Table 22 'Postoperative Respiratory Failure'

PSI 21: Postoperative Respiratory Failure
Origin: Review of an AHRQ PSI (3)
Dimension Description
Description of Specific
Aspects of Patient Safety
Postoperative Respiratory Failure is an important and potentially lifethreatening
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 postoperative respiratory
failure.
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
Complication screening program; CSP 3, ¡°postoperative pulmonary
compromise¡±. The CSP definition also includes pulmonary congestion,
other (or postoperative) pulmonary insufficiency, and acute pulmonary
edema.
The University Health System Consortium (#2927) and AHRQs
original HCUP Quality Indicators adopted the CSP indicator for major
surgery patients.
Needleman and Buerhaus identified postoperative pulmonary Failure
as an ¡°Outcome Potentially Sensitive to Nursing,¡± using the original
CSP definition (3).
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
(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 3.43
for Postoperative Respiratory Failure. 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
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performance predict future hospital safety-related performance. Riskadjusted
rates of the PSI for iatrogenic pneumothorax and failure to
rescue demonstrated significant trends 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 Postoperative Respiratory Failure 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 Respiratory Failure occurs
significantly more often among Asian and Pacific Islander, African
American, Non Hispanics and 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 (3-7).
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 acute respiratory failure per 1000 elective surgical discharges
with an operating room procedure.
Numerator Description Either 1) Discharges with ICD-9-CM codes for acute respiratory
Failure (518.81) in any secondary diagnosis field (After 1999, include
518.84) OR 2) ICD-9-CM procedure codes for postoperative
reintubation procedure based on number of days after the major
operating procedure code: 96.04 ¡Ý1 days, 96.70 or 96.71 ¡Ý2 days, or
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96.72 ¡Ý0 days.
Denominator Description All elective (Defined by admit type) surgical discharges age 18 and
over defined by specific DRGs and an ICD-9-CM code for an
operating room procedure.
Exclude cases:
− with ICD-9-CM codes for acute respiratory Failure in the principal
diagnosis field
− with an ICD-9-CM diagnosis code of neuromuscular disorder
− where a procedure for tracheostomy is the only operating room
procedure or tracheostomy occurs before the first operating room
procedure
− MDC 14 (pregnancy, childbirth, and puerperium)
− MDC 4 (diseases/disorders of respiratory system)
− MDC 5 (diseases/disorders of circulatory system)
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.
Data Source Administrative data.
Identifying the
institutional context
The impact of postoperative respiratory failure makes this PSI
important for both financial and quality improvement policies.
Care Setting The PSI applies for quality medical care.
Professionals Responsible
for Health Care
Surgeons, anaesthesiologists and nurses
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.