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Indicator Metadata

NameIn-Hospital Sepsis
Short/Other Names

Not applicable

DescriptionThe risk-adjusted rate of sepsis that is identified after admission
InterpretationA lower rate for this indicator is desirable.
HSP Framework Dimension

Health System Outputs: Safe

Areas of Need

Getting Better

Geographic Coverage

All provinces/territories

Reporting Level/Disaggregation

National, Province/Territory, Region, Facility

Indicator Results

Accessing Indicator Results on Your Health System: In Depth

Identifying Information
NameIn-Hospital Sepsis
Short/Other Names

Not applicable

Indicator Description and Calculation
DescriptionThe risk-adjusted rate of sepsis that is identified after admission
Calculation: Description

This indicator measures the rate of in-hospital sepsis per 1,000 discharges.

2 logistic regression models were built separately for children (younger than 18 years) and adults (18 years and older) to calculate the risk-adjusted results.

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 - Rate—per 1,000

Calculation: Adjustment Applied

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

Calculation: Method of Adjustment

Logistic regression

Denominator

Description:
Number of discharges from an acute care institution within a fiscal year
Inclusions:
1. Sex recorded as male or female

2. Length of stay of 2 days and longer

Exclusions:
1. Records with invalid age

2. Records with invalid admission or discharge dates

3. Mental illness (major clinical category [MCC] of Mental Diseases and Disorders [MCC = 17]): This is to account for differences in data collection between Ontario and other provinces and territories

4. Palliative care (ICD-10-CA: Z51.5) coded as most responsible diagnosis (MRDx). For Quebec data: palliative care (ICD-10-CA: Z51.5) coded as MRDx, or cancer (ICD-10-CA: C00–C97) coded as MRDx and Z51.5 coded in any secondary diagnosis field

5. Age at admission younger than 1 year; infants are excluded because they have different mechanisms and risk factors for developing sepsis, as well as different coding standards

Numerator

Description:
A subset of the denominator: hospital discharges with an in-hospital sepsis event identified during a hospital stay

Inclusions:
Based on clinical input, the most commonly occurring and significant codes for clinical practice are included in the indicator.

Sepsis events are identified as follows:

Non-Quebec abstracts:

1. Sepsis (ICD-10-CA: A40, A41, B37.7, R65.1, R57.2) as type (2)

OR

2. Sepsis as a post-procedural complication in the same cluster:

a. Sepsis (ICD-10-CA: A40, A41, B37.7, R65.1, R57.2) as type (3) and infection following a procedure (ICD-10-CA: T80.2, T81.4, T82.6, T82.7, T83.5, T83.6, T84.5, T84.6, T84.7, T85.7, T88.0) as type (2) and external cause code (ICD-10-CA: Y60–Y84) as type (9) OR

b. Septic shock (ICD-10-CA: R57.2) as type (3) and shock during or resulting from a procedure (ICD-10-CA: T81.1) as type (2) and external cause codes (ICD-10-CA: Y60–Y84) as type (9)

OR

3. Sepsis in obstetric patients:

a. Puerperal sepsis (ICD-10-CA: O85.002) as type (M), (1), (2), (W), (X) or (Y) OR

b. Sepsis (ICD-10-CA: A40, A41, B37.7, R65.1, R57.2) as type (3) and
– Abortive outcome complicated by infection (ICD-10-CA: O03.0, O03.5, O04.0, O04.5, O05.0, O05.5, O07.3, O08.0) as type (2) OR
– Other obstetric infections (ICD-10-CA: O98.502, O98.802) as type (M), (1), (2), (W), (X) or (Y)

Quebec abstracts:

1. Sepsis (ICD-10-CA: A40, A41, B37.7, R65.1, R57.2) as type (2)

OR

2. Sepsis as a post-procedural complication on the same abstract:

a. Sepsis (ICD-10-CA: A40, A41, B37.7, R65.1, R57.2) as type (3) and infection following a procedure (ICD-10-CA: T80.2, T81.4, T82.6, T82.7, T83.5, T83.6, T84.5, T84.6, T84.7, T85.7, T88.0) as type (2) and external cause code (ICD-10-CA: Y60–Y84) as type (9) OR

b. Septic shock (ICD-10-CA: R57.2) as type (3) and shock during or resulting from a procedure (ICD-10-CA: T81.1) as type (2) and external cause codes (ICD-10-CA: Y60–Y84) as type (9)

OR

3. Sepsis in obstetric patients:

a. Puerperal sepsis (ICD-10-CA: O85.002) as type (M), (C), (2), (W), (X) or (Y) OR

b. Sepsis (ICD-10-CA: A40, A41, B37.7, R65.1, R57.2) as type (3) and
– Abortive outcome complicated by infection (ICD-10-CA: O03.0, O03.5, O04.0, O04.5, O05.0, O05.5, O07.3, O08.0) as type (2) OR
– Other obstetric infections (ICD-10-CA: O98.502, O98.802) as type (M), (C), (2), (W), (X) or (Y)
Exclusions:
Abstracts where sepsis is also identified as a pre-admit condition are excluded from the numerator:

— Abstracts with sepsis codes (ICD-10-CA: A40, A41, B37.7, R65.1, R57.2) or the associated post-procedural complication codes (ICD-10-CA: T80.2, T81.1, T81.4, T82.6, T82.7, T83.5, T83.6, T84.5, T84.6, T84.7, T85.7, T88.0) identified as pre-admit [type (M), (1) [(C) for Quebec data], (W), (X) or (Y)]

— Abstract with sepsis in obstetric patients where the puerperal sepsis code or the associated obstetric infection code is identified as pre-admit (ICD-10-CA: O85.004, O85.009, O98.501, O98.503, O98.504, O98.509, O98.801, O98.803, O98.804, O98.809 — any diagnosis type or O03.0, O03.5, O04.0, O04.5, O05.0, O05.5, O07.3, O08.0 as type (M), (1) [(C) for Quebec data], (W), (X) or (Y))

As an exception, sepsis is not considered as a pre-admit condition when the above codes identified as type (M), (W), (X) or (Y) also appear as type (2) or within a post-admit sepsis coding scenario (sepsis code as type (2); sepsis code as type (3) or an associated infection code as type (2) in sepsis as post-procedural or obstetric complications).

Background, Interpretation and Benchmarks
Rationale

Sepsis is a clinical syndrome that occurs as a complication of infections. It is defined as a systemic inflammatory response due to infection. Sepsis is a leading cause of mortality and is linked to increased hospital resource utilization and prolonged stays in intensive care units. Appropriate preventive and therapeutic measures during a hospital stay can reduce the rate of infections and/or progression of infection to sepsis.

The indicator addresses the extent to which acute care hospitals are effective in preventing the development of sepsis. It will help hospitals improve patient safety and learn from their peers regarding best practice methods for appropriate treatment of infections and prevention of sepsis.

Interpretation

A lower rate for this indicator is desirable.

HSP Framework Dimension

Health System Outputs: Safe

Areas of Need

Getting Better

Targets/Benchmarks

Not applicable

References

Agency for Healthcare Research and Quality. Technical Specifications: Patient Safety Indicators Appendices Version 4.5. http://www.qualityindicators.ahrq.gov/Downloads/Modules/PSI/V45/TechSpecs/PSI%20Appendices.pdf. Accessed October 2013.

Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;29:1303-1310.

Canadian Institute for Health Information. In Focus: A National Look at Sepsis. https://secure.cihi.ca/free_products/HSMR_Sepsis2009_e.pdf. Accessed December 2009.

Canadian Institute for Health Information. Canadian Coding Standards for Version 2012 ICD-10-CA and CCI. Ottawa, ON: CIHI; 2012.

Drosler S. Organisation for Economic Co-operation and Development: Health Care Quality Indicators Project, Patient Safety Indicators—Report 2009. http://www.oecd.org/els/health-systems/44193189.pdf. Accessed October 22, 2013.

Levy MM, Dellinger RP, Townsend SR, et al. The Surviving Sepsis Campaign: Results of an international guideline-based performance improvement program targeting severe sepsis. Crit Care Med 2010;38:367-374.

Levy MM, Fink MP, Marshall JC et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 2003;31:1250-1256.

Martin CM, Priestap F, Fisher H et al. A prospective, observational registry of patients with severe sepsis: the Canadian Sepsis Treatment and Response Registry. Crit Care Med 2009;37:81-88.

Quan H, Li B, Couris CM, et al. Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries. Am J Epidemiol 2011;173:676-82.

Availability of Data Sources and Results
Data Sources

DAD, HMDB

Available Data Years

Type of Year:
Fiscal
First Available Year:
2012
Last Available Year:
2015

Geographic Coverage

All provinces/territories

Reporting Level/Disaggregation

National, Province/Territory, Region, Facility

Result Updates
Update Frequency

Every year

Indicator Results

Web Tool:
Your Health System: In Depth
URL:
Accessing Indicator Results on Your Health System: In Depth

Updates

Not applicable

Quality Statement
Caveats and Limitations

In-hospital sepsis events can be due to either community- or hospital-acquired infections. Therefore, the in-hospital sepsis indicator does not necessarily capture hospital-acquired infections only. In addition, despite the implementation of national coding standards, there may be variations in charting and coding practices across the country that could affect the results.

Trending Issues

Not applicable

Comments

Indicator results are also available in

–Your Health System: Insight
(https://www.cihi.ca/en/applications); data is updated monthly starting from 2012–2013

For additional information, please view the In-Hospital Sepsis FAQ document.