Hospital-wide Indicators

Hospital Wide Indicators

Background

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.

Unscheduled Returns to ICU

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.dbo.dbo.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

Ventilator-Associated Pneumonia

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 0.26 per thousand ventilator-days in 2008 (Figure 2).

Figure 2: Ventilator-associated pneumonia in Medical and Surgical ICUs

*2008 data for Singapore public hospitals is until June 2008 only, i.e., 1.09 per thousand vent-days (not shown in graph)

Likewise, the Coronary Care Units (CCUs) demonstrated a remarkable decline in VAP rates from 4.dbo.dbo.39 per thousand ventilator-days in 2001 to 'zero VAP', which has been maintained from 2004 until 2008 (Figure 3). These rates are better than the participating IQIP Project-wide and Teaching Hospitals' average VAP rates in CCUs.

Figure 3: Ventilator-associated Pneumonia in Coronary Care Units (CCUs)

*Singapore Public Hospitals data up to 2004 only

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.