Postoperative Hip Fracture
In-Hospital Hip Fracture or Fall
Patient Falls
PSI 35: Postoperative Hip Fracture
Origin: Review of a common OECD/AHRQ/CIHI PSI (3;33)
Dimension Description
Description of Specific
Aspects of Patient Safety
Hip fracture can have devastating consequences including pain, loss of
function and, sometimes, death. When hip fracture occurs in the postoperative
period it can reflect inappropriate prescribing by medical
staff (e.g., use of long-acting sedatives) or inadequate nursing
procedures (e.g., lack of patient monitoring and bedrail use). Thus
postoperative hip fracture is an adequate measure of patient safety.
Aim of the PSI This PSI is intended to survey the incidence of postoperative hip
fractures (as distinct from hip fractures occurring in non-surgical
settings).
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) This indicator was originally proposed by Iezzoni et al.
as part of the
Complications Screening Program: CSP 25, “in-hospital hip fracture or
fall”. The CSP definition also includes any documented fall, based on
external cause of injury codes.
The American Nurses Association, its State associations, and the
California Nursing Outcomes Coalition have identified the number of
patient falls leading to injury per 1000 patient days based on clinical
data collection as a “nursing-sensitive quality indicator for acute care
settings”(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
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
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90
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 1.14
for postoperative hip fracture. This PSI was not significantly
associated with any other of the studied PSIs. 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. 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. Postoperative hip fracture occurs significantly less
often among other races than among white, possibility due to genetic
differences. 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
safety (3-5;7;8;33;34).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Theme Related PSI: “In-Hospital Fall”
Data definitions Cases of in-hospital hip fracture per 100 surgical discharges with an
operating room procedure.
Numerator Description Discharges with ICD-9-CM code for hip fracture in any secondary
diagnosis field.
Denominator Description All surgical discharges.
Exclude cases:
− Who have musculoskeletal and connective tissue diseases
(MDC 8)
− With principal diagnosis codes for seizure, syncope, stroke,
coma, cardiac arrest, poisoning, trauma, delirium and other
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psychoses, or anoxic brain injury
− With any diagnosis of metastatic cancer, lymphoid malignancy
or bone malignancy, and self inflicted injury
− 17 years of age and younger
Data Source Administrative data.
Identifying the
institutional context
As postoperative hip fractures can cause pain, suffering, prolonged
hospital stays and additional surgical interventions, monitoring this PSI
is important for pursuing quality improvement, economic, legal and
ethical policies.
Care Setting The PSI applies for high quality surgical care.
Professionals Responsible
for Health Care
Surgeons.
Lowest Level of Health
Care Delivery Addressed
Individual clinical units or departments.
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.
Scoring AHRQ has PSI software for scoring.
PSI 36: In Hospital Hip Fracture or Fall
Review of an OECD PSI (33).
Dimension Description
Description of Specific
Aspects of Patient Safety
Falls are a common cause of morbidity and mortality especially among
elderly in-patients over 65 years of age. Falls are associated with
functional disability and injury, increased length of stay, and risk of
nursing home placement from hospital. Often falls are the result of the
interaction of many factors. Falls may be caused by the persons’ health
status, response to medical interventions, external factors such as the
type of floor or other factors. Thus in-hospital hip fracture or fall is an
adequate measure of patient safety.
Aim of the PSI This PSI is intended to flag cases of in-hospital hip fractures or falls.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) The complication screening programme (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 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
discharges” (37).
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93
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: “In-Hospital Fall”.
Data definitions Cases of in-hospital hip fracture or fall per 100 surgical discharges
with an operating room procedure.
Numerator Description Patients experiencing an in-hospital hip fracture or fall; defined as
secondary diagnosis only.
A fall is defined as unintentionally coming to rest on the ground, floor,
or other lower level, but not as a result of syncope or overwhelming
external force.
Exclude cases:
− With trauma or metastatic cancer as any diagnosis
− With principal diagnosis of seizure, syncope, stroke, coma, cardiac
arrest, or poisoning
− In MDC 8.
Denominator Description Inpatients undergoing major surgery OR minor or miscellaneous
surgery OR invasive cardiac procedures OR invasive radiologic
procedures OR endoscopy OR medical patients OR all patients as
defined by the CSP.
Data Source Administrative data.
Identifying the
institutional context
The impact of falls makes this PSI important for both financial and
quality improvement policies.
Care Setting The PSI applies for high quality care.
Professionals Responsible
for Health Care
All health care workers.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
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94
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 37: Patient Falls
Review of an OECD PSI (33).
Dimension Description
Description of Specific
Aspects of Patient Safety
Falls are a common cause of morbidity and mortality especially among
elderly in-patients over 65 years of age. Falls are associated with
functional disability and injury, increased length of stay, and risk of
nursing home placement from hospital. Often falls are the result of the
interaction of many factors. Falls may be caused by the persons’ health
status, response to medical interventions, external factors such as the
type of floor or other factors. Thus in-hospital fall is an adequate
measure of patient safety.
Aim of the PSI This PSI is intended to flag cases of in-hospital patient falls resulting
in death or major permanent loss of function.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) JCAHO sentinel events (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 OECD panel reviewed the literature and found that studies show
that intervention can decrease the risk of falls but also evidence that
interventions to reduce specific risk factors resulted in a 30% reduction
in falls over one year in a prospective community cohort (33).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Theme Related PSI: “In-Hospital Fall”.
Data definitions Cases of in-hospital fall with serous consequences per 1000
admissions.
Numerator Description Number of patient falls
that result in death or major permanent loss of
function as a result of the injuries sustained in the fall direct. A fall is
defined as unintentionally coming to rest on the ground, floor, or other
lower level, but not as a result of syncope or overwhelming external
force.
Denominator Description All hospital admissions.
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Data Source Administrative data.
Identifying the
institutional context
The impact of falls makes this PSI important for both financial and
quality improvement policies.
Care Setting The PSI applies for high quality care.
Professionals Responsible
for Health Care
All health care workers.
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
