Hospital Harm -- Opioid-Related Adverse Events

This measure assesses the proportion of encounters (acute inpatient hospital admissions) of patients 18 years of age or older who suffer the harm of an opioid-related adverse event for which a narcotic antagonist (naloxone) is administered, outside of the operating room. If naloxone was administered in the first 24 hours of the hospitalization, an opioid must have been administered prior to the naloxone administration to be considered a harm.

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.

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.

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

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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

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. 

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

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

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

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.

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

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

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 naloxone.

To calculate the hospital-level measure result, divide the total numerator events by the total number of eligible encounters (denominator). 

For each encounter, qualifying encounters (denominator) include all patients 18 years of age or older at the start of the encounter.

To create the numerator: 
1.	Include all encounters in which a patient was administered a narcotic antagonist (naloxone) during their hospitalization.
2.	Remove all administrations of naloxone administration in the operating room. 
a.	We exclude administrations of naloxone use in the operating room because naloxone could be part of the sedation plan as administered by an anesthesiologist. Encounters that include use of naloxone for procedures outside of the operating room (e.g. bone marrow biopsy) are included in the numerator, as it would indicate the patient was over sedated.
3.	Remove all administrations of naloxone during the first 24 hours of the hospitalization if an opioid was not administered by hospital medical staff prior. Opioid and naloxone administrations need to be within the encounter period, within the first 24 hours to be excluded. 
a.	The intended goal is to obtain evidence of hospital administration of opioids from community-acquired opioids.  This is to distinguish naloxone use for patients who present to the emergency room with a community-acquired opioid overdose, from those who have an adverse event related to in-hospital administration of an opioid. For naloxone administered over 24 hours after admission, we do not require documentation of opioid administration prior to naloxone.

All inpatient encounters when the patient is 18 years or older at the start of the encounter. An encounter is considered an inpatient admissions including time spent in the emergency department or in observation status when patients are ultimately admitted as inpatients.  

Equals Initial Population

None

All inpatient encounters that include a naloxone administration outside of the operating room: 
1.       24 hours or more after arrival to the hospital 
OR 
2.       during the first 24 hours of the encounter with evidence of an opioid administration by hospital medical staff (during the encounter) prior to the naloxone administration.

Only the first qualifying numerator event is counted in the numerator, and 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