Quality Patient Safety Indicators Research Articles

Patient Safety Indicators During the Initial COVID-19 Pandemic Surge in the United States.

The COVID-19 pandemic presented a challenge to inpatient safety. It is unknown whether there were spillover effects due to COVID-19 into non-COVID-19 care and safety. We sought to evaluate the changes in inpatient Agency for Healthcare Research and Quality patient safety indicators (PSIs) in the United States before and during the first surge of the pandemic among patients admitted without COVID-19. We analyzed trends in PSIs from January 2019 to June 2020 in patients without COVID-19 using data from IBM MarketScan Commercial Database. We included members of employer-sponsored or Medicare supplemental health plans with inpatient, non-COVID-19 admissions. The primary outcomes were risk-adjusted composite and individual PSIs. We analyzed 1,869,430 patients admitted without COVID-19. Among patients without COVID-19, the composite PSI score was not significantly different when comparing the first surge (Q2 2020) to the prepandemic period (e.g., Q2 2020 score of 2.46 [95% confidence interval {CI}, 2.34-2.58] versus Q1 2020 score of 2.37 [95% CI, 2.27-2.46]; P = 0.22). Individual PSIs for these patients during Q2 2020 were also not significantly different, except in-hospital fall with hip fracture (e.g., Q2 2020 was 3.42 [95% CI, 3.34-3.49] versus Q4 2019 was 2.45 [95% CI, 2.40-2.50]; P = 0.01). The first surge of COVID-19 was not associated with worse inpatient safety for patients without COVID-19, highlighting the ability of the healthcare system to respond to the initial surge of the pandemic.

Advancing Patient Safety: Effective Strategies for Reducing Pulmonary Embolism and Deep Venous Thrombosis in Fracture Patients During the Perioperative Period

Postoperative pulmonary emboli and deep venous thrombosis are significant causes of morbidity and mortality and the focus of the Agency for Healthcare Research and Quality Patient Safety Indicator 12 (PSI-12). Early identification of patients at moderate to high risk is critical for implementation of effective prophylaxis strategies. Patients at the highest risk are those who are injured or immobilized and require surgical procedures. Early intervention strategies such as mechanical prophylaxis, pharmacologic prophylaxis, ambulation, and early surgical intervention can reduce patient harm. Using retrospective case review, most postoperative PSI-12 cases at the study site were identified as fracture patients. A multidisciplinary team developed a robust approach for early identification of patients with orthopedic fractures who were at high risk for postoperative events. Interventions included a fracture alert system to identify and prioritize patients who might require early surgical intervention. Focus was placed on pharmacological prophylaxis prior to surgical intervention, and early ambulation after surgery. As a result, PSI-12 events were reduced from eight in the pre-implementation period to none following implementation. A fracture alert system and early surgical intervention with initiation of prophylaxis strategies and postoperative early ambulation can substantially reduce the rate of PSI-12 cases in patients with fractures.

Status of Quality and Compliance to Inpatient Quality Indicators and Patient Safety Indicators in a Selected Private Corporate Hospital at Dhaka City Bangladesh

Background: The stutus of quality and compliance to inpatient quality indicators (IQIs) and patient safety indicators (PSIs) in corporate hospitals at dhaka city Bangladesh are not known as they are not adequately studied. Objective: The present descriptive cross-sectional study was therefor undertaken to know the status of quality and compliance to selected IQIs and PSIs in a selected private (corporate) hospital at Dhaka City Bangladesh. The period of study and hospital data collection period were May to August 2019 and January to March 2019 respectively. Methods: Selected IQIs and PSIs developed by Agency for Healthcare Research and Quality (AHRQ), USA and hospital facilities utilization parameters were investigated. Data were collected using questionnaires and checklists for the period of January to March 2019 from the purposively selected private (corporate) hospital. Sociodemographic information of randomly selected junior doctors and nurses were taken. Randomly selected senior clinicians, nurses and executives were interviewed regarding knowledge about selective IQIs, PSIs, JCIS, ISO relevant to quality healthcare. Data were analysed by SPSS programme version 20. Results: The hospital has all relevant admistrative and clinical departments, bed patterns and has efficient admission and discharge processes for inpatients. Bed utilization was 87.5% of total 159 available beds. Patients visited OPD: 2434 per day, admitted: 28 per day and discharged with successful outcome: 27 per day. Average length of stay (ALS), hospital acquired infection (HAI) and hospital deaths were 3.6 days, 1.76% (18/1000 cases), and 124 (01 per day) respectively during data collection period. Tests done in Laboratory Medicine were 267637 with Clinical Biochemistry tests highest (51.21%) and investigations in Radiology-Imaging departments were 74997 with X-rays being highest (40.22%). Of the five selected IQIs, total CABG cases done were 191 with 04 hospital deaths i.e. 2.1% (21 per 1000 cases) and total AMI cases done were 140 with 12 hospital deaths i.e. 8.5% (85 per 1000 cases). No casualties were reported for caesarean deliveries or primary/normal deliveries. None of the five selected PSIs were traced over the data collection period. Conclusion: These findings suggested that the selected hospital’s services were demanding and it was concerned about quality healthcare services. However, comparative studies with other private corporate hospotals at Dhaka City including larger number of respodents are warrented. Bangladesh Medical Res Counc Bull 2023; 49(2): 98-112

Combined impact of Medicare’s hospital pay for performance programs on quality and safety outcomes is mixed

BackgroundThree major hospital pay for performance (P4P) programs were introduced by the Affordable Care Act and intended to improve the quality, safety and efficiency of care provided to Medicare beneficiaries. The financial risk to hospitals associated with Medicare’s P4P programs is substantial. Evidence on the positive impact of these programs, however, has been mixed, and no study has assessed their combined impact. In this study, we examined the combined impact of Medicare’s P4P programs on clinical areas and populations targeted by the programs, as well as those outside their focus.MethodsWe used 2007–2016 Healthcare Cost and Utilization Project State Inpatient Databases for 14 states to identify hospital-level inpatient quality indicators (IQIs) and patient safety indicators (PSIs), by quarter and payer (Medicare vs. non-Medicare). IQIs and PSIs are standardized, evidence-based measures that can be used to track hospital quality of care and patient safety over time using hospital administrative data. The study period of 2007–2016 was selected to capture multiple years before and after introduction of program metrics. Interrupted time series was used to analyze the impact of the P4P programs on study outcomes targeted and not targeted by the programs. In sensitivity analyses, we examined the impact of these programs on care for non-Medicare patients.ResultsMedicare P4P programs were not associated with consistent improvements in targeted or non-targeted quality and safety measures. Moreover, mortality rates across targeted and untargeted conditions were generally getting worse after the introduction of Medicare’s P4P programs. Trends in PSIs were extremely mixed, with five outcomes trending in an expected (improving) direction, five trending in an unexpected (deteriorating) direction, and three with insignificant changes over time. Sensitivity analyses did not substantially alter these results.ConclusionsConsistent with previous studies for individual programs, we detect minimal, if any, effect of Medicare’s hospital P4P programs on quality and safety. Given the growing evidence of limited impact, the administrative cost of monitoring and enforcing penalties, and potential increase in mortality, CMS should consider redesigning their P4P programs before continuing to expand them.

Hospital Magnet Status Associates With Inpatient Safety in Parkinson Disease.

BACKGROUND: Persons with Parkinson disease (PD) have complex care needs that may benefit from enhanced nursing care provided in Magnet-designated hospitals. Our primary objective was to determine whether an association exists between hospital Magnet status and patient safety events for PD inpatients in the United States. METHODS: We conducted a retrospective cohort study using the Nationwide Inpatient Sample and Agency for Healthcare Research and Quality databases from 2000 to 2010. Parkinson disease diagnosis and demographic variables were retrieved, along with Magnet designation and other hospital characteristics. Inpatient mortality and preventable adverse events in hospitals with and without Magnet status were then compared using relevant Agency for Healthcare Research and Quality patient safety indicators. RESULTS: Between 2000 and 2010, 493 760 hospitalizations among PD patients were identified. Of those, 40 121 (8.1%) occurred at one of 389 Magnet hospitals. When comparing PD patients in Magnet versus non-Magnet hospitals, demographic characteristics were similar. Multivariate regression models adjusting for patient and hospital characteristics identified a 21% reduction in mortality among PD inpatients in Magnet hospitals (adjusted odds ratio [AOR], 0.79; 95% confidence interval [CI], 0.74-0.85). PD inpatients in Magnet hospitals also had a lower odds of experiencing any patient safety indicator (AOR, 0.74; 95% CI, 0.68-0.79), pressure ulcers (AOR, 0.60; 95% CI, 0.55-0.67), death from a low mortality condition (AOR, 0.74; 95% CI, 0.68-0.79), and a higher odds of postoperative bleeding (AOR, 1.45; 95% CI, 1.04-2.04). CONCLUSIONS: PD patients had a reduced risk of inpatient mortality and several nursing-sensitive patient safety events, highlighting the possible benefits of Magnet status on inpatient safety in PD.

Poor concordance of contemporary performance measures in detecting complications in complex endovascular aortic repair

BackgroundThe Agency for Healthcare Research and Quality Patient Safety Indicators (PSI) are quality improvement indicators used to determine hospital performance and, increasingly, to rank surgical programs. The American College of Surgeons National Surgical Quality Improvement Program and the Society for Vascular Surgery Vascular Quality Improvement databases are also frequently used to compare outcomes, but definitions of complications vary between the systems and the optimal system for tracking complications in complex endovascular repair remains unclear. Herein we assess the three outcome tracking systems and their ability to capture complications after fenestrated endovascular abdominal aortic aneurysm repair (FEVAR) and open aortic aneurysm repair in a large complex aortic program. MethodsDemographic and operative data for patients undergoing repair of juxtarenal or pararenal aortic aneurysms between 2004 and 2018 via both open and FEVAR approaches at the Johns Hopkins Medical Institutions were compiled in a prospectively maintained retrospective database. Postoperative complications were defined according to a surgeon-defined system, the Society for Vascular Surgery Vascular Quality Initiative, the American College of Surgeons National Surgical Quality Improvement Program, and the Agency for Healthcare Research and Quality PSI data dictionaries and were compared between surgical approaches as well as eras before and after the introduction of FEVAR. Complication rates between the classification systems were compared using proportion testing and the strength of the correlation between the systems was evaluated with Spearman's rank test. ResultsOf 145 patients, 60 (41.4%) underwent FEVAR and 85 (58.6%) underwent open aortic aneurysm repair. The introduction of fenestrated technology was associated with a decrease in the overall number of complications from 37.2% to 20.6% by surgeon-defined classification system (P = .036). The VQI identified the most complications (39.9% of the entire cohort and 25% of FEVAR cases), followed by the NSQIP (29.0% and 33.3%, respectively) and PSI (4.1% and 5%). The two clinically focused databases were found to correlate well with a surgeon-designed classification system, as well as each other (Spearman ρ ≥ 0.735) but not with PSI (ρ < 0.23). Proportion testing demonstrated the rate of complications identified by PSI to be significantly less than either VQI or NSQIP (P < .001). Specifically, PSI did not effectively identify renal complications (1.4% vs 9.0% by NSQIP and 27.3% by VQI definitions; P < .001). ConclusionsThe introduction of FEVAR is associated with an overall decrease in complications in this study. The clinically relevant VQI and NSQIP databases show good concordance in capturing complications; however, PSI did not correlate with either and captured significantly fewer complications. These data highlight the value of high scrutiny classification systems to track postoperative complications and suggest that PSI are insufficient to rank complex aortic programs with high levels of FEVAR use.

Value-Based Care: An Executive Briefing

In today’s challenging health care environment, the paradigm shift from volume to value requires nurse leaders to develop enhanced skills to transform health care in 2020. Key drivers for success include: igniting innovation and change; embracing data and analytics; and launching new care delivery models that soar beyond organizational boundaries. Value-based care is here to stay, and nursing must be the catalyst for change. Equipped with new skills and the knowledge of CMS Pay for Performance programs, nurse leaders will design the future health care landscape.

A Sensitive Matter: Performance of Contemporary Outcomes Measures in Detecting Complications in Complex Endovascular Aortic Repair

Agency for Healthcare Research and Quality Patient Safety Indicators are quality improvement indicators used to determine hospital performance and, increasingly, to rank surgical programs. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the Society for Vascular Surgery Vascular Quality Initiative (SVS-VQI) databases are also frequently used to compare outcomes, but definitions of complications vary between the systems, and the optimal system for tracking complications in complex endovascular repair remains unclear. Herein we assess the three outcomes tracking systems and their ability to capture complications in fenestrated endovascular (FEVAR) and open aortic aneurysm (OAR) repair at a large complex aortic program. Demographic and operative data for patients undergoing repair of juxta- or pararenal aortic aneurysms between 2004 and 2018 via both open and fenestrated endovascular (FEVAR) approaches at the Johns Hopkins Medical Institutions were compiled in a prospectively maintained retrospective database. Postoperative complications were defined according to the SVS-VQI, ACS-NSQIP and data dictionaries and were compared between surgical approaches as well as eras before and after the introduction of FEVAR. Complication rates between the classification systems were compared using proportion testing and strength of correlation between the systems was evaluated with Spearman’s rank test. Statistical analysis was performed with Stata version 15.1 (StataCorp, Cary, NC). Introduction of fenestrated technology was associated with a decrease in the overall number of complications (37.2% to 20.6%; P = .036). By classification systems, VQI identified the most complications (39.9% of the entire cohort and 25% of FEVAR cases), followed by NSQIP (29.0% and 33.3%, respectively) and PSI (4.1% and 5%, respectively). The two clinically focused databases were found to correlate well with a surgeon-designed classification system as well as each other (Spearman ρ ≥ 0.735) but not with PSI (ρ < 0.23). Proportion testing demonstrated the rate of complications identified by PSI to be significantly less than either VQI or NSQIP (P < .001). Specifically, PSI did not effectively identify renal complications (1.4% vs 9% by NSQIP and 27.3% by VQI definitions; P < .001). The introduction of FEVAR is associated with an overall reduction in complications in this study, mostly owing to a reduction in respiratory complications. The clinically relevant VQI and NSQIP databases show good concordance in capturing complications; however, PSI did not correlate with either and captured significantly fewer complications. This highlights the value of high scrutiny classification systems to track endovascular complications and suggests that PSI are insufficient to rank complex aortic programs with high levels of FEVAR use.

Patient Safety Indicators are an insufficient performance metric to track and grade outcomes of open aortic repair

ObjectiveNational rankings of hospitals rely on outcomes-based evaluation to assess the performance of surgical programs, particularly those performing high-risk elective surgical procedures such as open aortic repair. Various classification systems exist for tracking outcomes, but increasingly the International Classification of Diseases, Tenth Revision-based Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) are used as a publicly reported comparison measure of hospital quality performance. We sought to critically evaluate the accuracy of the existing vehicles to assess open aortic repair outcomes in an established program. MethodsThis is a case-control study of patients who underwent open abdominal aortic aneurysm repair at the Johns Hopkins Medical Institutions from 2004 to 2018. Patients' characteristics and outcomes were collected as part of a prospectively maintained retrospective database. For each case, hemorrhagic, cardiac, respiratory, renal, wound, and thromboembolic complications were identified with the unique definitions used for open abdominal aortic aneurysm repair by the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, the Society for Vascular Surgery Vascular Quality Initiative (VQI) database, and the Agency for Healthcare Research and Quality PSI initiative. ResultsOf the 154 patients included in the study, 79 (51.0%) were identified as having a complication as defined by the VQI, 46 (29.7%) according to the NSQIP, and 15 (9.7%) according to the PSI system (P < .001). Patients most likely to incur a complication in the PSI system were those with a pararenal or more extensive aneurysm, with baseline congestive heart failure, requiring a supramesenteric clamp (all P < .01), or with an aneurysm >6.5 cm in diameter (P = .02). The NSQIP and VQI systems both identified more postoperative hemorrhagic, respiratory, renal, and wound complications than the PSI system did (P < .05). The VQI system identified the most renal complications (52; P < .001); factors unique to incurring a complication in the VQI include use of a suprarenal clamp and performance of an aortorenal bypass procedure as part of the repair (P < .01). Particularly weak correlation was noted between the PSI system and the VQI with respect to renal outcomes (ρ = 0.163). ConclusionsThe PSI system identified fewer important complications than either of the clinically focused databases, with the VQI capturing the most postoperative events, mostly because of its stringent definition of renal injury. We conclude that the PSI system should not form the basis of grading hospital performance in comparing clinically relevant complications of open aortic surgery programs.

Association of hospital volume with patient selection, risk of complications, and mortality from failure to rescue after open abdominal aortic aneurysm repair

ObjectiveThe association of higher hospital volume with lower mortality after open abdominal aortic aneurysm (OAAA) repair is well known; however, the underlying mechanism for improved outcomes is poorly understood. Better patient selection, lower risk of complications, and improved ability to rescue patients after adverse events are assumed mechanisms, but few data exist to validate this hypothesis. The purpose of this analysis was to determine the association of hospital volume with patient selection, incidence of complications, and failure to rescue (FTR) after adverse events resulting from OAAA repair. MethodsThe Vizient (Irving, Tex) database (>95% of all academic hospitals) was reviewed for OAAA repairs (elective, n = 2827; nonelective, n = 1622) performed from 2012 to 2014. Presentation type (elective vs nonelective) was considered in all analyses. Elixhauser comorbidity index and van Walraven weighted scores were assigned to patients and volume-outcome relationships explored. By use of logistic regression, risk-adjusted complications (including preventable complications; Agency for Healthcare Research and Quality patient safety indicators [PSIs]) and FTR rates were determined. Predicted risk scores were assigned to delineate hospital volume association with these outcomes. ResultsOverall, no relationship between hospital volume and composite patient comorbidity severity score was identified (Elixhauser comorbidity index and van Walraven weighted scores: Pearson [ρ, 0.02], P = .2; [ρ, −0.01], P = .4; Spearman correlation coefficient [ρ, 0.02], P = .4; [ρ, −0.02], P = .2). The lack of correlation persisted in considering elective vs nonelective status. However, for elective cases, differences in specific comorbidities were noted because high-volume hospitals were more likely to repair patients with a history of peripheral vascular disease (P = .01), diabetes (P = .07), obesity (P = .004), and alcohol abuse (P = .05). Lower volume hospitals more frequently repaired patients with hypothyroidism (P = .05), fluid and electrolyte disorders (P = .007), and chronic blood loss anemia (P = .05). No specific individual comorbidity differences were detected for nonelective cases. In examining hospital volume effects on the likelihood for development of any complication (45%), PSIs (12%), and FTR (9%), a significant risk reduction was noted in high-volume institutions. Specifically, a nonlinear relationship between hospital volume and risk of any complication (P = .0004), PSI (P = .0004), and FTR (P =. 0003) was present. In exploring the risk of specific complications or PSI events, greater hospital volume was strongly correlated to a lower likelihood of multiple adverse outcomes. ConclusionsAlthough high-volume institutions performing OAAA repair do not necessarily operate on patients with more comorbidities, there are important differences in the patients selected compared with lower volume hospitals. The risk for development of multiple specific postoperative complications as well as for preventable adverse events preceding FTR is significantly lower in high-volume centers. These findings provide benchmarks for multiple selected quality indicators and further support national initiatives to incentivize regionalization of OAAA care.

Increased reporting but decreased mortality associated with adverse events in patients undergoing lung cancer surgery: Competing forces in an era of heightened focus on care quality?

IntroductionAdvances in surgical techniques have improved clinical outcomes and decreased complications. At the same time, heightened attention to care quality has resulted in increased identification of hospital-acquired adverse events. We evaluated these divergent effects on the reported safety of lung cancer resection.Methods and materialsWe analyzed hospital-acquired adverse events in patients undergoing lung cancer resection using the National Hospital Discharge Survey (NHDS) database from 2001–2010. Demographics, diagnoses, and procedures data were abstracted using ICD-9 codes. We used the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSI) to identify hospital-acquired adverse events. Weighted analyses were performed using t-tests and chi-square.ResultsA total of 302,444 hospitalizations for lung cancer resection and were included in the analysis. Incidence of PSI increased over time (28% in 2001–2002 vs 34% in 2009–2010; P<0.001). Those with one or more PSI had increased in-hospital mortality (aOR = 11.1; 95% CI, 4.7–26.1; P<0.001) and prolonged hospitalization (12.5 vs 7.8 days; P<0.001). However, among those with PSI, in-hospital mortality decreased over time, from 17% in 2001–2002 to 2% in 2009–2010.ConclusionsIn a recent ten-year period, documented rates of adverse events associated with lung cancer resection increased. Despite this increase in safety events, we observed that mortality decreased. Because such metrics may be incorporated into hospital rankings and reimbursement considerations, adverse event coding consistency and content merit further evaluation.

1114: Operative vaginal delivery and rates of primary cesarean in California hospitals

Rates of primary cesarean section and obstetric anal sphincter injury (OASIS) are quality metrics and patient safety indicators for hospitals in the United States. Over the last decade, rates of cesarean section have risen while operative vaginal deliveries have fallen out of favor. We examined hospital-level rates of cesarean section associated with third- and fourth-degree laceration. This is retrospective study of California hospital deliveries from 2007-2011. We excluded hospitals with < 50 deliveries per year. Hospital rates of primary cesarean section and severe (3rd/4th degree) laceration in nulliparous, term, singleton, vertex (NSTV) deliveries were calculated. Rates of each respective variable were used to generate a scatter plot. Pearson correlation was used to calculate covariance in order to examine the relationship between each delivery method. We identified 269 hospitals meeting inclusion criteria. The mean proportion of primary cesarean section was 0.164 ± 0.035, and the mean proportion of NSTV deliveries with severe perineal lacerations was 0.064 ± 0.027. The proportion of primary cesarean deliveries is overall negatively correlated with the proportion of severe perineal laceration among NSTV deliveries (correlation coefficient = -0.21, p< 0.001). There is an inverse relationship between hospital-level rates of primary cesarean delivery and severe OASIS injury in NSTV deliveries. Strategies to reduce numbers of patient safety indicators like OASIS injury may result in higher rates of primary cesarean.

Postoperative respiratory failure: An update on the validity of the Agency for Healthcare Research and Quality Patient Safety Indicator 11 in an era of clinical documentation improvement programs

BackgroundAdministrative data can be used to identify cases of postoperative respiratory failure (PRF). We aimed to determine if recent changes to the Agency for Healthcare Research and Quality Patient Safety Indicator 11 (PSI 11) and adoption of clinical documentation improvement programs have improved the validity of PSI 11. We also analyzed reasons why PSI 11 was falsely triggered. Study designCross-sectional study of all eligible discharges using health record data from five academic medical centers between October 1, 2012 and September 30, 2015. ResultsOf 437 flagged records, 434 (99.3%) were accurately coded and 414 (94.7%) represented true clinical PRF. None of the false positive records involved respiratory failure present on admission. Most (78.3%) false positive records required airway protection but did not have respiratory failure. ConclusionThe validity of PSI 11 has improved with recent changes to the code criterion and adoption of clinical documentation improvement programs.

Increasing Numbers and Reported Adverse Events in Patients with Lung Cancer Undergoing Inpatient Lung Biopsies: A Population-Based Analysis.

The use of molecular biomarkers to guide lung cancer management has led to increasing frequency and amounts of tissue required for repeat lung biopsies. While patient safety and reporting of adverse events has been increasingly emphasized in recent decades, the safety of lung biopsies in patients with lung cancer has only been studied in small cohorts. We therefore analyzed adverse events in patients with lung cancer undergoing lung biopsies in the National Hospital Discharge Survey (NHDS) database. Data were abstracted using ICD-9 lung cancer diagnosis (162.X) and lung biopsy procedure codes (33.20, 33.24, 33.25, 33.26, 33.27, 33.28) from 2001 to 2010. Agency for Healthcare Research and Quality (AHRQ) Patient-Safety Indicators (PSI) were used to identify hospital-acquired adverse events. Weighted analyses were performed using SAS version 9.4. A total of 540,747 patients were included for analysis. The number of biopsies increased over time, from 51,221 in 2001, to 63,239 in 2010 (P < 0.001). Overall, 159,683 (30%) patients suffered ≥ 1-PSI event during their hospitalization. Incidence of PSI varied by biopsy type: bronchoscopic (26%), percutaneous (34%), surgical (39%). The proportion of patients with ≥ 1 PSI event increased from 24% in 2001 to 38% in 2010 (P < 0.001). Patients with ≥ 1 PSI had longer length of stay (mean, 11.6 vs 8.1days; P < 0.001) and higher in-hospital mortality (adjusted odds ratio, 5.9, 95% CI 3.9-8.9; P < 0.001). The frequency of lung biopsies performed and rate of documented adverse events in hospitalized lung cancer patients have increased. These findings have policy, funding, research, and practice implications.

Investing in Skilled Specialists to Grow Hospital Infrastructure for Quality Improvement.

ObjectivesHospitals can reduce labor costs by hiring lowest skill possible for the job, stretching clinical hours, and reducing staff not at bedside. However, these labor constraints designed to reduce costs may paradoxically increase costs. Specialty staff, such as board-certified clinicians, can redesign health systems to evaluate the needs of complex patients and prevent complications. The aim of the study was to evaluate whether investing in skilled specialists for supporting hospital quality infrastructure improves value and performance.MethodsWe evaluated pressure injury rates as an indicator of performance in a retrospective observational cohort of 55 U.S. academic hospitals from the Vizient clinical database between 2007 and 2012. Pressure injuries were defined by U.S. Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator 3 (PSI-03) for stage 3, 4, and unstageable pressure injuries not present on admission in hospitalized adults. We compared ratios of board-certified wound care nurses per 1000 hospital beds to hospital-acquired pressure injury rates in these hospitals using mixed-effects regression of hospital quarters.ResultsHigh-performing hospitals invested in prevention infrastructure with skilled specialists and observed performance improvements. Regression indicated that by adding one board-certified wound care nurse per 1000 hospital beds, hospitals had associated decreases in pressure injury rates by −17.7% relative to previous quarters, controlling for other interruptions. Highest performers supplied fewer skilled specialists and achieve improved outcomes.ConclusionsSkilled specialists bring important value to health systems as a representation of investment in infrastructure, and the proportion of these specialists could be scaled relative to the hospital’s patient capacity. Policy should support hospitals to make investments in infrastructure to drive down patient costs and improve quality.

Improved hospital safety performance and reduced medicolegal risk: an ecological study using 2 Canadian databases.

Few empirical studies have validated the relation between medicolegal risk and hospital patient safety performance. We sought to determine whether there was a relation between in-hospital patient safety events and medicolegal cases involving Canadian physicians. In this ecological study, we used Poisson regression to compare data from the Canadian Institute for Health Information's Discharge Abstract Database and the database of the Canadian Medical Protective Association (CMPA) of medicolegal cases over 10 years (2005/06 to 2014/15). We identified incidents and cases based on 15 Agency for Healthcare Research and Quality patient safety indicators within the Canadian Institute for Health Information and CMPA data sets. We performed subgroup analyses for obstetrical and surgical cases. We found a statistically significant positive association between volume changes in patient safety indicator events (n = 339 741) and medicolegal cases (n = 15 180) (parameter estimate 1.15, 95% confidence interval [CI] 0.4 to 1.9). This association suggests that, on average, a 10% decrease in events would correspond to a decrease of 11% in medicolegal cases. The degree of positive association varied by practice type, with obstetrics (97 982 patient safety indicator events, 865 cases) showing a 25% decrease in medicolegal cases for every 10% decrease in events (parameter estimate 2.9, 95% CI 0.5 to 5.3) and surgery (168 886 patient safety indicator events, 4568 cases) showing a decrease of 9% for every 10% decrease in events (parameter estimate 0.9, 95% CI 0.2 to 1.7). The statistically significant positive association between patient safety indicator events and medicolegal cases quantifies a relation between patient safety and physician medicolegal risk in Canadian hospitals. This suggests new, practical uses for both medicolegal and patient safety indicator data in system-level quality-improvement efforts.

Improved Identification of Venous Thromboembolism From Electronic Medical Records Using a Novel Information Extraction Software Platform.

The United States federally mandated reporting of venous thromboembolism (VTE), defined by Agency for Healthcare Research & Quality Patient Safety Indicator 12 (AHRQ PSI-12), is based on administrative data, the accuracy of which has not been consistently demonstrated. We used IDEAL-X, a novel information extraction software system, to identify VTE from electronic medical records and evaluated its accuracy. Medical records for 13,248 patients admitted to an orthopedic specialty hospital from 2009 to 2014 were reviewed. Patient encounters were defined as a hospital admission where both surgery (of the spine, hip, or knee) and a radiology diagnostic study that could detect VTE was performed. Radiology reports were both manually reviewed by a physician and analyzed by IDEAL-X. Among 2083 radiology reports, IDEAL-X correctly identified 176/181 VTE events, achieving a sensitivity of 97.2% [95% confidence interval (CI), 93.7%-99.1%] and specificity of 99.3% (95% CI, 98.9%-99.7%) when compared with manual review. Among 422 surgical encounters with diagnostic radiographic studies for VTE, IDEAL-X correctly identified 41 of 42 VTE events, achieving a sensitivity of 97.6% (95% CI, 87.4%-99.6%) and specificity of 99.8% (95% CI, 98.7%-100.0%). The performance surpassed that of AHRQ PSI-12, which had a sensitivity of 92.9% (95% CI, 80.5%-98.4%) and specificity of 92.9% (95% CI, 89.8%-95.3%), though only the difference in specificity was statistically significant (P<0.01). IDEAL-X, a novel information extraction software system, identified VTE from radiology reports with high accuracy, with specificity surpassing AHRQ PSI-12. IDEAL-X could potentially improve detection and surveillance of many medical conditions from free text of electronic medical records.

Retained foreign bodies and associated risk factors and outcomes in pediatric surgical patients

BackgroundRetained foreign bodies discovered after surgery are documented as Agency for Health Care Quality and Research Patient Safety Indicators. Our goal was to identify pediatric patient and procedure risk factors and outcomes associated with RFB based on AHRQ Definitions. MethodsWe performed a retrospective case–control study of children with RFB using the PHIS database. Patients were defined as having RFB based on the AHRQ PSI definition. Controls were matched in a 5:1 ratio on age, procedure date, and hospital. Our primary outcome was the presence of RFB. Secondary outcomes included hospital length of stay and mortality. ResultsPatients with RFB often underwent emergent procedures, experienced one or more chronic conditions, and required ICU admission or mechanical ventilation. Musculoskeletal procedures contribute the largest numbers of RFB (30.4%), but interventional radiology procedures had higher odds of having RFB (AOR 7.88, p < 0.0001). After multivariate adjustment, children with RFB required 4 more days of hospitalization (p < .001), but there was no difference in mortality (p = .579). ConclusionsThe implications of our study include identifying which administrative flags can be used to identify children at higher risks for RFB. Early identification of at-risk patients and prevention are key towards addressing the primary problem and corresponding sequela of RFB. Levels of EvidencePrognostic Study Level III.

Unintended consequences of quality improvement programs on the prevention of hospital-acquired conditions: Avoiding the temptation to bite into low-hanging fruit

Hospital-acquired conditions such as pressure injuries, falls, and infections are common, costly, and deadly. Addressing the simultaneous needs of evidence-based prevention guidelines for multiple conditions can be challenging for clinical teams. Current payment incentives created by The Centers for Medicare and Medicaid Services using the Agency for Healthcare Research and Quality Patient Safety Indicator 90 (PSI90) measure impact how clinical resources are allocated by prioritizing conditions that are simpler and less costly to prevent. Pressure injury prevention guidelines may be one of the more complex programs for hospitals to implement due to the financial investment in nursing time and technology. However, a quality improvement program focused around pressure injury prevention holds good value by tackling many of the tangential conditions caused by issues related to the decubitus patient and mobility, including fall injury, venous thromboembolism, catheter-associated urinary tract infection, and sepsis. Hospitals should reconsider their prioritization of different patient safety indicators, and The Centers for Medicare and Medicaid Services should create more focused payment incentives on harmful hospital-acquired conditions such as pressure injury that are independent of composite measures of harm, including PSI90.

Tailoring an educational program on the AHRQ Patient Safety Indicators to meet stakeholder needs: lessons learned in the VA

BackgroundGiven that patient safety measures are increasingly used for public reporting and pay-for performance, it is important for stakeholders to understand how to use these measures for improvement. The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) are one particularly visible set of measures that are now used primarily for public reporting and pay-for-performance among both private sector and Veterans Health Administration (VA) hospitals. This trend generates a strong need for stakeholders to understand how to interpret and use the PSIs for quality improvement (QI). The goal of this study was to develop an educational program and tailor it to stakeholders’ needs. In this paper, we share what we learned from this program development process.MethodsOur study population included key VA stakeholders involved in reviewing performance reports and prioritizing and initiating quality/safety initiatives. A pre-program formative evaluation through telephone interviews and web-based surveys assessed stakeholders’ educational needs/interests. Findings from the formative evaluation led to development and implementation of a cyberseminar-based program, which we tailored to stakeholders’ needs/interests. A post-program survey evaluated program participants’ perceptions about the PSI educational program.ResultsInterview data confirmed that the concepts we had developed for the interviews could be used for the survey. Survey results informed us on what program delivery mode and content topics were of high interest. Six cyberseminars were developed—three of which focused on two content areas that were noted of greatest interest: learning how to use PSIs for monitoring trends and understanding how to interpret PSIs. We also used snapshots of VA PSI reports so that participants could directly apply learnings. Although initial interest in the program was high, actual attendance was low. However, post-program survey results indicated that perceptions about the program were positive.ConclusionsConducting a formative evaluation was a highly important process in program development. The useful information that we collected through the interviews and surveys allowed us to tailor the program to stakeholders’ needs and interests. Our experiences, particularly with the formative evaluation process, yielded valuable lessons that can guide others when developing and implementing similar educational programs.