Toolkit for Using the AHRQ Quality Indicators
How To Improve Hospital Quality and Safety
1 Tool D.4f
Selected Best Practices and Suggestions for Improvement
PSI 09: Postoperative Hemorrhage or Hematoma
Why Focus on Postoperative Hemorrhage and Hematoma?
• Postoperative bleeding is a risk associated with all surgical procedures. The best way to
reduce the risk of hemorrhage is to identify and correct potential causes of coagulopathy
preoperatively as well as postoperatively.1
• Cases from the Nationwide Inpatient Sample that were flagged by this PSI had 3.0% excess
mortality, 3.9 days of excess hospitalization, and $21,431 in excess hospital charges, relative
to carefully matched controls that were not flagged.2
• As value-based purchasing evolves, quality will be increasingly linked to payment.
Perioperative hemorrhage or hematoma is not currently part of Medicare’s Hospital Value-
Based Purchasing, but could be considered for future inclusion.
Recommended Practice Details of Recommended Practice
Management of Blood Loss Proper management of blood loss, including frequent dressing
checks, is key to management of postoperative hemorrhage and
hematoma.1
Medication Management Determine if and when discontinuation of
antiplatelet/anticoagulant medication prior to the procedure or
surgery is appropriate.1,3,4,5
Best Processes/Systems of Care
Introduction: Essential First Steps
• Engage key preoperative/perioperative/procedure personnel, including nurses, physicians and
other providers, and surgical technicians, and representatives from the quality improvement
department to develop evidence-based protocols for care of the patient preoperatively,
intraoperatively, and postoperatively to prevent postoperative hemorrhage or hematoma.
• The above team:
o Identifies the purpose, goals, and scope and defines the target population for this
guideline.
o Analyzes problems with guidelines compliance, identifies opportunities for improvement,
and communicates best practices to frontline teams.
o Monitors measures that would indicate if changes are leading to improvement, identifies
process and outcome metrics, and tracks performance using these metrics.
o Determines appropriate facility resources for effective and permanent adoption of
practices.
Recommended Practice: Management of Blood Loss
• Interventions include applying pressure to the site and being prepared to return the patient to
the operating room:
