HOSPITAL-WIDE - ACHS · Hospital-Wide, version 12 1 ... 9.3 Tonsillectomy ... Rationale Unplanned...

HOSPITAL-WIDE VERSION 12

Retrospective data in full ACIR 2008 - 2015

Australasian Clinical Indicator Report 2008–2015

© ACHS. This work is copyright. Requests and inquiries concerning reproduction and rights should be addressed to [email protected]

Contents

Hospital-Wide, version 12 1

Hospital readmissions ....................................................................................................................... 1

1.1 Unplanned and unexpected readmissions within 28 days (L) 1 Return to the operating room ............................................................................................................ 3

2.1 Unplanned return to the operating room during the same admission (L) 3 2.2 Reviewed cases following an unplanned return to the operating room (H) 5

Pressure injuries ................................................................................................................................ 6

3.1 Inpatients who develop 1 or more pressure injuries (L) 6 Inpatient falls ...................................................................................................................................... 8

4.1 Inpatient falls (L) 8 4.2 Inpatient falls resulting in fracture or closed head injury (L) 9 4.3 Inpatient falls - patients 65 years and older (L) 11

Patient deaths ................................................................................................................................... 13

5.1 Patient deaths addressed within a clinical audit process (H) 13 5.2 Deaths in adult patients who do not have a NFR order (L) 15 5.3 Adult deaths (L) 16 5.4 Coronary artery graft surgery (CAGS) – death (L) 18 5.5 Elective coronary artery graft surgery – death (L) 19 5.6 Coronary artery graft surgery patients aged 71 years or older – death (L) 20 5.7 Elective abdominal aortic aneurysm (AAA) open repair – death (L) 21

Blood transfusion ............................................................................................................................ 22

6.1 Significant adverse blood transfusion events (L) 22 6.2 Transfusion episodes where informed patient consent was not documented (L) 25 6.3 RBC transfusion where Hb reading is 100 g/L or more (L) 27

Thromboprophylaxis........................................................................................................................ 29

7.1 VTE prophylaxis administered to high risk medical patients (N) 29 Minimum standards for rapid response system (RRS) calls ........................................................ 30

8.1 Rapid response system calls to adult patients (N) 30 8.2 Rapid response system calls to adult patients within 24 hours of admission (N) 31 8.3 Adult patients experiencing cardiopulmonary arrest (L) 32 8.4 Rapid response system attendances within 5 minutes (H) 34 8.5 Adult deaths avoided by rapid response system calls (H) 35

Surgery .............................................................................................................................................. 36

9.1 Pre-operative acute appendicitis (children) - normal histology (L) 36 9.2 Laparoscopic cholecystectomy - bile duct injury requiring operative intervention (L) 37 9.3 Tonsillectomy - significant reactionary haemorrhage (L) 39

Characteristics of contributing HCOs ............................................................................................ 41

Summary of Results 45

Hospital readmissions 45 Return to the operating room 45 Pressure injuries 45 Inpatient falls 45 Patient deaths 46 Blood transfusion 46 Thromboprophylaxis 47 Minimum standards for rapid response system (RRS) calls 47 Surgery 47

Australasian Clinical Indicator Report 2008–2015


Expert Commentary 49

The Royal Australasian College of Medical Administrators (RACMA) ........................................ 49

Introductory comments 49 Hospital readmissions 49 Return to the operating room 49 Pressure injuries 50 Inpatient falls 50 Patient deaths 50 Blood transfusion 51 Thromboprophylaxis 51 Minimum standards for rapid response system (RRS) calls 51 Surgery 51

Australian College of Nursing (ACN) .............................................................................................. 52

Introductory comments 52 Hospital readmissions 52 Return to the operating room 52 Pressure injuries 52 Inpatient falls 52 Patient deaths 53 Blood transfusion 53 General/closing comments 53 References 53

Australasian Clinical Indicator Report 2008–2015 Page 1


Hospital-Wide, version 12

Hospital readmissions

1.1 Unplanned and unexpected readmissions within 28 days (L)

Rationale

Unplanned and unexpected readmissions to a hospital may reflect less than optimal patient

management.

Numerator Number of unplanned and unexpected readmissions within 28 days of separation related to

the primary admission.

Denominator Number of separations (excluding deaths).

Desirable level: Low High Not specified

Type of Indicator: Process Outcome Structure

Year

No.

HCOs

Total

numerator

Total

denominator Rate#

Rate#

(20)

Rate#

(80)

Centile

Gains

Stratum

Gains

Outlier

Gains

2008 299 45,485 2,708,519 1.68 0.36 3.06 35,718 20,277

2009 274 46,056 2,695,411 1.71 0.30 2.60 37,845 21,175

2010 279 34,744 2,871,585 1.21 0.24 2.09 27,927 15,270

2011 294 34,239 2,964,712 1.15 0.26 2.05 26,553 14,318

2012 289 37,427 3,159,627 1.18 0.19 2.10 31,484 16,368

2013 278 30,851 3,096,888 1.00 0.19 1.79 24,856 12,535

2014 284 38,292 3,260,187 1.17 0.16 1.74 33,107 17,284

2015 288 45,658 3,648,033 1.25 0.15 1.50 40,248 26,140 22,622

# per 100 separations

In 2015, there were 525 records from 288 HCOs. The annual rate was 1.25 per 100 separations.

Trends

The fitted rate improved from 1.6 to 1.1, a change of 0.49 per 100 separations. This trend was also

significant after allowing for the changing composition of HCOs contributing over the period. The rate

change was 0.49 per 100 separations.

Trend plot of rates and centiles by year

A Low rate is desirable

80th centile rate

20th centile rate

Fitted rate

Aggregate rate x

Period average rate




Variation between strata

Rates by Public / Private

Year Stratum

No.

HCOs

Total

numerator

Total

denominator

Stratum

rate#

Standard

error

Stratum

gains

2015 Private 200 15,049 2,834,416 0.54 0.062

Public 88 30,609 813,617 3.75 0.12 26,140

# per 100 separations

Boxplot of Rates by Public / Private

Variation between HCOs

In 2015, the potential gains totalled 40,248 fewer unplanned and unexpected readmissions within 28

days, corresponding to a reduction by approximately four-fifths.

Outliers

In 2015, there were 88 outlier records from 57 outlier HCOs whose combined excess was 22,622

more unplanned and unexpected readmissions within 28 days. The outlier HCO rate was 4.4 per 100

separations.

Funnel plot of excess events




Return to the operating room

2.1 Unplanned return to the operating room during the same admission (L)

Rationale

Unplanned return of a patient to the operating room during the same admission may reflect less than

optimal management.

Numerator Number of patients having an unplanned return to the operating room during the same

admission.

Denominator Number of patients having an operation or procedure in the operating room.



Year

No.

HCOs

Total

numerator

Total

denominator Rate#

Rate#

(20)

Rate#

(80)

Centile

Gains

Stratum

Gains

Outlier

Gains

2008 280 6,660 1,838,190 0.36 0.11 0.42 4,678 1,602

2009 262 6,676 1,813,414 0.37 0.12 0.45 4,568 1,493

2010 268 6,142 1,968,002 0.31 0.12 0.38 3,792 1,466

2011 264 6,168 1,910,596 0.32 0.11 0.41 4,088 1,425

2012 251 5,872 1,921,087 0.31 0.11 0.40 3,780 1,248

2013 237 5,441 1,947,428 0.28 0.10 0.37 3,461 996

2014 229 5,643 2,008,707 0.28 0.100 0.36 3,641 1,175

2015 221 5,082 2,002,383 0.25 0.085 0.32 3,382 1,087

# per 100 patients

In 2015, there were 411 records from 221 HCOs. The annual rate was 0.25 per 100 patients.

Trends

The fitted rate improved from 0.37 to 0.26, a change of 0.11 per 100 patients. This trend was also


change was 0.11 per 100 patients.



There were no significant stratum differences in 2014 and 2015.


80th centile rate

20th centile rate

Fitted rate

Aggregate rate x

Period average rate





In 2015, the potential gains totalled 3,382 fewer patients having an unplanned return to the operating

room, corresponding to a reduction by approximately one-half.

Outliers

In 2015, there were 40 outlier records from 30 outlier HCOs whose combined excess was 1,087 more

patients having an unplanned return to the operating room. The outlier HCO rate was 0.64 per 100

patients.





2.2 Reviewed cases following an unplanned return to the operating room (H)

Numerator Number of cases reviewed following an unplanned return to the operating room during the

same admission.

Denominator Number of patients having an unplanned return to the operating room during the same

admission.



Year

No.

HCOs

Total

numerator

Total

denominator Rate#

Rate#

(20)

Rate#

(80)

Centile

Gains

Stratum

Gains

Outlier

Gains

2015 51 1,105 1,122 98.5 99.5 99.9 16 14

# per 100 patients having an unplanned return to the operating room

In 2015, there were 74 records from 51 HCOs. The annual rate was 98.5 per 100 patients having a

reviewed case following an unplanned return to the operating room.


There were no significant stratum differences in 2015.


There was relatively little variation between HCOs and so the potential gains were small in 2015.

Outliers

In 2015, there were three outlier records from three outlier HCOs whose combined excess was 14

fewer cases reviewed following an unplanned return to the operating room. The outlier HCO rate was

84.8 per 100 patients having a reviewed case following an unplanned return to the operating room.





Pressure injuries

3.1 Inpatients who develop 1 or more pressure injuries (L)

Rationale

Pressure injuries are largely preventable hospital acquired injuries caused by unrelieved pressure

resulting in damage to the skin and underlying tissue. In the majority of cases they can be regarded

as an adverse outcome of a health care admission. Many national and international healthcare

agencies acknowledge that pressure injuries not only affect the health of the individual, but also place

a significant strain on already stretched health resources.

Numerator Number of inpatients who develop one or more pressure injuries during their admission.

Denominator Number of inpatient bed days.



Year

No.

HCOs

Total

numerator

Total

denominator Rate#

Rate#

(20)

Rate#

(80)

Centile

Gains

Stratum

Gains

Outlier

Gains

2015 432 9,090 12,412,612 0.073 0.019 0.094 6,753 3,529 2,172

# per 100 bed days

In 2015, there were 745 records from 432 HCOs. The annual rate was 0.073 per 100 bed days.



Year Stratum

No.

HCOs

Total

numerator

Total

denominator

Stratum

rate#

Standard

error

Stratum

gains

2015 Private 197 2,501 5,853,043 0.045 0.003

Public 235 6,589 6,559,569 0.099 0.003 3,529

# per 100 bed days



In 2015, the potential gains totalled 6,753 fewer patients who develop one or more pressure injuries,

corresponding to a reduction by approximately two-thirds.




Outliers


patients who develop one or more pressure injuries. The outlier HCO rate was 0.17 per 100 bed days.





Inpatient falls

4.1 Inpatient falls (L)

Rationale

Fall-related injury is one of the leading causes of morbidity and mortality in older Australians and is

the single biggest reason for hospital admissions and emergency department presentations in people

over 65 years of age. Adverse events associated with falls may include bone fractures, soft tissue

injury, and fear of falling again. Interventions based on a proactive assessment, anticipation of patient

needs, and participation by multidisciplinary teams in prevention efforts are critical.

Numerator Number of inpatient falls.

Denominator Number of occupied bed days.



Year

No.

HCOs

Total

numerator

Total

denominator Rate#

Rate#

(20)

Rate#

(80)

Centile

Gains

Stratum

Gains

Outlier

Gains

2015 408 53,916 15,304,836 0.35 0.19 0.57 24,075 9,463

# per 100 bed days





In 2015, the potential gains totalled 24,075 fewer inpatient falls, corresponding to a reduction by

approximately one-third.

Outliers

In 2015, there were 153 outlier records from 104 outlier HCOs whose combined excess was 9,463

more inpatient falls. The outlier HCO rate was 0.65 per 100 bed days.





4.2 Inpatient falls resulting in fracture or closed head injury (L)

Numerator Number of fractures or closed head injuries that result because of an inpatient fall.

Denominator Number of occupied bed days.



Year

No.

HCOs

Total

numerator

Total

denominator Rate#

Rate#

(20)

Rate#

(80)

Centile

Gains

Stratum

Gains

Outlier

Gains

2015 349 1,343 14,069,400 0.010 0.004 0.011 713 205 282

# per 100 bed days



Rates by State

Year Stratum

No.

HCOs

Total

numerator

Total

denominator

Stratum

rate#

Standard

error

Stratum

gains

2015 NSW 125 326 4,570,690 0.007 0.001

Qld 58 249 2,415,588 0.010 0.002

SA 30 43 929,641 0.006 0.002

Tas 7 15 396,085 0.005 0.004

Vic 101 304 3,651,078 0.008 0.001

WA 19 130 1,423,498 0.009 0.002

Other 9 276 682,820 0.037 0.003 205

# per 100 bed days

Boxplot of Rates by State


In 2015, the potential gains totalled 713 fewer inpatient falls resulting in a fracture or closed head

injury, corresponding to a reduction by approximately one-half.




Outliers

In 2015, there were eight outlier records from eight outlier HCOs whose combined excess was 282

more inpatient falls resulting in a fracture or closed head injury. The outlier HCO rate was 0.089 per

100 bed days.





4.3 Inpatient falls - patients 65 years and older (L)

Numerator Number of falls in inpatients aged 65 years and older.

Denominator Number of occupied bed days of inpatients aged 65 years and older.



Year

No.

HCOs

Total

numerator

Total

denominator Rate#

Rate#

(20)

Rate#

(80)

Centile

Gains

Stratum

Gains

Outlier

Gains

2015 223 29,479 5,722,089 0.52 0.33 0.71 10,639 15,502 5,194

# per 100 bed days



Rates by State

Year Stratum

No.

HCOs

Total

numerator

Total

denominator

Stratum

rate#

Standard

error

Stratum

gains

2015 NSW 78 7,727 1,605,592 0.48 0.027 3,897

Qld 44 5,580 1,365,730 0.41 0.029 2,287

SA 11 1,514 256,778 0.59 0.066 898

Tas 5 467 124,908 0.38 0.095

Vic 64 10,979 1,513,647 0.72 0.027 7,247

WA 15 2,444 532,469 0.46 0.046 1,173

Other 6 768 322,965 0.24 0.059

# per 100 bed days



In 2015, the potential gains totalled 10,639 fewer inpatient falls in inpatients aged 65 years and older,

corresponding to a reduction by approximately one-third.




Outliers


inpatient falls in inpatients aged 65 years and older. The outlier HCO rate was 0.97 per 100 bed days.





Patient deaths

5.1 Patient deaths addressed within a clinical audit process (H)

Rationale

Although death can be the expected outcome from progression of all illness or disease, it can also be

the ultimate adverse event associated with or resulting from health care delivery. It is appropriate for

patient deaths occurring within a healthcare organisation to be analysed through clinical audit and

review processes to facilitate identification of any issues in patient care and the introduction of any

necessary improvements in safety.

Numerator Number of patient deaths addressed within a clinical audit process.

Denominator Number of patient deaths.



Year

No.

HCOs

Total

numerator

Total

denominator Rate#

Rate#

(20)

Rate#

(80)

Centile

Gains

Stratum

Gains

Outlier

Gains

2008 162 15,220 16,737 90.9 95.9 99.9 1,497 671 1,118

2009 195 17,557 18,776 93.5 98.4 99.9 1,204 657 919

2010 196 17,304 18,291 94.6 98.4 99.9 969 335 721

2011 201 19,077 20,091 95.0 97.1 99.9 989 646

2012 186 18,169 18,861 96.3 98.1 99.9 675 173 496

2013 176 16,988 17,518 97.0 98.5 99.9 515 394

2014 161 17,186 18,662 92.1 98.1 99.9 1,459 1,073

2015 192 19,201 20,086 95.6 98.4 99.9 869 678

# per 100 deaths

In 2015, there were 324 records from 192 HCOs. The annual rate was 95.6 per 100 deaths.

Trends

The fitted rate improved from 93.0 to 95.6, a change of 2.7 per 100 deaths. This trend was also


change was 2.6 per 100 deaths.


Fitted rate

20th centile rate

80th centile rate

Aggregate rate x

A High rate is desirable

Period average rate








Outliers

In 2015, there were 22 outlier records from 18 outlier HCOs whose combined excess was 678 fewer

patient deaths addressed within a clinical audit process. The outlier HCO rate was 64.3 per 100

deaths.





5.2 Deaths in adult patients who do not have a NFR order (L)

Numerator Number of deaths in adult patients who DO NOT have a not for resuscitation (NFR) order at

the time of death.

Denominator Number of adult hospital admissions.



Year

No.

HCOs

Total

numerator

Total

denominator Rate#

Rate#

(20)

Rate#

(80)

Centile

Gains

Stratum

Gains

Outlier

Gains

2015 65 1,145 784,447 0.15 0.020 0.27 985 469

# per 100 patients





In 2015, the potential gains totalled 985 fewer deaths in adult patients who do not have a not for

resuscitation order, corresponding to a reduction by approximately four-fifths.

Outliers

In 2015, there were 14 outlier records from 12 outlier HCOs whose combined excess was 469 more

deaths in adult patients who do not have a not for resuscitation order. The outlier HCO rate was 0.66

per 100 patients.





5.3 Adult deaths (L)

Numerator Number of adult deaths in all patients.




Year

No.

HCOs

Total

numerator

Total

denominator Rate#

Rate#

(20)

Rate#

(80)

Centile

Gains

Stratum

Gains

Outlier

Gains

2015 71 9,104 914,036 1.00 0.31 1.67 6,246 3,371 1,935

# per 100 patients




Year Stratum

No.

HCOs

Total

numerator

Total

denominator

Stratum

rate#

Standard

error

Stratum

gains

2015 Private 38 2,027 325,370 0.63 0.13

Public 33 7,077 588,666 1.20 0.098 3,371

# per 100 patients



In 2015, the potential gains totalled 6,246 fewer adult deaths, corresponding to a reduction by

approximately two-thirds.

Outliers


adult deaths. The outlier HCO rate was 1.8 per 100 patients.




5.4 Coronary artery graft surgery (CAGS) – death (L)

Numerator Number of patients who die in the same admission as having CAGS.

Denominator Number of patients having CAGS.



Year

No.

HCOs

Total

numerator

Total

denominator Rate#

Rate#

(20)

Rate#

(80)

Centile

Gains

Stratum

Gains

Outlier

Gains

2008 35 160 8,570 1.87 1.62 2.07 21 14

2009 35 141 8,159 1.73 1.58 1.90 12

2010 36 154 9,007 1.71 1.65 1.75 6 3

2011 34 93 6,603 1.41 1.23 1.52 12 6

2012 31 85 5,999 1.42 1.42 1.42

2013 29 80 6,062 1.32 1.18 1.49 8

2014 28 68 6,156 1.10 0.98 1.33 8

2015 30 65 5,057 1.29 1.28 1.28

# per 100 patients


Trends








There were no potential gains in 2015.

Outliers

There were no outlier HCOs in 2015.


80th centile rate

20th centile rate

Fitted rate

Aggregate rate x

Period average rate




5.5 Elective coronary artery graft surgery – death (L)

Numerator Number of elective patients who die in the same admission as having CAGS.

Denominator Number of patients having CAGS as an elective procedure.



Year

No.

HCOs

Total

numerator

Total

denominator Rate#

Rate#

(20)

Rate#

(80)

Centile

Gains

Stratum

Gains

Outlier

Gains

2008 26 68 4,958 1.37 1.22 1.44 8

2009 27 58 4,470 1.30 1.24 1.39 3

2010 24 57 4,296 1.33 1.32 1.33

2011 22 36 3,149 1.14 1.14 1.14

2012 20 31 2,891 1.07 0.95 1.16 4 2

2013 17 35 2,561 1.37 1.36 1.37

2014 16 22 2,501 0.88 1.13 1.13

2015 17 29 1,957 1.48 1.21 1.73 5

# per 100 patients


Trends

There was no significant trend in the fitted rate.





In 2015, the potential gains totalled five fewer elective patients who die in the same admission as

having CAGS, corresponding to a reduction by approximately one-tenth.

Outliers



80th centile rate

20th centile rate

Fitted rate

Aggregate rate x

Period average rate




5.6 Coronary artery graft surgery patients aged 71 years or older – death (L)

Numerator Number of patients aged 71 years or older who die in the same admission as having CAGS.

Denominator Number of patients aged 71 years or older having CAGS performed.



Year

No.

HCOs

Total

numerator

Total

denominator Rate#

Rate#

(20)

Rate#

(80)

Centile

Gains

Stratum

Gains

Outlier

Gains

2008 31 83 3,227 2.57 2.08 3.24 16

2009 28 75 3,105 2.42 2.04 2.96 12

2010 29 94 3,154 2.98 2.96 2.97 1

2011 26 42 2,215 1.90 1.89 1.90

2012 22 49 1,949 2.51 2.50 2.51

2013 21 42 1,860 2.26 2.26 2.26

2014 19 29 1,655 1.75 0.98 1.99 13 5 3

2015 20 31 1,225 2.53 2.54 2.54

# per 100 patients


Trends







Outliers



80th centile rate

20th centile rate

Fitted rate

Aggregate rate x

Period average rate




5.7 Elective abdominal aortic aneurysm (AAA) open repair – death (L)

Numerator Number of patients having an elective abdominal aortic aneurysm (AAA) open repair

performed, who die within the same admission.

Denominator Number of patients having an elective abdominal aortic aneurysm (AAA) repair performed.



Year

No.

HCOs

Total

numerator

Total

denominator Rate#

Rate#

(20)

Rate#

(80)

Centile

Gains

Stratum

Gains

Outlier

Gains

2008 33 20 653 3.06 3.06 3.07

2009 27 18 474 3.80 3.45 4.53 2

2010 28 9 696 1.29 0.97 1.33 2

2011 24 9 452 1.99 1.60 1.84 2 2

2012 18 3 302 0.99 0.99 0.99

2013 17 6 340 1.76 1.77 1.77

2014 15 5 294 1.70 1.70 1.70

2015 16 1 117 0.85 0.85 0.85

# per 100 patients


Trends









Outliers



80th centile rate

20th centile rate

Fitted rate

Aggregate rate x

Period average rate




Blood transfusion

6.1 Significant adverse blood transfusion events (L)

Rationale

In certain clinical circumstances, blood component therapy (the administration of components derived

from human blood) can save lives, restore normal life expectancy and improve quality of life.

However, it is increasingly clear that such therapy has limitations, and that the decision to transfuse

must be made with great care.

Numerator Number of significant adverse transfusion events related to a blood transfusion episode.

Denominator Number of transfusion episodes.



Year

No.

HCOs

Total

numerator

Total

denominator Rate#

Rate#

(20)

Rate#

(80)

Centile

Gains

Stratum

Gains

Outlier

Gains

2008 103 175 61,758 0.28 0.21 0.33 44 47 31

2009 122 187 73,940 0.25 0.13 0.35 93 80 48

2010 134 174 69,363 0.25 0.094 0.29 109 34

2011 146 187 80,966 0.23 0.093 0.32 112 47

2012 152 123 70,771 0.17 0.11 0.18 43 34 8

2013 146 136 70,276 0.19 0.12 0.18 52 70 14

2014 179 169 93,471 0.18 0.075 0.23 99 33

2015 183 147 95,433 0.15 0.10 0.15 48 64 12

# per 100 transfusions

In 2015, there were 324 records from 183 HCOs. The annual rate was 0.15 per 100 transfusions.

Trends

The fitted rate improved from 0.28 to 0.16, a change of 0.12 per 100 transfusions. This trend was also


change was 0.13 per 100 transfusions.



80th centile rate

20th centile rate

Fitted rate

Aggregate rate x

Period average rate






Year Stratum

No.

HCOs

Total

numerator

Total

denominator

Stratum

rate#

Standard

error

Stratum

gains

2015 Private 123 38 45,197 0.11 0.008

Public 60 109 50,236 0.20 0.008 44



Rates by State

Year Stratum

No.

HCOs

Total

numerator

Total

denominator

Stratum

rate#

Standard

error

Stratum

gains

2015 NSW 61 69 33,632 0.20 0.010 38

Qld 32 27 20,047 0.15 0.012 13

SA 9 1 4,407 0.084 0.026

Vic 58 27 26,096 0.11 0.011 6

WA 13 9 7,029 0.12 0.021

Other 10 14 4,222 0.25 0.027 7




In 2015, the potential gains totalled 48 fewer significant adverse blood transfusion events,

corresponding to a reduction by approximately one-quarter.




Outliers

In 2015, there were three outlier records from three outlier HCOs whose combined excess was 12

more significant adverse blood transfusion events. The outlier HCO rate was 0.65 per 100

transfusions.





6.2 Transfusion episodes where informed patient consent was not documented (L)

Numerator Number of transfusion episodes where informed patient consent was not documented.

Denominator Number of transfusion episodes.



Year

No.

HCOs

Total

numerator

Total

denominator Rate#

Rate#

(20)

Rate#

(80)

Centile

Gains

Stratum

Gains

Outlier

Gains

2015 99 757 23,449 3.23 0.30 6.20 686 323 496




Rates by State

Year Stratum

No.

HCOs

Total

numerator

Total

denominator

Stratum

rate#

Standard

error

Stratum

gains

2015 NSW 28 45 1,759 2.82 2.07

Qld 16 125 5,029 2.53 1.22

SA 10 21 2,623 0.84 1.70

Vic 28 169 9,396 1.78 0.90

WA 10 381 2,908 12.9 1.61 323

Other 7 16 1,734 0.93 2.09




In 2015, the potential gains totalled 686 fewer transfusion episodes performed without consent,

corresponding to a reduction by approximately four-fifths.

Outliers


transfusion episodes performed without consent. The outlier HCO rate was 22.1 per 100 transfusions.




6.3 RBC transfusion where Hb reading is 100 g/L or more (L)

Numerator Number of RBC transfusion episodes when the Hb reading is 100g/L or more.

Denominator Number of RBC transfusion episodes.



Year

No.

HCOs

Total

numerator

Total

denominator Rate#

Rate#

(20)

Rate#

(80)

Centile

Gains

Stratum

Gains

Outlier

Gains

2015 85 371 24,128 1.54 0.53 1.77 244 320 136




Rates by State

Year Stratum

No.

HCOs

Total

numerator

Total

denominator

Stratum

rate#

Standard

error

Stratum

gains

2015 NSW 30 41 2,391 1.69 0.41 36

Qld 10 220 9,622 2.28 0.21 201

SA 7 2 2,004 0.18 0.45

Vic 24 75 7,027 1.02 0.24 59

WA 8 7 1,954 0.50 0.46

Other 6 26 1,130 2.30 0.60 24




In 2015, the potential gains totalled 244 fewer transfusions where Hb reading is 100g/L or more,

corresponding to a reduction by approximately one-half.

Outliers

In 2015, there were nine outlier records from seven outlier HCOs whose combined excess was 136

more transfusions where Hb reading is 100g/L or more. The outlier HCO rate was 3.1 per 100

transfusions.




Thromboprophylaxis

7.1 VTE prophylaxis administered to high risk medical patients (N)

Rationale

This indicator has been included as an index of utilisation of evidence-based guidelines for

thromboprophylaxis in high risk medical patients.

Numerator Number of high-risk medical patients admitted who receive VTE prophylaxis.

Denominator Number of high-risk medical patients admitted.



Year

No.

HCOs

Total

numerator

Total

denominator Rate#

Rate#

(20)

Rate#

(80)

*Centile

Gains

*Stratum

Gains

*Outlier

Gains

2015 10 2,763 4,953 55.8 50.9 99.6

# per 100 high-risk medical patients *Gains are not calculated when the desirable level is not specified.

In 2015, there were 16 records from 10 HCOs. The annual rate was 55.8 per 100 high-risk medical

patients.




Outliers

Since it has not been specified whether high or low rates are desirable, outlier HCOs are not reported.




Minimum standards for rapid response system (RRS) calls

8.1 Rapid response system calls to adult patients (N)

Rationale

Recognising and responding effectively to clinical deterioration within an acute health care facility.

Numerator Number of rapid response system calls to adult patients.




Year

No.

HCOs

Total

numerator

Total

denominator Rate#

Rate#

(20)

Rate#

(80)

*Centile

Gains

*Stratum

Gains

*Outlier

Gains

2015 109 40,872 1,473,637 2.77 0.66 4.37

# per 100 admissions *Gains are not calculated when the desirable level is not specified.

In 2015, there were 175 records from 109 HCOs. The annual rate was 2.77 per 100 admissions.




Outliers





8.2 Rapid response system calls to adult patients within 24 hours of admission (N)

Numerator Number of rapid response system calls to adult patients within 24 hours of admission to

hospital.




Year

No.

HCOs

Total

numerator

Total

denominator Rate#

Rate#

(20)

Rate#

(80)

*Centile

Gains

*Stratum

Gains

*Outlier

Gains

2015 79 7,004 1,080,934 0.65 0.16 1.02

# per 100 admissions *Gains are not calculated when the desirable level is not specified.





Outliers





8.3 Adult patients experiencing cardiopulmonary arrest (L)

Numerator Number of adult patients who have experienced a cardiopulmonary arrest.




Year

No.

HCOs

Total

numerator

Total

denominator Rate#

Rate#

(20)

Rate#

(80)

Centile

Gains

Stratum

Gains

Outlier

Gains

2015 150 1,759 1,689,241 0.10 0.039 0.11 1,104 1,004 472

# per 100 admissions



Rates by State

Year Stratum

No.

HCOs

Total

numerator

Total

denominator

Stratum

rate#

Standard

error

Stratum

gains

2015 NSW 53 446 531,958 0.085 0.012 217

Qld 29 314 368,066 0.088 0.015 158

SA 10 231 98,382 0.23 0.028 179

Vic 41 578 423,604 0.13 0.014 378

WA 10 79 195,055 0.045 0.020

Other 7 111 72,176 0.14 0.033 72

# per 100 admissions



In 2015, the potential gains totalled 1,104 fewer adult patients who experience a cardiopulmonary

arrest, corresponding to a reduction by approximately one-half.

Outliers


adult patients who experience a cardiopulmonary arrest. The outlier HCO rate was 0.40 per 100

admissions.




8.4 Rapid response system attendances within 5 minutes (H)

Numerator Number of rapid response system calls attended to within 5 minutes.

Denominator Number of rapid response system calls to adult patients.



Year

No.

HCOs

Total

numerator

Total

denominator Rate#

Rate#

(20)

Rate#

(80)

Centile

Gains

Stratum

Gains

Outlier

Gains

2015 46 12,101 12,532 96.6 91.8 99.9 413 213

# per 100 rapid response system calls to adult patients

In 2015, there were 64 records from 46 HCOs. The annual rate was 96.6 per 100 rapid response

system calls to adult patients.





Outliers

In 2015, there were seven outlier records from seven outlier HCOs whose combined excess was 213

fewer rapid response system calls attended to within five minutes. The outlier HCO rate was 86.2 per

100 rapid response system calls to adult patients.





8.5 Adult deaths avoided by rapid response system calls (H)

Numerator Number of adult deaths avoided due to rapid response system calls.

Denominator Number of rapid response system calls to adult patients.



Year

No.

HCOs

Total

numerator

Total

denominator Rate#

Rate#

(20)

Rate#

(80)

Centile

Gains

Stratum

Gains

Outlier

Gains

2015 12 3,602 3,870 93.1 88.8 96.9 147 36

# per 100 rapid response system calls to adult patients

In 2015, there were 17 records from 12 HCOs. The annual rate was 93.1 per 100 rapid response

system calls to adult patients.





Outliers

In 2015, there were two outlier records from two outlier HCOs whose combined excess was 36 fewer

adult deaths avoided due to rapid response system calls. The outlier HCO rate was 87.2 per 100

rapid response system calls to adult patients.





Surgery

9.1 Pre-operative acute appendicitis (children) - normal histology (L)

Rationale

Appendicectomy is a commonly performed operation in childhood, where good management should

achieve a low rate of negative (normal) histology. Laparoscopic cholecystectomy is associated with

an increased risk of injury to the extra hepatic biliary system. Tonsillectomy is a commonly performed

discretionary procedure with a low, but definite morbidity.

Numerator Number of children with a pre-operative diagnosis of acute appendicitis, who undergo

appendicectomy with normal histology.

Denominator Number of children with a pre-operative diagnosis of acute appendicitis who undergo

appendicectomy.



Year

No.

HCOs

Total

numerator

Total

denominator Rate#

Rate#

(20)

Rate#

(80)

Centile

Gains

Stratum

Gains

Outlier

Gains

2015 16 103 750 13.7 13.7 20.7 1

# per 100 children with a pre-operative diagnosis of acute appendicitis who undergo appendicectomy

In 2015, there were 26 records from 16 HCOs. The annual rate was 13.7 per 100 children with a pre-

operative diagnosis of acute appendicitis who undergo appendicectomy with normal histology.





Outliers





9.2 Laparoscopic cholecystectomy - bile duct injury requiring operative intervention (L)

Numerator Number of patients having a laparoscopic cholecystectomy with a bile duct injury requiring

operative intervention.

Denominator Number of patients having a laparoscopic cholecystectomy performed.



Year

No.

HCOs

Total

numerator

Total

denominator Rate#

Rate#

(20)

Rate#

(80)

Centile

Gains

Stratum

Gains

Outlier

Gains

2008 117 69 15,012 0.46 0.23 0.53 34 8

2009 105 39 15,523 0.25 0.21 0.26 7

2010 103 79 15,648 0.50 0.30 0.68 32 6

2011 101 77 14,171 0.54 0.16 0.68 54 15

2012 85 50 13,527 0.37 0.30 0.42 10 7

2013 79 47 13,768 0.34 0.18 0.32 22 4

2014 68 50 13,247 0.38 0.13 0.33 33 29 15

2015 65 43 12,301 0.35 0.24 0.42 14 2

# per 100 patients


Trends






In 2015, the potential gains totalled 14 fewer patients having a laparoscopic cholecystectomy with a

bile duct injury requiring operative intervention, corresponding to a reduction by approximately one-

quarter.


80th centile rate

20th centile rate

Fitted rate

Aggregate rate x

Period average rate




Outliers

In 2015, there was one outlier record from one outlier HCO whose combined excess was two more

patients having a laparoscopic cholecystectomy with a bile duct injury requiring operative intervention.

The outlier HCO rate was 2.2 per 100 patients.




9.3 Tonsillectomy - significant reactionary haemorrhage (L)

Numerator Number of patients who have a significant reactionary haemorrhage following tonsillectomy.

Denominator Number of patients who have a tonsillectomy performed.



Year

No.

HCOs

Total

numerator

Total

denominator Rate#

Rate#

(20)

Rate#

(80)

Centile

Gains

Stratum

Gains

Outlier

Gains

2008 93 86 15,472 0.56 0.40 0.88 25 5

2009 87 74 16,091 0.46 0.39 0.63 12

2010 84 98 15,422 0.64 0.29 0.67 53 21

2011 85 94 14,473 0.65 0.31 0.91 49 13

2012 73 56 14,335 0.39 0.34 0.58 7

2013 64 57 13,449 0.42 0.34 0.58 11

2014 62 72 12,561 0.57 0.41 0.80 21 20 7

2015 56 70 11,284 0.62 0.38 0.83 27 14 6

# per 100 patients


Trends




80th centile rate

20th centile rate

Fitted rate

Aggregate rate x

Period average rate





Rates by State

Year Stratum

No.

HCOs

Total

numerator

Total

denominator

Stratum

rate#

Standard

error

Stratum

gains

2015 NSW 13 11 3,099 0.46 0.10

Qld 10 3 1,341 0.49 0.16

SA 7 20 1,892 0.89 0.13 8

Vic 12 16 1,541 0.86 0.15 6

WA 7 11 2,443 0.47 0.12

Other 7 9 968 0.77 0.18

# per 100 patients



In 2015, the potential gains totalled 27 fewer patients who have a significant reactionary haemorrhage

following tonsillectomy, corresponding to a reduction by approximately one-third.

Outliers

In 2015, there were two outlier records from two outlier HCOs whose combined excess was six more

patients who have a significant reactionary haemorrhage following tonsillectomy. The outlier HCO rate

was 5.7 per 100 patients.





Characteristics of contributing HCOs

Public/ Private and Metropolitan/ Non-metro total denominators and number of HCOs by clinical indicator

All indicators Combined

Public % Private % Metropolitan % Non-metro % Total

Hospital-Wide Indicators Combined HCOs 292 56% 233 44% 283 54% 242 46% 525

Indicators by Topic


Clinical Indicator Public % Private % Metropolitan % Non-metro % Total


HCOs 88 31% 200 69% 182 63% 106 37% 288

Denominator 813,617 22% 2,834,416 78% 2,901,741 80% 746,292 20% 3,648,033




HCOs 49 22% 172 78% 158 71% 63 29% 221

Denominator 241,251 12% 1,761,132 88% 1,697,216 85% 305,167 15% 2,002,383


HCOs 7 14% 44 86% 42 82% 9 18% 51

Denominator 129 11% 993 89% 907 81% 215 19% 1,122

Pressure injuries


3.1 Inpatients who develop 1 or more pressure injuries (L) HCOs 235 54% 197 46% 232 54% 200 46% 432

Denominator 6,559,569 53% 5,853,043 47% 9,880,196 80% 2,532,416 20% 12,412,612




Inpatient falls


4.1 Inpatient falls (L) HCOs 194 48% 214 52% 250 61% 158 39% 408

Denominator 8,376,320 55% 6,928,516 45% 12,341,062 81% 2,963,774 19% 15,304,836


HCOs 149 43% 200 57% 220 63% 129 37% 349

Denominator 7,082,081 50% 6,987,319 50% 11,321,425 80% 2,747,975 20% 14,069,400

4.3 Inpatient falls - patients 65 years and older (L) HCOs 101 45% 122 55% 145 65% 78 35% 223

Denominator 3,026,630 53% 2,695,459 47% 4,811,277 84% 910,812 16% 5,722,089

Patient deaths



HCOs 69 36% 123 64% 128 67% 64 33% 192

Denominator 12,049 60% 8,037 40% 16,141 80% 3,945 20% 20,086


HCOs 34 52% 31 48% 36 55% 29 45% 65

Denominator 442,005 56% 342,442 44% 613,926 78% 170,521 22% 784,447

5.3 Adult deaths (L) HCOs 33 46% 38 54% 46 65% 25 35% 71

Denominator 588,666 64% 325,370 36% 752,117 82% 161,919 18% 914,036

5.4 Coronary artery graft surgery (CAGS) - death (L) HCOs 10 33% 20 67% 27 90% 3 10% 30

Denominator 2,168 43% 2,889 57% 4,701 93% 356 7% 5,057

5.5 Elective coronary artery graft surgery - death (L) HCOs 10 59% 7 41% 14 82% 3 18% 17

Denominator 1,373 70% 584 30% 1,726 88% 231 12% 1,957

5.6 Coronary artery graft surgery patients aged 71 years or older - death (L)

HCOs 10 50% 10 50% 17 85% 3 15% 20

Denominator 757 62% 468 38% 1,121 92% 104 8% 1,225

5.7 Elective abdominal aortic aneurysm (AAA) open repair - death (L)

HCOs 9 56% 7 44% 15 94% 1 6% 16

Denominator 96 82% 21 18% 115 98% 2 2% 117




Blood transfusion


6.1 Significant adverse blood transfusion events (L) HCOs 60 33% 123 67% 120 66% 63 34% 183

Denominator 50,236 53% 45,197 47% 87,381 92% 8,052 8% 95,433


HCOs 47 47% 52 53% 52 53% 47 47% 99

Denominator 13,916 59% 9,533 41% 19,048 81% 4,401 19% 23,449


HCOs 40 47% 45 53% 46 54% 39 46% 85

Denominator 18,724 78% 5,404 22% 20,316 84% 3,812 16% 24,128

Thromboprophylaxis



HCOs 6 60% 4 40% 6 60% 4 40% 10

Denominator 1,555 31% 3,398 69% 3,802 77% 1,151 23% 4,953



8.1 Rapid response system calls to adult patients (N) HCOs 53 49% 56 51% 79 72% 30 28% 109

Denominator 857,269 58% 616,368 42% 1,256,492 85% 217,145 15% 1,473,637


HCOs 30 38% 49 62% 65 82% 14 18% 79

Denominator 571,745 53% 509,189 47% 938,579 87% 142,355 13% 1,080,934

8.3 Adult patients experiencing cardiopulmonary arrest (L) HCOs 42 28% 108 72% 116 77% 34 23% 150

Denominator 786,863 47% 902,378 53% 1,433,168 85% 256,073 15% 1,689,241

8.4 Rapid response system attendances within 5 minutes (H) HCOs 19 41% 27 59% 37 80% 9 20% 46

Denominator 9,729 78% 2,803 22% 10,461 83% 2,071 17% 12,532

8.5 Adult deaths avoided by rapid response system calls (H) HCOs 10 83% 2 17% 4 33% 8 67% 12

Denominator 3,787 98% 83 2% 1,501 39% 2,369 61% 3,870




Surgery



HCOs 9 56% 7 44% 13 81% 3 19% 16

Denominator 719 96% 31 4% 541 72% 209 28% 750


HCOs 21 32% 44 68% 54 83% 11 17% 65

Denominator 5,413 44% 6,888 56% 10,742 87% 1,559 13% 12,301

9.3 Tonsillectomy - significant reactionary haemorrhage (L) HCOs 14 25% 42 75% 50 89% 6 11% 56

Denominator 2,149 19% 9,135 81% 10,186 90% 1,098 10% 11,284




Summary of Results



In 2015, there were 3,648,033 separations reported from 288 HCOs. The annual rate was 1.25 per 100 separations. The fitted rate improved from 1.6 to 1.1, a change of 0.49 per 100 separations. This trend was also significant after allowing for the changing composition of HCOs contributing over the period. The rate change was 0.49 per 100 separations. In 2015, the potential gains totalled 40,248 fewer unplanned and unexpected readmissions within 28 days, corresponding to a reduction by approximately four-fifths. There were 88 outlier records from 57 outlier HCOs whose combined excess was 22,622 more unplanned and unexpected readmissions within 28 days. The outlier HCO rate was 4.4 per 100 separations.



In 2015, there were 2,002,383 patients reported from 221 HCOs. The annual rate was 0.25 per 100 patients. The fitted rate improved from 0.37 to 0.26, a change of 0.11 per 100 patients. This trend was also significant after allowing for the changing composition of HCOs contributing over the period. The rate change was 0.11 per 100 patients. In 2015, the potential gains totalled 3,382 fewer patients having an unplanned return to the operating room, corresponding to a reduction by approximately one-half. There were 40 outlier records from 30 outlier HCOs whose combined excess was 1,087 more patients having an unplanned return to the operating room. The outlier HCO rate was 0.64 per 100 patients.


In 2015, there were 1,122 patients having an unplanned return to the operating room reported from 51 HCOs. The annual rate was 98.5 per 100 patients having a reviewed case following an unplanned return to the operating room. There was relatively little variation between HCOs and so the potential gains were small in 2015. There were three outlier records from three outlier HCOs whose combined excess was 14 fewer cases reviewed following an unplanned return to the operating room. The outlier HCO rate was 84.8 per 100 patients having a reviewed case following an unplanned return to the operating room.

Pressure injuries

3.1 Inpatients who develop 1 or more pressure injuries (L)

In 2015, there were 12,412,612 bed-days reported from 432 HCOs. The annual rate was 0.073 per 100 bed-days. In 2015, the potential gains totalled 6,753 fewer patients who develop one or more pressure injuries, corresponding to a reduction by approximately two-thirds. There were 58 outlier records from 45 outlier HCOs whose combined excess was 2,172 more patients who develop one or more pressure injuries. The outlier HCO rate was 0.17 per 100 bed-days.

Inpatient falls

4.1 Inpatient falls (L)

In 2015, there were 15,304,836 bed-days reported from 408 HCOs. The annual rate was 0.35 per 100 bed-days. In 2015, the potential gains totalled 24,075 fewer inpatient falls, corresponding to a reduction by approximately one-third. There were 153 outlier records from 104 outlier HCOs whose combined excess was 9,463 more inpatient falls. The outlier HCO rate was 0.65 per 100 bed-days.


In 2015, there were 14,069,400 bed-days reported from 349 HCOs. The annual rate was 0.010 per 100 bed-days. In 2015, the potential gains totalled 713 fewer inpatient falls resulting in a fracture or closed head injury, corresponding to a reduction by approximately one-half. There were eight outlier records from eight outlier HCOs whose combined excess was 282 more inpatient falls resulting in a fracture or closed head injury. The outlier HCO rate was 0.089 per 100 bed-days.

4.3 Inpatient falls - patients 65 years and older (L)

In 2015, there were 5,722,089 bed-days reported from 223 HCOs. The annual rate was 0.52 per 100 bed-days. In 2015, the potential gains totalled 10,639 fewer inpatient falls in inpatients aged 65 years and older, corresponding to a reduction by approximately one-third. There were 69 outlier records from 47 outlier HCOs whose combined excess was 5,194 more inpatient falls in inpatients aged 65 years and older. The outlier HCO rate was 0.97 per 100 bed-days.




Patient deaths


In 2015, there were 20,086 deaths reported from 192 HCOs. The annual rate was 95.6 per 100 deaths. The fitted rate improved from 93.0 to 95.6, a change of 2.7 per 100 deaths. This trend was also significant after allowing for the changing composition of HCOs contributing over the period. The rate change was 2.6 per 100 deaths. There was relatively little variation between HCOs and so the potential gains were small in 2015. There were 22 outlier records from 18 outlier HCOs whose combined excess was 678 fewer patient deaths addressed within a clinical audit process. The outlier HCO rate was 64.3 per 100 deaths.


In 2015, there were 784,447 patients reported from 65 HCOs. The annual rate was 0.15 per 100 patients. In 2015, the potential gains totalled 985 fewer deaths in adult patients who do not have a not for resuscitation order, corresponding to a reduction by approximately four-fifths. There were 14 outlier records from 12 outlier HCOs whose combined excess was 469 more deaths in adult patients who do not have a not for resuscitation order. The outlier HCO rate was 0.66 per 100 patients.

5.3 Adult deaths (L)

In 2015, there were 914,036 patients reported from 71 HCOs. The annual rate was 1.00 per 100 patients. In 2015, the potential gains totalled 6,246 fewer adult deaths, corresponding to a reduction by approximately two-thirds. There were 28 outlier records from 20 outlier HCOs whose combined excess was 1,935 more adult deaths. The outlier HCO rate was 1.8 per 100 patients.

5.4 Coronary artery graft surgery (CAGS) - death (L)

In 2015, there were 5,057 patients reported from 30 HCOs. The annual rate was 1.29 per 100 patients. The fitted rate improved from 1.9 to 1.1, a change of 0.73 per 100 patients. This trend was also significant after allowing for the changing composition of HCOs contributing over the period. The rate change was 0.68 per 100 patients. There were no potential gains in 2015.

5.5 Elective coronary artery graft surgery - death (L)

In 2015, there were 1,957 patients reported from 17 HCOs. The annual rate was 1.48 per 100 patients. There was no significant trend in the fitted rate. In 2015, the potential gains totalled five fewer elective patients who die in the same admission as having coronary artery graft surgery, corresponding to a reduction by approximately one-tenth.

5.6 Coronary artery graft surgery patients aged 71 years or older - death (L)

In 2015, there were 1,225 patients reported from 20 HCOs. The annual rate was 2.53 per 100 patients. There was no significant trend in the fitted rate. There were no potential gains in 2015.

5.7 Elective abdominal aortic aneurysm (AAA) open repair - death (L)

In 2015, there were 117 patients reported from 16 HCOs. The annual rate was 0.85 per 100 patients. The fitted rate improved from 2.9 to 1.1, a change of 1.9 per 100 patients. This trend was also significant after allowing for the changing composition of HCOs contributing over the period. The rate change was 2.2 per 100 patients. There were no potential gains in 2015.

Blood transfusion

6.1 Significant adverse blood transfusion events (L)

In 2015, there were 95,433 transfusions reported from 183 HCOs. The annual rate was 0.15 per 100 transfusions. The fitted rate improved from 0.28 to 0.16, a change of 0.12 per 100 transfusions. This trend was also significant after allowing for the changing composition of HCOs contributing over the period. The rate change was 0.13 per 100 transfusions. In 2015, the potential gains totalled 48 fewer significant adverse blood transfusion events, corresponding to a reduction by approximately one-quarter. There were three outlier records from three outlier HCOs whose combined excess was 12 more significant adverse blood transfusion events. The outlier HCO rate was 0.65 per 100 transfusions.


In 2015, there were 23,449 transfusions reported from 99 HCOs. The annual rate was 3.23 per 100 transfusions. In 2015, the potential gains totalled 686 fewer transfusion episodes performed without consent, corresponding to a reduction by approximately four-fifths. There were 19 outlier records from 15 outlier HCOs whose combined excess was 496 more transfusion episodes performed without consent. The outlier HCO rate was 22.1 per 100 transfusions.





In 2015, there were 24,128 transfusions reported from 85 HCOs. The annual rate was 1.54 per 100 transfusions. In 2015, the potential gains totalled 244 fewer transfusions where Hb reading is 100g/L or more, corresponding to a reduction by approximately one-half. There were nine outlier records from seven outlier HCOs whose combined excess was 136 more transfusions where Hb reading is 100g/L or more. The outlier HCO rate was 3.1 per 100 transfusions.

Thromboprophylaxis


In 2015, there were 4,953 high-risk medical patients reported from 10 HCOs. The annual rate was 55.8 per 100 high-risk medical patients.


8.1 Rapid response system calls to adult patients (N)

In 2015, there were 1,473,637 admissions reported from 109 HCOs. The annual rate was 2.77 per 100 admissions.


In 2015, there were 1,080,934 admissions reported from 79 HCOs. The annual rate was 0.65 per 100 admissions.

8.3 Adult patients experiencing cardiopulmonary arrest (L)

In 2015, there were 1,689,241 admissions reported from 150 HCOs. The annual rate was 0.10 per 100 admissions. In 2015, the potential gains totalled 1,104 fewer adult patients who experience a cardiopulmonary arrest, corresponding to a reduction by approximately one-half. There were 13 outlier records from 10 outlier HCOs whose combined excess was 472 more adult patients who experience a cardiopulmonary arrest. The outlier HCO rate was 0.40 per 100 admissions.

8.4 Rapid response system attendances within 5 minutes (H)

In 2015, there were 12,532 rapid response system calls to adult patients reported from 46 HCOs. The annual rate was 96.6 per 100 rapid response system calls to adult patients. There was relatively little variation between HCOs and so the potential gains were small in 2015. There were seven outlier records from seven outlier HCOs whose combined excess was 213 fewer rapid response system calls attended to within five minutes. The outlier HCO rate was 86.2 per 100 rapid response system calls to adult patients.

8.5 Adult deaths avoided by rapid response system calls (H)

In 2015, there were 3,870 rapid response system calls to adult patients reported from 12 HCOs. The annual rate was 93.1 per 100 rapid response system calls to adult patients. There was relatively little variation between HCOs and so the potential gains were small in 2015. There were two outlier records from two outlier HCOs whose combined excess was 36 fewer adult deaths avoided due to rapid response system calls. The outlier HCO rate was 87.2 per 100 rapid response system calls to adult patients.

Surgery


In 2015, there were 750 children with a pre-operative diagnosis of acute appendicitis who undergo appendicectomy reported from 16 HCOs. The annual rate was 13.7 per 100 children with a pre-operative diagnosis of acute appendicitis who undergo appendicectomy with normal histology. There were no potential gains in 2015.


In 2015, there were 12,301 patients reported from 65 HCOs. The annual rate was 0.35 per 100 patients. There was no significant trend in the fitted rate. In 2015, the potential gains totalled 14 fewer patients having a laparoscopic cholecystectomy with a bile duct injury requiring operative intervention, corresponding to a reduction by approximately one-quarter. There was one outlier record from one outlier HCO whose combined excess was two more patients having a laparoscopic cholecystectomy with a bile duct injury requiring operative intervention. The outlier HCO rate was 2.2 per 100 patients.

9.3 Tonsillectomy - significant reactionary haemorrhage (L)

In 2015, there were 11,284 patients reported from 56 HCOs. The annual rate was 0.62 per 100 patients. There was no significant trend in the fitted rate. In 2015, the potential gains totalled 27 fewer patients who have a significant reactionary haemorrhage following tonsillectomy, corresponding to a reduction by approximately one third. There were two outlier records from two outlier HCOs whose combined excess was six more patients who




have a significant reactionary haemorrhage following tonsillectomy. The outlier HCO rate was 5.7 per 100 patients.




Expert Commentary

The Royal Australasian College of Medical Administrators (RACMA)

Introductory comments The Royal Australasian College of Medical Administrators (RACMA) is in a unique position within the

quality assurance space. Our Fellows manage and lead health service organisations across Australia

and New Zealand, within a range of roles predominantly as Chief Medical Officers and Directors of

Medical Services. Our Fellows coordinate the compliance of their organisations to the Australian

Commission on Safety and Quality in Health Care’s ten National Standards, as well as the ACHS’

additional five EQuIP standards. Most health service organisations use the ACHS to conduct the

compliance assessment and performance management. In addition, our Fellows will also coordinate

compliance assessments for the National Standards for Mental Health Services and the Standards

for Aged Care Services. Fortunately, very few health service organisations fail the aforementioned

quality assurance assessments.

As for clinical indicators (CIs), once again through the inherent roles that our Fellows hold they are

commonly the custodians of performance reporting frameworks and clinical data benchmarking. The

health service organisations that our Fellows lead will provide performance data to state, federal and

non-government groups. This data is then processed and distributed back to respective organisations

through several sources such as the Core Hospital-Based Outcome Indicators (CHBOIs), statebased

indicators (i.e. PRISM in Victoria), Quality Investigator (Dr Foster – Telstra Health) and the Health

Roundtable (HRT). There is generally very good compliance with indicator benchmarks across states

and jurisdictions. Through independent groups such as the HRT, there is very good information-

sharing and collaboration between organisations within Australia and New Zealand.


There is a pleasing continued downward trend for ‘Unplanned and unexpected readmission within 28

days’ (CI 1.1) that is likely to be indicative of continued improvements in care and discharge planning.

Rates of outlier HCOs continue to be more than three times the rate of the aggregate group. Careful

and detailed review of the data by these HCOs is required to identify potential differences in care or

discharge planning, thus identifying opportunities for improvement. HCOs should consider these

results in the context of their definition of “admission”, including changing models of care such as

short stay units and hospital avoidance to ensure they understand the local context behind potential

reasons for readmissions varying between HCOs.

Return to the operating room The rate for ‘Unplanned return to the operating room during the same admission’ (CI 2.1) continues its

downward trend which may be related to improvements in surgical techniques, clinician training and

supervision, credentialing and defining scope of practice as well as improved preoperative

assessment (including suitability for surgery) and postoperative practices. It is pleasing to note that

98.5 per 100 patients in this category have had their case reviewed (CI 2.2). Whilst this rate is

impressive, 100% of these cases should be reviewed in order to accurately identify potential practice

improvement issues.

It could be of interest to outlier HCOs to reflect on their case selection and access to tertiary centres

as well as risk adjusted rates that include comorbidity. It may also be of use to consider this CI in the

context of each outcome post-surgery (i.e. no further surgery required, further surgery required or

death post-surgery). Outlier HCOs may find value in mining their data to examine both patient and

non-patient factors. Important non-patient factors would include whether the primary surgery was

emergency or elective and at what time of day and day of the week the primary surgery occurred.




Pressure injuries

Both public and private HCOs have undertaken significant work to improve pressure ulcer screening,

assessment, management and prevention and to improve the training of clinicians, predominantly

nursing staff. This is in line with the requirements of the National Safety and Quality Health Service

(NSQHS) Standard 8: Preventing and Managing Pressure Injuries. This area of clinical practice

continues to require ongoing and concerted effort. The ageing of our patient population and

associated co-morbidities will continue to impact on CI 3.1. This CI should also be interpreted in the

context of external constraints such as funding structures and models that are designed to promote

awareness, detection and early treatment of pressure injuries. It is important to note the changing

definitions of pressure injuries and the impact that further detail in specific definitions will have on the

data over time.

Inpatient falls

The rate of ‘Inpatient falls’ (CI 4.1) remains an area of improvement for both public and private sectors

with no significant difference in rate noted. The outlier group of HCOs is of particular concern with a

fall rate nearly double that of the aggregate rate. The rate of ‘Inpatient falls resulting in fracture or

closed health injury’ (CI 4.2) was similar in all states except the “other group” with relatively few

outliers. It is unsurprising that the fall rates remain higher in patients over the age of 65 (CI 4.3). It

would be interesting to identify a sub-indicator: inpatient falls resulting in fracture or closed head injury

in this age group. This would be of benefit in the continued focus on falls screening, assessment,

management and prevention required by NSQHS Standard 10: Preventing Falls and Harm from Falls.

Patient deaths The review of patient deaths addressed within a clinical audit process (CI 5.1) is of great value in

understanding avoidable causes and improving clinical practice. The improving trend to 95.6 per 100

deaths reviewed is pleasing and indicates that death screening and review as part of Morbidity and

Mortality meetings has been widely implemented. It is a concern that there are still outlier HCOs and

that their rate was 64.3 per 100 deaths.

There are considerably fewer HCOs able to submit data for ‘Deaths in adult patients who do not have

an NFR order’ (CI 5.2). This could in part be due to differences in definitions of treatment limiting

orders and the way in which they are recorded and identified in the medical record. The numbers of

patients who died without an NFR order is low at 0.15 per 100 patients. The data is insufficiently

granular to allow interpretation on the appropriate timing of NFR orders throughout admission and

before death.

Given the scoping of ‘Adult deaths’ (CI 5.3), this may reflect the CI’s overall utility, as raw mortality

rates need to be considered in the context of casemix and comorbidity. Reflection on standardised or

casemix adjusted mortality rates may add understanding to the variations in mortality rate. Subsets of

data, such as “unexpected deaths” and “expected deaths” will be of utility. Unexpected deaths are

arguably the higher risk from a governance perspective and should be the first addressed in any

death review clinical audit process.

Although Coronary Artery Graft Surgery (CAGS) related deaths (CI 5.4) are small in number, data

volumes have showed consistency since 2008, allowing an interpretation that deaths related to CAGS

has decreased over time. This may be due to earlier detection and proactive management of

cardiovascular disease, improved surgical techniques and maintenance medical therapies

postoperatively.

CI 5.6 demonstrates the higher death rate post CAGS of patients aged 71 years and over. Further

detail is required to comment on whether age is an independent risk factor for death post CAGS.

There was a low data volume for death after elective abdominal aortic aneurysm (AAA) open repair

(CI 5.7), which likely represents the natural incidence and clinical detection of this issue as well as the

few centres nationally that are equipped to conduct these surgeries. Pleasing rates over time indicate

surgical advances, including non-open surgical techniques and improved screening and earlier

detection as well as advances in postoperative care.




Blood transfusion There is a continued downward trend in the rate of ‘Significant adverse blood transfusion events’ (CI

6.1). It is further noted that the public rate is nearly twice that of the private rate, but the state rates

are reasonably similar. Whilst the low rate for ‘Transfusion episodes where informed patient consent

was not documented’ (CI 6.2) is noted, variation between states remain and further work needs to be

undertaken particularly in the outlier HCOs where the outlier HCO rate was over six times higher at

22.1 per 100 transfusions compared to 3.23 per 100 transfusions. Similarly the low rate for ‘RBC

transfusion where the Hb reading is 100g/L or more’ (CI 6.3) is noted, but the variation between the

states and the significant spread in the box plots indicates that further improvement in this CI can

occur with continued focus on appropriate prescribing and administrative practices ensuring that a

scarce resource is effectively utilised.

Outlier HCOs should reflect on transfusion volumes and also indications for transfusion (i.e.

emergency, intraoperative or elective). Results also demonstrate the ongoing need for patient

engagement in relation to informed consent for blood transfusion. The work led by national and state

jurisdictions and underpinned for HCOs by the NSQHS Standard 7: Blood and Blood Products,

provides a framework for decreasing risks and improving safety in this clinical area. Outlier HCOs

should carefully review these requirements, audit their practices against them and implement

improvement strategies.

Thromboprophylaxis

The number of HCOs contributing data for ‘VTE prophylaxis administered to high risk medical

patients’ (CI 7.1) remains low and it is therefore difficult to comment productively. Further work needs

to be undertaken to continually raise awareness amongst clinicians of the importance of identifying

high-risk patients and administering appropriate thromboprophylaxis. HCOs should be routinely

examining their own data on this CI, preferably with the denominator of high risk patients who are

“eligible to receive” thromboprophylaxis.

Minimum standards for rapid response system (RRS) calls Whilst the rate of ‘RRS calls to adult patients’ (CI 8.1) is noted as 2.77 per 100 admissions from 109

contributing HCOs and no significant stratum differences were noted, it is impossible to make sensible

comment given the lack of a definition of what an appropriate rate might be. Similarly no sensible

comment is possible for the ‘RRS calls to adult patients within 24 hours of admission’ (CI 8.2) with a

rate of 0.65 per 100 admissions and no significant stratum difference for the same reasons.

Definitions of RRS calls are important, in that do they include cardiac arrest calls as well as calls

regarding acute deterioration? The literature indicates that RRS type calls vary between 26-56 per

1,000 separations; as such the rate is at the lower end of what can be anticipated.

With respect to ‘Adult patients experience cardiopulmonary arrest’ (CI 8.3) the annual rate was 0.10

per 100 admissions from 150 HCOs with wide variation between the states and an outlier HCO rate

four times that of the aggregate rate. What is not clear is the likely cause of this variation. This is an

area requiring additional study and discussion with appropriate clinical groups. HCOs should consider

examining their methods of detection and responding to clinical deterioration to determine the

contribution to the rate of cardiopulmonary arrest calls.

It was pleasing to note that the rate for ‘RRS attendances within 5 minutes’ (CI 8.4), granted from a

relatively small sample of 46 HCOs was 96.6 per 100 RRS calls to adult patients, with no significant

stratum differences. All organisations may find benefit in differentiating RRS calls occurring “in hours”

and “after hours” to further delineate the risks to the deteriorating patient.

Surgery

No significant trends noted.




Australian College of Nursing (ACN)

Introductory comments

The potential for nurse sensitive indicators (NSIs) is emerging but how they are used in relation to

supporting quality and safety of nursing care,1 how nurses perceive the quality,2 and the quality and

safety of care of the multidisciplinary team is yet to be determined.


The improved fitted rate of ‘Unplanned and unexpected hospital readmissions within 28 days’ (CI 1.1)

is acknowledged as a significant outcome of the efforts of multiple teams and processes within HCOs.

The role of nurses is integral to hospital admission risk programs, residential in-reach services, post-

acute care services, rapid assessment and discharge teams, clinical response services, case

management and discharge planning as consultants and members of multidisciplinary teams,3 all of

which have a strategic impact on readmissions. The changing composition of contributing HCOs is

noted.


This nurse sensitive criteria shows that patients are being closely monitored and the findings are

being reported in a timely manner. These support the National Safety and Quality Health Service

(NSQHS) Standards. Care of the patient with reference to Standard 9 of the National Standards

means identification, action and reporting of the antecedents to clinical deterioration by

ward/department nurses.4 The appropriate escalation of care5 by nurses for an unplanned return to

the operating room (CI 2.1) ensures quality and safe standards of care observations that may cause

concern.4 It is pleasing to note the fitted rate improved and remained significant after allowing for a

change in the composition of the contributing HCOs.

Pressure injuries

Pressure injuries are largely prevented from developing or becoming worse by sound nursing

practice. Nurses contribute significantly to the outcomes of this CI and it is pleasing to note a low rate

in the number of patients affected. Patients with one or more pressure injuries in hospital most

commonly develop them prior to admission and this indicates the need for greater education and

support of carers and aged care providers as partners in care.6

CI 3.1 is a NSI which requires interventions of routine nursing practice for all patients, but in particular

those frail and elderly individuals who are requiring hospitalisation in increasing numbers as the

population ages. Such practices include regular audits, air mattresses for patients at risk, incident

reporting systems and processes for identified education and supervision requirements. The research

shows that continued uses of evidence-based interventions are required, especially in aged care

facilities.7

Inpatient falls

The rate of falls in HCOs, especially in the elderly is decreasing. The Australian Commission on

Safety and Quality in Health Care delivered a national resource in 2009 to aide in the reduction of

falls. However, there does not appear to be a model that is consistently used nationwide as a

preventative measure.

Falls prevention in acute hospitals is complex and there remains no high quality evidence of

successful falls prevention strategies in wards.8 Patients at risk of falling require multidisciplinary

involvement in care planning, pro-active and accurate assessment, various sensor devices and

systems and risk identification. However, despite the lack of a successful empirical strategy, the

majority of the direct care remains the responsibility of nurses and the low rates reported for CIs 4.1 -

4.3 corresponds to safe and quality nursing practice to prevent those at risk from falling, injuring

themselves or others and is a pleasing trend.




Patient deaths

Nurses as part of the health professional team ensure there has been a documented not for

resuscitation (NFR) order (CI 5.2) on admission, including prior to transfer from Emergency

Department, as part of the admission process.

Blood transfusion

The highest number of HCOs contributed to CI 6.1 in 2015, and the changing composition is noted.

The fitted rate improved allowing for this pattern. Nurses identify the first changes to vital signs in

transfusion reaction and they are responsible for patient education to ask them to alert nurses to any

changes experienced. The first to be detected is usually T>374 followed by stopping transfusion and a

decision to escalate care. Intervention by nurses contributes directly to fewer adverse transfusion

events (CI 6.1).

Informed patient consent (CI 6.2) is part of the checking of documentation before administration of a

blood transfusion, thus providing safe and quality care. Nurses check consent orders at the same time

as checking administration orders for transfusion and provide another level of quality and safety

checking for this documentation. If not present, the transfusion would be delayed until completed.

Nurses check Hb prior to transfusion (CI 6.3), but reported blood is not provided by pathology

departments where Hb is 100g/L or more. Fewer transfusions in this range were reported in 2015,

and there were nine outlier records of a combined excess of 136 transfusions.

General/closing comments

Overall, this review has shown positive outcomes for nurse sensitive criteria.

References

1. Burston S, Chaboyer W and Gillespie B. Nurse-sensitive indicators suitable to reflect nursing care quality: a review and

discussion of issues. Journal of Clinical Nursing 2014; 23(13-14): 1785-1795.

2. Stalpers D, Kieft R, Van Der Linden D et al. Concordance between nurse-reported quality of care and quality of care as

publicly reported by nurse-sensitive indicators. BMC Health Services Research 2016; 16.

3. Department of Human Services. Improving Care: Hospital Admission Risk Program. Victorian Government, Melbourne;

2012.

4. Douw G, Schoonhoven L, Holwerda T et al. Nurses' worry or concern and early recognition of deteriorating patients on

general wards in acute care hospitals: a systematic review. Crit Care 2015; 19: 230.

5. Australian Commission on Safety and Quality in Health Care (ACSQHC). Safety and Quality Improvement Guide Standard

9: Recognising and Responding to Clinical Deterioration in Acute Health Care. 2012.

6. Australian Commission on Safety and Quality in Health Care (ACSQHC). Safety and Quality Improvement Guide Standard

8: Preventing and Managing Pressure Injuries. 2012.

7. Kwong EW, Pang SM, Aboo GH and Law SS. Pressure ulcer development in older residents in nursing homes: influencing

factors. J Adv Nurs 2009; 65(12): 2608-2620.

8. Barker AL, Morello RT, Wolfe R et al. 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised

controlled trial. BMJ 2016; 352.

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