Taking a Deep Dive into Understanding PSI 90

Turning data into information in reviewing PSIs 11, 12, and 13 is vital.

“You can have data without information, but you cannot have information without data.” – Daniel Keys Moran

The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSI) 90 has been the main topic of our recent four-part series on PSIs. This is the composite PSI, consisting of pressure ulcers, iatrogenic pneumothorax, hospital falls with hip fracture, postoperative hemorrhage or hematoma, postoperative acute kidney injury requiring dialysis, postoperative respiratory failure, postoperative pulmonary embolism (PE) and deep vein thrombosis (DVT), postoperative sepsis, postoperative wound dehiscence, and abdominopelvic accidental puncture and laceration. 

The PSIs can be used to help hospitals and healthcare organizations assess, monitor, track, and improve the safety of inpatient care. They can also be used for comparative public reporting, trending, and pay-for-performance initiatives.

Data in the absence of deeper analysis and understanding is just that: data. In order to glean meaning from your facilities’ PSIs and know what action needs to be taken to improve your metrics, you need to dig beyond the data itself. It is your duty to take your PSI data, analyze it, and improve it through clinical documentation and following best practices. 

Part of this improvement process includes an understanding of the AHRQ Technical Specifications, and inclusion and exclusion criteria for all PSIs. This takes a multidisciplinary approach, including providers, coders, and clinical documentation improvement specialists. Through a review of PSI 11, 12, and 13, we hope to demonstrate how to gain the most information from your data. 

Patient Safety Indicator 11 (PSI 11), Postoperative Respiratory Failure Rate, focuses on elective surgical discharges with a secondary diagnosis of acute postprocedural respiratory failure, prolonged mechanical ventilation, and reintubation.

If you drill down into the inclusion set, patients qualify for this PSI if they require intubation one or more days after the first major operating room procedure, if they are on a vent for greater than 96 consecutive hours, zero or more days following the first major operating procedure, or if the last date of the vent for 24-96 hours is two or more days after the first major operating room procedure.  

A few of the denominator exclusions include patients who have a principal diagnosis code (or secondary diagnosis present on admission, or POA) of acute respiratory failure, a tracheostomy POA, malignant hyperthermia, neuromuscular disorders, and degenerative neurological disorders. The neuromuscular disorders, including Guillain-Barre syndrome, Myasthenia gravis, and other myopathies, such as critical illness myopathy, need to be present on admission to serve as an exclusion for this PSI.   

It is important to be mindful of the technical specifications, as not all of these conditions have to be POA, as is the case with malignant hyperthermia. Certain procedure codes will exclude your patient (or potentially include your patient), so be sure to have a strong second-level coding review process to ensure that your major operating room (OR) procedures are properly coded and abstracted. Remember, something as simple as an incorrect vent date may erroneously place your patient in this PSI. Another important consideration for this PSI is provider documentation.

Providers may document “post-op respiratory failure,” using the words “post-op” as a means of describing a temporal relationship of respiratory failure that occurred after a surgical procedure. Yet not all respiratory failure following surgery is a complication of the procedure, and documentation should reflect if the respiratory failure is secondary to an underlying medical illness, or related to the surgery itself.

Patient Safety Indicator 12 (PSI 12), Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate, identifies patients with a perioperative PE or proximal DVT (as a secondary diagnosis). Appendix A, found within the AHRQ specifications, defines which procedure codes trigger the PSI. This PSI requires expertise from clinical and coding experts, as there are nuances to the inclusion criteria. Knowledge of anatomy and radiology reports play a role in confirming that a pulmonary embolism is appropriately documented as segmental versus single subsegmental, the latter of which is not included in PSI 12. 

Additionally, a distal DVT does not trigger a PSI; however, a proximal DVT will. Another consideration is whether the PE or DVT was present on admission. It is also important to familiarize the clinical documentation improvement (CDI) and coding team with the limited number of procedures that can exclude the PSI, such as pulmonary arterial or dialysis access thrombectomy that occurs before or on the same day as the first operating procedure, as noted in Appendix A in the PSI 12 specification. 

Lastly, there is a subset of acute brain or spinal injury diagnosis codes that may exclude the PSI. 

Patient Safety Indicator 13 (PSI 13), Postoperative Sepsis Rate, is another PSI that looks at elective surgeries with an admission type of 3 (elective). Here, once again, you want to be sure your admission type is properly abstracted. 

This PSI excludes discharges in which patients have a principal diagnosis of sepsis, or a secondary diagnosis of sepsis POA. In addition, discharges with a principal diagnosis of infection or secondary diagnosis of infection POA, as well as obstetric and newborn patients, are excluded from this PSI. It is important to review the infection diagnosis codes listed in Appendix F of the PSI 13 specification.

It is noteworthy to point out that some of the infections listed are for  chronic infections and wounds, such as osteomyelitis and pressure ulcers stage 3 and above (that are POA), all of which are exclusions for this PSI. In cases where sepsis is not present on admission, consider if there are clinical indicators that support the presence of a localized infection at time of admission. If this is not apparent in the documentation, a query would be warranted.  

The AHRQ PSIs “include hospital-level indicators to detect potential safety problems that occur during a patient’s hospital stay.” It is expected that your facility will have a percentage of cases that meet the inclusion criteria for PSI 90. 

Conducting a multidisciplinary chart review and comparing your data to a comparable cohort can shed light on areas of opportunity. If you do not have a multidisciplinary team, including coding, clinicians, and CDI, gather data and present a business case to support your PSI improvement plan. 

PSIs play an integral role in shaping the quality and safety of healthcare systems. It is imperative to understand both clinical and coding opportunities when a PSI is identified. The CDI and coding teams, in partnership with clinicians, can help identify improvements in care delivery and exclude the PSI when not applicable. With a shared understanding of both the coding and clinical components associated with PSIs, you can transform your data into meaningful information – and in turn make a significant impact in reducing the number of PSIs at your organization.

Programming note: Listen to Dr. Jennifer Brettler and Kimberley Seery report this story live today during Talk Ten Tuesdays at 10 a.m. EST.