# Presentation: 087698

## Examining Patient Safety Indicators in UHC Academic Medical Centers

**UHC Benchmarking Projects**

*Joanne Cuny RN, MBA*
*Director of Clinical Performance Improvement*
*University HealthSystem Consortium*

**Annual AHRQ Quality Indicators **
**User Meeting**
**September 10, 2008**

## Who is the UHC?

**Who is the UHC?**

**Notes:**
Mission: To advance knowledge, foster collaboration and promote change to help members succeed in their respective markets
Vision: To be a catalyst for change, accelerating the achievement of clinical and operational excellence

## Mission

*To advance knowledge, foster collaboration, and promote change to help members succeed **in their respective markets*

**Mission**

*To be a catalyst for change, *
*accelerating the achievement of clinical *
*and operational excellence*

**Vision**

**Notes:**
UHC’s vision is to be....This vision means that UHC will be an extension of your staff for performance improvement, financial improvement, and perhaps, supply chain optimization.  

## UHC Explores Patient Safety Indicators

**2004: Failure to Rescue**
**2007: DVT/PE**
**2008: Postoperative Respiratory Failure**
**2009: Pressure Ulcers (Decubitus)**

## Failure to Rescue 2004 Project Methods and Enrollment Criteria

***Inclusion Criteria:***
- Patients discharged prior to 10/1/2003 and after 9/30/2002 identified via the the AHRQ Patient Safety Indicators SAS software documentation, version 2.1, rev. 1, with one or more of the following complications of admission:
- _>_ 10 years of age
- < 75 years
***Exclusion Criteria:***
-  Transferred from acute care facility
-  Discharged/Transferred to acute care facility
-  Admitted from long-term facility
-  DNR on admission
-  Additional exclusions specific to each complication group

- NOTE: **41** UHC AMC hospitals submitted patient-level data for **5,376** complications

## FTR Distribution of Complications and Exclusions

- Of the 5,376 complications identified by AHRQ SAS software:
-  2,074 (38.6%)  complications were evaluable for FTR
- 3,302 (61.4%) complications were eliminated for the following reasons:
- 47.2% (1,560) were comorbid condition
- 19.7% (651) did not occur
- 16.4% (540) had complication specific exclusion
- 15.0% (494) had date of diagnosis too early
- 1.7% (57) were in cases with DNR at admission

- Not evaluable

- Not evaluable

- Evaluable Complications

## Failure to Rescue Remains a Serious Threat

**Failure to Rescue Remains a Serious Threat**

** **

- Weaknesses in methods of identifying the FTR patient did not mean the FTR rate was lower than estimated
- Improvement efforts are still warranted

**The mortality rate in the 1,592 **_**evaluable**_** cases was 57.3%**
**(n=912)**

**The mortality rate in the 2,125 excluded cases was 37.7% (n=801)**

- *Mortality data can be used only for comparison among groups as study was designed to capture 50% mortality in each complication group

## Commit to ACTion: Rapid Rescue

***Best Practice #1: ***
***Establish a standardized set of early warning signs***
***Best Practice #2: ***
***Use SBAR communication technique and a standard to speed escalation of communication up the chain of command***
***Best Practice #3: ***
***Implement and deploy a rapid response team***

## DVT/PE 2007 Project Methods and Enrollment Criteria

**Methods/Inclusion Criteria**
- Retrospective medical record review of a target of 60 cases meeting enrollment criteria
- 15 cases meeting the specific inclusion criteria* for each of 4 cohorts:
*Surgical patients with DVT or PE*
*Surgical patients without DVT or PE*
- Medical *patients with DVT or PE *
*Medical patients without DVT or PE*
- Patients meeting the inclusion criteria for each cohort were randomly selected from eligible cases discharged during Q1/2006 through Q1/2007
**Exclusion Criteria for all patients:**
- Patients with ICD-9-CM codes for DVT/PE in the principal diagnosis field
- (MDC 14) A primary diagnosis or reason for admission related to pregnancy, childbirth or puerperium
- Admitted for comfort care only or comfort care only ordered on the first day of admission

- * Specific inclusion/exclusion criteria for each cohort defined on the following slides

- NOTE: **34** UHC AMC hospitals submitted patient-level data for **2,100** patients

## Surgical Cohort Enrollment Criteria

**Inclusion Criteria for All Surgical Patients**
- Adult patients _>_ 18 years of age
- Surgical patients identified via the AHRQ Patient Safety Indicator SAS software documentation 3.1 (March 12, 2007) (all surgical discharges defined by specific DRGs and ICD-9-CM codes for an elective operating room procedure)
***Cohort #1 Surgical patients with DVT or PE****** – ***Include only cases with         ICD-9-CM codes for DVT or PE in any secondary diagnosis field
***Cohort #2 Surgical patients without DVT or PE****** – ***Exclude cases with    ICD-9-CM codes for DVT or PE in any diagnosis field
**Exclusion Criteria for All Surgical Patients**
- A procedure for interruption of vena cava is the only operating room procedure
- A procedure for interruption of vena cava occurs before or on the same day as the first operating room procedure

## Inclusion Criteria for All Medical Patients
Adult patients > 18 years of age
Patients in one of the following product lines:  Cardiology, Gastroenterology, HIV, Medical Oncology, General Medicine or Neurology
LOS > 2 Days
SOI score of moderate, major or extreme

Cohort #3 Medical patients with DVT or PE – Include only cases with ICD-9-CM codes for DVT or PE in any secondary diagnosis field

Cohort #4 Medical patients without DVT or PE – Exclude cases with ICD-9-CM codes for DVT or PE in any diagnosis field

Exclusion Criteria for All Medical Patients
LOS < 2 days
SOI score of “minor”

- Adult patients _>_ 18 years of age
- Patients in one of the following product lines:  Cardiology, Gastroenterology, HIV, Medical Oncology, General Medicine or Neurology
- LOS > 2 Days
- SOI score of moderate, major or extreme
***Cohort #3 Medical patients with DVT or PE****** – ***Include only cases with ICD-9-CM codes for DVT or PE in any secondary diagnosis field
***Cohort #4 Medical patients without DVT or PE****** – ***Exclude cases with ICD-9-CM codes for DVT or PE in any diagnosis field
**Exclusion Criteria for All Medical Patients**
- LOS _<_ 2 days
- SOI score of “minor”

**Medical Cohort Enrollment Criteria**

## Current Rate of Success in Capturing DVT/PE Complications

**Current Rate of Success in Capturing DVT/PE Complications**

| DVT/PE Status by CDB |  | DVT/PE Status by Data Abstraction |  |  |
| --- | --- | --- | --- | --- |
| N=2041* | Total | DVT/PE Complication | DVT/PE POA Only | No DVT/PE |
| Medical With DVT/PE | 513 | 156 (30.4%) | 250 (48.7%) | 107 (20.9%) |
| Medical Without DVT/PE | 506 | 4 (0.8%) | 4 (0.8%) | 498 (98.4%) |
| Surgical With DVT/PE | 505 | 306 (60.6%) | 114 (22.6%) | 85 (16.8%) |
| Surgical Without DVT/PE | 517 | 1 (0.2%) | 2 (0.4%) | 514 (99.4%) |

**	****	****	****	****	**

- Medical

- Surgical

| DVT/PE False Positives | Medical | Surgical |
| --- | --- | --- |
|  | N=107   n (%) | N=85      n (%) |
| Did not occur | 31 (29%) | 41 (48%) |
| History only | 76 (71%) | 44 (52%) |

**Final Distribution of CDB identified “with DVT/PE” Medical/Surgical Cases after Chart Review**

- * The 59 study patients enrolled from the one hospital that does not participate in CDB were not included in this analysis (2,041 + 59 = 2,100).

**Notes:**
Total patient sample was 2,100. This analysis was run on study cases in the CDB. One participant does not participate in the CDB. Those 59 cases are not included in this analysis. 

## Learnings Related to DVT/PE Patient Identification

- Identifying patients with complications of admission through administrative data remains problematic.
**Current accuracy rate**:
- Surgical cases: **60%**
- Medical cases: **30%**
- The good news!
- Appropriate use of the “present on admission” **(POA) flag** in coding will significantly improve accuracy rate:
- Surgical cases actually POA: 23%  [60% + 23% = **83%** accuracy]
- Medical cases actually POA: 49%   [30% + 49% = **79%** accuracy]
- The not so good news!
- Still work to be done related to coding to improve accuracy. Rate of **“did not occur” or “history only”** reflected as DVT/PE in coding:
- Surgical cases: **17%**
- Medical cases: **21%**

## Key Performance Measure Guideline-Directed DVT/PE Prophylaxis

- 54.4% (1072/1971) of eligible cases* received appropriate DVT/PE prophylaxis according     to ACCP guidelines, initiated:
- Surgical cases: prior to or on day of surgery
- Medical cases: by the 3rd day of admission
**Hospital Performance:**
- Mean: 54.5% 	SD: 11.4%
- Median: 53.8%	Range: 33.3% - 77.8%
- Achievable Benchmark of CareTM: 75.5%

**Guideline-Directed DVT/PE Prophylaxis**

- Numbers above bars represent the number of cases in the denominator for each institution.

**“****One of six cases of all VTE and two of three cases of VTE, for which thromboprophylaxis had been indicated could potentially have been prevented had physicians followed the recommended ACCP guidelines.  Inadequacy of prophylaxis was most often caused by omission of prophylaxis.”**
***Missed Opportunities for Prevention of Venous Thromboembolism; An Evaluation of the use of Thromboprophylaxis guidelines. CHEST 2001; 120: 1964-1971.***

## Guideline-Directed DVT/PE Prophylaxis for Surgical Cases Only

- 42.1% (393/933) of eligible **surgical **cases* received appropriate DVT/PE prophylaxis according to ACCP guidelines, initiated prior to or on day of surgery
**Hospital Performance:**
- Mean: 41.5% 	SD: 12.4%
- Median: 38.7%	Range: 19.2% - 72.5%
- Achievable Benchmark of CareTM: 68.8%

**Guideline-Directed DVT/PE Prophylaxis for Surgical Cases Only**

- Numbers above bars represent the number of cases in the denominator for each institution.

## Guideline-Directed DVT/PE Prophylaxis for Medical Cases Only

- 65.4% (679/1,038) of eligible **medical **cases received appropriate DVT/PE prophylaxis according to ACCP guidelines, initiated by the 3rd day of admission
**Hospital Performance:**
- Mean: 65.5% 	SD: 14.1%
- Median: 65.6%	Range: 36.7% - 100.0%
- Achievable Benchmark of CareTM: 89.1%

**Guideline-Directed DVT/PE Prophylaxis for Medical Cases Only**

- Numbers above bars represent the number of cases in the denominator for each institution.

## When is a DVT actually a DVT? 

| Specific segments where DVT occurred | N = 567                     n (%) |
| --- | --- |
| Lower Limb only (N = 283) | 283 (49.9%)* |
|    Femoral veins (common or superficial) | 153 (54.1%) |
|    Popliteal vein | 98 (34.6%) |
|    Deep lower extremity veins distal to the popliteal | 76 (26.9%) |
|    Superficial lower extremity veins | 43 (15.2%) |
| Upper Limb only (N = 209) | 209 (36.9%)* |
|    Subclavian axillary vein | 81 (38.8%) |
|    Internal jugular vein | 67 (32.1%) |
|    Superficial upper extremity | 57 (27.3%) |
|    Brachiocephalic (innominate) veins | 43 (20.6%) |
|    Deep upper extremity veins distal to the axillary | 32 (15.3%) |
|    Superficial neck veins | 2 (1.0%) |
| Central only (N = 27) | 27 (4.8%)* |
|    Iliac veins | 13 (48.1%) |
|    Inferior vena cava | 11 (40.7%) |
|    Superior vena cava | 4 (14.8%) |
| Combination | 24 (4.2%)* |
| Location not documented | 24 (4.2%)* |

- *Note: Segments are not mutually exclusive, i.e. cases could have more than one DVT diagnosed

**Reported Age of DVT **
- Of the 567 cases diagnosed with  DVT during admission, the reported age of the DVT was:
- 213 (37.6%) were “acute”
- 168 (29.6%) were “unspecified age”
- 65 (11.5%) were “chronic”
- 34 (6.0%) were “sub acute”
- 87 (15.3%) cases did not have a test or the report lacked DVT age information

## Only 54.4% of all cases received ACCP guideline-direct DVT/PE prophylaxis. Hospital performance ranged from 33.3% - 77.8%. 
The rate of early recognition and rapid intervention for DVT/PE has improved since the 2004 Failure to Rescue study
23.2% of all surviving study patients with active DVT/PE during the admission received no pharmacologic DVT/PE prophylaxis at discharge 
Patients with active DVT or PE during the target admission were: 
discharged to home on self care at nearly 1/2 the rate of patients without DVT/PE 
discharged to rehab or SNF facilities at > 2 times the rate of patients without DVT/PE
Patients with PE had a mortality rate nearly 2 times that of patients with DVT alone and nearly 4 times that of patient without either of these conditions

- The **rate of** **early recognition and rapid intervention for DVT/PE has improved **since the 2004 Failure to Rescue study
**23.2%** of all surviving study patients with active DVT/PE during the admission received **no pharmacologic DVT/PE prophylaxis** at discharge
- Patients **with active DVT or PE** during the target admission were:
**discharged to home** on self care at **nearly 1/2 the rate** of patients without DVT/PE
- discharged to **rehab or SNF** facilities at **> 2 times the rate** of patients without DVT/PE
- Patients with **PE **had a** mortality rate** nearly **2 times that of patients with DVT** alone and nearly **4 times that of patient without either** of these conditions

**DVT/PE Project Summary of Key Findings**

## Post Op Respiratory Failure 2008 Project Methodology

**Methods**
- Retrospective review and documentation of 40 eligible cases
- Discharged on or prior to June 30, 2007
- Enrolled in reverse chronological order by discharge date, proceeding back in time until the target number of cases were identified.
- To avoid selection bias, cases could not be skipped or excluded unless a specific exclusion criterion was identified
**Case Selection Criteria**
- UHC identified postoperative respiratory failure (PSI 11) cases from the clinical database for participating hospitals, using the AHRQ PSI SAS software and documentation version 3.1
- Only those cases that did not have a qualifying surgical procedure during the admission were excluded

- NOTE: **18** UHC AMC hospitals submitted patient-level data for **692** cases

## Inclusion Criteria
Adults > 18 years of age 
Elective admission type 
Surgical discharge as defined by specific DRGs (includes all surgical DRGs)
ICD-9-CM code for a specific major therapeutic, non-diagnostic, operating room (OR) procedure

Exclusion Criteria
 Pre-existing acute respiratory failure
Principal diagnosis
Secondary diagnosis present on admission (POA), if known
ICD-9-CM diagnosis code of specific neuromuscular disorders (NMD)
Tracheostomy
As the only OR procedure
Occurs before the first OR procedure
DRG falls into MDC 4 (respiratory), MDC 5 (circulatory), or MDC 14 (pregnancy)

- Adults _>_ 18 years of age
- Elective admission type** **
- Surgical discharge as defined by specific DRGs (includes all surgical DRGs)
- ICD-9-CM code for a specific major therapeutic, non-diagnostic, operating room (OR) procedure
***Exclusion Criteria***
-  Pre-existing acute respiratory failure
- Principal diagnosis
- Secondary diagnosis present on admission (POA), if known
- ICD-9-CM diagnosis code of specific neuromuscular disorders (NMD)
- Tracheostomy
- As the only OR procedure
- Occurs before the first OR procedure
- DRG falls into MDC 4 (respiratory), MDC 5 (circulatory), or MDC 14 (pregnancy)

**PSI-11 Denominator Cases**

## PSI-11 Numerator Cases

- Respiratory failure ICD-9-CM secondary diagnosis code
**518.81:** diagnosis of acute respiratory failure
**518.84:** diagnosis of acute and chronic respiratory failure
**or**
- Intubation or ventilation ICD-9-CM procedure code _with_ appropriate timing after a qualifying surgical procedure
**96.04: **(endotracheal tube insertion) procedure takes place **1 or more days** **after** a major OR procedure – i.e. reintubation
**96.70: **(continuous ventilation, unspecified duration) **or **
**     ****96.71:** (continuous ventilation, less than 96 hours)
-      identified **2 or more days after** a major OR procedure
**96.72** (continuous ventilation, for 96 hours or more) identified **on or any time** **after** the day of a major OR procedure

| Code Type | Diagnosis Code only | Re-intubation or Ventilation Code only | Both Code Types |
| --- | --- | --- | --- |
|  | Group 1 | Group 2 | Group 1 + 2 |
| All Cases (N=692) | 17.5% (121) | 44.5% (308) | 38.0% (263) |

## Postoperative Respiratory Failure:PSI with High Positive Predictive Value

**Postoperative Respiratory Failure:****PSI with High Positive Predictive Value**

**True-Positive PRF**

- The project’s retrospective chart review revealed that 93.2% (645/692) of cases were accurately flagged by the AHRQ software as having postoperative respiratory failure

## Potentially Useful PRF Predictors

- Type of surgery: AAA, thoracic, neuro, upper abdominal, peripheral vascular, neck
- Emergency surgery
- Albumin <30 g/L
- Blood urea nitrogen >30 mg/dL
- Partially or fully dependent functional status
- History of chronic obstructive pulmonary disease
- Age _>_ 60
- Estimated blood loss > 600 mL
- Lowest mean arterial pressure during surgery of > 55 mmHg
- Lowest heart rate during surgery > 75 beats per minute

## PRF Severity of Illness

**PRF Severity of Illness**

- Note: Severity of illness based on 3M’s APR-DRG grouper used in UHC’s CDB risk-adjustment

- Severity of Illness Distribution
**CDB CY 2007** Population With PSI 11 (N=5,454)

- Severity of Illness Distribution
- Study Population                           (N=645)

**Severity of Illness Distribution by Participating Hospital**

**Notes:**
UHC’s Severity of Illness Classification System:
Defined as the extent of physiologic decompensation or loss of organ system function 
Utilizes 3M’s APR-DRG software which evaluates all available diagnoses and procedures
Determined by incorporating the impact of principal diagnosis, age, OR procedure(s), non-OR procedure, and combinations of secondary diagnoses
In general, the proportion of SOI extreme cases is approximately 5%

## PRF Project Summary of Key Findings

- AHRQ algorithm shows** ~93.2**% **positive predictive value** for **PSI 11** cases
**SOI** classification **extreme** in **>75%** of study population and CDB cases
**80.6%** of the study population received a preoperative **ASA status of **  **3 or 4**
**1/2** the study population had **more than one patient safety indicator**
- Most common anesthesia was** general; **neuromuscular blocking **reversal **agent was used in **1/3** of these cases
**23.3% **of the study population** did not survive **to discharge
**8%** of surviving patients were **discharged on ventilator support**
**3.6% **of surviving patients** **had related** readmissions** within 30 days of discharge
**Questions remain **whether PSI 11 rate reflects quality of care

## Pressure Ulcer 2008/2009 Project Methods and Enrollment Criteria

**Methods**
- Retrospective medical record review for a target of 40 cases per site meeting enrollment criteria (20 cases in each of 2 patient groups):
*Group 1: Patients with hospital acquired pressure ulcers *_***with***_* *ICD-9-CM code of decubitus ulcer* as secondary diagnosis*
*Group 2: Patients with hospital acquired pressure ulcers *_***without***_* *ICD-9-CM code of decubitus ulcer* as secondary diagnosis*
- All patients meeting the inclusion criteria will be enrolled in reverse chronological order by discharge date, beginning with cases discharge on June 30, 2008, and proceeding back in time until **20 evaluable Group 1** **cases** and **20 evaluable Group 2 cases** are enrolled
**Denominator Enrollment Criteria for All Cases: **
- _>_18 years of age
- LOS > 4 days
**Excludes** cases with ICD-9-CM code of decubitus ulcer in the principal diagnosis field or in a secondary diagnosis field if present on admission (POA)

- NOTE: **33** UHC AMC hospitals have signed up to submit patient-level data for a target of **1,320** cases

## Numerator Populations

**Patient Group 1:**
- Identified as a case with hospital acquired decubitus ulcer (PSI 3) by AHRQ Patient Safety Indicator SAS software documentation 3.1 (i.e. discharged case **with** ICD-9-CM code of decubitus ulcer in any secondary diagnosis)
**Patient Group 2: **
- NOT Identified as a case with hospital acquired decubitus ulcer (PSI 3) by AHRQ Patient Safety Indicator SAS software documentation 3.1 (i.e. discharged case **without** an ICD-9-CM code of decubitus ulcer in any secondary diagnosis)
- Documentation in medical record of presence of pressure ulcer
- Cases with 1 of the 14 selected high risk* DRGs (see listing on next slide)

- *NOTE: The 14 “high risk” DRGs were identified by selecting DRGs that had ICD-9-CM coded rates of decubitus ulcer in secondary diagnosis > 80 per 1,000 cases (based on CDB cases from Q2/07 to Q1/08)

## Pressure Ulcer High Risk DRGs

**DRG ****	****Description****	**
- 465	Aftercare w/ history of malignancy as secondary DX*
- 575	Septicemia w/ MV96+ hours age >17
- 542	Trach w/ MV 96+hrs or PDX except face,mouth & neck DX w/o major OR PX
- 541	Trach w/ MV 96+hrs or PDX except face,mouth & neck DX w/ major OR PX
- 578	Infectious & Parasitic Diseases w/ OR PX
- 238	Osteomyelitis
- 129	Cardiac arrest –unexplained*
- 576	Septicemia w/o MV96+ hours age  >17
- 287	Skin graft/wound debridement; endocrine / nutritional / metabolic disorders*
- 113	Amputation for circulatory disorders except upper limb & toe
- 123	Circulatory disorders w/ AMI, expired
- 565	Respiratory system DX w/ ventilator support 96+ hours
- 072	Nasal trauma & deformity*
- 320	Kidney & UTI age > 17 w/CC

- NOTE: The 14 “high risk” DRGs were identified by selecting DRGs that had ICD-9-CM coded rates of decubitus ulcer in secondary diagnosis > 80 per 1,000 cases (based on CDB cases from Q2/07 to Q1/08)
- * < 100 denominator cases

## Anticipated Findings in 2008/2009 Pressure Ulcer Project

- Screened cases will yield data on POA versus HAC pressure ulcers and use of POA flag
- Prevalence of pressure ulcers that are not included in physician documentation
- Performance related to routine documentation of skin assessment
- Use of staging in documentation of pressure ulcers
- Specific patient characteristics and other circumstances common to patients with hospital acquired pressure ulcers
- Prevalence of routine use of special beds, bed coverings, and other devices to protect skin
- Identification of best practices
- Illuminate opportunities for improvement

## Questions