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Hospital Harm - Opioid-Related Adverse Events

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Measure Information 2023 Reporting Period
Title Hospital Harm - Opioid-Related Adverse Events
CMS eCQM ID CMS819v1
Short Name HH-03
NQF Number 3501e
Description

This measure assesses the proportion of inpatient hospital encounters where patients ages 18 years of age or older have been administered an opioid medication and are subsequently administered an opioid antagonist (naloxone) within 12 hours, an indication of an opioid-related adverse event. This measure excludes opioid antagonist (naloxone) administration occurring in the operating room setting.

Initial Population

Inpatient hospitalizations for patients 18 years or older during which at least one opioid medication was administered

Denominator

Equals Initial Population

Denominator Exclusions None
Numerator

Inpatient hospitalizations where an opioid antagonist (naloxone) was administered outside of the operating room and within 12 hours following administration of an opioid medication.

Only one numerator event is counted per encounter.

Numerator Exclusions

Not applicable

Denominator Exceptions

None

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

A lower proportion indicates higher quality

Guidance

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.

Meaningful Measure Safety
Next Version No Version Available
Previous Version No Version Available

Measure Information
CMS eCQM ID CMS819v1
Short Name HH-03
NQF Number 3501e
Description

This measure assesses the proportion of inpatient hospital encounters where patients ages 18 years of age or older have been administered an opioid medication and are subsequently administered an opioid antagonist (naloxone) within 12 hours, an indication of an opioid-related adverse event. This measure excludes opioid antagonist (naloxone) administration occurring in the operating room setting.

Initial Population

Inpatient hospitalizations for patients 18 years or older during which at least one opioid medication was administered

Denominator

Equals Initial Population

Denominator Exclusions

None

Numerator

Inpatient hospitalizations where an opioid antagonist (naloxone) was administered outside of the operating room and within 12 hours following administration of an opioid medication.

Only one numerator event is counted per encounter.

Numerator Exclusions

Not applicable

Denominator Exceptions

None

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

A lower proportion indicates higher quality

Guidance

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.

Meaningful Measure Safety
Last Updated: Aug 29, 2022