Use of AHRQ Patient Safety Indicators with Hospital Episode Statistics

1. Use of AHRQ Patient Safety Indicators with Hospital Episode Statistics Min Hua Jen, Alex Bottle & Paul Aylin Dr Foster Unit at Imperial College

2. Overview Counting harms: AHRQ PSI background Challenges to using PSIs in the NHS Rates in England for eight PSIs Case-note audit of PSIs at 18 volunteer trusts Next steps

3. AHRQ PSIs Agency for Healthcare Research and Quality (US) PSIs are evidence-based Twenty indicators designed for use in routine data Complement purpose-built adverse event reporting systems such as the NRLS Include e.g. post-op sepsis, obstetric tears and foreign body left in patient Some need case-mix adjustment

4. Each PSI comprises� Set of diagnosis, procedure and/or other codes in the numerator Set of diagnosis, procedure and/or other codes for the denominator Set of exclusions

6. List of 20 hospital level indicators Complications of anaesthesia (PSI 1) Death in low mortality DRGs (PSI 2) Decubitus ulcer (PSI 3) Failure to rescue (PSI 4) Foreign body left in during procedure (PSI 5) Iatrogenic pneumothorax (PSI 6) Selected infections due to medical care (PSI 7) Postoperative hip fracture (PSI 8) Postoperative haemorrhage or haematoma (PSI 9) Postoperative physiologic and metabolic derangements (PSI 10) Postoperative respiratory failure (PSI 11) Postoperative pulmonary embolism or deep vein thrombosis (PSI 12) Postoperative sepsis (PSI 13) Postoperative wound dehiscence in abdominopelvic surgical patients (PSI 14) Accidental puncture and laceration (PSI 15) Transfusion reaction (PSI 16) Birth trauma -- injury to neonate (PSI 17) Obstetric trauma -- vaginal delivery with instrument (PSI 18) Obstetric trauma -- vaginal delivery without instrument (PSI 19) Obstetric trauma -- caesarean delivery (PSI 20)

7. PSI adaptations required for NHS use Translation from ICD9 to ICD10 diagnosis codes was carried out using a look-up file from the internet Translation of the ICD9 procedure codes into OPCS4 was carried out by a trained clinical coder Conversion of DRGs into HRGs Validate in NHS: naming and coding issues Liaison with Healthcare Commission

8. Rates in England and USA

10. Validation: first report All NHS trusts in England were sent in March 2007 a report of their PSI rates with: Crude and age- +/- sex-adjusted rates Funnel plots showing their relative position to other trusts and national mean PSI specification Glossary explaining control limits etc Trusts were encouraged to ask questions

11. Validation: case-note audit 18 trusts volunteered and completed audit of 2150 records: Case note audit of 2005/6 PSI numerator adms: does HES record reflect reality? Note reason for difference, e.g. dx present on admission (not post-adm)

12. Results of audit (1) Obstetric tears were most reliable: 94% for vag del w instrument, 82% for vag del w/o instrument 35% decubiti present on admission, 57% correctly coded Selected infections (12% miscoded) and post-op sepsis (21% miscoded) were considered gross underestimates

13. Results of audit (2) Death in low-mortality HRGs: issue with HRG grouper giving priority to a minor op in ill patients PSI7: central line infections of more interest Foreign body often misinterpreted Post-op hip fracture rare: better ways to capture severe in-hospital falls with HES? Some renaming of PSIs needed

14. Next steps (1) Amendment of PSI specs e.g. changing PSI7 to central line infections Calculation of rates for one other AHRQ PSI: post-op DVT/PE Investigate specialty-specific indicators using HES

15. Next steps (2) Further use of HES to improve case-finding of existing PSIs e.g. admission for infection within 12 months of orthopaedic procedure Flip side: try to compare other data sources of PSIs e.g. bed sore register, Datix/NRLS, HPA with HES to find out how many HES misses and why