This ratio electronic clinical quality measure (eCQM) assesses the number of hospital days with a severe hyperglycemic event (a blood glucose result >300 mg/dL, or a day in which a blood glucose value was not documented and it was preceded by two consecutive days where at least one glucose value is >=200 mg/dL) per the total qualifying hospital days among inpatient encounters for patients 18 years and older who have either:
1. A diagnosis of diabetes mellitus, 2. Received at least one administration of insulin or an anti-diabetic medication during the hospital admission, or 3. Had an elevated blood glucose level (>200 mg/dL) during their hospital admission.
The total number of hyperglycemic days across all encounters divided by the total number of eligible days across all encounters. Hospital days are measured in 24-hour periods, starting from the time of arrival at the hospital (including Emergency Department). Days with a hyperglycemic event are defined as: - A day with at least one blood glucose value >300 mg/dL; or - A day in which a blood glucose value was not documented and it was preceded by two consecutive days where at least one glucose value is >=200 mg/dL.
We do not count >300 mg/DL events the first 24-hour period after admission to the hospital (including the Emergency Department) or the last time period before discharge, if it was less than 24 hours.
Denominator
1.15 Denominator
The initial population is all patients 18 years and older at the start of the measurement period with a discharged inpatient hospital admission 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 anti-diabetic medication during the encounter; or 3. Presence of at least one blood glucose value >200 mg/dL at any time during the encounter.
The eCQM includes inpatient encounters which began in the Emergency Department or in observation status.
The denominator is the total number of eligible days across all encounters which match the initial population criteria. We do not count the the first 24-hour period after admission to the hospital (including the Emergency Department) or the last time period before the discharge, if it was less than 24 hours. By excluding the first 24 hours of admission, we allow for correction of severe hyperglycemia that was present on admission. By excluding the last time period before discharge if it was less than 24 hours, we account for the fact that hospitals may not always be able to check glucose during the last time period, especially if it is only a few hours long. Eligible encounters that exceed 10 days are truncated to equal 10 days.
Exclusions
Exclusions
N/A; there are no denominator exclusions.
Measure Record
Most Recent Endorsement Activity
Endorsed Patient Safety Fall Cycle 2019
Initial Endorsement
Last Updated
Point of Contact
Steward Organization
Centers for Medicare & Medicaid Services
Steward POC email
Helen.Dollar-Maples@cms.hhs.gov
Steward Organization Copyright
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. CPT(R) contained in the Measure specifications is copyright 2004-2016 American Medical Association. LOINC(R) copyright 2004-2016 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2016 International Health Terminology Standards Development Organisation. ICD-10 copyright 2016 World Health Organization. All Rights Reserved.
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