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Background: Reducing 30-day readmission can potentially improve quality of stroke care. We investigated factors associated with 30-day readmission,1-year mortality and stroke recurrence post-ischemic stroke. Methods: Cohort included primary ischemic stroke discharges 1/1/2015 to 3/31/2021 from a large racial-ethnically diverse integrated healthcare delivery system. Assessment included demographics, comorbidity, NIHSS, IV thrombolytic, thrombectomy, hospital complications, and mRS score at discharge. Multivariate analysis was done to determine predictors for 30-day readmission, 1-year mortality and stroke recurrence. Results: Of 13,053 ischemic stroke patients,1,790 (13.7%) were readmitted within 30 days. The median time to readmission was 10 days (IQR 4-19). Readmission was most-commonly stroke-related (21.6%). Being older, having higher initial NIHSS or co-morbidity score or more hospital complications, not receiving IV thrombolysis, and being more disabled at discharged were seen more often among those who were readmitted (Table). In multivariate analysis, being older, having higher initial NIHSS and co-morbidity score were associated with higher odds of being readmitted by 30-day and having higher mortality and stroke recurrence at 1-year. Adjusted odds for stroke recurrence were elevated for black patients. Being readmitted by 30-day also predicted greater odds of 1-year stroke recurrence and 1-year mortality. On the other hand, receiving IV thrombolysis was associated with significantly less odds of being readmitted at 30-day (OR=0.74; 95% CI = 0.59 - 0.93) and less stroke recurrence (OR=0.75; 95% CI =0.64 - 0.87) and less mortality at 1-year (OR=0.57; 95% CI = 0.42 - 0.76). Conclusions: A number of factors predicted 30-day readmission as well as 1-year stroke recurrence and mortality. Receiving IV thrombolytic for acute stroke was strongly associated with lower odds of developing bad outcomes.

Background: Stroke is a major problem in Asia where more than half of the world population resides. Asian Americans are among the fastest growing racial-ethnic groups in the US, yet the incidence of stroke subtypes, stroke risk factors and outcomes have been largely unstudied in Asian Americans. We assessed acute stroke alert presentations in Asians compared to whites in a large integrated health care delivery system. Methods: In 2016, Kaiser Permanente Northern California launched a standardized telestroke program for 21 certified stroke centers to include immediate video evaluation by a teleneurologist. Non-cancelled stroke alerts included those patients who were potential candidates for further workup for acute ischemic stroke treatment. We evaluated all non-cancelled stroke alerts evaluated by Telestroke in 2019. Assessment included demographics, mode of arrival, initial NIHSS, neuroimaging results, IV thrombolytic, door-to-needle (DTN) time, large vessel occlusion (LVO), thrombectomy referral, and discharge disposition. Results: We identified 427 Asian and 1262 White patients with potential acute ischemic stroke. Compared with whites, Asians were younger, just as likely to arrive via EMS and arrived quicker from their last known well time, but presented with more severe NIHSS, were more likely to have bleeding on the initial head CT, and less likely to receive IV thrombolytic within 30 minutes from ED arrival (Table). Asians had less detected LVO, but those with LVO were transferred out for thrombectomy faster compared with whites. There were less stroke mimics in Asians presenting with stroke alerts, and no difference in inpatient mortality compared with whites. Conclusions: Several differences existed between Asian and white patients evaluated by Telestroke as non-cancelled stroke alerts. Further research is needed to understand these differences and assess outcomes for Asians as well as major Asian subgroups presenting with acute ischemic stroke.

OBJECTIVE: To reweight the Agency for Healthcare Research and Quality Patient Safety for Selected Indicators Composite (Patient Safety Indicator [PSI] 90) from weights based solely on the frequency of component PSIs to those that incorporate excess harm reflecting patients' preferences for outcome‐related health states. DATA SOURCES: National administrative and claims data involving hospitalizations in nonfederal, nonrehabilitation, acute care hospitals. STUDY DESIGN: We estimated the average excess aggregate harm associated with the occurrence of each component PSI using a cohort sample for each indicator based on denominator‐eligible records. We used propensity scores to account for potential confounding in the risk models for each PSI and weighted observations to estimate the “average treatment effect in the treated” for those with the PSI event. We fit separate regression models for each harm outcome. Final PSI weights reflected both the disutilities and the frequencies of the harms. DATA COLLECTION/EXTRACTION METHODS: We estimated PSI frequencies from the 2012 Healthcare Cost and Utilization Project State Inpatient Databases with present on admission data and excess harms using 2012–2013 Centers for Medicare & Medicaid Services Medicare Fee‐for‐Service data. PRINCIPAL FINDINGS: Including harms in the weighting scheme changed individual component weights from the original frequency‐based weighting. In the reweighted composite, PSIs 11 (“Postoperative Respiratory Failure”), 13 (“Postoperative Sepsis”), and 12 (“Perioperative Pulmonary Embolism or Deep Vein Thrombosis”) contributed the greatest harm, with weights of 29.7%, 21.1%, and 20.4%, respectively. Regarding reliability, the overall average hospital signal‐to‐noise ratio for the reweighted PSI 90 was 0.7015. Regarding discrimination, among hospitals with greater than median volume, 34% had significantly better PSI 90 performance, and 41% had significantly worse performance than benchmark rates (based on percentiles). CONCLUSIONS: Reformulation of PSI 90 with harm‐based weights is feasible and results in satisfactory reliability and discrimination, with a more clinically meaningful distribution of component weights.

The Poisson distribution is used to find the probability of an event occurring over an interval of time, distance, area, or volume.It is a helpful statistical tool, especially when evaluating rare events, and is underused in nursing practice.A single-group study design is used to demonstrate use of the Poisson distribution in determining whether a change in the number of discrete events is due to random variation or reflects a change in practice patterns and in determining the probability of seeing the number of observed events.Steps demonstrate how one can easily use the Poisson distribution to answer common questions.Use of the Poisson distribution can help nurses make better informed decisions about observed variations in care, especially when the data are not normally distributed, and can prevent undue concern when fluctuations in the number of events are associated with random fluctuations.

Background and Purpose: In large artery occlusion stroke, both intravenous (IV) tPA (tissue-type plasminogen activator) and endovascular stroke treatment (EST) are standard-of-care. It is unknown how often tPA causes distal embolization, in which a procedurally accessible large artery occlusion is converted to a more distal and potentially inaccessible occlusion. Methods: We analyzed data from a decentralized stroke telemedicine program in an integrated healthcare delivery system covering 21 hospitals, with 2 high-volume EST centers. We captured all cases sent for EST and examined the relationship between IV tPA administration and the rate of distal embolization, the rate of target recanalization (modified Treatment in Cerebral Infarction scale 2b/3), clinical improvement before EST, and short-term and long-term clinical outcomes. Results: Distal embolization before EST was quite common (63/314 [20.1%]) and occurred more often after IV tPA before EST (57/229 [24.9%]) than among those not receiving IV tPA (6/85 [7.1%]; P P Conclusions: IV tPA administration before EST for large artery occlusion is associated with distal embolization, which in turn may reduce the chance that EST can be attempted and recanalization achieved. At the same time, some IV tPA-treated patients show symptomatic improvement and complete recanalization. Because IV tPA is associated with both distal embolization and improved long-term clinical outcome, there is a need for prospective clinical trials testing the net benefit or harm of IV tPA before EST.

Background: Race and sex disparities have been reported in endovascular stroke treatment, the most effective treatment to prevent long-term disability from stroke associated with large vessel occlusion (LVO). In this study, we sought to determine if there are racial and sex disparities in endovascular stroke treatment for patients with acute ischemic stroke due to LVO across 21 community hospitals, part of an integrated delivery system, using a centralized telestroke service and standardized process for rapid stroke evaluation and treatment. Methods: Study population included patients seeking care for suspected acute stroke that were diagnosed with a LVO at one of 21 Northern California Emergency Departments between January 1, 2016 and December 31, 2019. Patients were excluded if they were less than 18 years of age or had a canceled stroke alert. Logistic regression (SAS proc genmod) was used for multivariate models. Results: Of 1519 patients with LVO, 918 underwent endovascular treatment. There were no differences in sex, Healthcare membership (yes or no), or race in patients that received endovascular stroke treatment compared to those that did not in the multi-variate models (Table). As expected, increased age, greater initial NIHSS (greater than 6), arrival by Emergency Medical Service (yes or no), and shorter time to ED arrival were associated with increased treatment rates (Table). There were no significant differences by race or sex. There were no differences in 90-day mortality rates by race (p=0.085). Non-treatment was primarily associated with patient/family refusal and or poor functioning at baseline. Conclusions: Implementation of the telestroke plus standardized workflows within all facilities provided equitable care regarding race and gender on endovascular treatment odds.

Background: In 2020, a large integrated healthcare system consisting of 21 stroke centers implemented IV tenecteplase as the first line pharmaceutical treatment for acute ischemic stroke (AIS) prior to universal adoption in national clinical practice guidelines and FDA approval for stroke. Purpose: To describe the steps taken for successful implementation of IV tenecteplase as a first therapy for AIS in 21 stroke centers, part of an integrated system. Methods: Pre-implementation steps included gaining systemwide acceptance, especially from key stakeholders such as emergency department staff, patient care services, tele-stroke and neurology physicians, as well as risk management. We addressed potential impacts to related to reimbursement, stroke certification, and national award status. Inclusive changes were made to related policy and procedures, order sets, and other documentation. Standardized training and beta-testing were conducted and a sequential roll-out implemented along the real-time central monitoring. Results: Stakeholder groups were engaged prior to implementation with town halls and in-person and desktop simulation exercises. Beta-testing took place in August 2020 with three pilot sites with full system wide implementation by Nov. 2020. Since full implementation, tenecteplase is the only thrombolytic that has been ordered (n=423). Door in door out times have decreased (median 131 minutes pre- to 88 minutes post; p Conclusion: Tenecteplase has been shown to be safe and feasible as a first line thrombolytic within our organization. Strong nurse and physician leads, as well as thoughtful and inclusive implementation steps were key in the successful adoption of this system-wide change.

Little is known about the risk of angioedema with low-dose alteplase administration in the treatment of thrombotically occluded central vascular access devices (CVADs). To identify potential cases, the US Food and Drug Administration Adverse Event Reporting System database was searched. Between March 15, 2001, and August 15, 2018, there were 568 low-dose alteplase reports. Of these, 11 appear to be related to complications associated with a device or device occlusion that resulted in an angioedema-like reaction. This suggests that angioedema is a potential complication of alteplase when used for declotting CVADs-a complication that nurses should know how to recognize and treat.

Background: “ Missed nursing care” is a unique type of error known as medical underuse. These errors of omission are related to events, such as patient falls, nosocomial infections, and pressure injuries, associated with increased stroke mortality and morbidity. This study aimed to measure the phenomena of missed care in patients with stroke from the perspective of staff RNs working on a stroke unit and neuro intensive care unit at a Comprehensive Stroke Center. Methods: A Missed Care Survey was developed. Building on the work by Kalisch, the new Missed Care Survey focused entirely on nurse-sensitive measures and related evidence-based bundle steps. Two versions of the 25- question ordinal survey were developed, differing only in how the responses were worded. One asked how often care was missed [never missed (5), rarely missed (4), occasionally missed (3), frequently missed (2), always missed (1)]. and the other how frequently care was completed [always completed (5),usually completed (4), etc.).Descriptive statistics were used to evaluate results. Staff volunteered to take the survey during an annual stroke review class, rating their perception of care over the last 30-days. The IRB determined that the human subject regulation did not apply. Results: Completion rate was 93% (n=140). Differences between the two surveys were minimal with the overall summary score being the same (4.1; range 3.5-4.5). Individual scores ranged from 2.6 to 5. Items most frequently described as never missed included timely administration of pre-operative antibiotics and use of barrier precautions with central venous access device insertion. Care most missed included bathing and peri-care (with/without indwelling catheter), mobility, incentive spirometry, and the prevention of loops in urinary drainage catheter tubing. There were minor changes in rankings between the two survey versions. Conclusions: Scores reflect that known interventions to prevent iatrogenic complications are frequently or occasionally missed (or only usually and occasionally completed). Next steps include validation with real time observations. When missed care is not addressed, it can become routine, known as normalization of deviance, negatively impacting patient outcomes and the quality of care.

Background: The modified Rankin Scale (mRS) is a validated tool used to assess a patient’s functional status. Comprehensive Stroke Centers are required to obtain mRS scores at 90-days for acute ischemic stroke patients who received intravenous alteplase and/or endovascular stroke treatment. Purpose: To develop and implement a sustained process for obtaining mRS scores 90-days post-hospitalization for all stroke patient types discharging from the acute hospital setting. Methods: A team of front-line nurses from various departments were trained on the mRS scoring tool. A smartphrase was developed to standardize documentation. CSTK-02 criteria were used and extended to all ischemic and hemorrhagic stroke discharges regardless of treatment or intervention received. A weekly call list was generated and provided. Calls were made to patients or caregivers between 8am and 7pm on weekdays, and occasionally on weekends, depending on the department making the calls. Three attempted calls were considered compliant. If a validation error occurred during screening, additional questions were asked based on the tool algorithm to resolve the error and ensure accuracy. Calls were rotated monthly by department. Results: Between May 2017 and May 2019, 1235 patients were discharged. A total of 297 patients were unable to be screened due to various reasons. 1115 patient contacts were attempted. Of those, 84% (938 patients) were screened. A retrospective breakdown of the mRS scores was stratified: 158 (17%) scored mRS of 0, 55 (6%) scored mRS of 1, 60 (6%) scored mRS of 2, 187 (20%) scored mRS of 3, 155 (17%) scored mRS of 4, 74 (8%) scored mRS of 5, and 249 (27%) scored mRS of 6. Conclusion: Having front-line nurses conduct 90-day post-discharge phone calls to obtain mRS scores appears to be an effective sustainable method in obtaining functional outcomes for all stroke types discharging from the acute hospital setting.

Background: An ICU Neuroscience Nursing Committee was formed to function as a unit-based council, empowering nurses to impact unit decision-making and problem-solving. The committee members serve as neuroscience leaders in the Neuro ICU (NICU). Purpose: To determine the impact of the ICU Neuroscience Nursing Committee on staff education, quality of care, staff morale and empowerment, and health outcomes in a large NICU. Methods: Staff-led committee interventions include: A quarterly comprehensive neuroscience newsletter Curriculum development for an annual Neuroscience Symposium and other education eventsAnnual neurological competency review for unit staffNew employee neurological orientation and educationICU protocol, pathway, process, and policy development and reviewParticipation in neuro patient roundsReal-time hands-on education in response to unit-specific needs and identified opportunities. Results: Mixed methodology was used to evaluate the impact of the committee. External Ventricular Drain infections less than 1% for the last 3 years Improved stroke symptom recognition and inpatient stroke alert times Best practice recognition from The Joint Commission on nursing knowledge and expertise in caring for complex stroke patients Improved collaboration between nursing and physicians Increase in national neuroscience nursing certifications Decrease in nurse-sensitive events Abstract submission and poster presentations at premier conferences Improved neurocritical care physician satisfaction with nursing care Enhanced nurse morale and empowerment Improved patient satisfaction Input and development of new policy and procedures Duplication of neuroscience committee efforts in other departments. Conclusion: Establishment of the ICU Neuroscience Nursing Committee has proven to have a significant impact in improving the quality of care, patient health outcomes and enriching staff morale.

Background: As a Comprehensive Stroke Center (CSC), The Joint Commission requires post-discharge follow-up phone calls to be conducted within 7 days of discharge for all complex stroke patients. Purpose: To develop and sustain a feasible approach for Hospital Based Specialist (HBS) physicians to conduct follow-up phone calls within 7 days. Methods: A baseline evaluation of all post-discharge phone calls was conducted. It was determined that patients were receiving several phone calls already, therefore the team did not want to add an additional call to meet compliance. HBS calls were realigned to include a stroke-specific focus, reinforcing stroke education and secondary prevention. Calls were made within 7 days by the discharging physician. All stroke patient types discharged with a stroke diagnosis were contacted regardless of severity. Patients discharged to skilled nursing facilities, board and care, acute rehabilitation or other acute care hospitals were excluded. A templated note was developed to ensure all stroke-specific components were covered. All HBS physicians were trained. Telephone interactions occurred between the patient, family member, and/or caregiver. Those unable to be reached but had messages left or secure messaging sent were counted as compliant. Reminders were sent out to physicians to improve call compliance. Tracking occurred weekly for call compliance and note template utilization. Results: Between January 2018 and May 2019, 612 patients discharged home from the acute care setting. Of those, 55% (334) were contacted. Of those, 73% had the templated note documented. Several hurdles were encountered along the way, but utilization of the templated note and physician reminders improved compliance. Conclusion: Post-discharge follow-up phone calls initiated by HBS physicians and utilization of a templated note are a feasible means of meeting and sustaining the CSC requirement.

Background: Comprehensive Stroke Centers (CSC) are required by The Joint Commission to have an interdisciplinary peer review process. Most hospitals structure their peer review programs, also known as morbidity and mortality meetings, by specialty and not by Centers of Excellence. Often these meetings are closed, with minimal information sharing for making program-wide improvements. Purpose: To develop and implement a process for conducting morbidity and mortality reviews for a CSC based on best practices to foster improved clinical outcomes. Methods: A literature review was performed to establish best practices for such reviews. An interdisciplinary team including key stakeholders was developed for a non-biased comprehensive chart review. All deaths within 30-days, sentinel events, serious incidents, adverse events, close calls, stroke mimics treated with alteplase, delays in care, complications, and major complaints were reviewed. Cases were captured by formal and informal processes (see diagram). Outcomes and trends are monitored. Recommendations are made for changes in clinical processes. Results: Between January 2016 - June 2018, 853 charts were reviewed for the criteria discussed above. A total of 89 charts were referred to the committee for further chart review, of which, 3 were identified for department peer review. Of those 3 cases, all were determined to be outliers, and no trends have been identified . While there were no blatant opportunities identified for improvement, the review process provides helpful information regarding the quality of the program. Members of the interdisciplinary team feel that the process is robust and valuable. Conclusion: Establishing a succinct process for chart evaluation and interdisciplinary team review has proven effective in identifying cases for referral to peer review. These data have been helpful in improving performance and monitoring patient-centered outcomes.

Background: Comprehensive Stroke Centers are required by The Joint Commission to screen stroke patients with stroke for depression prior to discharge. Stroke related depression, however, may occur weeks or months after the acute event. Adding a 90-day screen may help identify additional patients with depression after discharge from the acute hospital setting. Purpose: To evaluate the impact of having a registered nurse (RN) perform 90-day post-discharge depression screening by telephone for patients with recent stroke. Methods: A team of RNs were trained on the Patient Health Questionnaires (PHQ2 and PHQ9). Both tools have been validated for telephone use. All ischemic and hemorrhagic stroke patients discharged home were included. Patients were called 90 days +/- 15 days post-discharge. Patients scoring positive on the PHQ2 (a score of > or equal to 3) were further evaluated by the RN using the PHQ9. Nurses referred patients scoring > or equal to 9 on the PHQ9 to the Stroke Medical Director for further evaluation. See graphic below. Results: Between August 2017 and July 2018, 297 patients were screened (56% of total stroke discharges, 297/527), of whom 8.8% (26/297) scored > or equal to 3 on the PHQ2. Of these, 73% had a PHQ9 score > or equal to 9 (19/26). All patients with a positive PHQ9 screen (19/19) were referred to the Stroke Medical Director and received appropriate triage and referral for ongoing care. This yielded a 6.4% rate (19/297) of stroke patients with symptoms of depression 90-days post-discharge. While some patients had a history of depression, most had no history or risk factors for depression. Conclusion: Conducting RN-facilitated 90-day post-hospital discharge telephone depression screening in patients with recent stroke appears to be an effective method to identify additional patients with stroke related depression who would not have been identified otherwise.

Background: Designated Stroke Centers are required by The Joint Commission to evaluate all acute ischemic stroke (AIS) patients for rehabilitation prior to discharge. Timing of this evaluation is controversial. Purpose: To evaluate the feasibility and safety of having a Physical Therapist (PT) or Occupational Therapist (OT) evaluate AIS patients within 24 hours of alteplase administration. Methods: Based on a comprehensive literature review, various committee discussions and agreement, the PT/OT team initiated evaluations within 24-hours for AIS patients treated with alteplase. The target post-alteplase evaluation time was 12-hours. Medical stability was determined by the physician as evidenced by an initial request for PT/OT evaluation. Prior to the evaluation, the therapist performed a thorough chart review. Patients with unstable vital signs, a fluctuating neurological assessment, and/or inability to participate in therapies were excluded. During the therapy evaluation, reassessment was ongoing. If any adverse change was observed, the evaluation was immediately stopped, the patient placed back in bed, and the primary nurse and/or physician notified. Results: A baseline review of data was performed. In 2016, 77 patients received alteplase, none of whom were evaluated within 24-hours following alteplase administration. Evaluations within 24 hours post-alteplase began in mid-March 2017 and continued through July 2018. A total of 103 patients received alteplase during this period, of whom 11 patients met initial exclusion criteria. Of these, 83% (76/92) were seen within the initial 24-hour timeframe. All patients reviewed and evaluated by the team were in the Intensive Care Unit. No mobility-associated complication or adverse neurologic change occurred during therapy evaluations or because of mobilization within the initial 24-hours. Conclusion: PT/OT neurological evaluations within 24-hours of alteplase administration did not result in adverse events or complications. Although difficult to quantify, therapy staff determined this change in practice was beneficial to patients as it allowed for earlier mobilization and initiation of the rehabilitation plan.

Context Lack of early stroke recognition and delays in seeking emergency care by persons experiencing a stroke severely limit acute treatment options. Sparse and sometimes conflicting evidence suggests sex differences in care-seeking behaviors in stroke, stroke knowledge, perceptions of stroke symptoms, and the importance of physical location at the time of stroke and of having a witnessed stroke. Objective To explore specific sex-based differences in stroke presentation and associated care-seeking behaviors. Design Descriptive study based on a convenience sample of 60 patients with stroke admitted to an academic medical center in Northern California. Main outcome measures Impact of the patient's sex on 1) time to presentation (early [≤ 4.5 hours] vs late [> 4.5 hours]); 2) perception of symptoms and clinical signs; 3) stroke knowledge and decision making; 4) physical location at the time of stroke; and 5) bystander presence and assistance with decision making. Results There was a discrepancy between how patients perceive symptoms and their medical findings on physical examination. Although most patients had at least one sign or symptom associated with nationally used stroke recognition acronyms, both sexes delayed care because they did not perceive their symptoms as urgent. Early-presenting men were more likely to have a higher stroke severity score at admission, receive alteplase, arrive by Emergency Medical Services, and have a witnessed stroke. Both early- and late-presenting women reported more nonfocal symptoms than did men. Conclusion This study suggests that there are sex-based differences in symptom perception and care-seeking behavior in acute ischemic stroke.

Background: Evidence suggests gender differences in: care seeking behaviors during stroke; stroke knowledge; perceptions of stroke symptoms; physical location at the time of event and decision making, and the impact of having a witness. Aims: To determine the impact of gender on the time to presentation (greater or equal to 4.5 hours or greater than 4.5 hours), symptom perception and clinical signs, stroke knowledge and decision making, physical location at the time of stroke, and the presence and impact of having a witnessed stroke. Study Design: A descriptive study based on a convenience sample of 60 subjects admitted to an academic medical center for stroke. Methods: Patients were asked a series of questions regarding the care seeking decision process, the role of others in the decision process, physical location at the time of event and the decision to seek care, and general stroke knowledge. They also answered a 28 symptom questionnaire which was compared to medical findings. Results: There were approximately equal number of men and women in the late and early presenting groups. Early presenting men were more likely to: have a higher admission NIHSS score (7.7 vs 4.8), to receive alteplase (71% vs 20%), to arrive by EMS, and have a witnessed stroke compared to early arriving women. Men were more likely to take an active role in the decision making process to seek care, while care seeking decision making in females was more likely to be transferred to nonspousal family members. Both early and late presenting women reported more non-focal symptoms than men. While most patients had at least one sign or symptom associated with national used stroke symptom acronyms, both genders delayed care because they didn’t perceive their symptoms as being urgent. Limitations: Small convenience sample from a single hospital with no control for stroke etiology. Conclusion: More research is needed to better understand the influence of gender on patient perception of stroke and care seeking behaviors.

OBJECTIVE The Agency for Healthcare Research and Quality Patient Safety Indicator (PSI) 10, "Postoperative Physiologic and Metabolic Derangement" (PPMD), uses administrative data to detect postoperative acute kidney injury (AKI) requiring dialysis and diabetes-related complications. We sought to evaluate the indicator's criterion validity. RESEARCH DESIGN We conducted a retrospective cross-sectional study of hospitalization records flagged positive and negative by PSI 10 from a diverse set of 35 hospitals between February 1, 2006 and June 30, 2009. Trained nurse abstractors reviewed medical records. We determined the indicator's sensitivity, specificity, and positive and negative predictive values. RESULTS Of 94 records flagged by PSI 10 (87 for AKI, 7 for diabetic complications, 1 for both), 69 (73%) involved an accurately coded event; 60 (64%; 95% CI, 46%-79%) represented true PPMD from a clinical perspective. Two of 8 records flagged for diabetic complications were true events. Nineteen false positives involved preoperative renal failure. Three of 230 records flagged negative (enriched with questionably negative records) represented true PPMD. The indicator's sensitivity was 66% (20%-94%), specificity 99.9% (99.5%-100%), and negative predictive value 99.9% (99.4%-100%). Considering dialysis access procedures tantamount to dialysis and excluding records with lower urinary tract obstruction might increase the sensitivity and positive predictive value to 98% (87%-100%) and 72% (50%-87%), respectively. CONCLUSIONS PSI 10 mostly concerns AKI and currently has moderate criterion validity, which might improve with increased use of "present on admission" coding, abandonment of the diabetes criteria, and adjustments to the indicator specifications regarding dialysis access and urinary tract obstruction.

Background Patient Safety Indicator (PSI) 13, or "Postoperative Sepsis," of the Agency for Healthcare Quality and Research (AHRQ), was recently adopted as part of a composite measure of patient safety by the Centers for Medicare and Medicaid Services (CMS). We sought to examine its positive predictive value (PPV) by determining how well it identifies true cases of postoperative sepsis. Study Design Two retrospective cross-sectional studies of hospitalization records that met PSI 13 criteria were conducted, one within the Veterans Administration (VA) Hospitals from fiscal years (FY) 2003 to 2007, and one within community hospitals between October 1, 2005 and March 31, 2007. Trained abstractors reviewed medical records from each database using standardized abstraction instruments. We determined the PPV of the indicator and performed descriptive analyses of cases. Results Of 112 cases flagged and reviewed within the VA system, 59 were true events of postoperative sepsis, yielding a PPV of 53% (95% CI 42% to 64%). Within the community hospital sector, of 164 flagged and reviewed cases, 67 were true cases of postoperative sepsis, yielding a PPV of 41% (95% CI 28% to 54%). False positives were due to infections that were present on admission, urgent or emergent cases, no clinical diagnosis of sepsis, or other coding limitations such as nonspecific shock in postoperative patients. Conclusions PSI 13 has relatively poor predictive ability to identify true cases of postoperative sepsis in both the VA and nonfederal sectors. The lack of information on diagnosis timing, confusion about the definition of elective admission, and coding limitations were the major reasons for false positives. As it currently stands, the use of PSI 13 as a stand-alone measure for hospital reporting appears premature.

To determine the positive predictive value of International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) discharge codes for acute deep vein thrombosis or pulmonary embolism.Retrospective review of 3456 cases hospitalized between 2005 and 2007 that had a discharge code for venous thromboembolism, using 3 sample populations: a single academic hospital, 33 University HealthSystem Consortium hospitals, and 35 community hospitals in a national Joint Commission study. Analysis was stratified by position of the code in the principal versus a secondary position.Among 1096 cases that had a thromboembolism code in the principal position the positive predictive value for any acute venous thrombosis was 95% (95%CI:93-97), whereas among 2360 cases that had a thromboembolism code in a secondary position the predictive value was lower, 75% (95%CI:71-80). The corresponding positive predictive values for lower extremity deep-vein thrombosis or pulmonary embolism were 91% (95%CI:86-95) and 50% (95%CI:41-58), respectively. More highly defined codes had higher predictive value. Among codes in a secondary position that were false positive, 22% (95%CI:16-27) had chronic/prior venous thrombosis, 15% (95%CI:10-19) had an upper extremity thrombosis, 6% (95%CI:4-8) had a superficial vein thrombosis, and 7% (95%CI:4-13) had no mention of any thrombosis.ICD-9-CM codes for venous thromboembolism had high predictive value when present in the principal position, and lower predictive value when in a secondary position. New thromboembolism codes that were added in 2009 that specify chronic thrombosis, upper extremity thrombosis and superficial venous thrombosis should reduce the frequency of false-positive thromboembolism codes.

Hospital administrative data are being used to identify hospitals with hospital-acquired complications such as iatrogenic pneumothorax. This was a retrospective cross-sectional study of hospitalization records to estimate the positive predictive value (PPV) of the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator for iatrogenic pneumothorax. A probability sample of inpatient medical records from 2006 to 2007 was reviewed in a national sample of 28 volunteer hospitals. Among the 200 flagged cases, the PPV was 78% (95% confidence interval = 73%-82%). False positive cases were mostly a result of exclusionary conditions (11%) and pneumothoraxes that were present on admission (7%). About 44% of events followed attempted central venous catheter (CVC) placement. Of the 69 CVC-associated events, only 5 occurred with ultrasound guidance. AHRQ's iatrogenic pneumothorax indicator can serve in quality of care improvement. At least 1725 hospital-acquired pneumothoraxes could have been prevented in 2004 through universal use of ultrasound guidance during internal jugular cannulation.

Hospital administrative data are being used to identify patients with postoperative venous thromboembolism (VTE), either pulmonary embolism (PE) or deep-vein thrombosis (DVT). However, few studies have evaluated the accuracy of these ICD-9-CM codes across multiple hospitals.The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator (PSI)-12 was used to identify cases with postoperative VTE in 80 hospitals that volunteered for either an AHRQ or University HealthSystem Consortium (UHC) validation project. Trained abstractors using a standardized tool and guidelines retrospectively verified all coded VTE events.In the combined samples, the positive predictive value of the set of prespecified VTE codes for any acute VTE at any time during the hospitalization was 451 of 573 = 79% (95% CI: 75%-82%). However, the positive predictive value for acute lower extremity DVT or PE diagnosed after an operation was 209 of 452 = 44% (95% CI: 37%-51%) in the UHC sample and 58 of 121 = 48% (95% CI: 42-67%) in the AHRQ sample. Fourteen percent of all cases had an acute upper extremity DVT, 6% had superficial vein thrombosis and 21% had no acute VTE, however, 61% of the latter had a documented prior/chronic VTE. In the UHC cohort, the sensitivity for any acute VTE was 95.5% (95% CI: 86.4%-100%); the specificity was 99.5% (95% CI: 99.4%-99.7%).Current PSI 12 criteria do not accurately identify patients with acute postoperative lower extremity DVT or PE. Modification of the ICD-9-CM codes and implementation of "present on admission" flags should improve the predictive value for clinically important VTE events.

Patient Safety Indicator (PSI) 15, or "Accidental Puncture or Laceration" (APL), of the US Agency for Healthcare Research and Quality was recently endorsed as a consensus standard for quality of care by the National Quality Forum. We sought to determine the positive predictive value (PPV) of this indicator.We conducted a retrospective cross-sectional study of hospitalization records that met PSI 15 criteria. We sampled cases from 32 geographically diverse hospitals, including both teaching and nonteaching hospitals, between October 1, 2005 and March 31, 2007. Trained abstractors from each center reviewed randomly sampled medical records, using a standard instrument. We determined the PPV of the indicator and conducted descriptive analyses of the cases.Of the 249 cases that met PSI 15 criteria, 226 (91%; 95% CI: 88%-94%) represented true APL. Fifty-six of the true APL cases (24%) represented injuries that generally would be expected to heal without repair, yielding, from the standpoint of clinical relevance, a PPV of 68% (95% CI: 62%-74%). True positive cases that would typically warrant repair (n=170) were most likely to involve the gastrointestinal tract (30%), bladder (25%), dura (19%), or an important blood vessel (16%). In 97 of the true APL cases (43%), adhesions or other scar tissue were thought to have contributed to the complication. The 23 false-positive cases involved no apparent event other than normal operative conduct (n=7), a complication other than APL (bleeding, infection, dislodgement of a gastrostomy tube, or fracture) (7), an APL present on admission (5), or a disease-related lesion (4).Although PSI 15 is highly predictive of APL from a coding perspective, the indicator is less predictive of APL that could be considered clinically important. A significant proportion of cases represent relatively inconsequential injuries or injuries for which the risk may have been acceptable relative to the goals of the procedure.

Quantifying the critical impact nurses have on the prevention and early recognition of potential complications and adverse events, such as those identified by the Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSI), is becoming increasingly important. In this paper, we describe how the AHRQ PSI may be used to identify nursing-specific opportunities to improve care based on data from the national AHRQ PSI validation pilot project.

© 2013 Wolters Kluwer Health, Inc. All rights reserved. Background: Symptomatic venous thromboembolism is a common postoperative complication. The Agency for Healthcare Research and Quality (AHRQ) has developed a Patient Safety Indicator 12 to assist hospitals, payers, and other stakeholders to identify patients who experienced this complication. Objectives: To determine whether newly created and recently redefined ICD-9-CM codes improved the criterion validity of Patient Safety Indicator 12, based on new samples of records dated after October 2009. Research Design, Subjects, Measures: Two sources of data were used: (1) UHC retrospective case-control study of risk factors for acute symptomatic venous thromboembolism occurring within 90 days after total knee arthroplasty in teaching hospitals; (2) chart abstraction data by volunteer hospitals participating in the Validation Pilot Project of the AHRQ. Results: In the UHC sample, the positive predictive value (PPV) was 99% (125/126) and the negative predictive value was 99.4% (460/463). In the AHRQ sample, the overall PPV was 81% (126/156). Conclusions: The PPV based on both samples shows substantial improvement compared with the previously reported PPVs of 43%-48%, suggesting that changes in ICD-9-CM code architecture and better coding guidance can improve the usefulness of coded data.

Background Patient Safety Indicator (PSI) 9, “postoperative hemorrhage or hematoma” (PHH), of the US Agency for Healthcare Research and Quality has been considered for public quality of care reporting. We sought to evaluate its performance in detecting true complications. Methods We conducted a retrospective, cross-sectional study of hospitalizations that met PSI 9 eligibility criteria. We sampled records flagged positive and negative by PSI 9 from a diverse set of 31 hospitals between February 2006, and June 2009. Trained abstractors reviewed medical records using standard instruments. We determined the sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values of the indicator. Results Of 181 analyzable records flagged by PSI 9, 168 (93%; weighted PPV, 95% [95% confidence interval (CI), 90–98%]) involved an accurately coded event, but only 126 (70%; weighted PPV, 78% [95% CI, 58–90%]) represented true PHH. Thirty-two false positives involved only intraoperative hemorrhage. Among true positives, hypotension occurred in 28% and death attributed to the PHH in 4%. Thirty-two of 281 records flagged negative by PSI 9 (but enriched with questionably negative records) represented true PHH. The indicator's sensitivity was 42% (95% CI, 23–64%), specificity 99.9% (95% CI, 99.8–100%), and NPV 99.7% (95% CI, 99.0–99.9%). Modifying the indicator to include additional procedure codes improved both sensitivity (85% [95% CI, 67–94%]) and PPV (76% [95% CI, 60–88%]). Conclusion PSI 9 holds promise in detecting serious, possibly preventable complications. The indicator might be improved by specification of the 998.11 hemorrhage code to exclude purely intraoperative events and addition of procedure codes to the indicator's numerator criteria.

Commentary on: B Byrne, P O’Halloran, C Cardwell. Accuracy of stroke diagnosis by registered nurses using the ROSIER tool compared to doctors using neurological assessment on a stroke unit: a prospective audit.Int J Nurs Stud2011;48:979–85.

As part of the Agency for Healthcare Research and Quality Patient Safety Indicator (PSI) Validation Pilot Project, we evaluated the criterion validity of PSI 7. At the time of this study, PSI 7 was entitled "Selected Infections Due to Medical Care" and targeted catheter-related infections and inflammatory reactions. We conducted a retrospective cross-sectional study of 23 volunteer U.S. hospitals, where trained abstractors reviewed a sample of records that met PSI 7 criteria from October 1, 2005 to March 31, 2007. Of the 191 cases that met PSI 7 criteria, 104 (positive predictive value = 54%, 95% confidence interval: 40-69%) represented true infections. Of these cases, 77 (74%) were associated with central venous catheters, 15 (15%) were associated with peripheral intravenous (n=13) and or or arterial catheters (n=6), and 12 (11%) were associated with unknown catheters. Of the 87 (46%) false-positive cases, 41 (47%) did not have a qualifying infection identified by the abstractor, 38 (44%) had an infection present on admission, and 8 (9%) had an exclusionary diagnosis. PSI 7 has a low positive predictive value compared with other PSIs recently studied. Present on admission diagnoses and improved coding for infections related to central venous catheters (implemented October 2007) may improve validity.

We sought to identify magnetic resonance- (MR)-imaged structures associated with declarative memory in a community-dwelling sample of elderly Mexican-American individuals with a spectrum of cognitive decline. Measured structures were the hemispheric volumes of the hippocampus (HC), parahippocampal gyrus, and remaining temporal lobes, as well as severity of white matter signal hyperintensities (WMH). Participants were an imaged subsample from the Sacramento Area Latino Study of Aging (SALSA), N = 122. Individuals were categorized as normal, memory impaired (MI), cognitively impaired non-demented (CIND), or demented. We show that WMH was the strongest structural predictor for performance on a delayed free-recall task (episodic memory) in the entire sample. The association of WMH with delayed recall was most prominent in elderly normals and mildly cognitively impaired individuals with no dementia or impairment of daily function. However, the left HC was associated with verbal delayed recall only in people with dementia. The right HC volume predicted nonverbal semantic-memory performance. We conclude that WMH are an important pathological substrate that affects certain memory functions in normal individuals and those with mild memory loss and discuss how tasks associated with WMH may rely upon frontal lobe function.

Background: Previous studies have found that hippocampal atrophy and white matter hyperintensities (WMH) on MRI are linked to cognitive impairment and dementia. The authors measured these variables in a population-based cohort of older Mexican Americans with a wide spectrum of cognitive ability, ranging from normal cognition to dementia. Objective: To investigate whether these structural brain changes were seen in individuals prior to the development of dementia and how these changes were related to the presence of dementia. Methods: A sample of 122 subjects was selected from the Sacramento Area Latino Study on Aging, and subjects were categorized into four groups of increasing levels of cognitive impairment: normal, memory impaired (MI), cognitively impaired but not demented (CIND), and demented. Hippocampal volume was quantified using a region of interest approach. WMH was rated on a semiquantitative scale as the percent of total volume of white matter. Results: Hippocampal volume was significantly reduced in CIND and demented individuals, and WMH were significantly increased in demented subjects. MI subjects did not have any significant changes in hippocampal volume or WMH. The risk for developing dementia was significantly and comparably increased in subjects with either hippocampal atrophy or high WMH. However, the risk for dementia increased dramatically in subjects with both hippocampal atrophy and a high degree of WMH. Conclusion: Reductions in hippocampal volume may be present before dementia but not until cognitive impairment is relatively severe. Because there is a synergistic effect between high WMH and hippocampal atrophy, interactions between vascular and degenerative processes may be important determinants of dementia.

Article-at-a-Glance Background The U.S. Agency for Healthcare Research and Quality (AHRQ) and other organizations have developed quality indicators based on hospital administrative data. Characteristics of effective abstraction instruments were identified for determining both the positive predictive value (PPV) of Patient Safety Indicators (PSIs) and the extent to which hospitals and clinicians could have prevented adverse events. Methods Through an iterative process involving nurse abstractors, physicians, and nurses with quality improvement experience, and health services researchers, 25 abstraction instruments were designed for 12 AHRQ provider-level morbidity PSIs. Data were analyzed from 13 of these instruments, and data are being collected using several more. Findings Common problems in designing the instruments included avoiding uninformative questions and premature termination of the abstraction process, anticipating misinterpretation of questions, allowing an appropriate range of response options; using clear terminology, optimizing the flow of the abstraction process, balancing the utility of data against abstractor burden, and recognizing the needs of end users, such as hospitals and quality improvement professionals and researchers, for the abstracted information. Conclusions Designing medical record abstraction instruments for quality improvement research involves several potential pitfalls. Understanding how we addressed these challenges might help both investigators and users of outcome indicators to appreciate the strengths and limitations of outcome-based quality indicators and tools designed to validate or investigate such indicators within provider organizations.

Background Patient Safety Indicator (PSI) 11, or postoperative respiratory failure, was developed by the US Agency for Healthcare Research and Quality to detect incident cases of respiratory failure after elective operations through use of ICD-9-CM diagnosis and procedure codes. We sought to determine the positive predictive value (PPV) of this indicator. Study Design We conducted a retrospective cross-sectional study, sampling consecutive cases that met PSI 11 criteria from 18 geographically diverse academic medical centers on or before June 30, 2007. Trained abstractors from each center reviewed medical records using a standard instrument. We assessed the PPV of the indicator (with 95% CI adjusted for clustering within centers) and conducted descriptive analyses of the cases. Results Of 609 cases that met PSI 11 criteria, 551 (90.5%; 95% CI, 86.5–94.4%) satisfied the technical criteria of the indicator and 507 (83.2%; 95% CI, 77.2–89.3%) represented true cases of postoperative respiratory failure from a clinical standpoint. The most frequent reasons for being falsely positive were nonelective hospitalization, prolonged intubation for airway protection, and insufficient evidence to support a diagnosis of acute respiratory failure. Fifty percent of true-positive cases involved substantial baseline comorbidities, and 23% resulted in death. Conclusions Although PSI 11 predicts true postoperative respiratory failure with relatively high frequency, the indicator does not limit detection to preventable cases. The PPV of PSI 11 might be increased by excluding cases with a principal diagnosis suggestive of a nonelective hospitalization and those with head or neck procedures. Removing the diagnosis code criterion from the indicator might also increase PPV, but would decrease the number of true positive cases detected by 20%.