Table 19 'Postoperative Sepsis'

PSI 18: Postoperative Sepsis
Origin: Review of a common OECD/AHRQ PSI (3;33)
Dimension Description
Description of Specific
Aspects of Patient Safety
The occurrence of sepsis following surgery is a severe complication
with a mortality rate of up to 30%. Even less severe cases will require
prolonged ICU treatment for organ failure. As many cases of
postoperative sepsis can be prevented through the appropriate use of
prophylactic antibiotics, good surgical site preparation, careful and
sterile surgical techniques and good post-op care this postoperative
sepsis is a suitable measure of patient safety.
Aim of the PSI This PSI is intended to flag cases of nosocomial postoperative sepsis.
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 7 “Septicamia” Needlemann
and Buerhaus identified sepsis as an “Outcome Potential Sensitive to
Nursing” using the same CSP definition (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 6.13
for postoperative sepsis. This PSI was significantly associated with the
AHRQ PSI for postoperative respiratory failure. 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. 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 sepsis occurs 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).
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 sepsis per 1000 elective surgery patients with an operating
room procedure and a length of stay of four days or more.
Numerator Description Discharges with ICD-9-CM code for sepsis in any secondary diagnosis
field
Denominator Description All elective* surgical discharges age 18 and older defined by specific
DRGs and an ICD-9-CM code for an operating room procedure.
*Elective - Admission type # is recorded as elective (Admission Type
= 3)
Exclude cases:
− with ICD-9-CM codes for sepsis in the principal diagnosis field
− with a principal diagnosis of infection, or any code for
immunocompromised state, or cancer
− MDC 14 (pregnancy, childbirth, and puerperium)
− with a length of stay of less than 4 days
Data Source Administrative data.
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Identifying the
institutional context
This PSI is relevant to both quality improvement and cost containment.
Care Setting The PSI applies for high quality nursing care.
Professionals Responsible
for Health Care
Surgeons and nurses.
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.