Table 18 'Postoperative Pulmonary Embolism or Deep Vein Thrombosis'

PSI 17: Postoperative Pulmonary Embolism or Deep Veins Thrombosis
Origin: Review of OECD/AHRQ/CIHI PSI (3;33)
Dimension Description
Description of Specific
Aspects of Patient Safety
The occurrence of postoperative pulmonary embolism (PE) or deep
vein thrombosis (DVT) can range from mild symptoms to devastating
clinical consequences including pain, respiratory distress, and death.
PE/DVT can be prevented through the appropriate use of
anticoagulants and other preventive measures. Thus PE or DVT is a
suitable measure of patient safety.
Aim of the PSI This PSI is intended to capture cases of PE or DVT.
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 22, “venous thrombosis and
pulmonary embolism” and it was one of AHRQs original HCUP
Quality Indicators for major surgery and invasive vascular procedure
patients.
(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 (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 13.00
for postoperative PE or DVT. This PSI was significantly associated
with the AHRQ PSI for failure to rescue. 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).
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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 among these also this one. 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 PE or DVT occurs significantly
more often among African American, Non-Hispanic 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).
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 deep vein thrombosis or pulmonary embolism per 1000
surgical discharges with an operating room procedure.
Numerator Description Discharges with ICD-9-CM codes for deep vein thrombosis or
pulmonary embolism in any secondary diagnosis field.
Denominator Description All surgical discharges age 18 and older defined by specific DRGs and
an ICD-9-CM code for an operating room procedure.
Exclude cases:
− with ICD-9-CM codes for deep vein thrombosis or pulmonary
embolism in the principal diagnosis field
− where a procedure for interruption of vena cava is the only
operating room procedure
− where a procedure for interruption of vena cava occurs before or
on the same day as the first operating room procedure
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Note: If day of procedure is not available in the input data file, the
rate may be slightly lower than if the information was available.
− With obstetrical patients in MDC 14 (Pregnancy, Childbirth and
the Puerperium
Data Source Administrative data.
Identifying the
institutional context
Because PE/DVT can cause unnecessary prolongation of hospital stays
as well as unnecessary pain, suffering and death, this PSI is important
in financial and quality 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.