The links below will take you to QSM information for the April – June 2015 quarter.
- Safe surgery (previously perioperative harm)
- Hand hygiene
- Surgical site infection
- Medication safety
Nationally, 93 percent of older patients* were given a fall risk assessment in quarter 2, 2015. This is 17 percentage points higher than the baseline level of 76 percent in quarter 1, 2013. Compared with the previous quarter, one more DHB achieved the 90 percent threshold, increasing the total number of DHBs achieving this to 14. Lower achievement levels are reducing.
*Patients aged 75+ (55+ for Māori and Pacific peoples)
(Note: for this update, baselines and the most recent two quarters are shown for all tables.)
About 90 percent of patients at risk of falling received an individualised care plan. This measure has remained broadly consistent at 90 percent or above since quarter 2, 2014. Some reduced achievement levels are noticeable in this latest quarter, which have been impacted by seasonal patient flows, transition to new documentation protocols and inconsistencies in data collection being addressed.
When assessments and care plans are plotted against each other, a trend of movement over time from the bottom left corner to the top right corner is shown. Compared with only four DHBs sitting at the top right corner in quarter 3, 2013, in the current quarter, more than half of DHBs are in this ‘ideal’ box.
There were 81 falls resulting in fractured neck of femur in the 12 months ending June 2015. This is significantly lower than the 106 falls we would have expected in this year given the falls rate observed in the period from July 2010-June 2012.
The precise cost of in-hospital falls with a fractured neck of femur is difficult to estimate. We have to date used a cost of $27,000 per incident. However, we have become increasingly concerned that this is too conservative an estimate and we have been underestimating the cost. In short, this figure covers little other than the excess hospital stay and does not consider the additional costs of diagnosis, repair and rehabilitation. Having revisited the literature on this we have decided to use a more comprehensive estimate of $47,000 cost for a fall with a fractured neck of femur. Using this estimate, the reduction in falls noted above would result in $1.2 million savings.
However, this itself may be too conservative an estimate, as it assumes that all patients who fall and break their hip in hospital return home. We know that at least some of these 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. If only 20 percent of the avoided falls would have entered aged residential care, the total avoided costs associated with the reduction in falls would have been $1.6m.
This sustained significant decrease during December 2014 to June 2015 is also shown in the run chart below. The median of monthly falls reduced from eight to five, the first time this outcome marker has shown a significant improvement.
Safe surgery (previously perioperative harm)
The recorded use of the surgical safety checklist reached 97 percent in quarter 2, 2015, an increase of 26 percentage points from the baseline. Almost all DHBs showed an improvement in this measurement since 2013.
Auckland DHB is currently moving from using audit forms to a direct observation process. This has the advantage of allowing us to know how well the checklist is enabling improved surgical teamwork and communication and represents a step in the right direction.
The current measure requiring DHBs to report compliance with all three parts of the surgical safety checklist has now been retired and DHBs no longer need to report on it. A new QSM aimed at measuring levels of teamwork and communication will be rolled out during the 2015–16 financial year. The first public reporting will be in November 2016 on data for quarter 3, 2016.
Compared with the baseline year of 2012, we estimate there have been 81 fewer postoperative cases of deep vein thrombosis/pulmonary embolism (DVT/PE), resulting in 2793 fewer bed-days and a $2.2 million reduction in costs. However, there has been an increase of 225 more postoperative sepsis cases than would have been expected using 2012 rates, resulting in 2311 more bed-days and more than $1.8 million in extra costs. Overall, additional bed-days and costs across the two measures have reduced. We are planning a review on the current outcome assessment method. We believe that increasing number of patients more at risk of suffering complications are being operated upon, and that this is likely to distort the results. However we need to reliably quantify this effect.
National compliance with the five moments for hand hygiene continues to increase. DHBs achieved an average of 80 percent in quarter 2, 2015, which is the national target. Almost all DHBs met or came close to the target. All DHBs once again submitted 100 percent or more of the required hand hygiene data in this period.
Comparisons between the performance of different DHBs should be made with caution due to differences between the auditing process at individual DHBs, including the range of ward types audited, the composition of the various hand hygiene ‘moments’ collected, and the proportion of ‘moments’ collected for different professional groups.
The run chart below shows the monthly national average for healthcare associated Staphylococcus aureus bacteraemia per 1000 bed-days. This measure still fluctuates considerably month-by-month, with no signs of a significant shift.
As the Commission uses 90-day outcome measures for surgical site infection, these data run one quarter behind other measures. Information in this section relates to quarter 1, 2015.
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 be happening in all cases, the threshold is set at 100 percent. In quarter 1, 2015, 96 percent of hip and knee arthroplasty procedures were given an antibiotic within 60 minutes before ‘knife to skin’, an increase of two percentage points from the previous quarter. It has remained broadly consistent at 94 percent or above since quarter 2, 2014.
Process measure 2: Right antibiotic in the right dose – cefazolin 2g or more or cefuroxime 1.5g or more
The Surgical Site Infection Improvement Programme has recently decided that 1.5g or more of cefuroxime is an acceptable alternative to cefazolin 2g or more for routine antibiotic prophylaxis for hip and knee replacements. This change has been included in the QSM in this report. In some instances, the patient has a beta-lactam allergy and requires a non-beta-lactam antimicrobial agent, or is colonised with multi-resistant Staphylococcus aureus, in which case they should receive both cefazolin and vancomycin. To allow for these relatively rare instances, the threshold is set at 95 percent.
In quarter 1, 2015, 95 percent of hip and knee arthroplasty procedures were given the right antibiotic in the right dose. It was the first time this measurement met the target. There was a six percentage point increase compared with the last quarter. A three percentage point increase was due to accepting cefuroxime and another three percentage point increase was due to more procedures being given cefazolin 2g or more. Sixteen DHBs reached the threshold level compared with only three in the baseline quarter.
Process measure 3: Appropriate skin antisepsis in surgery using alcohol/chlorhexidine or alcohol/povidone iodine
Skin preparation involving either chlorhexidine or povidone iodine in alcohol should occur on all occasions, so the threshold is set at 100 percent. Sixteen DHBs achieved the threshold. Appropriate skin antisepsis is clearly normal practice across DHBs as the national compliance rate of 99 percent attests, an increase from 87 percent at baseline.
In quarter 1, 2015, DHBs performed 2502 hip and knee arthroplasty procedures, which increased by 6 percent (152 procedures) compared with the same quarter last year. Within those, there were 25 surgical site infections; the infection rate was 1.0 percent, which dropped from annual average of 1.2 percent in 2014. But there is no sign yet of a significant change.
We introduced a quality and safety marker for medication safety in September 2014. It focuses on the task of medication reconciliation – a process by which health care professionals ensure all medicines a patient is taking and their adverse reaction history are accurately documented and the information used across the health care continuum. An accurate medicine list allows it to be reviewed to ensure they are appropriate and safe and to document which should be continued, stopped or temporarily stopped. Doing this reduces the risk of medicines with potentially dangerous interactions being prescribed.
A key first step to allow medication reconciliation to be done routinely and in a more straightforward manner is the introduction of an electronic system, known as electronic medication reconciliation (eMR). There is a national programme to roll out eMR throughout the country; four DHBs have access to the system currently; six have an expected date for implementation.
Structure: Implementation of eMR
Northland and Taranaki DHBs also use the eMR system to report on the proportion of medication reconciliation undertaken in older patients, who typically, are most likely to benefit from eMR. Waitemata and Counties Manukau are awaiting infrastructure upgrades to enable an updated eMR version with electronic reporting capability, to be installed before reporting process markers.