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25 July
Comments Off on Hospital death rates higher than expected

Hospital death rates higher than expected

Mortality rates: John Hunter’s rate for haemorrhagic stroke improved between 2009 and 2015 from higher than expected to no different than expected. Cessnock Hospital had a similar improvement for heart attack.PATIENTS who attend John Hunter Hospital for ischaemic stroke, chronic obstructive pulmonary disease (COPD)or hip fracture surgeryare dying at a rate “higher than expected”considering their ages and conditions when compared to counterparts in other hospitals, according to new data.
Nanjing Night Net

The Bureauof Health Information’sreport Exploring clinical variation in mortality analyses deathwithin 30 days of hospitalisation for seven different conditions as either lower than,higher than, or no different to the expected rate.

BHI chief executive Dr Jean-Frederic Levesque said the July 2012 to June 2015 data assessed a patient’s “entire journey”, from diagnosis in the emergency department to care provided on the ward.

“Patients in NSW can trust the care they receive,” he said. “We provide this information so hospitals can target their assessments to further improve quality of care.”

Hunter New England Health executive director of greater metropolitan health servicesKaren Kelly said it had undertaken an “extensive review” of the data. “In response, we also conducted our own audit of patient information for the identified chronic diseases,” she said. “The results tell us that overall patients consistently received timely and appropriate care for all of these conditions.

“We haveidentified opportunities to improve the clinical pathways for these conditions andstrategies will be put into place with the aim of improving outcomes.”

Dr Levesquesaid there had been a “substantial improvement” in NSW death rates for all sevenconditions over the past 15 years, including a 41 per cent decrease forheart attack, which now has the equal lowest rate.

Calvary Mater Newcastle is one of only four NSW hospitals to record higher than expected death rates for heart attack:10.3 per cent compared to a NSW figure of 6.9 per cent. This is up from 2009 to 2012, when its rate was no different than expected. Its ratefor COPD also grewto higher than expected. Chief executive officer Greg Flint said it would“assess and enhance the clinical pathways for the conditions highlighted”.

DrLevesque said NSW death rates fell most sharplybetween the two time periods for ischaemic stroke. At John Hunter, its rate hasbeenhigher than expected for the past six years. Ms Kelly said it had a highproportion of severe stroke patientsbecause of its dedicated stroke unit. Its rates for COPD and hip fracture surgery grew to higher than expected.

Belmont Hospital’s death rates for congestive heart failure and COPD also rose to higher than expected. It is the only Hunter hospital with a lower than expected rate, for ischaemic stroke.

Statement fromCalvary Mater Newcastle (CVM) chief executive officerGreg FlintCalvary Mater Newcastle is the major cancer care centre and palliative care service for the Hunter New England Local Health District.

CMN delivers more than 320,000 occasions of outpatient services and in excess of 16,000 inpatient treatments per year.

Further to the latest BHI report, CMN also conducted a general audit on the conditions reported on by the BHI.

CMN dedicates significant time to improve and strengthen clinical pathways to ensure that our patients are getting to where they need to be quicker and therefore start their treatment faster.

Work has already begun to assess and enhance the clinical pathways for the conditions highlighted in the most recent BHI report. This will ensure we continue to improve the quality of care we provide for our community.

CMN regularly reviews its performance and clinical outcomes. CMN submits data to the Australian Council on Healthcare Standards and submits data for comparative purposes to the Health Roundtable. Performance is also reviewed with Hunter New England Local Health District.

Acute Myocardial Infarction (AMI)

An older and frailer cohort of people present to CMN with AMI compared to NSW state averages.

The BHI Report identified that patients who presented to CMN with acute myocardial infarction had significantly higher rates of other chronic health conditions compared to NSW similar cohorts. These included: Hypertension (14.5% higher), Renal Failure (3.9% higher), Malignancy (2.1% higher), Dementia (0.9% higher).

Patients were also significantly older, with 41% of the presentations to CMN being 75 years or older when compared to 38% in NSW. Our audit showed that the average age of patients who died was 80 years.

Our own audit has shown that all patients were under the care of, or had a consultation with a cardiologist. Documentation on the Chest Pain Pathway indicates that all elements on the pathway are well adhered to at CMN.

A change in process for Cardiac Rehabilitation for AMI patients in the Coronary Care Unit at CMN has seen a marked improvement in inpatient cardiac rehabilitation review and outpatient cardiac rehabilitation referrals. This also included an improvement in education for the patient upon discharge and providing individualised care plans to patients.

CMN will make some adjustments to the current process and documentation of the cardiac rehabilitation inpatient review system to indicate when patients have received a cardiac rehabilitation review while an inpatient.

CMN will improve the documentation of education provided to cardiac patients during admission and at discharge through the development of a check list.

Chronic Obstructive Pulmonary Disease (COPD)

Patients presenting to CMN with COPD had one or more significant chronic health condition.

Significant co-morbidity and patient factors among the CMN patients were higher than the NSW index. These included pulmonary circulation disorders, congestive heart failure, fluid and electrolyte disorders, cardiac arrhythmia, solid tumour without metastasis, metastatic cancer, diabetes (complicated), psychoses, lymphoma and liver disease.

Our audit has shown that an average of 93.5 percent of patients had their discharge summary provided to their primary care clinician within two days and there was improved use of antibiotics in the audit period.

Improvements can be made to the number of referrals to pulmonary rehabilitation and patient education relating to COPD, including smoking cessation. There has been some improvement from 2014 to 2016, reflecting a slight increase of consults by the Chronic Disease Nurse.

Spirometry (a test that can help diagnose various lung conditions, most commonly COPD) was not well attended within 24 hours of admission and decreased in 2016, while previous patient history spirometry attendance was not well documented. This is anticipated to improve with spirometry being added to the Clinical Application Portal in the future.

It is recommended that spirometry education and training for nursing staff is provided with a review of available equipment and spirometry be attended in the emergency department to determine baseline and confirm diagnosis.

It is also recommended that promotion of the referral and access to a Chronic Disease Nurse is increased and supported to include Congestive Cardiac Failure and diabetes in their service to COPD patients.

Statement from Hunter New England Health executive director of general metropolitan health services Karen KellyHunter New England Health has undertaken an extensive review of the BHI data. In response, we also conducted our own audit of patient information for the identified chronic diseases.

The results of our audit tell us that overall patients consistently received timely and appropriate care for all of these conditions.

We haveidentified opportunities to improve the clinical pathways for these conditions andstrategies will be put into place with the aim of improving outcomes in patient care.

For each condition, improvement strategies include:

Chronic Obstructive Pulmonary Disease: The Respiratory Stream has identified COPD management as a priority on the 2017 annual plan with specific focus on expansion of John Hunter Hospital’s AcuteNon-Invasive Ventilationservice to other sites using a telehealth model, increasing the number of patients having access to quit smoking programs and increasing the uptake and completion of pulmonary rehabilitation programs.

Hip Fracture: Consolidate the implementation of the Australian Commission on Safety and Quality in Health Care Clinical Care Standard,Hip Fracture Care.

Ischemic Stroke: Improve access to dedicated stroke beds or units as a priority.

Congestive Heart Failure: Development of a check list for best practice in the management of Congestive Heart Failure. Increase referrals to community and primary care for early intervention

Hunter New England Health is also rolling out the use of electronic discharge summaries, which will improve the information patients get when they leave the hospital and the communication to GPs and other care providers. This will enhance the coordination of follow-up care.

John Hunter Hospital

John Hunter Hospital is the tertiary referral centre for the entire northern NSW region with more than 76,000 presentations each year to our emergency department.

John Hunter Hospital is also the Major Trauma Service for Northern NSW and the only one outside of Sydney.

The hospital provides a full spectrum of care for patients along with education, clinical support and workforce development and treats the more seriously ill patients transferred for more specialised care.

Many patients receiving care in these categories are transferred to John Hunter Hospital from other hospitals.

Hospitals right across the district transfer patients to John Hunter Hospital for its highly specialised services. Often patients are first treated and stabilised in their local facility, but then transferred to John Hunter Hospital for further treatment.

Ischaemic stroke: John Hunter Hospital has a renowned stroke service with a track record of world-class care for patients who present with stroke.

The quality of stroke care we provide and the fact we have a dedicated stroke unit means that a high proportion of severe stroke patients present at John Hunter Hospital.

Our stroke team prides itself on accurate diagnosis and assessment of initial stroke severity. Since early 2016 this has been done with the assistance of more sophisticated imaging, including the Bi Plane Angiography.

We acknowledge that travel distances between people’s homes and hospitals in the rural areas where patients are being transferred from means that it can take longer for them to start receiving the care. We have begun work that focuses on reducing the time it takes to start treatment for a number of conditions.

We are also strengthening our relationship with NSW Ambulance, with initiatives such as the on-route thrombolysis program and stroke by-pass protocol. These initiatives mean that suspected stroke patients can begin receiving treatment while they are on their way to hospital.

We are always working to improve stroke management at John Hunter Hospital. We have recently expanded our Acute Stroke Unit four to 12 beds. This will improve the delivery of care, rehabilitation and outcomes for stroke patients. In addition, our Stroke Team is at the cutting edge of research, working to find ways to provide better care for our patients.

Research has shown that initial stroke severity at onset is the most powerful determinant of mortality and dependency. Since initial stroke severity was not recorded in the BHI data, small differences in the severity case mix could explain the small absolute difference in average 30 day mortality, which gave a higher than expected result.

Hip fracture surgery: Each year at John Hunter Hospital we admit more than 400 hip fracture patients who are older than 65 years of age. The BHI report shows that 94.7 percent of hip fracture patients between 2012 and 2015 were aged 65 years or older and 81.2 percent were aged 75 years or older.

In addition to this, our patients had more chronic diseases than the NSW index, including dementia and renal failure. Our audit data shows that John Hunter Hospital patients had a 6.6 percent higher incidence of dementia.

In early 2015, the Australian and New Zealand Guidelines for Hip Fracture Care were introduced and are now implemented for patients admitted with hip fractures. The Orthopaedic Clinical Nurse Consultant ensures all seven standards in the guidelines are followed for every patient. The BHI data will not yet reflect these changes in practice, but we would hope to see future improvement.

Since the introduction of the guidelines, 92 percent of patients at John Hunter Hospital have had their surgery within 48 hours of admission, receiving more timely and appropriate pain relief and being mobilised sooner.

Chronic Obstructive Pulmonary Disease: John Hunter Hospital audit data shows a relatively high proportion of our patients were experiencing acute respiratory failure. This may indicate that the COPD patients treated at John Hunter Hospital were very sick patients transferred for specialist and Intensive Care services.

Our internal audit of patient information showed that 94 percent of patients had one or more significant other chronic diseases, while a high proportion of patients (92 percent) were current or ex-smokers.

John Hunter Hospital patients had more chronic diseases than the NSW index, including Congestive Heart Failure, pulmonary circulation disorders, diabetes (complicated), other neuro disorders, psychoses and lymphoma.

To address this, we are creating medical records to accurately document COPD severity, in particular pre-existing COPD severity and other chronic diseases. This will enable more accurate prognosis and support treatment decisions for each patient.

Staff will also improve the promotion of interventional programs with evidence to improve COPD outcomes: including smoking cessation, pulmonary rehabilitation and co-ordination of care following discharge.

Belmont Hospital

Belmont Hospital is a community hospital with 23,000 presentations each year to the emergency department.

Many of the patients treated at Belmont Hospital live in the surrounding area. This has an impact on the type of conditions and the acuity of patients treated at the hospital. The patients presenting are older, with many other chronic diseases.

Belmont Hospital dedicates significant time to improving and strengthening clinical pathways to ensure that patients are getting to where they need to be quicker and therefore start their treatment faster.

Work has already begun to replicate this methodology for the conditions highlighted in the most recent report. This will ensure we continue to improve the quality of care we provide for our community.

Congestive heart failure: The BHI reports showed that Congestive Heart Failure patients at Belmont Hospital were older than their cohorts across NSW. 94 percent of patients were aged 65 years or older (90.2% NSW average) and 75 percent of patients were aged 75 years or older (73% NSW average).

The Belmont Hospital patients had more chronic diseases than the NSW cohort, including hypertension (27.4 percent higher), renal failure, other neuro disorders, fluid and electrolyte retention, metastatic cancer, three or more previous acute related admissions and paralysis.

Belmont Hospital is working to increase referrals to community-based clinical services for patients with heart failure conditions and introduce a checklist management guide to clearly identify best practice and allow staff to record adherence and completion of this.

Chronic Obstructive Pulmonary Disease: Cigarette smoking is the most significant risk factor for these patients and our audit showed that 98 percent of COPD patients reviewed at Belmont Hospital were former or current smokers.

Age also played a significant factor for COPD patients at Belmont Hospital, with the BHI report showing that 85.1 percent of patients were aged 65 years or older (79.5% NSW average) and 58.3 percent of COPD patients at Belmont Hospital were aged 75 years or older (50.7% NSW average).

Belmont Hospital COPD patients also had more chronic diseases than the NSW cohort, including congestive heart failure, diabetes (complicated), other neuro disorders, three or more previous acute related admissions, solid tumour without metastasis and fluid and electrolyte disorders.

 
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