The National University Hospital has been monitoring several hospital-wide Clinical Quality Indicators. These indicators are based on the Quality Indicator Projects (QIP) by the Maryland Hospital Association and its subsidiary, the Centre for Performance Sciences (CPS).
The QIP indicators were initiated in Maryland in 1985. As interest in the project spread outside the US, the International Quality Indicator Project (IQIP) was formed in 1997. It is a comparative analysis research project, with participants from various hospitals around the globe. It provides a clinical outcome-based approach to measuring and evaluating organisational performance.
The Ministry of Health's Healthcare Performance Group employs Clinical Quality Indicators to fulfill one of its key objectives of monitoring and assessing the clinical performance of hospital institutions so as to facilitate continuous quality improvement and benchmarking.
By adopting and tracking Clinical Quality Indicators, the results can be used to compare or benchmark information related to clinical care. Possible problems and/or opportunities for improvement are flagged out within the organisation. The data can help to highlight problem areas in clinical performance, inform or drive quality improvement activities, prompt reflections on clinical practice, ensure proper channeling of resources and identify important issues for further research. Valid and reliable data concerning desired and undesired results play an important role in a comprehensive monitoring and evaluation system.
Why Monitor Clinical Performance?
Clinical indicators serve to examine the trends in the standards of care in NUH beyond fulfilling regulatory requirements.
Clinical Performance Indicators
By participating in the IQIP, hospitals have a choice of monitoring a large number of clinical performance indicators. At present, NUH monitors 11 hospital-wide clinical quality indicators under the IQIP. NUH also monitors other performance indicators undertaken by various clinical audit committees.
Hand hygiene refers to the process of cleaning the hands by performing hand washing or through the use of alcohol-based hand rub solutions. In a healthcare setting, proper hand washing is the simplest way to reduce cross-transmission of microorganisms associated with infections which lead to increased length of stay, cost of care, and even mortality.
Despite this knowledge being imparted across all categories of healthcare staff, hand hygiene compliance rates have remained low. In multi-centre studies from 1981 to 1999, compliance to hand hygiene in ICUs has been observed to be less than 50%.1 In 2004, the WHO World Alliance for Patient Safety has initiated a global response in an effort to reduce healthcare-associated infections (HCAI), emphasizing the promotion of hand hygiene. Since then, various measurement tools and improvement efforts have been developed and implemented within and across countries.2
Measuring Hand Hygiene Compliance in NUH
Different institutions have their own ways of measuring hand hygiene compliance. They range from direct observation by trained observers, self-report by healthcare workers (HCWs), direct observation by patients, consumption of hygiene products and automated monitoring systems.3
The NUH audit process to measure hand hygiene compliance is very rigorous and it covers all thirty-four wards and six ICUs. The NUH Infection Control team, hospital management and clinical stakeholders have been working together to refine its hand hygiene programme since 2006. It includes training and assessment of healthcare staff at all levels of seniority on the proper techniques and timing of hand washing. In addition, it uses measurement tools such as direct observation, measurement of product use and conducting surveys. The ultimate aim is to decrease the number of healthcare associated infections, especially that of MRSA (Methicillin-resistant Staphylococcus aureus).
NUH Infection Control monitors staff hand hygiene compliance via covert observation. This means that the healthcare workers are not aware that they are being observed by an “undercover” auditor. This reduces bias because auditees tend to change their behaviour when they know that they are being audited (Hawthorne effect). Compliance is defined as the number of hand hygiene actions divided by the number of opportunities that require hand hygiene actions, multiplied by 100 and expressed as a percentage. NUH adopts the World Health Organisation’s guidelines on the “Five Moments of Hand Hygiene”4
Training of healthcare staff on hand hygiene is done during orientation for new staff. Posters on hand washing techniques are put up at strategic locations. Hand Hygiene campaigns, like observance of Hand Hygiene week in 2010, and the video competition in 2012 have increased staff's awareness of its importance.
The chart below shows the compliance rate from the baseline taken in 2008 (Figure 1). These overall rates have been encouraging as the hospital targets achieving >75% hand hygiene compliance. We have over 2000 observations per month hospital wide conducted by a variety of auditors including an external inter-hospital trained team.
Figure 1: Hand Hygiene Compliance in NUH (ICUs and Wards)
Source: NUH Infection Control
Figure 2 below shows the compliance rate by healthcare worker category. These include the doctors, nurses, therapists, radiographers, patient care associates (PCAs), medical and nursing students. Compared to the overall baseline in 2008 (i.e. 38%), improved rates are generally observed in all categories.
Figure 2: Compliance Rate by Healthcare Worker Category
Source: NUH Infection Control
Information correct as at Feruary 2013
1. Pittet, D, “Improving Adherence to Hand Hygiene Practice: A Multidisciplinary Approach”, Emerging Infectious Diseases, Vol. 7, No. 2, March–April 2001
2. National Hand Hygiene: NHS Campaign Audit Report, 2007 http://www.documents.hps.scot.nhs.uk/hai/infection-control/national-hand-hygiene-campaign/audit-report.pdf, accessed on 20 May 2010
3. Measuring Hand Hygiene Adherence: Overcoming the Challenges http://www.jointcommission.org/NR/rdonlyres/68B9CB2F-789F-49DB-9E3F-2FB387666BCC/0/hh_monograph.pdf, accessed on 20 May 2010
4. “First Global Safety Challenge: Clean Care is Safer Care”, 2009, WHO Guidelines on Hand Hygiene in Health Care
The occurrence of inpatient falls is one of the most commonly reported patient safety incidents. It is well known that falls can be a significant cause of morbidity, prolonged hospital stay and increased healthcare costs. Falls can result in soft tissue injury, fractures and even death. The event may also cause anxiety and depression to patients and may lead to decreased mobility due to fear of further falls. 1
In view of the above, falls prevention has been a healthcare challenge, requiring a multi-faceted approach.2 Identification of risk factors is a key to success in preventing falls. These risk factors may be intrinsic (physiologic) or extrinsic (environmental).3 Intrinsic factors are those that pertain to the patient’s health status, effects of polypharmacy (taking more than 6 drugs at any given time), leading to confusion, altered toilet needs, dizziness and changes in gait. Extrinsic factors would include poor lighting, physical obstruction, and slippery floors.
NUH monitors falls as one of the patient safety indicators to ensure safety. It is adopted from the hospital-wide indicators of the International Quality Indicator Project (IQIP) 4 since 2002. An inpatient fall is defined as one that is recorded by staff in the hospital’s incident report database. These documented falls are expressed as number of inpatient falls per 100 patient days.
Figure1. Falls Rate in NUH
IQIP (International Quality Indicators Project): NUH & Project-wide Data
Figure 1 above shows the trend over the years, as compared with IQIP project wide data. NUH exhibits a marked decrease in fall rates over the past ten years from 0.19 to 0.09 falls per 100 patient days.
This clinical outcome data monitoring has proved to be very useful for our hospital in the planning and implementation of interventional measures. Multi-disciplinary involvement from the medical, nursing, allied health and administration teams has contributed largely to the goal of reducing inpatient falls.
Periodic review of guidelines, nursing staff education on risk assessment tools using the Hendrich II Fall Risk Model3, and visual identifiers such as green wrist tags and name boards for patients at risk for falls, have considerably reduced our falls rate over time.
Our rates compare favourably with that of other international healthcare institutions’ reports. Different institutions express their fall rates, either as falls per 100, or per 1000 patient days. The IQIP, which receives indicator reports from more than 500 healthcare organisations around the world, has a mean falls rate of 0.19 per 100 patient days from 2002-2008.4
Information correct as at February 2013
1. MOH Clinical Practice Guidelines: “Prevention of Falls in Hospitals and Long Term Care Institutions”, 2005, Ministry of Health, Singapore
2. Koh SL, et al, 2009, “Impact of a fall prevention programme in acute hospital settings Singapore”, Singapore Med J, Vol 50, Issue 4, pp 425-432
3. Hendrich A, May/June 2006, “Inpatient Falls: Lessons from the Field”, Patient Safety and Quality Healthcare, http://www.psqh.com/mayjun06/falls.html
4. Acute Care Implementation Manual, October 2006 Revision, International Quality Indicator Project, Center for Performance Sciences: Maryland, USA
Unscheduled ICU Returns
This is an indicator that measures the rate of unexpected returns to an intensive care unit (ICU) during the same admission episode. The return may be the result of factors such as the deterioration or exacerbation of the patient's clinical condition. Monitoring these unexpected returns to ICU can help identify premature transfers and review ICU admission and discharge protocol.
Since the adoption of the IQIP indicators, NUH has successfully reduced its rate of unscheduled returns to ICU to 3.21% in 2008 from 7.36% in 2002. NUH's has performed better than the other hospitals participating in the IQIP, both local and international (Figure 1) for this indicator.
Figure 1: Unscheduled Returns to ICU
Information correct as at February 2013
Ventilator-associated pneumonia (VAP) is defined as nosocomial (hospital-acquired) pneumonia in a patient on mechanical ventilatory support (by endotracheal tube or tracheostomy) for more than 48 hours. VAP is a medical condition that results from infection which involves the small, air-filled sacs (alveoli) in the lung responsible for absorbing oxygen from the atmosphere.
Ways of preventing VAP in patients include limiting exposure to resistant bacteria, discontinuing mechanical ventilation as soon as possible, and a variety of strategies to limit infection while the patient is intubated. Drug-resistant infections increase the risk of death and are often associated with prolonged hospital stay. Hence, infection control measures are mandated in NUH with strict adherence to proper hand washing, sterile techniques for invasive procedures and isolation of individuals with known resistant organisms. As proposed by the US-based Institute of Healthcare Improvement (IHI), NUH has also implemented the 'ventilator bundle'. This bundle refers to care processes which aim to reduce VAP, a key component of which is the elevation of the head of the bed at 30° - 45°.
Since the adoption of this IQIP indicator and the implemention of the above measures, NUH has decreased its VAP rates. Medical and surgical ICU VAP rates showed significant improvement from 11 per thousand ventilator-days in 2001 to 0 per thousand ventilator-days in the first three quarters of 2012 (Figure 2).
Figure 2: Ventilator-associated pneumonia in Medical and Surgical ICUs
Likewise, the Coronary Care Unit (CCU) demonstrated a remarkable decline in VAP rates from 4.39 per thousand ventilator-days in 2001 to 'zero VAP'from 2004. There was one isolated case in 2011(Figure 3). These rates compare favourably with the participating IQIP Project-wide VAP rates in CCUs.
Figure 3: Ventilator-associated Pneumonia in Coronary Care Unit (CCU)
Information correct as at February 2013
This material does not cover all information and is not intended as a substitute for professional care. Please consult with your physician on any matters regarding your health.
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