Selected Infections due to Medical Care
Hospital Acquired-Infection Registration - Post Operative Wound Infections
Wound Infections
Ventilator Pneumonia
Hand Hygiene - Measuring the Alcohol Consumption
Hand Hygiene - Staff's Compliance with Guidelines for use of Jewellery
PSI 9: Selected Infections due to Medical Care
Origin: Review of a common OECD/AHRQ PSI (3;33)
Dimension Description
Description of Specific
Aspects of Patient Safety
Many infections acquired in the course of medical care are preventable
by proper hygiene, rational use of antibiotics and other measures.
Infections related to medical care can be a very serious problem in
some cases leading to pain, other discomfort or even death. Thus the
occurrence of infections in the course of medical care is an important
measure of safety.
Aim of the PSI This PSI is intended to flag cases of infection due to medical care,
primarily those related to intravenous (IV) lines and catheters. This
PSI is defined on a provider level by including cases based on
secondary diagnosis associated with the same hospitalisation. Patients
with potential immuno-compromised states (e.g., AIDS, cancer, and
transplant) are excluded, as they may be more susceptible to such
infections. This PSI includes children and neonates. It should be noted
that high-risk neonates are at particularly high risk for catheter-related
infections.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s)
This PSI was originally proposed by Iezzoni et al. as part of the
Complications Screening Program (CSP 11, “miscellaneous better
physician skill mix, or more experienced complications”).
The
University Health System Consortium adopted the CSP indicator for
major and minor surgery patients.
A much narrower definition, including only “other infection after
infusion, injection, transfusion, vaccination”, was proposed by Miller
et al. in the “Patient Safety Indicator Algorithms and Groupings”.
The American Nurses Association and its State have identified the
number of laboratory-over time confirmed bacteremic episodes
associated with central lines per critical care patient day as a “nursingsensitive
quality indicator for acute care settings.” (3;33).
Extent of Clinically
Testing
The OECD Health Care Quality Indicators (HCQI) Project was
initiated to implement quality measures for international
benchmarking of medical care at the health system level. Five priority
areas including patient safety were selected. International expert
panels were formed to identify clinically important, scientifically
sound, and feasible measures based on a structured consensus process.
The consensus process lead to a recommendation of 86 indicators of
SImPatIE WP4 – Catalogue of Patients Safety Indicators
28
which 21 covers aspects of patient safety (34).
The project team developing the AHRQ PSI conducted extensive
empirical analyses on this PSI. The team concluded that this PSI
generally performs well on several different dimensions, including
reliability, bias, relatedness of indicators, and persistence over time (3).
The AHRQ PSI software was applied to Veteran Affairs (VA)
administrative data to identify potential instances of compromised
patient safety; determine occurrence rates of PSI events in the VA;
and examine the construct validity of the PSIs. The study population
was 97% male, with a mean age of 65 years, 54% were age 65 and
older. All together 11411 PSI events were identified, 46% of PSI
events occurred in surgical hospitalisation and 54% in medical
hospitalisation. The observed PSI rate per 1000 discharges was 2.37
for selected infections due to medical care. This PSI was significantly
associated with the AHRQ PSIs for complications of anesthesia,
foreign body left during procedure and iatrogenic pneumothorax.
Statistical significantly differences were found for hospitalisations
with PSI events and those without PSI events for longer lengths of
stay, mortality and higher costs (4).
The performance of the AHRQ PSIs was analysed to: 1) provide a
descriptive analysis of the incidence of PSI events from 2001 to 2004
in the VA; 2) examine trends in national PSI rates at the hospital
discharge level over time; and 3) assess whether hospital
characteristics (teaching status, number of beds, and degree of quality
improvement implementation) and baseline safety-related hospital
performance predict future hospital safety-related performance. Riskadjusted
rates of the PSI for iatrogenic pneumothorax and failure to
rescue demonstrated a consistent rate over time. After accounting for
patient and hospital characteristics, hospitals' baseline risk-adjusted PSI
rates were the most important predictors of the 2004 risk-adjusted rates
for eight PSIs (decubitus ulcer, failure to rescue, iatrogenic
pneumothorax, infection resulting from medical care, postoperative
hemorrhage or hematoma, postoperative respiratory failure,
postoperative pulmonary embolism or deep vein thrombosis and
accidental puncture/laceration). It was concluded, that the PSIs are
useful tools for tracking and monitoring patient safety events. Future
research should investigate whether trends reflect better or worse care
or increased attention to documenting patient safety events (5).
Administrative data from community hospitals in 16 US states with
reliable race/ethnicity measures using the AHRQ PSIs was analysed to
determine whether racial and ethnic differences in patient safety
events disappear when income (a proxy for socioeconomic status) is
taken into account. Infections due to medical care occur significantly
more often among other races than among white. It was concluded
that: ”The AHRQ PSIs are a broad screen for potential safety events
that point to needed improvement in the quality of care for specific
populations” (7).
The results suggest that this PSI may be useful as a measure of patient
SImPatIE WP4 – Catalogue of Patients Safety Indicators
29
safety (3-5;7;33;34).
AHRQ is determining the feasibility and practicality in a project
concerning validation of selected AHRQ Quality Indicators (8).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Theme Related PSI: “Infection Control”.
Data definitions Discharges with ICD-9-CM code of 999.3 or 996.62 in any secondary
diagnosis field per 100 discharges.
Numerator Description Discharges with ICD-9-CM code of 999.3 or 996.62 in any secondary
diagnosis field.
Denominator Description All medical and surgical discharges defined by specific DRGs.
Exclude cases with any:
− ICD-9-CM code of 9993 or 99662 in the hospital diagnosis field.
− Diagnosis code for immuno-compromised state or cancer.
Data Source Administrative data.
Identifying the
institutional context
As infections also prolong pain and suffering and the duration of
hospitalisation, this PSI also has important economic and legal policy
implications.
Care Setting The PSI applies for high quality nursing care.
Professionals Responsible
for Health Care
Nurses.
Lowest Level of Health
Care Delivery Addressed
Individual clinical unit or department.
Allowance for Patient
Factors
Risk Adjustment for: Age, sex, DRG, comorbidity categories.
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison No specific standards given. Hospital-wide surveillance.
Scoring AHRQ has PSI software for scoring.
PSI 10: Hospital Acquired-Infection Registration – Post Operative Wound Infections
Origin: PSI by SimPatIE
Dimension Description
Description of Specific
Aspects of Patient Safety
Hospital acquired infections are a major problem, leading to prolonged
hospital stay increased morbidity and mortality for patients and to
increased costs for the health care system. Among 1510 patients the
overall prevalence of hospital-acquired infections (HAI) was found to
be 10%. The distribution of the most frequent HAIs was urinary tract
infection (34%), postoperative wound infection (19%), pneumonia
(12%) and septicaemia (9%), respectively. A total of 456 patients
(30%) received antibiotics on the prevalence day. The antibiotics were
given as prophylaxis to 64 (14%) of these patients (35)
Consequently, Hospital Acquired-Infection Registration (HAIR) is a
suitable patient safety measure.
Aim of the PSI The PSI aims at surveillance of post operative wound infections.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) This method was developed by A. Leth and J.K. Moller in the
Department of Clinical Microbiology, Aarhus University Hospital, DK
(35;36).
Extent of Clinically
Testing
Registration of HAI was compared with conventional manual
registration (the gold standard i.e. reference method) by chart reviews
of nosocomial infections in patients from surgical and medical
departments. By combining selected infection parameters from various
electronic hospital registries, the computer detected postoperative
wound infections with a sensitivity of 94% and a specificity of ) 91%
(35;36).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Theme Related PSI: “Infection Control”.
Data definitions Cases of post operative wound infection
Numerator Description Discharges with code for postoperative wound infections (ICD-10).
Patients admitted less than two days, except for readmission are
excluded.
Denominator Description All elective surgical discharges age 18 and older defined by specific
DRGs and an ICD-10 code for an operating room procedure.
Patients admitted less than two days, except for readmission are
excluded.
Data Source HAIR is based on selected laboratory and administrative data,
including individual use of antimicrobial agents.
SImPatIE WP4 – Catalogue of Patients Safety Indicators
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Identifying the
institutional context
This PSI is relevant to quality improvement, accreditation and cost
containment, as prolonged hospital stays due to infections have
considerable economic impact.
Care Setting The PSI applies for high quality surgical site preparation, careful and
sterile surgical techniques and high quality post-op care.
Professionals Responsible
for Health Care
Surgeons and nurses.
Lowest Level of Health
Care Delivery Addressed
Individual clinical units or departments.
Allowance for Patient
Factors
No risk adjustment described.
Stratification by
Vulnerable Populations
No stratification
Standard of Comparison No time comparison specified.
Scoring Type of surgical procedure must be registered, and one or more of the
following criteria:
− culture positive swab from wound/drainage
− discharge code for postoperative wound infection (ICD-10)
− relevant antibiotic treatment prescribed after surgery and not for
other infections.
PSI 11: Wound Infection
Origin: Review of a OECD PSI (33)
Dimension Description
Description of Specific
Aspects of Patient Safety
The occurrence of a wound infection can have clinical consequences
ranging from insignificant inflammation to considerable pain and
suffering, wound disruption, septicaemia and death. Due to infection
re-operation and prolonged hospitalisation might required. The
incidence of wound infection can be reduced by proper pre-, intra- and
post-operative care, in particular strict hygiene. Various clinical work
processes are proven to be linked to wound infections. Thus wound
infection is a suitable measure of patient safety.
Aim of the PSI This PSI is intended to flag cases of wound infections.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) Origin the Complications Screening Programme.
Extent of Clinically
Testing
The OECD Health Care Quality Indicators (HCQI) Project was
initiated to implement quality measures for international benchmarking
of medical care at the health system level. Five priority areas including
patient safety were selected. International expert panels were formed to
identify clinically important, scientifically sound, and feasible
measures based on a structured consensus process. The consensus
process was successfully completed in all five priority areas leading to
a recommendation of 86 indicators of which 21 cover patient safety
(34).
The Complications Screening Program (CSP) aims to identify 28
potentially preventable complications of hospital care using
computerised discharge abstracts, including demographic information,
diagnosis and procedure codes. A study was set up to validate the CSP
as a quality indicator. Explicit process of care criteria were used to
determine whether hospital discharges flagged by the CSP experienced
more process problems than unflagged discharges. The CSP was
applied to computerised hospital discharge abstracts from Medicare
beneficiaries > 65 years old admitted in 1994 to hospitals in California
and Connecticut for major surgery or medical treatment. The final
sample included 740 surgical and 416 medical discharges. Rates of
process problems were high, ranging from 24.4 to 82.5% across CSP
screens for surgical cases. Problems were lower for medical cases,
ranging from 2.0 to 69.1% across CSP screens. Problem rates were
45.7% for surgical and 5.0% for medical controls. Rates of problems
did not differ significantly across flagged and unflagged discharges.
The researchers concluded: “The CSP did not flag discharges with
significantly higher rates of explicit process problems than unflagged
SImPatIE WP4 – Catalogue of Patients Safety Indicators
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discharges” (37).
Another study of the CSP was undertaken to study the accuracy of
computer algorithms on administrative data to identify hospital
complications. The assessment was based on a medical records
indicator differentiating hospital-acquired conditions from pre-existing
comorbidities. Indicators for identifying potential hospital
complications were applied to all secondary diagnoses for all 1997-
1998 discharges. The researchers concluded: “Current complication
algorithms identify many cases where the condition was actually
present on hospital admission. This fact, coupled with the known
variability in coding between institutions, makes comparisons between
hospitals on many of the complications problematic. Collection of the
present-on-admission flag significantly reduces the noise in monitoring
complication rates (38).
The results suggest that this PSI may be useful as a measure of patient
safety (33;37).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Theme Related PSI: “Infection Control”.
Data definitions Cases of wound infection.
Numerator Description Patients experiencing a wound infection (ICD-9 998.51 and 998.52).
Secondary diagnosis only.
Denominator Description All hospitalised patients.
Data Source Administrative data.
Identifying the
institutional context
The impact of wound infections makes this PSI important for both
financial and quality improvement policies.
Care Setting The PSI applies for high quality nursing care.
Professionals Responsible
for Health Care
Nurses.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
Allowance for Patient
Factors
No risk adjustment described.
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison No specific standards given.
Scoring No specific standards for scoring given.
PSI 12: Ventilator Pneumonia
Origin: Review of a OECD PSI (33)
Dimension Description
Description of Specific
Aspects of Patient Safety
Ventilator-associated pneumonia (VAP) is a leading cause of morbidity
and mortality in the Intensive Care Unit (ICU). Incidence of VAP
varies greatly, ranging from 6-52% of intubated patients depending on
patient risk factors. Overall VAP is associated with an attributable
mortality of up to 30%. Given the consequences of VAP, VAP rates
appear to be a suitable patient safety measure (33).
Aim of the PSI This PSI is intended to flag cases of ventilated inpatients developing
pneumonia.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) The Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) Indicator Measurement System: Infection Control (39).
Similar national organisations, responding to the same issue are
Australian Incident Monitoring System and the National Patient Safety
Agency in the UK (33).
Extent of Clinically
Testing
The OECD Health Care Quality Indicators (HCQI) Project was
initiated to implement quality measures for international
benchmarking of medical care at the health system level. Five priority
areas including patient safety were selected. International expert
panels were formed to identify clinically important, scientifically
sound, and feasible measures based on a structured consensus process.
The consensus process was successfully completed in all five priority
areas leading to a recommendation of 86 indicators of which 21 cover
patient safety (33).
The results suggest that this PSI may be useful as a measure of patient
safety (33).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Theme Related PSI: “Infection Control”.
Data definitions
Numerator Description Number of ventilated inpatients developing pneumonia.
Denominator Description Number of inpatient (ICU and Non-ICU) ventilator days.
Data Source Administrative data.
Identifying the
institutional context
The impact of pneumonia makes this PSI important for both financial
and quality improvement policies.
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Care Setting The PSI applies for high quality intensive nursing care.
Professionals Responsible
for Health Care
Nurses.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
Allowance for Patient
Factors
No risk adjustment described.
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison No specific standards given.
Scoring No specific scoring standards given.
PSI 13: Hand Hygiene – Measuring the Alcohol Consumption
Origin: PSI by SimPatIE
Dimension Description
Description of Specific
Aspects of Patient Safety
Improved adherence to hand hygiene (i.e. hand washing or use of
alcohol-based hand rubs) has been shown to terminate outbreaks in
health care facilities, to reduce transmission of antimicrobial resistant
organisms (e.g. methicillin resistant staphylococcus aureus) and reduce
overall infection rates (40;41) also it is the cheapest way of preventing
nosocomial infections. Hand disinfection has been shown to be the
most effective method of hand hygiene (42).
The patient harm of bad hand hygiene makes surveillance of the
alcohol consumption a suitable patient safety measure.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Aim of the PSI The PSI aims at monitoring the alcohol consumption used for hand
hygiene.
Source(s) This PSI is part of the Accréditation des médecins Programme by
Haute Autorité de Santé in France.
Extent of Clinically
Testing
This PSI is in use in numerous hospitals in Scandinavia, England,
France and other parts of Europe. Never the less no specific scientific
evidence describing clinical testing and validation of the PSI was
identified.
The Antimicrobial Resistance Prevention and Control study assessed
the organisation, components and human resources of infections
control programmes in European hospitals. A questionnaire survey of
policies and procedures implemented in 2001 for the surveillance and
control of nosocomial infection and antibiotic resistance was
completed by 169 acute-care hospitals from 32 European countries,
categorised by five geographical regions. A formal (Infection control)
IC programme existed in 72% of hospitals, and a multidisciplinary IC
committee was operational in 90%. Written guidelines promoted hand
hygiene for healthcare workers in 89% of hospitals, education in 85%,
and audit in 46%. Guidelines recommended use of alcohol-based
solutions (70%) and/or medicated/antiseptic soap (43%) for
decontamination of non-soiled hands. Use of alcohol-based solutions
varied according to region, from 41% in southern Europe to 100% in
northern Europe, compared with use of medicated soap from 77% in
southern Europe to 11% in northern Europe (p < 0.01). These findings
showed that IC programmes in European hospitals suffer from major
deficiencies in human resources and policies. (43).
Evidence of Clinically use
of Standards
This PSI has been used in Aarhus University Hospital, Denmark
together with another five PSIs related to hand hygiene. The standard
SImPatIE WP4 – Catalogue of Patients Safety Indicators
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used for this PSI within the first year of monitoring was and increase in
the use for hand disinfection at 50%.
PSI category Theme Related PSI: “Infection Control”.
Data definitions Litre of alcohol consumption used for hand hygiene pr. patient in a bed
unit.
Numerator Description Alcohol consumption (Litre) relating to hand hygiene.
Denominator Description The number of patient per bed unit.
Data Source Registration of bought/delivered alcohol for hand hygiene.
Identifying the
institutional context
This PSI is relevant to quality improvement, accreditation and cost
containment, as prolonged hospital stays due to infections have
considerable economic impact.
Care Setting The PSI generally applies for high quality hygiene related to patient
contact.
Professionals Responsible
for Health Care
All health care providers dealing with patients in bed units.
Lowest Level of Health
Care Delivery Addressed
Individual clinical units or departments.
Allowance for Patient
Factors
No patient factors involved.
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison The time frame is monthly monitoring.
Scoring No specified scoring advice.
PSI 14: Hand Hygiene – Staff’s Compliance with Guidelines for us of Jewellery
Origin: PSI by SimPatIE
Dimension Description
Description of Specific
Aspects of Patient Safety
Improved adherence to hand hygiene has been shown to terminate
outbreaks in health care facilities, to reduce transmission of
antimicrobial resistant organisms and reduce overall infection rates
(40;41). Also it is the cheapest way of preventing nosocomial
infections.
Surgical wound infection may be caused by transfer of bacteria from
the hands of the surgical team during operative procedures. The
wearing of finger rings and nail polish is thought to reduce the efficacy
of the scrub as they are thought to harbour bacteria in microscopic
imperfections of nail polish and on the skin beneath finger rings.
The patient harm of bad hand hygiene makes surveillance of Staff’s
Compliance with Guidelines for us of Jewellery a suitable patient
safety measure.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Aim of the PSI The PSI aims at monitoring presence of hand- and arm jewellery
among health care staff.
Source(s) Surveillance of hand hygiene is commonly known in Europe. This PSI
has been used in Aarhus University Hospital, Denmark together with
another five indicators related to hand hygiene.
Extent of Clinically
Testing
Though this indicator is in use in numerous hospitals in Scandinavia,
England and other parts of Europe, we have not found specific
scientific evidence describing clinical testing of the indicator.
A randomised controlled trail from 2001determined risk factors for
hand contamination and compared the efficacy of three randomly
allocated hand hygiene agents in a group of surgical intensive care unit
nurses. Cultured samples of one of the nurses’ hands before and
samples of the other hand after hand hygiene were made and
compared. Ring wearing was found to be associated with 10-fold
higher median skin organism counts; contamination with
Staphylococcus aureus, gram-negative bacilli, or Candida species; and
a stepwise increased risk of contamination with any transient organism
as the number of rings worn increased (44).
A Cochrane Review from 2000 was performed to assess the effect of
removal of finger rings and nail polish by the surgical scrub team, on
postoperative wound infection rates. The researchers concluded:
“Given the lack of evidence for either the safety or the harm associated
with nail polish and finger rings, health care organisations must
continue to develop institutional policies based on expert
opinions”(45).
SImPatIE WP4 – Catalogue of Patients Safety Indicators
39
Evidence of Clinically use
of Standards
The standard used in Aarhus University Hospital; Denmark for this
indicator was: 98% of health care staff do not use hand and arm
jewellery on duty.
PSI category Theme Related PSI: “Infection Control”.
Data definitions Presence of hand- and arm jewellery per 1000 health care staff.
Numerator Description Number of staff wearing hand- and/or arm jewellery.
Denominator Description Total number of health care staff present on the day of observation in
the unit/department.
Data Source An unannounced observational cross-sectional survey on the
prevalence of hand- and arm jewellery worn by health care staff.
Identifying the
institutional context
This PSI is relevant to quality improvement, accreditation and cost
containment, as prolonged hospital stays due to infections have
considerable economic impact.
Care Setting The PSI generally applies for high quality hygiene related to patient
contact by all health care workers.
Professionals Responsible
for Health Care
All health care providers in contact with patients in bed units.
Lowest Level of Health
Care Delivery Addressed
Individual clinical units or departments.
Allowance for Patient
Factors
No patient factors involved.
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison The timeframe is yearly monitoring.
Scoring No scoring advice given.
