AHRQ patient safety indicators: time to include hemorrhage and infection during childbirth

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.

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.

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.

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.