Dimension: Patient Care and Treatment

Rationale for measurement

Hip Fracture, which is associated with increasing age, can lead to a significant risk of serious illness and sometimes death. The standard treatment for hip fracture is surgery. It is known that the outcomes for patients are better if surgery is timely i.e. that the surgery happens as soon as possible after admission and when the patient is ready and fit for surgery. This may mean that the patient needs to be stabilised and therefore, there can be a delay between admission and surgery, whether for medical stabilisation of the patient’s co-morbidities, or for administrative / logistical reasons. A delay in surgery can mean that as well as an increased length of hospital stay for the patient, there may also be an associated increased risk of serious illness and death. Based on this evidence the HSE has a target of 95% of emergency hip fracture surgeries to be carried out within 48 hours of admission. Due to small numbers each month rolling 12 month rates are presented.

Measurement methodology and data sources

  • Local HIPE data extrapolated from Hospital Performance Metrics HSE BIU. Supplied one month in arrears.
  • Measurement has changed to only include the cohort of patients who are medically fit and requiring an emergency hip fracture.

Target

  • 85% of emergency hip fractures surgeries are carried out within 48 hours of admission

Performance

Beaumont Hospital

  • Beaumont Hospital performance was above national target for period measured (September 2019 100%)

Connolly Hospital

  • Connolly Hospital performance was above national target for period measured (September 2019 95.5%)

Our Lady of Lourdes, Drogheda

  • Our Lady of Lourdes Hospital performance was above national target for period measured (September 2019 89.0%)

RCSI Hospital Group

  • RCSI HG performance was above national target for period measured (September 2019 94.8%)

National Performance Comparator 

  • nationally this target has not been achieved (Q2 2019 75.2%)
  • from 2019, national data reported on a quarterly basis, one month in arrears

Rationale for measurement

A number of measures are also outlined which reflect the outcomes of care for patients undergoing emergency hip surgery. These reflect the standards outlined in the Irish Hip Fracture Database National Office of Clinical Audit,

  • Standard 1: All patients with hip fracture should be admitted to an acute orthopaedic ward within 4 hours of presentation or brought to the theatre from the ED within 4 hours
  • Standard 2: All patients with hip fracture who are medically fit should have surgery within 48 hours of admission and during normal working hours (Mon-Sun 8:00-17:59),
  • Standard 3: All patients with hip fracture should be assessed and cared for with a view to minimising their risk of developing a pressure ulcer,
  • Standard 4: All patients presenting with a fragility fracture should be managed on an orthopaedic ward with routine access to acute orthogeriatric medical support from the time of admission,
  • Standard 5: All patients presenting with fragility fracture should be assessed to determine their need for therapy to prevent future osteoporotic fractures,
  • Standard 6: All patients presenting with a fragility fracture following a fall should be offered multidisciplinary assessment and intervention to prevent future falls 

Measurement methodology and data sources

  • Local Hospital HIPE data extrapolated for analysis, supplied one quarter in arrears.

Performance

  • National Performance IHFD Data Quarter 4 2018
  • RCSI Hospital Group Performance Local Hospital HIPE Data Quarter 2 2019

Rationale for measurement

Falls particularly in the elderly can lead to an increased time spent in Hospital and in significant health decline. As well as physical injuries suffered, the psychological and social consequences of falling can have a huge impact. Recurrent falls in the elderly can result in long term care, consequently falls prevention is a key area for hospitals. All Hospitals in the RCSI Group are committed to preventing patient falls where possible, and where not possible to minimising their incidence and impact.

Measurement methodology and data sources

  • Number of patient falls associated with Patient death or disability whilst being cared for in a health service facility per 10,000 hospital bed days
  • Local data extrapolated from Hospital Performance Metrics

Targets

  • No patient falls associated with mortality or morbidity whilst being cared for in a health service facility

Performance

  • the average rate of falls reported for 2019 YTD is comparable to the average rate of falls reported for the same period in 2018, except for July, August and September

Rationale for measurement

Bedsores, also called pressure ulcers, are injuries to skin and underlying tissue resulting from prolonged pressure on the skin. Bedsores most often develop on skin that covers bony areas such as heels, ankles, hips and tailbone. Hospitalised and immobile persons can be at risk of pressure sores. Pressure sores can cause pain, poor recovery and lead to serious infections. Pressure sores are graded Stage 1 to 4. At Stage 3, the ulcer is a deep wound with loss of skin and the damage may extend beyond the primary wound and below layers of healthy skin. At Stage 4, the ulcer shows large scale loss of tissue and may expose muscle, bone and tendon. Prevention of Grade 3 and Grade 4 bed sores / ulcers are a marker of good care. The target therefore is to achieve no sores of Stage 3 or higher.

Measurement methodology and data sources

  • Number of Stage 3 or 4 pressure sores per 10,000 hospital bed days
  • Local data extrapolated from Hospital Performance Metrics
  • Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. This stage may include undermining and tunneling.
  • Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. This stage often includes undermining and tunneling. Exposed bone/muscle is visible or directly palpable.

Reference: European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: quick reference guide. Washington DC.

  • Local hospital data (no national comparator data available)

Target

  • No grade 3/4 pressure sores

Performance

RCSI Hospital Group

  • RCSI HG set itself an aim to reduce the incidence of stage 3 and 4 pressure injuries; the incidence within 1 year has reduced by 30%. Oct-19 illustrating a comparative rate to Oct-18 (0.8 Oct-19 v 0.9 Oct-18).

Rationale for measurement

Readmissions rates can be influenced by a variety of factors, including the quality of inpatient and outpatient care, the effectiveness of the care transition and coordination, and the availability and use of effective disease management community based programmes. Whilst not all unplanned readmissions are avoidable, interventions during and after a hospitalisation can be effective in reducing rates (Government of Alberta – Alberta Health Service Plan 2014-2017).

Measurement Methodology and Data Sources

  • local retrospective HIPE data extracted, extrapolated and published by HSE – BIU. Published one month in arrears.

Target:

  • Surgical readmission to same hospital within 30 days  → ≤3%
  • Medical readmission to same hospital within 30 days   ≤11.1%

Performance

RCSI Hospital Group

  • RCSI HG is achieving overall compliance with national target for reporting period

  • RCSI HG is achieving overall compliance with national target for reporting period

Rationale for measurement:

Patients who have been identified as no longer requiring acute medical care i.e. medically fit for discharge, but remain in hospital waiting for provision of Community Home Care, Long Term Care and Rehabilitation are described as experiencing a “delayed discharge”. This delay can result in increased likelihood of hospital acquired infection or a loss of confidence and necessary skills for daily living required for returning home. As well, their ongoing inappropriate accommodation in an acute bed causes resultant delays in accommodating other emergency / elective patient requiring acute hospital accommodation.

Measurement methodology and data sources

  • periodic local data submitted weekly to the BIU for analysis and publication.

Target

  • No more than 112 patients experiencing an inappropriately delayed discharge within the RCSI Hospital Group.

Performance

RCSI Hospital Group

  • target of <112 patients not achieved for reporting period (n=124 October average)
  • 11% increase 2019 / 2018 YTD in the average number of patients experiencing a “delayed discharge
    • 11% increase Oct-19 v Oct-18
      • monthly average of 4240 bed days YTD were inappropriately utilised for accommodation of patients experiencing “delayed discharge” – equating to an acute bed day capacity equivalent to the monthly treatment and accommodation of 606 elective / emergency patients (based on a 7 day average length of stay)

Rationale for measurement:

It is important that every hospital measures and monitors mortality from specific conditions. Over the past two decades in-hospital mortality patterns have been used as one key indicator of quality of care internationally. Standardised Mortality Ratio (SMR) is a commonly used statistical method for examining hospital mortality patterns within a country or within a hospital group. The SMR compares the observed number of deaths to the expected number of deaths for a specific diagnosis.

Measurement methodology: 

Standardised mortality ratio (SMR) is 2018 datasets for:

  • Acute Myocardial Infarction (Acute MI)
  • Ischaemic Stroke
  • Haemorrhagic Stroke

Datasets for Heart Failure and Chronic obstructive pulmonary disease and bronchiectasis currently available for 2018 are for national and county only (and not for Hospital Groups)

Data provided by National Patient Safety Office (National Healthcare Quality Reporting System) in July 2019

Performance

RCSI Hospital Group Acute Myocardial Infarction (Acute MI)

All hospitals in the RCSI Hospital Group had a SMR within the expected range for patients admitted with a principal diagnosis of AMI.

Description: Age-sex standardised in-hospital mortality within 30 days for acute myocardial infarction (AMI) (heart attack) is defined as the number of patients aged 45 and over who die in hospital within 30 days of being admitted with a principal diagnosis of an AMI, as a proportion of the total number of patients aged 45 and over admitted to that hospital with a principal diagnosis of an AMI.

Notes:
Hospitals with small numbers of cases tend to have unstable rates and wider confidence intervals. For this report rates are not displayed for hospitals with less than 100 cases, although the data for these hospitals have been included in the calculation of the national rates. However some hospitals with more than 100 cases may still have unstable rates and caution should be exercised in interpreting rates with wide confidence intervals. The data presented above are age-sex standardised mortality rates per 100 cases. 95% confidence intervals for hospitals and hospital groups are shown by H. Where the 95% confidence interval for a hospital or hospital group overlaps the 95% confidence interval of the national rate (i.e. the dashed green lines), it can be concluded that the rate is not statistically significantly different from the national rate and so is within the expected range. Where the 95% confidence interval for a hospital or hospital group does not overlap the confidence interval of the national rate, it implies that the mortality rate is statistically significantly different from the national rate and is therefore outside the expected range.

There can be many reasons for variations in mortality rates including differences in patient profiles; data quality issues; and differences in the quality of care. Age-sex standardised mortality rates that are statistically significantly higher at the 95% confidence level than the national rate are shown in amber. Rates for all other hospitals and hospital groups are below or within the expected range of the national rate.

Performance

RCSI Hospital Acute Ischaemic Stroke

All hospitals in the RCSI Hospital Group had a SMR within the expected range for patients admitted with a principal diagnosis of Ischaemic Stroke.

Description: Age-sex standardised in-hospital mortality rate within 30 days after ischaemic stroke – caused by a blood clot, is defined as the number of patients aged 45 and over who die in hospital within 30 days of being admitted to hospital with a principal diagnosis of ischaemic stroke, as a proportion of the total number of patients aged 45 and over admitted to that hospital with a principal diagnosis of ischaemic stroke.

Notes:
Hospitals with small numbers of cases tend to have unstable rates and wider confidence intervals. For this report rates are not displayed for hospitals with less than 100 cases, although the data for these hospitals have been included in the calculation of the national rates. However some hospitals with more than 100 cases may still have unstable rates and caution should be exercised in interpreting rates with wide confidence intervals. The data presented above are age-sex standardised mortality rates per 100 cases. 95% confidence intervals for hospitals and hospital groups are shown by H. Where the 95% confidence interval for a hospital or hospital group overlaps the 95% confidence interval of the national rate (i.e. the dashed green lines), it can be concluded that the rate is not statistically significantly different from the national rate and so is within the expected range. Where the 95% confidence interval for a hospital or hospital group does not overlap the confidence interval of the national rate, it implies that the mortality rate is statistically significantly different from the national rate and is therefore outside the expected range.

There can be many reasons for variations in mortality rates including differences in patient profiles; data quality issues; and differences in the quality of care. Age-sex standardised mortality rates that are statistically significantly higher at the 95% confidence level than the national rate are shown in amber. Rates for all other hospitals and hospital groups are below or within the expected range of the national rate.

Performance

RCSI Hospital Haemorrhagic StrokeAll hospitals in the RCSI Hospital Group had a SMR within the expected range for patients admitted with a principal diagnosis of Haemorrhagic Stroke.

Description: Age-sex standardised in-hospital mortality rate within 30 days for haemorrhagic stroke – caused by bleeding, is defined as the number of patients aged 45 and over who die in hospital within 30 days of being admitted to hospital with a principal diagnosis of haemorrhagic stroke, as a proportion of the total number of patients aged 45 and over admitted to that hospital with a principal diagnosis of haemorrhagic stroke.

Notes:
Hospitals with small numbers of cases tend to have unstable rates and wider confidence intervals. For this report rates are not displayed for hospitals with less than 100 cases, although the data for these hospitals have been included in the calculation of the national rates. However some hospitals with more than 100 cases may still have unstable rates and caution should be exercised in interpreting rates with wide confidence intervals. The data presented above are age-sex standardised mortality rates per 100 cases.95% confidence intervals for hospitals and hospital groups are shown by H. Where the 95% confidence interval for a hospital or hospital group overlaps the 95% confidence interval of the national rate (i.e. the dashed green lines), it can be concluded that the rate is not statistically significantly different from the national rate and so is within the expected range. Where the 95% confidence interval for a hospital or hospital group does not overlap the confidence interval of the national rate, it implies that the mortality rate is statistically significantly different from the national rate and is therefore outside the expected range.

There can be many reasons for variations in mortality rates including differences in patient profiles; data quality issues; and differences in the quality of care. Age-sex standardised mortality rates that are statistically significantly higher at the 95% confidence level than the national rate are shown in amber. Rates for all other hospitals and hospital groups are below or within the expected range of the national rate.

Rationale for measurement

A stroke occurs when the blood supply to the brain is interrupted or reduced. This deprives the brain of oxygen and nutrients, which can cause the brain cells to die. A stroke may be caused by a blocked artery (ischaemic stroke) or the leaking or bursting of a blood vessel (haemorrhagic stroke). Thrombolysis is a treatment to dissolve clots in blood vessels, improve blood flow, and thus help prevent damage to tissues and organs. Thrombolysis can be of benefit in patients with acute ischaemic stroke. The window of opportunity for effective thrombolysis is four and a half hours from the onset of the stroke. Therefore within that timeframe, a firm diagnosis of ischaemic stroke must be made.

Measurement methodology and data sources:

Periodic local data extracts extrapolated for analysis and publication

Rationale for measurement

Stroke is known to be a leading cause of disability and death in patients worldwide. Care in a Stroke Unit is provided in hospital by nurses, doctors and therapists who specialise in looking after stroke patients and work as a co-ordinated team. Evidence shows, that patients who receive this type of care are more likely to survive their stroke, return home and become independent in caring for themselves. Hospital based Stroke Units are associated with a reduction in death and institutional care of around 20%, with one additional patient returned to community living for every 20 patients treated (Stroke Clinical Care Programme, 2012).

Measurement methodology and data sources

KPI1 % of acute stroke patients who spend all or some of their hospital stay in an acute or combined stroke unit*

KPI2 For acute stroke patients admitted to an acute or combined stroke unit, the % of their hospital stay spent in the stroke unit*

KPI3 % of patients with confirmed acute ischaemic stroke who receive thrombolysis

The data is recorded at hospital level via a Stroke Portal within the HIPE file and data is collected by clinical staff. The data is reported quarterly to the BIU via the Health Pricing Office and the National Stroke Programme.

*A Stroke Unit is defined by the European Stroke Organisation as: “a geographically discreet area with the capacity to monitor and regulate basic physiological function, access to immediate imaging and is staffed by a specialist multidisciplinary team”.

Targets

KPI1 90% of acute stroke patients are admitted to an acute or combined stroke unit

KPI2 90% of hospital stay for acute stroke patients should be spent in an acute or combined stroke unit

KPI3 12% of patients with confirmed acute ischaemic stroke receive thrombolysis

Performance

2018 YTD is reported against national KPI performance via validated National Stroke Programme data.

  • RCSI Hospitals not achieving target of 90%. National performance not achieving target

  • Cavan Hospital (98%) and OLOL (90%) achieving target of 90%. National performance not achieving target (68%)

  • RCSI Hospitals not achieving target of 12%. National performance not achieving target