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## Complete Summary

#### TITLE

Selected infection due to medical care: rate per 1,000 eligible
admissions.

#### SOURCE(S)

AHRQ quality indicators. Pediatric quality indicators: technical
specifications \[version 3.2\]. Rockville (MD): Agency for Healthcare
Research and Quality (AHRQ); 2008 Feb 29. various p.

McDonald K, Romano P, Davies S, Haberland C, Geppert J, Ku A, Choudhry
K. Measures of pediatric health care quality based on hospital
administrative data: the pediatric quality indicators. Rockville (MD):
Agency for Healthcare Research and Quality (AHRQ); 2006 Sep. 130 p. \[82
references\]

### Measure Domain

#### PRIMARY MEASURE DOMAIN

Outcome

The validity of measures depends on how they are built. By examining the
key building blocks of a measure, you can assess its validity for your
purpose. For more information, visit the [Measure
Validity](http://www.qualitymeasures.ahrq.gov/resources/measure_domains.aspx)
page.

#### SECONDARY MEASURE DOMAIN

Does not apply to this measure

### Brief Abstract

#### DESCRIPTION

This measure is used to assess the number of patients with specific
infection codes\* per 1,000 eligible admissions.

\*International Classification of Diseases, Ninth Revision, Clinical
Modification (ICD-9-CM) codes 999.3 or 996.62 in any secondary diagnosis
field.

#### RATIONALE

This indicator is intended to capture infections that are due to medical
care, but are limited to those easily captured using administrative
data. This indicator likely captures mostly line and other vascular
access related infections. High quality care is likely to reduce the
risk for this complication.

#### PRIMARY CLINICAL COMPONENT

Line and other vascular access related infections

#### DENOMINATOR DESCRIPTION

All surgical and medical discharges under age 18 defined by specific
Diagnosis Related Groups (DRGs)

Exclude cases:

-   with International Classification of Diseases, Ninth Revision,
    Clinical Modification (ICD-9-CM) code of 999.3 or 996.62 in the
    principal diagnosis field

-   newborns

-   neonates weighing less than 500 grams

-   with length of stay less than 2 days

-   Major Diagnostic Category (MDC) 14 (pregnancy, childbirth, and
    puerperium)

**Note**: Refer to the original measure documentation for specific DRGs.

#### NUMERATOR DESCRIPTION

Discharges among cases meeting the inclusion and exclusion rules for the
denominator with International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM) code of 999.3 or 996.62 in
any secondary diagnosis field

### Evidence Supporting the Measure

#### EVIDENCE SUPPORTING THE CRITERION OF QUALITY

-   A clinical practice guideline or other peer-reviewed synthesis of
    the clinical evidence

-   A formal consensus procedure involving experts in relevant clinical,
    methodological, and organizational sciences

-   One or more research studies published in a National Library of
    Medicine (NLM) indexed, peer-reviewed journal

### Evidence Supporting Need for the Measure

#### NEED FOR THE MEASURE

Variation in quality for the performance measured

#### EVIDENCE SUPPORTING NEED FOR THE MEASURE

Agency for Healthcare Research and Quality (AHRQ). National healthcare
quality report. Rockville (MD): Agency for Healthcare Research and
Quality (AHRQ); 2003.

Miller MR, Elixhauser A, Zhan C. Patient safety events during pediatric
hospitalizations. Pediatrics2003 Jun;111(6 Pt 1):1358-66.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12777553)

Miller MR, Zhan C. Pediatric patient safety in hospitals: a national
picture in 2000. Pediatrics2004 Jun;113(6):1741-6. \[32 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15173500)

Sedman A, Harris JM 2nd, Schulz K, Schwalenstocker E, Remus D, Scanlon
M, Bahl V. Relevance of the Agency for Healthcare Research and Quality
Patient Safety Indicators for children\'s hospitals. Pediatrics2005
Jan;115(1):135-45. \[17 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15579669)

### State of Use of the Measure

#### STATE OF USE

Current routine use

#### CURRENT USE

Internal quality improvement\
Quality of care research

### Application of Measure in its Current Use

#### CARE SETTING

Hospitals

#### PROFESSIONALS RESPONSIBLE FOR HEALTH CARE

Advanced Practice Nurses\
Nurses\
Physicians

#### LOWEST LEVEL OF HEALTH CARE DELIVERY ADDRESSED

Single Health Care Delivery Organizations

#### TARGET POPULATION AGE

Age less than 18 years

#### TARGET POPULATION GENDER

Either male or female

#### STRATIFICATION BY VULNERABLE POPULATIONS

Stratify patients by three risk groups:

i.  High risk: High risk immunodeficient patients (HIV, immune system
    disorders, transplant, short bowel syndrome, cancer, renal failure
    and severe malnutrition)

ii. Intermediate risk: Cystic fibrosis, Hemophilia, Intermediate risk
    immunodeficient patients (lupus, renal disease and other rare
    autoimmune, hepatic failure, cachexia, spleen disorders)

iii. Low risk: All other patients

### Characteristics of the Primary Clinical Component

#### INCIDENCE/PREVALENCE

Bloodstream infections associated with a central intravascular line were
found to be the most common infection site in a sample of pediatric
intensive care units between 1992 and 1997. Guidelines have been
published in an attempt to decrease the rates of intravascular
catheter-related infections. Other groups have analyzed rates of this
indicator using the publicly available indicator definition applied to a
pediatric population; this definition differs slightly from the
definition proposed for this measure. This indicator was applied to
pediatric hospital populations (e.g., 1.89 per 1,000 discharges at 0 to
17 years, 1.89 at 18 to 44 years, 2.50 at 45 to 64 years, and 1.66 at 65
or more years). Miller and colleagues analyzed Healthcare Cost and
Utilization Project (HCUP) data from 1997 and found an incidence of
\"infection attributed to procedures\" (999.3 alone) of 0.13 per 1,000
discharges among children aged 0 to 18 years. In the HCUP data from
2000, using the current Patient Safety Initiative (PSI) definition, they
found a rate of 1.3 per 1,000 discharges for \"infection as a result of
medical care\". Sedman et al. found observed rates varying from 3.2 per
1,000 in 1999 to 4.0 per 1,000 in 2002 in the National Association of
Children\'s Hospitals and Related Institutions (NACHRI) database (i.e.,
a slight upward trend over time). Additionally, Miller and Zahn found
that this complication resulted in an increased mean length of stay (by
30 days) and \$121,010 in increased charges in affected patients, with
2.2 times higher odds of in-hospital mortality (after adjusting for age,
gender, expected payer, up to 30 comorbidities, and multiple hospital
characteristics, including ownership, teaching status, nursing
expertise, urban location, bed size, pediatric volume, coding intensity,
intensive care unit (ICU) bed percentage, and surgical discharge
percentage).

#### EVIDENCE FOR INCIDENCE/PREVALENCE

Agency for Healthcare Research and Quality (AHRQ). National healthcare
quality report. Rockville (MD): Agency for Healthcare Research and
Quality (AHRQ); 2003.

Garland JS, Henrickson K, Maki DG, Hospital Infection Control Practices
Advisory Committee Centers for Disease Control and Prevention. The 2002
Hospital Infection Control Practices Advisory Committee Centers for
Disease Control and Prevention guideline for prevention of intravascular
device-related infection. Pediatrics2002 Nov;110(5):1009-13.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12415044)

Miller MR, Elixhauser A, Zhan C. Patient safety events during pediatric
hospitalizations. Pediatrics2003 Jun;111(6 Pt 1):1358-66.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12777553)

Miller MR, Zhan C. Pediatric patient safety in hospitals: a national
picture in 2000. Pediatrics2004 Jun;113(6):1741-6. \[32 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15173500)

O\'Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki
DG, Masur H, McCormick RD, Mermel LA, Pearson ML, Raad II, Randolph A,
Weinstein RA. Guidelines for the prevention of intravascular
catheter-related infections. Pediatrics2002 Nov;110(5):e51.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12415057)

Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in
pediatric intensive care units in the United States. National Nosocomial
Infections Surveillance System. Pediatrics1999 Apr;103(4):e39.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10103331)

Sedman A, Harris JM 2nd, Schulz K, Schwalenstocker E, Remus D, Scanlon
M, Bahl V. Relevance of the Agency for Healthcare Research and Quality
Patient Safety Indicators for children\'s hospitals. Pediatrics2005
Jan;115(1):135-45. \[17 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15579669)

#### ASSOCIATION WITH VULNERABLE POPULATIONS

Infections due to medical devices are of great concern to those caring
for critically ill infants and children. These infections represent a
significant iatrogenic problem in pediatric health care.

See the \"Incidence/Prevalence\" field.

#### EVIDENCE FOR ASSOCIATION WITH VULNERABLE POPULATIONS

McDonald K, Romano P, Davies S, Haberland C, Geppert J, Ku A, Choudhry
K. Measures of pediatric health care quality based on hospital
administrative data: the pediatric quality indicators. Rockville (MD):
Agency for Healthcare Research and Quality (AHRQ); 2006 Sep. 130 p. \[82
references\]

#### BURDEN OF ILLNESS

See the \"Incidence/Prevalence\" field.

#### UTILIZATION

See the \"Incidence/Prevalence\" field.

#### COSTS

See the \"Incidence/Prevalence\" field.

### Institute of Medicine National Healthcare Quality Report Categories

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness\
Safety

### Data Collection for the Measure

#### CASE FINDING

Users of care only

#### DESCRIPTION OF CASE FINDING

All surgical and medical discharges under age 18 defined by specific
Diagnosis Related Groups (DRGs) (see the \"Denominator
Inclusions/Exclusions\" field)

#### DENOMINATOR SAMPLING FRAME

Patients associated with provider

#### DENOMINATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
All surgical and medical discharges under age 18 defined by specific
Diagnosis Related Groups (DRGs)

**Exclusions**\
Exclude cases:

-   with International Classification of Diseases, Ninth Revision,
    Clinical Modification (ICD-9-CM) code of 999.3 or 996.62 in the
    principal diagnosis field

-   newborns

-   neonates weighing less than 500 grams

-   with length of stay less than 2 days

-   Major Diagnostic Category (MDC) 14 (pregnancy, childbirth, and
    puerperium)

**Note**: Refer to the original measure documentation for specific DRGs.

#### RELATIONSHIP OF DENOMINATOR TO NUMERATOR

All cases in the denominator are equally eligible to appear in the
numerator

#### DENOMINATOR (INDEX) EVENT 

Clinical Condition\
Institutionalization\
Therapeutic Intervention

#### DENOMINATOR TIME WINDOW

Time window is a single point in time

#### NUMERATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
Discharges among cases meeting the inclusion and exclusion rules for the
denominator with International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM) code of 999.3 or 996.62 in
any secondary diagnosis field

**Exclusions**\
Unspecified

#### MEASURE RESULTS UNDER CONTROL OF HEALTH CARE PROFESSIONALS, ORGANIZATIONS AND/OR POLICYMAKERS

The measure results are somewhat or substantially under the control of
the health care professionals, organizations and/or policymakers to whom
the measure applies.

#### NUMERATOR TIME WINDOW

Institutionalization

#### DATA SOURCE

Administrative data

#### LEVEL OF DETERMINATION OF QUALITY

Not Individual Case

#### OUTCOME TYPE

Adverse Outcome

#### PRE-EXISTING INSTRUMENT USED

Unspecified

### Computation of the Measure

#### SCORING

Rate

#### INTERPRETATION OF SCORE

Better quality is associated with a lower score

#### ALLOWANCE FOR PATIENT FACTORS

Analysis by high-risk subgroup (stratification on vulnerable
populations)\
Analysis by subgroup (stratification on patient factors, geographic
factors, etc.)\
Case-mix adjustment\
Risk adjustment method widely or commercially available

#### DESCRIPTION OF ALLOWANCE FOR PATIENT FACTORS

Risk adjustment of the data is recommended using, at minimum,
birthweight, age in days, age and AHRQ Clinical Classification
Software\*.

Application of multivariate signal extraction (MSX) to smooth risk
adjusted rates is also recommended.

[Specifically, for this measure]{.underline}:

Stratify patients by three risk groups:

i.  High risk: High risk immunodeficient patients (HIV, immune system
    disorders, transplant, short bowel syndrome, cancer, renal failure
    and severe malnutrition)

ii. Intermediate risk: Cystic fibrosis, Hemophilia, Intermediate risk
    immunodeficient patients (lupus, renal disease and other rare
    autoimmune, hepatic failure, cachexia, spleen disorders)

iii. Low risk: All other patients

\***Note**: Information on the Clinical Classification Software (CCS)
for ICD-9-CM is available at
<http://hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp>.

#### STANDARD OF COMPARISON

Internal time comparison

### Evaluation of Measure Properties

#### EXTENT OF MEASURE TESTING

The development of the Agency for Healthcare Research and Quality (AHRQ)
Pediatric Quality Indicators utilizes a four pronged approach:
identification of candidate indicators, literature review, empirical
analyses, and panel review. Candidate indicators were identified through
both published literature and a brief survey of national organizations.
Literature review provided descriptions and evaluations of some
candidate indicators and the underlying relationship to quality of care.
Empirical analyses were conducted to explore alternative definitions; to
assess nationwide rates and hospital variation; and to develop
appropriate methods to account for variation in risk. Clinical panel
review helped to refine indicator definitions and risk groupings, and to
establish face validity in light of the limited evidence from the
literature for most pediatric indicators. Information from these sources
was used to specify indicator definitions and make recommendations to
AHRQ regarding the best indicators for inclusion in the pediatric
indicator set.

A structured review of each indicator was undertaken to evaluate face
validity (from a clinical perspective). This process mirrored that
undertaken during the initial development of the Patient Safety
Indicators. Specifically, the panel approach established *consensual
validity*, which \"extends face validity from one expert to a panel of
experts who examine and rate the appropriateness of each item\....\" The
methodology for the structured review was adapted from the RAND/UCLA
Appropriateness Method and consisted of an initial independent
assessment of each indicator by clinician panelists using an initial
questionnaire, a conference call among all panelists, followed by a
final independent assessment by clinician panelists using the same
questionnaire. The panel process served to refine definitions of some
indicators, add new measures, and dismiss indicators with major concerns
from further consideration.

Empirical analyses were conducted to provide the clinical panels and
peer review participants with additional information about the
indicators. These analyses were also used by the development team to
test the alternative specifications and the relative contribution of
indicator components in the numerator and denominator. These analyses
were not intended to inform issues of precision, bias and construct
validity, which will be addressed separately. The data source used in
the empirical analyses was the 2003 Kids\' Inpatient Sample (KID).

Refer to the original measure documentation for additional details.

#### EVIDENCE FOR RELIABILITY/VALIDITY TESTING

Fitch K, Bernstein SJ, Aguilar MD, et al. The RAND/UCLA appropriateness
method user\'s manual. Santa Monica (CA): RAND; 2001. 109 p.

Green L, Lewis F. Measurement and evaluation in health education and
health promotion. Mountain View (CA): Mayfield Publishing Company; 1998.

McDonald K, Romano P, Davies S, Haberland C, Geppert J, Ku A, Choudhry
K. Measures of pediatric health care quality based on hospital
administrative data: the pediatric quality indicators. Rockville (MD):
Agency for Healthcare Research and Quality (AHRQ); 2006 Sep. 130 p. \[82
references\]

### Identifying Information

#### ORIGINAL TITLE

Selected infection due to medical care (PDI 12).

#### MEASURE COLLECTION

[Agency for Healthcare Research and Quality (AHRQ) Quality
Indicators](http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=9&doc=341)

#### MEASURE SET NAME

[Agency for Healthcare Research and Quality (AHRQ) Pediatric Quality
Indicators](http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=9&doc=8832)

#### DEVELOPER

Agency for Healthcare Research and Quality

#### ADAPTATION

This measure was adapted from the AHRQ Patient Safety Quality
Indicators.

#### PARENT MEASURE

Selected Infections Due to Medical Care, Provider Level (PSI 7) (Agency
for Healthcare Research and Quality \[AHRQ\])

#### RELEASE DATE

2006 Feb

#### REVISION DATE

2008 Feb

#### MEASURE STATUS

This is the current release of the measure.

#### SOURCE(S)

AHRQ quality indicators. Pediatric quality indicators: technical
specifications \[version 3.2\]. Rockville (MD): Agency for Healthcare
Research and Quality (AHRQ); 2008 Feb 29. various p.

McDonald K, Romano P, Davies S, Haberland C, Geppert J, Ku A, Choudhry
K. Measures of pediatric health care quality based on hospital
administrative data: the pediatric quality indicators. Rockville (MD):
Agency for Healthcare Research and Quality (AHRQ); 2006 Sep. 130 p. \[82
references\]

#### MEASURE AVAILABILITY

The individual measure, \"Selected Infection Due to Medical Care (PDI
12),\" is published in \"Measures of Pediatric Health Care Quality Based
on Hospital Administrative Data: The Pediatric Quality Indicators\" and
\"AHRQ Quality Indicators. Pediatric Quality Indicators: Technical
Specifications \[version 3.2\].\" These documents are available in
Portable Document Format (PDF) from the [Pediatric Quality Indicators
Download](http://www.qualityindicators.ahrq.gov/pdi_download.htm) page
at the Agency for Healthcare Research and Quality (AHRQ) Quality
Indicators Web site.

For more information, please contact the QI Support Team at
<support@qualityindicators.ahrq.gov>.

#### COMPANION DOCUMENTS

The following are available:

-   AHRQ quality indicators. Pediatric quality indicators: software
    documentation \[version 3.2\] - SAS. Rockville (MD): Agency for
    Healthcare Research and Quality (AHRQ); 2008 Mar 10. 40 p. This
    document is available in Portable Document Format (PDF) from the
    [AHRQ Quality Indicators Web
    site](http://www.qualityindicators.ahrq.gov/downloads/pdi/pdi_sas_documentation_v32.pdf).

-   AHRQ quality indicators. Software documentation: Windows \[version
    3.1a\]. Rockville (MD): Agency for Healthcare Research and Quality
    (AHRQ); 2007 Apr 6. 99 p. This document is available in PDF from the
    [AHRQ Quality Indicators Web
    site](http://www.qualityindicators.ahrq.gov/downloads/winqi/AHRQ_QI_Windows_Software_Documentation_V31a.pdf).

-   Pediatric quality indicators (PedQI): covariates \[version 3.1\].
    Rockville (MD): Agency for Healthcare Research and Quality (AHRQ);
    2007 Mar 12. 52 p. This document is available in PDF from the [AHRQ
    Quality Indicators Web
    site](http://www.qualityindicators.ahrq.gov/downloads/pdi/pdi_covariates_v31.pdf).

-   Pediatric quality indicators (PedQI): covariates (with POA)
    \[version 3.1\]. Rockville (MD): Agency for Healthcare Research and
    Quality (AHRQ); 2007 Mar 12. 52 p. This document is available in PDF
    from the [AHRQ Quality Indicators Web
    site](http://www.qualityindicators.ahrq.gov/downloads/pdi/pdi_covariates_poa_age_v31.pdf).

-   HCUPnet. \[internet\]. Rockville (MD): Agency for Healthcare
    Research and Quality (AHRQ); 2004 \[accessed 2007 May 21\].
    \[Various pagings\]. HCUPnet is available from the [AHRQ Web
    site](http://hcup.ahrq.gov/HCUPnet.asp). See the related
    [QualityTools](http://www.innovations.ahrq.gov/content.aspx?id=543)
    summary.

#### NQMC STATUS

This NQMC summary was completed by ECRI Institute on December 28, 2007.
The information was verified by the measure developer on March 31, 2008.

#### COPYRIGHT STATEMENT

No copyright restrictions apply.

### Disclaimer

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© 2008 National Quality Measures Clearinghouse

Date Modified: 11/3/2008