• AHRQ quality indicators. Guide to patient safety indicators [version 3.1]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ)AHRQ Pub; 2007 Mar 12. 76 p. (AHRQ Pub; no. 03-R203).



• AHRQ quality indicators. Patient safety indicators: technical specifications [version 3.2]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2008 Mar 10. 107 p.

Does not apply to this measure

This measure is used to assess the number of cases of birth trauma, injury to neonate, per 1,000 liveborn births.

Hospitals in the United States provide the setting for some of life's most pivotal events - the birth of a child, major surgery, treatment for otherwise fatal illnesses. These hospitals house the most sophisticated medical technology in the world and provide state-of-the-art diagnostic and therapeutic services. But access to these services comes with certain costs. About 30% of personal health care expenditures in the United States go towards hospital care, and the rate of growth in spending for hospital services has only recently leveled out after several years of increases following a half a decade of declining growth. Simultaneously, concerns about the quality of health care services have reached a crescendo with the Institute of Medicine's series of reports describing the problem of medical errors and the need for a complete restructuring of the health care system to improve the quality of care. Policymakers, employers, and consumers have made the quality of care in U.S. hospitals a top priority and have voiced the need to assess, monitor, track, and improve the quality of inpatient care.

Widespread consensus exists that health care organizations can reduce patient injuries by improving the environment for safety from implementing technical changes, such as electronic medical record systems, to improving staff awareness of patient safety risks. Clinical process interventions also have strong evidence for reducing the risk of adverse events related to a patient's exposure to hospital care. Patient Safety Indicators (PSIs), which are based on computerized hospital discharge abstracts from the AHRQ's Healthcare Cost and Utilization Project (HCUP), can be used to better prioritize and evaluate local and national initiatives. Analyses of these and similar inexpensive, readily available administrative data sets may provide a screen for potential medical errors and a method for monitoring trends over time.

The Birth Trauma-Injury to Neonate indicator* is intended to flag cases of birth trauma for infants born alive in a hospital. The indicator excludes patients born pre-term, as birth trauma in these patients may be less preventable than for full-term infants.

*The following concerns affect the validity of this indicator:

• Condition definition varies: This indicator includes conditions for which diagnosis may be subjective, depending in the threshold of the physician, and patients with the same clinical state may not have the same diagnosis.
• Unclear preventability: As compared to other Patient Safety Indicators (PSIs), the conditions included in this indicator may be less preventable by the health system.
• Heterogeneous severity: This indicator includes codes that encompass several levels of severity of a condition that cannot be ascertained by the codes.

Refer to the original measure documentation for further information.

Birth trauma

All liveborn births (newborns)

The definition of newborn is any neonate with either 1) an International Classification for Diseases, Ninth Revision, Clinical Modifications (ICD-9-CM) diagnosis code for an in-hospital liveborn birth or 2) an admission type of newborn (Admission Type=4), age in days at admission equal to zero, and not an ICD-9-CM diagnosis code for an out-of-hospital birth. A neonate is defined as any discharge with age in days at admission between zero and 28 days (inclusive). If age in days is missing, then a neonate is defined as any Diagnosis-Related Group (DRG) in Major Diagnostic Category (MDC) 15, an admission type of newborn (Admission Type=4), or an ICD-9-CM diagnosis code for an in-hospital liveborn birth.

Note: Refer to the Technical Specifications document for specific ICD-9-CM codes.

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 for birth trauma in any diagnosis field

Exclude infants:

• With a subdural or cerebral hemorrhage (subgroup of birth trauma coding) and any diagnosis code of pre-term infant (denoting birth weight of less than 2,500 grams and less than 37 weeks gestation or 34 weeks gestation or less)
• With injury to skeleton (767.3, 767.4) and any diagnosis code of osteogenesis imperfecta (756.51)

Note: Refer to the Technical Specifications document for specific ICD-9-CM codes.

• 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

Variation in quality for the performance measured

• AHRQ quality indicators. Guide to patient safety indicators [version 3.1]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ)AHRQ Pub; 2007 Mar 12. 76 p. (AHRQ Pub; no. 03-R203).

Current routine use

Internal quality improvement
National reporting
Quality of care research

Hospitals

Advanced Practice Nurses
Physicians

Individual Clinicians

Newborn infants age 0 to 28 days

Either male or female

Unspecified

Unspecified

Unspecified

Unspecified

Unspecified

Unspecified

Getting Better

Safety

Users of care only

All liveborn births (newborns)

The definition of newborn is any neonate with either 1) an International Classification for Diseases, Ninth Revision, Clinical Modifications (ICD-9-CM) diagnosis code for an in-hospital liveborn birth or 2) an admission type of newborn (Admission Type=4), age in days at admission equal to zero, and not an ICD-9-CM diagnosis code for an out-of-hospital birth. A neonate is defined as any discharge with age in days at admission between zero and 28 days (inclusive). If age in days is missing, then a neonate is defined as any Diagnosis-Related Group (DRG) in Major Diagnostic Category (MDC) 15, an admission type of newborn (Admission Type=4), or an ICD-9-CM diagnosis code for an in-hospital liveborn birth.

Note: Refer to the Technical Specifications document for specific ICD-9-CM codes.

Patients associated with provider

Inclusions
All liveborn births (newborns)

The definition of newborn is any neonate with either 1) an International Classification for Diseases, Ninth Revision, Clinical Modifications (ICD-9-CM) diagnosis code for an in-hospital liveborn birth or 2) an admission type of newborn (Admission Type=4), age in days at admission equal to zero, and not an ICD-9-CM diagnosis code for an out-of-hospital birth. A neonate is defined as any discharge with age in days at admission between zero and 28 days (inclusive). If age in days is missing, then a neonate is defined as any Diagnosis-Related Group (DRG) in Major Diagnostic Category (MDC) 15, an admission type of newborn (Admission Type=4), or an ICD-9-CM diagnosis code for an in-hospital liveborn birth.

Note: Refer to the Technical Specifications document for specific ICD-9-CM codes.

Exclusions
Unspecified

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

Clinical Condition
Institutionalization

Time window is a single point in time

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 for birth trauma in any diagnosis field

Exclusions
Exclude infants:

• With a subdural or cerebral hemorrhage (subgroup of birth trauma coding) and any diagnosis code of pre-term infant (denoting birth weight of less than 2,500 grams and less than 37 weeks gestation or 34 weeks gestation or less)
• With injury to skeleton (767.3, 767.4) and any diagnosis code of osteogenesis imperfecta (756.51)

Note: Refer to the Technical Specifications document for specific ICD-9-CM codes.

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

Institutionalization

Administrative data

Not Individual Case

Adverse Outcome

Unspecified

Rate

Better quality is associated with a lower score

Analysis by subgroup (stratification on patient factors, geographic factors, etc.)
Risk adjustment method widely or commercially available

Risk adjustment of the data is recommended using sex.

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

External comparison at a point in time
External comparison of time trends
Internal time comparison

The Patient Safety Indicators (PSIs) were evaluated by the project team using empirical analyses to explore the frequency and variation of the indicators, the potential bias, based on limited risk adjustment, and the relationship between indicators. The data sources used in the empirical analyses were the 1997 Florida State Inpatient Database (SID) for initial testing and development and the 1997 Healthcare Cost and Utilization Project (HCUP) State Inpatient Database for 19 States for the final empirical analyses.

All potential indicators were examined empirically by developing and conducting statistical tests for precision, bias, and relatedness of indicators. Three different estimates of hospital performance were calculated for each indicator:

1. The raw indicator rate was calculated using the number of adverse events in the numerator divided by the number of discharges in the population at risk by hospital.
2. The raw indicator was adjusted to account for differences among hospitals in age, gender, modified Diagnosis-Related Group (DRG), and comorbidities.
3. Multivariate signal extraction methods were applied to adjust for reliability by estimating the amount of "noise" (i.e., variation due to random error) relative to the amount of "signal" (i.e., systematic variation in hospital performance or reliability) for each indicator.

The project team constructed a set of statistical tests to examine the precision, bias, and relatedness of indicators for all accepted Provider-level Indicators, and precision and bias for all accepted Area-level Indicators. It should be noted that rates based on fewer than 30 cases in the numerator or the denominator are not reported.

The project team conducted a structured review of each indicator to evaluate the face validity (from a clinical perspective) of the indicators. 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 review sought to establish consensual validity, which "extends face validity from one expert to a panel of experts who examine and rate the appropriateness of each item..." The panel process served to refine definitions of some indicators, add new measures, and dismiss indicators with major concerns from further consideration.

Refer to the original measure documentation for additional details.

• AHRQ quality indicators. Guide to patient safety indicators [version 3.1]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ)AHRQ Pub; 2007 Mar 12. 76 p. (AHRQ Pub; no. 03-R203).

Birth trauma -- injury to neonate (PSI 17).

Agency for Healthcare Research and Quality

Agency for Healthcare Research and Quality (AHRQ)

The Agency for Healthcare Research and Quality (AHRQ) Quality Indicators are in the public domain and the specifications come from multiple sources, including the published and unpublished literature, users, researchers, and other organizations. AHRQ as an agency is responsible for the content of the indicators.

None

National Quality Forum

National Healthcare Disparities Report (NHDR)
National Healthcare Quality Report (NHQR)

This indicator has been widely used in the obstetric community, although it is most commonly based on chart review rather than administrative data. It was proposed by Miller and colleagues (2001) in the original "Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator (PSI) Algorithms and Groupings." Based on expert consensus panels, McKesson Health Solutions included a broader version of this indicator in its CareEnhance Resource Management Systems, Quality Profiler Complications Measures Module.

2003 Mar

2008 Mar

This is the current release of the measure.

This measure updates previous versions:

• AHRQ quality indicators. Guide to patient safety indicators [version 3.0a]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2006 May 1. 78 p. (AHRQ Pub; no. 03-R203).
• AHRQ quality indicators. Patient safety indicators: technical specifications [version 3.1]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2007 Mar 12. 107 p.

• AHRQ quality indicators. Guide to patient safety indicators [version 3.1]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ)AHRQ Pub; 2007 Mar 12. 76 p. (AHRQ Pub; no. 03-R203).



• AHRQ quality indicators. Patient safety indicators: technical specifications [version 3.2]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2008 Mar 10. 107 p.

This NQMC summary was completed by ECRI on October 1, 2003. The information was verified by the measure developer on October 29, 2003. This summary was updated by ECRI on February 7, 2005 and on April 11, 2006. The information was verified by the measure developer on July 31, 2006. This NQMC summary was updated by ECRI Institute on June 12, 2007 and again on October 15, 2008.

No copyright restrictions apply.