Table 40 'Iatrogenic Pneumothorax'

PSI 40: Iatrogenic Pneumothorax
Origin: Review of an AHRQ PSI (3)
Dimension Description
Description of Specific
Aspects of Patient Safety
Pneumothorax is a frequent and preventable complication in medical
care. Thus it is a suitable measure of patient safety.
Aim of the PSI This PSI aims at surveillance of cases of pneumothorax caused by
medical care.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) This diagnosis code was proposed by Miller et al. as one component of
a broader indicator for “iatrogenic conditions” in the “Patient Safety
Indicator Algorithms and Groupings.” It was also included as one
component of a broader indicator; “adverse events and iatrogenic
events complications” in AHRQ Version 1.3 HCUP (3).
This AHRQ indicator is defined on both a provider level by including
cases of iatrogenic pneumothorax occurring as a secondary diagnosis
during hospitalisation and on an area level by including all cases of
iatrogenic pneumothorax (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.
Also they team concluded, that the overall usefulness of this PSI is
favourable. In their literature review the AHRQ project team found no
published evidence for this PSI that supports that hospitals; a)
providing better processes of care experience fewer adverse events; b)
providing better overall care experience fewer adverse events; and c)
offering more nursing hours per patient day, better nursing skill mix,
better physician skill mix, or more experienced physicians experience
fewer adverse events (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 1.17
for iatrogenic pneumothorax. This PSI was significantly associated
with the AHRQ PSIs for decubitus ulcer, infections due to medical
care, postoperative haemorrhage or haematoma, postoperative wound
dehiscence and technical difficulties with procedure. Significant
differences were found for hospitalisations with PSI and those without
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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 a significant increasing rate 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 iatrogenic pneumothorax 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. Iatrogenic Pneumothorax occur significantly less
often among Hispanic people 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).
The results suggest that this PSI may be useful as a measure of patient
safety (3-6).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Diagnose Specific as well as other Specific PSIs.
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Data definitions Cases of iatrogenic pneumothorax per 1000 discharges.
Numerator Description Discharges with ICD-9-CM code of 512.1 in any secondary diagnosis
field.
Denominator Description All medical and surgical discharges age 18 years and older defined by
specific DRGs.
Exclude cases:
− ICD-9-CM code of 512.1 in the principal diagnosis field
− MDC 14 (pregnancy, childbirth, and puerperium)
− with an ICD-9-CM diagnosis code of chest trauma or pleural
effusion
− with an ICD-9-CM procedure code of diaphragmatic surgery
repair
− with any code indicating thoracic surgery or lung or pleural biopsy
or assigned to cardiac surgery DRGs
Data Source Administrative data.
Identifying the
institutional context
The impact of iatrogenic pneumothorax 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
Doctors 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.