®
Evaluation of AHRQ Patient Safety Indicators
identified through administrative data
in Academic Medical Centers
AcademyHealth 26th Annual Research Meeting
June 30, 2009
Presented by:
Joanne Cuny RN, BSN, MBA
Director of Quality
Clinical Process Improvement
University HealthSystem Consortium
© 2009 University HealthSystem Consortium
UHC Patient Safety Indicator (PSI)
Project Goals
• Evaluate the positive predictive value of the Agency for Healthcare
Research and Quality (AHRQ) Patient Safety Indicator SAS software and
documentation most current version in identifying cases with the PSI
• Explore the clinical components used in the screening, prevention,
and recognition of the PSI
• Describe specific patient characteristics and other factors that identify
patients at increased risk for the PSI
• Share successful strategies used at AMC in managing patients at risk
for the PSI
• Previously completed UHC studies:

Failure to Rescue (2004)

Postop DVT/PE (2006)

Postop Respiratory Failure (2007)

Pressure Ulcer (2008)
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UHC PSI Project Methodology
 UHC member AMC hospitals volunteer to participate in data
abstraction for the each study
 UHC identifies PSI cases from UHC’s clinical database*, using the
AHRQ PSI SAS software and documentation most current version
 Participants conduct retrospective medical record review of
cases selected by UHC
 Cases are enrolled in reverse chronological order by discharge
date; beginning with most recent and proceeding back in time until
the target number of cases are identified
 To avoid selection bias, cases can not be skipped unless a
specific exclusion criterion is identified in the medical record
 All data abstractors receive Web conference instructions from
UHC on the functionality of the online data collection tool and data
definitions for every data element required
*UHC’s clinical database (CDB) is an all-payer, UB-04 administrative data set.
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Postoperative Respiratory Failure
Study
•
18 hospitals submitted patient-level data
•
692 cases identified by AHRQ PSI software were reviewed
•
97%1 of cases were discharged between October 2005 - July 2007
•
645 true-positive PSI 11 cases are included in study analyses
•
54.1% of study patients were male
•
Median age was 63 years (range 18 – 92)
•
Most common PRF high risk comorbid conditions in the study
population: COPD 22.2%, CHF 16.3%, and current smokers 12.7%
•
75.2% of study patients had an SOI2 classification of extreme; In the
general population, the proportion of extreme SOI cases is ~ 5%
•
80.6% of study patients received a preoperative ASA3 status of 3 or 4
1.
2.
3.
UHC queried the CDB as far back as October 2002 to locate 29 eligible cases for one participant
Severity of illness (SOI) class relates the extent of physiologic decompensation or loss of organ system
function at admission; utilizes 3M’s APR-DRG software to categorize the impact of principal diagnosis,
age, OR procedure(s), non-OR procedure, and combinations of secondary diagnoses
American Society of Anesthesiologists (ASA) status of 3 or 4 indicates
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severe systemic disease
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Postoperative Respiratory Failure
PSI with High Positive Predictive Value
0.4%
True-Positive
PRF
6.8%
2.3%
1.3%
93.2%
2.7%
False-Pos: PRF Before OR
False-Pos: PRF POA
False-Pos: Excluded NMD
False-Pos: Not PRF
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Cases with Qualifying ICD-9-CM Codes, But
Abstractor Finds No PRF
Sample comments from abstractors:
• On post op day 2 following brain biopsy, patient had an intracranial bleed
and was reintubated for surgery to evacuate hematoma; extubated in
less than 24 hrs post 2nd surgery - no PRF
• Intubated for airway protection, neuro case
• Seizures, remained intubated for airway protection in Neuro ICU
• Patient had acute epidural hematoma postop, unable to move upper
extremities, obtunded for some time
• Patient had 2 planned OR procedures; to ICU post-op after each OR
procedure
• Planned temporary tracheostomies for malignant tumor resection; radical
neck dissection; repair of gunshot wound to face
• Surgery for facial abscess, remained intubated due to swelling
• patient was somnolent and hemiplegic postoperatively due to
spontaneous carotid artery rupture, remained intubated
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PRF Project Summary of Highlights
• Cases identified as PSI 11 through diagnosis code alone (518.81 or 518.84)
had the highest false positive rate (14.9%); statistically higher than all other
groups (p < 0.0001)
• 7 patients receiving the diagnosis code for respiratory failure were never
intubated during the admission; not before or after the qualifying procedure
• 6.1% of operative procedures were conducted outside the OR; 3.5% in cath
lab or other specialty room; 2.5% at bedside
• Most common anesthesia was general; neuromuscular blocking reversal
agent was used in only 1/3 of these cases
• 49.1% the study population had more than one PSI
• 24.1% of the study population died during stay or were discharged to
hospice
•
7.7% of surviving patients were discharged on ventilator support
• 3.6% had related readmissions within 30 days of discharge
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Pressure Ulcer Study
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•
•
•
•
•
•
•
•
32 organizations submitted patient-level data
6,090 cases were screened for inclusion in 1 of 2 patient cohorts with
hospital acquired pressure ulcers (PU):
 Cohort 1: Cases with DRGs specified in AHRQ PSI 3 specifications
(version 3.2) with ICD-9 code for PU in any secondary diagnosis
 Cohort 2: Cases with any of 14 DRGs identified as high risk for PU*,
without any ICD-9 code for PU
1,234 evaluable cases with hospital acquired PUs were included in study
analyses
All cases were discharged between July 2007 - July 2008
55.2% of study patients were male
Median age was 64 years (range 18 – 100)
The median LOS was 26 days (range: 5-319 days)
The median days before hospital-acquired PU documented 8 (range 0 154 days)
The median albumin level on admission was 2.7 g/dL (range: 0.0-6.4 g/dL)
*See Appendix for list of specific DRGs
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Pressure Ulcer Status Determined by
CDB (Before Medical Record Review)
Pressure Ulcer Documentation
Pressure Ulcer Status After Data Abstraction (After Medical Record Review)
N = 6090
Total
Pressure ulcer
POA Only
No pressure
ulcer present
Pressure ulcer
hospital acquired*
Cohort 1a cases
with POA
pressure ulcer
1240
71.6% (888)
13.7% (170)
14.7% (182)
Cohort 1b cases
without POA
pressure ulcer
795
24.7% (196)
15.2% (121)
60.1% (478)
4055
10.8% (437)
74.5% (3019)
14.8% (599)
Cohort 2 cases
14.2% of Cohort 1 cases with ICD-9 code for pressure ulcer were found not to have
a pressure ulcer after chart review (i.e. documentation mischaracterized the wound)
24.7% of Cohort 1 cases were false positive due to POA, but lacked POA flag
Cases with both a POA PU and a hospital acquired PU were included in the study,
accounting for 45% Cohort 1a cases with POA flag. The other 55% of Cohort 1a
cases had only one documented PU during admission.
* 31 of the 1,259 cases with hospital acquired pressure ulcers had incomplete data
submission and therefore were not included in the 1,234 final study sample.
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Factors Contributing to PU Resolution
• Cases with documentation of being up ad lib or turned at least every
2 hours had a higher rate of resolution of hospital acquired PU before
discharge (61.1%) compared to cases without such documentation
(50.3%) [p=0.003]

There was documentation of turning every 2 hours for at risk
patients (bed rest and Braden score <19) on just 49.1% of all
observation days (range 9.4 – 93.9% of obs days)
• Cases with longer overall LOS (>26 days) had a higher incidence of
hospital acquired PU resolution (57.3%) compared to cases with
shorter LOS (46.1%) [p=0.002]

The median LOS in the study was 26 days (range: 5-319 days)
• Cases with a LOS > 22 days after documentation of the hospital
acquired PU had a higher incidence of resolution prior to discharge
(41.8%) compared to cases with shorter post- diagnosis LOS (30.1%)
[p< 0.001]
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PU Project Summary of Highlights
• PSI 3 had a 60.1% positive predictive value; 24.7% of cases
had PUs that were POA; 15.2% of cases has documentation of
a PU, when the wound was another kind of tissue injury (e.g.
skin tear), mischaracterized as a PU in documentation
• The hospital acquired PU rate was 14.8% in cases in high risk
DRG with no ICD-9 diagnosis code for PU
• A major contributor to PU resolution is turning the patient and
getting them up out of bed
• A statistically higher rate of compliance to documentation of
admission risk assessment was seen in hospitals that require a
pressure ulcer risk assessment within 4 hours of admission
(93.1%) compared to hospitals without this time requirement
(80.5%) [P < 0.001]
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Policy Implications for Policy, Practice, or
Delivery
PSI 11 (PRF)
 Some coding changes are needed to eliminating cases reintubated or
continued ET tube for airway protection, rather than respiratory disease
 Improved physician documentation, specifically related to the misuse of
the term “respiratory failure,” will contribute to increased accuracy in
coding
 Research is needed to better understand methods to screen for and
prevent avoidable postoperative complications in patients at high risk
PSI 3 (PU)
• Coding changes should be employed to allow staging of each PU and
facilitate capture of a hospital acquired PU, when a POA PU is also
present
• Improved physician documentation of skin injuries and capture of
documentation by other professionals can increase coding accuracy
• Turning patients regularly and getting them up out of bed is an effective
method in preventing and resolving PUs. This practice must be an
organizational priority and an interdisciplinary team effort
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®
The Power of Collaboration
UHC contact:
Joanne Cuny
Director of Quality
cuny@uhc.edu
Anna Narayanan
Executive Assistant
Narayanan@uhc.edu
630/954-6673
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Appendix
The following 14 DRGs were identified as high risk for pressure ulcers based on a ICD9 coded pressure ulcer rate of > 80 per 1000 cases in CDB discharged Q2/07-Q1/08.
Study cases without ICD-9 codes for pressure ulcer, but found in chart review to have
hospital acquired pressure ulcers (Cohort 2) were selected from these DRGs.
DRG
Code
465
575
542
541
578
238
129
576
287
113
123
565
072
320
Description
Aftercare w/ history of malignancy as secondary DX
Septicemia w/ MV96+ hours age >17
Trach w/ MV 96+hrs or PDX except face, mouth & neck DX w/o major OR PX
Trach w/ MV 96+hrs or PDX except face, mouth & neck DX w/ major OR PX
Infectious & Parasitic Diseases w/ OR PX
Osteomyelitis
Cardiac arrest -unexplained
Septicemia w/o MV96+ hours age >17
Skin graft/wound debridement endocr/nutrtional/metablic disorders
Amputation for circulatory disorders except upper limb & toe
Circulatory disorders w/ AMI, expired
Respiratory system DX w/ ventilator support 96+ hours
Nasal trauma & deformity
Kidney & UTI age > 17 w/CC
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