Table 10 'Selected Infections due to Medical Care'

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.