Enhancing Measurement of the AHRQ
Pediatric Patient Safety Indicators: A
Canadian Perspective
A Guttmann1,2,3,4 A Matlow 2,3 C Parshuram2,3,4 G Cernat 1 J Bennie1
G Anderson1,4
1. Institute for Clinical Evaluative Sciences
2. Hospital for Sick Children
3. Department of Paediatrics, Faculty of Medicine, University of Toronto
4. Department of Health Policy, Management and Evaluation, University of Toronto
Enhancing the effectiveness of health care
for Ontarians through research
Disclosures
• Funded by
Canadian Institute for Health Research
 Ontario Ministry of Health and Longterm
Care

Enhancing the effectiveness of health care
for Ontarians through research
Clostridium difficile (C. difficile)
Sept 30, 2008
Methicillin-resistant Staphylococcus aureus
Dec 31, 2008
Vancomycin-resistant Enterococci (VRE)
Dec 31, 2008
Hospital Standardized Mortality Ratio (HSMR)
Dec 31, 2008
Rates of ventilator-associated pneumonia
April 30, 2009
Rates of central line infections
April 30, 2009
Rates of Surgical site infections –Hips and Knees
April 30, 2009
Hand hygiene compliance among health care
workers
April 30, 2009
Monitoring of Safety in Hospitalized
Children
• Far fewer studies than in adults
• No suggestion thus far that adverse
•
events are any less common than in
adults
Most studies have focused on care in
children’s hospitals

Care for sicker and more complex patients but
not the majority of children needing acute care
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•
Pediatric Safety Measures Using
Administrative Data
Developed by AHRQ

Pediatric expert panel and data analysis
to refine adult measures for children
• McDonald et al. Pediatrics 2008 (122)e416-425
• Based on inpatient, single admission
•
data
Predominantly used to assess care
in children’s hospitals
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Measures
•
•
•
•
•
•
Accidental
puncture/laceration
FB left in
Post-op hemorrhage
Post-op resp failure
Post-op sepsis
Post-op wound
dehiscence
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•
•
•
•
Iatrogenic
pneumothorax
(neonates and nonneonates)
Infection due to
medical care
Decubitus ulcer
Transfusion reaction
AHRQ PDIs
• Validation that admissions with these
•
adverse events are longer and more
costly
• Kronman et al Pediatrics 2008(121):e1653-1659
Serious concerns about the data
quality (present on admission) as
well as preventability
• Scanlon et al Pediatrics 2008 (121):e1731-1731
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Goals of our Study
• Refine these measures for use in Canada

Adaptation to ICD-10 and increase case
ascertainment through data linkage

Explore the appropriateness of these
measures for other acute care populations
• Same day surgery
• Use linked administrative data to calculate
the refined measures across all hospitals
in Ontario, Canada ( 12 million, 40% of
Canadian population)
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Expert Panel
• National experts in pediatric patient
•
•
•
safety (NICU, pediatric neurosurgery,
infection control)
Pediatric and community-based
surgeons
Pediatric hospitalist and ICU
physician
Community-based pediatricians
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•
Process
Rate each indicator on the basis of
Common
 Significant morbidity to patients
 Preventable
 Drive QI
 Useful for accountability purpose
 Relevance for other populations

• Discussion of refinements to
indicators
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for Ontarians through research
Results
• 4 indicators dropped
Transfusion reaction
 Post-op resp failure
 Post-op wound dehiscence
 Accidental puncture

• 1 added

Post-op pneumonia
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Figure 1. Proportion of Surgical Cases by Venue
and Hospital Type, 2003 - 2007
Inpatient-Academic
Children's
N=42,677 (11% )
Inpatient-Other academic
N=8,134 (2% )
Inpatient-Community
N=43,038 (11% )
SDS-Community
N=207,091 (56% )
SDS-Academic
Children's
N=63,753 (17% )
SDS-Other academic
N=12,312 (3% )
Inpatient
Same Day
Surgery
Comparison of Cases Detected Using
Enhanced Definitions (2003-7)
Measure Cases
AHRQ
Inpatient
# of
Cases
hospitals Linkage
Inpatient
# of
Cases
hospitals SDS
# of
hospitals
Decub
ulcer
59
9
152
31
28
14
Foreign
body
9
5
13
7
5
4
Post-op
sepsis
202
20
281
27
40
17
Post-op
hemorrh
131
27
170
36
401
63
Post-op
pneum
160
24
285
45
170
48
Comparative Rates for Patient Safety Indicators - US 2003 vs Ontario 2003-2006
Rate per 1000 patients eligible for each indicator
25
US 2003 Rate
20
Ontario- AHRQ 2003-2007
15
10
5
0
Decubitus ulcer
Infections due to
medical care
Iatrogenic
pneumothorax
Postoperative
Hemorrhage or
hematoma
Postoperative
sepsis*
Patient Safety Indicator
Conclusions
• Data systems that allow linkage across
hospital episodes increases the # of cases
detected and # of hospitals included

Applicable to other indicators – SSI’s
• Most children who have surgery do so in
same day setting


Lower risk but huge volume
Adverse events occur
• Post hemorrhage most common in this group
(tonsillectomies)

Potential to bring community hospitals under
the performance measurement umbrella
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Conclusions (cont’d)
• Important issues still to be resolved
around data quality

Infections due to medical care (line infections)
• Important adverse event, admin data not good
enough
• Some events are exceedingly rare (FB,
pneumothoraces)

Challenges in use for routine monitoring +/reporting
• Currently no way to make hospital/peer
group comparisons because no risk
adjustment software for ICD10
Enhancing the effectiveness of health care
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