Part 1: CMS Metrics for Severe Hypoglycemia and Severe Hyperglycemia
On February 8, the KHA Quality department presented the first of two Quality Webinars on the KHA Quality Metric Updates. Part 1 covered the Centers for Medicare & Medicaid Services (CMS) Metrics for Severe Hypoglycemia and Severe Hyperglycemia. KHA’s Jessica Covington, PharmD, BCPS and Shafrin Choudhury, MPH, discussed restructuring of the CMS metrics for events involving severe hypoglycemia and severe hyperglycemia.
To support the work of Kentucky hospitals in tracking, trending, and improving performance in these areas, as well as to avoid duplicative work for hospital quality leaders, KHA has aligned with the new CMS design by updating the metrics in Kentucky Quality Counts (KQC). The team discussed the updates in Kentucky Quality Counts (KQC), including the CMS definitions of the measures, what the measures entail, and the process for enrolling your hospital in these measures to report the data.
To enroll in the Severe Hypoglycemia and the Severe Hyperglycemia measure and begin reporting in Kentucky Quality Counts, you can contact Shafrin Choudhury (email@example.com). Calendar Year 2024 begins the monitoring period.
Severe Hypoglycemia and Hyperglycemia Metric Resources:
- Pioneers in Quality Expert to Expert Series 2023 Annual Updates for 2024 Reporting Year for Severe Hyperglycemia and Hypoglycemia eCQMs (jointcommission.org)
- Hospital Harm – Severe Hyperglycemia | eCQI Resource Center (healthit.gov)
- Hospital Harm – Severe Hypoglycemia | eCQI Resource Center (healthit.gov)
Part 2: Standardized Antimicrobial Administration Ratio (SAAR) All Antibacterial Agents
On February 12, the KHA Quality department presented the second webinar in the series covering Standardized Antimicrobial Administration Ratio (SAAR) All Antibacterial Agents. Covington and Choudhury discussed the final ruling of the of the updated Public Health and Clinical Data Exchange Objective from CMS, which adds the Antimicrobial Use and Resistance (AUR) measure to the 4 required reporting domains starting with the calendar year (CY) 2024 reporting period. The Centers for Disease Control & Prevention (CDC) prioritizes AU tracking and reporting to NHSN to achieve compliance with the core elements of hospital ASP.
A SAAR, Standardized Antimicrobial Administration Ratio, is a summary measure of antimicrobial use (AU) for hospitals in the AU Option of the National Healthcare Safety Network (NHSN) AUR Module. NHSN originally developed the metric as a quantitative tool for hospitals to make comparisons of AU within and across facilities to help guide antimicrobial stewardship efforts.
- The KHA Quality team again discussed the updates in KQC, including what the measures entail, and the process for enrolling your hospital in these measures to report the data.
Standardized Antimicrobial Administration Ratio (SAAR) Resources:
Kentucky Quality Counts has added three new measures:
- ADE-1D Severe Hypoglycemia in inpatients
- ADE-1E Severe Hyperglycemia in inpatients
- AMS-1a Standardized Antimicrobial Administration Ratio (SAAR)- All Antibacterial Agents
The data source for the ADE measures is Facility whereas the AMS measure’s source is NHSN. To retrieve this data from NHSN and have it populated in Kentucky Quality Counts; facilities will need to re-confer rights in NHSN. The AUR Microbiology Laboratory and AUR Pharmacy checkboxes will need to be selected in addition to the previously selected ones. Once conferred, please email Shafrin Choudhury at firstname.lastname@example.org to inform her so that she may complete the process of enrollment. Please do not hesitate to reach out to Shafrin if there are any questions.