ORIGINAL ARTICLES The Agency for Healthcare Research and Quality (AHRQ) Pediatric Quality Indicators (PDIs) Accidental Puncture or Laceration During Surgery in Children Melissa Camp, MD, MPH, David C. Chang, PhD, MPH, MBA, Yiyi Zhang, MHS, Kristin Chrouser, MD, MPH, Paul M. Colombani, MD, MBA, and Fizan Abdullah, MD, PhD Context: The Agency for Healthcare Research and Quality (AHRQ) pedi- atric quality indicators (PDIs) are measures designed to evaluate the quality of pediatric healthcare. They specifically focus on adverse events that are potentially avoidable, including complications and iatrogenic events. PDI 1 refers to accidental puncture or laceration. Objective: To determine risk factors and outcomes associated with PDI 1 in a population of pediatric surgical patients. Design, Setting, and Patients: The Nationwide Inpatient Sample and Kids Inpatient Database were used to identify hospitalized pediatric surgical patients in the United States (age: 0 –18) from 1988 to 2005. The data from these 1,939,540 patients was linked to the AHRQ PDIs using AHRQ WinQI software, and 7033 pediatric patients with PDI 1 were identified. A 1:3 matched case control design was implemented with 6459 cases (patients with PDI 1) and 19,377 controls (patients without PDI 1) matched on age, race, gender, and hospital ID. Cases and controls were stratified into procedure categories based on diagnosis related group procedure codes. Main Outcome Measures: To examine the relationship between PDI 1 and procedure category, as well as the outcomes of in-hospital mortality, length of stay, and total hospital charges for cases compared with controls. Results: Of the 4627 patients with PDI 1 stratified into procedure categories, the highest proportion of PDI 1 cases occurred in the gastrointestinal (30.19%), cardiothoracic (19.6%), and the orthopedic (11.13%) categories. Logistic regression analysis for PDI 1, controlling for admission type and insurance status, revealed a statistically significant higher odds of PDI 1 in the gynecology (OR: 1.69, P  0.001) and transplant (OR: 1.45, P: 0.026) procedure categories. Multivariable regression analysis revealed patients with PDI 1 were more likely to die (OR: 1.91, P  0.001), had a 4.81 day longer length of stay (95% CI: 4.26 –5.36, P  0.001) and had $36,291 higher total hospital charges (95% CI: $32,583–$40,000, P  0.001) com- pared with patients without PDI 1. Conclusions: Cases of PDI 1 were most commonly associated with the gastrointestinal, cardiothoracic, and orthopedic procedure categories, and these were also 3 of the most common procedure categories overall. Con- trolling for type of procedure and other variables, the procedure categories having the highest likelihood of PDI 1 were gynecology and transplant. PDI 1 was found to be associated with greater mortality, longer length of stay, and greater total hospital charges. (Ann Surg 2010;251: 165–170) T he Institute of Medicine report To Err is Human, published in 1999, identified medical errors as a significant problem with an annual cost upwards of $29 billion and a human cost of 44,000 to 98,000 Americans dying each year from medical errors. 1–3 Crossing the Quality Chasm: A New Health System for the 21st Century, published by the Institute of Medicine in 2001, emphasized the importance of patient safety. 2,4 In response to To Err is Human, the Agency for Healthcare Research and Quality (AHRQ) developed a set of patient safety indicators (PSIs) which were designed to identify adverse events occurring in the inpatient setting that are associated with compromised patient safety. 2,3 By linking the PSIs to hospital administrative data, institutions can identify areas of concern and then address patient safety-related quality improvement efforts in a targeted fashion. 3 The occurrence of a PSI event has been shown to be associ- ated with worse clinical outcomes. When AHRQ applied the PSIs to patients of all ages, patient discharge records with identified PSI events were found to have 2-fold to 3-fold longer hospital stays, 2-fold to 20-fold higher rates of inpatient mortality, and 2-fold to 8-fold higher total hospital charges than patient discharge records without PSI events. 3 In 2006, AHRQ developed another set of patient safety indicators, known as the pediatric quality indicators (PDIs), specifically designed for use in evaluating the quality and safety of pediatric healthcare. 5,6 Similar to the PSIs, the PDIs can be linked to hospital inpatient administrative databases. They specifi- cally focus on iatrogenic and other potentially preventable adverse events that occur in children, with the aim of providing a perspective on problems in the healthcare system that may be amenable to changes at the systems level. 6 There are 13 PDIs, which are listed in Table 1. This study sought to examine the risk factors and outcomes associated with PDI 1, accidental puncture or laceration, in a population of pediatric surgical patients. METHODS Databases A retrospective analysis of a nonoverlapping combination of the Nationwide Inpatient Sample (NIS) and Kids’ Inpatient Data- base (KID) from 1988 through 2005 was performed. The KID was used for the years for which it was available (1997, 2000, and 2003) and the NIS was used for all of the remaining years. Both databases have been developed as part of the Healthcare Cost and Utilization of the AHRQ. The NIS is an all-payer database that contains data on up to 8 million inpatient discharges from approximately 1000 hospitals across the United States each year. The NIS samples at the hospital level to represent a 20% sample of all community hospitals. Currently data is available from 37 states. 7 The KID contains a sample of pediatric (age: 20 or less) discharges from all community, nonrehabilitation hospitals in states which participate in the Health- care Cost and Utilization. The KID samples patient discharges using a systematic random sampling algorithm to select 10% of uncom- From the Center for Pediatric Surgical Clinical Trials and Outcomes Research, Division of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, MD. Reprints: Fizan Abdullah, MD, PhD, Johns Hopkins University School of Med- icine, 600 North Wolfe St, Harvey 319, Baltimore, MD 21287-0005. E-mail: fa@jhmi.edu. Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are available in the HTML text of this article on the journal’s Web site (www.annalsofsurgery.com). Copyright © 2009 by Lippincott Williams & Wilkins ISSN: 0003-4932/10/25101-0165 DOI: 10.1097/SLA.0b013e3181b977c4 Annals of Surgery • Volume 251, Number 1, January 2010 www.annalsofsurgery.com | 165