Haytham M.A. Kaafarani

Validity of Selected Patient Safety Indicators: Opportunities and Concerns

BACKGROUND The Agency for Healthcare Research and Quality (AHRQ) recently designed the Patient Safety Indicators (PSIs) to detect potential safety-related adverse events. The National Quality Forum has endorsed several of these ICD-9-CM-based indicators as quality-of-care measures. We examined the positive predictive value (PPV) of 3 surgical PSIs: postoperative pulmonary embolus and deep vein thrombosis (pPE/DVT), iatrogenic pneumothorax (iPTX), and accidental puncture and laceration (APL). STUDY DESIGN We applied the AHRQ PSI software (v.3.1a) to fiscal year 2003 to 2007 Veterans Health Administration (VA) administrative data to identify (flag) patients suspected of having a pPE/DVT, iPTX, or APL. Two trained nurse abstractors reviewed a sample of 336 flagged medical records (112 records per PSI) using a standardized instrument. Inter-rater reliability was assessed. RESULTS Of 2,343,088 admissions, 6,080 were flagged for pPE/DVT (0.26%), 1,402 for iPTX (0.06%), and 7,203 for APL (0.31%). For pPE/DVT, the PPV was 43% (95% CI, 34% to 53%); 21% of cases had inaccurate coding (eg, arterial not venous thrombosis); and 36% featured thromboembolism present on admission or preoperatively. For iPTX, the PPV was 73% (95% CI, 64% to 81%); 18% had inaccurate coding (eg, spontaneous pneumothorax), and 9% were pneumothoraces present on admission. For APL, the PPV was 85% (95% CI, 77% to 91%); 10% of cases had coding inaccuracies and 5% indicated injuries present on admission. However, 27% of true APLs were minor injuries requiring no surgical repair (eg, small serosal bowel tear). Inter-rater reliability was >90% for all 3 PSIs. CONCLUSIONS Until coding revisions are implemented, these PSIs, especially pPE/DVT, should be used primarily for screening and case-finding. Their utility for public reporting and pay-for-performance needs to be reassessed.

Trends, outcomes, and predictors of open and conversion to open cholecystectomy in Veterans Health Administration hospitals.

BACKGROUND Laparoscopic cholecystectomy (LC) accounts for more than 85% of cholecystectomies. Factors prompting open cholecystectomy (OC) or conversion from LC to OC (CONV) are not completely understood. METHODS Prospectively collected data from the National Surgical Quality Improvement Program (NSQIP) were combined with administrative data to identify patients undergoing cholecystectomy from October 2005 to October 2008. Three cohorts were defined: LC, OC, and CONV. Using logistic hierarchical modeling, we identified predictors of the choice of OC and the decision to CONV. RESULTS A total of 11,669 patients underwent cholecystectomy at 117 VA hospitals, including 9,530 LC (81.7%). While the rate of conversion from LC to OC remained stable over the study period (9.0% overall), the percentage of OC decreased from 11.5% in 2006 to 10.1% in 2007 and 8.9% in 2008 (P = .0002). Compared with LC, the OC cohort had more comorbidities (35 of 41 preoperative characteristics, all P <.05), a higher 30-day morbidity rate (18.7% vs 4.8%. P <.0001), and a higher 30-day mortality rate (2.4% vs .4%, P <.0001). American Society of Anesthesiologist (ASA) class, patient comorbidities (eg, ascites, bleeding disorders, pneumonia) and functional status predicted a choice of OC. Age, preoperative albumin, previous abdominal surgery and emergency status predicted OC and CONV (all P <.05). A higher hospital conversion rate was independently predictive of OC (odds ratio [1% rate increase]: 1.05 [1.02-1.07]; P = .0004). CONCLUSION In the last 3 years, there has been a trend towards performing fewer OCs in VA hospitals. More patient comorbidities and higher hospital-level conversion rates are predictive of the choice to perform or convert to OC.

Validating the patient safety indicators in the Veterans Health Administration: do they accurately identify true safety events?

Background:The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) use administrative data to detect potentially preventable in-hospital adverse events. However, few studies have determined how accurately the PSIs identify true safety events. Objectives:We examined the criterion validity, specifically the positive predictive value (PPV), of 12 selected PSIs using clinical data abstracted from the Veterans Health Administration (VA) electronic medical record as the gold standard. Methods:We identified PSI-flagged cases from 28 representative hospitals by applying the AHRQ PSI software (v.3.1a) to VA fiscal year 2003 to 2007 administrative data. Trained nurse-abstractors used standardized abstraction tools to review a random sample of flagged medical records (112 records per PSI) for the presence of true adverse events. Interrater reliability was assessed. We evaluated PPVs and associated 95% confidence intervals of each PSI and examined false positive (FP) cases to determine why they were incorrectly flagged and gain insight into how each PSI might be improved. Results:PPVs ranged from 28% (95% CI, 15%−43%) for Postoperative Hip Fracture to 87% (95% CI, 79%−92%) for Postoperative Wound Dehiscence. Common reasons for FPs included conditions that were present on admission (POA), coding errors, and lack of coding specificity. PSIs with the lowest PPVs had the highest proportion of FPs owing to POA. Conclusions:Overall, PPVs were moderate for most of the PSIs. Implementing POA codes and using more specific ICD-9-CM codes would improve their validity. Our results suggest that additional coding improvements are needed before the PSIs evaluated herein are used for hospital reporting or pay for performance.

The better colectomy project: association of evidence-based best-practice adherence rates to outcomes in colorectal surgery.

Objective:To evaluate whether adherence to evidence-based best practices in colorectal surgery predicts improved postoperative outcomes. Summary and Background Data:Over a quarter of a million colon and rectal resections are performed annually in the United States. The average postoperative complication rate for these procedures approaches 30%. Methods:A panel of colorectal and general surgeons from 3 hospitals (1 academic medical center and 2 community hospitals) was assembled to ascertain a set of 37 evidence-based practices that they felt were the most pertinent to the evaluation and management of a patient undergoing a colorectal resection. Fifteen of these practices were classified as “key processes” for the prevention of complications. We then retrospectively reviewed medical records for 370 consecutive patients undergoing colorectal resection at these institutions. We evaluated the association of best-practice adherence to complications in the subset of patients with outcome data available through the American College of Surgeons National Surgical Quality Improvement Program. Results:Nonadherence rates exceeded 40% for 11 practices (including 2 key processes: avoidance of unnecessary blood transfusions and timely removal of central venous catheters). Among 198 patients with American College of Surgeons National Surgical Quality Improvement Program outcomes data, 38 (19%) experienced complications, of which 31 (82%) involved postoperative infection. Nonadherence to key-processes significantly predicted the occurrence of a complication (P = 0.002). Each additional process missed increased the odds of a postoperative complication by 60% (odds ratio: 1.6; 95% confidence interval: 1.2–2.2). Conclusions:Failures of adherence with best practices in colorectal surgery is associated with an increased occurrence of complications. This study merits further research to confirm that improvement in compliance with perioperative best practices will reduce complication rates significantly.

Seroma in ventral incisional herniorrhaphy: incidence, predictors and outcome

BACKGROUND Factors leading to seroma following ventral incisional herniorrhaphy (VIH) are poorly understood. METHODS Between 2004 and 2006, patients were prospectively randomized at 4 Veterans Affairs hospitals to undergo laparoscopic or open VIH. Patients who developed seromas within 8 weeks postoperatively were compared with those who did not. Multivariate analyses were performed to identify predictors of seroma. RESULTS Of 145 patients who underwent VIH, 24 (16.6%) developed seromas. Patients who underwent open VIH had more seromas than those who underwent laparoscopic VIH (23.3% vs 6.8%, P = .011). Seroma patients had hernias that were never spontaneously reducible (0% vs 21%, P = .015), had more abdominal incisions preoperatively (mean, 2.4 vs 1.8; P = .037), and were less likely to have drain catheters placed than those without seromas (30.0% vs 63.1%, P = .011). In multivariate analyses, open VIH predicted seroma (odds ratio, 5.5; 95% confidence interval, 1.6-18.8), as well as the specific hospital at which the procedure was performed. Spontaneous resolution occurred in 71% of seromas; 29% required aspiration. CONCLUSIONS Procedural characteristics and hernia characteristics rather than patient comorbidities predicted seroma in VIH.

Examining the impact of the AHRQ Patient Safety Indicators (PSIs) on the Veterans Health Administration: the case of readmissions.

Background:By focusing primarily on outcomes in the inpatient setting one may overlook serious adverse events that may occur after discharge (eg, readmissions, mortality) as well as opportunities for improving outpatient care. Objective:Our overall objective was to examine whether experiencing an Agency for Healthcare Research and Quality Patient Safety Indicator (PSI) event in an index medical or surgical hospitalization increased the likelihood of readmission. Methods:We applied the Agency for Healthcare Research and Quality PSI software (version 4.1.a) to 2003–2007 Veterans Health Administration inpatient discharge data to generate risk-adjusted PSI rates for 9 individual PSIs and 4 aggregate PSI measures: any PSI event and composite PSIs reflecting “Technical Care,” “Continuity of Care,” and both surgical and medical care (Mixed). We estimated separate logistic regression models to predict the likelihood of 30-day readmission for individual PSIs, any PSI event, and the 3 composites, adjusting for age, sex, comorbidities, and the occurrence of other PSI(s). Results:The odds of readmission were 23% higher for index hospitalizations with any PSI event compared with those with no event [confidence interval (CI), 1.19–1.26], and ranged from 22% higher for Iatrogenic Pneumothorax (CI, 1.03–1.45) to 61% higher for Postoperative Wound Dehiscence (CI, 1.27–2.05). For the composites, the odds of readmission ranged from 15% higher for the Technical Care composite (CI, 1.08–1.22) to 37% higher for the Continuity of Care composite (CI, 1.26–1.50). Conclusions:Our results suggest that interventions that focus on minimizing preventable inpatient safety events as well as improving coordination of care between and across settings may decrease the likelihood of readmission.

Using administrative data to identify surgical adverse events: an introduction to the Patient Safety Indicators

BACKGROUND The Patient Safety Indicators (PSIs) are algorithms based on the International Classification of Diseases, Ninth Revision, Clinical Modification, aimed at identifying potential safety-related adverse events through the automated screening of readily available administrative databases. Many of these indicators focus on surgical care, and a few have been endorsed by the National Quality Forum as performance measures. The aim of this report is to give a brief overview of the development and definitions of the PSIs as well as the current evidence for their validity, compared with the National Surgical Quality Improvement Program and chart abstraction designed for the purpose of PSI validation. METHODS Several articles published in the past few years, in addition to primary data collected from an ongoing study of PSI validation in the Veterans Health Administration, were examined. RESULTS Selected surgical PSIs have positive predictive values ranging from 22% to 89%, depending on the nature of the PSI and the method of validation used. CONCLUSIONS With adequate coding revisions, PSI performance can be substantially improved.

Adequate Nutrition May Get You Home Effect of Caloric/Protein Deficits on the Discharge Destination of Critically Ill Surgical Patients

BACKGROUND Macronutrient deficit in the surgical intensive care unit (ICU) is associated with worse in-hospital outcomes. We hypothesized that increased caloric and protein deficit is also associated with a lower likelihood of discharge to home vs transfer to a rehabilitation or skilled nursing facility. MATERIALS AND METHODS Adult surgical ICU patients receiving >72 hours of enteral nutrition (EN) between March 2012 and May 2014 were included. Patients with absolute contraindications to EN, <72-hour ICU stay, moribund state, EN prior to surgical ICU admission, or previous ICU admission within the same hospital stay were excluded. Subjects were dichotomized by cumulative caloric (<6000 vs ≥ 6000 kcal) and protein deficit (<300 vs ≥ 300 g). Baseline characteristics and outcomes were compared using Wilcoxon rank and χ(2) tests. To test the association of macronutrient deficit with discharge destination (home vs other), we performed a logistic regression analysis, controlling for plausible confounders. RESULTS In total, 213 individuals were included. Nineteen percent in the low-caloric deficit group were discharged home compared with 6% in the high-caloric deficit group (P = .02). Age, body mass index (BMI), Acute Physiology and Chronic Health Evaluation II (APACHE II), and initiation of EN were not significantly different between groups. On logistic regression, adjusting for BMI and APACHE II score, the high-caloric and protein-deficit groups were less likely to be discharged home (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.08-0.96; P = .04 and OR, 0.29; 95% CI, 0.0-0.89, P = .03, respectively). CONCLUSIONS In surgical ICU patients, inadequate macronutrient delivery is associated with lower rates of discharge to home. Improved nutrition delivery may lead to better clinical outcomes after critical illness.

Damage Control Resuscitation In Trauma

Introduction: Most preventable trauma deaths are due to uncontrolled hemorrhage. Methods: In this article, we briefly describe the pathophysiology of the classical triad of death in trauma, namely, acidosis, hypothermia, and coagulopathy, and then suggest damage control resuscitation strategies to prevent and/or mitigate the effects of each in the bleeding patient. Results: Damage control resuscitation strategies include body rewarming, restrictive fluid administration, permissive hypotension, balanced blood product administration, and the implementation of massive transfusion protocols. Conclusion: Resuscitating and correcting the coagulopathy of the exsanguinating trauma patient is essential to improve chances of survival.

β-Blockade in Noncardiac Surgery: Outcome at All Levels of Cardiac Risk

HYPOTHESIS We hypothesized that the relationship among beta-blocker use, heart rate control, and perioperative cardiovascular outcome would be similar in patients at all levels of cardiac risk. DESIGN Retrospective cohort study. SETTING Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas. PATIENTS Among all patients who underwent various noncardiac surgical procedures in 2000, those who received perioperative beta-blockers were matched and compared with a control group from the same patient population. MAIN OUTCOME MEASURES Thirty-day stroke, cardiac arrest, myocardial infarction, and mortality, as well as mortality at 1 year. RESULTS Patients at all levels of cardiac risk who received beta-blockers had lower preoperative and intraoperative heart rates. The beta-blocker group had higher rates of 30-day myocardial infarction (2.94% vs 0.74%, P =.03) and 30-day mortality (2.52% vs 0.25%, P =.007) compared with the control group. In the beta-blocker group, patients who died perioperatively had significantly higher preoperative heart rate (86 vs 70 beats/min, P =.03). None of the deaths occurred among the patients at high cardiac risk. CONCLUSION Among patients at all levels of cardiac risk undergoing noncardiac surgery, administration of beta-blockers should achieve adequate heart rate control and should be carefully monitored in patients who are not at high cardiac risk.