Hospital Harm - Severe Hyperglycemia

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

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Hyperglycemia, i.e., elevated glucose level, is common among hospitalized patients, especially those with preexisting diabetes (Umpierrez et al., 2012) and accounts for over 30% of noncritically ill hospitalized patients (Korytkowski, 2022). 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 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., 2021; Umpierrez et al., 2012, 2015). Lower rates of inpatient severe hyperglycemia may not only improve care for patients, but also reduce costs for healthcare payers (Krinsley et al., 2016). The rate of hyperglycemia varies across hospitals, suggesting opportunities for improvement in inpatient glycemic management (Bersoux et al., 2013; Seisa et al., 2022). 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 (Leroy et al., 2020; Maynard et al., 2015).

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 16, Diabetes Care in the Hospital, in the Standards of Medical Care in Diabetes by the American Diabetes Association, (American Diabetes Association, 2023): 

16.4 Insulin therapy should be initiated for the treatment of persistent hyperglycemia starting at a threshold ≥180 mg/dL (10.0 mmol/L) (checked on two occasions). Once insulin therapy is started, a target glucose range of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for most critically ill and noncritically ill patients.

16.5 More stringent goals, such as 110–140 mg/dL (6.1–7.8 mmol/L) or 100–180 mg/dL (5.6–10.0 mmol/L), may be appropriate for selected patients and are acceptable if they 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 (Korytkowski et al., 2022): 

Recommendation 10.1
In adults with no prior history of diabetes hospitalized for noncritical illness with hyperglycemia [defined as blood glucose (BG) > 140 mg/dL (7.8 mmol/L)] during hospitalization, we suggest initial therapy with correctional insulin over scheduled insulin therapy (defined as basal or basal/bolus insulin) to maintain glucose targets in the range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L). For patients with persistent hyperglycemia [≥2 point-of-care blood glucose (POC-BG) measurements ≥ 180 mg/dL (≥10.0 mmol/L) in a 24-hour period on correctional insulin alone], we suggest the addition of scheduled insulin therapy. 

Recommendation 10.2
In adults with diabetes treated with diet or noninsulin diabetes medications prior to admission, we suggest initial therapy with correctional insulin or scheduled insulin therapy to maintain glucose targets in the range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L). For hospitalized adults started on correctional insulin alone and with persistent hyperglycemia [≥2 point-of-care blood glucose (POC-BG) measurements ≥ 180 mg/dL in a 24-hour period (≥10.0 mmol/L)], we suggest addition of scheduled insulin therapy. We suggest initiation of scheduled insulin therapy for patients with confirmed admission blood glucose (BG) ≥ 180 mg/dL (≥10.0 mmol/L). 

Recommendation 10.3
In adults with insulin-treated diabetes prior to admission who are hospitalized for noncritical illness, we recommend continuation of the scheduled insulin regimen modified for nutritional status and severity of illness to maintain glucose targets in the range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L).

Remarks
Reductions in the dose of basal insulin (by 10% to 20%) at time of hospitalization may be required for patients on basal heavy insulin regimens (defined as doses of basal insulin ≥ 0.6 to 1.0 units/kg/day), in which basal insulin is being used inappropriately to cover meal-related excursions in BG.

There is no clinically accepted cutoff for severe hyperglycemia. Studies have used thresholds of >140, >180 , >300, >350 and >400 mg/dL, among other values (American Diabetes Association, 2023; Umpierrez et al, 2012, 2015; Jamesen et al., 2015; Donihi et al., 2011; Mendez et al, 2015; Seisa et al., 2022). BGL <180 mg/dL is associated with lower rates of mortality and stroke compared with a target glucose <200 mg/dL (Sathya et al., 2013). Glycemic goals may also differ among hospitalized patients. For inpatient management of hyperglycemia in noncritical care, the expert consensus recommends a target range of 100–180 mg/dL (5.6–10.0 mmol/L) for noncritically ill patients with “new” hyperglycemia as well as people with known diabetes prior to admission. Glycemic levels >250 mg/dL (13.9 mmol/L) may be acceptable in terminally ill patients with short life expectancy. In these individuals, less aggressive insulin regimens to minimize glucosuria, dehydration, and electrolyte disturbances are often more appropriate. (ElSayed et al., 2023). In an older patient with a prior history of severe hypoglycemia, some degree of hyperglycemia may be tolerated to maximize safety. Intensive insulin therapy to target glucose of 100 and 140mg/dLin the ICU didn’t significantly reduce perioperative complications compared with target glucose of 141and180mg/dL after coronary artery bypass surgery (Umpierrez et al., 2015). The current recommendation is to maintain a blood glucose level between 140-180 mg/dL (7.8-10.0 mmol/L) in both cardiac and non-cardiac ICU patients (Sreedharan et al., 2022). 

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).

From the Endocrine Society clinical practice guideline on the Management of Hyperglycemia in Hospitalized Patients in Non-critical Care Setting (Korytkowski et al., 2022):
Recommendation 1.1
In adults with insulin-treated diabetes hospitalized for noncritical illness who are at high risk of hypoglycemia, we suggest the use of real-time continuous glucose monitoring (CGM) with confirmatory bedside point-of-care blood glucose (POC-BG) monitoring for adjustments in insulin dosing rather than point-of-care blood glucose (POC-BG) testing alone in hospital settings where resources and training are available.

A lower measure score indicates higher quality

Reference Type: CITATION

Reference Text: 'American Diabetes Association, 16. Diabetes care in the hospital: Standards of care in diabetes—2023. Diabetes Care 1 January 2023; 46 (Supplement_1): S267–S278'

Reference Type: CITATION

Reference Text: 'Bersoux, S., Cook, C.B., Kongable, G.L., & Shu, J. (2013). Trends in glycemic control over a 2-year period in 126 US hospitals. J Hosp Med. 2013;8(3):121-125. doi:10.1002/jhm.1997'

Reference Type: CITATION

Reference Text: 'Donihi, A.C., Gibson, J.M., Noschese, M.L., DiNardo, M.M., Koerbel, G.L., Curll, M., & Korytkowski, M.T. (2011). Effect of a targeted glycemic management program on provider response to inpatient hyperglycemia. Endocr Pract. 2011 Jul-Aug;17(4):552-7. doi: 10.4158/EP10330.OR. PMID: 21454237'

Reference Type: CITATION

Reference Text: 'ElSayed, N., Aleppo, G., Aroda, V., Bannuru, R., Brown, F., Bruemmer, D., Collins, B., Hilliard, M., Isaacs, D., Johnson, E., Kahan, S., Khunti, K., Leon, J., Lyons, S., Perry, M., Prahalad, P., Pratley, R., Jeffrie Seley, J., Stanton, R., & Gabbay, R. (2023). On behalf of the American Diabetes Association, 16. Diabetes care in the hospital: Standards of care in diabetes. Diabetes Care 1 January 2023; 46 (Supplement_1): S267–S278. https://doi.org/10.2337/dc23-S016'

Reference Type: CITATION

Reference Text: 'Gosmanov, A.R., Gosmanova, E.O., & Kitabchi, A.E. (2021). Hyperglycemic crises: diabetic ketoacidosis and hyperglycemic hyperosmolar state. [Updated 2021 May 9]. In: Feingold, K.R., Anawalt, B., Boyce, A., et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK279052/'

Reference Type: CITATION

Reference Text: 'Jamesen, E., Nevalainen, P.L., Eskelinen, A., Kalliovalkama, J., & Moilanen, T. (2015). Risk factors for perioperative hyperglycemia in primary hip and knee replacements. Acta Orthop. 2015 Apr;86(2):175-82. doi: 10.3109/17453674.2014.987064. Epub 2014 Nov 18. PMID: 25409255; PMCID: PMC4404767'

Reference Type: CITATION

Reference Text: 'Korytkowski, M.T., Muniyappa, R., Antinori-Lent, K., Donihi, A.C., Drincic, A.T, Hirsch, I.B., Luger, A., McDonnell, M.E., Murad, M.H., Nielsen, C., Pegg, C., Rushakoff, R.J., Santesso, N., & Umpierrez, G.E. (2022). Management of hyperglycemia in hospitalized adult patients in non-critical care settings: An Endocrine Society clinical practice guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 107, Issue 8, August 2022, Pages 2101–2128,  https://doi.org/10.1210/clinem/dgac278'

Reference Type: CITATION

Reference Text: 'Krinsley, J.S., & Jones, R.L. (2016). Cost analysis of intensive glycemic control in critically ill adult patients. Chest. 2016;129(3)644-650. doi: 10.1378/chest.129.3.644. PMID: 16537863'

Reference Type: CITATION

Reference Text: 'LeRoy, L., & Richard, S. (2020). Harms due to diabetic agents (Chapter 8), making healthcare safer III: A critical analysis of existing and emerging patient safety practices. Retrieved from: https://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/diabetes-1.pdf'

Reference Type: CITATION

Reference Text: 'Maynard, G., Kulasa, K., Ramos, P., Childers, D., Clay, B., Sebasky, M., Fink, E., Field, A., Renvall, M., Juang, P.S., Choe, C., Pearson, D., Serences, B., & Lohnes, S. (2015). Impact of a hypoglycemic reduction bundle and a systems approach to inpatient glycemic management. Endocr Pract. 2015;21(4):355-367. doi: 10.4158/EP14367.OR. Epub 2014 Dec 22. PMID: 25536971'

Reference Type: CITATION

Reference Text: 'Mendez, C.E., Ata, A., Rourke, J.M., Stain, S.C., & Umpierrez, G. (2015). 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. doi: 10.4158/EP14577.OR. Epub 2015 Jun 29. PMID: 26121456'

Reference Type: CITATION

Reference Text: 'Pasquel, F.J., Lansang, M.C., Dhatariya, K., & Umpierrez, G.E. (2021). Management of diabetes and hyperglycaemia in the hospital. The Lancet Diabetes & Endocrinology. 2021; 9: 174–88. doi: 10.1016/S2213-8587(20)30381-8. Epub 2021 Jan 27. PMID: 33515493; PMCID: PMC10423081'

Reference Type: CITATION

Reference Text: 'Sathya, B., Davis, R., Taveira, T., Whitlatch, H., & Wu, W.C. (2013). Intensity of peri-operative glycemic control and postoperative outcomes in patients with diabetes: a meta-analysis. Diabetes Res Clin Pract. 2013 Oct;102(1):8-15. doi: 10.1016/j.diabres.2013.05.003. Epub 2013 Jun 6. PMID: 23746852'

Reference Type: CITATION

Reference Text: 'Seisa, M. O., Saadi, S., Nayfeh, T., Muthusamy, K., Shah, S. H., Firwana, M., Hasan, B., Jawaid, T., Abd-Rabu, R., Korytkowski, M. T., Muniyappa, R., Antinori-Lent, K., Donihi, A. C., Drincic, A. T., Luger, A., Torres Roldan, V. D., Urtecho, M., Wang, Z., & Murad, M. H. (2022). A systematic review supporting the Endocrine Society clinical practice guideline for the management of hyperglycemia in adults hospitalized for noncritical illness or undergoing elective surgical procedures. The Journal of Clinical Endocrinology and Metabolism, 107(8), 2139–2147. https://doi.org/10.1210/clinem/dgac277'

Reference Type: CITATION

Reference Text: 'Sreedharan, R., Martini, A., Das, G., Aftab, N., Khanna, S., & Ruetzler, K. (2022). Clinical challenges of glycemic control in the intensive care unit: A narrative review. World Journal of Clinical Cases, 10(31), 11260–11272. https://doi.org/10.12998/wjcc.v10.i31.11260'

Reference Type: CITATION

Reference Text: 'Umpierrez, G., Cardona, S., Pasquel, F., Jacobs, S., Peng, L., Unigwe, M., Newton, C.A., Smiley-Byrd, D., Vellanki, P., Halkos, M., Puskas, J.D., Guyton, R.A., & Thourani, V.H. (2015). Randomized controlled trial of intensive versus conservative glucose control in patients undergoing coronary artery bypass graft surgery: gluco-CABG trial. Diabetes Care. 2015;38(9):1665-1672. doi: 10.2337/dc15-0303. Epub 2015 Jul 15. PMID: 26180108; PMCID: PMC4542267'

Reference Type: CITATION

Reference Text: 'Umpierrez, G.E., Hellman, R., Korytkowski, M.T., Kosiborod, M., Maynard, G.A., Montori, V.M., Seley, J.J., & Van den Berghe, G.. (2012). 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. doi: 10.1210/jc.2011-2098. PMID: 22223765'

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 glucose with a result of >300 mg/dL, or (2) a day in which a glucose test with a result was not found 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 glucose had a result >=200 mg/dL. 

Hospital days are not defined as midnight-to-midnight but 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 from hospital inpatient if it is less than 24 hours.

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

When evaluating for days with a glucose level >300 mg/dL, the first 24-hour period after admission to the hospital is not evaluated to account for potentially poor glucose control outside of the hospital setting or that preceded the start of hospital care. The admission starts in the emergency department (ED) or observation when the transition between the ED encounter, observation encounter, and the inpatient encounter are within an hour or less of each other.

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 “Days in Hospitalization” logic within Measure Observation 1 (associated with the denominator), in conjunction with other logic, returns the day number (e.g., day 1 to day 10) for each day within the hospitalization period to determine the eligible hospital days (e.g., from day 2 to day 10). 

The “Days in Hospitalization” logic within Measure Observation 2 (associated with the numerator), in conjunction with other logic, returns the day number (e.g., day 1 to day 10) for each day within the hospitalization period to determine the eligible hyperglycemic event days (e.g., from day 2 to day 10).

Since the measure does not count any hyperglycemic events that occur in the first 24 hours, day 1 is not considered an eligible hospital day for the Measure Observations. Eligible days range from day 2 up to day 10.

Although the measure does not count any hyperglycemic events that occur in the first 24 hours as a hyperglycemic event day in Measure Observation 2, the first 24 hours of the encounter is considered day 1. This is because if there was a day during the encounter where a glucose result is not found, the measure evaluates the two days preceding to see if each had a glucose value >=200 mg/dL. The measure allows the first 24 hours of the encounter, i.e., day 1, to be one of the preceding days.

Multiple hyperglycemic events can occur during a ‘day’, but this is still considered one hyperglycemic event day.

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.

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.

The specimen source for the glucose test is blood, serum, plasma, or interstitial fluid, and can be obtained by a laboratory test, a Point of Care (POC) test, or a continuous glucose monitor (CGM).
Glucose test results from urine specimens are not 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 that end during the measurement period, as well as either: 

- A diagnosis of diabetes that starts before the end of the encounter; or
- Administration of at least one dose of insulin or any hypoglycemic medication that starts during the encounter; or
- Presence of at least one glucose value >=200 mg/dL at any time during the encounter.

Equals Initial Population

-Inpatient hospitalizations for patients with a 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.

-Inpatient hospitalizations for patients who have comfort care measures ordered or provided during the encounter.

-Inpatient hospitalizations for patients who have a discharge disposition to home or to a health care facility for hospice care.

There are two Measure Observations:  

Encounter Observation 2, associated with the numerator of the ratio: The total number of hyperglycemic days during the inpatient hospitalization that meet the numerator criteria and did not meet the numerator exclusion criteria. Days with a hyperglycemic event are defined as: 

- All days with a 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
- All days where a glucose was not measured, and it was immediately preceded by two contiguous, consecutive days where at least one glucose value during each of the two days was >=200 mg/dL.

Encounter Observation 1, associated with the denominator of the ratio: The total number of eligible days of the inpatient hospitalization which match the initial population/denominator criteria and did not meet the denominator exclusion criteria.

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 from the hospital if less than 24 hours.

A hyperglycemic event is defined as: 

- A day with at least one glucose value >300 mg/dL.

OR

- A day where a glucose test and result was not found, and it was immediately preceded by two contiguous, consecutive days where at least one glucose value during each of the two days was >=200 mg/dL.

Inpatient hospitalizations that meet the Denominator Exclusions:

-Inpatient hospitalizations for patients with a 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.

-Inpatient hospitalizations for patients who have comfort care measures ordered or provided during the encounter.

-Inpatient hospitalizations for patients who have a discharge disposition to home or to a health care facility for hospice care.

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