Table 36 'Postoperative Hip Fracture'

PSI 35: Postoperative Hip Fracture
Origin: Review of a common OECD/AHRQ/CIHI PSI (3;33)
Dimension Description
Description of Specific
Aspects of Patient Safety
Hip fracture can have devastating consequences including pain, loss of
function and, sometimes, death. When hip fracture occurs in the postoperative
period it can reflect inappropriate prescribing by medical
staff (e.g., use of long-acting sedatives) or inadequate nursing
procedures (e.g., lack of patient monitoring and bedrail use). Thus
postoperative hip fracture is an adequate measure of patient safety.
Aim of the PSI This PSI is intended to survey the incidence of postoperative hip
fractures (as distinct from hip fractures occurring in non-surgical
settings).
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 25, “in-hospital hip fracture or
fall”. The CSP definition also includes any documented fall, based on
external cause of injury codes.
The American Nurses Association, its State associations, and the
California Nursing Outcomes Coalition have identified the number of
patient falls leading to injury per 1000 patient days based on clinical
data collection as a “nursing-sensitive quality indicator for acute care
settings”(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
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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 1.14
for postoperative hip fracture. This PSI was not significantly
associated with any other of the studied PSIs. 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).
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. 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 hip fracture occurs significantly less
often among other races than among white, possibility due to genetic
differences. 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).
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: “In-Hospital Fall”
Data definitions Cases of in-hospital hip fracture per 100 surgical discharges with an
operating room procedure.
Numerator Description Discharges with ICD-9-CM code for hip fracture in any secondary
diagnosis field.
Denominator Description All surgical discharges.
Exclude cases:
− Who have musculoskeletal and connective tissue diseases
(MDC 8)
− With principal diagnosis codes for seizure, syncope, stroke,
coma, cardiac arrest, poisoning, trauma, delirium and other
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psychoses, or anoxic brain injury
− With any diagnosis of metastatic cancer, lymphoid malignancy
or bone malignancy, and self inflicted injury
− 17 years of age and younger
Data Source Administrative data.
Identifying the
institutional context
As postoperative hip fractures can cause pain, suffering, prolonged
hospital stays and additional surgical interventions, monitoring this PSI
is important for pursuing quality improvement, economic, legal and
ethical 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.