Moh National Patient Safety Indicators

NATIONAL PATIENT SAFETY

INDICATORS

2009

TECHNICAL SPECIFICATIONS

INDICATOR 1 Mild Head Injury Case Fatality Rate

Discipline : General Surgery

Quality DimensionArea of Concern

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EFFECTIVENESS Head Injury Management

Rationale :

Head injury is one of the leading causes of morbidity and mortality in Malaysia. It is unacceptable for patient admitted with mild head injury (GCS 13-15) to die. This indicator measures the impact of high quality, comprehensive and co-ordinated patient-centred service delivered

Definition of Terms :

Mild Head Injury All patients admitted with a Glasgow Coma Score of 13 or more on first examination by Medical Officer at the Emergency Department

Type of indicator :

Rate-based Outcome indicator It measures the quality of clinical judgement, diagnostic services, resuscitation and other processes of care in the management of head injury.

Numerator :Number of deaths due to mild head injury

Denominator : Number of admissions with a diagnosis of mild head injury

Formula N x 100%D

Standard : Not > 5 %

Comments :

The previous indicator - Head Injury Case Fatality Rate, did not accurately measure the quality of care in head injury patients. This was because there were a number of "fixed" factors contributing to mortality from head injury that could not be adjusted for in determining the quality of care in head injury patients. The previous indicator did not discriminate between factors and problems that were not related to quality of care.

Indicator 2 Incidence of Wound Infection in Clean Elective Orthopaedic Surgery

Discipline : Orthopaedic Surgery


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EFFECTIVENESS & SAFETYTechnical skill in the Internal Fixation of Fractures

Rationale :

Infection of surgical wounds is a significant nosocomial infection problem in hospitals, which in turn is an important issue in patient safety. Timely investigation of higher than expected rates of infection may identify issues relating to preventative factors for corrective action

Definition of Terms

Wound infection Includes both the superficial and deep infection. (CDC guideline).

Clean surgerySurgery in patients with no prior laceration wound at the surgical site or present of wound/sore in the body.

CDC Definitions of surgical site infection (SSI)---

Superficial infection:(i) Involves only the skin and subcutaneous tissue of the

incision And (ii) The patient has at least one of the following:

(a) Purulent drainage from the superficial incision.(b) Organisms isolated from an aseptically obtained

culture of fluid or tissue from the superficial incision.(c) At least one of the following signs or symptoms of infection-.pain or tenderness סlocalized swelling סredness or heat ס superficial incision is deliberately opened by סsurgeon, unless incision is culture-negative

(c) Diagnosis of superficial incisional SSI by the surgeon or attending physician.

Deep infection:

(i) Infection involved deep soft tissues (e.g. fascia and muscle layers) of the incision

AND(ii) The patient has at least one of the following:

(a) Purulent drainage from the deep incision but not from the organ/space component of the surgical site.

(b) A deep incision spontaneously dehisces or is

deliberately opened by a surgeon when the patient has at least one of the following signs or symptoms (unless incision is culture-negative):fever (>380C) סlocalized pain or tenderness ס

(c) An abscess or other evidence of infection involving the deep incision is found on direct examination, during reoperation, or by histopathologic or radiologic examination

(d) Diagnosis of deep incisional surgical site infection by a surgeon or attending physician.

Note: Do not count stitch abscesses (minimal inflammation and

discharge confined to the points of suture penetration), or a localized stab wound infection as a surgical site infection.

If the incisional site infection involves or extends into the fascia and muscle layers, report as a deep incisional SSI.

An infection that involves both the superficial and deep incision sites should be classified as a deep incisional surgical site infection.

Cut-off point for SSI

The cut -off point to be considered SSI is 3 months post-surgery.Therefore, all the clean elective operative patients must be seen/reviewed at around 3 months post-op.

Type of indicator : Rate-based Outcome indicator

Numerator : No of clean elective orthopaedic wound infection

Denominator : Total no. of clean elective orthopaedic surgery

Formula :Numerator__ x 100%

Denominator

STANDARD : Less than 3 %

Indicator 4: Unplanned Return to the Operating Room / Theatre within 24 hours of Surgery

Discipline : Orthopedic Surgery

Quality Dimension

Area of Concern

:

:

Effectiveness & Safety

In-patient care of Orthopedic patients undergoing surgery

Rationale :Unplanned return to OT is usually due to complications of a surgical procedure. It could be life threatening and/or increase morbidity.

Cases : Any immediate post-op complications that may cause ischaemia, excess bleeding or neurological deficit.

Type of indicator :Rate-based Outcome indicator measuring the quality of surgical performance in the operating theatre as well as subsequent post-operative management of the patient undergoing surgery

Numerator : Total no of post-op complications that require immediate operative intervention to reduce mortality and morbidity

Denominator : Total number of orthopedic surgeries performed

Formula : Numerator__ x 100%

Denominator

Standard :

< 1%

Indicator 5 Safe Performance of Percutaneous Nephrolithotripsy (PCNL)

Discipline : Urology

Quality Dimension

Area of Concern

:

:

Safety

PCNL

Rationale :

Endourological or minimally invasive Urological procedures form the bulk of present day Urological practice. PCNL is the major Urological procedure performed for the treatment of large or complex renal stones. As Urolithiasis forms 60-70% of Urological practice in Malaysia, the safe performance of this procedure is an accurate reflection of the quality of care in Urology.

Definition of terms

The safety in the performance of PCNL is defined in terms of absence of either one or more of the following complications:

Septicaemia Bleeding requiring transfusion of 2 or more units of

blood Pleural injury Injury to adjacent organ e.g. lung, bowel Wound infection Unplanned admission to ICU

Exclusion Criteria Morbidity not caused directly by the procedure


Numerator : Number of PCNL cases performed safely

Denominator : Total number of PCNL performed

Formula : Numerator__ x 100%Denominator

STANDARD : > 85%

Indicator 6 Safe Performance of Transurethral Resection of the Prostate (TURP)


Quality Dimension

Area of Concern

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Safety

TURP

Rationale :

Transurethral resection of the prostate (TURP) is the gold standard surgical treatment for Benign Prostatic Hyperplasia (BPH). BPH is predominantly treated by medication and surgery is reserved for severe symptomatic BPH, failure of medical management and in situations where there are complications of BPH such as urinary retention. The safe manner in which TURP is performed is a reflection of the standard of Urological training. It also indicates appropriate case selection and supervision.

Definition of terms

The safety in the performance of TURP is defined by the absence of either one or more of the following complications:

Post op length of stay greater than 5 days Bleeding requiring blood transfusion Return to OT during the same admission Perforation of the prostatic capsule or the bladder TUR syndrome Septicaemia Unplanned admission to ICU

Exclusion Criteria Morbidity not caused directly by the procedure


Numerator : Number of TURP cases performed safely

Denominator : Total number of TURP performed


STANDARD : > 90%

Indicator 7 Safe Performance of Ureterorenoscopy (URS) with Lithotripsy


Quality Dimension

Area of Concern

:

:

Safety

Ureterorenoscopy (URS) with Lithotripsy

Rationale :

Endourological or minimally invasive Urological procedures form the bulk of present day Urological practice. Ureterorenoscopy (URS) with ureteric stone lithotripsy is the commonest Endourological procedure performed. As Urolithiasis forms 60-70% of Urological practice in Malaysia, the safe performance of this procedure is an accurate reflection of the quality of care in Urology.

Definition of terms

The safety in the performance of URS with ureteric stone lithotripsy is defined by the absence of either one or more of the following complications

Post op stay greater than 3 days Septicaemia Any ureteric perforation regardless of management Haematuria persisting for more than 24 hours Ureteric avulsion Unplanned admission to ICU

Exclusion Criteria

Morbidity not caused directly by the procedure. Also excludes

RIRS (Retrograde Intrarenal Surgery) Diagnostic URS Therapeutic URS for other indications such as ureteric

stricture and ureteric tumours


Numerator : Number of Ureterenoscopy (URS) with Lithotripsy cases performed safely x100%

Denominator : Total number of Ureterorenoscopy (URS) and Lithotripsy performed


STANDARD : > 95%

Indicator 8 Occurrence of Post-Tonsillectomy Haemorrhage

Discipline : ENT

Quality Dimension

Area of Concern

:

:

Safety

Tonsillectomy

Rationale :

Tonsillectomy is one of the commonest Otorhino-laryngological surgical procedures and can be conducted by the Specialist as well as trained Medical Officers. It can potentially cause significant morbidity and mortality.

Definition of terms

Haemorrhage occurs after recovery from general anaesthesia .

The haemorrhage shall be objectively identified clinically e.g. : active bleeding or clots on the tonsillar bed Post tonsillectomy haemorrhage includes the following:

Reactionary haemorrhage : bleeding within 24 hours of surgery

Secondary haemorrhage : bleeding after 24 hours of surgery


Numerator : Number of post tonsillectomy haemorrhages occurring in the month

Denominator : Total number of tonsillectomies conducted in the month


Standard : < 5%

Indicator 9 Wound Infection Following Elective Craniotomy for Brain Cancer

Discipline : NeuroSurgery

Quality Dimension

Area of Concern

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Safety

Craniotomy for Brain Cancer

Rationale :

The occurrence of infection following clean neurosurgery operation has undesirable effects. It may implies a less than optimal surgical technique contributing significantly to the infection, which can cause much morbidity

Type of indicator : Rated-based Outcome Indicator

Numerator Total number of patients diagnosed with infected craniotomy wound within hospitalization

Denominator Number of elective craniotomy for brain cancer

Formula : Numerator x 100%Denominator

Standard < 8 %

Indicator 10 Rate of Infectious Endophthalmitis following Intraocular Surgery

Discipline : Ophthalmology

Quality Dimension

Area of Concern

:

:

Safety

Intra Ocular Surgery

Rationale :Infectious endophthalmitis following intraocular surgery has an important bearing on the surgical outcome and is an important reflection of the quality of care provided.

Definition of terms

Infectious endophthalmitis: - Intraocular inflammation judged on clinical grounds to be caused by an infectious process

Intraocular Surgery: - Any ocular surgery where the full thickness of the cornea and /or sclera has been breached, excluding intraocular surgery for penetrating eye injury

Exclusion Criteria Patient with recent penetrating eye injury and those with intraocular foreign body

Type of indicator : Rate-based Outcome Indicator

Numerator :Total number of patients developing post-operative endophthalmitis following intraocular surgery performed

Denominator :Total number of intraocular surgeries performed

Formula : Numerator x 100% Denominator

STANDARD : < 0.2% (2 cases per 1000 operations)*

Note

* Estimated based on the performance world wide for cataract surgery, i.e. 0.1%. In addition this takes into considerations of the constraints within which the local working environment operates as well as performance reflected in the National Cataract Surgery Registry.

Data Collection

The doctor who diagnoses a case of post-operative infectious endophthalmitis should report the incident in a incident reporting form. The form is to be sent to coordinator of national eye database for data entry to electronic cataract surgery registry.Number of intraocular surgery per month is to be obtained from operation book or electronic cataract surgery registry.

Rate to be calculated at the end of the month. Performance is judged every 6 months.

Indicator 11 Rate of Posterior Capsular Rupture during Cataract Surgery)

Discipline : Ophthalmology

Quality Dimension

Area of Concern

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Safety

Cataract Surgery

Rationale :

Cataract surgery is a commonly performed procedure, which should be associated with low morbidity and a short hospital stay.

Posterior capsular rupture is a known intra-operative complication that predisposes to a poor visual outcome and risk of infectious post-operative endophthalmitis. Efforts should be made to minimize this occurrence with good medical and surgical practices.

Definition of termsPosterior capsular rupture – a breach in the posterior capsule of the lens with or without vitreous loss at any point in the performance of cataract surgery.

Type of indicator : Rate-based Outcome Indicator

Numerator : Total number of cases of posterior capsular rupture during cataract surgery performed in a specified month

Denominator : Total number of cataract surgeries performed in the corresponding month.


STANDARD : < 5 % (50 cases per 1000 operations)*

Note* Estimated based on performance reflected in the National Cataract Surgery Registry for the years 2002 – 2004

Data Collection

Doctors who encounter posterior capsular rupture to record it in the cataract surgery registry form, either direct into electronic cataract surgery registry, or hard copy of data collection forms; to be entered into electronic cataract surgery registry later. Number of cataract surgery per month is to be obtained either from electronic cataract surgery registry or from operation book.Rate to be calculated at the end of the month.

Indicator 12 Incidence of Intubation in the Recovery Room

Discipline : Anaesthesia

Quality Dimension

Area of Concern

:

:

Safety

Post-anesthetic care in the Recovery Room

Rationale :The occurrence of adverse events leading to intubation in the post-anaesthetic patient in the Recovery Room (RR) may indicate less than optimal anaesthetic care and performance

Definitions :“Intubation” - Refers to all patients requiring endo-tracheal intubation following anaesthesia in the Recovery Room.

Exclusion criteria Patients operated under sedation OR Local anaesthesia administered by surgeons


Numerator : Total number of patients requiring intubation in the Recovery Room

Denominator : Total number of patients undergoing GA

Formula Numerator__ x 100 %Denominator

Standard : < 0.3%

(Reference: Anaesth & Intensive Care 1996; Vol 24. No 6)

INDICATOR 13 Percentage of Post-operative Patients Leaving the Recovery Room with Pain Scores of > 4


Quality Dimension

Area of Concern

:

:


Patient Management in the Recovery Room

Rationale :

All post-operative patients (receiving GA) should receive adequate and effective analgesia. Pain scores of > 4 indicates inadequate management of post-operative pain.

Definitions

Pain scores are determined by the Recovery Room nurse just before the patient leaves the Recovery Room

Pain scores are measured according to the Numerical Rating scale of 0 to 10 (0 refers to no pain and 10 refers to worst pain imaginable)


Numerator : Total number of patients leaving the recovery room (RR) with pain scores > 4

Denominator : Total number of patients undergoing surgery (and receiving GA)

FormulaNumerator__ x 100 %Denominator

Standard : < 10%

Indicator 14 Percentage of Patients Awaiting Emergency Surgery for more than 24 hours



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Efficiency & Equity of AccessEmergency Surgery Waiting Time

Rationale : Emergency surgery has to be done as early as possible in order to reduce morbidity and mortality and potentially public complaints

Definitions

Duration of waiting time = from the time the patient is ready for operation to the time the operation takes place

Patients who are postponed by surgeons for whatever reason/s will have the time adjusted to the time of rebooking

Type of indicator : Rate-based Process indicator

Numerator :Total number of patients who waited more than 24 hours for emergency operation under anaesthesia

Denominator :Total number of patients undergoing emergency operation under anaesthesia

Formula Numerator X 100%Denominator

Standard : < 1%

INDICATOR 15 Incidence of Massive Primary Post-partum Haemorrhage (PPH)

Discipline : Obstetrics & Gynaecology

Quality Dimension

Area of Concern

:

:

Efficiency & Effectiveness

Obstetric Care

Rationale :

This indicator reflects the EFFICIENCY of labour management and the EFFECTIVENESS of interventional measures. It is proposed as an indicator of the quality of obstetric care because:

PPH is the leading cause of maternal death Prompt management of PPH should avert massive PPH (with its

attendant higher morbidity and mortality)It reflects the effectiveness of a multi-disciplinary approach in the management of this obstetric emergency

PPH is often under reported in most hospitals which reflects the problem in recording the types of obstetric complications in the present data system.


Massive PPH :

Blood loss of more than 1.5 litres

Exclusion Criteria: Cases of PPH occurring as a result of deliveries outside of

Government hospitals

Type of indicator:

Rate based Outcome Indicator

Numerator : Number of cases of Primary PPH with blood loss > 1.5 liters

Denominator : Total number of deliveries

Formula :Numerator x 100%Denominator

Standard : Not more than 0.5 % of total deliveries

Comments :As PPH remains the leading cause of maternal mortality, an indicator measuring the effectiveness and efficiency of care in this condition is proposed as an NIA

INDICATOR 16 Incidence of Recurrent Eclamptic Fits Occurring After Hospital Admission


Quality Dimension

Area of Concern

:

:

EFFECTIVENESS

In-Patient Obstetric Care

Rationale :

This indicator was selected as a generic indicator of the quality of in-patient care in obstetrics because:- With prompt and effective management on admission,

recurrent fits should not occur. The recognition of the severity of the condition is essential for

subsequent management and outcome of the condition. Morbidity and mortality from eclampsia can be reduced


Eclampsia

Recurrent fits

As per ICD classification

The occurrence of fits on MORE THAN ONE occasion in the hospital

Exclusion Criteria : Cases occurring at home or at health centres

Type of indicator : Rate-based Process Indicator

Numerator : Number of eclampsia patients experiencing more than one fit in hospital

Denominator : Nil

Formula :

Numerator only

Standard : Sentinel event

Comments

This indicator was created to measure the timeliness (promptness) and effectiveness of the management of eclamptic patients after admission. The recognition of its severity is important in preventing further morbidity and mortality. Recurrent fits carry a high rate of morbid sequelae and mortality.

INDICATOR 17 Death Due to Heart Disease in Pregnancy


Quality Dimension

Area of Concern

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:

EFFECTIVENESS & APPROPRIATENESS

Pre-pregnancy Care

Rationale :

This indicator was selected as a generic indicator of the quality of obstetric care because:-

Heart disease is the leading cause of indirect maternal deaths Maternal death due to heart disease is preventable with early

recognition and “combined care” management

Definition of Terms : Maternal death from heart disease

As determined by the attending doctor

Type of indicator : Outcome Indicator

Numerator Number of deaths due to Heart Disease in Pregnancy

Denominator : Nil

Formula :Numerator only

Standard : NO DEATHS (Sentinel event)

Comments :

Using such an indicator will emphasise fertility regulation and prevention as a strategy in the elimination of deaths. There has already been a recommendation that a statement to advise the doctor early regarding pregnancy be inserted in the appointment cards of all female patients in medical out-patient clinics.

INDICATOR 18 Occurrence of Urinary Tract Injury Following Hysterectomy



:

:

Efficiency & Effectiveness

Obstetric Care

Rationale :

This indicator looks at safety and competency in obstetrical and gynaecological surgery. It measures the quality of care provided to patients undergoing the common major Gynaecological surgery of hysterectomy (abdominal, vaginal or laparoscopic) and includes Obstetric Hysterectomies.Injuries to the urinary tract are a known complication but can be avoided by adequate pre-operative assessment, good surgical techniques, knowledge of normal and abnormal anatomy as well as a multi-disciplinary approach in appropriate cases. Good care in avoidance of such injuries will avert a medico-legal scenario.


Urinary tract injuries :Urinary tract injuries to be defined as anatomical disruptions to the ureter, bladder and urethra

Inclusion Criteria :Patients who present during the same admission or in another admission to the same hospital.

Exclusion Criteria:

Patients who are admitted to a hospital with urinary tract injuries following hysterectomy done at a different hospital to the one they are presently admitted to

Cases of urinary tract injury as a result of hysterectomy done outside of Government hospitals

Type of indicator : Rate based Outcome Indicator

Numerator :Number of patients with urinary tract injuries following hysterectomy

Denominator :Total number of obstetrical and gynaecological hysterectomies performed

Formula : Numerator x 100%

Denominator

Standard : Not more than 1 %

Comments :This new indicator is relevant to the current-day scenario of increasing medico legal implications for Obs./Gyn. Services

INDICATOR 19 Acute Coronary Syndrome Case Fatality Rate

Discipline : Medical

Quality Dimension:Area of Concern :

: EFFECTIVENESS In patient care for patients with Acute Coronary Syndrome (ACS)

Rationale : Acute Coronary Syndrome is a frequent cause of hospital death in Malaysian Government hospitals


Acute Coronary Syndrome (ACS)

:

Includes patients with ST Elevation Myocardial Infarction (STEMI),Non-ST Elevation Myocardial Infarction (NSTEMI) and unstable angina

Diagnosis of Acute Coronary Syndrome is in accordance with the National CPG.

Type of indicator :

Rate-based Outcome indicator. It measures the: standard of care e.g. clinical decision-making and treatment management of resources e.g. CCU

Numerator Number of DEATHS from Acute Coronary Syndrome

Denominator Total number of CASES of Acute Coronary Syndrome

Formula Numerator x 100%Denominator

Standard : < 20 %

Comments :

For ICD 10 coding, the following should be adopted:

1) unstable angina I202) acute myocardial infarction (STEMI or NSTEMI) I21

INDICATOR 20 Percentage of Patients with Ischemic Stroke Treated with Anti-platelet Therapy within 48 hours

Discipline : Medical

Quality Dimension

Area of Concern

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EFFECTIVENESS

In-patient medical care

Rationale :Stroke is a major cardiovascular event. Cardiovascular disease is the leading cause of death. Stroke accounts of 11.97 per 100, 000 population in MOH hospitals in 2002


Ischemic Stroke : As per clinical judgement of Medical specialist


Numerator : : Total number of patients with Ischemic stroke treated with Anti-platelet therapy within 48 hours of clinical diagnosis

Denominator : : Total number of patients with Ischemic stroke


Standard : > 80% of patients (with Ischemic stroke) treated with Anti-platelet therapy within 48 hours

INDICATOR 21 Community-Acquired Pneumonia Death Rate in Previously Healthy Children aged from > 1 month to < 5 years

Discipline : Paediatric Medical

Quality Dimension

Area of Concern

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:

EFFECTIVENESS

In-patient care of children with pneumonia

Rationale :

Community-acquired Pneumonia is a common childhood condition whose severity and frequency may be decreased by careful management planning.

This indicator is a measure of the OUTCOME of care of children with pneumonia.


Pneumonia Definition of pneumonia as per ICD 10. Decided by the doctor based on clinical findings as well as the relevant investigations


Numerator : Number of deaths due to Community-Acquired pneumonia for age > 1 month to < 5 years

Denominator : Number of cases admitted for Community-Acquired pneumonia for age > 1 month to < 5 years


Standard:

< 2.5%

Indicator 22 Mortaliy of Very Low Birth Weight (VLBW) Infants 1000 grams to 1499 grams in Hospitals WITH Neonatologist (s)


Quality Dimension

Area of Concern

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:


In-patient care of very low birth-weight infants

Rationale :

This indicator was selected as an indicator of the quality of neonatal services.

The survival of VLBWs has improved over the years, However, it has been noted that there wide variation in survival of VLBWs among hospitals with and without neonatologists. Care of VLBWs is in the in-patient neonatal ICU setting and is related to resource allocation.

Definition of Terms

VLBW Very Low Birth weight infants (1000g to 1499 g)

Type of indicator : Rate-based outcome indicator

Numerator : Number of VLBWs 1000g to 1499 g deaths

Denominator : Number of VLBWs 1000g to 1499 g admitted to NICU


STANDARD : < 15 %

Indicator 23 Mortality of Very Low Birth Weight (VLBW) infants 1000g to 1499g in Hospitals WITH PAEDIATRICIAN but WITHOUT Neonatologist(s)


Quality Dimension

Area of Concern

:

:


In-patient care of very low birth-weight infants

Rationale :

This indicator was selected as an indicator of the quality of neonatal services.

The survival of VLBWs has improved over the years, However, it has been noted that there wide variation in survival of VLBWs among hospitals with and without neonatologists. Care of VLBWs is in the in-patient neonatal ICU setting and is related to resource allocation.

Definition of Terms

VLBW Very Low Birth weight infants (1000g to 1499 g)


Numerator : Number of VLBWs 1000g to 1499 g deaths

Denominator : Number of VLBWs 1000g to 1499 g admitted to NICU


STANDARD : < 20 %)

Indicator 24 Dengue Hemorrhagic Fever Deaths in Pediatric cases


Quality Dimension

Area of Concern

:

:


In-patient paediatric care (dengue hemorrhagic fever)

Rationale :

Dengue fever has now become endemic in Malaysia and is a potentially fatal condition whose severity and frequency may be decreased by careful management planning. This indicator is a measure of the OUTCOME of care of patients with dengue fever.


Dengue feverAs per ICD 10. Decided by the doctor based on clinical findings as well as the relevant investigations

Type of indicator : Rate based Outcome Indicator

Numerator : No. of dengue Hemorrhagic fever deaths

Denominator : -

Formula : Numerator only. Any death due to DHF to be investigated

Standard : No deaths

Indicator 25 Death Due To Acute Gastroenteritis In Paediatric Patients


Quality Dimension

Area of Concern

:

:


In-patient paediatric care (Acute gastro-enteritis)

Rationale :

It is perceived as an indicator for both hospital care as well as care in the rural health system and peripheral clinics. Early diagnosis and appropriate management can prevent mortality.


Numerator : Number of acute gastroenteritis deaths

Denominator : -

Formula : Numerator only. Any death due to acute gastroenteritis to be investigated.

Standard : No death

Remarks : Every case should have an Investigation conducted to determine Root Causes in order to prevent future deaths

Indicator 26 Number Of Paediatric Patients Who Are Readmitted To Hospital for Acute Exacerbation of Bronchial Asthma Within 28 Days of Discharge


Quality Dimension

Area of Concern

:

:


In-patient paediatric care (Bronchial asthma)

Rationale :

Asthma is a common childhood respiratory illness where the severity and frequency of attacks can be decreased by careful management. This indicator measures the total care of patients with asthma which includes patient education and drug therapy.

Type of indicator : SENTINEL EVENT outcome indicator

Numerator Number of paediatric patients who are readmitted to hospital acute exacerbation of bronchial asthma within 28 days of discharge

Denominator -

Formula :

Numerator only.

Any readmission due to acute exacerbation of bronchial asthma has to be investigated to determine root causes

Standard : Sentinel event

Indicator 27 Infection Rate of Skin Biopsy Wounds

Discipline : Dermatology

Quality Dimension

Area of Concern

:

:

Safety

Skin Biopsy

Rationale :Skin biopsies are performed for diagnostic or therapeutic reasons. The site where a skin biopsy has been performed can become infected and the infection may produce a poor cosmetic result and morbidity.

Exclusion criteria : Infected skin lesions before biopsy performed


Numerator: Total number of infected skin biopsy wounds in a 6 month period

(Jan-June or July – December)

Denominator : Total number of skin biopsies performed in that 6 month period (Jan-June or July – December)


Standard : Less than 2%

Indicator 28 Peritonitis Rate in Adult patients on Continuous Ambulatory Peritoneal Dialysis (CAPD)

Discipline : Nephrology


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Effectiveness and Safety Continuous Ambulatory Peritoneal Dialysis (CAPD)

Rationale :

Continuous ambulatory peritoneal dialysis (CAPD) is one of the main modes of renal replacement therapy which is found in Nephrology Units in the Ministry of Health (about 24% of all dialysis patients in MOH in 2006). It costs the Ministry of Health RM 31,635 per life year saved in 2001. One of the indicators of safety and efficacy is the peritonitis rate. It is affected by the training of patients, the peritoneal dialysis system used and the long term care of the CAPD patient especially in preventing and treating exit site infection. Peritonitis is the main cause of technique failure. It causes pain, suffering and impacts on the workload of the haemodialysis unit as the patient may have to go on acute or permanent haemodialysis. The indicator is a measure of the work done by CAPD nurses and the clinical care and counseling given to patients in clinic.

Scope : For State hospitals and H. Selayang only (except H. Kangar)

Inclusion criteria:

Patients on CAPD in the unit who are on CAPD for more than 3 months. Peritonitis is defined as 2 of the following 3 criteria: abdominal pain, positive peritoneal fluid culture, white cells in the peritoneal fluid of more than 100 cells per ml. Relapsing or recurring peritonitis is defined as the same bacteria growing in the peritoneal fluid causing peritonitis by the above criteria less than one month after treatment of the original episode has ended

Exclusion criteria:

Patients who have peritonitis at initiation of CAPD training and all patients who were on CAPD less than 3 months. CAPD units with less than 10 patients for the calendar year need not report this indicator


Numerator : Number of peritonitis episodes in patients on CAPD in the calendar year in the CAPD unit

Denominator : Total number of patient days, months and years of treatment on CAPD for the calendar year.

Formula : Numerator Denominator

Standard :less than 1 episode per 24 patient months in adult patients in the CAPD unit (median was 33 months in 2006, 16.1 months min, 102.9 months max)

Indicator 29 Occurrence of Unnatural Death

Discipline : Psychiatric Medicine


: SAFETY In-patient care

Rationale :

With proper evaluation, care and treatment and a safe environment, unnatural death should not occur in a Psychiatric Ward

Definition of Terms : Unnatural Death : Unnatural Death

Any death that occurs in the ward that is due to suicide, homicide or accidental factors

1. Suicide – any deliberate self harm inflicted after admission

to the psychiatric ward/hospital that result in death e.g.

hanging, cutting/slashing, jumping, drowning. etc.

2. Accidental death – fall, choking, drowning, electrocuted,

poisoning etc.

3. Homicide – a patient dies subsequent to an injury inflicted

by another person after admission to the Psychiatric Ward/

hospitals.

A. Any death due to medical reasons is not an unnatural death.

Examples :

1. A patient with diabetic complications is not unnatural death.

2. A patient who dies due to serious side effect such as NMS,

cardiac toxicity. Etc.

3. Death arising from psychiatric intervention such as ECT/

Anaesthesia.

B. Sudden death –

Medico legal - a sudden death is death occurring with no known

medical cause within 24 hours of admission.

CPC – Any death in a “mental asylum/institution” has to be reported

to the police. This does not mean that any death reported to the

police is an unnatural death

Type of indicator : Sentinel Event

Numerator No of deaths

Denominator Not relevant

Formula No death

Standard : Sentinel Event

INDICATOR 30 Percentage of Acute ST Elevation Myocardial Infarction (STEMI) Patients Receiving Thrombolytic Therapy within 30 Minutes of Presentation at the Emergency Department

Discipline : Emergency Department


EFFICIENCY Emergency Department (ED) management of STEMI

Rationale :

Randomised controlled trials have shown that timing of thrombolytic therapy has significant impact on mortality and morbidity of patients with STEMI (ST Elevation Myocardial Infarction). The earlier the reperfusion is achieved, the more myocardial muscle can be salvaged and morbidity will be reduced. Data has shown that thrombolytic therapy administered within 1 hour after onset of chest pain reduced mortality by 23% while thrombolytic therapy administered 3 hours to 6 hours after onset of chest pain reduced mortality by 17%


Door- to-Needle time Time between arrival in Emergency Department and administration of thrombolytic therapy


Numerator :Patients admitted with STEMI who received thrombolytic therapy within 30 minutes of presentation in the Emergency Department

Denominator :Patients admitted with STEMI who received thrombolytic therapy in the Emergency Department

Formula Numerator x 100%Denominator

Standard : More than 70%

Comments :

The previous indicator for the management of AMI i.e. AMI Case Fatality Rate mainly stressed on the final outcome. This indicator will directly assess the quality of standard therapy instituted, which is expected to improve the outcome for AMI patients.Thrombolytic therapy should be made available even at district level, since "Time is myocardium". Protocol /CPG for AMI to be made available and implemented.

TIME should be standardized in the hospitals according to the Clock at the Emergency Department (ED)Suitable candidates will be those recommended by the Malaysian AMI Clinical Practice Guidelines 3.1.1 p 15 & 16

INDICATOR 31 Dispatch and Ambulance Preparedness for Primary Response

Discipline : Emergency Medical and Trauma Services.

Quality Dimension

Area of Concern

EFFICIENCY

Primary Emergency Response Services

Rationale :

Delay in ambulance dispatch and response time may contribute to increased morbidity and mortality. The aim is to reduce the ambulance response time and ensuring an appropriate ambulance response in order to improve pre-hospital care.


Ambulance Calls

All incoming request / calls for emergency medical assistance which require emergency medical services. It must exclude request for inter hospital transfer, patient transportation, secondary response and during disaster situation

Ambulance dispatch : Time taken for the ambulance to leave the hospital to the designated target after the call is received

Preparedness Appropriate ambulance that is capable of providing basic emergency medical and trauma care

Dispatch time :

Time taken for an ambulance to leave the hospital after the call is received .

Dispatch time : less than 5 minutes ( < 5 minutes)

Inclusion criteria Failure to send an appropriate team within the stipulated time is considered a delayed dispatch

Type of indicator : Rate-based Process Indicator.

Numerator : Number of Dispatches with dispatch Time of less than 5 minutes

Denominator : Total Number of Ambulance calls

FormulaNumber of Dispatches with dispatch Time less than 5 minutes x 100%Total Number of Ambulance Calls

Standard : More than 90 %

INDICATOR 32 Inappropriate Triaging (UNDER- TRIAGING): Percentage of Cat. Green Patients Who Should Have Been Triaged As Cat. Red

Discipline : Emergency Medical and Trauma Services


Appropriateness & Safety

Accuracy and Appropriateness of triaging

Rationale :

Triage is an essential function in Emergency Departments (EDs), where many patients may present simultaneously. Triage aims to ensure that patients are treated in the order of their clinical urgency and that their treatment is appropriately timely. It also allows for allocation of the patient to the most appropriate assessment and treatment area. Thus, the Malaysian Triage Category (MTC) has been designed for use in the emergency departments of MOH hospitals’. It is a scale for rating clinical urgency. The scale directly relates triage category with a range of outcome measures (inpatient length of stay, ICU admission, mortality rate) and resource consumption (staff time, cost). This indicator measures the accuracy and appropriateness of the Triaging system in the Emergency Department (ED) to ensure that critically ill patients are not missed and categorized as “non-critical”. Critically ill (MTC Red) patients who are “under triaged” to the lower acuity (MTC Green) category can result in increase morbidity and mortality for the patient.


“Under”- Triaged Critically ill patient (MTC Red) who is triaged as non critical (MTC Green)

MTC Malaysian Triage Category (MTC), please see appendix

Type of indicator : Rate-based process indicator

Numerator : Number of “under-triaged” patients (“Green” Patients who should have been “Red”)

Denominator : Total number of MTC GREEN patients

Formula : Total number of “under triaged” patients X 100%Total number of “MTC Green” patients

Standard : Not more than 0.5%

Comments :

Studies have shown that the “under triaging” of critically ill patients can increase their morbidity and mortality due to delay in their resuscitation and the provision of definitive care. Urgency refers to the need for time-critical intervention. Patients “over-triaged” to higher acuity categories may be able to tolerate longer waiting times for assessment and treatment. However, under triaged patients may lead to poor outcomes

INDICATOR 34 Morbidity Associated With Percutaneous Needle Aspiration Cytology / Biopsy of Chest - Significant Pneumothorax

Discipline : Diagnostic Imaging

Quality Dimension:Area of Concern

:

:

Safety

Aspiration Cytology / Biopsy of Chest

Rationale :These are commonly-performed invasive procedures which may be associated with morbidity. Thus, the morbidity arising from these procedures should be kept to an absolute minimum


This indicator includes performance biopsy of lung and mediastinum (lesions) under image guidance

Pneumothorax :

Defined as the presence of air in FIRST post-procedural chest x-ray. (The first procedural chest x-ray is defined as occurring from 0-4 hours after the procedure). Significant pneumothorax is one that requires chest tube insertion

Type of indicator :Rate-based Outcome indicator which addresses the safety of the process of diagnostic procedures in patient management

Numerator :

Total number of patients undergoing percutaneous biopsy of the CHEST for which there is documented evidence of significant PNEUMOTHORAX following the procedure

Denominator :Total number of patients undergoing percutaneous biopsy of the chest


Standard : Significant Pneumothorax : Not more than 10%

Comments :

Standards derived from review of medical literature.

INDICATOR 35 Morbidity associated with Percutaneous Needle Aspiration Cytology / Biopsy of Abdomen- Haemorrhage

Discipline : Diagnostic Imaging

Quality Dimension:Area of Concern

::

Safety Aspiration Cytology / Biopsy of Abdomen

Rationale :These are commonly-performed invasive procedures which may be associated with morbidity. Thus, the morbidity arising from these procedures should be kept to an absolute minimum

Definition of Terms :This indicator includes performance biopsy of abdominal organs (lesions) under image guidance.

Hemorrhage : Defined as bleeding requiring transfusion within 24 hours of the procedure

Type of indicator : Rate-based Outcome indicator which addresses the safety of diagnostic procedures in patient management

Numerator :

Total number of patients undergoing percutaneous biopsy of the ABDOMEN, for which there is documented evidence of significant HAEMORRHAGE following the procedure

Denominator : Total number of patients undergoing percutaneous biopsy of the ABDOMEN


Standard : Haemorrhage : Not more than 10 %

Comments :

Standards derived from review of medical literature.

INDICATOR 36 Burns Sustained During Delivery of Electrotherapeutic Modalities and Thermal Agents

Discipline : Physiotherapy


SAFETY

Physiotherapy care

Rationale :Burns should not occur if a model of good care is followed. The emphasis is on prevention because safety of patients is of utmost importance during the delivery of heat therapy


BurnsTissue damage following the application of electrotherapeutic modalities and thermal agents resulting in excessive/latent redness and pain or blistering of skin over the area treated

Electro-therapeutic Modalities

: Short wave Diathermy, Microwave Diathermy, Infra Red Ray

Thermal Agents

: Hot packs, Paraffin wax baths

Type of indicator : SENTINEL EVENT Outcome indicator.

Data to be collected / FORMULA

: Number of patients with Burns sustained during delivery of Electrotherapeutic Modalities and Thermal agents

Standard : NO CASE of burns (Sentinel Event)

INDICATOR 37 Incidence of Physical Contamination of Food Served to Patients Patients

Discipline : Dietetics and Food Services


:

:SAFETY Food served to patients

Rationale :

There should be no occurrences of food contamination if high quality food preparation, handling and transport are implemented or adhered to.


Contaminated food When material that is not normally found in food served / prepared is present in the food served to clients.

Exclusion Criteria : Micro-organisms and toxic chemicals

Type of indicator : SENTINEL EVENT.

FORMULA / Data to be collected

: Number of cases of Physical Contamination of Food

Standard : 0 % (Sentinel event) No physical contamination of food

INDICATOR 38 Incidence of Thrombophlebitis Among ADULT In-patients Receiving Intravenous Therapy

Discipline : Nursing


: EFFECTIVENESS & SAFETY Nursing Care for in-patients on intravenous therapy

Rationale :Occurrence of thrombophlebitis has an impact on the patient's health as it causes discomfort, pain and increases health care costs. It also reflects the quality of patient care.

Definition of Terms : Thrombophlebitis Thrombophlebitis is an infection of the veins (Grade 2 to 4 only)

Grading of Thrombophlebitis (0-4)Severity Criteria

Pain Redness Warmth Swelling Palpable Venous Cord0 No No No No No

1 Yes No No No No

2 Yes Yes Yes Yes< 5cm

Yes< 7.5 cm above IV site

3 Yes Yes Yes Yes > 5cm with slight Necrosis

Yes> 7.5 cm ” above IV site

4 Yes Yes Yes Yes > 5cm with Large Necrotic site

YesFrank venous thrombosis and all signs present

Inclusion Criteria :Adult Patients receiving Intravenous therapy will be observed till discontinued. Thrombophlebitis = Grade 2 to 4 only

Exclusion CriteriaRestless Patients All Patients on IV Medication Blood Transfusion


Numerator : Number of cases of Thrombophlebitis (Grades 2 to 4 only) x 1000

Denominator : Total number of intravenous lines set up

Formula : Numerator x 1000 (i.e. x no. of cases per 1000 lines set up Denominator

Standard : < 9 cases per 1000 lines set ( or < 0.9%) (based on 2008 national averages)

CommentsArea of Study : All Adult Wards excluding Labour RoomPeriod of Study: 1 week in first half of the year; 1 week in 2nd half of the year (to be decided)

Moh National Patient Safety Indicators

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