Obstetric Trauma - Vaginal Delivery without Instrument
Obstetric Trauma - Vaginal Delivery with Instrument
Obstetric Trauma - Cesarian Delivery
Problems with Childbirth
Birth Trauma - Injury to Neonate
PSI 30: Obstetric Trauma – Vaginal Delivery without Instrument
Origin: Review of an AHRQ PSI (3)
Dimension Description
Description of Specific
Aspects of Patient Safety
Obstetric trauma during delivery is often preventable. The percentage
of deliveries involving third and fourth degree lacerations is a useful
quality indicator of obstetrical care and can assist in reducing the
morbidity from extensive perineal tears.
Aim of the PSI This PSI is intended to flag cases of potentially preventable trauma
during vaginal delivery without instrument.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) An overlapping subset of this indicator (third- or fourth-degree perineal
laceration) has been adopted by the Joint Commission for the
Accreditation of Healthcare Organisations (JCAHO) as a core
performance measure for “pregnancy and related conditions” (PR-25).
Based on expert consensus panels, McKesson Health Solutions
included the JCAHO indicator in its Care Enhance Resource
Management Systems, Quality Profiler Complications Measures
Module. Fourth-Degree Laceration, one of the codes mapped to this
PSI, was included as one component of a broader indicator
(“obstetrical complications”) in AHRQs original HCUP Quality
Indicator (3).
Modified this PSI is included in the Danish National Board of Health’s
Obstetric Indicators.
Extent of Clinically
Testing
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).
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. Obstetric trauma – Vaginal delivery without
instrument occurs significantly less often among African American,
Non Hispanic and Hispanic than among white. Where as Vaginal
delivery without instrument occurs a little more often among Asian
and Pacific Islander than among White. This was explained due to the
fact that race is a risk factor for severe perineal laceration after vaginal
delivery, and black woman are at lower risk than whites and Asian
women are at the highest risk. It was concluded that: ”The AHRQ
PSIs are a broad screen for potential safety events that point to needed
SImPatIE WP4 – Catalogue of Patients Safety Indicators
80
improvement in the quality of care for specific populations” (7).
AHRQ is determining the feasibility and practicality in a project
concerning validation of selected AHRQ Quality Indicators (8).
The results suggest that this PSI may be useful as a measure of patient
safety (3;7)
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Theme Related PSI: “Obstetrics”.
Cases of obstetric trauma (third or fourth degree lacerations) per 1000
vaginal deliveries without instrument.
Obstetric trauma includes uterine rupture, fracture of pelvis, including
coccyx, laceration or haematoma of cervix, vagina, vulva, perineum
and anus
Numerator Description Discharges with ICD-9-CM code for third and fourth degree obstetric
trauma in any diagnosis or procedure field.
Denominator Description All vaginal delivery discharges.
Exclude instrument-assisted delivery.
Data Source Administrative data: hospital morbidity data collection.
Identifying the
institutional context
Complications to delivery can have an ongoing burden on the hospital
system in increased length of stays and readmissions making this PSI
theme important in clinical, quality and economic policies.
Care Setting The PSI applies for high quality maternity care.
Professionals Responsible
for Health Care
Midwifes and doctors.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
Allowance for Patient
Factors
Risk adjustment for age and comorbidity categories.
Stratification by
Vulnerable Populations
No stratification given.
Standard of Comparison No specific standards given.
Scoring AHRQ has PSI software for scoring.
PSI 31: Obstetric Trauma – Vaginal Delivery with Instrument
Review of OECD/AHRQ/CIHI PSI (3;33)
Dimension Description
Description of Specific
Aspects of Patient Safety
Obstetric trauma during delivery is often preventable. The percentage
of deliveries involving third and fourth degree lacerations is a useful
quality indicator of obstetrical care and can assist in reducing the
morbidity from extensive perineal tears
Aim of the PSI This PSI is intended to flag cases of potentially preventable trauma
during vaginal delivery with instrument.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) An overlapping subset of this indicator (third- or fourth-degree perineal
laceration) has been adopted by the Joint Commission for the
Accreditation of Healthcare Organisations (JCAHO) as a core
performance measure for “pregnancy and related conditions” (PR-25).
Based on expert consensus panels, McKesson Health Solutions
included the JCAHO indicator in its Care Enhance Resource
Management Systems, Quality Profiler Complications Measures
Module. Fourth degree laceration, one of the codes mapped to this
indicator, was included as one component of a broader indicator:
“obstetrical complications” in AHRQs original HCUP Quality
Indicators (3;33).
Modified this PSI is included in the Danish National Board of Health’s
Obstetric Indicators.
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
Although AHRQ/CIHI Safety Indicators collects data for obstetric
trauma separately for instrument assisted and non-instrument assisted
vaginal deliveries (SY021) the OECD panel decided to combine these
two measures. The OECD PSI panel assessed the indicator to be well
operationalised. Though concluding: “However, it may be necessary to
exclude or adjust for additional high-risk conditions to ensure
comparability of this indicator across countries” (33).
The AHRQ project team developing the PSI conducted empirical
analyses on this PSI. This PSI generally performs well on several
different dimensions, including reliability, relatedness indicators, and
persistence over time (3).
SImPatIE WP4 – Catalogue of Patients Safety Indicators
82
AHRQ is determining the feasibility and practicality in a project
concerning validation of selected AHRQ Quality Indicators (8).
The results suggest that this PSI may be useful as a measure of patient
safety (3;33).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Theme Related PSI: “Obstetrics”.
Data definitions Cases of obstetric trauma (third or fourth degree lacerations) per 1000
instrument-assisted vaginal deliveries. Obstetric trauma includes
uterine rupture, fracture of pelvis, including coccyx, laceration or
haematoma of cervix, vagina, vulva, perineum and anus
Numerator Description Discharges with ICD-9-CM code for third and fourth degree obstetric
trauma in any diagnosis or procedure field.
Denominator Description All vaginal delivery discharges with any procedure code for
instrument-assisted delivery.
Data Source Administrative data: hospital morbidity data collection.
Identifying the
institutional context
Complications to delivery can have an ongoing burden on the hospital
system in increased length of stays and readmissions making this PSI
theme important in clinical, quality and economic policies.
Care Setting The PSI applies for high quality maternity care.
Professionals Responsible
for Health Care
Midwifes and nurses.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
Allowance for Patient
Factors
Risk adjustment for age.
Stratification by
Vulnerable Populations
No stratification given.
Standard of Comparison No specific standards given.
Scoring AHRQ has PSI software for scoring.
PSI 32: Obstetric Trauma – Cesarian Delivery
Review of OECD/AHRQ PSI (3;33)
Dimension Description
Description of Specific
Aspects of Patient Safety
Obstetric trauma during delivery: vaginal or cesarian is often
preventable. Thus trauma during cesarian delivery is a suitable measure
of patient safety.
Aim of the PSI This PSI is intended to flag cases of potentially preventable trauma
during cesarian delivery.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) An overlapping subset of this indicator (third- or fourth-degree perineal
laceration) has been adopted by the Joint Commission for the
Accreditation of Healthcare Organisations (JCAHO) as a core
performance measure for “pregnancy and related conditions” (PR-25).
Based on expert consensus panels, McKesson Health Solutions
included the JCAHO indicator in its Care Enhance Resource
Management Systems, Quality Profiler Complications Measures
Module. Fourth degree laceration, one of the codes mapped to this
indicator, was included as one component of a broader indicator:
“obstetrical complications” in AHRQs original HCUP Quality
Indicators (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 was successfully completed in all five priority areas leading to
a recommendation of 86 indicators of which 21 cover patient safety
(3;33).
The OECD PSI panel assessed the indicator to be well operationalised.
Though concluding: “However, it may be necessary to exclude or
adjust for additional high-risk conditions to ensure comparability of
this indicator across countries” (33).
The AHRQ project team developing the PSI conducted empirical
analyses on this PSI. This PSI generally performs well on several
different dimensions, including reliability, relatedness indicators, and
persistence over time (3).
The results suggest that this PSI may be useful as a measure of patient
safety (3;33).
AHRQ is determining the feasibility and practicality in a project
concerning validation of selected AHRQ Quality Indicators (8).
SImPatIE WP4 – Catalogue of Patients Safety Indicators
84
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Theme Related PSI: “Obstetrics”.
Data definitions Cases of obstetric trauma (third or fourth degree lacerations) per 1000
Cesarian deliveries.
Numerator Description Discharges with ICD-9-CM codes for obstetric trauma in any diagnosis
or procedure field.
Denominator Description All cesarian delivery discharges.
Data Source Administrative data.
Identifying the
institutional context
Complications to delivery can have an ongoing burden on the hospital
system in increased length of stays and readmissions making this PSI
theme important in clinical, quality and economic policies.
Care Setting The PSI applies for high quality maternity care.
Professionals Responsible
for Health Care
Midwifes and doctors.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
Allowance for Patient
Factors
No risk adjustment.
Stratification by
Vulnerable Populations
No stratification given.
Standard of Comparison No specific standards given.
Scoring AHRQ has PSI software for scoring.
PSI 33: Problems with Child Birth
Review of an OECD PSI (33).
Dimension Description
Description of Specific
Aspects of Patient Safety
Serious complications or even death from delivery are catastrophic
events. Proper pre- and perinatal care and monitoring should be able to
avoid such events, making this theme suitable as a measure of patient
safety.
Aim of the PSI This PSI is intended to flag cases of maternal death or serious
morbidity associated with labour or delivery.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) Originally a PSI from the Australian Council for Safety and Quality.
Maternal death is part of the JCAHO sentinel events indicator set and
is defined as the number of intrapartum (related to the birth process)
maternal deaths. Also WHO has developed a maternal death indicator
(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
covered patient safety (33).
The OECD panel considered an alternative measure to this one; the
alternative PSI serves as a fallback indicator should data collection for
this indicator prove difficult. The alternative measure captures
maternal complications and Maternal Death. Maternal death is part of
the JCAHO sentinel events indicator set and is defined as the number
of intrapartum (related to the birth process) maternal deaths. Also
WHO has developed a maternal death indicator (33).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Theme Related PSI: “Obstetrics”.
Data definitions Not specified.
Numerator Description Maternal death or serious morbidity associated with labour or delivery.
Denominator Description Total number of labour and deliveries.
Data Source Hospital morbidity data collection.
SImPatIE WP4 – Catalogue of Patients Safety Indicators
86
Identifying the
institutional context
Problems with child birth can have an ongoing burden on the hospital
system in increased length of stays and readmissions making this PSI
theme important in clinical, quality and economic policies.
Care Setting The PSI applies for high quality maternal care.
Professionals Responsible
for Health Care
Doctors and midwifes.
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 Not specified.
PSI 34: Birth Trauma – Injury to Neonate
Review of OECD/AHRQ/CIHI PSI (3;33)
Dimension Description
Description of Specific
Aspects of Patient Safety
A US study regarding newborns with a discharge diagnosis of birth
trauma found that 25% had sustained a significant injury to the head,
neck, or shoulder. Birth trauma injury is preventable, making birth
trauma a suitable measure of patient safety.
Aim of the PSI This indicator is intended to flag cases of birth trauma for live born
infants born in hospital.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) This indicator was proposed by Miller et al. (2001) in the original
“AHRQ INDICATOR Algorithms and Groupings,” although their
definition also includes injury to the brachial plexus (767.6), which
was excluded from this PSI. Based on expert consensus panels,
McKesson Health Solutions included a broader version of this
indicator (767.xx) in its Care Enhance Resource Management Systems,
Quality Profiler Complications Measures Module (3).
Modified this PSI is included in the Danish National Board of Health’s
Obstetric Indicators.
Extent of Clinically
Testing
This indicator has been widely used in the obstetric community,
although it is most commonly based on chart review rather than
administrative data (3).
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 AHRQ project team developing the PSI conducted empirical
analyses on this PSI. The overall usefulness of this indicator was rated
as favourable. Birth Trauma generally performs well on several
different dimensions, including reliability, relatedness of indicators,
and persistence over time (3).
AHRQ is determining the feasibility and practicality in a project
concerning validation of selected AHRQ Quality Indicators (8).
This indicator may require further discussion as the WHO has data
concerning the deaths of neonates in all settings (33).
The results suggest that this PSI may be useful as a measure of patient
SImPatIE WP4 – Catalogue of Patients Safety Indicators
88
safety (3;33).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Theme Related PSI: “Obstetrics”.
Data definitions Cases of birth trauma, injury to neonate, per 1000 live born births.
Numerator Description Discharges with ICD-9-CM code for birth trauma in any diagnosis
field.
Exclude infants with
− A subdural or cerebral hemorrhage (subgroup of birth trauma
coding) and any diagnosis code of pre-term infant (denoting birth
weight of less than 2,500 grams and less than 37 weeks gestation
or 34 weeks gestation or less).
− Injury to skeleton (767.3, 767.4) and any diagnosis code of
osteogenesis imperfecta (756.51).
The OECD-panel decided to use Perinatal death/loss of function
(SY058) as fallback for SY019 if data are not widely available for the
later. SY058 comes from JCAHO sentinel events. It measures the
number of perinatal deaths unrelated to a congenital condition in an
infant having a birth weight greater than 2500 grams (33).
Denominator Description Discharges with ICD-9-CM codes for birth trauma in any diagnosis
field per 100 live born births.
Data Source Administrative data – hospital morbidity data collection.
Identifying the
institutional context
Birth trauma can lead to prolonged disability of the infant requiring
substantial resources for rehabilitation and care making this PSI theme
important in clinical, quality and economic policies.
Care Setting This PSI applies for high quality maternity care.
Professionals Responsible
for Health Care
Midwifes and doctors.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
Allowance for Patient
Factors
Risk adjustment: Sex.
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison No specific standards given.
Scoring AHRQ has PSI software for scoring.
