Quality and safety markers update, July–September 2016
Falls
Nationally, 90 percent of older patients* were given a falls risk assessment in quarter
3, 2016. The rate has remained at the expected achievement level of 90 percent
since quarter 4, 2013, in spite of some variations in a few quarters. At the district
health board (DHB) level, 14 out of 20 DHBs achieved the target. Bay of Plenty DHB
showed significantly lower results over the last few quarters compared with the
national target of 90 percent (see Figure 1). We will engage with the DHB to better
understand the reasons for the variance.
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•
•
Upper group: ≥ 90 percent
Middle group: 75–89 percent
Lower group: < 75 percent
* Patients aged 75+ (55+ for Māori and Pacific peoples)
1
About 93 percent of patients at risk of falling received an individualised care plan.
This measure has increased 15 percentage points compared with the baseline in
quarter 1, 2013. Variances in achievement levels need to be understood, but overall
where an individual has been assessed at risk of falling, then completion of
individualised care plans for that population group should be at a consistently high
level.
•
•
•
Upper group: ≥ 90 percent
Middle group: 75–89 percent
Lower group: < 75 percent
2
When assessments and care plans are plotted against each other, a trend of
movement over time is shown from the bottom left corner (low assessment and
individualised care plan) to the top right corner (high assessment and individualised
care plan). Only five DHBs sat at the top right corner in quarter 1, 2013, but in the
current quarter, 11 DHBs are in this ‘ideal’ box (see Figure 3). This is a pleasing
result and we look for it to be sustained at these levels.
There were 64 falls resulting in a fractured neck of femur in the 12 months ending
September 2016. The median of monthly falls reduced from eight to six since
December 2014 and this improvement has been remained in the latest quarter.
To control the impact from changes in the number of admissions per month, Figure 4
shows in-hospital falls causing fractured neck of femur per 100,000 admissions. The
median of this measure has moved down since November 2014, from 12 to 8 per
3
100,000 admissions. While the rate in February 2016 was a high outlier, it does not
indicate any shift in trend. Within these 23 months, 22 were below the original
median level. This is the eighth quarter where this outcome marker has shown a
significant improvement.
These in-hospitals patient outcomes have been reported as world-leading, 1 2 3 with
New Zealand referred to as the first country to achieve such results at a national
level.
If New Zealand is to sustain these gains and continue to improve, it will be vital to
maintain our focus in this area of high harm.
1
Jones S, Blake S, Hamblin R, et al. 2016. Reducing harm from falls. NZ Med J 129(1446): 89–103.
Healey F. 2016. Falls prevention as everyday heroism. NZ Med J 129(1446): 14–16.
3
Wise J. 2016. Individual care plans reduce falls and broken hips in New Zealand hospitals. BMJ
355: i6490.
2
4
The number of 64 in-hospital falls resulting in a fractured hip is significantly lower
than the 110 we would have expected in this year, given the falls rate observed in
the period between July 2010 and June 2012. The reduction is estimated to have
saved $2.2 million in the year ending September 2016, based on an estimate of
$47,000 4 for a fall with a fractured neck of femur.
The estimate may be too conservative, however, as it assumes all patients who fall
and break their hip in hospital return home. We know that at least some of these
patients are likely to be admitted to aged residential care on discharge from hospital.
This is a far more expensive proposition – estimated at $135,000 a time. 5 If we
conservatively estimate that 20 percent of the patients who avoided falls were
admitted to a residential care facility, the reduction in falls represents $3.0 million in
total avoidable costs since October 2015.
4
5
de Raad J-P. 2012. Towards a value proposition: scoping the cost of falls. Wellington: NZIER.
Ibid.
5
6
Hand hygiene
National compliance with the five moments for hand hygiene remains high.
Nationally, DHBs achieved an average of 83 percent compliance in quarter 3, 2016,
the highest since the baseline quarter 3, 2012.
•
•
•
•
Upper group: ≥ 70 percent before quarter 3, 2014, then 75 percent in quarters 3 and 4, 2014, and
then 80 percent since quarter 1, 2015
Middle group: 60 percent to target
Lower group: < 60 percent
Hand hygiene national compliance data is reported on three times every year; therefore, no data
point is shown specifically for quarter 4 in any year
The run chart below shows the monthly healthcare associated Staphylococcus
aureus bacteraemia per 1000 bed-days. It indicates a decline in variation recently,
but with no signs of a significant shift in trend.
7
8
Surgical site infection
As the Commission uses a 90-day outcome measure for surgical site infection, the
data runs one quarter behind other measures. Information in this section relates to
hip and knee arthroplasty procedures in quarter 2, 2016.
Process measure 1: Antibiotic administered in the right time
For primary procedures, an antibiotic should be administered in the hour before the
first incision (‘knife to skin’). As this should happen in all primary cases, the threshold
is set at 100 percent. In quarter 2, 2016, 98 percent of hip and knee arthroplasty
procedures involved the giving of an antibiotic within 60 minutes before ‘knife to
skin’. There has been a slow increase for the measure since the start of the Surgical
Site Infection Improvement programme. Six DHBs achieved the national goal.
•
•
•
Upper group: 100 percent
Middle group: 80–99 percent
Lower group: < 80 percent
9
Process measure 2: Right antibiotic in the right dose – cefazolin 2 g or
more or cefuroxime 1.5 g or more
In quarter 1, 2015, 1.5 g or more of cefuroxime was accepted as an alternative agent
to 2 g or more of cefazolin for routine antibiotic prophylaxis for hip and knee
replacements. It improved the results of this process measure for MidCentral DHB
significantly, from 10 percent before the change to 96 percent immediately after the
change. It also increased the national result from 90 percent to 95 percent in quarter
1, 2015. In the current quarter, 15 DHBs reached the threshold level of 95 percent
compared with only three in the baseline quarter.
•
•
•
Upper group: ≥ 95 percent
Middle group: 80–94 percent
Lower group: < 80 percent
10
Process measure 3: Appropriate skin antisepsis in surgery using
alcohol/chlorhexidine or alcohol/povidone iodine
Skin preparation using either chlorhexidine or povidone iodine in alcohol is
recommended for all orthopaedic procedures, so the threshold is set at 100 percent.
Appropriate skin antisepsis is clearly normal practice across DHBs, as the rounded
national compliance rate of 99 percent attests. Thirteen DHBs achieved the target
compared with nine at the baseline quarter.
•
•
•
Upper group: 100 percent
Middle group: 80–99 percent
Lower group: < 80 percent
11
The surgical site infection rate has shown a significant improvement since August
2015, compared with the baseline rate of 1.6 percent in quarter 3, 2013. The
improvement remains in this quarter, with the median dropping down from 1.3
percent to 0.8 percent. During the reduction period, there is a spike of 2.1 percent in
February 2016. Examination of the DHB–level data shows no special cause
variation.
12
Safe surgery
This is the first report of a new quality and safety marker, which measures levels of
teamwork and communication.
Direct observational audit was used to assess the use of the three surgical checklist
parts: sign in, time out and sign out. A minimum of 50 observational audits per
quarter per part (sign in, time out and sign out) are required before the observation is
included in uptake and engagement assessments. Rates are greyed out in the tables
below where there are fewer than 50 audits.
Figure 12 shows for each part of the checklist, how many audits were undertaken.
Eight out of 20 DHBs achieved 50 audits for all three parts in quarter 3, 2016 (see
Figure 12). Compared with the other two parts, sign out was the least audited part of
the checklist.
13
Uptake rates are only presented where at least 50
audits were undertaken for a part. Uptake rates
were calculated by measuring the number of
audits of a part where all components of the
surgical checklist were reviewed against the total
number of audits undertaken. The components
for each part of the checklist are shown in the
image on the right. Hauora Tairāwhiti was the
only DHB that met the minimum number of audits
for all three parts and also achieved the 100
percent uptake target (see Figure 13).
14
The levels of team engagement with each part of the checklist were scored using a
7-point Likert scale. This scale was developed by the World Health Organisation. A
score of one represents poor engagement from the team, four is average
engagement and seven means team engagement was excellent. The target is that
95 percent of surgical procedures score engagement levels of five or above. As
Figure 14 shows, four DHBs achieved the target in one of the three parts. As this is
the first quarter in which DHBs have implemented the new auditing method, the
focus is on embedding the new method and better results are expected in
subsequent quarters.
15
The postoperative sepsis rate and the deep-vein thrombosis/pulmonary embolism
rate are the two outcome markers for safe surgery. We are in the process of
developing a risk-adjustment model for use in the near future to:
•
•
help us understand the factors driving changes in these two measurements over
time
provide risk-adjusted outcomes in the monitoring and improvement of surgical
quality and safety.
16
Medication safety
The quality and safety marker for medication safety focuses on medicine
reconciliation. This is a process by which health professionals accurately document
all medicines a patient is taking and their adverse reactions history (including
allergy). The information is then used during the patient’s journey across transitions
in care. An accurate medicines list can be reviewed to check the medicines are
appropriate and safe. Medicines that should be continued, stopped or temporarily
stopped can be documented on the list. Reconciliation reduces the risk of medicines
being:
•
•
•
•
omitted
prescribed at the wrong dose
prescribed to a patient who is allergic
prescribed when they have the potential to interact with other prescribed
medicines.
The introduction of electronic medicine reconciliation (eMR) allows reconciliation to
be done more routinely, including at discharge. There is a national programme to roll
out eMR throughout the country; five DHBs have implemented the system to date.
Figure 15: Structure marker, implementation of eMR
DHB
Status
Counties Manukau Health Implemented
Northland
Implemented
Taranaki
Implemented
Waitemata
Implemented
Canterbury
Implemented
Auckland
Not implemented
Bay of Plenty
Not implemented
Capital & Coast
Not implemented
Hawke’s Bay
Not implemented
Hutt Valley
Not implemented
Lakes
Not implemented
MidCentral
Not implemented
Nelson Marlborough
Not implemented
South Canterbury
Not implemented
Southern
Not implemented
Hauora Tairāwhiti
Not implemented
Waikato
Not implemented
Wairarapa
Not implemented
West Coast
Not implemented
Whanganui
Not implemented
17
Figure 16: Structure markers, eMR implementation
Structure marker
Northland
DHB
Taranaki
DHB
Counties
Manukau
Health
Structure 1:
eMR implemented
anywhere in the
DHB (yes/no)
Yes
Yes
Yes
Yes
Yes
6
6
29
32
14
60%
50%
97%
84%
26%
Structure 2:
Number and
percentage of
relevant wards with
eMR implemented
Waitemata Canterbury
DHB
DHB
Within the five DHBs that have implemented eMR, Northland DHB and Taranaki
DHB are able to produce the results of these process measures. The other three
DHBs are in the process of system upgrades or tests and will be able to report in the
near future.
Figure 17: Process markers, eMR
Northland
DHB (%)
Taranaki
DHB (%)
Process marker 1: Percentage of
relevant patients aged 65 and over (55
and over for Māori and Pacific peoples)
where electronic medicines reconciliation
was undertaken within 72 hours of
admission
71
37
Process marker 2: Percentage of
relevant patients aged 65 and over (55
and over for Māori and Pacific peoples)
where electronic medicines reconciliation
was undertaken within 24 hours of
admission
55
11
Process marker 3: Percentage of
patients aged 65 and over (55 and over
for Māori and Pacific peoples)
discharged where electronic medicines
reconciliation was included as part of the
discharge summary
74
49
Process marker
18