The links below will take you to QSM information for the October – December 2014 quarter.
Nationally, risk assessments of older patients* remain broadly consistent (91 percent in quarter four compared with 89 percent in quarter three). Of the 20 district health boards (DHBs), 18 assessed 85 percent or more of older patients in quarter four of 2014. 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.)
The number of patients receiving an individualised care plan of all patients at risk has improved to 91 percent compared with 80 percent at baseline.
When assessments and care plans are plotted against each other, there is a trend of movement from the lower end to the higher end in both measurements in quarter four of 2014 compared with quarter three of 2013.
In terms of harm, we compared the number of falls in 2014 resulting in fractured neck of femur, their associated additional bed-days and estimated costs with the baseline in 2012. Fractured neck of femur cases slightly increased between these two periods, resulting in a slight increase in the estimated cost based on a fixed cost per fractured of neck of femur. A major change is the reduction in the additional occupied bed-days associated with these patients. This reduction is due to a combination of there being a few very long stay cases in early 2012, which have not been repeated since, and more short stay patients in 2014.
These figures disguise a disproportionate increase, since the baseline period, in admissions for older people most at risk of falling. This increase indicates there has been no significant change in falls resulting in fractured neck femur in hospital since the Open for better care campaign started in May 2013.
Looking at this month by month to identify a trend, falls resulting in fractured neck of femur remain fairly consistent at 6–12 incidents a month for the first half of 2014. Although the number of falls was more fluctuated in the second half of 2014, it is too early to see any major shift in trend.
The recorded use of the surgical safety checklist remained above 90 percent in quarter four 2014, an increase of more than 20 percent from the baseline. Nearly all DHBs achieved the threshold level, or were not significantly lower than it. However, the paper-based method of data collection for this measure may be contributing to an overly compliance-focused use of the checklist, rather than enhancing team work and communication among surgical teams, as it intends to do. Several DHBs, including Auckland, are trialling a paperless approach to the checklist using a wall poster to prompt discussion. The Commission is considering options to adapt the data collection for this measure, and will consult with DHBs on potential new approaches this year.
There is now enough data to estimate how many cases of postoperative deep vein thrombosis (DVT)/pulmonary embolism (PE) and sepsis were avoided in the last two years compared with the baseline year of 2012. Our calculations suggest there have been 61 fewer postoperative cases of DVT/PE in this period, which led to 1811 fewer bed-days and a $1.4 million reduction in cost. Sepsis rate comparison shows an increase of 138 more cases than would have been expected using 2012 rates, resulting in 725 more bed-days and more than $0.5 million in extra cost.
The very high level of compliance with the insertion bundle continues. Nationally, 96 percent of insertions were compliant with the bundle.
(Note: Wairarapa DHB does not return data for this measure.)
As the following run chart shows, CLAB infections continue to be rare, at well under 1 per 1000 line days.
Based on the initial estimate of CLAB prevalence prior to the introduction of the Target CLAB Zero collaborative, we estimate over 260 CLAB infections have been avoided in two years, at a cost saving of over $5.2 million.
The continued and sustainable success of the CLAB collaborative is remarkable, as good as anywhere in the world. As this level of performance has now been observed for two years, this is the last quarter that CLAB will be included in the quality and safety marker set.
As the Commission uses 90-day outcome measures for surgical site infection, these data run one quarter behind other measures. Information relates to July–September 2014.
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’). This should be happening in all cases, so the Commission has set the threshold at 100 percent. Recent data shows two improvements. Firstly, 13 DHBs achieved 95 percent or higher in the last quarter and, of those, five DHBs met the 100 percent threshold. Secondly, the number of operations where the timing of antibiotic process was recorded increased from 91.5 percent at baseline to 97.1 percent.
Process measure 2: Right antibiotic in the right dose – cefazolin 2g or more
Cefazolin 2g is recommended for routine antibiotic prophylaxis for hip and knee replacements unless 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. The use of 2g or more of cefazolin continues to increase; in the most recent quarter, 11 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. Twelve DHBs achieved the threshold. This is clearly normal practice across DHBs as the national compliance rate of 98 percent attests, an increase from 87 percent at baseline.
After a reduction in infection rates between February and April, the most recent months have seen volatile movement around the long-term trend of 1.2–1.3 infections per 100 operations. We will monitor this trend over the next two quarters to determine whether or not there has been a sustained significant improvement.