title: AHRQ patient safety indicators: time to include hemorrhage and infection during childbirth.
abstract: BACKGROUND
  Many Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) partially or completely exclude pregnant women. Both postoperative hemorrhage or hematoma (PSI 9; hemorrhage), and Postoperative Sepsis (PSI 13; infection) appear to be adaptable to pregnancy hospitalizations.
  
  
  METHODS
  Using the 2009 California Patient Discharge Dataset (N [total] = 508,842), the hemorrhage and infection PSIs were examined for their potential to include pregnant women in gynecological, antepartum, postpartum, and delivery subpopulations. The statewide and hospital-level indicator rates were calculated using hierarchical models adjusted for case mix.
  
  
  RESULTS
  Only the delivery population had sufficient cases for hospital-level analysis. Both PSIs required major changes to the technical specifications because of pregnancy-specific codes and coding practices. Nevertheless, these revised indicators identified substantial morbidity that varied widely across hospitals. The hemorrhage indicator rate was 2.50% (95% confidence interval [CI], 2.45-2.54) for all deliveries, compared with 0.26% (95% CI, 0.25-0.27) in the AHRQ population and 0.18% (95% CI, 0.15-0.21) for nonpregnant women of reproductive age. Adjusted hospital rates averaged 2.52%, with a midquartile range of 1.16% to 3.09% Although infection rates were lower for all deliveries than for the AHRQ population (0.18% versus 1.20%), they were highly associated with cesarean versus vaginal birth (0.43% versus 0.05%) and ranged from 0% to 1.15% across hospitals.
  
  
  CONCLUSIONS
  Although codes and coding practices for pregnancy hospitalizations differ from those used for nonpregnant adults, hospital-level measures of childbirth-associated hemorrhage and infection are feasible, vary widely, and demonstrate considerable opportunity for improvement.
authors.affiliation: Women's Healthcare Quality and Performance Improvement, Department of Obstetrics and Gynecology, Cedans-Sinai Medical Center, USA. kimberly.gregory@cshs.org
authors.forename: Kimberly D
authors.initials: KD
authors.lastname: Gregory
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Korst
authors.forename: Michael C
authors.initials: MC
authors.lastname: Lu
authors.forename: Moshe
authors.initials: M
authors.lastname: Fridman
mesh_terms: D000328:Adult; D002140:California; D059019:Clinical Coding; D036861:Delivery, Obstetric / Q000009:adverse effects* / Q000379:methods / Q000592:standards; D005260:Female; D006406:Hematoma / Q000145:classification; D006801:Humans; D038801:International Classification of Diseases; D010351:Patient Discharge / Q000706:statistics & numerical data; D061214:Patient Safety / Q000592:standards*; D011183:Postoperative Complications / Q000145:classification; D006473:Postpartum Hemorrhage / Q000145:classification; D011247:Pregnancy; D011248:Pregnancy Complications / Q000145:classification*; D019984:Quality Indicators, Health Care; D018805:Sepsis / Q000145:classification; D014481:United States; D016270:United States Agency for Healthcare Research and Quality