Table 31 'Obstetric Trauma - Vaginal Delivery without Instrument'

PSI 30: Obstetric Trauma – Vaginal Delivery without Instrument
Origin: Review of an AHRQ PSI (3)
Dimension Description
Description of Specific
Aspects of Patient Safety
Obstetric trauma during delivery is often preventable. The percentage
of deliveries involving third and fourth degree lacerations is a useful
quality indicator of obstetrical care and can assist in reducing the
morbidity from extensive perineal tears.
Aim of the PSI This PSI is intended to flag cases of potentially preventable trauma
during vaginal delivery without instrument.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) An overlapping subset of this indicator (third- or fourth-degree perineal
laceration) has been adopted by the Joint Commission for the
Accreditation of Healthcare Organisations (JCAHO) as a core
performance measure for “pregnancy and related conditions” (PR-25).
Based on expert consensus panels, McKesson Health Solutions
included the JCAHO indicator in its Care Enhance Resource
Management Systems, Quality Profiler Complications Measures
Module. Fourth-Degree Laceration, one of the codes mapped to this
PSI, was included as one component of a broader indicator
(“obstetrical complications”) in AHRQs original HCUP Quality
Indicator (3).
Modified this PSI is included in the Danish National Board of Health’s
Obstetric Indicators.
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).
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. Obstetric trauma – Vaginal delivery without
instrument occurs significantly less often among African American,
Non Hispanic and Hispanic than among white. Where as Vaginal
delivery without instrument occurs a little more often among Asian
and Pacific Islander than among White. This was explained due to the
fact that race is a risk factor for severe perineal laceration after vaginal
delivery, and black woman are at lower risk than whites and Asian
women are at the highest risk. It was concluded that: ”The AHRQ
PSIs are a broad screen for potential safety events that point to needed
SImPatIE WP4 – Catalogue of Patients Safety Indicators
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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: “Obstetrics”.
Cases of obstetric trauma (third or fourth degree lacerations) per 1000
vaginal deliveries without instrument.
Obstetric trauma includes uterine rupture, fracture of pelvis, including
coccyx, laceration or haematoma of cervix, vagina, vulva, perineum
and anus
Numerator Description Discharges with ICD-9-CM code for third and fourth degree obstetric
trauma in any diagnosis or procedure field.
Denominator Description All vaginal delivery discharges.
Exclude instrument-assisted delivery.
Data Source Administrative data: hospital morbidity data collection.
Identifying the
institutional context
Complications to delivery can have an ongoing burden on the hospital
system in increased length of stays and readmissions making this PSI
theme important in clinical, quality and economic policies.
Care Setting The PSI applies for high quality maternity care.
Professionals Responsible
for Health Care
Midwifes and doctors.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
Allowance for Patient
Factors
Risk adjustment for age and comorbidity categories.
Stratification by
Vulnerable Populations
No stratification given.
Standard of Comparison No specific standards given.
Scoring AHRQ has PSI software for scoring.