Today in the chart

If you’re tired of all the depressing bad news lately in the healthcare sphere, we actually have some positive news for you today! A new study has found that rates of adverse events occurring in the hospital have steadily declined over the past decade. The findings suggest that quality improvement (Q.I.) programs may truly be making a difference in patient safety.

Noel Eldrige, of the Agency for Healthcare Research and Quality in the US Department of Health and Human Services, wrote “The current study represents the largest and most comprehensive evaluation to date of adverse events among hospitalized patients in the US, which included a large majority of US acute care hospitals and all US states…Although it cannot be certain that the trends represent improvement in patient safety, some factors support that this may be the case.”

The researchers conducted a cross-sectional analysis using data from the Medicare Patient Safety Monitoring System on 244,542 adult patients hospitalized in 3,156 US hospitals from 2010 to 2019. They primarily examined outcomes across four categories of conditions: acute myocardial infarction (17% of patients), heart failure (17%), pneumonia (21%), and major surgical procedures (22%) as these four conditions were the only conditions included in the CMS Hospital Inpatient Quality Reporting Program and the CMS Surgical Care Improvement Project in 2010-2011. 

The other 22% of patients included those hospitalized from 2012 through 2019 for all other conditions which the CMS databases were expanded to include in 2012. The four categories of in-hospital adverse events were adverse drug events, hospital-acquired infections, adverse events after a procedure, and general adverse events, such as hospital-acquired pressure ulcers and falls. The authors looked at the total change in rates over time and the rates within subpopulations that were adjusted for other risk factors.

The findings revealed that rates dropped across all categories:

• From 218 to 139 adverse events per 1000 discharges for acute myocardial infarction, a 36% reduction before adjustments for other confounding factors
• From 168 to 116 adverse events per 1000 discharges for heart failure, a 31% pre-adjustment drop
• From 195 to 119 adverse events per 1000 discharges for pneumonia, a 39% pre-adjustment drop
• From 204 to 130 adverse events per 1000 discharges for major surgical procedures, a 36% pre-adjustment drop.

The researchers made statistical adjustments to account for patient and hospital characteristics that could affect the rates. Patient characteristics included age, sex, race/ethnicity, comorbidities, and smoking status. The hospital characteristics were also adjusted to include teaching status, Joint Commission certification status, geographic location (urban vs rural), ownership (private not-for-profit vs other), number of beds, and treatment rates for coronary artery bypass graft surgery and percutaneous coronary intervention.

After these adjustments, in-hospital adverse events dropped 6% each year for acute myocardial infarction and pneumonia, 5% per year for heart failure, and 7% per year for major surgical procedures.

The researchers reported, “From 2012 to 2019, the rate of adverse events for all other conditions remained unchanged at 70 adverse events per 1000 discharges.” After adjustment, however, their calculations revealed a statistically significant 3% drop each year in adverse events for all other conditions during that seven-year period.

The authors explored several possible reasons for the overall improvement in hospital adverse events. They noted several major patient safety improvement efforts that occurred during this study period including the Partnership for Patients program, the Surgical Care Improvement Project, and CMS programs that focus on acute myocardial infarction, heart failure, and pneumonia. 

“New technologies to support safety also were implemented along with new initiatives to increase person and family engagement in safety efforts,” they wrote. “Even though these efforts may have contributed to the improvements measured in this study, other factors such as spread of safer processes of care may also have played a role. Advances in care not directly attributable to patient safety efforts also may have contributed to the improvements, [such as] the widespread adoption of minimally invasive surgical techniques.”

While the authors do not directly attribute the gains seen in patient safety to nurses and other non-physician clinicians, there is no question that the efforts of all clinicians would have contributed to the improved number seen in this study. 

The researchers also noted that the lower levels of improvement seen with the general adverse events category may be partly due to Q.I. programs that specifically target the other four groups. Other explanations include that patients in the “general” category tended to be younger, and “the baseline adverse event rates were much lower in the all other conditions group, potentially leaving less opportunity to achieve improvement.” 

The following were the 21 specific measures examined across the four adverse event domains:‍

Hospital-Acquired Infections

• Central line associated bloodstream infections
• Postoperative pneumonia
• Hospital-acquired antibiotic-associated Clostridium difficile
• Physician-diagnosed catheter-associated urinary tract infections
• Hospital-acquired methicillin-resistant Staphylococcus aureus
• Hospital-acquired vancomycin-resistant Enterococcus‍
• Ventilator-associated pneumonia

Adverse Events After a Procedure

• Associated with a hip joint replacement
• Associated with a knee joint replacement
• Mechanical complications associated with central lines
• Postoperative venous thromboembolic events
• Postoperative cardiac events (cardiac and noncardiac surgeries) 
• Associated with femoral artery puncture for catheter angiographic procedures
• Contrast nephropathy associated with catheter angiography

General Adverse Events

• Hospital-acquired pressure ulcers
• Inpatient falls

Adverse Drug Events‍

• Associated with digoxin
• Associated with hypoglycemic agents
• Associated with heparin
• Associated with low-molecular-weight heparin and factor Xa inhibitors
• Associated with warfarin