioid-Related Adverse Events

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

Qualifying encounters (denominator) include all patients 18 years of age or older at the start of the encounter with at least one opioid medication administered during the encounter.

To create the numerator:

1. First, start with those encounters meeting denominator criteria

2. Next, remove all events where an opioid antagonist (naloxone) was only administered in the operating

room.

Opioid antagonist administrations in the operating room are excluded because they could be part of the sedation plan as administered by an anesthesiologist. Encounters that include use of opioid antagonists for procedures and recovery outside of the operating room (e.g., bone marrow biopsy and PACU) are included in the numerator, as it would indicate the patient was over-sedated. Note that should a facility not utilize temporary patient locations, alternative times may be used to determine whether a patient is in the operating room during opioid antagonist administration. Since anesthesia end time could represent the time the anesthesiologist signed off, and thus may include the patient’s time in the PACU, this should be avoided.

3. Finally, remove all administrations of naloxone that were given greater than 12 hours following

hospital administration of an opioid medication.

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 QDM page for more information on the QDM.

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

Qualifying encounters (denominator) include all patients 18 years of age or older with at least one opioid medication administered outside of the operating room.

To create the numerator:

1. First, start with those encounters meeting denominator criteria.

2. Next, remove all events where an opioid or opioid antagonist was only administered in the operating room.

Opioid antagonist administrations in the operating room are excluded because they could be part of the sedation plan as administered by an anesthesiologist. Encounters that include use of opioid antagonists for procedures and recovery outside of the operating room (e.g., bone marrow biopsy and PACU) are included in the numerator, as it would indicate the patient was over-sedated. Note that should a facility not utilize temporary patient locations, alternative times may be used to determine whether a patient is in the operating room during opioid antagonist administration. Since anesthesia end time could represent the time the anesthesiologist signed off, and thus may include the patient’s time in the PACU, this should be avoided.

3. Next, remove all events where the opioid antagonist was administered via an enteral route. Only opioid antagonists given by a non-enteral (i.e., intravenous, intramuscular, subcutaneous, intranasal, inhalation) route are considered.

4. Finally, remove all administrations of opioid antagonist that were given greater than 12 hours following hospital administration of an opioid medication.

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.