Table 37 'In-Hospital Hip Fracture or Fall'

PSI 36: In Hospital Hip Fracture or Fall
Review of an OECD PSI (33).
Dimension Description
Description of Specific
Aspects of Patient Safety
Falls are a common cause of morbidity and mortality especially among
elderly in-patients over 65 years of age. Falls are associated with
functional disability and injury, increased length of stay, and risk of
nursing home placement from hospital. Often falls are the result of the
interaction of many factors. Falls may be caused by the persons’ health
status, response to medical interventions, external factors such as the
type of floor or other factors. Thus in-hospital hip fracture or fall is an
adequate measure of patient safety.
Aim of the PSI This PSI is intended to flag cases of in-hospital hip fractures or falls.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) The complication screening programme (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 was successfully completed in all five priority
areas leading to a recommendation of 86 indicators of which 21 cover
patient safety (33).
The Complications Screening Program (CSP) aims to identify 28
potentially preventable complications of hospital care using
computerised discharge abstracts, including demographic information,
diagnosis and procedure codes. A study was set up to validate the CSP
as a quality indicator. Explicit process of care criteria were used to
determine whether hospital discharges flagged by the CSP experienced
more process problems than unflagged discharges. The CSP was
applied to computerised hospital discharge abstracts from Medicare
beneficiaries > 65 years old admitted in 1994 to hospitals in California
and Connecticut for major surgery or medical treatment. The final
sample included 740 surgical and 416 medical discharges. Rates of
process problems were high, ranging from 24.4 to 82.5% across CSP
screens for surgical cases. Problems were lower for medical cases,
ranging from 2.0 to 69.1% across CSP screens. Problem rates were
45.7% for surgical and 5.0% for medical controls. Rates of problems
did not differ significantly across flagged and unflagged discharges.
The researchers concluded: “The CSP did not flag discharges with
significantly higher rates of explicit process problems than unflagged
discharges” (37).
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Another study of the CSP was undertaken to study the accuracy of
computer algorithms on administrative data to identify hospital
complications. The assessment was based on a medical records
indicator differentiating hospital-acquired conditions from pre-existing
comorbidities. Indicators for identifying potential hospital
complications were applied to all secondary diagnoses for all 1997-
1998 discharges. The researchers concluded: “Current complication
algorithms identify many cases where the condition was actually
present on hospital admission. This fact, coupled with the known
variability in coding between institutions, makes comparisons between
hospitals on many of the complications problematic. Collection of the
present-on-admission flag significantly reduces the noise in monitoring
complication rates (38).
The results suggest that this PSI may be useful as a measure of patient
safety (33;37).
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 or fall per 100 surgical discharges
with an operating room procedure.
Numerator Description Patients experiencing an in-hospital hip fracture or fall; defined as
secondary diagnosis only.
A fall is defined as unintentionally coming to rest on the ground, floor,
or other lower level, but not as a result of syncope or overwhelming
external force.
Exclude cases:
− With trauma or metastatic cancer as any diagnosis
− With principal diagnosis of seizure, syncope, stroke, coma, cardiac
arrest, or poisoning
− In MDC 8.
Denominator Description Inpatients undergoing major surgery OR minor or miscellaneous
surgery OR invasive cardiac procedures OR invasive radiologic
procedures OR endoscopy OR medical patients OR all patients as
defined by the CSP.
Data Source Administrative data.
Identifying the
institutional context
The impact of falls makes this PSI important for both financial and
quality improvement policies.
Care Setting The PSI applies for high quality care.
Professionals Responsible
for Health Care
All health care workers.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
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Allowance for Patient
Factors
No risk adjustment described.
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison No specific standards given.
Scoring Not specified