The links below will take you to quality and safety marker (QSM) information for the October–December 2016 quarter. You can download the full October–December QSM results (1.3 MB, pdf) or view the commentary and interactive charts below.

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)

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

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 been 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 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.

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 $47,000[4] 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 facility, the reduction in falls represents $2.5 million in total avoidable costs since January 2016. 

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.

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 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 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
  • Lower group: < 80 percent
Process measure 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
Process measure 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.     

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 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.

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).

SSC poster Dec 2016Uptake (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).

The levels of team engagement with each part of the checklist were scored using a seven-point Likert scale developed by the World Health Organization. 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 risk-adjusted outcomes in the monitoring and improvement of surgical quality and safety, we have developed a risk-adjustment model [7] 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.

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.

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.  

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 

QSMs Oct Dec16 Figure17

Figure 18: Structure markers, eMR implementation

QSMs Oct Dec16 Figure18

Figure 19: Process markers, eMR 

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.

QSMs Oct Dec16 Figure19

Local DHB report

Using the interactive charts (below) to read individual QSM results for each DHB.

  • Use the drop-down box on the homepage below to access a list of DHBs.
  • Select your DHB.
  • Use the tabs along the top to look at reports on falls and SSI over time.
  • Return to the homepage to select a different DHB.
  • Results can be downloaded as a PDF by using the 'download' button on the bottom right of each page.


References

  1. Jones S, Blake S, Hamblin R, et al. 2016. Reducing harm from falls. NZ Med J 129(1446): 89–103.
  2. 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.
  4. de Raad J-P. 2012. Towards a value proposition: scoping the cost of falls. Wellington: NZIER.
  5. Ibid.
  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.
  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.

Last updated 31/03/2017