Looking for further clarification for definition of "inpatient encounter" for HAPIS

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    • Type: Hosp Inpt eCQMs - Hospital Inpatient eCQMs
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
    • None
    • Rochelle Mareno
    • 6036704775
    • Lahey Hosptial
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      Thank you for your question regarding CMS826v2, Hospital Harm - Pressure Injury.

      Regarding your first question: The inpatient hospitalization period assessed by this measure includes time in the emergency department (ED) and/or observation when the transition between discharge from these encounters and admission to the inpatient encounter is one hour or less. For example, if a patient is discharged from the ED at 9:45AM and admitted to the inpatient encounter at 10AM on the same day, then the inpatient hospitalization period assessed for that patient would begin at the start of the patient’s ED encounter.

      Regarding your second question: Currently the measure does not include denominator exception criteria for inpatient hospitalizations for patients who refuse pressure injury prevention care, as pressure injury prevention care is a critical part of quality clinical care.

      Regarding your third question: For the 2025 reporting period version of this eCQM, only inpatient hospitalizations for (1) patients with a deep tissue pressure injury or stage 2, 3, 4 or unstageable pressure injury diagnosis present on admission (noted via Present On Admission indicators or by skin exam results) and (2) patients with a COVID-19 diagnosis are excluded from the measure's denominator. While encounters for patients with Kennedy terminal ulcers are not currently excluded from the measure’s denominator, we will consider the addition of new exclusion criteria in future iterations of the eCQM.
      Show
      Thank you for your question regarding CMS826v2, Hospital Harm - Pressure Injury. Regarding your first question: The inpatient hospitalization period assessed by this measure includes time in the emergency department (ED) and/or observation when the transition between discharge from these encounters and admission to the inpatient encounter is one hour or less. For example, if a patient is discharged from the ED at 9:45AM and admitted to the inpatient encounter at 10AM on the same day, then the inpatient hospitalization period assessed for that patient would begin at the start of the patient’s ED encounter. Regarding your second question: Currently the measure does not include denominator exception criteria for inpatient hospitalizations for patients who refuse pressure injury prevention care, as pressure injury prevention care is a critical part of quality clinical care. Regarding your third question: For the 2025 reporting period version of this eCQM, only inpatient hospitalizations for (1) patients with a deep tissue pressure injury or stage 2, 3, 4 or unstageable pressure injury diagnosis present on admission (noted via Present On Admission indicators or by skin exam results) and (2) patients with a COVID-19 diagnosis are excluded from the measure's denominator. While encounters for patients with Kennedy terminal ulcers are not currently excluded from the measure’s denominator, we will consider the addition of new exclusion criteria in future iterations of the eCQM.
    • CMS0826v2
    • Hide
      Looking for further clarification for definition of "inpatient encounter".

      "The inpatient hospitalization period assessed by this measure includes time in the emergency department and observation when the transition between discharge from these encounters and admission to the inpatient encounter is one hour or less. "
      There is confusion regarding what exactly this means.

      Currently we look for documentation of skin assessment within 24 hr of admission time, and do not look for a skin assessment while the patient is in ED.

      Does this now mean that the clock starts when pt arrives to the ED? Please be as specific as possible. Some pts are admitted from ED, some are made observation. TX
      Show
      Looking for further clarification for definition of "inpatient encounter". "The inpatient hospitalization period assessed by this measure includes time in the emergency department and observation when the transition between discharge from these encounters and admission to the inpatient encounter is one hour or less. " There is confusion regarding what exactly this means. Currently we look for documentation of skin assessment within 24 hr of admission time, and do not look for a skin assessment while the patient is in ED. Does this now mean that the clock starts when pt arrives to the ED? Please be as specific as possible. Some pts are admitted from ED, some are made observation. TX

      "The inpatient hospitalization period assessed by this measure includes time in the emergency department and observation when the transition between discharge from these encounters and admission to the inpatient encounter is one hour or less. " 
      There is confusion regarding what exactly this means. 

      Currently we look for documentation of skin assessment within 24 hr of admission time, and do not look for a skin assessment while the patient is in ED. 

      Does this now mean that the clock starts when pt arrives to the ED? Please be as specific as possible. Some pts are admitted from ED, some are made observation.
      We are finding more and more patients who refuse PIP interventions even after education from provider and wound care team. Why are these patients not able to be excluded from the measure for refusal of care if well documanted? Also in reagrds to crtically ill pts who deteriotate quickly and pass away with 24 hrs or less of pressure injury discovery and injury was deemed unaviodable when all interventions/prevenative measures were in place?

            Assignee:
            Mathematica EH eCQM Team
            Reporter:
            Rochelle Mareno
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