Hospital Harm - Severe Hyperglycemia

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

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This measure and specifications are subject to further revisions. 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.

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Hyperglycemia, i.e., elevated blood glucose level, is common among hospitalized patients, especially those with preexisting diabetes (Swanson, et al., 2011; Umpierrez et al., 2012). Hyperglycemia can also affect individuals with no prior history of diabetes and may be induced by medications such as steroids, or parenteral (intravenous) or enteral (tube) feeding.

Severe hyperglycemia, i.e., extremely elevated blood glucose level, is significantly associated with a range of harms, including increased in-hospital mortality, infection rates, and hospital length of stay (Pasquel, et al., 2010 and 2021; Rady, et al., 2005; Umpierrez, et al., 2002; Falciglia et al., 2009; Lee et al., 2012; King et al., 2011; Jackson et al., 2012; Umpierrez et al., 2012; Krinsley 2003). Lower rates of inpatient severe hyperglycemia may not only improve care for patients, but also reduce costs for healthcare payers (Krinsley 2003; Newton et al., 2006; Krinsley et al., 2016). The rate of hyperglycemia varies across hospitals, suggesting opportunities for improvement in inpatient glycemic management (Swanson et al., 2011; Cook et al., 2009; Matheny et al., 2008). The rate of inpatient hyperglycemia can be considered a marker for quality of hospital care, since inpatient hyperglycemia is largely avoidable with proper glycemic management. The use of evidence-based standardized protocols and insulin management protocols have been shown to improve glycemic control and safety (Maynard et al., 2015; Donihi et al., 2006).

It should be noted that this measure does not aim to measure overall glucose control in hospitalized patients; rather, our goal is to assess the occurrence and extent of severe hyperglycemia. This measure is also intended to be used in combination with its companion measure of hypoglycemia (Hospital Harm – Hypoglycemia) to reduce unintended consequences of measurement. 

Multiple guidelines address recommended levels of glycemic control, though these do not define severe hyperglycemia: 

From Section 15, Diabetes Care in the Hospital, in the Standards of Medical Care in Diabetes by the American Diabetes Association, (American Diabetes Association, 2020): 
Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold >=180 mg/dL (10.0 mmol/L). Once insulin therapy is started, a target glucose range of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for the majority of critically ill patients and noncritically ill patients. More stringent goals, such as 110-140 mg/dL (6.1-7.8 mmol/L), may be appropriate for selected patients, as long as this can be achieved without significant hypoglycemia. 

From the Endocrine Society clinical practice guideline on the Management of Hyperglycemia in Hospitalized Patients in Non-critical Care Setting (Umpierrez et al., 2012):
3.1. We recommend a pre-meal glucose target of less than 140 mg/dL (7.8 mmol/liter) and a random [blood glucose] of less than 180 mg/dL (10.0 mmol/liter) for the majority of hospitalized patients with non-critical illness.

There is no clinically accepted cutoff for severe hyperglycemia. Studies have used thresholds of >140, >180 , >300, and >350 mg/dL, among other values (American Diabetes Association, 2020; Umpierrez et al, 2012; Jamesen et al., 2015; Cook et al., 2009; Donihi et al., 2011; Weinberg et al, 2010; Mendez et al, 2015). Glycemic goals may also differ among hospitalized patients. For example, in an older patient with a prior history of severe hypoglycemia, some degree of hyperglycemia may be tolerated to maximize safety.

For patients who present with hyperglycemic crises, neurologic status must be monitored closely, with frequent re-examination. Care should be taken to prevent over-correction of hyperglycemia and hyperosmolarity following initial fluid resuscitation of these patients to prevent cerebral edema, which carries a high mortality rate. (Gosmanov et al., 2021).

A lower measure score indicates higher quality

Reference Type: CITATION

Reference Text: 'American Diabetes Association. 15. Diabetes care in the hospital: standards of medical care in diabetes—2020. Diabetes Care 2020; 43 (suppl 1): S193–202.'

Reference Type: CITATION

Reference Text: 'Cook CB, Kongable GL, Potter DJ, et al. Inpatient glucose control: a glycemic survey of 126 U.S. hospitals. J Hosp Med. 2009;4(9):E7-E14'

Reference Type: CITATION

Reference Text: 'Donihi AC, DiNardo MM, DeVita MA, et al. Use of a standardized protocol to decrease medication errors and adverse events related to sliding scale insulin. Qual Saf Health Care. 2006;15(2):89-91.'

Reference Type: CITATION

Reference Text: 'Donihi AC, Gibson JM, Noschese ML, et al. Effect of targeted glycemic management program on provider response to inpatient hyperglycemia. Endocr Pract. 2011; (4)552-557.'

Reference Type: CITATION

Reference Text: 'Falciglia M, Freyberg RW, Alemenoff PL, et al. Hyperglycemia-related mortality in critically ill patients varies with admission diagnosis. Crit Care Med. 2009; 37(12):3001-3009.'

Reference Type: CITATION

Reference Text: 'Jackson RS, Amdur RL, White JC, et al. Hyperglycemia is associated with increased risk of morbidity and mortality after colectomy for cancer. J Am Coll Surg. 2012;214(1):68-80.'

Reference Type: CITATION

Reference Text: 'Jamesen E, Nevalainen PL, Eskelinen A, et al. Risk factors for perioperative hyperglycemia in primary hip and knee replacements. Acta Orthop. 2015; 86(2):175-182.'

Reference Type: CITATION

Reference Text: 'King JT, Goulet JL, Perkal MF, et al. Glycemic control and infections in patients with diabetes undergoing noncardiac surgery. Ann surg. 2011;253(1):158-165.'

Reference Type: CITATION

Reference Text: 'Krinsley JS. Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clin Proc. 2003 Dec;78(12):1471-1478.'

Reference Type: CITATION

Reference Text: 'Krinsley JS, Jones RL. Cost analysis of intensive glycemic control in critically ill adult patients. Chest. 2016;129(3)644-650'

Reference Type: CITATION

Reference Text: 'Lee LJ, Emons MF, Martin SA, et al. Association of blood glucose levels with in-hospital mortality and 30-day readmission in patients undergoing invasive cardiovascular surgery. Curr Med Res Opin. 2012;28(1):1657-1665.'

Reference Type: CITATION

Reference Text: 'Matheny ME, Shubina M, Kimmel ZK., et al. Treatment intensification and blood glucose control among hospitalized diabetic patients. J Gen Intern Med. 2008;23(2).'

Reference Type: CITATION

Reference Text: 'Maynard G, Kulasa K, Ramos P, et al. Impact of a hypoglycemic reduction bundle and a systems approach to inpatient glycemic management. Endocr Pract. 2015;21(4):355-367.'

Reference Type: CITATION

Reference Text: 'Mendez CE, Ata A, Rourke JM, et al. Daily inpatient glycemic survey (DINGS): A process to remotely identify and assist in the management of hospitalized patients with diabetes and hyperglycemia. Endocr Pract. 2015;21(8):927-935.'

Reference Type: CITATION

Reference Text: 'Newton CA, Yong, S. Financial implications of glycemic control: Results of an inpatient diabetes management program. Endocr Pract. 2006;3:43-48.'

Reference Type: CITATION

Reference Text: 'Pasquel FJ, Spiegelman R, McCauley M. Hyperglycemia during total parenteral nutrition: An important marker of poor outcome and mortality in hospitalized patients. Diabetes Care. 2010;(33)4:739-741.'

Reference Type: CITATION

Reference Text: 'Rady MY. Influence of individual characteristics on outcome of glycemic control in intensive care unit patients with or without diabetes mellitus. Mayo Clin Proc 2005;80(12):1558-1567.'

Reference Type: CITATION

Reference Text: 'Swanson CM, Potter DJ, Kongable GL, et al. Update on inpatient glycemic control in hospitals in the United States. Endocrine Practice. 2011;17(6):853-861.'

Reference Type: CITATION

Reference Text: 'Umpierrez, GE, Hellman, R, Korytkowski, MT, et al. Management of Hyperglycemia in Hospitalized Patients in Non-critical Care Setting: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97, 16-38'

Reference Type: CITATION

Reference Text: 'Umpierrez GE, Issacs DS, Bazargan N, et al. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endorinol Metab. 2002;87(3):978-982.'

Reference Type: CITATION

Reference Text: 'Weinberg ME, Bacchetti P, Rushakoff, RJ. Frequently repeated glucose measurements overestimate the incidence of inpatient hypoglycemia and severe hyperglycemia. J Diabetes Sci Technol. 2010;May 1;4(3):577-582.'

Reference Type: CITATION

Reference Text: 'Gosmanov AR, Gosmanova EO, Kitabchi AE. Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. [Updated 2021 May 9]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279052/'

Reference Type: CITATION

Reference Text: 'Francisco J Pasquel, M Cecilia Lansang, Ketan Dhatariya, Guillermo E Umpierrez. Management of diabetes and hyperglycaemia in the hospital. The Lancet Diabetes & Endocrinology. 2021; 9: 174–88'

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. 

This measure defines a severe hyperglycemic day (harm) as either (1) a day with a test (lab or point-of-care (POC)) for blood glucose with a result of >300 mg/dL, or (2) a day in which a test for blood glucose was not measured and it was preceded by two consecutive days where at least one lab or point-of-care (POC) test during each of the two days for blood glucose had a result >=200 mg/dL. 

Hospital days are full 24-hour periods that start at the time of admission to the hospital (including emergency department and observation), excluding the last period before discharge if it is less than 24 hours.

The measure is using mg/dL as the unit of measurement for glucose results.

To determine the measure outcome, the total number of hyperglycemic days during the inpatient hospitalization is divided by the total number of eligible hospital days of the inpatient hospitalization.

When evaluating for days with a blood glucose level >300 mg/dL, the first 24-hour period after admission to the hospital (including the emergency department or observation) is not evaluated to account for potentially poor glucose control outside of the hospital setting or that preceded the start of hospital care.

This measure evaluates the first 10 days of an eligible inpatient hospitalization in determining eligible days for the denominator and numerator (i.e., the length of stay is truncated to <=10 days when the length exceeds 10 days). Patients admitted for longer length of stays are more likely to have more complex medical conditions.  

The numerator returns the first eligible encounter that meets the qualifying criteria: an inpatient hospitalization with a hyperglycemic event. Only one numerator is counted per encounter. Note that the Numerator returns the encounters, not days, that meet the criteria.

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

TBD

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 observation

Equals Initial Population

Inpatient hospitalizations for patients with an initial blood glucose result of >=1000 mg/dL anytime between 1 hour prior to the start of the encounter to 6 hours after the start of the encounter

There are two Measure Observations:

Measure Observation 1, associated with the Denominator: The total number of eligible days of the inpatient hospitalization which match the initial population/denominator criteria. 

Measure Observation 2, associated with the Numerator: The total number of hyperglycemic days during the inpatient hospitalization. Days with a hyperglycemic event are defined as: 

a)  All days 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
b)  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 was >=200 mg/dL.

The length of stay for all eligible inpatient hospitalizations is truncated to <=10 days when the length exceeds 10 days.

Do not count the last day if it was less than a 24-hour period as this is not considered a full day.

Inpatient hospitalizations with a hyperglycemic event within the first 10 days of the encounter minus the first 24 hours, and minus the last period before discharge if less than 24 hours

A hyperglycemic event is defined as: 
1)  A day with at least one blood glucose value >300 mg/dL; 
OR
2)  A day where a blood glucose test was not done, and it was preceded by two consecutive days where at 
     least one glucose value during each of the two days was >=200 mg/dL

Not Applicable

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