Rationale for measurement

Falls particularly in the elderly can lead to an increased time spent in Hospital and in significant health decline. As well as physical injuries suffered, the psychological and social consequences of falling can have a huge impact. Recurrent falls in the elderly can result in long term care, consequently falls prevention is a key area for hospitals. Serious falls that have caused patient death or disability while being cared for in a healthcare facility are defined as serious reportable events (SRE) in Irish Hospitals. While all falls do not result in injury, they can cause distress and anxiety to patients and their families. All Hospitals in the RCSI Group are committed to preventing patient falls where possible, and where not possible to minimising their incidence and impact.

Measurement methodology and data sources

• Number of patient falls associated with Patient death or disability whilst being cared for in a health service facility per 10,000 hospital bed days
• Number of patient falls whilst being cared for in a health service facility per 10,000 hospital bed days
• Local data extrapolated from Hospital Performance Metrics

Targets

• No patient falls associated with mortality or morbidity whilst being cared for in a health service facility

Performance

• overall rate of serious falls reported for RCSI HG for December 2021 (1.1) is higher than the rate of falls reported for December 2020 (0.8)

• RCSI Acute Hospitals reported a rate of 54.2 patient falls per 10,000 BDU (n=2,809) in Quarter 1 – Quarter 4 2021
• national values not available

Rationale for measurement

Falls are one of the most frequently reported incidents for hospital inpatients. Falls particularly in the elderly can lead to an increased time spent in Hospital and in significant health decline. As well as physical injuries suffered, the psychological and social consequences of falling can have a huge impact. Consequently, prevention and injury management is a key priority in healthcare.

The Quality Care Metric indicators below check that patients at risk of falling are managed in accordance with local and national policies, procedures, protocols and guidelines (PPPGs).

• Falls risk assessment was recorded on admission/transfer if applicable
• If the patient is identified as at risk of falling, nursing interventions are in place to minimise the risk of falling
• The patient, if identified at risk of falling, has been offered information about falls
• If a patient has fallen, the relevant post falls documentation have been completed

Measurement methodology and data sources

Based on total bed capacity, samples of 25% of patient records are randomly selected per month from each ward/unit with a minimum of 5 data collections per month for each ward/unit. National Guideline for Nursing and Midwifery Quality Care Metrics Data Measurement in Acute Care (2018) outlines the essential criteria for measurement of data for recording of falls https://healthservice.hse.ie/filelibrary/onmsd/national-guideline-for-nursing-and-midwifery-quality-care-metrics-data-measurement-in-acute-care.pdf

Target

90% compliance of the key indicators identified. Quality Care Metrics KPI set is identified as ‘areas of good practice’ are demonstrated 90-100%; ‘areas requiring some improvement’ 80-89%; ‘areas requiring immediate attention and action plans’ 0-79%.

Performance – % Compliance

• Cavan/Monaghan and Connolly Hospitals achieved target of 90%
• Beaumont and Drogheda Hospitals did not achieve target of 90%
• national data not collected

Rationale for measurement

Pressure ulcers, also called bedsores, are injuries to skin and underlying tissue resulting from prolonged pressure on the skin. Pressure ulcers most often develop on skin that covers bony areas such as heels, ankles, hips and tailbone. Hospitalised and immobile persons can be at risk of pressure ulcers. Pressure ulcers can cause pain, poor recovery and lead to serious infections. Pressure ulcers are graded Stage 1 to 4. At Stage 3, the ulcer is a deep wound with loss of skin and the damage may extend beyond the primary wound and below layers of healthy skin. At Stage 4, the ulcer shows large scale loss of tissue and may expose muscle, bone and tendon. Prevention of Grade 3 and Grade 4 bed ulcers are a marker of good care.

Measurement methodology and data sources

• Number of Stage 1 and 2 pressure ulcers per quarter
• Number of Stage 3 or 4 pressure ulcers per 10,000 hospital bed days
• Local data extrapolated from Hospital Performance Metrics

Definitions

• Stage 1: Intact skin with non – blanchable redness of a localised area usually over a bony Discolouration of the skin, warmth, oedema, hardness or pain may also be present. Darkly pigmented skin may not have visible blanching. The area may be painful, firm, soft, warmer or cooler as compared to adjacent skin
• Stage 2: Partial thickness skin loss of dermis presenting as a shallow ulcer with a red pink wound bed, without slough. May present as an intact or open/ ruptured serum filled blister filled with serous or sero-sanguineous fluid. Presents as a shiny or dry shallow ulcer without slough or bruising
• Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. This stage may include undermining and tunneling.
• Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. This stage often includes undermining and tunneling. Exposed bone/muscle is visible or directly palpable.

Reference: European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers (2009)

• Local hospital data (no national comparator data available)

Target

• No grade 3/4 pressure ulcers (RCSI Hospital Group target)

Performance

RCSI Hospital Group

• RCSI HG rate of grade 3 and 4 pressure ulcer incidents is 0.7 December 2021
• number of grade 3 and 4 pressure ulcers YTD 2021 (n=54) vs YTD 2020 (n=36)

• RCSI Acute Hospitals reported a rate of 13.6 pressure ulcers per 10,000 BDU (n=707) in Quarter 1 to Quarter 4 2021
• national values not available

Rationale for measurement

Most pressure injuries can be avoided, providing individuals at risk are correctly identified and appropriate measures are put into place to combat risk (Pressure Ulcers a practical guide to review, HSE 2018).

The following metrics will measure if pressure ulcer risk assessment was recorded using a validated tool within 6 hours of admission or transfer to the ward and is dated, timed and signed by the assessing nurse and If a patient is identified as at risk, daily skin inspections have been recorded.

Measurement methodology and data sources

Based on total bed capacity, samples of 25% of patient records are randomly selected per month from each ward/unit with a minimum of 5 data collections per month for each ward/unit. National Guideline for Nursing and Midwifery Quality Care Metrics Data Measurement in Acute Care (2018) outlines the essential criteria for measurement of data for recording of falls, see it here.

Target

90% compliance of the key indicators identified. Quality Care Metrics KPI set is identified as ‘areas of good practice’ are demonstrated 90-100%; ‘areas requiring some improvement’ 80-89%; ‘areas requiring immediate attention and action plans’ 0-79%.

Performance – % Compliance

• Cavan & Monaghan and Drogheda Hospitals achieved target of 90%
• Beaumont and Connolly Hospitals did not achieve target of 90%
• national data not collected

Rationale for measurement

Adequate food and hydration is fundamental to a person’s health and wellbeing. Nutrition and hydration in the acute hospital setting is an important element in the provision of safe quality care. Patients can be found to be malnourished when they are admitted to hospital and a patient’s nutritional status can deteriorate during a hospital stay. Therefore, malnutrition screening followed by an appropriate plan of care are seen as essential factors in recognising, managing and promoting improved nutritional and hydration status for patients in our care.

The Quality Care Metric indicators below check that Nutrition and Hydration nursing assessment, screening, and care planning are completed. This is in accordance with local policies, procedures, protocols and guidelines (PPPGs) and as documented in the Nutrition Screening and use of Oral Nutrition Support for Adults in the Acute Care Setting National Clinical Guideline No. 22 (DOH 2020) and the national Food Nutrition and Hydration Policy for Adult Patients in Acute Hospitals (HSE 2018).

• The patient’s risk of malnutrition has been screened on admission/transfer
• A plan of care has been developed based on the patient’s risk of malnutrition
• The patient’s risk of malnutrition has been re-screened
• The patient’s oral health status assessment has been completed
• The nursing care provided for the patient’s oral health has been documented
• Changes in the patient’s bowel pattern have been assessed, recorded and managed

Measurement methodology and data sources

Based on total bed capacity, samples of 25% of patient records are randomly selected per month from each ward/unit with a minimum of 5 data collections per month for each ward/unit

Target

90% compliance of the key indicators identified.

Performance – % Compliance

• Cavan & Monaghan Hospital achieved target of 90%
• Beaumont, Drogheda and Connolly Hospitals did not achieve target of 90%
• Beaumont and Connolly area identified for quality improvement is re-screening of malnutrition risk assessment
• national data not collected

Rationale for measurement

Readmissions rates can be influenced by a variety of factors, including the quality of inpatient and outpatient care, the effectiveness of the care transition and coordination, and the availability and use of effective disease management community based programmes. Whilst not all unplanned readmissions are avoidable, interventions during and after a hospitalisation can be effective in reducing rates (Government of Alberta – Alberta Health Service Plan 2014-2017).

Measurement Methodology and Data Sources

• local retrospective data extracted, extrapolated and published by HSE – BIU. Published one month in arrears.

Target:

• Surgical readmission to same hospital within 30 days  → ≤2%
• Medical readmission to same hospital within 30 days  → ≤11.1%

Performance – Surgical

Beaumont Hospital

• Beaumont achieved compliance with national target during monthly reporting period (2021) (1.5%)

Cavan General Hospital

• Cavan achieved compliance with national target during monthly reporting period (2021) (0.2%)

Connolly Hospital

• Connolly achieved compliance with national target during monthly reporting period (2021) (1.5%)

Drogheda Hospital

• Drogheda did not achieve compliance with national target during monthly reporting period (2021) (3.3%)

RCSI Hospital Group

• RCSI Hospital Group achieved compliance with national target during monthly reporting period (2021) (1.1%)

National Comparator

• RCSI Hospital Group and national performance achieving target for December 2021

Performance – Medical

Beaumont Hospital

• Beaumont achieved compliance with national target during monthly reporting period (2021) (10.8%)

Cavan General Hospital

• Cavan achieved compliance with national target during monthly reporting period (2021) (10.4%)

Connolly Hospital

• Connolly achieved compliance with national target during monthly reporting period (2021) (9.5%)

Drogheda Hospital

• Drogheda achieved compliance with national target during monthly reporting period (2021) (9.6%)

RCSI Hospital Group

• RCSI Hospital Group achieved compliance with national target during monthly reporting period (2021) (10.3%)

National Comparator

• RCSI Hospital Group and national performance achieving target for December 2021

Introduction

Chronic obstructive pulmonary disease (COPD) is a disease of the lungs characterised by airflow obstruction. This airflow obstruction is usually progressive and only partially reversible. The disease is associated with increasing dyspnoea (breathlessness) and in more severe cases can be associated with exacerbations of the disease, which may require intervention either in primary care, attendance at the hospital or even admission to hospital. Patients with severe COPD may suffer frequent exacerbations of their disease requiring medical attendance, potential hospitalisation and severe disruption of their quality-of-life. (End to End COPD Model of Care, December 2019, National Clinical Programme for Respiratory).

Rationale for measurement

Ireland has the highest rate of hospitalisation for COPD of all Organisation for Economic Co-operation and Development (OECD) countries. In 2013 (the latest year for which OECD data are currently available), the age standardised hospitalisation rate in Ireland based on OECD age standardisation equated to an age-sex standardised rate of 395/100,000 is almost double the OECD average of 201 hospitalisations per 100,000 population. Early supported discharge from hospital can benefit patients as they receive treatment in their own home. In addition the risk of patients contracting a hospital acquired infection is reduced. The RCSI HG measures re-admission of patients within 30 Days, this is the same timeframe as that measured in the medical readmission rate. International data demonstrates a variation in 30 day readmission rates for COPD patients. A systematic review of 34 studies has found the range of avoidable readmissions can vary between 5 and 79% with a median of 27%1. A more recent review by Shah et al suggest that patients hospitalized for COPD are likely to have a 30-day re-admission rate of 22.6%²

Measurement methodology and data sources

KPI 1: Median LOS for patients admitted with COPD

KPI 2: % re-admission to same acute hospitals of patients with COPD within 30 days.

Local HIPE Data extrapolated quarterly for analysis and publication

Targets

KPI 1: Median LOS for patients admitted with COPD – 5 Days

KPI 2: % re-admission to same acute hospitals of patients with COPD within 30 days – 22.6%

Performance

KPI 1: Median LOS for patients admitted with COPD

• Connolly Hospital is achieving national target for KPI 1 in Q3 2021
• Beaumont, Cavan and Drogheda Hospitals are not achieving national target for KPI 1 in Q3 2021
• no national comparable data is available

1 Van Walraven C, Bennett C, Jennings A, Austin PC, Forster AJ. Proportion of hospital readmissions deemed avoidable: a systematic review. CMAJ. 2011;183 (7):E391–E402.

2 Shah T, Press V, Huisingh-Scheetz M, White SR. COPD readmissions: addressing COPD in the era of value-based health care. Chest. 2016;150 (4):916–926.

KPI 2: % re-admission to same acute hospitals of patients with COPD within 30 days

• RCSI Hospitals achieving target for KPI 2 in Q3 2021
• Note: data outlined is re-admission within 30 Days to same acute hospital, the same timeframe as measured in the medical readmission rate. National KPI for COPD measures readmission within 90 Days.
• recent international data suggests a re-admission rate for COPD patients of 22.6% within 30 days
• no national comparable data is available

2 Shah T, Press V, Huisingh-Scheetz M, White SR. COPD readmissions: addressing COPD in the era of value-based health care. Chest. 2016;150 (4):916–926.

Rationale for measurement:

Patients who have been identified as no longer requiring acute medical care i.e. medically fit for discharge, but remain in hospital waiting for provision of Community Home Care, Long Term Care and Rehabilitation are described as experiencing a “delayed discharge”. This delay can result in increased likelihood of hospital acquired infection or a loss of confidence and necessary skills for daily living required for returning home. As well, their ongoing inappropriate accommodation in an acute bed causes resultant delays in accommodating other emergency / elective patient requiring acute hospital accommodation.

Measurement methodology and data sources

• periodic local data submitted weekly to the BIU for analysis and publication.

Target

• No more than 112 patients experiencing an inappropriately delayed discharge within the RCSI Hospital Group.

Performance

RCSI Hospital Group

• target of <112 patients achieved for reporting period (n=76 December)
• 64% of December value relates to impact of shortage of nursing home availability in the North East for Drogheda Hospital
• 15% decrease 2021 / 2020 YTD in the average number of patients experiencing a “DTOC”
  • 81% increase (n=34) Dec-21 v Dec-20
    • monthly average of 1636 bed days YTD were inappropriately utilised for accommodation of patients experiencing “DTOC” – equating to an acute bed day capacity equivalent to the monthly treatment and accommodation of 234 elective / emergency patients (based on a 7 day average length of stay)
    • nationally 2% decrease 2021 / 2020 YTD in the average number of patients experiencing a “delayed discharge”. 25% increase (n=90) Dec-21 v Dec-20.
• from 10^th May 2020 criteria for transfer to nursing home changed to requirement for patient to have 2 negative swabs within 48 hours of discharge to nursing home and then be isolated in nursing home for first 2 weeks of admission

Rationale for measurement

The role of COVID-19 testing in assisting with decision-making regarding transfers to congregated settings. People for admission to a Long Term Residential Care Facility (LTRCF) should be tested for SARS-CoV-2. This is to help identify most of those who have infection, but it will not detect all of those with infection (Guidance on COVID-19 Admissions, transfers to and discharges from residential care facilities V1.2 23.12.20).

Measurement methodology and data sources

Testing should be performed within three days of planned admission/transfer to the LTRCF.

Target

100 % compliance of all residents who meet the criteria is tested and result available prior to admission/transfer

Performance – December 2021

• National data not available

• Principal diagnosis of Acute Myocardial Infarction
• Principal diagnosis of Heart failure
• Principal diagnosis of Ischaemic Stroke
• Principal diagnosis of Haemorrhagic Stroke
• Principal diagnosis of Chronic obstructive pulmonary disease and bronchiectasis

Rationale for measurement:

It is important that every hospital measures and monitors mortality from specific conditions. Over the past two decades in-hospital mortality patterns have been used as one key indicator of quality of care internationally. Standardised Mortality Ratio (SMR) is a commonly used statistical method for examining hospital mortality patterns within a country or within a hospital group. The SMR compares the observed number of deaths to the expected number of deaths for a specific diagnosis.

Measurement methodology: 

Standardised mortality ratio (SMR) is 2019 datasets for:

• Acute Myocardial Infarction (Acute MI)
• Ischaemic Stroke
• Haemorrhagic Stroke

Datasets for Heart Failure and Chronic obstructive pulmonary disease and bronchiectasis currently available for 2019 are for national and county only (and not for Hospital Groups)

Data provided by National Patient Safety Office (National Healthcare Quality Reporting System) in December 2020

RCSI HOSPITAL GROUP ACUTE MYOCARDIAL INFARCTION (ACUTE MI) – AGE-SEX STANDARDISED IN-HOSPITAL MORTALITY RATES WITHIN 30 DAYS OF ADMISSION FOR AMI BY HOSPITAL GROUP AND HOSPITAL, 2017-2019

All hospitals in the RCSI Hospital Group had a SMR within the expected range for patients admitted with a principal diagnosis of AMI.

Description: Age-sex standardised in-hospital mortality within 30 days for acute myocardial infarction (AMI) (heart attack) is defined as the number of patients aged 45 and over who die in hospital within 30 days of being admitted with a principal diagnosis of an AMI, as a proportion of the total number of patients aged 45 and over admitted to that hospital with a principal diagnosis of an AMI.

Notes:

Hospitals with small numbers of cases tend to have unstable rates and wider confidence intervals. For this report rates are not displayed for hospitals with less than 100 cases, although the data for these hospitals have been included in the calculation of the national rates. However some hospitals with more than 100 cases may still have unstable rates and caution should be exercised in interpreting rates with wide confidence intervals. The data presented above are age-sex standardised mortality rates per 100 cases. 95% confidence intervals for hospitals and hospital groups are shown by H. Where the 95% confidence interval for a hospital or hospital group overlaps the 95% confidence interval of the national rate (i.e. the dashed green lines), it can be concluded that the rate is not statistically significantly different from the national rate and so is within the expected range. Where the 95% confidence interval for a hospital or hospital group does not overlap the confidence interval of the national rate, it implies that the mortality rate is statistically significantly different from the national rate and is therefore outside the expected range.

There can be many reasons for variations in mortality rates including differences in patient profiles; data quality issues; and differences in the quality of care. Age-sex standardised mortality rates that are statistically significantly higher at the 95% confidence level than the national rate are shown in amber. Rates for all other hospitals and hospital groups are below or within the expected range of the national rate.

RCSI HOSPITAL ACUTE ISCHAEMIC STROKE – AGE-SEX STANDARDISED IN-HOSPITAL MORTALITY RATES WITHIN 30 DAYS OF ADMISSION FOR ISCHAEMIC STROKE BY HOSPITAL GROUP AND HOSPITAL, 2017-2019

All hospitals in the RCSI Hospital Group had a SMR within the expected range for patients admitted with a principal diagnosis of Ischaemic Stroke.

Description: Age-sex standardised in-hospital mortality rate within 30 days after ischaemic stroke – caused by a blood clot, is defined as the number of patients aged 45 and over who die in hospital within 30 days of being admitted to hospital with a principal diagnosis of ischaemic stroke, as a proportion of the total number of patients aged 45 and over admitted to that hospital with a principal diagnosis of ischaemic stroke.

Notes:

Hospitals with small numbers of cases tend to have unstable rates and wider confidence intervals. For this report rates are not displayed for hospitals with less than 100 cases, although the data for these hospitals have been included in the calculation of the national rates. However some hospitals with more than 100 cases may still have unstable rates and caution should be exercised in interpreting rates with wide confidence intervals. The data presented above are age-sex standardised mortality rates per 100 cases. 95% confidence intervals for hospitals and hospital groups are shown by H. Where the 95% confidence interval for a hospital or hospital group overlaps the 95% confidence interval of the national rate (i.e. the dashed green lines), it can be concluded that the rate is not statistically significantly different from the national rate and so is within the expected range. Where the 95% confidence interval for a hospital or hospital group does not overlap the confidence interval of the national rate, it implies that the mortality rate is statistically significantly different from the national rate and is therefore outside the expected range.

There can be many reasons for variations in mortality rates including differences in patient profiles; data quality issues; and differences in the quality of care. Age-sex standardised mortality rates that are statistically significantly higher at the 95% confidence level than the national rate are shown in amber. Rates for all other hospitals and hospital groups are below or within the expected range of the national rate.

RCSI Hospital Haemorrhagic Stroke – Age-sex standardised in-hospital mortality rates within 30 days of admission for haemorrhagic stroke by hospital group and hospital, 2017-2019

All hospitals in the RCSI Hospital Group had a SMR within the expected range for patients admitted with a principal diagnosis of Haemorrhagic Stroke.

Description: Age-sex standardised in-hospital mortality rate within 30 days for haemorrhagic stroke – caused by bleeding, is defined as the number of patients aged 45 and over who die in hospital within 30 days of being admitted to hospital with a principal diagnosis of haemorrhagic stroke, as a proportion of the total number of patients aged 45 and over admitted to that hospital with a principal diagnosis of haemorrhagic stroke.

Notes:

Hospitals with small numbers of cases tend to have unstable rates and wider confidence intervals. For this report rates are not displayed for hospitals with less than 100 cases, although the data for these hospitals have been included in the calculation of the national rates. However some hospitals with more than 100 cases may still have unstable rates and caution should be exercised in interpreting rates with wide confidence intervals. The data presented above are age-sex standardised mortality rates per 100 cases.95% confidence intervals for hospitals and hospital groups are shown by H. Where the 95% confidence interval for a hospital or hospital group overlaps the 95% confidence interval of the national rate (i.e. the dashed green lines), it can be concluded that the rate is not statistically significantly different from the national rate and so is within the expected range. Where the 95% confidence interval for a hospital or hospital group does not overlap the confidence interval of the national rate, it implies that the mortality rate is statistically significantly different from the national rate and is therefore outside the expected range.

There can be many reasons for variations in mortality rates including differences in patient profiles; data quality issues; and differences in the quality of care. Age-sex standardised mortality rates that are statistically significantly higher at the 95% confidence level than the national rate are shown in amber. Rates for all other hospitals and hospital groups are below or within the expected range of the national rate.

Introduction:

In-hospital mortality is defined as death occurring during the hospital stay.

In the past 5 years the National Audit of Irish Hospital Mortality (NAHM) has provided mortality data from 33 of the 44 publicly funded Irish hospitals. This data relates to acute cases admitted to hospital, where the principal reason for admission, established at time of discharge is one of six key diagnoses. Both chronic obstructive pulmonary disease (COPD) and pneumonia are extracted from the NAHM report as these have not been captured as part of the NHQRS data set.

The purpose of the NAHM report is to provide an analysis of in-hospital mortality to patients, the public and the wider healthcare system, and to communicate the recommendations made on the basis of the findings. This report provides reassurance that there is a process in place to monitor mortality data, and any outliers are acted upon and the learnings shared.

Rationale for measurement:

It is important that every hospital measures and monitors mortality from specific conditions. Over the past two decades in-hospital mortality patterns have been used as one key indicator of quality of care internationally.

Measurement methodology:

Standardised Mortality Ratio (SMR) is a commonly used statistical method for examining hospital mortality patterns within a country or within a group of hospitals. The SMR compares the observed number of deaths to the expected number of deaths for a specific diagnosis. The graphs beneath are used to assess performance outcomes for individual Hospitals in comparison to the national average (straight line). The dashed lines in each graph represent the 99.8% control limits. It is very unlikely a Hospital would lie outside these limits by chance. A finding of a statistical outlier does not indicate that a hospital is providing poor quality of care, but rather that there is a difference between the expected value and the result that is unlikely to have arisen from random variation alone.

Only hospitals with 100 or more admissions in each diagnosis are included for analysis by NAHM in order to ensure statistical reliability.

Chronic obstructive pulmonary disease (COPD) is a disease that causes inflammation of the lungs and obstruction of the airways which is usually progressive and only partially reversible. It may be a life-threatening condition and is one of the most common respiratory diseases in Irish adults. It usually affects people over the age of 35 years. The disease causes increasing breathlessness, a chronic cough and increasing mucous production. Severe cases can result in frequent intervention at primary care level, hospital admissions, and often premature death. It is a significant cause of morbidity and mortality in Ireland. The most common specific cause of emergency hospital admission among adults in Ireland is COPD.

• Beaumont Hospital is outside the expected control limits. An audit of COPD 2019 data has taken place in Beaumont and this audit demonstrated significantly improved performance
• Cavan General Hospital, Connolly Hospital and Drogheda Hospital are within the expected control limits

Pneumonia is an acute inflammatory condition (swelling) of the tissue in one or both lungs. There are clusters of tiny air sacs at the end of the breathing tubes in the lungs, which will fill with air when lungs are healthy. If an individual has pneumonia, these tiny sacs become inflamed and fill up with fluid, which makes breathing painful and limits oxygen intake.

• Beaumont Hospital and Connolly Hospital are outside the expected control limits
• Cavan General Hospital and Drogheda Hospital are within the expected control limits

Introduction

The Irish National Audit of Stroke (INAS) provides an annual report in conjunction with the National Office of Clinical Audit (NOCA). The aim of collecting and publishing this data is to assist in monitoring and improving stroke services. It also allows individual units to benchmark their performance against other units in Ireland.

Rationale for measurement

Door to Imaging (DTI): this is a term used to indicate the time interval between the arrival of the patient at the hospital and the time of the first brain scan. The acute management for ischaemic and haemorrhagic strokes differs substantially.  Timely performance of a brain scan is the only reliable method of distinguishing between an ischemic and haemorrhagic cause.

Door to needle (DTN): this is a term used to indicate the time interval between the arrival of the patient at the hospital and the time of thrombolysis treatment (using medication to breakdown blood clots which have formed in blood vessels) where clinically indicated. Thrombolysis can be of benefit to patients with acute ischaemic stroke, therefore not all patients who receive imaging will meet the criteria for thrombolysis. The window of opportunity for effective thrombolysis is four and a half hours from the onset of the stroke.

Measurement Methodology and data sources 

Targets

• Door to imaging: < 60 minutes of arrival at hospital (Royal College of Physicians, 2016)
• Door to needle time < 60 minutes (Irish Heart Foundation, 2015)

Performance

Door to Imaging (DTI)

• Beaumont Hospital is achieving target of 60 minutes in Q4 2021
• Cavan, Connolly and Drogheda Hospitals are not achieving target of 60 minutes in Q4 2021

Door to needle (DTN)

• Beaumont and Connolly Hospitals are achieving target of 60 minutes in Q4 2021
• Cavan and Drogheda Hospitals are not achieving target of 60 minutes in Q4 2021
• Thrombolysis can be of benefit to patients with acute ischaemic stroke, therefore not all patients who receive imaging will meet the criteria for thrombolysis

Rationale for measurement

A stroke occurs when the blood supply to the brain is interrupted or reduced. This deprives the brain of oxygen and nutrients, which can cause the brain cells to die. A stroke may be caused by a blocked artery (ischaemic stroke) or the leaking or bursting of a blood vessel (haemorrhagic stroke). Thrombolysis is a treatment to dissolve clots in blood vessels, improve blood flow, and thus help prevent damage to tissues and organs. Thrombolysis can be of benefit in patients with acute ischaemic stroke. The window of opportunity for effective thrombolysis is four and a half hours from the onset of the stroke. Therefore within that timeframe, a firm diagnosis of ischaemic stroke must be made.

Measurement methodology and data sources:

Periodic local data extracts extrapolated for analysis and publication

Rationale for measurement

Stroke is known to be a leading cause of disability and death in patients worldwide. Care in a Stroke Unit is provided in hospital by nurses, doctors and therapists who specialise in looking after stroke patients and work as a co-ordinated team. Evidence shows, that patients who receive this type of care are more likely to survive their stroke, return home and become independent in caring for themselves. Hospital based Stroke Units are associated with a reduction in death and institutional care of around 20%, with one additional patient returned to community living for every 20 patients treated (Stroke Clinical Care Programme, 2012).

Measurement methodology and data sources

KPI1 % of acute stroke patients who spend all or some of their hospital stay in an acute or combined stroke unit*

KPI2 For acute stroke patients admitted to an acute or combined stroke unit, the % of their hospital stay spent in the stroke unit*

KPI3 % of patients with confirmed acute ischaemic stroke who receive thrombolysis

The data is recorded at hospital level via a Stroke Portal within the HIPE file and data is collected by clinical staff. The data is reported quarterly to the BIU via the Health Pricing Office and the National Stroke Programme.

*A Stroke Unit is defined by the European Stroke Organisation as: “a geographically discreet area with the capacity to monitor and regulate basic physiological function, access to immediate imaging and is staffed by a specialist multidisciplinary team”.

Targets

KPI1 90% of acute stroke patients are admitted to an acute or combined stroke unit

KPI2 90% of hospital stay for acute stroke patients should be spent in an acute or combined stroke unit

KPI3 12% of patients with confirmed acute ischaemic stroke receive thrombolysis

Performance

2021 Q4 is reported

• RCSI Hospitals are not achieving target of 90%
• KPI 1 data includes Stroke/ICU/CCU/HDU beds as applicable

• RCSI Hospitals are not achieving target of 90%
• KPI 2 data includes Stroke/ICU/CCU/HDU beds as applicable

• Beaumont Hospital is exceeding target of 12%
• Connolly, Drogheda and Cavan Hospitals are below target of 12%
• KPI 3 data includes Stroke/ICU/CCU/HDU beds as applicable

Introduction

Deep vein thrombosis (DVT, the formation of a blood clot in a deep vein) and pulmonary embolism (PE, a blood clot that travels to the lungs), known together as venous thromboembolism (VTE), comprise the most common preventable cause of hospital-related death. There are 5,000 cases of VTE in Ireland each year. Recent international data suggests that over 50 per cent of all VTE events are hospital acquired (defined as a VTE event occurring during hospital admission or within 90 days of discharge).

There are certain groups of hospital patients that are at increased risk of VTE, including maternity patients, patients with cancer, having surgery, patients who have had with major trauma or patients who have been immobilized. There is strong evidence that (1) by taking specific steps to identify high-risk hospital patients (risk assessment) and (2) by implementing VTE prevention measures where appropriate,  up to 70% of these VTE events can be prevented thus saving lives.

Currently robust data relating to patterns of VTE incidence within the Republic of Ireland is lacking. A recent study⁽¹⁾ from Ireland East Hospital Group suggested an incidence of 1.44 (95% CI 1.36 to 1.51) per 1000 per annum. A 2018 National Medication Safety Improvement Programme HSE (Quality Improvement Division) report⁽²⁾ cited an incidence of 8 per 1000 discharges. UK incidence rates have been reported as 1–2 per 1,000.

Rationale for measurement

It is estimated that 70% of healthcare-associated VTE is potentially preventable with appropriate VTE prophylaxis. A VTE risk assessment performed on admission and at 24 hours (at a minimum) identifies which risks are present and clarifies whether the overall risk is high enough that the patient needs VTE prophylaxis.

Measurement methodology and data sources:

Number of hospital-acquired venous thromboembolism (VTE, blood clots) for each quarter, compared to the number of discharges for that period

• Local HIPE Data extrapolated quarterly for analysis and publication
• Local hospital data

Numerator: Number of hospital-acquired VTE per quarter

Denominator: Number of inpatient discharges for that period

Performance

• Beaumont Hospital performance is above the rate of 0.8 for Q2-21
• Connolly, Cavan and Monaghan, Drogheda and Louth County Hospitals’ performance are below the rate of 0.8 for Q2-21.
• no national comparable data is available, RCSI HG data presents only those cases which have been confirmed as Hospital Acquired VTE

Ref:
1. Hospital-acquired venous thromboembolism: Barry Kevane, Mary Day, Noirin Bannon, Leo Lawler, Tomas Breslin, Claire Andrews, Howard Johnson, Michael Fitzpatrick, Karen Murphy, Olivia Mason, Annemarie O’Neill, Fionnuala Donohue, Fionnuala Ní Áinle. BMJ Open Jun 2019, 9 (6) e030059; DOI: 10.1136/bmjopen-2019-03005
2. Preventing blood clots in Hospitals. Improvement Collaborative Report National Recommendations and Improvement Toolkit. July 2018. National Medication Safety Improvement Programme HSE Quality Improvement Division