Table 20 'Postoperative Haemorrhage or Haematoma'

PSI 19: Postoperative Haemorrhage or Haematoma
Origin: Review of an AHRQ PSI (3)
Dimension Description
Description of Specific
Aspects of Patient Safety
Postoperative Haemorrhage or Haematoma is a harmful and potentially
life-threatening complication in surgical care. Thus it is a suitable
measure of patient safety.
Aim of the PSI This PSI aims at surveillance of cases of hemorrhage or hematoma
following a surgical procedure.
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 24, “post-procedural
hemorrhage or hematoma”), although their definition allowed either
procedure or diagnosis codes. The indicator was also included as one
component of a broader indicator in AHRQs original HCUP Quality
Indicators (3).
This AHRQ indicator is defined on both a provider level by including
cases of Postoperative Haemorrhage or Haematoma occurring as a
secondary diagnosis during hospitalisation and on an area level by
including all cases of Postoperative Haemorrhage or Haematoma in the
area.
Extent of Clinically
Testing
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.
Also they team concluded, that the overall usefulness of this PSI is
favourable. AHRQ panellists noted in their review of the PSI that
some patients may be at higher risk for developing a postoperative
hemorrhage or hematoma than others, especially patients with
coagulopathies and those on anticoagulants. The panellist also noted
that patients admitted for trauma may be at a higher risk for
developing postoperative hemorrhage or may have a hemorrhage
diagnosed that occurred during the trauma. AHRQ panellists
suggested this PSI to be stratified for patients with underlying clotting
differences and for trauma and non-trauma patients – if possible (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 3.23
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for Postoperative Haemorrhage or Haematoma. This PSI was
significantly associated with the AHRQ PSIs for failure to rescue,
iatrogenic pneumothorax, postoperative wound dehiscence, technical
difficulties with procedure and infections due to medical care.
Significant differences were found for hospitalisations with PSI 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 no trend in the rate over time. After accounting
for patient and hospital characteristics, hospitals' baseline riskadjusted
PSI rates were the most important predictors of the 2004 riskadjusted
rates for Postoperative Hemorrhage or Hematoma among
seven other PSIs. It was concluded, that this PSI is a 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).
The Agency for Healthcare Research and Quality PSI algorithms were
applied to administrative data across four years of 1.92 million
discharges from children's hospitals. The mean risk-adjusted rates of
PSI events ranged from 0.1 events per 1000 discharges for a foreign
body left in during a procedure to 140 events per 1000 discharges for
failure to rescue. The researchers concluded: “PSIs derived from
administrative data are indicators of patient safety concerns and can be
relevant as screening tools for children's hospitals; however, cases
identified by these indicators do not always represent preventable
events. Some, such as a foreign body left in during a procedure,
iatrogenic pneumothorax, infection attributable to medical care,
decubitus ulcer, and venous thrombosis, seem to be appropriate for
paediatric care and may be directly amenable to system changes”(6).
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 Haemorrhage or Haematoma occur
significantly more often among Asian and Pacific Islander and
African American, Non Hispanics 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).
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The results suggest that this PSI may be useful as a measure of patient
safety (3-7).
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 hematoma or hemorrhage requirering a procedure per 1000
surgical discharges with an operating room procedure.
Numerator Description Discharges with ICD-9-CM code for postoperative hematoma or
hemorrhage require ring a procedure in any secondary diagnosis field
and code for postoperative control of hemorrhage or drainage of
hematoma (respectively) in any procedure field.
Denominator Description All medical and surgical discharges 18 years and older defined by
specific DRGs and an ICD-10-CM code for an operating room
procedure.
Exclude cases with:
− With an ICD-9-CM codes postoperative hematoma or hemorrhage
diagnosis in any principal diagnosis field
− Where the only operating room procedure is postoperative control
of hemorrhage or drainage of hematoma
− Where a procedure for postoperative control of hemorrhage or
drainage of hematoma occurs before the first operating procedure.
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.
− MDC 14 (pregnancy, childbirth, and puerperium)
Data Source Administrative data.
Identifying the
institutional context
The impact of postoperative haemorrhage or haematoma makes this
PSI important for both financial and quality improvement policies.
Care Setting The PSI applies for quality surgical care.
Professionals Responsible
for Health Care
Surgeons.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
Allowance for Patient
Factors
Risk adjustment for age, sex and comorbidity categories.
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison No specific standards given.
Scoring AHRQ has PSI software for scoring.