Table 16 'Complications of Anesthesia'

PSI 15: Complications of Anesthesia
Origin: Review of a common OECD/AHRQ/CIHI PSI (3;33)
Dimension Description
Description of Specific
Aspects of Patient Safety
Death due to anaesthesia has become rare, by contrast morbid events,
i.e. complications related to anaesthetic care such as anaesthetic
overdose, reaction, or endotrachial tube misplacement are much more
prevalent causing harm to the patient to a different extend. Thus
complications due to anesthesia are a relevant measure of patient
safety.
Aim of the PSI The PSI aims at surveillance of complications of anesthesia.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s)
A subset of this AHRQ indicator was originally proposed by Iezzoni et
al. as part of Complications Screening Program (CSP) (CSP 21,
“Complications relating to anesthetic agents and other CNS
depressants”). The CPS definition also included poisoning due to
centrally acting muscle relaxants and accidental poisoning by nitrogen
oxides, which are omitted from this AHRQ PSI. The CPS definition
excludes other codes included in this PSI, namely, poisoning by other
and unspecified general anesthetics and external cause of injury codes
for “endotracheal tube wrongly place during anesthetic procedure” and
adverse effects of anesthetics in therapeutic use.
Organisations responding to the same indicator theme are Australian
Incident Monitoring System and the National Patient Safety Agency in
the UK (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
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.
The literature review of the AHRQ project team focused on the
validity of complication indicators based on ICD-9-CM diagnosis or
SImPatIE WP4 – Catalogue of Patients Safety Indicators
41
procedure codes. Results of the literature review indicate no published
evidence for the sensitivity or predictive value of this indicator based
on detailed chart review or prospective data collection (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 0.56
for complications of anesthesia. This PSI was significantly associated
with the AHRQ PSI for “Technical Difficulty with Procedure”. No
significant differences were found for hospitalisations with PSI events
and those without PSI events for longer lengths of stay, higher
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. Complications of anesthesia occur significantly
more often among black and Hispanic people 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).
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 (3-5;7;8;33;34).
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42
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Theme Related PSI: “Surgical Complication”.
Data definitions Cases of anesthetic overdose, reaction, or endotrachial tube
misplacement per 1000 surgery discharges with an operating room
procedure.
Numerator Description Discharges with ICD-9-CM diagnosis codes for anesthesia
complications in any secondary diagnosis field.
Denominator Description All surgical discharges, 18 years and older or MDC 14 (pregnancy,
childbirth, and puerperium), defined by specific DRGs and an ICD-9-
CM code for an operating room procedure.
Exclude cases with:
− ICD-9-CM diagnosis codes for anesthesia complications in the
principal diagnosis field
− codes for self-inflicted injury, poisoning due to anesthetics
(E8551, 9681-4, 9687) and any diagnosis code for active drug
dependence, or active non-dependent abuse of drugs.
Data Source Administrative data. Ideally, this PSI is used with a coding designation
that distinguishes conditions present on admission from those that
develop in-hospital.
Identifying the
institutional context
This PSI is relevant to quality improvement, accreditation and cost
containment, as complications due to anesthetic overdose, reaction, or
endotrachial tube misplacement can have considerable economic
impact.
Care Setting The PSI applies for high quality anaesthesia care.
Professionals Responsible
for Health Care
Anaesthesiologists.
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. Hospital-wide surveillance.
Scoring AHRQ has PSI software for scoring.