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. |

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| | |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 |

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|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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