Quality and safety markers update, October–December 2016
Falls
Nationally, 91 percent of older patients* were assessed on their falls risk in quarter 4,
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, 13 out of 20 DHBs achieved the target. Bay of Plenty DHB
showed an improvement after a few significantly lower results over the last few
quarters compared with the national target of 90 percent (see Figure 1).
•
•
•
Upper group: ≥ 90 percent
Middle group: 75–89 percent
Lower group: < 75 percent
* Patients aged 75+ (55+ for Māori and Pacific peoples)
1
About 94 percent of patients assessed as being at risk of falling had an
individualised care plan completed. This measure has increased 17 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 future improvement and for it to be sustained at these levels.
There were 72 falls resulting in a fractured neck of femur in the 12 months ending
December 2016. The median of monthly falls reduced from eight to six since
December 2014 and this improvement has continued in the latest quarter.
To control the impact of changes in the number of admissions per month, Figure 4
shows in-hospital falls causing a fractured neck of femur per 100,000 admissions.
The median of this measure has moved down since November 2014, from 13 to 8
3
per 100,000 admissions. While the rates in February and November 2016 were the
high outliers, they do not indicate any shift in trend. Within these 26 months, 24 were
below the original median level. We are now in quarter nine of monitoring, where this
outcome marker has shown a significant and sustained 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 72 in-hospital falls resulting in a fractured hip is significantly lower
than the 109 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 $1.8 million in the year ending December 2016, based on an estimate of
$47,0004 for a fall with a fractured neck of femur.
The estimate may be too conservative, 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.
Aged care is a far more expensive proposition – estimated at $135,000 each time
this occurs.5 If we conservatively estimate that 20 percent of the patients who
avoided a fall related fractured neck of femur were admitted to a residential care
4
5
de Raad J-P. 2012. Towards a value proposition: scoping the cost of falls. Wellington: NZIER.
Ibid.
5
facility, the reduction in falls represents $2.5 million in total avoidable costs since
January 2016.
6
Hand hygiene
Hand hygiene national compliance data is reported on three times every year;
therefore, no update specifically for quarter 4 each year. The next update will be
included in the January–March quarter QSM report.
7
Surgical site infection improvement – orthopaedic surgery
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 3, 2016.
Process marker 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 3, 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 (SSII) programme. Eight DHBs achieved the national
goal.
•
•
Upper group: 100 percent
Middle group: 80–99 percent
8
•
Lower group: < 80 percent
Process marker 2: Right antibiotic in the right dose – cefazolin 2 g or
more or cefuroxime 1.5 g or more
In the current quarter, 17 DHBs reached the threshold level of 95 percent compared
with only three in the baseline quarter.6 Taranaki DHB made a significant
improvement from 67 percent in quarter two to 84 percent in quarter three.
•
•
•
Upper group: ≥ 95 percent
Middle group: 80–94 percent
Lower group: < 80 percent
6
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.
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Process marker 3: Appropriate skin antisepsis in surgery using
alcohol/chlorhexidine or alcohol/povidone iodine
Compliance with the skin preparation QSM has been consistently high with 99
percent or more procedures meeting the QSM every surveillance quarter since
January 2015. Due to the continual high compliance against the QSM the SSII
Programme has stopped reporting skin antisepsis preparation as a QSM for
orthopaedic surgery. Using an alcohol-based skin preparation agent is a simple and
effective method of preventing SSIs and is still an important intervention for the
programme. The results will no longer be included in this report.
Outcome marker
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 are a couple of spikes in February and September
2016. Examination of the September DHB level data shows the number of surgical
site infections increased by one or two cases in seven DHBs compared with their
baseline levels of zero or one case per month. Figures in both February and
September are higher outliers. They indicate some one-time occurrence of a special
cause, but this does not indicate any significant shift in trend.
10
Surgical site infection improvement – cardiac surgery
This is the first QSM report for cardiac surgery. Since quarter 3, 2016, all five DHBs
performing cardiac surgery have summited process and outcome marker data. There
are three process markers and one outcome marker, which are similar to the QSMs
for orthopaedic surgery.
Process marker 1 is ‘timing’, which requires an antibiotic to be given 0–60 minutes
before ‘knife to skin’. The target is 100 percent of procedures achieving this marker.
Capital & Coast DHB and Southern DHB achieved this target in the first quarter of
reporting.
Process marker 2 is ‘dosing’, which requires the antibiotic prophylaxis of choice to be
≥2 g or more of cefazolin for adults and ≥30 mg/kg of cefazolin for paediatric
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patients, not to exceed the adult dose. The target is that either dose is used in at
least 95 percent of procedures. All five DHBs performing cardiac surgery for adult or
paediatric patients achieved this target.
Process marker 3 is ‘skin preparation’, which requires use of an appropriate skin
antisepsis in surgery using alcohol/chlorhexidine or alcohol/povidone iodine. The
target is 100 percent of procedures achieving this marker. Auckland DHB for
paediatric patients, Capital & Coast DHB, Southern DHB and Waikato DHB achieved
this target.
The outcome marker is the surgical site infection rate. In quarter 3, there were 31
surgical site infections of 637 procedures, an infection rate of 5 percent.
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Safe surgery
This is the second report for the safe surgery QSM, which measures levels of
teamwork and communication around the paperless surgical safety checklist.
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 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.
Nine out of 20 DHBs achieved 50 audits for all three parts in quarter 4, 2016, an
increase of one compared with the previous quarter (see Figure 12).
13
Uptake (all components of the checklist were
reviewed by the surgical team) rates are only
presented where at least 50 audits were
undertaken for a checklist part. Uptake rates were
calculated by measuring the number of audits of a
part where all components of the 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.
Five of the nine DHBs achieved the 100 percent
uptake target in at least one part of the checklist
(see Figure 13).
14
The levels of team engagement with each part of the checklist were scored using a
seven-point Likert scale developed by the World Health Organisation. A score of one
represents poor engagement from the team 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, Auckland DHB and
Wairarapa DHB achieved the target in all three parts and four other DHBs achieved
the target in one or two parts. As this is only the second quarter in which DHBs have
measured the impact of the safe surgery programme, the focus is still on embedding
the programme and the auditing method. Better results are expected in subsequent
quarters.
The postoperative sepsis rate and the deep-vein thrombosis/pulmonary embolism
(DVT/PE) rate are the two outcome markers for safe surgery. These rates fluctuated
over time. To understand the factors driving these changes and to provide risk15
adjusted outcomes in the monitoring and improvement of surgical quality and safety,
we have developed a risk-adjustment model7 for these two outcome measures.
This model is used to identify how likely patients being operated on were to develop
sepsis or DVT/PE based on their conditions, health history, the operation being
undertaken and so forth. From this, we can calculate how many patients we would
have predicted develop sepsis or DVT/PE based on historic trends. We can then
compare how many actually did to create an observed/expected (O/E) ratio. If the
O/E ratio is more than 1 then there are more sepsis or DVT/PE cases than expected,
even allowing for the risk of the patient. A ratio of less than 1 indicates fewer sepsis
or DVT/PE cases than expected.
7
In the logistic regression model, postoperative sepsis or DVT/PE is the dependent variable. The health and
clinical conditions within 12 months prior to the surgical room procedure, the information about the surgical room
procedure and the demographic information of the patient are the independent variables. A stepwise SAS
procedure is used to select significant factors. The final model shows that the most significant factors are
information about the surgical room procedure, patients admission type, health and clinical conditions in the 12
months prior to the surgical room procedure, such as the clinical complicity level. The Charlson comorbidity score
and intensive care unit stay of the patient in hospital events in that period are also important. Some demographic
characteristics also play important roles. Based on those risk factors, a predicted probability of sepsis or DVT/PE
is calculated for each room procedure, then it is summed as an expected number of sepsis or DVT/PE over time.
An O/E ratio is calculated using observed number divided by expected number per month.
16
Figure 15 shows the sepsis risk adjustment model results in three charts. The first
chart shows the observed number of sepsis fluctuated overtime, especially during
2016. The second chart compares the observed rate and expected rate by
controlling the impact from the changes in the number of operations, which shows
the observed rate is higher than the expected rate in the same period. The last chart
is the control chart of the O/E ratio, which shows 11 consecutive points above 1
since December 2015. It shifts the average of O/E ratio from 1.01 to 1.14 and
indicates a statistically significant increase in observed number of sepsis in 2016,
even after taking into account of the increasing number of high-risk patients treated
by hospitals and more complex procedures undertaken by hospitals. Further analysis
at the DHB level will be needed in the near future.
17
Figure 16 shows the DVT/PE risk adjustment model results in three charts. Using the
same methodology as above, there were 17 consecutive points below 1 shown by
the O/E ratio control chart at the bottom. It reduced the average O/E ratio from 0.98
to 0.88, which indicates a statistically significant decrease in the observed number of
DVT/PE since May 2014, taking into account of the increasing number of high-risk
patients treated by hospitals and more complex procedures undertaken by hospitals.
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Medication safety
The QSM 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 17: 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
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Figure 18: 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
33
14
60%
50%
97%
87%
26%
Structure 2:
Number and
percentage of
relevant wards with
eMR implemented
Waitemata Canterbury
DHB
DHB *
* Preliminary results from Canterbury DHB
Within the five DHBs that have implemented eMR, Northland DHB, Taranaki DHB
and Canterbury DHB are able to produce the results of these process measures.
The other two DHBs are in the process of system upgrades or tests and will be able
to report in the near future.
Figure 19: Process markers, eMR
Northland
DHB (%)
Taranaki
DHB (%)
Canterbury
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
64
39
6*
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
16
5*
68
47
9*
Process marker
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
* These numbers are low in Canterbury DHB and reflect that eMR was not fully implemented
during this quarter, paper based MR was still occurring on wards where eMR was available.
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