NATIONAL PATIENT SAFETY INDICATORS
NATIONAL PATIENT SAFETY INDICATORS
2009
TECHNICAL SPECIFICATIONS
INDICATOR 1 Mild Head Injury Case Fatality Rate
|Discipline |: |General Surgery |
|Quality Dimension |: |EFFECTIVENESS |
|Area of Concern |: |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. |
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Indicator 2 Incidence of Wound Infection in Clean Elective Orthopaedic Surgery
|Discipline |: |Orthopaedic Surgery |
|Quality Dimension |: |EFFECTIVENESS & SAFETY |
|Area of Concern |: |Technical 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 surgery | |Surgery in patients with no prior laceration wound at the surgical site or present of wound/sore in |
| | |the body. |
|CDC Definitions of surgical site | |Superficial infection: |
|infection (SSI)--- | |Involves only the skin and subcutaneous tissue of the incision |
| | |And |
| | |The patient has at least one of the following: |
| | |Purulent drainage from the superficial incision. |
| | |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- |
| | |ס pain or tenderness. |
| | |ס localized swelling |
| | |ס redness or heat |
| | |ס superficial incision is deliberately opened by surgeon, unless incision is culture-negative |
| | | |
| | |Diagnosis of superficial incisional SSI by the surgeon or attending physician. |
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| | |Deep infection: |
| | |Infection involved deep soft tissues (e.g. fascia and muscle layers) of the incision |
| | |AND |
| | |The patient has at least one of the following: |
| | |Purulent drainage from the deep incision but not from the organ/space component of the surgical site.|
| | |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): |
| | |ס fever (>380C) |
| | |ס localized pain or tenderness |
| | |An abscess or other evidence of infection involving the deep incision is found on direct examination,|
| | |during reoperation, or by histopathologic or radiologic examination |
| | |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 |: |Effectiveness & Safety |
| | | |
|Area of Concern |: |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 |: | |
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| | |< 1% |
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Indicator 5 Safe Performance of Percutaneous Nephrolithotripsy
(PCNL)
|Discipline |: |Urology |
| |: |Safety |
|Quality Dimension | | |
| |: | |
|Area of Concern | |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. |
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|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 |
|Type of indicator |: |Rate-based Outcome indicator |
|Numerator |: |Number of PCNL cases performed safely |
|Denominator |: |Total number of PCNL performed |
|Formula |: |Numerator__ x 100% |
| | |Denominator |
|STANDARD |: | |
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| | |> 85% |
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Indicator 6 Safe Performance of Transurethral Resection of the
Prostate (TURP)
|Discipline |: |Urology |
| |: |Safety |
|Quality Dimension |: | |
| | |TURP |
|Area of Concern | | |
|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 |
|Type of indicator |: |Rate-based Outcome indicator |
|Numerator |: |Number of TURP cases performed safely |
|Denominator |: |Total number of TURP performed |
|Formula |: |Numerator__ x 100% |
| | |Denominator |
|STANDARD |: |> 90% |
Indicator 7 Safe Performance of Ureterorenoscopy (URS) with
Lithotripsy
|Discipline |: |Urology |
| |: |Safety |
|Quality Dimension | | |
| |: |Ureterorenoscopy (URS) with Lithotripsy |
|Area of Concern | | |
|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 |
|Type of indicator |: |Rate-based Outcome indicator |
|Numerator |: |Number of Ureterenoscopy (URS) with Lithotripsy cases performed safely x100% |
|Denominator |: |Total number of Ureterorenoscopy (URS) and Lithotripsy performed |
|Formula |: |Numerator__ x 100% |
| | |Denominator |
|STANDARD |: |> 95% |
Indicator 8 Occurrence of Post-Tonsillectomy Haemorrhage
|Discipline |: |ENT |
| |: |Safety |
|Quality Dimension | | |
| |: |Tonsillectomy |
|Area of Concern | | |
|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 |
|Type of indicator |: |Rate-based Outcome indicator |
|Numerator |: |Number of post tonsillectomy haemorrhages occurring in the month |
|Denominator |: |Total number of tonsillectomies conducted in the month |
|Formula |: |Numerator__ x 100% |
| | |Denominator |
| Standard |: |< 5% |
Indicator 9 Wound Infection Following Elective Craniotomy for
Brain Cancer
|Discipline |: |NeuroSurgery |
| |: |Safety |
|Quality Dimension |: | |
| | |Craniotomy for Brain Cancer |
|Area of Concern | | |
|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 |: |Safety |
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|Area of Concern |: |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 |: |Safety |
| |: | |
|Area of Concern | |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 terms | | |
| | |Posterior 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. |
|Formula |: |Numerator__ x 100% |
| | |Denominator |
|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. |
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Indicator 12 Incidence of Intubation in the Recovery Room
|Discipline |: |Anaesthesia |
|Quality Dimension |: | |
| | |Safety |
|Area of Concern |: | |
| | |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 |
|Type of indicator |: | |
| | |Rate-based Outcome indicator |
|Numerator |: |Total number of patients requiring intubation in the Recovery Room |
|Denominator |: |Total number of patients undergoing GA |
|Formula | | |
| | |Numerator__ x 100 % |
| | |Denominator |
|Standard |: | |
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| | |< 0.3% |
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| | |(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
|Discipline |: | Anaesthesia |
| |: |Effectiveness & Safety |
|Quality Dimension | | |
| |: |Patient Management in the Recovery Room |
|Area of Concern | | |
|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) |
|Type of indicator |: | |
| | |Rate-based Outcome indicator |
|Numerator |: |Total number of patients leaving the recovery room (RR) with pain scores > 4 |
|Denominator |: |Total number of patients undergoing surgery (and receiving GA) |
|Formula | |Numerator__ x 100 % |
| | |Denominator |
|Standard |: |< 10% |
Indicator 14 Percentage of Patients Awaiting Emergency Surgery for
more than 24 hours
|Discipline |: | Anaesthesia |
| |: | |
|Quality Dimension |: |Efficiency & Equity of Access |
|Area of Concern | |Emergency 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 |: |Efficiency & Effectiveness |
| | | |
|Area of Concern |: |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. |
|Definition of Terms |: | |
|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
|Discipline |: |Obstetrics & Gynaecology |
|Quality Dimension |: |EFFECTIVENESS |
| | | |
|Area of Concern |: |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 |
|Definition of Terms |: | |
| Eclampsia | |As per ICD classification |
| | | |
|Recurrent fits | |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
|Discipline |: |Obstetrics & Gynaecology |
|Quality Dimension |: |EFFECTIVENESS & APPROPRIATENESS |
| | | |
|Area of Concern |: |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. |
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INDICATOR 18 Occurrence of Urinary Tract Injury Following Hysterectomy
|Discipline |: |Obstetrics & Gynaecology |
|Quality Dimension |: |Efficiency & Effectiveness |
|Area of Concern | | |
| |: |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. |
|Definition of Terms |: | |
|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: |: | EFFECTIVENESS |
|Area of Concern : | |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 |
|Definition of Terms |: | |
| 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 I20 |
| | |2) 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 |: |EFFECTIVENESS |
| |: | |
|Area of Concern | |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 |
|Definition of Terms |: | |
| Ischemic Stroke |: |As per clinical judgement of Medical specialist |
|Type of indicator |: |Rate-based Process Indicator |
|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 |
|Formula |: |Numerator x 100% |
| | |Denominator |
|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 |: |EFFECTIVENESS |
| | | |
|Area of Concern |: |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. |
|Definition of Terms |: | |
| Pneumonia | | |
| | | |
| | |Definition of pneumonia as 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 |: | |
| | |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 |
|Formula |: | |
| | |Numerator x 100% |
| | |Denominator |
|Standard | | |
| |: | |
| | |< 2.5% |
| | | |
Indicator 22 Mortaliy of Very Low Birth Weight (VLBW) Infants 1000 grams to 1499 grams
in Hospitals WITH Neonatologist (s)
|Discipline |: |Paediatric Medical |
|Quality Dimension |: |Effectiveness & Safety |
| | | |
|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) |
|Type of indicator |: |Rate-based outcome indicator |
| |: | |
|Numerator | |Number of VLBWs 1000g to 1499 g deaths |
| |: |Number of VLBWs 1000g to 1499 g admitted to NICU |
|Denominator | | |
| |: |Numerator x 100% |
|Formula | |Denominator |
| |: | < 15 % |
|STANDARD | | |
Indicator 23 Mortality of Very Low Birth Weight (VLBW) infants 1000g to 1499g in
Hospitals WITH PAEDIATRICIAN but WITHOUT Neonatologist(s)
|Discipline |: |Paediatric Medical |
|Quality Dimension |: |Effectiveness & Safety |
| | | |
|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) |
|Type of indicator |: |Rate-based outcome indicator |
| |: | |
|Numerator | |Number of VLBWs 1000g to 1499 g deaths |
| |: |Number of VLBWs 1000g to 1499 g admitted to NICU |
|Denominator | | |
| |: |Numerator x 100% |
|Formula | |Denominator |
| |: | < 20 %) |
|STANDARD | | |
Indicator 24 Dengue Hemorrhagic Fever Deaths in Pediatric cases
|Discipline |: |Paediatric Medical |
|Quality Dimension |: |Effectiveness & Safety |
| | | |
|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. |
|Definition of Terms |: | |
|Dengue fever | |As 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
|Discipline |: |Paediatric Medical |
|Quality Dimension |: |Effectiveness & Safety |
| | | |
|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. |
|Definition of Terms |: | |
| | | |
|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
|Discipline |: |Paediatric Medical |
|Quality Dimension |: |Effectiveness & Safety |
| | | |
|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 |
| |: |Safety |
|Quality Dimension | | |
| |: |Skin Biopsy |
|Area of Concern | | |
|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 |
|Type of indicator |: |Rate-based Outcome indicator |
| |: | |
|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) |
|Formula |: |Numerator x 100% |
| | |Denominator |
|Standard |: | Less than 2% |
Indicator 28 Peritonitis Rate in Adult patients on Continuous
Ambulatory Peritoneal Dialysis (CAPD)
|Discipline |: |Nephrology |
|Quality Dimension |: |Effectiveness and Safety |
|Area of Concern |: |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 |
|Type of indicator |: |Rate-based Outcome 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 |
|Quality Dimension: |: | SAFETY |
|Area of Concern : | |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 |
| | |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. |
| | |Accidental death – fall, choking, drowning, electrocuted, poisoning etc. |
| | |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 |
|Quality Dimension | |EFFICIENCY |
|Area of Concern | |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% |
|Definition of Terms |: | |
| Door- to-Needle time | |Time between arrival in Emergency Department and administration of thrombolytic therapy |
|Type of indicator |: | Rate-based Process Indicator |
|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 | |EFFICIENCY |
| | | |
|Area of Concern | |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. |
|Definition of Terms |: | |
| 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 |
|Formula | |Number 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 |
|Quality Dimension | |Appropriateness & Safety |
|Area of Concern | | |
| | |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. |
|Definition of Terms |: | |
|“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: |: |Safety |
|Area of Concern | | |
| |: |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 |
|Definition of Terms |: | |
| | |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 |
|Formula |: |Numerator__ x 100% |
| | |Denominator |
|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: |: |Safety |
|Area of Concern |: |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 |
|Formula |: |Numerator__ x 100% |
| | |Denominator |
|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 |
|Quality Dimension: |: |SAFETY |
|Area of Concern | | |
| | |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 |
|Definition of Terms |: | |
| Burns | | |
| | |Tissue damage following the application of electro- therapeutic 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 |
| |: |Hot packs, Paraffin wax baths |
|Thermal Agents | | |
|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 |
|Quality Dimension |: | |
|Area of Concern | |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. |
| | | |
|Definition of Terms |: | |
|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 |
|Quality Dimension: |: |EFFECTIVENESS & SAFETY |
|Area of Concern : | |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 Cord |
| |
|0 |
|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 |
|Yes |
|Frank 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 Criteria | |Restless Patients |
| | |All Patients on IV Medication |
| | |Blood Transfusion |
|Type of indicator |: |Rate-based outcome indicator |
|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) |
|Comments | |Area of Study : All Adult Wards excluding Labour Room |
| | |Period of Study: 1 week in first half of the year; 1 week in 2nd half of the year (to be |
| | |decided) |
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