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  1. eCQM Issue Tracker
  2. CQM-6930

Hospital Harm Opioid-related Adverse Events, Maryland Hospital Dispense Naloxone (Not Given) STOP ACT 2022

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    • Icon: EH/CAH eCQMs EH/CAH eCQMs
    • Resolution: Answered
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    • Adventist Healthcare
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      Thank you for your question regarding CMS819v2 Hospital Harm - Opioid-Related Adverse Events.
      The intent of this measure is to identify patients who are administered an opioid antagonist outside of the operating room within 12 hours of opioid administration, as this indicates an opioid related adverse event. The QDM datatype, “Medication, Administered” addresses medication taken. Based on the example you have provided, the patients flagged by your EMR should not be included in the ‘Numerator’ population for this measure since the medications were dispensed but not administered.
      Show
      Thank you for your question regarding CMS819v2 Hospital Harm - Opioid-Related Adverse Events. The intent of this measure is to identify patients who are administered an opioid antagonist outside of the operating room within 12 hours of opioid administration, as this indicates an opioid related adverse event. The QDM datatype, “Medication, Administered” addresses medication taken. Based on the example you have provided, the patients flagged by your EMR should not be included in the ‘Numerator’ population for this measure since the medications were dispensed but not administered.
    • CMS0819v2
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      2024 eCQM Performance Year for Public Reporting on measure HH-ORAE CMS819
      Maryland Bill SB394 STOP Act of 2022
      Brief description: hospitals to have a protocol to dispense naloxone free of charge to certain individuals
      https://www.billtrack50.com/billdetail/1436230
      Show
      2024 eCQM Performance Year for Public Reporting on measure HH-ORAE CMS819 Maryland Bill SB394 STOP Act of 2022 Brief description: hospitals to have a protocol to dispense naloxone free of charge to certain individuals https://www.billtrack50.com/billdetail/1436230

      Adventist healthcare has three Maryland hospitals, the state has a bill "MD SB394 STOP Act of 2022" which authorizes EMS providers and hospitals to dispense naloxone free of charge to certain individuals. https://www.billtrack50.com/billdetail/1436230

      Clinical staff provide the medication, naloxone nasal spray 4mg/0.1, prior to discharge from the hospital for emergency use post discharge by the patient. The hospital staff is required to place the dispense of this medication into the EMR (MAR summary) for record keeping and state requirements. This medication is not given (administered) to the patient. 

      With review of this measure for Q1 2024 the three hospitals had five patients who received "naloxone (STOP ACT) 4 mg/0.1 mL nasal spray (2 EA)" directly prior to discharge. 

      We at Adventist healthcare are following state legislation to prevent overdose in the community. Since these patients did not require administration of the naloxone while hospital, we believe these cases should NOT be in the numerator. 

        1. HHORAE STOP Act of 2022 Med Kit for Discharge.pdf
          466 kB

            JLeflore Mathematica EH eCQM Team
            esolomon Emily Solomon
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