Hospital Harm – Falls with Injury

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

Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. American Institutes for Research(R), formerly IMPAQ International, disclaims all liability for use or accuracy of any third party codes contained in the specifications.

LOINC(R) copyright 2004-2023 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2023 International Health Terminology Standards Development Organisation. ICD-10 copyright 2023 World Health Organization. All Rights Reserved.

This performance measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications.

THE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].

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/

None

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.

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

A lower measure score indicates higher quality

Reference Type: CITATION

Reference Text: 'Ganey, P. (2020). Guidelines for data collection and submission on patient falls indicator.'

Reference Type: CITATION

Reference Text: 'Mintz, J., Duprey, M. S., Zullo, A. R., Lee, Y., Kiel, D. P., Daiello, L. A., Rodriguez, K. E., Venkatesh, A. K., & Berry, S. D. (2022). Identification of Fall-Related Injuries in Nursing Home Residents Using Administrative Claims Data. The journals of gerontology. Series A, Biological sciences and medical sciences, 77(7), 1421–1429. https://doi.org/10.1093/gerona/glab274'

Reference Type: CITATION

Reference Text: 'Mohanty, S., Rosenthal, R.A., Russell, M.M., Neuman, M.D., Ko, C.Y., & Esnaola, N.F. (2016). Optimal Perioperative Management of the Geriatric Patient: Best Practices Guideline from ACS NSQIP/AGS. Journal of the American College of Surgeons 222(5), 930-947. doi: 10.1016/j.jamcollsurg.2015.12.026'

Reference Type: CITATION

Reference Text: 'Montero-Odasso, M., van der Velde, N., Martin, F. C., Petrovic, M., Tan, M. P., Ryg, J., Aguilar-Navarro, S., Alexander, N. B., Becker, C., Blain, H., Bourke, R., Cameron, I. D., Camicioli, R., Clemson, L., Close, J., Delbaere, K., Duan, L., Duque, G., Dyer, S. M., … Rixt Zijlstra, G. A. (2022). World guidelines for falls prevention and management for older adults: a global initiative. Age and Ageing, 51(9), 1–36. https://doi.org/10.1093/ageing/afac205'

Reference Type: CITATION

Reference Text: 'National Quality Forum. (2019). Serious reportable events. http://www.qualityforum.org/topics/sres/serious_reportable_events.aspx. Accessed July 24, 2019'

Reference Type: CITATION

Reference Text: 'National Institute for Health and Care Excellence. (2013). Falls in older people: assessing risk and prevention. Retrieved 4 December 2023, from https://www.nice.org.uk/guidance/cg161/resources/falls-in-older-people-assessing-risk-and-prevention-pdf-35109686728645'

Reference Type: CITATION

Reference Text: 'Network of Patient Safety Databases Chartbook. (2022). Retrieved 4 December 2023, from https://www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2022.pdf'

Reference Type: CITATION

Reference Text: 'Registered Nurses’ Association of Ontario. (2017). Preventing falls and reducing injury from falls (4th ed.). Toronto, ON: Author. Retrieved from https://rnao.ca/bpg/guidelines/prevention-falls-and-fall-injuries'

Reference Type: CITATION

Reference Text: 'Schoberer, D., Breimaier, H. E., Zuschnegg, J., Findling, T., Schaffer, S., & Archan, T. (2022). Fall prevention in hospitals and nursing homes: Clinical practice guideline. Worldviews on evidence-based nursing, Vol. 19. https://doi.org/10.1111/wvn.12571'

Reference Type: CITATION

Reference Text: 'WHO. (2009). Conceptual framework for the international classification for patient safety, Version 1.1. https://apps.who.int/iris/bitstream/handle/10665/70882/WHO_IER_PSP_2010.2_eng.pdf'

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.

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.

TBD

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

Equals Initial Population

Inpatient hospitalizations where the patient has a fall diagnosis present on admission

There are two Measure Observations:

- Associated with the Denominator: The total number of eligible days across all encounters which match the initial population/denominator criteria. 

 - Associated with the Numerator: The total number of inpatient hospitalizations where a fall with major or moderate injury occurred, across all eligible encounters.

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.

Inpatient hospitalizations where the patient has a fall diagnosis present on admission

For every patient evaluated by this measure also identify payer, race, ethnicity and sex

Table of Contents

• Population Criteria
• Definitions
• Functions
• Terminology
• Data Criteria (QDM Data Elements)
• Supplemental Data Elements
• Risk Adjustment Variables

Population Criteria

Definitions

Functions

Terminology

Data Criteria (QDM Data Elements)

Supplemental Data Elements

• SDE Ethnicity

  • • ["Patient Characteristic Ethnicity": "Ethnicity"]

     
• SDE Payer

  • • ["Patient Characteristic Payer": "Payer Type"]

     
• SDE Race

  • • ["Patient Characteristic Race": "Race"]

     
• SDE Sex

  • • ["Patient Characteristic Sex": "ONC Administrative Sex"]

     

Risk Adjustment Variables

• Risk Variable All Encounter Diagnoses with Rank and POA Indication

  • • "Initial Population" QualifyingEncounter
        return Tuple {
          encounterId: QualifyingEncounter.id,
          diagnosis: QualifyingEncounter.diagnoses.code,
          rank: QualifyingEncounter.diagnoses.rank,
          POA: QualifyingEncounter.diagnoses.presentOnAdmissionIndicator
        }

     
• Risk Variable Body Mass Index (BMI)

  • • from
        ["Physical Exam, Performed": "Body mass index (BMI) [Ratio]"] BMI
        with "Initial Population" QualifyingEncounter
          such that Global."NormalizeInterval" ( BMI.relevantDatetime, BMI.relevantPeriod ) starts during Global."HospitalizationWithObservation" ( QualifyingEncounter )
            and BMI.result is not null
        return BMI.result as Quantity

     
• Risk Variable Encounter with Abnormal Weight Loss or Malnutrition Present on Admission

  • • "Initial Population" QualifyingEncounter
        where exists ( QualifyingEncounter.diagnoses Malnutrition
            where Malnutrition.code in "Abnormal Weight Loss and Malnutrition"
              and Malnutrition.presentOnAdmissionIndicator in "Present on Admission or Clinically Undetermined"
        )

     
• Risk Variable Encounter with Anticoagulant Active at Admission

  • • "Initial Population" QualifyingEncounter
        with ["Medication, Active": "Anticoagulants for All Indications"] Anticoagulants
          such that Anticoagulants.relevantPeriod contains start of Global."HospitalizationWithObservation" ( QualifyingEncounter )

     
• Risk Variable Encounter with Anticoagulant Administration During Encounter

  • • "Initial Population" QualifyingEncounter
        with ["Medication, Administered": "Anticoagulants for All Indications"] Anticoagulants
          such that Global."NormalizeInterval" ( Anticoagulants.relevantDatetime, Anticoagulants.relevantPeriod ) starts during Global."HospitalizationWithObservation" ( QualifyingEncounter )

     
• Risk Variable Encounter with Antidepressant Active at Admission

  • • "Initial Population" QualifyingEncounter
        with ["Medication, Active": "Antidepressants"] AntidepressantMed
          such that AntidepressantMed.relevantPeriod contains start of Global."HospitalizationWithObservation" ( QualifyingEncounter )

     
• Risk Variable Encounter with Antihypertensive Active at Admission

  • • "Initial Population" QualifyingEncounter
        with ["Medication, Active": "Antihypertensives"] BPMeds
          such that BPMeds.relevantPeriod contains start of Global."HospitalizationWithObservation" ( QualifyingEncounter )

     
• Risk Variable Encounter with CNS Depressant Active at Admission

  • • "Initial Population" QualifyingEncounter
        with ["Medication, Active": "Central Nervous System Depressants"] CNSMedication
          such that CNSMedication.relevantPeriod contains start of Global."HospitalizationWithObservation" ( QualifyingEncounter )

     
• Risk Variable Encounter with Coagulation Disorder Present on Admission

  • • "Initial Population" QualifyingEncounter
        where exists ( QualifyingEncounter.diagnoses Coagulation
            where Coagulation.code in "Coagulation Disorders"
              and Coagulation.presentOnAdmissionIndicator in "Present on Admission or Clinically Undetermined"
        )

     
• Risk Variable Encounter with Delirium or Dementia or Other Psychosis Present on Admission

  • • "Initial Population" QualifyingEncounter
        where exists ( QualifyingEncounter.diagnoses Psychotic
            where Psychotic.code in "Delirium or Dementia and Other Psychoses"
              and Psychotic.presentOnAdmissionIndicator in "Present on Admission or Clinically Undetermined"
        )

     
• Risk Variable Encounter with Depression Present on Admission

  • • "Initial Population" QualifyingEncounter
        where exists ( QualifyingEncounter.diagnoses Depressed
            where Depressed.code in "Depression"
              and Depressed.presentOnAdmissionIndicator in "Present on Admission or Clinically Undetermined"
        )

     
• Risk Variable Encounter with Diuretic Active at Admission

  • • "Initial Population" QualifyingEncounter
        with ["Medication, Active": "Diuretics"] DiureticMeds
          such that DiureticMeds.relevantPeriod contains start of Global."HospitalizationWithObservation" ( QualifyingEncounter )

     
• Risk Variable Encounter with Epilepsy Present on Admission

  • • "Initial Population" QualifyingEncounter
        where exists ( QualifyingEncounter.diagnoses Epileptic
            where Epileptic.code in "Epilepsy"
              and Epileptic.presentOnAdmissionIndicator in "Present on Admission or Clinically Undetermined"
        )

     
• Risk Variable Encounter with Leukemia or Lymphoma Present on Admission

  • • "Initial Population" QualifyingEncounter
        where exists ( QualifyingEncounter.diagnoses Cancer
            where Cancer.code in "Leukemia or Lymphoma"
              and Cancer.presentOnAdmissionIndicator in "Present on Admission or Clinically Undetermined"
        )

     
• Risk Variable Encounter with Liver Disease Moderate to Severe Present on Admission

  • • "Initial Population" QualifyingEncounter
        where exists ( QualifyingEncounter.diagnoses LiverDisease
            where LiverDisease.code in "Liver Disease Moderate to Severe"
              and LiverDisease.presentOnAdmissionIndicator in "Present on Admission or Clinically Undetermined"
        )

     
• Risk Variable Encounter with Malignant Bone Disease Present on Admission

  • • "Initial Population" QualifyingEncounter
        where exists ( QualifyingEncounter.diagnoses BoneCancer
            where BoneCancer.code in "Malignant Bone Disease"
              and BoneCancer.presentOnAdmissionIndicator in "Present on Admission or Clinically Undetermined"
        )

     
• Risk Variable Encounter with Neurologic Disorder Present on Admission

  • • "Initial Population" QualifyingEncounter
        where exists ( QualifyingEncounter.diagnoses MovementDisorder
            where MovementDisorder.code in "Neurologic Movement and Related Disorders"
              and MovementDisorder.presentOnAdmissionIndicator in "Present on Admission or Clinically Undetermined"
        )

     
• Risk Variable Encounter with Obesity Present on Admission

  • • "Initial Population" QualifyingEncounter
        where exists ( QualifyingEncounter.diagnoses Overweight
            where Overweight.code in "Obesity"
              and Overweight.presentOnAdmissionIndicator in "Present on Admission or Clinically Undetermined"
        )

     
• Risk Variable Encounter with Opioid Medication Active at Admission

  • • "Initial Population" QualifyingEncounter
        with ["Medication, Active": "Opioids"] Opioid
          such that Opioid.relevantPeriod contains start of Global."HospitalizationWithObservation" ( QualifyingEncounter )

     
• Risk Variable Encounter with Osteoporosis Present on Admission

  • • "Initial Population" QualifyingEncounter
        where exists ( QualifyingEncounter.diagnoses PorousBones
            where PorousBones.code in "Osteoporosis"
              and PorousBones.presentOnAdmissionIndicator in "Present on Admission or Clinically Undetermined"
        )

     
• Risk Variable Encounter with Peripheral Neuropathy Present on Admission

  • • "Initial Population" QualifyingEncounter
        where exists ( QualifyingEncounter.diagnoses PeripheralNerveDamage
            where PeripheralNerveDamage.code in "Peripheral Neuropathy"
              and PeripheralNerveDamage.presentOnAdmissionIndicator in "Present on Admission or Clinically Undetermined"
        )

     
• Risk Variable Encounter with Stroke Present on Admission

  • • "Initial Population" QualifyingEncounter
        where exists ( QualifyingEncounter.diagnoses BrainStroke
            where BrainStroke.code in "Stroke"
              and BrainStroke.presentOnAdmissionIndicator in "Present on Admission or Clinically Undetermined"
        )

     
• Risk Variable Encounter with Suicide Attempt

  • • "Initial Population" QualifyingEncounter
        where exists ( QualifyingEncounter.diagnoses SuicideIntent
            where SuicideIntent.code in "Suicide Attempt"
        )