Indicator Metadata

NameNursing-Sensitive Adverse Events for Medical Patients
Short/Other Names

Not applicable

Description

This indicator measures the rate of nursing-sensitive adverse events for all medical patients. The following adverse events are captured in this indicator:

• Urinary tract infections (UTIs)
• Pressure ulcers
• In-hospital fractures
• Pneumonia

For further details, please see the General Methodology Notes.

Interpretation

Lower rates are desirable.

High or low rates for this indicator must be interpreted with caution as they may be a consequence of inconsistent coding practices by hospitals when reporting post-admission adverse events to the DAD.

HSP Framework Dimension

Health System Outputs: Safe

Areas of Need

Getting Better

Geographic Coverage

All provinces/territories except Quebec

Reporting Level/Disaggregation

National, Province/Territory, Region, Facility, Peer Group

Indicator Results

https://www.cihi.ca/en/cihi-health-indicators

Identifying Information
NameNursing-Sensitive Adverse Events for Medical Patients
Short/Other Names

Not applicable

Indicator Description and Calculation
Description

This indicator measures the rate of nursing-sensitive adverse events for all medical patients. The following adverse events are captured in this indicator:

• Urinary tract infections (UTIs)
• Pressure ulcers
• In-hospital fractures
• Pneumonia

For further details, please see the General Methodology Notes.

Calculation: Description

The indicator is expressed as a rate of nursing-sensitive adverse events per 1,000 medical discharges.

Risk-adjusted rate = Observed cases ÷ Expected cases × Canadian average

Unit of analysis: Single admission

Calculation: Geographic Assignment

Place of service

Calculation: Type of Measurement

Rate - per 1,000

Calculation: Adjustment Applied

The following covariates are used in risk adjustment:
For a detailed list of covariates used in the model, please refer to the Model Specification document.

Calculation: Method of Adjustment

Logistic regression

Denominator

Description:
Acute care hospitalizations with medical conditions
Inclusions:
1. Admission to an acute care institution (Facility Type Code = 1)
2. Patients within the medical patient group (MCC diagnostic partition)
3. Age at admission 55 years and older
4. Sex recorded as male or female
Exclusions:
1. Obstetric (MCC 13), neonatal (MCC 14) or mental health (MCC 17) patients
2. Records with admission category of cadaveric donor or stillbirth (Admission Category Code = R or S)

Numerator

Description:
Cases within the denominator with one or more adverse events
Inclusions:
One of the following ICD-10-CA codes, coded as type 2 (except where specified):
 
Urinary tract infection (UTI):
– Site not specified (N39.0)
– 2012–2013 onward: Related to Foley catheter (T83.5 [type 2] + N39.0 [type 3] + Y84.6 [type 9] all within same diagnostic cluster)
 
Pressure ulcers:
– Decubitus ulcer (L89)
 
In-hospital fractures:
– Fracture of shoulder and upper arm (S42)
– Fracture of forearm (S52)
– Fracture at wrist and hand level (S62)
– Fracture of femur (S72)
– Fracture of lower leg, including ankle (includes malleolus) (S82)
– Fracture of foot, except ankle (S92)
– Fractures involving multiple regions of one upper limb (T02.2)
– Fractures involving multiple regions of one lower limb (T02.3)
– Fractures involving multiple regions of both upper limbs (T02.4)
– Fractures involving multiple regions of both lower limbs (T02.5)
– Fractures involving multiple regions of upper limb(s) (T02.6)
– Fracture of upper limb, level unspecified (T10)
– Fracture of lower limb, level unspecified (T12)
 
Pneumonia:
– Non-viral pneumonia (J13, J14, J15, J16, J18, J85.1 or J69.0)
– 2013–2014 onward: Ventilator-assisted pneumonias* (J95.88 [type 2] + J15 [type 3], J16.8 [type 3], J18 [type 3] or J85.1 [type 3] + Y60–Y84 [type 9], all within same diagnosis cluster)
*For ventilator-assisted pneumonias, all 3 conditions must be present on the same abstract and all 3 conditions must have the same cluster code that is not blank.

Background, Interpretation and Benchmarks
Rationale

A study of adverse events estimated that approximately 70,000 preventable adverse events occur annually in Canadian hospitals. Based on the definition used by the World Health Organization and other studies, adverse events refer to incidents caused by medical management instead of complications of disease.

Some studies have found that adverse events increase the costs of patient care and have suggested that nurse staffing, in particular, is associated with adverse events such as pneumonia, urinary tract infections, pressure ulcers and in-hospital falls.

While nurses are not solely responsible for adverse events that occur in hospital, many believe that there is a strong relationship between nurse staffing and patient outcomes. This indicator can help hospitals identify potential issues in nursing care. Further investigation and analysis based on the indicator results may possibly lead to quality improvement in nursing care.

Interpretation

Lower rates are desirable.

High or low rates for this indicator must be interpreted with caution as they may be a consequence of inconsistent coding practices by hospitals when reporting post-admission adverse events to the DAD.

HSP Framework Dimension

Health System Outputs: Safe

Areas of Need

Getting Better

Targets/Benchmarks

Not applicable

References

Baker GR, et al. The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada. CMAJ. 2004.

World Health Organization. WHO Draft Guidelines for Adverse Event Reporting and Learning Systems. 2005.

Kellogg VA, Havens DS. Adverse events in acute care: An integrative literature review. Research in Nursing & Health. 2003.

Cho SH, et al. The effects of nurse staffing on adverse events, morbidity, mortality, and medical costs. Nursing Research. 2003.

Pappas SH. The cost of nurse-sensitive adverse events. Journal of Nursing Administration. 2008.

Needleman J, et al. Nurse staffing in hospitals: Is there a business case for quality? Health Affairs. 2006.

Unruh L. Licensed nurse staffing and adverse events in hospitals. Medical Care. 2003.

Blegen MA, Vaughn TE, Goode CJ. Nurse experience and education: Effect on quality of care. Journal of Nursing Administration. 2001.

White P, Hall LM. Chapter 6: Patient safety outcomes. In: Doran DM, ed. Nursing Sensitive Outcomes: State of the Science. 2003.

Canadian Health Services Research Foundation. Staffing for Safety: A Synthesis of the Evidence on Nurse Staffing and Patient Safety. 2006.

Availability of Data Sources and Results
Data Sources

DAD

Available Data Years

Type of Year:
Fiscal
First Available Year:
2011
Last Available Year:
2015

Geographic Coverage

All provinces/territories except Quebec

Reporting Level/Disaggregation

National, Province/Territory, Region, Facility, Peer Group

Result Updates
Update Frequency

Every year

Indicator Results

Web Tool:
CIHI Health Indicators
URL: https://www.cihi.ca/en/cihi-health-indicators

Updates

Starting in 2012–2013, the following inclusion/exclusion criteria updates were made:
– Added new numerator inclusion for Foley catheter–associated UTI
– Removed exclusion criteria for invalid or non-unique Health Card Number, invalid admission date or time, invalid discharge date or time, and records with Canada (CA) as the province/territory issuing the Health Card Number

Starting in 2013–2014, the following inclusion criteria updates were made:
– Added ventilator-assisted pneumonias

Quality Statement
Caveats and Limitations

Not applicable

Trending Issues

Not applicable

Comments

Not applicable