Hospital Harm - Opioid-Related Adverse Events

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

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CPT(R) contained in the Measure specifications is copyright 2004-2020 American Medical Association. LOINC(R) copyright 2004-2020 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2020 International Health Terminology Standards Development Organisation. ICD-10 copyright 2020 World Health Organization. All Rights Reserved

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.

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

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Opioids are often the foundation for sedation and pain relief. However, use of opioids can also lead to serious adverse events, including constipation, over sedation, delirium, and respiratory depression. Opioid-related adverse events have both patient-level and financial implications. Patients who experience this event have been noted to have 55% longer lengths of stay, 47% higher costs, 36% higher risk of 30-day readmission, and 3.4 times higher payments than patients without these adverse events (Kessler et al., 2013). 

Most opioid-related adverse events are preventable. Of the adverse drug events reported to the Joint Commissions Sentinel Event database, 47% were due to a wrong medication dose, 29% to improper monitoring, and 11% to other causes (e.g., medication interactions, drug reactions) (Overdyk, 2009). Additionally, in a closed-claims analysis, 97% of adverse events were judged preventable with better monitoring and response (Lee et al., 2015). Naloxone administration is often used as an indicator of a severe opioid-related adverse event, and implementation of this measure can advance safe use of opioids in hospitals and prevent these serious and potentially lethal adverse drug events.

Naloxone is an opioid reversal agent typically used for severe opioid-related adverse events. Naloxone administration has been used in a number of studies as an indicator of opioid-related adverse events (Nwulu et al., 2013; Eckstrand et al., 2009).

From Section 10 of the 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (Lavonas et al., 2015), the following recommendation is listed for use of Naloxone:

Naloxone is a potent opioid receptor antagonist in the brain, spinal cord, and gastrointestinal system. Naloxone has an excellent safety profile and can rapidly reverse CNS and respiratory depression in a patient with an opioid-associated resuscitative emergency.

A lower proportion indicates higher quality

Reference Type: CITATION

Reference Text: 'Agency for Healthcare Research and Quality. National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts to Make Health Care Safer. 2016; https://www.ahrq.gov/professionals/quality-patient-safety/pfp/2015-interim.html?utm_source=AHRQ&utm_medium=PSLS&utm_term=&utm_content=14&utm_campaign=AHRQ_NSOHAC_2016. Accessed January 13, 2017.'

Reference Type: CITATION

Reference Text: 'Eckstrand, J. A., Habib, A. S., Williamson, A., Horvath, M. M., Gattis, K. G., Cozart, H., & Ferranti, J. (2009). Computerized surveillance of opioid-related adverse drug events in perioperative care: a cross-sectional study. Patient Saf Surg, 3(1), 18. doi: 10.1186/1754-9493-3-18'

Reference Type: CITATION

Reference Text: 'Kessler, E. R., Shah, M., Gruschkus, S. K., & Raju, A. (2013). Cost and quality implications of opioid-based postsurgical pain control using administrative claims data from a large health system: opioid-related adverse events and their impact on clinical and economic outcomes. Pharmacotherapy, 33(4), 383-391. doi: 10.1002/phar.1223'

Reference Type: CITATION

Reference Text: 'Lavonas, E. J., Drennan, I. R., Gabrielli, A., Heffner, A. C., Hoyte, C. O., Orkin, A. M., . . . Donnino, M. W. (2015). Part 10: Special Circumstances of Resuscitation. 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, 132(18 suppl 2), S501-S518. doi: 10.1161/cir.0000000000000264'

Reference Type: CITATION

Reference Text: 'Lee, L. A., Caplan, R. A., Stephens, L. S., Posner, K. L., Terman, G. W., Voepel-Lewis, T., & Domino, K. B. (2015). Postoperative opioid-induced respiratory depression: a closed claims analysis. Anesthesiology, 122(3), 659-665.'

Reference Type: CITATION

Reference Text: 'Makary, M. A., & Daniel, M. (2016). Medical error-the third leading cause of death in the US. BMJ, 353, i2139. doi: 10.1136/bmj.i2139'

Reference Type: CITATION

Reference Text: 'Nwulu, U., Nirantharakumar, K., Odesanya, R., McDowell, S. E., & Coleman, J. J. (2013). Improvement in the detection of adverse drug events by the use of electronic health and prescription records: an evaluation of two trigger tools. Eur J Clin Pharmacol, 69(2), 255-259. doi: 10.1007/s00228-012-1327-1'

Reference Type: CITATION

Reference Text: 'Overdyk, F. J. (2009). Postoperative respiratory depression and opioids. Initiatives in Safe Patient Care.'

This measure defines the indication of a harm for an opioid-related adverse event by assessing administration of an opioid antagonist (naloxone).

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 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. 

This version of the eCQM uses QDM version 5.5.  Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

Inpatient hospitalizations for patients 18 years or older during which at least one opioid medication was administered. An inpatient hospitalization includes time spent in the emergency department or in observation status when the patients are ultimately admitted to inpatient status.

Equals Initial Population

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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.

Not applicable

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