CLINICAL INDICATORS.pptx

Clinical indicator

1. CLINICAL INDICATORS PRESENTED BY: Dr. REKHA MULCHANDANI(2010HO027) SNEHA LABHANE(2010HO015)

2. DEFINITION Clinical Indicators can be defined as : AS MEASURES THAT ASSESS A PARTICULAR HEALTH CARE PROCESS OR OUTCOME

3. WHY IS THERE A NEED FOR CLINICAL INDICATORS? The Harvard Medical Practice Study, which reviewed over 30,000 hospital records in New York state, found injuries from care itself (“adverse events”) to occur in 3.7% of hospital admissions, over half of which were preventable and 13.6% of which led to death.

4. Other reasons…… A lack of documentation about how major illnesses are treated in most health care systems A lack of systematic outcome assessment A lack of resource evaluation related to quality for specific diseases; Persisting variations among providers in care for similar patients

5. To identify those clinical indicators which are potentially relevant and appropriate, the following points should be considered Does the indicator measure an important aspect of clinical practice? Will the data collected on this indicator assist in improving clinical care? Will the information be useful and meaningful to clinicians in demonstrating how the service is performing and ways that it may be improved? Will the data be accessible to clinicians to allow for monitoring of the indicator? Are existing resources sufficient to allow for ongoing monitoring of the indicator?

6. CATEGORIES OF CLINICAL INDICATORS

7. RATE-BASED VERSUS SENTINEL INDICATORS A rate-based indicator uses data about events that are expected to occur with some frequency. These can be expressed as proportions or rates (proportions within a given time period), ratios, or mean values for a sample population. A sentinel indicator identifies individual events or phenomena that are intrinsically undesirable, and always trigger further analysis and investigation.

8. EXAMPLES Rate-based indicators      Clean and contaminated wound infection        Numerator: the number of patients who develop wound infection from the fifth post-operative day after clean surgery        Denominator: the total number of patients undergoing clean surgery within the time period under study who have a post-operative length of stay of ≥5 days.      Sentinel indicators      Numbers of patients who die during surgery      Numbers of patients who die during the perinatal period

9. INDICATORS RELATED TO STRUCTURE, PROCESS, AND OUTCOME

10. RISK ADJUSTMENT Factors that are frequently included in risk adjustment models include patient demographic, psychosocial characteristics (such as age, sex, and functional status), lifestyle factors (smoking, alcohol use), severity of the illness that is the focus for measurement, health status, and co-morbid conditions. Risk adjustment is essential before comparing patient outcomes across hospitals or providers

11. GENERIC AND DISEASE-SPECIFIC INDICATORS Generic indicators measure aspects of care that are relevant to most patients, disease-specific indicators are diagnosis-specific and measure particular aspects of care related to specific diseases . Both generic and disease-specific indicators can focus on structure, process, or outcome.

12. HOSPITAL-WIDE INDICATORS MEDICATION SAFETY Documentation of previous adverse drug reactions on the medication chart Error-prone abbreviations in medication orders HOSPITAL READMISSIONS Unplanned and unexpected readmissions within 28 days unplanned readmission rate within 14 days

13. UNEXPECTED RETURNS TO OPERATING THEATRE PRESSURE ULCERS one or more pressure ulcers during their admission A number of patients have pressure ulcers at the time of admission INPATIENT FALLS Inpatient falls Inpatient falls that require intervention Inpatient falls in people aged 65 years and over that resulted in a closed head injury In people aged 65 years and older inpatient falls

14. REVIEW FOLLOWING PATIENT DEATH The proportion of patient deaths that were followed by a clinical audit and review process BLOOD TRANSFUSION Rate for adverse events related to a blood transfusion Informed patient consent was not documented DAY OF SURGERY ADMISSIONS Measure of appropriateness for admission of elective surgery patients on the day of surgery THROMBOPROPHYLAXIS use of prophylaxis for venous thrombo embolism for high risk medical patients

15. Patient safety Return to operating room- rate of unplanned return to OR In patient falls no intervention require some sort of intervention as a result of the fall Head injury in inpatients

16. Infection Control Indicators Surgical site infections Infection Control indicator MRSA infection indicators per 10,000 bed days in ICU Haemodialysis-associated infection surveillancethe infection rate for AV fistula access infections in central lines Neonatal infections first 48 hours following birth, the rate for blood and/or CSF gestational age greater than 37 weeks After 48 hours, the rate for bloodstream infections among low birth weight babies Significant blood infections in the neonatal ICU for babies <1,000 g and babies >1,000 g

17. Volume Indicators : Volume of procedures Bed Occupancy ALOS Mortality

18. Hospital Standardized Mortality Ratio The hospital standardized mortality ratio (HSMR) is a measure of patient safety that compares a hospital's mortality rate with a national standard . The HSMR is a ratio of "observed" to "expected" deaths, multiplied by 100. A ratio greater than 100 means more deaths occurred than expected, while a ratio less than 100 suggests fewer deaths occurred than expected. Therefore, hospitals want to have an HSMR below 100.

19. DEPARTMENT SPECIFIC indicators

20. NURSING-SENSITIVE INDICATORS The structure of nursing care is indicated by the supply of nursing staff, the skill level of the nursing staff, the education/certification of nursing staff . Process indicators measure aspects of nursing care such as assessment, intervention, and RN job satisfaction. Patient outcomes that are determined to be nursing sensitive are those that improve if there is a greater quantity or quality of nursing care (e.g., pressure ulcers, falls, and intravenous infiltrations).

21. .. contd Some patient outcomes are more highly related to other aspects of institutional care, such as medical decisions and institutional policies (e.g., frequency of primary C-sections, cardiac failure) and are not considered "nursing-sensitive". Nursing Hours per Patient Day    Registered Nurses (RN) Hours per Patient Day Unlicensed Assistive (UAP) Hours per Patient Day Nursing Turnover  

22. .. contd Nosocomial Infections  Patient Falls   Patient Falls with Injury   Injury Level Pressure Ulcer Rate Community-acquired Hospital-acquired Unit-acquired Paediatric Pain Assessment, Intervention, Reassessment (AIR) Cycle

23. .. contd Paediatric Peripheral Intravenous Infiltration Registered nurses Survey Job Satisfaction Scales Practice Environment Scale (PES)  Restraints  Additional Data Elements Collected: Patient population – Adult or Pediatric . Hospital Category, e.g. Teaching, Non-teaching, etc. Type of Unit (Critical Care, Step-Down, Medical, Surgical, Combined Med- Surg , Rehab & Psychiatric). Number of staffed beds designated by the hospital

24. SURGICAL SAFETY CHECKLIST Before the patient receives anesthesia , (briefing) Before the incision, (surgical pause), Before the patient leaves the OR ( debriefing), patient safety communication tool used by the operating room team to facilitate team discussion and ensure that everyone is familiar with the case, reducing reliance on memory for certain necessary interventions. Improved patient care and safety , D ecreased complications and deaths from surgery Better OR efficiency .

25. OPTHOMALMOLOGY SURGERY Total No. of readmissions (related to the operated eye)within 28 days of discharge following surgery / Total number of patients having cataract surgery. Total no. of pats. having an unplanned readmission within 28 days of discharge following surgery , due to endophthalmitis in the operated eye/ Total number of patients having cataract surgery during the 6 month time period.

26. .. contd CATARACT Total No. of pats. having a discharge intention of 1day, who had an overnight admission following surgery/ Total number of pats. having surgery Retinal detachment surgery Total number of patients with a LOS greater than 4 days following surgery/ Total no. of pats. having surgery GLAUCOMA surgery Total number of patients with a LOS greater than 3 days following glaucoma surgery / Total no. of pats.having surgery

27. .. contd REFRACTIVE SURGERY Total No. of pats. having a discharge intention of 1day, who had an overnight admission following surgery/ Total number of pats. having surgery during the 6 month time period

28. EMERGENCY DEPARTMENT Emergency Department waiting times Treatment of acute myocardial infarction (AMI) Access block (MORE THAN 8 HRS) Overall   Length of Stay (hours)   < 2:35 Admitted   Length of Stay (minutes) <253 Left Without Being Seen  <2% Triage to RN Evaluation < 30 min Triage to MD Evaluation <30 min.

29. DAY SURGERY Patient fails to arrive Procedure cancelled after arrival due to preexisting medical conditions Unplanned return to OR during the same admission. Unplanned transfer following a procedure Delay in patient discharge

30. GYNAECOLOGY Injury to major viscera during lap surgery eg . bladder, ureter , % of recieving Lap management of ectopic pregnancy Urogynaecology : - Injury to major viscus during pelvic floor surgery Antibiotic prophylaxis prior to hystrectomy (95%) Blood transfusion following gynaecology sg for benign disease

31. OBSTETRICS Vaginal delievery following previous C-section Appropriate antibiotic prophylaxis for Cosection Appropriate thromboprophylaxis for high risk women for C-section Peer review of serious adverse event % of induction of labour % of spontaneous vaginal births % of instumental vaginal delieveries % of C-SECTION % of having perineum following vaginal births

32. .. contd % of who underwent episiotomy &had no tear % of vaginal birth with perineal tears without episiotmy % of vaginal birth with perineal tears with episiotmy % of required Surgical repair of 3 rd degree tear % of required Surgical repair of 4 th degree tear Management of C-section % with general anaesthesia Rate of Postpartum haemorrhage for VAGINAL &C-section. Rate of term babies transferred to NICU Rate of IUGR

33. INTERNAL MEDICINE Endocrine diseases-rate of insulin treated diabetic pat. experiencing blood sugar level < 4mmol/l preoperative & postoperatively. Neurological disease - propotion of inpatient with a discharge diagnosis of stroke who also had CT-SCAN Aged pats.-% of pats. For whom there is documented assessment of mental functions Rate of assessment of physical functions Success rate of PTCA with or without Stenting

34. .. contd CVS : Patient with AcMI should receive thrombolysis within 1 hour of presentation to the hospital Proportion of pats. who has CABG within 24 hrs of PTCA RESPIRATORY DISEASES - referral of COPD pats. to chronic disease management Rate for documented objective assessment of asthma severity on initial presentation Rate of ongoing assessment of severity Documented discharge plan for asthma pats.

35. .. contd GASTROINTESTINA L - Proportion of patients Admitted for haematemesis & malaena who received Bloodtransfusion & had Gastroscopry wihin 24hrs Proportion of patients Admitted for haematemesis & malaena who received blood transfusion & subsequently die MEAN Rate of Patients discharged with specific diagnosis Rate for Notification of patients condition

36. .. contd RENAL - % of patients who develop macroscopic haematuria within 24 hrs of renal biopsy Oncology - Proportion of premenopausal pats. withstage II CA breast who has documented evidence of treatment With poly chemotherapy

37. DENTAL The rate for teeth requiring retreatment within six months of restorative treatment was 5.0%. The rates for complications within 7days of routine surgical extraction The proportion of dentures that had to be remade within 12 months Retreatment within 6months of completing a course of endodontic treatment The Rate of completed / updated Medical histories Rate of completed charting at initial assessment for a general course of care

38. PEDIATRICS Immunisation status documented and be offered or given Catch up immunisation, particularly infants less than two years old. The rate for catch-up immunisation given or planned Average length of stay for asthma The rate for Readmission within 28 days of discharge Access block measured by an inability to admit a patient into a paediatric ICU

39. .. contd The rate for deferred or cancelled elective surgery due to a lack of ICU beds. The proportion of patients whose discharge from the ICU was delayed by more than 12 hour Unplanned readmission into the ICU within 72 hours of discharge

40. ICU Nurse - Patient Ratio is 1:1 Hospital acquired infection Doctor patient ratio is 1:12 (ideal ratio is1:5) ICU Utilisation ICU Mortality Adherence to interventions utilisation of patient assessment systems. Access and exit block to the ICU The proportion of patients who were not admitted to an ICU because of inadequate resources

41. .. contd Access and exit block to the ICU Rate of deferred elective surgery due to lack of ICU / HDU beds R ate for transferring patients to another unit due to a lack of ICU beds Intensive care patient management R ates for unplanned readmission to the ICU reflect : less than optimal management of a patient. premature discharge as a consequence of inadequate resources or reflect the standard of ward care.in 72 hours

42. .. contd Intensive care patient treatment Proportion of patients receiving thromboembolism prophylaxis within 24 hours of admission to the ICU

43. GENERAL SURGERY Delay in elective cases-around 15-30 minutes Case cancellation rate on day of surgery- 4-5 per month(4/199=2%), reasons being patient refusal, unwilling. Pac reviewed on table and patient not fit, due to bad weather patient does not turn up. Turn over time for set up & cleaning (mean time from previous patient out to next patient in) is10-30min .

44. .. contd Prediction bias about duration of case Pre-operative & Post operative stay-10-15 minutes Readmission within 2 weeks

45. .. contd The rate of bile duct injury requiring operative intervention following laparoscopic cholecystectomy Orthopaedic surgery The proportion of patients having a total hip replacement who had a post-operative infection Vascular surgery - Elective abdominal aortic aneurysm (AAA) reported each year Cardiothoracic surgery The death rate for coronary artery graft surgery (CAGS) Neurosurgery - The neurosurgical infection rate

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