Clinical Indicator Summary Guide 2012

Indicator Set

Anaesthesia

Anaesthesia

Anaesthesia

Anaesthesia

Anaesthesia

Anaesthesia

Anaesthesia

Version CI No.

5.1

5.1

5.1

5.1

5.1

5.1

5.1

Topic

Rationale

Total number of patients with a

documented pre-anaesthesia
assessment completed by an
anaesthetist prior to transfer to
the operating theatre or
procedure room, during the
time period under study

Total number of patients

who undergo a procedure
with an anaesthetist in
attendance, during the time
period under study.

High

95.0

96.8

100

1.1.1, 1.1.2,
Continuity of Care,
1.1.4, 1.1.6,
Process Appropriateness,
1.1.8, 1.3.1,
Effectiveness
1.4.1

High

97.1

98.9

100

Continuity of Care, 1.1.2, 1.1.3,

Process Appropriateness, 1.1.4, 1.1.8,
Effectiveness
1.3.1, 1.4.1

High

91.8

81.6

99.3

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of patients

who undergo a procedure
with an anaesthetist in
attendance during the time
period under study

High

98.9

100

100

Continuity of Care,
1.1.2, 1.1.4,
Structure Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of patients

who undergo a procedure
with an anaesthetist in
attendance, during the time
period under study

High

97.0

93.9

100

Continuity of Care, 1.1.2, 1.1.4,

Process Appropriateness, 1.1.8, 1.3.1,
Effectiveness
1.4.1

Low

0.063

0.016

0.085

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Low

0.72

0.019

1.01

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

1.2

Documentation of risks
and benefits of
anaesthesia

Consent for anaesthesia is a separate process

from consent for surgical procedures. Information
about anaesthesia and the risks associated with it
are a necessary part of the pre-anaesthesia
consultation process.

Total number of patients who

have documentation of risks and
benefits of the anaesthetic
procedure(s) during the time
period under study

Total number of patients

receiving anaesthesia care,
during the time period under
study

1.3

Prophylactic anti-emetic
treatment in patients with
a documented history of
post-operative nausea and
vomiting (PONV).

PONV is a frequent and distressing consequence

of many surgical procedures. There is a wealth of
literature highlighting known risk factors, and
international consensus guidelines for
prophylaxis.

Total number of patients with a

history of PONV to whom a
prophylactic anti-emetic has
been administered, during the
time period under study

Total number of patients

receiving anaesthesia care
who have a history of PONV,
during the time period under
study

3.1

3.2

Total number of patients who

undergo a procedure with an
The presence of a trained assistant for the
anaesthetist in attendance,
anaesthetist during the conduct of anaesthesia is
Presence of a trained
where there is a trained
a major contributory factor to safe patient
assistant.
assistant to the anaesthetist,
management.
during the time period under
study
Total number of patients who
undergo a procedure with an
Compliance of anaesthesia
anaesthetist in attendance,
An adequate anaesthesia record is an essential
records with ANZCA
where the anaesthesia records
part of the patients medical record and should
minimum requirements
chart all aspects of management relevant to the substantially complies with the
for anaesthesia
ANZCA requirements for the
anaesthetic.
information.
anaesthetic record, during the
time period under study
Total number of patients
undergoing a procedure who
The occurrence of a clinical event may indicate
require tracheal intubation or
less than optimal performance in anaesthesia.
Avoiding severe
insertion of a laryngeal mask (or
respiratory distress in the These indicators should encourage recovery room
equivalent) to relieve
staff to report any significant departure from the
recovery room
respiratory distress, in the
usual recovery process.
recovery period, during the time
period under study
Established protocol for
treatment for post
operative nausea and
vomiting in the post
anaesthesia recovery
room

ACHS Clinical Indicator Summary Guide 2012

As described above.

EQuIP5
Criterion

Denominator

1.1

2.2

Dimension of
Quality

Numerator

Consultation by an anaesthetist is essential for

Adequate pre-anaesthesia the medical assessment of a patient prior to
anaesthesia for surgery or other procedure to
consultation of the
ensure that the patient is in the optimal state for
surgical patient.
anaesthesia and surgery.

2.1

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Total number of patients

undergoing treatment for post
operative nausea and vomiting
in the post anaesthesia recovery
room according to a hospitalapproved protocol, during the
time period under studyperiod.

Total number of patients

receiving post-anaesthesia
care who are admitted to
the post anaesthesia
recovery room during the
time period under study

Total number of patients

receiving post-anaesthesia
care who are admitted to
the post anaesthesia
recovery room, during the
time period under study

Yes

Yes

Yes

Indicator Set

Anaesthesia

Anaesthesia

Anaesthesia

Anaesthesia

Anaesthesia

Anaesthesia

Anaesthesia

Version CI No.

5.1

5.1

5.1

5.1

5.1

5.1

5.1

Topic

Rationale

3.3

Inadvertent hypothermia
after surgery

3.4

Established protocol for

treatment of severe pain
in the post anaesthesia
recovery room

3.5

Unplanned recovery room

stay of longer than 2 hours As described above.
for medical reasons

4.1

Unplanned patient
admission to an intensive
care unit within 24 hours
of a procedure.

Unplanned admission to an intensive care unit

may be due to an avoidable incident in
anaesthesia.

5.1

Measurement and
documentation of pain
intensity scores after
major surgery.

Analgesic efficacy and the occurrence of clinical

events are an essential component of an acute
pain audit. Continuous collection of information
regarding major adverse events may allow a
more accurate estimation of the prevalence of
rare events over time.

5.2

At least daily review by an

anaesthetist of patients
receiving postoperative
As described above.
epidural analgesia, until
removal of catheter.

6.1

As described above.

As described above.

These indicators have been included to monitor

the incidence of complications and the process of
Minimisation of post-dural care for obstetric patients. Major regional
analgesia is a safe and effective method of pain
puncture headache.
relief during labour

ACHS Clinical Indicator Summary Guide 2012

Numerator

Total number of patients

admitted to the post
anaesthesia recovery room with
a temperature recorded in the
recovery period of less than 36
degrees, during the time period
under study
Total number of patients
undergoing a procedure who
are reviewed by an anaesthetist
to manage severe pain NOT
responding to the post
anaesthesia recovery room pain
protocol, in the recovery period,
during the time period under
study
Total number of patients
undergoing a procedure with an
anaesthetist in attendance who
have an unplanned stay in the
post anaesthesia recovery room
for longer than 2 hours for
medical reasons, during the time
period under study
Total number of patients having
an unplanned admission to an
intensive care unit within 24
hours of a procedure with an
anaesthetist in attendance,
during the time period under
study
Total number of surgical
patients staying at least one
night, with pain intensity scores
regularly recorded by nursing
staff, during the time period
under study
Total number of patients
receiving post-operative
epidural analgesia that are
reviewed at least daily by an
anaesthetist until removal of
catheter, during the time period
under study

Denominator

Total number of patients

receiving post-anaesthesia
care who are admitted to
the post anaesthesia
recovery room, during the
time period under study

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Yes

Dimension of
Quality

EQuIP5
Criterion

Low

0.18

0.012

0.22

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Total number of patients

receiving post-anaesthesia
care who are admitted to
the post anaesthesia
recovery room, during the
time period under study

Yes

Low

0.34

0.068

0.49

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Total number of patients

receiving post-anaesthesia
care who are admitted to
the post anaesthesia
recovery room, during the
time period under study

Yes

Low

1.03

0.089

1.13

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Low

0.17

0.025

0.20

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of patients

receiving anaesthesia care,
during the time period under
study

Yes

Total number of surgical

patients staying at least one
night who receive acute pain
management, during the
time period under study

Yes

High

95.3

89.0

100

Continuity of Care, 1.1.1, 1.1.2,

Process,
Appropriateness, 1.1.4, 1.1.8,
Outcome
Effectiveness
1.3.1, 1.4.1

Total number of patients

receiving post-operative
epidural analgesia, during
the time period under study

Yes

High

99.9

99.9

100

Continuity of Care, 1.1.1, 1.1.2,

Process,
Appropriateness, 1.1.4, 1.1.8,
Outcome
Effectiveness
1.3.1, 1.4.1

Low

0.46

0.29

0.47

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Total number of obstetric

Total number of obstetric
patients receiving
patients who experience a postepidural/spinal analgesia,
dural puncture headache, during
during the time period under
the time period under study.
study.

Yes

Indicator Set

Anaesthesia

Version CI No.

5.1

Topic

Rationale

6.2

Total number of patients who

commence surgery within 30
minutes of request for
immediate lower segment
cesarian section (LSCS), during
the time period under study

Total number of patients

requiring immediate lower
segment cesarian section
(LSCS), during the time
period under study.

Total number of obstetric

patients who have
documentation of risks and
benefits of spinal
analgesia/epidural, during the
time period under study.
Total number of patients
booked into a day procedure
facility who fail to arrive.

Anaesthesia

5.1

6.3

Day Surgery

1.1

Failure to arrive.

This indicator provides evidence of the

effectiveness of the booking system in a day
procedure facility.

1.2

Cancellation after arrival

due to pre-existing
medical conditions.

This indicator provides evidence of the

appropriateness of selection of patients for
management in a day procedure facility and the
appropriateness of the booking system.

Day Surgery

1.3

Cancellation after arrival

due to an acute medical
condition

Day Surgery

1.4

Cancellation after arrival

due to
As described above.
administrative/organisatio
nal reasons.

Day Surgery

2.1

Unplanned return to the

This indicator may reflect possible problems in
operating room during the
the performance of procedures.
same admission.

Day Surgery

Day Surgery

Denominator

Commencement of
surgery within 30 minutes
of a request for
As described above.
emergency caesarean
section.
Provision of patient
information regarding
risks and benefits of
As described above.
epidural / spinal analgesia
for labour.

Day Surgery

Numerator

As described above.

3.1

Unplanned overnight
admission.

This indicator may reflect possible problems in

the performance of procedures, or in the
appropriate selection of patients for management
in a day procedure facility.

4.1

Unplanned delay in
discharge of a patient
following
operation/procedure.

This indicator may reflect possible problems in

the administration of anaesthesia or sedation or
the selection of patients or other aspects of
management in a day procedure facility.

ACHS Clinical Indicator Summary Guide 2012

Total number of patients

booked into a day procedure
facility, whose procedure is
cancelled after their arrival at
the facility due to a pre-existing
medical condition.
Total number of patients
booked into a day procedure
facility, whose procedure is
cancelled after their arrival at
the facility due to an acute
medical condition.
Total number of patients
booked into a day procedure
facility, whose procedure is
cancelled after their arrival at
the facility due to
administrative/organisational
reasons.

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Dimension of
Quality

EQuIP5
Criterion

High

77.3

57.3

95.9

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of obstetric

patients receiving
epidural/spinal analgesia,
during the time period under
study.

High

57.7

28.4

99.8

Continuity of Care, 1.1.2, 1.1.3,

Process Appropriateness, 1.1.4, 1.1.8,
Effectiveness
1.3.1, 1.4.1

Total number of patients

booked into a day procedure
facility.

Low

0.93

0.023

1.08

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of patients

who arrive at the day
procedure facility for a
booked procedure.

Low

0.24

0.040

0.28

Continuity of Care, 1.1.1, 1.1.2,

Process Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Total number of patients

who arrive at the day
procedure facility for a
booked procedure.

Low

0.26

0.060

0.42

Continuity of Care, 1.1.1, 1.1.2,

Process Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Low

0.54

0.041

1.03

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Low

0.049

0.016

0.067

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Yes

Total number of patients

who arrive at the day
procedure facility for a
booked procedure.

Total number of patients

Total number of patients having
who have an operation/
an unplanned return to the
procedure performed in the
operating/procedure room.
day procedure facility.

Yes

Yes

Total number of patients having

a discharge intention of one day,
who had an unplanned transfer
or overnight admission (as
defined in the manual) following
an operation/procedure.

Total number of patients

who have an operation/
procedure performed in the
day procedure facility.

Yes

Low

1.23

0.090

1.99

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of patients who

have an unplanned delayed
discharge greater than 1 hour
beyond that expected for the
procedure.

Total number of patients

who have an operation/
procedure performed in the
day procedure facility.

Yes

Low

0.57

0.020

0.46

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Indicator Set

Emergency
Medicine

Emergency
Medicine

Emergency
Medicine

Emergency
Medicine

Emergency
Medicine

Emergency
Medicine

Emergency
Medicine

Version CI No.

Topic

Rationale

Numerator

Denominator

Triage systems are fundamental to the effective

management of emergency departments, as they
Total number of patients
ensure consistency and fairness for the patient
allocated ATS Category 1 who
requiring medical attention and provide an
are attended to immediately.
effective tool for departmental organisation,
monitoring, and evaluation.

Total number of patients

attending the emergency
department triaged to ATS
Category 1.

As described above.

Total number of patients

allocated ATS Category 2 who
are attended to within 10
minutes.

Total number of patients

attending the emergency
department triaged to ATS
Category 2.

As described above.

Total number of patients

allocated to ATS Category 3 who
are attended to within 30
minutes.

Total number of patients

attending the emergency
department triaged to ATS
Category 3.

As described above.

Total number of patients

allocated to ATS Category 4 who
are attended to within 60
minutes.

Total number of patients

attending the emergency
department triaged to ATS
Category 4.
Total number of patients
attending the emergency
department triaged to ATS
Category 5.

1.1

ATS Category 1 patients

attended to immediately

1.2

ATS Category 2 patients

attended to within 10
minutes

1.3

ATS Category 3 patients

attended to within 30
minutes

1.4

ATS Category 4 patients

attended to within 60
minutes

1.5

ATS Category 5 patients

attended to within 120
minutes

As described above.

Total number of patients

allocated to ATS Category 5 who
are attended to within 120
minutes.

2.1

Patients with an AMI

requiring thrombolysis
who receive thrombolytic
therapy within 30 minutes
of presentation to the ED,
as their primary treatment

Multi-centre studies have shown that the

mortality rate of AMI is directly proportional to
the time delay before the commencement of
definitive therapy. Thrombolytic therapy
administered within the first 90 minutes of
symptoms has been shown to reduce mortality
and infarction size in patients with AMI.

Total number of patients with

an AMI requiring thrombolysis
who receive thrombolytic
therapy within 30 minutes of
presentation to the ED, as their
primary treatment, during the 6
month time period.

Total number of patients

with an AMI requiring
thrombolysis who receive
thrombolytic therapy after
presentation to the ED,
during the 6 month time
period.

3.1

Patients admitted or
planned for admission
without reaching an
inpatient bed, transferred
to another hospital for
admission, or died in the
ED whose total ED time
from time of arrival
exceeded 8 hours

Access block has been strongly linked to

overcrowding in emergency departments, with
overcrowding referring to the situation where
emergency department function is impeded,
primarily by overwhelming of staff resources and
physical capacity by extreme numbers of patients
needing or receiving care.

Total number of patients

admitted or planned for
admission without reaching an
inpatient bed, transferred to
another hospital for admission,
or died in the ED whose total ED
time from time of arrival (as
defined in the manual)
exceeded 8 hours, during the 6
month time period.

Total number of patients

admitted or planned for
admission, transferred to
another hospital, or died in
the ED, during the 6 month
time period.

ACHS Clinical Indicator Summary Guide 2012

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Yes

Yes

Yes

Yes

Yes

High

99.5

High

77.0

High

High

High

High

Low

62.7

67.1

85.7

99.5

71.4

57.7

59.3

80.4

Dimension of
Quality

EQuIP5
Criterion

Continuity of Care,
1.1.1, 1.1.2,
Accessibility,
1.1.4, 1.2.2,
Appropriateness,
1.3.1, 1.4.1
Effectiveness

100

Process

94.2

Continuity of Care,
1.1.1, 1.1.2,
Accessibility,
1.1.4, 1.2.2,
Process
Appropriateness,
1.3.1, 1.4.1
Effectiveness

94.9

Continuity of Care,
1.1.1, 1.1.2,
Accessibility,
1.1.4, 1.2.2,
Process
Appropriateness,
1.3.1, 1.4.1
Effectiveness

97.4

Continuity of Care,
1.1.1, 1.1.2,
Accessibility,
1.1.4, 1.2.2,
Process
Appropriateness,
1.3.1, 1.4.1
Effectiveness

99.2

Continuity of Care,
1.1.1, 1.1.2,
Accessibility,
1.1.4, 1.2.2,
Process
Appropriateness,
1.3.1, 1.4.1
Effectiveness

Modified
for
2H2011

Care Planning and

Delivery,
Evaluation of Care,
1.1.2, 1.1.4,
Process Appropriateness
1.3.1, 1.4.1
of Care,
Effectiveness of
Care

Modified
for
2H2011

Care Planning and

Delivery,
Evaluation of Care,
Access &
1.1.2, 1.1.4,
1.2.2, 1.3.1,
Process Admission,
Appropriateness
1.4.1
of Care,
Effectiveness of
Care

Indicator Set

Emergency
Medicine

Emergency
Medicine

Emergency
Medicine

Emergency
Medicine

Emergency
Medicine

Version CI No.

Topic

Rationale

Numerator

Denominator

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

As described above.

Total number of mental health

admitted patients (as defined in
the manual) whose total ED
time from time of arrival (as
defined in the manual)
exceeded 4 hours, during the 6
month time period.

Total number of mental

health patients (as defined
in the manual) who were
admitted, during the 6
month time period.

Low

Modified
for
2H2011

Process

As described above.

Total number of critical care

admitted patients (as defined in
the manual) whose total ED
time from time of arrival (as
defined in the manual)
exceeded 4 hours, during the 6
month time period.

Total number of critical care

patients (as defined in the
manual) who were
admitted, during the 6
month time period.

Low

Modified
for
2H2011

Process

Process

Dimension of
Quality

Care Planning and

Delivery,
Evaluation of Care,
Access &
Admission,
Appropriateness
of Care,
Effectiveness of
Care
Care Planning and
Delivery,
Evaluation of Care,
Access &
Admission,
Appropriateness
of Care,
Effectiveness of
Care
Accessment, Care
Planning and
Delivery,
Evaluation of Care,
Ongoing Care,
Access &
Admission,
Appropriateness
of Care,
Effectiveness of
Care
Accessment, Care
Planning and
Delivery,
Evaluation of Care,
Ongoing Care,
Access &
Admission,
Appropriateness
of Care,
Effectiveness of
Care

EQuIP5
Criterion

3.2

Mental health admitted

patients whose total ED
time from time of arrival
exceeded 4 hours

3.3

Critical care admitted

patients whose total ED
time from time of arrival
exceeded 4 hours

4.1

A reduction of turnaround times (patient

presentation to either discharge or hospital
admission) improves the efficiency of the
The mean time (in
emergency department, and positively influences
minutes) from referral by
the patients perceptions of the health care
an ED clinician to the
organisation and its services. Studies have shown
mental health team to
that patients presenting with mental health
assessment by a mental
problems are in the emergency department
health worker
longer on average than medical patients, and are
one of the most common groups affected by
access block and overcrowding.

The mean time (in minutes)

from referral by an ED clinician
to the mental health team to
assessment by a mental health
worker, during the 6 month time
period.

The total number of patients

presenting to the ED with a
discharge ICD-10 code of F20F69, during the 6 month
time period.

Low

New
indicator
for
2H2011

4.2

The median time (in

minutes) from referral by
an ED clinician to the
As described above.
mental health team to
assessment by a mental
health worker

The median time (in minutes)

from referral by an ED clinician
to the mental health team to
assessment by a mental health
worker, during the 6 month time
period.

The total number of patients

presenting to the ED with a
discharge ICD-10 code of F20F69, during the 6 month
time period.

Low

New
indicator
for
2H2011

Process

5.1

Although morbidity and mortality rates have

significantly improved during the past decades,
severe sepsis remains one of the leading causes
The mean time (in
of death in infants. The term neonatal sepsis has
minutes) from time of
been conventionally referred to as bacteraemia
arrival to time of first
antibiotic administration accompanied by haemodynamic compromise and
in infants less than 28 days systemic signs of infection. Neonates are the
most susceptible of all age groups to infectious
of age with a primary
pathogens, in part because they are
discharge diagnosis of
immunocompromised with host response shifted
sepsis
towards immune tolerance rather than defence
from infection.

The mean time (in minutes)

from time of arrival to time of
first antibiotic administration in
infants less than 28 days of age
with a primary discharge
diagnosis of sepsis (ICD-10
code), during the 6 month time
period.

The total number of infants

less than 28 days of age
discharged from the ED with
a primary diagnosis of sepsis
(ICD-10 code), during the 6
month time period.

New
indicator
for
2H2011

Care Planning and

Delivery,
Evaluation of Care,
1.1.2, 1.1.4,
Appropriateness
1.3.1, 1.4.1,
Process
of Care,
1.5.2
Effectiveness of
Care, Infection
Control

ACHS Clinical Indicator Summary Guide 2012

Low

1.1.2, 1.1.4,
1.2.2, 1.3.1,
1.4.1

1.1.2, 1.1.4,
1.2.2, 1.3.1,
1.4.1

1.1.1, 1.1.2,
1.1.4, 1.1.6,
1.2.2, 1.3.1,
1.4.1

1.1.1, 1.1.2,
1.1.4, 1.1.6,
1.2.2, 1.3.1,
1.4.1

Indicator Set

Emergency
Medicine

Emergency
Medicine

Emergency
Medicine

Emergency
Medicine

Version CI No.

5.2

6.1

6.2

7.1

Topic

Rationale

Paediatric patients who

presented to the ED with
asthma and received
salbutamol therapy within
30 minutes of arrival

Following early recognition, recommended

management of an acute exacerbation of asthma
in the emergency department is treatment aimed
at immediate correction of hypoxaemia, rapid
reversal of airflow obstruction, and prevention of
progression or recurrence of symptoms.

Patients 65 years or older

discharged from the ED to
home or residential
accommodation with
discharge communication
provided to a primary care
provider

Older people are particularly vulnerable when

discharged home from the emergency
department5-6, with studies revealing that
almost 40% of these patients report some kind of
unmet need7, and over 50% are unable to carry
out basic activities of daily living6. Effective
assessment, communication, and liaison are seen
as integral to the provision of high quality care of
the older person in the emergency department
and to continuity of care between sectors.

Patients 65 years or older

who have had a
documented risk
assessment prior to
As described above.
discharge from the ED to
home or residential
accommodation

Adult patients who

presented to the
emergency ED with
abdominal or limb pain
and have a documented
initial pain assessment
score

ACHS Clinical Indicator Summary Guide 2012

Acute abdominal pain is the most common

reason for attending an emergency department
in Australia and internationally, accounting for
around one third of all pain presentations. Acute
abdominal pain is a symptom of many conditions,
ranging from low acuity to high acuity and lifethreatening, and identifying the cause and
establishing a definitive diagnosis is often difficult.
Limb pain is also a common reason for attending
an emergency department, particularly in the
elderly, and includes strains, sprains, dislocations,
and fractures.

Numerator

The number of paediatric

patients who presented to the
ED with asthma and received
salbutamol therapy within 30
minutes of arrival, during the 6
month time period

The number of patients 65 years

or older discharged from the ED
to home or residential
accommodation with discharge
communication provided to a
primary care provider, during
the 6 month time period.

The number of patients 65 years

or older who have had a
documented risk assessment
prior to discharge from the ED
to home or residential
accommodation, during the 6
month time period.

The number of adult patients

who presented to the
emergency ED with abdominal
or limb pain and have a
documented initial pain
assessment score, during the 6
month time period.

Denominator

The total number of

paediatric patients who
presented to the ED with a
primary diagnosis of asthma
(ICD-10 code), during the 6
month time period.

The total number of patients

65 years or older discharged
from the ED to home or
residential accommodation,
during the 6 month time
period.

The total number of patients

65 years or older discharged
from the ED to home or
residential accommodation,
during the 6 month time
period.

The total number of adult

patients who presented to
the ED with abdominal or
limb pain, during the 6
month time period.

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Low

High

High

High

Dimension of
Quality

EQuIP5
Criterion

New
indicator
for
2H2011

Continuity of Care, 1.1.1, 1.1.2,

Process Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

New
indicator
for
2H2011

Accessment, Care
Planning and
Delivery,
Evaluation of Care,
Discharge/Transfe
r, Ongoing Care,
Process
Health Record
Documentation,
Appropriateness
of Care,
Effectiveness of
Care

1.1.1, 1.1.2,
1.4.1, 1.1.5,
1.1.6, 1.1.8,
1.3.1, 1.4.1

New
indicator
for
2H2011

Accessment, Care
Planning and
Delivery,
Evaluation of Care,
Discharge/Transfe
r, Ongoing Care,
Process
Health Record
Documentation,
Appropriateness
of Care,
Effectiveness of
Care

1.1.1, 1.1.2,
1.4.1, 1.1.5,
1.1.6, 1.1.8,
1.3.1, 1.4.1

New
indicator
for
2H2011

Accessment, Care
Planning and
Delivery,
Evaluation of Care,
1.1.1, 1.1.2,
Health Record
1.1.4, 1.1.8,
Process
Documentation,
1.3.1, 1.4.1
Appropriateness
of Care,
Effectiveness of
Care

Indicator Set

Emergency
Medicine

Emergency
Medicine

Emergency
Medicine

Emergency
Medicine

Version CI No.

Topic

Rationale

Numerator

Denominator

The total number of adult

The number of adult patients
patients who presented to
who presented to the ED with
the ED with abdominal or
abdominal or limb pain and have
limb pain and had a
a documented pain
documented initial pain
reassessment score, during the
assessment score, during the
6 month time period.
6 month time period.

7.2

Adult patients who

presented to the ED with
abdominal or limb pain
and have a documented
pain reassessment score

7.3

Acute pain is one of the most common reasons

why both adults and children present to an
Adult patients who
emergency department in Australia and
presented to the ED with
internationally. Level I evidence reveals that
abdominal or limb pain
opioid analgesics improve patient comfort
and received analgesic
without increasing the risk of errors in diagnosis
therapy within 30 minutes
and treatment, and can be safely administered
of presentation
before full assessment and diagnosis in acute
abdominal pain.

The number of adult patients

who presented to the ED with
abdominal or limb pain and
received analgesic therapy
within 30 minutes of
presentation, during the 6
month time period.

The total number of adult

patients who presented to
the ED with abdominal or
limb pain, during the 6
month time period.

7.4

Paediatric patients who

presented to the ED with a
primary diagnosis of limb
fracture and received
As described above.
analgesic therapy within
30 minutes of
presentation

The number of paediatric

patients who presented to the
ED with a primary diagnosis of
limb fracture (ICD-10 code) and
received analgesic therapy
within 30 minutes of
presentation, during the 6
month time period.

The total number of

paediatric patients who
presented to the ED with a
primary diagnosis of limb
fracture (ICD-10 code),
during the 6 month time
period.

8.1

Patients who present to an emergency

department and leave before medical assessment
represent a significant problem. These patients
Patients presenting to the who did not wait have been triaged and may or
may not have been given preliminary treatment,
ED with a mental health
but have decided to leave prior to being assessed
complaint who did not
wait after having clinical by a medical officer. There is limited follow up
information documented data for these patients, but they are unlikely to
be satisfied with the quality of the service
about their presenting
provided, might be at risk from conditions that
complaint
have not been assessed or treated, and could
potentially have unrecognised poor outcomes
from lack of treatment.

ACHS Clinical Indicator Summary Guide 2012

As described above.

The number of patients

presenting to the ED with a
mental health complaint who
did not wait after having clinical
information documented about
their presenting complaint,
during the 6 month time period.

The total number of patients

presenting to the ED with a
mental health complaint,
during the 6 month time
period.

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

High

High

High

Low

Dimension of
Quality

EQuIP5
Criterion

New
indicator
for
2H2011

Accessment, Care
Planning and
Delivery,
Evaluation of Care,
1.1.1, 1.1.2,
Health Record
1.1.4, 1.1.8,
Process
Documentation,
1.3.1, 1.4.1
Appropriateness
of Care,
Effectiveness of
Care

New
indicator
for
2H2011

Accessment, Care
Planning and
Delivery,
Evaluation of Care,
1.1.1, 1.1.2,
Health Record
1.1.4, 1.1.8,
Process
Documentation,
1.3.1, 1.4.1
Appropriateness
of Care,
Effectiveness of
Care

New
indicator
for
2H2011

Accessment, Care
Planning and
Delivery,
Evaluation of Care,
1.1.1, 1.1.2,
Health Record
1.1.4, 1.1.8,
Process
Documentation,
1.3.1, 1.4.1
Appropriateness
of Care,
Effectiveness of
Care

New
indicator
for
2H2011

Accessment, Care
Planning and
Delivery,
Evaluation of Care,
Ongoing Care,
Health Record
Process Documentation,
Access &
Admission,
Appropriateness
of Care,
Effectiveness of
Care

1.1.1, 1.1.2,
1.1.4, 1.1.6,
1.1.8, 1.2.2,
1.3.1, 1.4.1

Indicator Set

Emergency
Medicine

Gastrointestinal
Endoscopy

Gastrointestinal
Endoscopy

Gastrointestinal
Endoscopy

Gastrointestinal
Endoscopy

Gastrointestinal
Endoscopy

Version CI No.

Topic

Rationale

Numerator

The number of patients

presenting to the ED who did
The total number of patients
not wait after having clinical
presenting to the ED, during
information documented about
the 6 month time period.
their presenting complaint,
during the 6 month time period.

8.2

Patients presenting to the

ED who did not wait after
having clinical information As described above.
documented about their
presenting complaint

1.1

Colonoscopy is the optimal procedure for

Incomplete colonoscopies examining the colon and thus the completion rate Total number of incomplete
should be high. A low complication rate is
performed
colonoscopies performed.
desirable.

1.2

Patients treated for

possible perforation
following polypectomy

1.3

1.4

2.1

Patients treated for

possible perforation not
related to polypectomy

Patients who have

bleeding.

Patients treated for

possible perforation
related to dilation.

ACHS Clinical Indicator Summary Guide 2012

Denominator

As described above.

As described above.

Total number of
Total number of patients
colonoscopies less total
treated for possible perforation
number of colonoscopy with
not related to polypectomy.
polypectomies.

A low complication rate is desirable.

Total number of patients who

have bleeding.

Low

Total number of
colonoscopies.

Total number of patients

Total number of
treated for possible perforation
colonoscopy with
who have had a polypectomy
polypectomies.
performed.

As described above.

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Yes

Yes

Yes

Total number of
colonoscopy with
polypectomies.

Total number of patients

Total number of
treated for possible perforation
oesophageal dilatations.
related to dilation.

Yes

Yes

Low

Low

Low

Low

Low

Accessment, Care
Planning and
Delivery,
Evaluation of Care,
Ongoing Care,
Health Record
Process Documentation,
Access &
Admission,
Appropriateness
of Care,
Effectiveness of
Care

New
indicator
for
2H2011

1.37

0.062

0.036

0.068

0.13

Dimension of
Quality

0.28

0.046

0.023

EQuIP5
Criterion

1.1.1, 1.1.2,
1.1.4, 1.1.6,
1.1.8, 1.2.2,
1.3.1, 1.4.1

2.10

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

0.073

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

0.038

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

0.33

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

0.13

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

0.14

Indicator Set

Gastrointestinal
Endoscopy

Gastrointestinal
Endoscopy

Gastrointestinal
Endoscopy

Version CI No.

2.2

Patients treated for

possible perforation
secondary to instrument
related causes

2.3

As described above.

Total number of patients

Total number of upper GIT
treated for possible perforation
polypectomies.
related to polypectomy.

3.1

Patients having an
overnight stay as a result
of aspiration.

Total number of patients

May reflect possible problems in the performance transferred or admitted for an
overnight stay as a result of
of anaesthesia.
aspiration.

Gynaecology

1.2

Gynaecology

Denominator

Patients treated for

possible perforation
related to upper GIT
polypectomy

1.1

Gynaecology

Numerator

As described above.

Rationale

Total number of patients

Total number of
treated for possible perforation
gastroscopies less dilatations
secondary to instrument related
and polypectomies.
causes.

Gynaecology

Gynaecology

Topic

2.1

Total number of patients

who have an endoscopy
procedure (involving
sedation).

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Yes

Yes

This indicator has been included as an index of

unintentional intra-operative morbidity
associated with gynaecological procedures.

Total number of patients

suffering injury to a major viscus
Total number of patients
with repair, during a
undergoing gynaecology
gynaecological operative
surgery.
procedure or subsequently up to
2 weeks post-operatively.

3.1

Laparoscopic
These indicators have been included as an index
gynaecological surgery for of the utilisation of a laparoscopic approach for
injury to a major viscus
gynaecological surgery.

Total number of patients

receiving an injury to a major
Total number of patients
viscus with repair, during a
undergoing laparoscopic
laparoscopic gynaecological
gynaecological operative
operative procedure or
procedure.
subsequently up to 2 weeks postoperatively.

3.2

Laparoscopic
gynaecological surgery for As described above.
a ureter injury

Total number of patients

receiving a ureter injury at the
Total number of patients
time of a laparoscopic
undergoing laparoscopic
hysterectomy with repair during
hysterectomy.
the procedure or subsequently
up to 2 weeks post-operatively.

ACHS Clinical Indicator Summary Guide 2012

Low

Yes

Yes

Yes

0.015

0.034

0.006

0.034

EQuIP5
Criterion

0.015

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

0.034

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

Low

0.017

0.013

0.016

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

Yes

Low

0.74

0.41

1.15

Continuity of Care,
Outcome,
1.1.2, 1.1.4,
Appropriateness,
Process
1.3.1, 1.4.1
Effectiveness

Yes

Low

9.19

5.15

12.2

Continuity of Care,
Outcome,
1.1.2, 1.1.4,
Appropriateness,
Process
1.3.1, 1.4.1
Effectiveness

0.50

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

0.69

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Process
Quality
1.4.1, 2.1.3
Improvement and
Risk

0.18

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

Yes

Total number of patients

receiving an unplanned blood
Blood transfusion for
Total number of patients
This indicator is included as a general measure of transfusion during their hospital
gynaecological surgery for
undergoing gynaecology
admission for any type of
surgical management.
benign disease
surgery for benign disease.
gynaecological surgery for
benign disease.
Total number of patients
Blood transfusion for
Total number of patients
undergoing gynaecology
gynaecological surgery for As described above.
undergoing gynaecology surgery
surgery for malignant
malignant disease
for malignant disease.
disease.
Injury to a major viscus,
with repair during a
gynaecological operative
procedure, or
subsequently during the
same admission.

Low

Dimension of
Quality

Low

Low

Low

0.32

0.51

0.18

0.15

0.43

0.18

Indicator Set

Version CI No.

Topic

Rationale

Numerator

Denominator

Total number of patients

receiving a bladder injury at the
Total number of patients
time of a laparoscopic
undergoing laparoscopic
hysterectomy with repair during
hysterectomy.
the procedure or subsequently
up to 2 weeks post-operatively.
Total number of patients having Total number of patients
laparoscopic management
presenting with an ectopic
following an ectopic pregnancy. pregnancy.

Gynaecology

3.3

Laparoscopic
gynaecological surgery for As described above.
a bladder injury

Gynaecology

4.1

Laparoscopic
This indicator has been included as an index of
management of an ectopic the utilisation of a laparoscopic approach in the
pregnancy
management of ectopic pregnancy.

5.1

This indicator provides an index of unintentional

intraoperative morbidity associated with pelvic
floor repair procedures.

Total number of patients

receiving injury to a major viscus
Total number of patients
with repair, during a pelvic floor
undergoing a pelvic floor
repair procedure or
repair procedure.
subsequently up to 2 weeks postoperatively.

As described above.

Total number of patients

receiving a ureter injury at the
Total number of patients
time of a pelvic floor repair
undergoing a pelvic floor
procedure with repair during
repair procedure.
the procedure or subsequently
up to 2 weeks post-operatively.

Gynaecology

Gynaecology

5.2

Urogynaecology

Urogynaecology

Gynaecology

5.3

Urogynaecology

As described above.

Total number of patients

receiving a bladder injury at the
Total number of patients
time of a pelvic floor repair
undergoing a pelvic floor
procedure with repair during
repair procedure.
the procedure or subsequently
up to 2 weeks post-operatively.

Gynaecology

6.1

Antibiotic prophylaxis in
hysterectomy

This indicator has been included as an index of

the utilisation of evidence-based guidelines for
antibiotic prophylaxis in selected gynaecological
surgery.

Total number of patients who

undergo hysterectomy who
receive antibiotic prophylaxis
prior to surgery.

Total number of patients

who undergo hysterectomy.

7.1

Thromboprophylaxis in
moderate to high risk
women having
hysterectomy

This indicator has been included as an index of

utilisation of evidence based practice guidelines
for thromboprophylaxis in moderate to high risk
women having gynaecological surgery.

Total number of moderate to

high-risk patients (as per
guidelines) over 40 years who
undergo hysterectomy who
receive thromboprophylaxis.

7.2

Thromboprophylaxis in
moderate to high risk
As described above.
women having pelvic floor
surgery

Total number of moderate to

high-risk patients (as per
guidelines) over 40 years who
undergo pelvic floor surgery
who receive
thromboprophylaxis.

Gynaecology

Gynaecology

ACHS Clinical Indicator Summary Guide 2012

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Yes

Yes

Low

0.64

0.64

0.64

High

84.5

77.3

92.5

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

1.32

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

0.037

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk
Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

Low

Yes

EQuIP5
Criterion

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

Low

Yes

Dimension of
Quality

0.85

0.037

0.57

0.037

Low

0.48

1.13

1.13

Yes

High

99.0

99.1

99.2

Process

Total number of moderate

to high-risk patients (as per
guidelines) over 40 years
who undergo hysterectomy.

Yes

High

95.7

96.7

99.3

Continuity of Care, 1.1.1, 1.1.2,

Process Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Total number of moderate

to high-risk patients (as per
guidelines) over 40 years
who undergo pelvic floor
surgery.

Yes

High

88.8

88.4

96.0

Continuity of Care, 1.1.1, 1.1.2,

Process Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.2
Safety

10

Indicator Set

Version CI No.

Topic

Rationale

Numerator

Denominator

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

The number of patients making

The total number of patients
1 or more unexpected
commenced on a HITH
telephone calls during their
program.
HITH admission.

Yes

Low

Modified
indicator
for 2011

As described above.

The number of patients having 1 The total number of patients

unscheduled staff callout during commenced on a HITH
their HITH admission.
program.

Yes

Low

1.36

0.59

3.48

Continuity of Care, 1.1.2, 1.1.4,

Process Appropriateness, 1.1.6, 1.3.1,
Effectiveness
1.4.1

Yes

Low

0.24

0.11

0.46

Continuity of Care, 1.1.2, 1.1.4,

Process Appropriateness, 1.1.6, 1.3.1,
Effectiveness
1.4.1

2.07

4.45

Continuity of Care, 1.1.1, 1.1.2,

Outcome,
Appropriateness, 1.1.4, 1.1.6,
Process
Effectiveness
1.3.1, 1.4.1

Hospital in the
Home

1.1

Hospital in the
Home

1.2

One unscheduled staff

callout during the HITH
admission

1.3

More than one

unscheduled staff callout As described above.
during the HITH admission

The number of patients having

more than 1 unscheduled staff
callout during their HITH
admission.

2.1

Unplanned interruption to a HITH program is an

important outcome, as it may reveal difficulties
with eligibility criteria, care choice, skill of
Unplanned return to
hospital - did not return to assessor, initial choice of therapy, and
misdiagnosis. High rates of unplanned returns
the HITH program
could result in patient anxiety, added cost, and
possible deterioration of the patients condition

Total number of patients having

an unplanned return to hospital
Total number of patients
(as defined in the manual)
commenced on a HITH
where the patient does not
program.
return to the HITH program,
during that admission.

Yes

Low

2.98

As described above.

Total number of patients who

have an unplanned return to
hospital (as defined in the
manual) and are transferred
back to the HITH program.

Total number of patients

commenced on a HITH
program.

Yes

Not
specified

Modified
indicator
for 2011

As described above.

Total number of HITH patients

who have an unplanned return
to hospital.

Total number of patients

commenced on a HITH
program.

Yes

Not
specified

4.91

Hospital in the
Home

EQuIP5
Criterion

Success in HITH care requires the selection of

patients with appropriate conditions, who
consent to care and have a safe and stable home
environment. Careful patient selection prior to a
HITH admission may avoid potential problems
during admission.

One unexpected
telephone call during the
HITH admission.

Hospital in the
Home

Dimension of
Quality

The total number of patients

commenced on a HITH
program.

Continuity of Care, 1.1.2, 1.1.4,

Process Appropriateness, 1.1.6, 1.3.1,
Effectiveness
1.4.1

Hospital in the
Home

2.2

Unplanned return to
hospital - back to HITH
program

Continuity of Care, 1.1.1, 1.1.2,

Outcome,
Appropriateness, 1.1.4, 1.1.6,
Process
Effectiveness
1.3.1, 1.4.1

Hospital in the
Home

2.3

Unplanned returns to
hospital

Total number of unexpected

deaths in patients during the
HITH admission.

Total number of patients

commenced on a HITH
program.

Low

New
indicator
for 2011

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of patients

commenced on a HITH
program.

Low

New
indicator
for 2011

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

2.79

7.99

Continuity of Care, 1.1.1, 1.1.2,

Outcome,
Appropriateness, 1.1.4, 1.1.6,
Process
Effectiveness
1.3.1, 1.4.1

Hospital in the
Home

3.1

Whilst there are expected deaths among HITH

Unexpected deaths in
patients, such as those receiving palliative care,
patients commenced on a
unexpected deaths in HITH patients should be
Hospital in the Home
very low. Monitoring death rates is viewed as
program
measure of HITH safety.

Hospital in the
Home

3.2

As described above.

As described above.

Total number of unexpected

deaths subsequent to an
unplanned return to hospital
during the HITH admission.

Hospital-Wide

11.1

1.1

Unplanned and
unexpected hospital
readmissions.

Unplanned and unexpected readmissions to a

hospital may reflect less than optimal patient
management.

Total number of unplanned and

unexpected readmissions within Total number of separations
28 days of separation related to (excluding deaths).
the primary admission.

Yes

Low

1.22

0.24

2.11

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Hospital-Wide

11.1

1.2

Unplanned and
unexpected hospital
readmissions.

As described above.

Total number of unplanned and

unexpected readmissions within Total number of separations
14 days of separation related to (excluding deaths).
the primary admission.

Yes

Low

1.14

0.26

1.79

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

ACHS Clinical Indicator Summary Guide 2012

11

Indicator Set

Version CI No.

Hospital-Wide

11.1

2.1

Hospital-Wide

11.1

3.1

Hospital-Wide

Hospital-Wide

Hospital-Wide

Hospital-Wide

Hospital-Wide

11.1

11.1

11.1

11.1

11.1

3.2

4.1

4.2

4.3

4.4

Topic

Rationale

Numerator

Total number of patients having

Unplanned return to the Unplanned return of a patient to the operating
an unplanned return to the
operating room during the room during the same admission may reflect less
operating room during the same
same admission
than optimal management.
admission.
Pressure ulcers are largely preventable hospital
acquired injuries. In the majority of cases they
can be regarded as an adverse outcome of a
Total number of inpatients who
Identification of pressure health care admission. Many national and
develop one or more pressure
international healthcare agencies acknowledge
ulcers.
ulcers, during their admission
that pressure ulcers not only affect the health of
the individual but also place a significant drain on
already stretched health resources.

As described above.

Identification of falls
during an admission.

Fall-related injury is one of the leading causes of

morbidity and mortality in older Australians and
the single biggest reason for hospital admissions
and emergency department presentations in
people over 65 years of age.
Adverse events associated with falls may include Total number of inpatient falls
bone fractures, soft tissue injury, and fear of
falling again. Interventions based on a proactive
assessment, anticipation of patient needs, and
participation of the multidisciplinary teams in
prevention efforts are critical.

Identification of falls
during an admission.

Identification of falls
during an admission.

ACHS Clinical Indicator Summary Guide 2012

As described above.

Total number of inpatient falls

where the patients condition
requires intervention.

Dimension of
Quality

EQuIP5
Criterion

Total number of patients

having an operation or
procedure in the operating
room.

Yes

Low

0.32

0.12

0.39

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Total number of inpatient

bed days.

Yes

Low

0.075

0.019

0.10

Outcome

0.77

Continuity of Care,
1.1.1, 1.1.2,
Appropriateness,
1.1.4, 1.3.1,
Outcome
Effectiveness,
1.4.1, 1.5.3
Safety

0.58

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Outcome
Effectiveness,
1.5.4
Safety

0.19

Continuity of Care,
Appropriateness, 1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Safety, Quality
1.4.1, 1.5.4,
Improvement and
2.1.3
Risk

0.011

Continuity of Care,
Appropriateness, 1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Safety, Quality
1.4.1, 1.5.4,
Improvement and
2.1.3
Risk

0.82

Continuity of Care,
Appropriateness,
1.1.2, 1.1.4,
Effectiveness,
1.3.1, 1.4.1,
Outcome
Safety, Quality
1.5.4, 2.1.3
Improvement and
Risk

Total number of inpatients who

are admitted with one or more Total number of admissions.
pressure ulcers.

Identification of pressure
ulcers.

Identification of falls
during an admission.

Denominator

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Yes

Total number of occupied

bed days.

Total number of occupied

bed days

As described above.

Total number of fractures or

closed head injuries that result
because of an inpatient fall.

Total number of occupied

bed days.

As described above.

Total number of falls in

inpatients aged 65 years and
older.

Total number of occupied

bed days of inpatients aged
65 years and older.

Low

Yes

Yes

Low

Low

Yes

Low

Yes

Low

0.28

0.37

0.11

0.009

0.51

0.053

0.21

0.017

0.005

0.33

Continuity of Care,
1.1.1, 1.1.2,
Appropriateness,
1.1.4, 1.3.1,
Effectiveness,
1.4.1, 1.5.3
Safety

12

Indicator Set

Hospital-Wide

Hospital-Wide

Hospital-Wide

Hospital-Wide

Version CI No.

11.1

11.1

11.1

11.1

5.1

Topic

Although death can be the expected outcome

from progression of all illness or disease, it can
also be the ultimate adverse event associated
with or resulting from health care delivery.
Deaths addressed within a
It is appropriate for patient deaths occurring
clinical audit process.
within a healthcare organisation to be analysed
through clinical audit and review processes to
facilitate identification and introduction of any
necessary improvements in safety.

6.1

Administration of blood
transfusion.

6.2

Administration of blood
transfusion.

6.3

Administration of blood
transfusion.

Hospital-Wide

11.1

7.1

Hospital-Wide

11.1

8.1

Rationale

Denominator

Total number of patient deaths

Total number of patient
addressed within a clinical audit
deaths.
process.

High

95.0

98.4

Dimension of
Quality

EQuIP5
Criterion

99.9

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

0.31

Continuity of Care,
Appropriateness, 1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Safety, Quality
1.4.1, 1.5.5,
Improvement and
2.1.3
Risk

10.9

Continuity of Care, 1.1.2, 1.1.3,

Appropriateness, 1.1.4, 1.1.8,
Process
Effectiveness,
1.3.1, 1.4.1,
Safety
1.5.5

In certain clinical circumstances, blood

component therapy (the administration of
components derived from human blood) can save
lives, restore normal life expectancy and improve
quality of life. However, it is increasingly clear
that such therapy has limitations, and that the
decision to transfuse must be made with great
care.

Total number of significant

adverse transfusion events
related to a blood transfusion
episode.

Total number of transfusion

episodes.

As described above.

Total number of transfusion

episodes where informed
patient consent was not
documented.

Total number of transfusion

episodes.

As described above.

Total number of RBC transfusion

Total number of RBC
episodes when the HB reading is
transfusion episodes.
100g / L or more.

Yes

Low

2.22

1.15

3.41

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Process
Effectiveness,
1.5.5
Safety

Total number of elective surgery

patients admitted to the
Total number of elective
organisation on the day of
surgery patients admitted.
surgery.

Yes

High

86.3

81.1

98.1

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of high risk

medical patients admitted who
receive VTE prophylaxis.

Yes

High

77.1

51.3

91.1

Continuity of Care, 1.1.1, 1.1.2,

Process Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Elective surgery patients

This indicator is a measure of appropriateness of
admitted to the
admission of elective surgery patients on the day
organisation on the day of
of surgery.
surgery.
This indicator has been included as an index of
utilisation of evidence-based guidelines for
High risk medical patients thromboprophylaxis in high risk medical patients.
admitted who receive VTE Improving the prevention of venous
thromboembolism (VTE) in hospitalised patients
prophylaxis.
is a major priority for the National Institute of
Clinical Studies (NICS).

ACHS Clinical Indicator Summary Guide 2012

Numerator

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Total number of high risk

medical patients admitted.

Yes

Low

Yes

Low

0.25

4.49

0.082

0.63

13

Indicator Set

Infection Control

Infection Control

Infection Control

Infection Control

Version CI No.

3.1

3.1

3.1

3.1

Topic

Rationale

Numerator

Denominator

1.1

Health care organisations that perform, routinely,

at least 100 surgical procedures of the same type
per year, may evaluate patient safety by
reporting on the frequency of infection and
related issues. A higher volume of procedures will
produce a more statistically reliable rate. Timely Total number of superficial
Superficial incisional SSI in
investigation of higher than expected rates of
incisional SSI in hip prosthesis
hip prosthesis procedures
infection may identify issues relating to
procedures performed.
preventative factors for documentation and
corrective action. For example, errors may have
occurred in administration of the correct type,
dose route and timing of antimicrobial
prophylaxis in surgical patients.

1.2

Deep incisional SSI in hip

prosthesis procedures

As described above.

Total number of deep incisional Total number of hip

SSI in hip prosthesis procedures prosthesis procedures
performed.
performed.

1.3

Superficial incisional SSI in

knee prosthesis
As described above.
procedures

Total number of superficial

Total number of knee
incisional SSI in knee prosthesis
prosthesis procedures.
procedures performed.

1.4

Deep incisional SSI in knee

As described above.
prosthesis procedures

Total number of deep incisional

Total number of knee
SSI in knee prosthesis
prosthesis procedures.
procedures performed.

As described above.

Infection Control

3.1

1.5

Superficial incisional SSI

(chest incision site) in
CABG

Infection Control

3.1

1.6

Deep incisional/organ
space SSI (chest incision
site) in CABG

As described above.

Infection Control

3.1

1.7

Superficial incisional SSI

(donor incision site) in
CABG

As described above.

Infection Control

3.1

1.8

Deep incisional/organ
space SSI (donor incision
site) in CABG

As described above.

ACHS Clinical Indicator Summary Guide 2012

Total number of superficial

incisional SSI (in the chest
incision site) in coronary artery
bypass graft procedures
performed.
Total number of deep
incisional/organ space SSI (in the
chest incision site) in coronary
artery bypass graft procedures
performed.
Total number of superficial
incisional SSI (in the donor
incision site) in coronary artery
bypass graft (involving chest &
donor incisions) procedures
performed.
Total number of deep
incisional/organ space SSI (in the
donor incision site) in coronary
artery bypass graft (involving
chest & donor incisions)
procedures performed.

Total number of hip

prosthesis procedures
performed.

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Yes

Yes

Yes

Yes

Low

Low

Low

Low

0.73

0.71

0.61

0.43

0.57

0.52

0.51

0.34

Dimension of
Quality

EQuIP5
Criterion

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.2
Safety

1.04

Outcome

0.94

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Outcome
Effectiveness,
1.5.2
Safety

0.77

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Outcome
Effectiveness,
1.5.2
Safety

0.53

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Outcome
Effectiveness,
1.5.2
Safety

Total number of coronary

artery bypass graft
procedures performed.

Yes

Low

1.16

0.85

1.45

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Outcome
Effectiveness,
1.5.2
Safety

Total number of coronary

artery bypass graft
procedures performed.

Yes

Low

1.14

0.72

1.55

Outcome

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.2
Safety

Total number of coronary

artery bypass graft
procedures performed.

Yes

Low

1.61

0.65

2.04

Outcome

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.2
Safety

Total number of coronary

artery by pass graft
procedures performed.

Yes

Low

0.31

0.30

0.32

Outcome

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.2
Safety

14

Indicator Set

Infection Control

Version CI No.

Topic

Rationale

Superficial incisional SSI in

As described above.
elective colectomy

Numerator

Total number of superficial

incisional SSI in elective partial
or total colectomy procedures
(where there is an anastomosis
but no stoma formed)
performed.
Total number of deep
incisional/organ space SSI in
elective partial or total
colectomy procedures (where
there is an anastomosis but no
stoma formed) performed.

Denominator

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Dimension of
Quality

EQuIP5
Criterion

Total number of elective

partial or total colectomy
procedures (where there is
an anastomosis but no
stoma formed) performed.

Yes

Low

2.99

1.54

4.20

Outcome

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.2
Safety

Total number of elective

partial or total colectomy
procedures (where there is
an anastomosis but no
stoma formed) performed.

Yes

Low

2.23

1.68

2.56

Outcome

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.2
Safety

6.22

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Outcome
Effectiveness,
1.5.2
Safety

1.08

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Outcome
Effectiveness,
1.5.2
Safety

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Outcome
Effectiveness,
1.5.2
Safety

3.1

1.9

3.1

Deep incisional/organ
1.10 space SSI in elective
colectomy

3.1

Superficial incisional SSI in

1.11
As described above.
femoro-popliteal bypass

Total number of superficial

Total number of femoroincisional SSI in femoro-popliteal popliteal bypass procedures
bypass procedures performed. performed.

3.1

Deep incisional SSI in

1.12
femoro-popliteal bypass

Total number of deep incisional Total number of femoroSSI in femoro-popliteal bypass popliteal bypass procedures
procedures performed.
performed.

3.1

Superficial incisional SSI in

1.13 open abdominal aortic
As described above.
aneurysm

Total number of superficial

incisional SSI in open abdominal Total number open AAA
aortic aneurysm (AAA)
procedures performed.
procedures performed.

Infection Control

3.1

Deep incisional/organ
space SSI in open
1.14
abdominal aortic
aneurysm

Total number of deep

incisional/organ space SSI in
open abdominal aortic
aneurysm (AAA) procedures
performed.

Total number open AAA

procedures performed.

Yes

Low

0.95

0.95

0.95

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Outcome
Effectiveness,
1.5.2
Safety

Infection Control

3.1

Superficial incisional SSI in

1.15 lower segment caesarean As described above.
section

Total number of superficial

incisional SSI in lower segment
caesarean section procedures.

Total number of lower

segment caesarean section
procedures performed.

Yes

Low

0.79

0.29

1.40

Outcome

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.2
Safety

Infection Control

3.1

1.16

Deep
incisional/organ/space SSI
As described above.
in lower segment
caesarean section

Total number of deep

incisional/organ space SSI in
lower segment caesarean
section procedures.

Total number of lower

segment caesarean section
procedures performed.

Yes

Low

0.17

0.080

0.25

Outcome

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.2
Safety

Infection Control

3.1

1.17

Superficial incisional SSI in

As described above.
abdominal hysterectomy

Total number of superficial

incisional SSI in abdominal
hysterectomy procedures.

Total number of abdominal

hysterectomy procedures
performed.

Yes

Low

0.47

0.44

0.51

Outcome

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.2
Safety

Infection Control

3.1

Deep incisional/organ
1.18 space SSI in abdominal
hysterectomy

Total number of deep

incisional/organ space SSI in
abdominal hysterectomy
procedures.

Total number of abdominal

hysterectomy procedures
performed.

Yes

Low

0.90

0.64

0.84

Outcome

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.2
Safety

Infection Control

Infection Control

Infection Control

Infection Control

ACHS Clinical Indicator Summary Guide 2012

As described above.

As described above.

As described above.

As described above.

Yes

Yes

Yes

Low

Low

Low

5.38

1.08

3.76

1.08

15

Indicator Set

Infection Control

Infection Control

Infection Control

Version CI No.

3.1

3.1

3.1

Topic

Rationale

Numerator

Denominator

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

2.1

As absolute rates of central line-associated

infections are in general quite low, it is important
for units to realise that unless the line-day
denominator for the surveillance period is large,
the standard error of an individual rate
measurement is high. Suspected infection trends
within a unit should therefore be carefully
examined by appropriate statistical measures
Adult ICU-related centrallyTotal number of CI central line- Total number of patient
such as process control charts and other quality
inserted CLUR
days in Adult ICU.
days in Adult ICU.
improvement tools to evaluate significance, at
time intervals also determined by statistical
considerations.
Timely investigation of significantly higher than
expected numbers of events or in larger units,
rates of infection, may identify system issues
relating to preventative factors for
documentation and corrective action.

Not
specified

2.2

Adult ICU-related
peripherally-inserted
CLUR

Not
specified

2.3

Paediatric ICU-related
centrally-inserted (CI)
CLABSI rate

As described above.

Total number of PI central line

days in Adult ICU.

Total number of patient

days in Adult ICU.

As described above.

Total number of Paediatric ICU- Total number of CI central

associated CI- CLABSI.
line-days in Paediatric ICU.

As described above.

Total number of CI central line- Total number of patient

days in Paediatric ICU.
days in Paediatric ICU.

Yes

Low

54.8

8.82

4.16

26.7

5.01

4.16

69.5

Outcome

Dimension of
Quality

EQuIP5
Criterion

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.2
Safety

17.4

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Process
Effectiveness,
1.5.2
Safety

4.16

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Outcome
Effectiveness,
1.5.2
Safety
Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Process
Effectiveness,
1.5.2
Safety

Infection Control

3.1

2.4

Paediatric ICU-related
centrally-inserted CLUR

Infection Control

3.1

2.5

Paediatric ICU-related
peripherally-inserted (PI)
CLABSI rate

As described above.

Total number of Paediatric ICU- Total number of PI central

associated PI- CLABSI.
line-days in Paediatric ICU.

Infection Control

3.1

2.6

Paediatric ICU-related
peripherally-inserted
CLUR

As described above.

Total number of PI central line

days in Paediatric ICU.

Total number of patient

days in Paediatric ICU.

Infection Control

3.1

2.7

Haematology Unit CI
CLABSI rate

As described above.

Total number of Haematology

Unit-related CI CLABSI.

Total number of CI central

line-days in the
Haematology Unit.

Yes

Low

1.88

0.75

3.16

Outcome

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.2
Safety

Infection Control

3.1

2.8

Haematology Unit PI
CLABSI rate

As described above.

Total number of Haematology

Unit-related PI CLABSI.

Total number of PI central

line-days in the
Haematology Unit.

Yes

Low

1.06

0.89

1.39

Outcome

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.2
Safety

ACHS Clinical Indicator Summary Guide 2012

Yes

Not
specified

36.4

36.4

36.4

Low

Outcome

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.2
Safety

Not
specified

34.7

33.7

35.7

Process

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.2
Safety

16

Indicator Set

Version CI No.

Topic

Rationale

Numerator

Denominator

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Dimension of
Quality

EQuIP5
Criterion

Infection Control

3.1

2.9

Oncology Unit CI CLABSI

rate

As described above.

Total number of CI central

Total number of Oncology Unitline-days in the Oncology
related CI CLABSI.
Unit.

Yes

Low

0.21

0.038

0.86

Outcome

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.2
Safety

Infection Control

3.1

2.10

Oncology Unit PI CLABSI

rate

As described above.

Total number of PI central

Total number of Oncology Unitline-days in the Oncology
related PI CLABSI.
Unit.

Yes

Low

0.19

0.039

0.73

Outcome

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.2
Safety

As described above.

Total number of Outpatient

Total number of CI central
Intravenous Therapy (OPIV) Unitline-days in the OPIV Unit.
related CI CLABSI.

0.063

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Outcome
Effectiveness,
1.5.2
Safety

As described above.

Total number of OPIV Unitrelated PI CLABSI.

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Outcome
Effectiveness,
1.5.2
Safety

0.15

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Outcome
Effectiveness,
1.5.2
Safety

Infection Control

Infection Control

Infection Control

3.1

3.1

3.1

2.11 OPIV Unit CI CLABSI rate

2.12 OPIV Unit PI CLABSI rate

3.1

Haemodialysis fistula associated BSI

Total number of PI central

line-days in the OPIV Unit.

Dialysis-associated blood stream infections cause

considerable morbidity. A proportion of infections
Total number of AV-fistula
Total number of patientare potentially preventable through adherence to
access - associated blood stream months for patients dialysed
appropriate standards of care and the avoidance
infections.
through AV-fistula.
where possible of devices that have more
frequent occurrence of infection.

Yes

Yes

Yes

Low

Low

Low

0.063

0.067

0.063

0.072

As described above.

Total number of synthetic graft Total number of patient access-associated blood stream months for patients dialysed
infections.
through synthetic grafts.

Yes

Low

0.67

0.67

0.67

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Outcome
Effectiveness,
1.5.2
Safety

Infection Control

3.1

3.2

Haemodialysis synthetic
graft - associated BSI

Infection Control

3.1

3.3

Haemodialysis native
vessel graft - associated
BSI

As described above.

Total number of native vessel

graft access-associated blood
stream infections.

Total number of patientmonths for patients dialysed

through native vessel grafts.

Yes

Low

1.32

0.85

1.08

Outcome

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.2
Safety

Infection Control

3.1

3.4

Haemodialysis centrally
inserted non-cuffed line
(temporary) - associated
BSI

As described above.

Total number of centrally

inserted non-cuffed line accessassociated blood stream
infections.

Total number of patientmonths for patients dialysed

through centrally inserted
non-cuffed line.

Yes

Low

1.93

1.92

1.92

Outcome

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.2
Safety

Infection Control

3.1

3.5

Haemodialysis centrally
inserted cuffed
(semipermanent) line associated BSI

As described above.

Total number of centrally

inserted cuffed line accessassociated blood stream
infections.

Total number of patientmonths dialysed through

centrally inserted cuffed
line.

Yes

Low

2.28

0.94

3.79

Outcome

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.2
Safety

ACHS Clinical Indicator Summary Guide 2012

17

Indicator Set

Infection Control

Infection Control

Infection Control

Infection Control

Infection Control

Infection Control

Version CI No.

3.1

3.1

3.1

3.1

3.1

3.1

Topic

Rationale

4.1

Early onset infections are usually acquired from

the mother during the birth process. A
proportion of these infections are preventable
through adherence to appropriate standards of
maternal care.
Early onset infection rate - Late onset infections within Neonatal Intensive
Care may also be prevented through adherence
inborn neonates
to appropriate standards of care, particularly with
management of intravascular lines.
The risk of early and late onset infections is
strongly correlated with birth weight and
gestational age.

4.2

Early onset infection rateinborn neonates 37

As described above.
weeks

4.3

Late onset intensive care

infection rate - neonates
As described above.
of < 1000g birth weight
admitted to intensive care

Numerator

Denominator

Total number of live babies born

at the reporting hospital who
Total number of live babies
develop blood stream and/or
born at the reporting
CSF infection within 48 hours of hospital.
birth and who were born.

Total number of live babies of

37 weeks GA born at the
reporting hospital who develop
a blood and / or CSF infection
within 48 hours of birth and who
were born.
Number of babies of birth
weight < 1000g admitted to
NICU during the time period
under study who have a
significant blood infection
occurring more than 48 hours
after birth at any time during
their whole admission.

Total Number of live babies

37 weeks GA born at the
reporting hospital.

Total number of babies of

birth weight < 1000g who
survive 48 hours admitted
to NICU.

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Yes

Yes

Yes

Low

Low

Low

0.073

0.016

27.3

0.059

0.016

27.3

Dimension of
Quality

EQuIP5
Criterion

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.2
Safety

0.065

Outcome

0.016

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Outcome
Effectiveness,
1.5.2
Safety

27.3

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Outcome
Effectiveness,
1.5.2
Safety

Total number of babies of

1000g birth weight, admitted to
NICU during the time period
under study who have a
significantblood infection
occurring more than 48 hours
after birth at any time during
their whole admission.

Total number of babies of

1000g birth weight, who
survive 48 hours admitted
to NICU.

Yes

Low

1.21

1.20

1.20

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Outcome
Effectiveness,
1.5.2
Safety

4.4

Late onset intensive care

infection rate - neonates
of > 1000g birth weight

4.5

Late onset intensive care

infection incidence As described above.
neonates of < 1000g birth
weight

Total number of significant

blood infections in NICU
admitted babies of < 1000g birth
weight, occurring more than 48
hours of birth.

Total number of patientdays accrued by babies of <

1000g birth weight, during
the time period under study
(includes NICU level 3 and 2
bed-days).

Yes

Low

0.51

0.51

0.51

Outcome

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.2
Safety

4.6

Late onset intensive care

infection incidence As described above.
neonates of > 1000g birth
weight

Total number of significant

blood infections in NICU
admitted babies of 1000g birth
weight occurring more than 48
hours of birth.

Total number of patientdays accrued by babies of

1000g birth weight admitted
to NICU.

Yes

Low

0.096

0.096

0.096

Outcome

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.2
Safety

ACHS Clinical Indicator Summary Guide 2012

As described above.

18

Indicator Set

Infection Control

Infection Control

Infection Control

Infection Control

Infection Control

Infection Control

Version CI No.

3.1

3.1

3.1

3.1

3.1

3.1

Topic

Rationale

Numerator

Denominator

5.1

These indicators are derived from the Primary

MRO Morbidity indicator that has been
recommended by the Australian Council for
Safety and Quality in Health Care.
ICU-associated new MRSA
It is recommended that as a minimum, individual
healthcare-associated
facilities also do surveillance for the secondary
infections in a sterile site
indicators (acquisition and burden) for MRSA.
These indicators have value for comparison over
time within the facility to show greater detail
about the dynamics of MRO epidemiology.

Total number of ICU-associated

Total number of ICU
new MRSA healthcareovernight occupied bed
associated infections in a sterile
days.
site.

5.2

ICU-associated new MRSA

healthcare-associated
As described above.
infections in a non-sterile
site

The total number of ICUThe total number of ICU

associated new MRSA
overnight occupied bed
healthcare-associated infections
days.
in a non-sterile site.

5.3

Non ICU-associated new

MRSA healthcareassociated infections in a
sterile site

As described above.

The total number of Non ICUThe total number of Non ICU

associated new MRSA inpatient
overnight occupied bed
healthcare-associated infections
days.
in a sterile site.

5.4

Non ICU-associated new

MRSA inpatient healthcareAs described above.
associated infections in a
non-sterile site

The total number of Non ICUThe total number of Non ICU

associated new MRSA
overnight occupied bed
healthcare-associated infections
days.
in a non-sterile site.

6.1

6.2

Reported parenteral
exposures sustained by
staff

Reported non-parenteral
exposures sustained by
staff

ACHS Clinical Indicator Summary Guide 2012

An occupational exposure as defined below may

put the injured person at risk of acquiring a
blood borne infection. International reports
suggest that determining the magnitude of
occupation exposures is the first step in
developing local programs and strategies
designed to
reduce this risk.

As described above.

The total number of reported

The total number of
parenteral exposures sustained
occupied bed days.
by staff.

The total number of reported

non-parenteral exposures
sustained by staff.

The total number of

occupied bed days.

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Yes

Yes

Yes

Yes

Yes

Yes

Low

Low

Low

Low

Low

Low

1.65

7.43

0.29

1.66

0.039

0.014

1.52

2.94

0.18

0.42

0.025

0.008

Dimension of
Quality

EQuIP5
Criterion

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.2
Safety

1.87

Outcome

10.7

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Outcome
Effectiveness,
1.5.2
Safety

0.26

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Outcome
Effectiveness,
1.5.2
Safety

1.68

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Outcome
Effectiveness,
1.5.2
Safety

0.046

Continuity of Care,
Appropriateness,
1.1.2, 1.1.4,
Effectiveness,
1.3.1, 1.4.1,
Outcome
Safety, Quality
1.5.2, 2.1.3
Improvement and
Risk

0.015

Continuity of Care,
Appropriateness,
1.1.2, 1.1.4,
Effectiveness,
Outcome
1.3.1, 1.4.1,
Safety, Quality
1.5.2, 2.1.3
Improvement and
Risk

19

Indicator Set

Intensive Care

Intensive Care

Intensive Care

Intensive Care

Intensive Care

Intensive Care

Intensive Care

Version CI No.

Topic

Rationale

Numerator

While ICUs in Australian hospitals compare

favourably with international benchmarks,
occupancy rates are often high and result in
limited reserve capacity for several days each
month1. Conversely, high hospital occupancy
rates can result in the inability to discharge a
patient from ICU to a less-acute unit. These
phenomena are respectively referred to as ICU
access and exit block, and should be routinely
monitored and reported by health services as a
key performance indicator of resources.

Total number of appropriate

adult patients referred to an
ICU, who have documented
evidence by an Intensivist that
they could not be admitted to
the unit because of inadequate
resources.

As described above.

Total number of adult elective

surgical cases deferred or
cancelled due to lack of an ICU
bed.

As described above.

Total number of adult patients

who were transferred to
another facility/ICU due to
unavailability of an ICU bed.

Denominator

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Total number of adult

admissions into the ICU plus
the non-admissions resulting
from inadequate resources.

Structure

Low

Modified
indicator
for 2011

Continuity of Care,
1.1.2, 1.1.4,
Assessiblity,
1.2.2, 1.3.1,
Structure
Appropriateness,
1.4.1
Effectiveness

Low

Modified
indicator
for 2011

Continuity of Care,
1.1.2, 1.1.4,
Assessiblity,
1.2.2, 1.3.1,
Structure
Appropriateness,
1.4.1
Effectiveness

Low

Modified
indicator
for 2011

Continuity of Care,
1.1.2, 1.1.4,
Assessiblity,
1.2.2, 1.3.1,
Process
Appropriateness,
1.4.1
Effectiveness

Low

15.8

Continuity of Care,
1.1.2, 1.1.4,
Assessiblity,
1.2.2, 1.3.1,
Process
Appropriateness,
1.4.1
Effectiveness

Yes

Low

New
indicator
for 2011

Continuity of Care, 1.1.1, 1.2.1,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Yes

High

Modified
indicator
for 2011

Continuity of Care, 1.1.1, 1.2.1,

Process Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

1.2

Adult elective surgical

cases deferred or
cancelled due to lack of
ICU bed

1.3

Adult patients were

transferred to another
facility/ICU due to
unavailability of an ICU
bed

1.4

Adult patients discharge

from the ICU was delayed As described above.
more than 6 hours

Total number of adult patients Total number of adult

whose discharge from the ICU patients discharged alive
was delayed more than 6 hours. from the ICU.

1.5

Adult patients discharged

from the ICU between
As described above.
6pm and 6am

Total number of adult patients

discharged from the ICU
between 6pm and 6am

Total number of adult

patients discharged alive
from the ICU.

Yes

2.1

Recognising and
responding to clinical
deterioration within 72
hours of being discharged
from an Intensive Care
Unit

The patient discharged from an ICU is particularly

vulnerable to clinical deterioration, as high ICU
occupancy rates sometimes result in patients
being discharged prior to a team-planned
discharge day.

Total number of rapid response

Total number of adult
calls to adult ICU patients within
patients discharged alive
72 hours of being discharged
from the ICU unit.
from the ICU.

3.1

Venous
Thromboembolism (VTE)
prophylaxis

Venous Thromboembolism (VTE), which includes

both deep vein thrombosis (DVT) and pulmonary
embolism (PE), is a significant cause of morbidity,
mortality, and resource expenditure in patients
admitted to the ICU.

Total number of adult patients

being treated appropriately for
VTE prophylaxis, according to
local protocol, within 24 hours
of admission to the ICU.

ACHS Clinical Indicator Summary Guide 2012

Continuity of Care,
1.1.2, 1.1.4,
Assessiblity,
1.2.2, 1.3.1,
Appropriateness,
1.4.1
Effectiveness

Modified
indicator
for 2011

ICU access block

Total number of adult

admissions into the ICU.

EQuIP5
Criterion

Low

1.1

Total number of adult

admissions into the ICU plus
the non-admissions resulting
from deferred or cancelled
surgical cases due to lack of
an ICU bed.
Total number of adult
admissions into the ICU plus
the non-admissions resulting
from transfers to other
facility/ICU due to bed
unavailability.

Dimension of
Quality

Yes

Yes

Yes

4.89

26.7

20

Indicator Set

Intensive Care

Intensive Care

Version CI No.

Topic

Rationale

Numerator

The occurrence of healthcare-associated

bloodstream infections like CLABSI can be used as
a measure of the safety of key clinical practice
processes within an ICU. Timely investigation of
all CLABSIs should occur to identify potential
Total number of Adult ICUissues for corrective action. The use of
associated CI-CLAB
comparative data and feedback to individual
hospitals can lead to a reduction in infection
rates, and it also can be a guide to monitoring the
effectiveness of other interventions and can alert
hospitals that have unacceptable rates of CLABSI.

Denominator

4.1

Centrally-inserted CLAB
attributed to the ICU

4.2

Peripherally-inserted CLAB
As described above.
attributed to the ICU

Total number of Adult ICUassociated PI-CLAB.

Total number of adult intensive

care submissions to the ANZICS Total number of adult
CORE Adult Patient Database
admissions into the intensive
with completed information and care unit.
review of results.

Have you responded to the most

recent ANZICS CORE Critical
Care Resources Survey?

Intensive Care

5.1

ANZICS is the peak professional and advocacy

body for medical practitioners specialising in the
treatment and management of critically ill
Participation in the ANZICS patients in public and private hospitals1.
Participation in the national APD provides local
CORE Adult Patient
and national comparative patient data, while the
Database
CCRS provides a more comprehensive review of
resources and department activities and is
adjusted to include topical items.

Intensive Care

5.2

Participation in the ANZICS

CORE Critical Care
As described above.
Resources Survey

Total number of CI central

line-days in Adult ICU.

Total number of PI central

line-days in Adult ICU.

Yes

1.00

0.70

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.2
Safety

1.20

Outcome

0.86

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Outcome
Effectiveness,
1.5.2
Safety

High

Modified
indicator
for 2011

Continuity of Care, 1.1.2, 1.1.4,

Process Appropriateness, 1.1.8, 1.3.1,
Effectiveness
1.4.1

Not
specified

Modified
indicator
for 2011

Continuity of Care, 1.1.2, 1.1.4,

Process Appropriateness, 1.1.8, 1.3.1,
Effectiveness
1.4.1

Not
specified

New
indicator
for 2011

Continuity of Care, 1.1.1, 1.1.2,

Process Appropriateness, 1.1.4, 1.1.8,
Effectiveness
1.3.1, 1.4.1

Total number of rapid response

system calls to adult patients
Total number of adult
within 24 hours of admission to hospital admissions.
hospital.

Not
specified

New
indicator
for 2011

Continuity of Care, 1.1.1, 1.1.2,

Process Appropriateness, 1.1.4, 1.1.8,
Effectiveness
1.3.1, 1.4.1

6.1

Recognising and
responding to clinical
deterioration within an
acute health care facility

Intensive Care

6.2

As described above.

As described above.

0.78

EQuIP5
Criterion

0.77

Intensive Care

Yes

Low

Dimension of
Quality

Low

Serious adverse events are common in

hospitalised patients, and these events are
usually preceded by warning signs that manifest
as deteriorations of vital signs or a change in
clinical condition up to 24 hours prior to an inhospital death, cardiac arrest, or unplanned ICU
admission. Early recognition of clinical
Total number of rapid response Total number of adult
deterioration, followed by prompt and effective
system calls to adult patients.
hospital admissions.
action, can avert or minimise the probability of a
poor clinical outcome for at-risk patients, and
may mean that a lower level of intervention is
required to stabilise a patient. The need for early
identification of at-risk patients has resulted in
the introduction of a Rapid Response System
(RRS) in Australia and internationally.

ACHS Clinical Indicator Summary Guide 2012

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

21

Indicator Set

Version CI No.

Topic

Rationale

Numerator

Denominator

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Dimension of
Quality

EQuIP5
Criterion

Intensive Care

6.3

As described above.

As described above.

Total number of adult patients

who have experienced a
cardiopulmonary arrest.

Total number of adult

hospital admissions.

Low

New
indicator
for 2011

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Intensive Care

6.4

As described above.

As described above.

Total number of deaths in adult

patients who DO NOT have an Total number of adult
NFR (not for resuscitation) order hospital admissions.
at the time of death.

Low

New
indicator
for 2011

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Intensive Care

6.5

As described above.

As described above.

Total number of adult deaths in Total number of adult

all patients.
hospital admissions.

Low

New
indicator
for 2011

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

1.1

Prescription of ACE
Inhibitor (ACEI) or
Angiotensin II Receptor
Antagonist (A2RA) for the
treatment of patients
discharged with any
diagnosis of Congestive
Heart Failure (CHF) in
whom there is no
contraindication to their
use.

There is NHMRC Level I evidence that ACEIs

improve symptoms of heart failure, improve
heart function, decrease admissions to hospital
and prolong life. Evidence suggests that all
patients with left systolic dysfunction should be
treated with an ACEI regardless of whether the
patients symptoms are mild, moderate or severe
or the patient is asymptomatic.

Total number of patients

discharged with a diagnosis of
CHF who have no
contraindications to the use of
ACE1/A2RA and who are
prescribed an ACEI/A2RA .

Total number of patients

discharged with a diagnosis
of CHF and who have no
contraindications to
ACEI/A2RA .

High

N/A

N/A

N/A

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

1.2

Prescription of beta
blocker therapy to
patients discharged with
any diagnosis of
congestive heart failure
(CHF) in whom there is no
contraindication to their
use.

There is NHMRC Level I evidence that betablocker therapy can improve survival, reduce
hospitalisations and improve left ventricular
function. Evidence suggests that all patients with
left systolic dysfunction should be treated with
beta-blockers after stabilisation with diuretic and
ACEI therapy regardless of whether or not
symptoms persist.

Total number of patients

discharged with a diagnosis of
CHF who have no
contraindications to use of beta
blockers and who are prescribed
beta blocker therapy.

Total number of patients

discharged with a diagnosis
of CHF and who have no
contraindications to use of
beta blockers.

High

N/A

N/A

N/A

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

1.3

There is NHMRC Level I evidence that oral

anticoagulants (warfarin and other coumarin
derivates) reduce the risk of stroke and other
major vascular events in high-risk patients with
non-valvular AF, previous ischaemic stroke or
Prescription of warfarin in
transient ischaemic attack (TIA) and with no prior
patients discharged with
stroke or transient ischaemic attack. The
CHF in association with
combination of atrial fibrillation and congestive
atrial fibrillation (AF) in
heart failure leads to a high risk of stroke for the
whom there is no
patient and appropriate antithrombotic therapy
contraindication to its use.
can minimise this incidence of stroke. Stroke risk
can be markedly reduced by treatment with
warfarin and complications of anticoagulation
minimised by close attention to maintaining the
INR between 2.0 and 3.0.

Total number of patients

discharged with a diagnosis of
CHF and atrial fibrillation who
have no contraindications to the
use of warfarin, who are
prescribed warfarin.

Total number of patients

discharged with a diagnosis
of CHF and atrial fibrillation
who have no
contraindications to the use
of warfarin.

High

N/A

N/A

N/A

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

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Topic

Rationale

Numerator

Denominator

1.4

Referral to a chronic
disease management
service for patients
discharged with a
diagnosis of congestive
heart failure (CHF).

Exercise-based cardiac rehabilitation in stable,

chronic heart failure improves exercise capacity,
(possibly) symptoms, myocardial perfusion,
quality of life, and reduces total mortality and
hospital admissions. Exercise improves skeletal
muscle function and therefore overall functional
capacity. Patients should be encouraged and
advised on how to carry out daily physical and
leisure time activities that do not induce
symptoms. Exercise training programs are
encouraged in stable patients in NYHA class IIIII.

Total number of patients

discharged with any diagnosis of
Total number of patients
CHF who are referred for a
discharged with any
chronic disease management
diagnosis of CHF.
service that includes physical
rehabilitation.

1.5

Receipt of thrombolytic
therapy for acute
myocardial infarction
(AMI).

Thrombolysis is a life saving treatment, which

must be given as soon as possible after AMI.

Total number of patients with

AMI requiring thrombolysis who
receive thrombolytic therapy
within 1 hour of presentation to
the hospital.

1.6

Clinical outcome of
percutaneous transluminal
coronary angioplasty
(PTCA) with or without
stenting.

PTCA should be performed with a high primary

success rate and a low rate of immediate
complication, eg. acute myocardial infarction
(AMI) or coronary artery bypass grafts (CABG).

Total number of vessels in which

Total number of vessels in
PTCA (with or without stenting)
which PTCA (with or without
is undertaken where primary
stenting) is undertaken.
success is achieved.

As described above.

Total number of inpatients

Total number of inpatients
undergoing CABG within 24
undergoing PTCA (with or
hours of a PTCA (with or without
without stenting).
stenting) in the same admission.

Total number of patients

with AMI requiring
thrombolysis who receive
thrombolytic therapy.

1.7

As described above.

2.1

Diabetic foot disease (DFD) is a frequent

complication of diabetes and is the most common
risk factor for non-traumatic lower limb
amputation and the most frequent cause of
hospitalisation in this patient group. There is
Lower limb assessment in NHMRC Level II evidence that peripheral
neuropathy precedes diabetic foot ulceration and
patients admitted with
any diagnosis of diabetes. the absence of foot pulses increases the
likelihood of amputation. DFD is often not
assessed or appropriately managed. A regular
and comprehensive lower limb assessment will
detect these markers of lower limb neuropathy
and / or peripheral vascular disease (PVD).

Total number of patients

admitted with diabetes having
assessment of lower limbs
according to guidelines.

Total number of patients

admitted with diabetes.

2.2

Elective surgery requires an alteration of the

Insulin treated diabetics - treatment schedule for insulin treated diabetic
patients. It is estimated that between 0.5 and
at least four BSL
measurements on the first 2.0% of patients undergoing elective surgery are
insulin treated diabetics. Inappropriate
post operative day
management creates the risk of hypoglycaemia.

Total number of insulin treated

diabetic inpatients having an
elective operation, and a length
of stay 48 hours, whose
medical record shows at least 4
blood glucose measurements on
the first post-operative day.

Total number of insulin

treated diabetic inpatients
having an elective operation
and a length of stay 48
hours.

ACHS Clinical Indicator Summary Guide 2012

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Dimension of
Quality

EQuIP5
Criterion

High

N/A

N/A

N/A

Continuity of Care, 1.1.2, 1.1.4,

Process Appropriateness, 1.1.6, 1.3.1,
Effectiveness
1.4.1

High

80.8

76.5

87.5

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Yes

High

96.5

95.6

98.3

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Yes

Low

0.17

0.087

0.20

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

High

89.3

89.3

89.3

Continuity of Care, 1.1.1, 1.1.2,

Process Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

High

95.9

90.6

98.7

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Yes

Yes

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Denominator

2.3

Insulin treated diabetics at least four BSL

As described above.
measurements on the first
post operative day

Total number of insulin treated

diabetic inpatients having an
elective operation, and a length
of stay 48 hours, with a
recorded blood glucose level
less than 4mmol/l in the post
operative period.

Total number of insulin

treated diabetic inpatients
having an elective operation
and a length of stay 48
hours.

3.1

Stroke is a common condition that is resource

intensive. Appropriate and timely assessment
makes an important contribution to patient
management. The incidence of dysphagia is
Assessment of swallowing
common (2750%) in acute stroke and is
function in patients
associated with an increased risk of
admitted with a diagnosis
complications, such as aspiration pneumonia,
of stroke.
dehydration and malnutrition. Prompt screening,
accurate assessment and early management are
therefore needed to prevent these complications
and promote recovery of functional swallow.

Total number of inpatients with

a primary diagnosis of acute
stroke (ICD-10 Code) with
documented evidence of a
swallowing screen conducted
prior to documented evidence
of food or fluid intake.

3.2

A computerised tomography (CT) or magnetic

resonance imaging (MRI) scan of the brain is a
fundamental component of acute stroke care.
This process of care applies to all patients with
acute stroke and is required for specific
diagnostic and management decisions. A CT scan
of the brain is essential for confirmation of the
clinical diagnosis of stroke and for identifying
patients in whom anticoagulation and
thrombolytic therapy is contraindicated (e.g.
intracranial haemorrhage). Evidence suggests the
most cost-effective strategy in acute stroke is for
all patients to undergo immediate imaging.

3.3

3.4

Topic

Stroke Investigation.

Allied health assessment

in patients admitted with
a diagnosis of stroke.

Receipt of hyperacute
pharmacological therapy
for ischaemic stroke.

ACHS Clinical Indicator Summary Guide 2012

Rationale

Early allied health assessment is an important and

clear starting point to the acute care assessment,
management, rehabilitation, and discharge
planning process. If applied systematically, early
allied health assessment should improve the
appropriateness of the ongoing inpatient and
discharge care needs.
It is well documented that anti-platelet and antithrombotic agents have a vital role in the
secondary prevention of any future ischaemic
stroke. Evidence from large robust studies
confirm that early use of aspirin, within 48 hours
of stroke, has small but important benefits on
patient outcomes.

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Dimension of
Quality

EQuIP5
Criterion

Low

12.10

3.31

19.4

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of inpatients

separated from hospital with
a primary diagnosis of acute
stroke (ICD-10 Code).

High

85.0

71.6

96.0

Continuity of Care, 1.1.1, 1.1.2,

Process Appropriateness, 1.1.4, 1.1.8,
Effectiveness
1.3.1, 1.4.1

Total number of inpatients with

a primary diagnosis of acute
stroke (ICD-10 Code) that had a
documented scan (CT or MRI) of
their brain within 24 hours of
presentation to hospital.

Total number of inpatients

separated from hospital with
a primary diagnosis of acute
stroke (ICD-10 Code).

High

93.4

91.6

99.1

Continuity of Care, 1.1.2, 1.1.4,

Process Appropriateness, 1.1.8, 1.3.1,
Effectiveness
1.4.1

Total number of inpatients with

a primary diagnosis of acute
stroke (ICD-10 Code) with
documented physiotherapy
assessment within 48 hours of
presentation to hospital.

Total number of inpatients

separated from hospital with
a primary diagnosis of acute
stroke (ICD-10 Code).

High

72.6

70.3

72.7

Continuity of Care, 1.1.1, 1.1.2,

Process Appropriateness, 1.1.4, 1.1.8,
Effectiveness
1.3.1, 1.4.1

Total number of inpatients with

a diagnosis of ischaemic stroke
(ICD-10 Code) receiving aspirin
within 48 hours of presentation
to hospital.

Total number of inpatients

separated from hospital with
a diagnosis of ischaemic
stroke (ICD-10 Code),
without contraindication for
aspirin.

High

60.4

39.1

86.2

Continuity of Care, 1.1.2, 1.1.4,

Process Appropriateness, 1.1.8, 1.3.1,
Effectiveness
1.4.1

Yes

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3.5

3.6

3.7

3.8

Topic

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Dimension of
Quality

EQuIP5
Criterion

Rationale

Numerator

Denominator

Receipt of hyperacute
pharmacological therapy
for ischaemic stroke.

Thrombolysis is a life saving treatment that must

be given as soon as possible after stroke. Pooled
analysis from the rt-PA trials confirm that
treatment with intravenous rt-PA has a clear net
benefit in reducing the risk of death or
dependency if given within 4.5 hours. Due to risk
of harm from this intervention; however,
intravenous rt-PA therapy should be delivered in
well equipped and skilled emergency
departments and/or stroke care units with
adequate stroke expertise and infrastructure for
monitoring, rapid assessment and investigation of
acute stroke patients.

Total number of inpatients with

a diagnosis of ischaemic stroke
(ICD-10 Code), presenting to the
hospital within 4.5 hours of
stroke onset, with documented
evidence that an intravenous
thrombolysis agent was
administered.

Total number of inpatients

separated from hospital with
a diagnosis of ischaemic
stroke (ICD-10 Code),
presenting to the hospital
within 4.5 hours of stroke
onset, who satisfy the
inclusion criteria, without
contraindication for
thrombolytic agents.

High

28.0

11.6

79.1

Continuity of Care, 1.1.2, 1.1.4,

Process Appropriateness, 1.1.8, 1.3.1,
Effectiveness
1.4.1

Appropriate discharge
planning for stroke.

Good discharge planning is crucial for successful

reintegration into the community as well as
Total number of inpatients with
effective and efficient use of limited hospital
a primary diagnosis of acute
resources. A care plan is normally completed
stroke (ICD-10 Code) with
prior to discharge and identifies appropriate
evidence that a documented
management strategies to guide care after the
plan for their ongoing care in the
stroke survivor returns to the community. Care
community was developed and
plans are based on the needs identified in the preprovided to the patient/family
discharge assessment, and are useful in building
prior to discharge.
self-management strategies for those with
stroke.

Total number of inpatients

discharged to a private
residence from hospital with
a primary diagnosis of acute
stroke (ICD-10 Code).

High

67.0

55.1

83.5

Continuity of Care, 1.1.2, 1.1.4,

Process Appropriateness, 1.1.6, 1.1.8,
Effectiveness
1.3.1, 1.4.1

Appropriate discharge
planning for stroke.

High blood pressure is the major risk factor for

both first and subsequent stroke. Reduction in
blood pressure, irrespective of initial blood
pressure, has been shown to reduce the
recurrence of stroke and combined vascular
events including myocardial infarction.

Total number of inpatients with

a primary diagnosis of acute
stroke (ICD-10 Code) who are
prescribed and administered
antihypertensive medication
prior to discharge.

Total number of inpatients

discharged from hospital
with a primary diagnosis of
acute stroke (ICD-10 Code),
without symptomatic
hypotension or other
contraindications for
antihypertensive agents.

High

84.2

77.5

89.1

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Stroke Unit Care.

Stroke unit care is defined as dedicated, coordinated care for stroke patients in hospital
under a multidisciplinary team who specialise in
stroke management. Robust data from
randomised, controlled clinical studies have been
available for over 10 years highlighting the
benefits of providing care in organised units,
known as (stroke units). The updated Cochrane
review (Stroke Unit Trialists' Collaboration, 2007)
now includes 26 studies which provide
overwhelming and consistent evidence that
stroke unit care significantly reduces death and
disability (~20% improvement) after stroke
compared with conventional care in general
wards for all people with stroke. Stroke unit care
is the most generalisable, effective intervention
for acute stroke.

Total number of inpatients with

a primary diagnosis of acute
stroke (ICD-10 Code) that have
documented treatment in a
stroke unit at any time during
their hospital stay.

Total number of inpatients

separated from hospital with
a primary diagnosis of acute
stroke (ICD-10 Code).

High

86.9

75.8

91.7

Continuity of Care, 1.1.2, 1.1.4,

Process Appropriateness, 1.1.8, 1.3.1,
Effectiveness
1.4.1

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Topic

Rationale

Screening acutely hospitalised older patients'

cognitive status is important for predicting
functional outcomes after admission and
discharge. Impaired cognitive performance on
admission was associated with limited recovery
Assessment of cognitive
both for routine tasks (eg. basic ADL such as
function for all general
eating and bathing) and tasks that required
medical patients 65 years
higher-order cognitive processing (eg. ADL such
or over at admission.
as managing money and using the telephone).
Cognitive screening increases the likelihood of
detecting delirium, where early intervention and
treatment may reduce the severity and duration
of delirium.

Numerator

Denominator

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Dimension of
Quality

EQuIP5
Criterion

Total number of medical

patients 65 years or older who
have had their cognition
assessed using a validated tool
such as the AMTS or MMSE.

Total number of patients 65

years or older during the 6
month time period.

High

71.5

62.1

91.9

Continuity of Care, 1.1.1, 1.1.2,

Process Appropriateness, 1.1.4, 1.1.8,
Effectiveness
1.3.1, 1.4.1

4.2

Assessment of physical
function

Patients who are admitted to a geriatric medicine

or geriatric rehabilitation unit must have a
documented objective assessment of physical
function. Comprehensive functional assessment
and reassessment are vital to planning
appropriate treatment programs and should be
done at least twice during an inpatient stay.

Total number of patients

admitted to a geriatric medicine
or geriatric rehabilitation unit
for whom there is documented
objective assessment of physical
function on admission, and at
least once more during the
inpatient stay.

Total number of patients

admitted to a geriatric
medicine or geriatric
rehabilitation unit.

High

94.7

87.1

99.9

Continuity of Care, 1.1.1, 1.1.2,

Process Appropriateness, 1.1.4, 1.1.8,
Effectiveness
1.3.1, 1.4.1

4.3

Prescription of vitamin D
therapy in patients 65
years and over admitted
to general medical units
with a documented
vitamin D deficiency.

More than 50% of medical in-patients are vitamin

D-deficient. Vitamin D supplementation has been
shown to reduce hip fracture and fall risk in
institutionalised elderly. (Vitamin D
supplementation is probably unnecessary if
serum 25-OH vitamin D level >50 nmol/L).

Total number of general medical

patients 65 years and over who
have a documented vitamin D
deficiency and who are
prescribed vitamin D.

Total number of general

medical patients 65 years
and over who have a
documented vitamin D
deficiency.

High

65.8

50.3

85.8

Continuity of Care, 1.1.1, 1.1.2,

Process Appropriateness, 1.1.4, 1.1.8,
Effectiveness
1.3.1, 1.4.1

Referral to a chronic
disease management
service for patients with
COPD.

There is NHMRC Level I evidence that

participation in a chronic disease management
service that includes physical rehabilitation
relieves dyspnoea and fatigue, improves
emotional function and enhances patients sense
of control over their condition. These
improvements are moderately large and clinically
significant. Rehabilitation forms an important
component of the management of COPD.

Total number of patients

discharged from a general
medical unit with any diagnosis
of COPD who are referred for a
chronic disease management
service that includes physical
rehabilitation.

Total number of patients

discharged from a general
medical unit with any
diagnosis of COPD.

High

10.9

10.9

10.9

Continuity of Care, 1.1.2, 1.1.4,

Process Appropriateness, 1.1.6, 1.3.1,
Effectiveness
1.4.1

Assessment of asthma
severity and asthma
management plans.

Asthma is a common condition with most

hospitals involved in both outpatient and
inpatient management. The condition affects
approximately 8% of the population. There are
approximately 700 deaths per year in Australia.
An admission to hospital for acute asthma should
include evidence of a documented review of
maintenance therapy, and formulation of an
individual crisis plan with the patient.

Total number of patients

admitted to hospital with a
Total number of patients
diagnosis of acute asthma for
admitted to hospital with a
whom there is documented
diagnosis of acute asthma
objective assessment of severity
on initial presentation.

High

98.1

99.1

99.8

Continuity of Care, 1.1.1, 1.1.2,

Process Appropriateness, 1.1.4, 1.1.8,
Effectiveness
1.3.1, 1.4.1

4.1

5.1

5.2

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5.3

Topic

As described above.

5.4

As described above.

6.1

Management of patients
admitted with
haematemesis and / or
melaena who receive a
blood transfusion.

6.2

6.3

6.4

As described above.

As described above.

As described above.

ACHS Clinical Indicator Summary Guide 2012

Rationale

As described above.

Numerator

Total number of patients

admitted to hospital with a
diagnosis of acute asthma for
Total number of patients
whom there is documented
admitted to hospital with a
objective assessment of
diagnosis of acute asthma
severity, in addition to the initial
assessment, which facilitates
ongoing inpatient management.

Total number of patients

admitted to hospital with a
diagnosis of acute asthma for
As described above.
whom there is documented
evidence of an appropriate
discharge plan.
Total number of patients
admitted to hospital with
Haematemesis and melaena (H&M) are common haematemesis and / or
melaena, who receive a blood
symptoms necessitating admission to hospital
and often indicate significant potential morbidity. transfusion and have a
gastroscopy within 24 hours of
admission.
Total number of patients
admitted to hospital with
haematemesis and / or
melaena, who receive a blood
As described above.
transfusion, who are discharged
with a specific diagnosis that
explains the cause of bleeding.

As described above.

As described above.

Denominator

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Total number of patients

admitted to hospital with
haematemesis and / or
melaena, who receive a blood
transfusion, for whom there is
documented evidence that a
member of surgical staff has
been notified of their condition.
Total number of patients
admitted to hospital with
haematemesis and / or
melaena, who receive a blood
transfusion, and have an
operation, during the same
admission.

Total number of patients

admitted to hospital with a
diagnosis of acute asthma

Total number of patients

admitted to hospital with
haematemesis and / or
melaena who receive a
blood transfusion.

Dimension of
Quality

EQuIP5
Criterion

High

84.5

62.4

98.9

Continuity of Care, 1.1.1, 1.1.2,

Process Appropriateness, 1.1.4, 1.1.8,
Effectiveness
1.3.1, 1.4.1

High

70.8

33.8

82.4

Continuity of Care, 1.1.1, 1.1.2,

Process Appropriateness, 1.1.4, 1.1.8,
Effectiveness
1.3.1, 1.4.1

High

73.1

67.9

76.7

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Outcome
Effectiveness,
1.5.5
Safety

Total number of patients

admitted to hospital with
haematemesis and / or
melaena who receive a
blood transfusion.

High

83.1

78.1

88.0

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of patients

admitted to hospital with
haematemesis and / or
melaena who receive a
blood transfusion.

High

16.3

16.5

16.5

Continuity of Care, 1.1.2, 1.1.4,

Process Appropriateness, 1.1.8, 1.3.1,
Effectiveness
1.4.1

Total number of patients

admitted to hospital with
haematemesis and / or
melaena who receive a
blood transfusion.

Not
specified

4.64

3.52

5.17

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Yes

27

Indicator Set

Internal Medicine

Version CI No.

6.5

Topic

As described above.

Rationale

Numerator

Total number of patients

admitted to hospital with
haematemesis and / or
melaena, having both blood
As described above.
transfusion and endoscopic
therapy, who subsequently have
an operation, during the same
admission.
Total number of patients
admitted to hospital with
haematemesis and / or
As described above.
melaena, who receive a blood
transfusion and subsequently
die.
Total number of inpatients
having a renal biopsy who
Renal biopsy is a procedure commonly performed
subsequently develop
as part of the assessment of patients with renal
macroscopic haematuria in any
disease. It is an invasive technique, which may
of their voided urine specimens
put the patient at risk.
within 24 hours of the
procedure.
Total number of premenopausal patients with Stage
Stage II carcinoma of the breast with nodal
II carcinoma of the breast for
involvement is a common malignancy in prewhom there is documented
menopausal women. The standard management
evidence of treatment, or
usually includes systemic adjuvant therapy.
intention to treat, with polychemotherapy.

Denominator

Total number of patients

admitted to hospital with
haematemesis and / or
melaena who receive a
blood transfusion.

Total number of inpatients

having a renal biopsy.

Yes

Low

5.04

2.65

8.01

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

High

93.2

92.8

93.9

Continuity of Care, 1.1.2, 1.1.4,

Process Appropriateness, 1.1.8, 1.3.1,
Effectiveness
1.4.1

Adequacy and safety of

renal biopsy.

8.1

Use of systemic adjuvant

treatment for Stage II
Breast Cancer.

1.1

Reporting of adverse drug

reactions to Office of
Reporting of adverse drug reactions to an
Product Compliance
external body may be beneficial for the future
(OPC), Therapeutic Goods management and safety of patients.
Administration (TGA)

The total number of adverse

drug reactions, which were
reported to OPC, TGA.

2.1

Medication errors
resulting in an adverse
event requiring
intervention beyond
routine observation and
monitoring.

Total number of medication

errors resulting in an adverse
Total number of occupied
event requiring intervention
bed days.
beyond routine observation and
monitoring.

ACHS Clinical Indicator Summary Guide 2012

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

7.1

3.09

4.80

Medication
Safety

3.09

4.80

Internal Medicine

The use of medication remains the most common

intervention in health care. Medicine misuse,
underuse or over use and adverse reactions
annually result in an estimated 140,000 annual
hospital admissions in Australia; most of these
adverse drug events are preventable.

3.09

4.81

As described above.

Not
specified

Low

6.6

Medication
Safety

EQuIP5
Criterion

Yes

Dimension of
Quality

Total number of patients

admitted to hospital with
haematemesis and / or
melaena who receive a
blood transfusion.

Internal Medicine

Internal Medicine

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Total number of premenopausal patients with

Stage II carcinoma of the
breast.

The total number of non

same-day separations.

Yes

Not
specified

Low

Modified
indicator
for 2011

Continuity of Care,
Appropriateness,
1.1.2, 1.1.4,
Effectiveness,
1.3.1, 1.4.1,
Process
Safety, Quality
1.5.1, 2.1.3
Improvement and
Risk

0.023

Continuity of Care,
Appropriateness,
1.1.2, 1.1.4,
Effectiveness,
Outcome
1.3.1, 1.4.1,
Safety, Quality
1.5.1, 2.1.3
Improvement and
Risk

0.001

0.015

28

Indicator Set

Medication
Safety

Medication
Safety

Medication
Safety

Medication
Safety

Medication
Safety

Medication
Safety

Medication
Safety

Version CI No.

3.1

4.1

5.1

5.2

5.3

5.4

5.5

Topic

Documentation of a
patients known adverse
drug reactions (ADRs) on
the medication chart.

Rationale

Numerator

Denominator

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

The purpose of ADR documentation is to avoid

further harm to patients who have previously
experienced an ADR to that (or similar)
medication. Data from NSW audits of the
National Inpatient Medication Chart (NIMC) show
Total number of patients whose
that completion of ADR documentation occurs 49Total number of patients in
known ADRs are documented
85% of the time. Incidents involving medication
the sample.
on the current medication chart.
administration to patients with a known ADR to
that medication continue to occur. Prevention of
such errors depends on current and complete
information being available at the time of
prescribing, dispensing and administration.

High

This indicator addresses the effectiveness of

processes that encourage clear and unambiguous
Percentage of medication communication and medication orders. One of
Total number of medication
Total number of medication
orders that include error- the major causes of medication errors is the use orders that include error-prone
orders in the sample.
of potentially dangerous abbreviations in
prone abbreviations.
abbreviations.
prescribing.
Total number of non same-day
Warfarin is a widely used drug with a narrow
Total number of non sameseparations receiving warfarin
Management of warfarin. therapeutic index and with potentially serious
day separations receiving
as an inpatient who experience
adverse reactions such as spontaneous bleeding.
warfarin as an inpatient.
abnormal bleeding.

As described above.

As described above.

As described above.

As described above.

ACHS Clinical Indicator Summary Guide 2012

Yes

88.0

EQuIP5
Criterion

97.3

Continuity of Care,
Appropriateness,
1.1.2, 1.1.4,
Effectiveness,
1.3.1, 1.4.1,
Process
Safety, Quality
1.5.1, 2.1.3
Improvement and
Risk

Low

5.8

0.33

9.3

Continuity of Care,
Appropriateness,
1.1.2, 1.1.4,
Effectiveness,
1.3.1, 1.4.1,
Process
Safety, Quality
1.5.1, 2.1.3
Improvement and
Risk

Yes

Low

0.95

0.39

0.62

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Yes

Low

Modified
indicator
for 2011

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness
Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.1.5, 1.3.1,
Process
Effectiveness,
1.4.1, 1.5.1
Safety

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

As described above.

Total number of non same-day

separations receiving warfarin
as an inpatient with an INR
reading greater than 5.

As described above.

Total number of patients

Total number of non samedischarged on warfarin who
day separations receiving
receive written drug information
warfarin as an inpatient.
prior to discharge.

Yes

High

Modified
indicator
for 2011

As described above.

Total number of patients on

warfarin with an INR of 4 or
above whose dosage has been
adjusted or reviewed prior to
the next warfarin dose.

Total number of patients on

warfarin with an INR result
of 4 or above.

Yes

High

Modified
indicator
for 2011

As described above.

Total number of patients

prescribed hospital initiated
warfarin whose starting doses
are consistent with a hospital
approved protocol.

Total number of patients

initiated on warfarin

High

New
indicator
for 2011

Total number of non sameday separations receiving

warfarin as an inpatient.

74.3

Dimension of
Quality

Outcome

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Effectiveness,
1.5.1
Safety

29

Indicator Set

Medication
Safety

Mental Health
Community
Based

Mental Health
Community
Based

Mental Health
Community
Based

Mental Health
Community
Based

Version CI No.

Topic

Rationale

6.1

Aminoglycosides are useful but toxic medicines

with a narrow therapeutic index. In patients
treated with aminoglycosides for more than 48
Timely and appropriate
hours, dosage should be adjusted according to
monitoring of
aminoglycoside antibiotics plasma drug concentrations and renal function.
Failure to act on a toxic concentration result
could lead to renal impairment and ototoxicity.

1.1

Registered consumers
seen face-to-face by the
community service

Numerator

Denominator

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Total number of patients with a

toxic aminoglycoside
Total number of patients
concentration whose dosage has with a toxic aminoglycoside
been adjusted prior to the next concentration in the sample.
aminoglycoside dose.

High

New
indicator
for 2011

The role of community care is to provide safe,

Total number of registered
quality and consistent service to consumers in the
Total number of consumers
consumers seen face-to-face by
community and to minimise the admission of
registered with the service
the community service
those consumers to psychiatric hospitals.

Not
specified

1.2

Consumers or nominated
carers with greater than As described above.
24 treatment days

Total number of consumers or

Total number of consumers
nominated carers with greater
or nominated carers seen
than 24 treatment days over a 3
within a 3 month period
month period

Not
specified

1.3

Consumers or nominated
carers with 3 or more face- As described above.
to-face contacts

Total number of consumers or

nominated carers with 3 or
more face-to-face contacts
within a 7 day period

Not
specified

10.9

1.4

Consumers who were

admitted to hospital for
As described above.
psychiatric reasons (by
that service) once or more

Total number of consumers who

were admitted to hospital for
Total number of registered
psychiatric reasons (by that
consumers seen by the
service) once or more in the first community service
year of treatment

Low

Total number consumers with

current completed care plans
Collaborative planning encourages consumer
ownership of their care with more following care (including consumer
involvement and signature) in
plans recovery outcomes.
the file

Total number of registered

consumers with the mental
health service during the
reporting period

Total number of consumers

or nominated carers seen

Yes

Process

Dimension of
Quality

EQuIP5
Criterion

Continuity of Care,
1.1.1, 1.1.2,
Appropriateness,
1.1.4, 1.3.1,
Effectiveness,
1.4.1, 1.5.1
Safety

98.3

Continuity of Care,
1.1.2, 1.1.4,
Accessibility,
1.2.1, 1.2.2,
Process
Appropriateness,
1.3.1, 1.4.1
Effectiveness

14.4

Continuity of Care,
1.1.2, 1.1.4,
Accessibility,
1.2.1, 1.2.2,
Process
Appropriateness,
1.3.1, 1.4.1
Effectiveness

0.23

16.5

Continuity of Care,
1.1.2, 1.1.4,
Accessibility,
1.2.1, 1.2.2,
Process
Appropriateness,
1.3.1, 1.4.1
Effectiveness

8.95

1.88

13.4

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.4.1, 1.3.1,
Effectiveness
1.4.1

High

86.2

55.4

99.9

Continuity of Care, 1.1.2, 1.1.4,

Outcome Appropriateness, 1.1.8, 1.3.1,
Effectiveness
1.4.1

81.7

16.2

69.5

0.17

Mental Health
Community
Based

2.1

Consumers with current

completed care plans
(including consumer
involvement and
signature) in the file

Mental Health
Community
Based

2.2

Carers involved in
developing care plans

As described above.

Total number of registered

Total number of carers involved
consumers with the mental
in developing care plans
health service

High

83.8

13.2

100

Continuity of Care, 1.1.2, 1.1.4,

Outcome Appropriateness, 1.1.6, 1.3.1,
Effectiveness
1.4.1

Mental Health
Inpatient

1.1

Inpatients - diagnosis
within 24 hours of
admission

This is an index of the process of patient care.

Total number of inpatients

allocated a diagnosis within 24
hours of admission.

High

93.3

90.7

99.6

Continuity of Care, 1.1.1, 1.1.2,

Process Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Mental Health
Inpatient

1.2

Inpatients - diagnosis
recorded on hospital
discharge

As described above.

Total number of inpatients with

a diagnosis on hospital discharge Total number of inpatient
which is recorded in the medical separations.
record.

High

89.6

80.3

99.7

Continuity of Care, 1.1.2, 1.1.4,

Process Appropriateness, 1.1.8, 1.3.1,
Effectiveness
1.4.1

1.3

Inpatient with an
individual care plan, which
is constructed and
As described above.
regularly reviewed with
the consumer

Total number of inpatients with

an individual care plan, which is Total number of inpatient
constructed and regularly
separations.
reviewed with the consumer.

High

82.8

73.5

99.4

Continuity of Care, 1.1.2, 1.1.4,

Process Appropriateness, 1.1.8, 1.3.1,
Effectiveness
1.4.1

Mental Health
Inpatient

ACHS Clinical Indicator Summary Guide 2012

Total number of inpatients

admitted.

Yes

30

Indicator Set

Version CI No.

Topic

Rationale

Numerator

Mental Health
Inpatient

2.1

Inpatients - complete
physical examination
within 48 hours of
admission

Mental Health
Inpatient

3.1

Inpatients - three or more

psychotropic medications This is an index of the safety of patient care.
on discharge

4.1

These indicators focus on the appropriateness of

the number of ECT treatments given during a
Total number of patients
Inpatients - more than 12
defined course and all patients undergoing any
undergoing more than 12
treatments of ECT
ECT treatment who experience a major medical treatments of E.C.T.
complication.

Mental Health
Inpatient

This is an index of the completeness of patient

care.

Mental Health
Inpatient

4.2

Inpatients - major medical

As described above.
complications during ECT

Mental Health
Inpatient

5.1

Inpatients - at least one

episode of seclusion

5.2

Inpatients - at least two

episodes of seclusion

As described above.

Mental Health
Inpatient

5.3

Inpatients - seclusion for

more than 4 hours

As described above.

5.4

Inpatients - secluded and

not reviewed by sight at
least half hourly

As described above.

Total number of inpatients

having at least 2 episodes of
seclusion, in an admission or in a
1 month period of an extended
admission.
Total number of inpatients
having seclusion for more than 4
hours in 1 episode, in an
admission.

EQuIP5
Criterion

Yes

High

83.0

74.1

99.3

Continuity of Care, 1.1.1, 1.1.2,

Process Appropriateness, 1.1.4, 1.1.8,
Effectiveness
1.3.1, 1.4.1

Total number of inpatients

on psychotropic medications
on discharge.

Yes

Low

4.07

0.23

6.8

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of patients

undergoing a course of
E.C.T.

Yes

Low

8.80

5.56

16.2

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Low

0.63

0.49

0.68

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

Total number of inpatient

separations.

Low

8.45

3.41

13.3

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of inpatient

separations having
seclusion.

Low

35.6

32.7

39.4

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of inpatient

separations having
seclusion.

Low

52.7

23.1

70.2

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Low

0.096

0.096

0.096

Continuity of Care, 1.1.1, 1.1.2,

Process Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Yes

Total number of inpatients in

seclusion who were not
Total number of inpatient
reviewed by sight, by a medical separations having
practitioner or nurse on at least seclusion.
a half-hourly basis.

Mental Health
Inpatient

5.5

Inpatients - major
complications while in
seclusion

As described above.

Total number of inpatients

Total number of inpatient
experiencing major
separations having
complications while in seclusion. seclusion.

Mental Health
Inpatient

5.6

Inpatients having
seclusion

As described above.

Total number of inpatients

having seclusion.

ACHS Clinical Indicator Summary Guide 2012

Dimension of
Quality

Total number of inpatients

admitted with a length of
stay of 48 hours or more.

Total number of patients

Total number of patients
experiencing major medical
undergoing a course of
complications while undergoing
E.C.T.
E.C.T.

Total number of inpatients

This is an index of the use and safety of seclusion
having at least 1 episode of
and physical restraint in patient care.
seclusion, in an admission.

Mental Health
Inpatient

Mental Health
Inpatient

Total number of inpatients with

a complete documented
physical examination within 48
hours of admission.
Total number of inpatients on 3
or more psychotropic
medications, from 1 sub-group
category, at the time of
discharge.

Denominator

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Total number of inpatient

separations having
seclusion.

Yes

Yes

Low

0.64

0.46

0.71

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

Low

2.78

1.0

1.90

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

31

Indicator Set

Mental Health
Inpatient

Mental Health
Inpatient

Mental Health
Inpatient

Mental Health
Inpatient

Mental Health
Inpatient

Mental Health
Inpatient

Mental Health
Inpatient

Mental Health
Inpatient

Version CI No.

Topic

Rationale

Numerator

Denominator

5.7

Inpatients having at least 1

episode of physical
As described above.
restraint, in an admission

Total number of inpatients

having at least 1 episode of
physical restraint, in an
admission.

5.8

Inpatient separations
having physical restraint
who experience major
As described above.
complications while under
restraint

Total number of inpatient

separations having physical
Total number of inpatient
restraint who experience major
separations having restraint.
complications while under
restraint.

6.1

Major critical incidents are any untoward

happenings, which are not consistent with the
Total number of inpatients with
Inpatients - attempted or routine operation of the organisation. These
an attempted or actual suicide Total number of inpatients.
indicators measure the process and outcome for
actual suicide
in an admission.
patients who attempt / actual suicide, assault,
self-mutilate or suffer significant other injuries.

6.2

6.3

6.4

Inpatients - assault

Inpatients - assault twice

or more

As described above.

As described above.

Inpatients - significant self

As described above.
mutilation

6.5

Inpatients - significant
other injuries

6.6

Inpatients assaulted by
staff, visitors, or other
inpatient

ACHS Clinical Indicator Summary Guide 2012

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Total number of inpatient

separations.

Total number of inpatients who

Total number of inpatients.
assault in an admission.

Total number of inpatients who

Total number of inpatients
assault twice or more in an
who assault in an admission.
admission.

Total number of inpatients who

undertake significant selfTotal number of inpatients.
mutilation in an admission.

As described above.

Total number of inpatients

suffering significant other
injuries in an admission.

As described above.

Total number of inpatients

assaulted by staff / visitors /
Total number of inpatients.
other inpatients in an admission.

Total number of inpatients.

Low

Low

Yes

Yes

Yes

Yes

Yes

Yes

Low

Low

Low

Low

Low

Low

1.51

0.23

0.50

2.04

26.9

0.41

0.25

0.82

0.078

0.23

0.12

0.12

24.8

0.19

0.13

0.043

Dimension of
Quality

EQuIP5
Criterion

2.23

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

0.23

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

0.70

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

3.62

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

29.1

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

0.58

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

0.42

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

1.25

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

32

Indicator Set

Mental Health
Inpatient

Version CI No.

7.1

Topic

Unplanned readmissions
within 28 days

Rationale

This is an index of the quality of care on the

patients initial admission.

Numerator

Total number of unplanned readmissions within 28 days of

separation.

Whilst not all deaths may be amendable, this

indicator focuses on the safety and quality of care
Total number of inpatient
for psychiatric patients in an inpatient psychiatric
Inpatient death
deaths.
service or a medical / surgical ward of an
attached hospital only.
Total number of inpatients who
Inpatients - discharge
have a discharge summary or
summary or letter on
This is an index of the continuity of patient care.
letter at the time of hospital
discharge
discharge.
Total number of inpatients who
have a final discharge summary
Inpatients - final discharge
recorded in the medical record
summary within 2 weeks As described above.
within 2 weeks of hospital
of discharge
discharge.

Mental Health
Inpatient

8.1

Mental Health
Inpatient

9.1

Mental Health
Inpatient

9.2

Mental Health
Inpatient

Inpatient who have a

10.1 multidisciplinary review
recorded every 3 months

This is an index of the continuity of patient care.

Mental Health
Inpatient

Inpatient in an acute unit

11.1 with a length of stay
greater than 30 days

Mental Health
Inpatient

12.1

Voluntary inpatient
admission

Denominator

Dimension of
Quality

EQuIP5
Criterion

Total number of inpatient

separations.

Yes

Low

6.92

2.60

10.10

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1,

Total number of inpatients.

Yes

Low

0.058

0.042

0.055

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1,
Effectiveness

High

69.1

52.0

96.0

Continuity of Care, 1.1.2, 1.1.4,

Process Appropriateness, 1.1.5, 1.1.8,
Effectiveness
1.3.1, 1.4.1,

Total number of inpatient

separations.

Total number of inpatient

separations.

Yes

High

78.7

61.0

99.1

Continuity of Care, 1.1.2, 1.1.4,

Process Appropriateness, 1.1.5, 1.1.8,
Effectiveness
1.3.1, 1.4.1,

Total number of inpatient who

have a multidisciplinary review
recorded every 3 months.

Total number of inpatient

with the stay of greater than
3 months.

Yes

High

94.2

90.0

98.5

Continuity of Care, 1.1.1, 1.1.2,

Process Appropriateness, 1.1.4, 1.1.8,
Effectiveness
1.3.1, 1.4.1

This indicator focuses on the appropriateness of

length of stay in an acute inpatient unit.

Total number of inpatient in an

acute unit with a length of stay
greater than 30 days.

Total number of completed

inpatient episodes in the
acute unit.

Yes

Low

15.3

9.05

21.9

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

This indicator focuses on voluntary admission.

Total number of voluntary

inpatient admissions.

Total number of admissions.

Not
specified

58.7

36.9

93.5

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

High

45.8

36.4

57.7

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

The selected primipara represents an

uncomplicated pregnancy whereby intervention
and complication rates should be low and
consistent across hospitals. Use of the selected
Total number of selected
primipara (rather than all women giving birth) as primipara who have a
the basis for inter-hospital comparison of
spontaneous vaginal birth.
maternity care controls for differences in case
mix and increases the validity of those
comparisons.
Total number of selected
primipara who undergo
As described above.
induction of labour.

Obstetrics

1.1

Selected primipara who

have a spontaneous
vaginal birth.

Obstetrics

1.2

Selected primipara who

undergo induction of
labour.

Obstetrics

1.3

Selected primipara who

undergo an instrumental
vaginal birth.

As described above.

The number of selected

primipara who undergo an
instrumental vaginal birth.

Obstetrics

1.4

Selected primipara
undergoing caesarean
section.

As described above.

Total number of selected

Total number of selected
primipara undergoing caesarean
primipara who give birth.
section.

ACHS Clinical Indicator Summary Guide 2012

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Total number of selected

primipara who give birth.

Total number of selected

primipara who give birth.

Yes

Low

29.1

22.8

34.0

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of selected

primipara who give birth.

Yes

Low

24.3

19.2

27.8

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Low

28.0

22.4

33.9

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Yes

33

Indicator Set

Obstetrics

Obstetrics

Version CI No.

Topic

Rationale

2.1

This Indicator monitors mode of birth in those

women who have had a previous primary (first)
caesarean section and no other vaginal births.
With caesarean section rates continuing to
increase to the highest level in history, the issue
of whether it is safe to have a vaginal birth after
Vaginal delivery following caesarean section (VBAC) is of the highest
primary caesarean section importance. There is evidence that repeat
caesarean section can be associated with
(VBAC).
significant morbidity for women but VBAC carries
increased risks for the baby when compared with
repeat elective caesarean section. The Indicator is
designed to monitor the incidence of VBAC in
women whose previous pregnancy ended in
caesarean section.

3.1

Selected primipara with

an intact perineum or
unsutured perineal tear

Obstetrics

3.2

Selected primipara
undergoing episiotomy
and no perineal tear.

Obstetrics

3.3

Selected primipara
sustaining a perineal tear
and no episiotomy.

Numerator

Total number of women

delivering vaginally following a
previous primary caesarean
section.

Denominator

Total number of women

delivering who have had a
previous primary caesarean
section and NO intervening
pregnancies greater than 20
weeks gestation.

Yes

Not
specified

14.4

8.24

21.0

Dimension of
Quality

EQuIP5
Criterion

Continuity of Care,
Process,
1.1.2, 1.1.4,
Appropriateness,
Outcome
1.3.1, 1.4.1
Effectiveness

Vaginal birth is the most common cause of anal

sphincter injuries in women1 and as such
obstetric anal sphincter injury is considered a
major complication of vaginal birth a
complication that can have a significant impact on
a womans quality of life.

Total number of selected

Total number of selected
primipara with an intact
primipara delivering
perineum or unsutured perineal
vaginally.
tear.

Yes

High

Modified
indicator
for 2011

As described above.

Total number of selected

Total number of selected
primipara undergoing
primipara delivering
episiotomy AND no perineal tear
vaginally.
while giving birth vaginally.

Yes

Low

29.2

17.7

39.6

Continuity of Care,
Process,
1.1.2, 1.1.4,
Appropriateness,
Outcome
1.3.1, 1.4.1
Effectiveness

As described above.

Total number of selected

primipara sustaining a perineal
tear AND no episiotomy.

Total number of selected

primipara delivering
vaginally.

Yes

Low

47.1

38.9

50.5

Continuity of Care,
Process,
1.1.2, 1.1.4,
Appropriateness,
Outcome
1.3.1, 1.4.1
Effectiveness

As described above.

Total number of selected

primipara undergoing
episiotomy AND sustaining a
perineal tear while giving birth
vaginally.

Total number of selected

primipara delivering
vaginally.

Yes

Low

5.89

2.90

6.75

Continuity of Care,
Process,
1.1.2, 1.1.4,
Appropriateness,
Outcome
1.3.1, 1.4.1
Effectiveness

Yes

Low

4.49

2.72

5.15

Continuity of Care,
Process,
1.1.2, 1.1.4,
Appropriateness,
Outcome
1.3.1, 1.4.1
Effectiveness

Low

0.35

0.31

0.38

Continuity of Care,
Process,
1.1.2, 1.1.4,
Appropriateness,
Outcome
1.3.1, 1.4.1
Effectiveness

Obstetrics

3.4

Selected primipara
undergoing episiotomy
and sustaining a perineal
tear.

Obstetrics

3.5

Surgical repair of the third

degree of damage to the As described above.
lower genital tract.

Total number of selected

Total number of selected
primipara undergoing surgical
primipara delivering
repair of the perineum for third
vaginally.
degree tear.

Obstetrics

3.6

Surgical repair of the

fourth degree of damage As described above.
to the lower genital tract.

Total number of selected

primipara undergoing surgical
repair of the perineum for
fourth degree tear.

ACHS Clinical Indicator Summary Guide 2012

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Total number of selected

primipara delivering
vaginally.

Yes

Continuity of Care,
Process,
1.1.2, 1.1.4,
Appropriateness,
Outcome
1.3.1, 1.4.1
Effectiveness

34

Indicator Set

Obstetrics

Obstetrics

Obstetrics

Version CI No.

Topic

Rationale

Numerator

Denominator

General anaesthesia for

caesarean section.

This indicator monitors the number of women

who have a caesarean section performed under
general anaesthesia.
There is now evidence that women who are
having a caesarean section should be offered
regional anaesthesia rather than general
anaesthesia because it is safer and results in less
maternal and neonatal morbidity.

Total number of women having

Total number of women
a general anaesthetic for a
having a caesarean section.
caesarean section

5.1

Antibiotic prophylaxis in
elective and emergency
caesarean section.

An appropriate prophylactic antibiotic at the time

of caesarean section, both elective and
emergency, significantly reduces maternal post
operative infectious morbidity.
This indicator is included as an index of utilisation
of evidence based practice for antibiotic
prophylaxis for women undergoing both elective
and emergency caesarean section.

Total number of women who

receive an appropriate
prophylactic antibiotic at the
time of caesarean section.

6.1

Pharmacological
thromboprophylaxis for
women at high risk for
venous thromboembolism
(VTE) giving birth by
caesarean section.

Thromboembolism is a major cause of maternal

morbidity. Pregnancy is a risk factor for VTE and
the risk is higher if birth is by caesarean section,
especially emergency caesarean section.

4.1

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Low

6.15

3.60

Dimension of
Quality

EQuIP5
Criterion

9.48

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Yes

High

85.3

75.6

97.8

Continuity of Care,
1.1.2, 1.1.4,
Appropriateness,
1.3.1, 1.4.1,
Process
Effectiveness,
1.5.2
Safety

Total number of high risk

women undergoing caesarean Total number of high risk
section who receive appropriate women undergoing
pharmacological
caesarean section.
thromboprophylaxis.

Yes

High

69.2

36.5

90.1

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Postpartum haemorrhage (PPH) is a potentially

life threatening complication of birth that occurs
in about 3-5% of vaginal births1. The condition
remains a leading cause of maternal morbidity
and mortality.

Total number of women who

give birth vaginally who receive Total number of women
a blood transfusion during the who give birth vaginally.
same admission.

Yes

Low

1.26

0.78

1.57

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of women who

Total number of women
undergo caesarean section who
who undergo caesarean
receive a blood transfusion
section.
during the same admission.

Yes

Low

1.64

1.02

2.27

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of women

undergoing caesarean
section.

Obstetrics

7.1

Incidence of postpartum
haemorrhage (PPH) and
blood transfusions after
vaginal birth.

Obstetrics

7.2

Incidence of postpartum
haemorrhage (PPH) and
blood transfusions after
caesarean section.

As described above.

8.1

Identification of babies
with severe intrauterine
growth restriction (IUGR),
babies less than the 3rd
centile delivered after 40
weeks.

Profound IUGR is a major cause of perinatal

mortality and morbidity with mortality increasing Total number of deliveries with Total number of deliveries at
with IUGR in late pregnancy.
birth weight less than 2750g at 40 weeks gestation or
This indicator aims to identify undiagnosed IUGR 40 weeks gestation or beyond. beyond.
for babies born at term.

Yes

Low

1.82

1.49

2.03

Continuity of Care,
Process,
1.1.2, 1.1.4,
Appropriateness,
Outcome
1.3.1, 1.4.1
Effectiveness

Apgar score of term

babies.

Virginia Apgar proposed the Apgar score in 1952

as a means of evaluating the physical condition of
babies at birth. The Apgar score can provide a
basis for the uniform assessment of condition of
the infant at specific time periods after the infant
is born. The five minute Apgar score measures
how well the infant is adapting to the new
environment and is an assessment of how the
baby responds to resuscitation, should it be
required.

Yes

Low

1.15

0.74

1.42

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Obstetrics

Obstetrics

9.1

ACHS Clinical Indicator Summary Guide 2012

Total number of term babies

born with an Apgar score of less Total number of term babies
than 7 at five minutes post
born.
delivery.

35

Indicator Set

Obstetrics

Obstetrics

Ophthalmology

Ophthalmology

Version CI No.

Topic

Rationale

This indicator is included to determine whether

the rate of admission of inborn term infants to
SCN or NICN for reasons other than birth defects
is principally due to non-avoidable factors.
Inborn term infants without birth defects are not
normally expected to be admitted to a SCN or
NICN.

Term babies transferred

or admitted to a Neonatal
Intensive Care Nursery
10.1 (NICN) or Special Care
Nursery (SCN) for reasons
other than congenital
abnormality.

Serious unanticipated or unusual adverse events

occur in healthcare settings which result in
Specified, serious adverse maternal or perinatal mortality or morbidity. A
11.1 events addressed within a peer review process ensures that incidents are
reviewed and the outcome evaluated with the
peer review process.
aim of improving the safety and quality of
obstetric care.

1.1

Cataract surgery Readmission within 28

days

1.2

Cataract surgery Readmission within 28

days due to
endophthalmitis

Numerator

Denominator

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Total number of inborn term

babies transferred / admitted to
a neonatal intensive care
Total number of inborn term
nursery or special care nursery live babies.
for reasons other than
congenital abnormality.

Yes

Total number of serious adverse

Total number of serious
events that are addressed
adverse events.
within a peer review process.

Low

10.0

2.22

Dimension of
Quality

EQuIP5
Criterion

12.5

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

High

84.2

94.6

99.1

Continuity of Care,
Appropriateness, 1.1.2, 1.1.4,
Effectiveness,
1.3.1, 1.4.1,
Process
Quality
2.1.1, 2.1.2,
Improvement and
2.1.3
Risk

This is a commonly performed operation, which

should be associated with low morbidity and a
short length of stay.

Total number of re-admissions

(related to the operated eye)
within 28 days of discharge
following cataract surgery.

Total number of patients

having cataract surgery.

Yes

Low

0.35

0.058

0.49

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

As described above.

Total number of patients having

a re-admission within 28 days of
Total number of patients
discharge following cataract
having cataract surgery.
surgery, due to endophthalmitis
in the operated eye.

Yes

Low

0.041

0.029

0.038

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Yes

Low

0.44

0.034

0.59

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Yes

Low

0.62

0.18

0.76

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Ophthalmology

1.3

Cataract surgery unplanned overnight

admission

As described above.

Total number of patients having

a discharge intention of 1 day, Total number of patients
who had an overnight admission having cataract surgery.
following cataract surgery.

Ophthalmology

1.4

Cataract surgery - anterior

As described above.
vitrectomy

Total number of patients having

Total number of patients
an anterior vitrectomy at the
having cataract surgery.
time of cataract surgery.

Ophthalmology

2.1

Glaucoma surgery readmission within 28

days

This is a commonly performed operation, which

should be associated with a low morbidity and a
short length of stay.

Total number of re-admissions

(related to the operated eye)
within 28 days of discharge
following glaucoma surgery.

Total number of patients

having glaucoma surgery.

Yes

Low

3.07

1.88

2.79

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Yes

Low

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Low

4.16

0.50

1.68

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Ophthalmology

2.2

Glaucoma surgery readmission within 28

days due to
endophthalmitis

As described above.

Total number of patients having

a re-admission within 28 days of
Total number of patients
discharge following glaucoma
having glaucoma surgery.
surgery, due to endophthalmitis
in the operated eye.

Ophthalmology

2.3

Glaucoma surgery - Length

of stay (LOS) greater than As described above.
3 days following surgery

Total number of patients with a

Total number of patients
LOS greater than 3 days
having glaucoma surgery.
following glaucoma surgery.

ACHS Clinical Indicator Summary Guide 2012

Yes

36

Indicator Set

Ophthalmology

Ophthalmology

Version CI No.

Topic

Rationale

3.1

Retinal detachment
surgery - unplanned
readmission within 28
days

3.2

Retinal detachment
surgery - unplanned
As described above.
readmission within 28 due
to endophthalmitis

As described above.

This is a commonly performed operation, which

should be associated with a low morbidity and a
short length of stay.

Numerator

Total number of unplanned readmissions within 28 days of

discharge following retinal
detachment surgery.

Denominator

EQuIP5
Criterion

Yes

Low

2.49

0.36

1.27

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Total number of patients having

an unplanned re-admission
Total number of patients
within 28 days of discharge
having retinal detachment
following retinal detachment
surgery.
surgery, due to endophthalmitis
in the operated eye.

Yes

Low

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Low

1.13

1.03

1.31

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Low

1.78

1.63

1.71

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Low

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Low

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Ophthalmology

3.3

Ophthalmology

3.4

Retinal detachment
surgery - re-operation
within 28 days

As described above.

4.1

Refractive surgery unplanned readmission

within 28 days

This is a commonly performed operation, which

should be associated with low morbidity and a
short length of stay.

Total number of patients having

a re-admission within 28 days of
Total number of patients
discharge following refractive
having refractive surgery.
surgery, due to endophthalmitis
in the operated eye.

Dimension of
Quality

Total number of patients

having retinal detachment
surgery.

Retinal detachment
surgery - Length of stay
(LOS) greater than 4 days
following surgery

Ophthalmology

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Total number of patients with a

LOS greater than 4 days,
following retinal detachment
surgery.
Total number of patients having
an unplanned re-operation on
the same eye within 28 days,
following retinal detachment
surgery.
Total number of re-admissions
(related to the operated eye)
within 28 days of discharge
following refractive surgery.

Total number of patients

having retinal detachment
surgery.
Total number of patients
having retinal detachment
surgery.

Yes

Yes

Total number of patients

having refractive surgery.

Yes

Ophthalmology

4.2

Refractive surgery readmission within 28 due As described above.

to endophthalmitis

Ophthalmology

4.3

Refractive surgery unplanned overnight

admission

As described above.

Total number of patients having

a discharge intention of 1 day, Total number of patients
who had an overnight admission having refractive surgery.
following refractive surgery.

Yes

Low

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Ophthalmology

4.4

Refractive surgery anterior vitrectomy

As described above.

Total number of patients having

Total number of patients
an anterior vitrectomy at the
having refractive surgery.
time of refractive surgery.

Yes

Low

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Ophthalmology

4.5

Excimer laser surgery complication (medical or

surgical) within 28 days
following surgery

As described above.

Total number of patients having

Total number of patients
a complication (medical or
having excimer laser
surgical) within 28 days
surgery.
following excimer laser surgery.

Low

0.065

0.065

0.065

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Oral Health

1.1

Retreatment following
restorative treatment

Unplanned returns may cause patient

inconvenience and decrease patient satisfaction.
As well, they decrease cost effectiveness and
efficiency.

Total number of permanent

teeth restored

Low

Modified
indicator
for 2012

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Oral Health

1.2

Return following simple

extraction

As described above.

Total number of attendances

for simple extraction(s), of
one or more permanent
teeth

Low

Modified
indicator
for 2012

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

ACHS Clinical Indicator Summary Guide 2012

Total number of permanent

teeth retreated within 6 months
of an episode of restorative
treatment
Total number of attendances for
complications within 7 days of
routine extraction of a
permanent tooth or teeth

Yes

Yes

37

Indicator Set

Version CI No.

Topic

Rationale

Numerator

Denominator

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Dimension of
Quality

EQuIP5
Criterion

Oral Health

1.3

Return following surgical

extractions

As described above.

Total number of attendances for

complications within 7 days of
surgical extraction of a
permanent tooth or teeth

Total number of attendances

for surgical extraction(s), of
one or more permanent
teeth

Low

Modified
indicator
for 2012

Oral Health

1.4

Denture Remakes

As described above.

Total number of same denture

type (full or partial) and same
arch remade within 12 months

Total number of dentures

provided

Low

2.64

2.1

Completed endodontic
treatment

Total number of completed

Endodontic treatment may not be successful for a
courses of endodontic
number of reasons. Treatment outcomes have a
treatment on the same
direct bearing on cost, utilisation of resources,
permanent tooth within 6
future treatment options and patient satisfaction.
months of initial treatment

Total number of permanent

teeth on which there has
been a commencement of a
course of endodontic
treatment commenced

High

Modified
indicator
for 2012

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

2.2

Extraction following
commencement of
endodontic treatment

Endodontic treatment may not be successful for a

number of reasons. Incomplete endodontic
treatment may have a direct bearing on
unscheduled returns.

Total number of permanent

Total number of permanent
teeth on which there has
teeth extracted within 12
been a commencement of a
months of commencement of a
course of endodontic
course of endodontic treatment
treatment

Low

Modified
indicator
for 2012

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

3.1

Children's Dental Care Retreatment following

restorative treatment

Re-restoration, endodontic treatment or

extraction after placement of dental fillings
(restorations) may cause patient inconvenience
and decrease patient satisfaction.
As well, they decrease cost effectiveness and
efficiency.

Total number of teeth retreated

Total number of teeth
within 6 months of an episode of
restored
restorative treatment

Low

New
indicator
for 2012

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

3.2

Deciduous tooth endodontic treatment

(pulpotomy) may fail for a number of reasons:
poor initial prognosis
split / fractured crown / root or advanced root
Children's Dental Care resorption & apical pathology
Failure of deciduous
poor technique resulting in perforation / over
endodontic therapy
(pulpotomy / pulpectomy) instrumentation
treatment outcomes have a direct bearing on
cost, utilisation of resources, future treatment
options and patient satisfaction.

Total number of deciduous

teeth extracted (for pathological
reasons) within 6 months
following pulpotomy /
pulpectomy treatment

Total number of deciduous

teeth receiving a pulpotomy
/ pulpectomy treatment in
the period of assessment

Low

3.59

1.14

4.07

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

3.3

Children's Dental Care Fissure sealant

retreatment by treatment
modes not including resealant

Total number of teeth requiring

retreatment (restoration,
endodontic or extraction, but
not including Pit & Fissure
Sealants) within 24 months of
the initial fissure sealant
treatment

Total number of teeth

receiving a fissure sealant
treatment in the period of
assessment

Low

2.61

2.46

3.54

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Oral Health

Oral Health

Oral Health

Oral Health

Oral Health

ACHS Clinical Indicator Summary Guide 2012

Fissure sealants need to be well done and well

maintained in order to maintain the integrity of
the bond that ensures the fissure system is not
subjected to bacterial invasion and advancement
of the carious process.

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

1.26

5.84

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

38

Indicator Set

Oral Health

Paediatric

Paediatric

Paediatric

Paediatric

Paediatric

Paediatric

Version CI No.

Topic

Rationale

Numerator

Denominator

4.1

Maximum diagnostic
ability of bite-wing
radiographs.

Bite-wing radiographs remain the most common

type of radiographs taken for diagnostic
purposes. Criteria to assist in maximising their
diagnostic ability (in addition to the contrast etc
of the final radiograph) will aid in achieving this
Total number of radiographs
outcome.
Total number of (bite-wing)
(bite-wing) that meet all of the 8
radiographs audited
criteria
Correct identification and attribution of the
radiograph to the correct patient record, date
and provider is important for accurate clinical
diagnosis and correct patient, correct site, correct
procedure quality systems.

1.1

Documented current
immunisation status

All children admitted to hospital should have their

immunisation status documented and be offered
or given immunisation if this is not up-to-date,
particularly infants less than 2 years old.

Total number of infants

admitted as inpatients for whom Total number of infants
there is documented current
admitted as inpatients.
immunisation status.

As described above.

Total number of infants

admitted as inpatients with not
up-to-date immunisation status
for whom there is documented
evidence that they were either
given catch-up immunisation; or
that such immunisation was
planned.

Total number of infants

admitted as inpatients with
a not up-to-date
immunisation status.

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Dimension of
Quality

EQuIP5
Criterion

High

Modified
indicator
for 2012

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Yes

High

91.2

81.3

98.7

Continuity of Care, 1.1.2, 1.1.4,

Process Appropriateness, 1.1.8, 1.3.1,
Effectiveness
1.4.1

Yes

High

60.2

33.4

84.6

Continuity of Care, 1.1.2, 1.1.4,

Process Appropriateness, 1.1.8, 1.3.1,
Effectiveness
1.4.1

1.2

Catch-up immunisation
given or planned

2.1

Average length of stay for Asthma is a common childhood condition, the

primary diagnosis of
severity and frequency of which may be
asthma
decreased by careful planning.

Total: Average length of stay for

all episodes of children admitted
N/A
with a primary diagnosis of
asthma.

Yes

Low

Mean =
1.64

1.40

1.91

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

2.2

Average length of stay

primary diagnosis of
asthma - excluding same
day admissions

Total: Average length of stay for

all episodes of children admitted
with a primary diagnosis of
N/A
asthma excluding same day
admissions.

Yes

Low

Mean =
1.88

1.52

2.04

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

2.3

Readmissions to hospital
for asthma within 28 days As described above.
of discharge

Total number of children with a

primary diagnosis of asthma,
Total number of separations
who have a readmission to
of children, with a primary
hospital for asthma within 28
diagnosis of asthma.
days of discharge.

Yes

Low

3.92

3.25

4.40

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

High

72.5

0.055

100

Continuity of Care, 1.1.2, 1.1.4,

Process Appropriateness, 1.1.8, 1.3.1,
Effectiveness
1.4.1

3.1

Entry onto the Australian

and New Zealand
Paediatric Intensive Care
Registry

ACHS Clinical Indicator Summary Guide 2012

As described above.

Participation in the National Patient Database

and the ANZICS Research Centre for Critical Care
Resources (ARCCCR) Survey provides national
comparative data to objectively assess casemix
and severity adjusted mortality together with
available ICU resources.

Total number of paediatric

intensive care submissions to
the Australian and New Zealand Total number of paediatric
Paediatric Intensive Care
admissions into the intensive
Registry with completed
care unit.
information and review of
results.

39

Indicator Set

Paediatric

Paediatric

Paediatric

Paediatric

Paediatric

Paediatric

Paediatric

Pathology

Version CI No.

Topic

Rationale

Numerator

Denominator

As described above.

As described above.

Have you responded to the most

N/A
recent ARCCCR survey?

4.1

ICU access block

Inability by a facility to admit a patient into a

paediatric intensive care unit may be a
consequence of inadequate resources.

Total number of appropriate

patients referred to an intensive
care unit, who are not admitted
to the unit because of
inadequate resources

4.2

Elective surgical cases

deferred or cancelled due As described above.
to lack of ICU / HDU bed

The total number of

Total number of elective surgical admissions into the intensive
cases deferred or cancelled due care unit plus the nonadmissions (as defined in the
to lack of ICU / HDU bed.
numerator).

4.3

Patients were transferred

to another facility / area /
As described above.
ICU due to unavailability
of an ICU bed

Total number of patients who

were transferred to another
facility / area / ICU due to
unavailability of an ICU bed.

4.4

Patients discharge from

the ICU was delayed more As described above.
than 12 hours

Total number of patients whose

Total number of patients
discharge from the ICU was
discharged from the ICU.
delayed more than 12 hours.

4.5

Patients discharged from

the ICU between 6pm and As described above.
6am

Total number of patients

discharged from the ICU
between 6pm and 6am.

5.1

Unplanned re-admission into an intensive care

Unplanned re-admissions unit may reflect less than optimal management of
a patient. It may also reflect premature discharge
into an ICU within 72
as a consequence of inadequate resources or
hours
reflect the standard of ward care.

3.2

1.1

Turnaround time of
requests for serum /
plasma potassium from
the Emergency
Department (ED), (or
requests specified as
urgent)

ACHS Clinical Indicator Summary Guide 2012

Abnormal potassium levels constitute a threat to

patient well being. They may require constant
monitoring in ill patients and rapid correction
where abnormal. Test requests originating from
the ED are assumed to be urgent and therefore
this indicator is recommended for use in health
care organisations that have a defined ED.
Timely pathology results on patients in the
Emergency Department enables timely diagnosis,
treatment, discharge and potentially, admission.
It can improve patient outcomes and patient
flows.

Total number of admissions

into the intensive care unit
plus the non-admissions (as
defined in the numerator)

Total number of admissions

into the intensive care unit
plus the non-admissions (as
defined in the numerator).

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Yes

Yes

Yes

Yes

Dimension of
Quality

EQuIP5
Criterion

Continuity of Care, 1.1.2, 1.1.4,

Process Appropriateness, 1.1.8, 1.3.1,
Effectiveness
1.4.1

Not
specified

N/A

N/A

N/A

Low

2.14

0.97

3.37

Structure

0.81

Continuity of Care,
1.1.2, 1.1.4,
Accessibility,
1.2.2, 1.3.1,
Structure
Appropriateness,
1.4.1
Effectiveness

Continuity of Care,
1.1.2, 1.1.4,
Accessibility,
1.2.2, 1.3.1,
Structure
Appropriateness,
1.4.1
Effectiveness

23.4

Continuity of Care,
1.1.2, 1.1.4,
Accessibility,
1.2.2, 1.3.1,
Process
Appropriateness,
1.4.1
Effectiveness

Low

Low

Low

0.81

15.4

0.81

0.083

Continuity of Care,
1.1.2, 1.1.4,
Accessibility,
1.2.2, 1.3.1,
Appropriateness,
1.4.1
Effectiveness

Yes

Low

13.6

11.1

16.4

Continuity of Care,
1.1.2, 1.1.4,
Accessibility,
1.2.2, 1.3.1,
Process
Appropriateness,
1.4.1
Effectiveness

Total number of unplanned readmissions into the intensive

Total number of admissions
care unit within 72 hours of
into an intensive care unit.
discharge from an intensive care
unit.

Yes

Low

2.33

1.62

2.88

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Total number of serum / plasma

potassium validated report
results for ED (or requests
specified as urgent) with a
turnaround time (Received to
Validated time) less than 60
minutes during the 2-4 week
time period.

Yes

High

85.3

80.5

91.9

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of patients

discharged from the ICU.

Total number of requests

from ED (or requests
specified as urgent) for
serum / plasma potassium
results received by the
laboratory during the 2-4
week time period.

40

Indicator Set

Pathology

Pathology

Pathology

Pathology

Pathology

Pathology

Pathology

Version CI No.

2.1

Topic

Rationale

Knowledge of haemoglobin provides valuable

information on the causation and management of
certain disorders. Test requests originating from
the ED are assumed to be urgent and therefore
this indicator is recommended for use in health
Turnaround time of
requests for haemoglobin care organisations that have a defined ED.
Timely pathology results on patients in the
from the Emergency
Emergency Department enables timely diagnosis,
Department (ED)
treatment, discharge and potentially, admission.
It can improve patient outcomes and patient
flows.

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Dimension of
Quality

EQuIP5
Criterion

Numerator

Denominator

Total number of haemoglobin

validated report results from ED
with a turnaround time
(Received to Validated time) less
than 40 minutes during the 2-4
week time period.

Total number of requests for

haemoglobin results
received by the laboratory
from ED during the 2-4 week
time period.

Yes

High

88.5

81.0

95.1

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of requests for

haemoglobin results
received by the laboratory
from ED during the 2-4 week
time period

Yes

High

80.0

62.9

93.6

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of requests for

Coag results received by the
laboratory from ED during
the 2-4 week time period.

Yes

High

55.3

44.7

82.2

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of requests for

Coag results received by the
laboratory from ED during
the 2-4 week time period.

Yes

High

58.4

40.9

86.8

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of haemoglobin

validated report results from ED
with a turnaround time
(Collected to Validated time)
less than 60 minutes during the
2-4 week time period
Total number of Coag validated
report results from ED with a
turnaround time (Received to
Validated time) less than 40
minutes during the 2-4 week
time period.
Total number of Coag validated
report results from ED with a
turnaround time (Collected to
Validated time) less than 60
minutes during the 2-4 week
time period.

2.2

Turnaround time of
requests for haemoglobin
As described above.
from the Emergency
Department (ED)

2.3

Turnaround time of
requests for Coagulation
As described above.
Tests from the Emergency
Department (ED)

2.4

Turnaround time of
requests for Coagulation
As described above.
Tests from the Emergency
Department (ED)

3.1

Timely information on the results of biopsies is

Turnaround time of
important for patient management, quality
requests for small biopsies
control and cost effectiveness.

Total number of validated small

biopsy results with a turnaround
time (Received to Validated
time) less than 44 hours, during
the 1-2 week time period.

Total number of all small

biopsies received by the
laboratory, during the 1-2
week time period.

Yes

High

54.8

35.0

78.9

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

3.2

Turnaround time of
As described above.
requests for large biopsies

Total number of validated large

biopsy results with a turnaround
time (Received to Validated
time) less than 92 hours, during
the 1-2 week time period.

Total number of all large

biopsies received by the
laboratory, during the 1-2
week time period.

Yes

High

52.8

32.7

76.0

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

3.3

Turnaround time of
As described above.
requests for small biopsies

Total number of validated small

biopsy results with a turnaround
time (Collected to Validated
time) less than 48 hours, during
the 1-2 week time period.

Total number of all small

biopsies received by the
laboratory, during the 1-2
week time period.

Yes

High

49.8

17.4

76.4

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

ACHS Clinical Indicator Summary Guide 2012

41

Indicator Set

Pathology

Pathology

Pathology

Radiation
Oncology

Radiation
Oncology

Radiation
Oncology

Radiation
Oncology

Radiation
Oncology

Version CI No.

Topic

Rationale

Numerator

Total number of validated large

biopsy results with a turnaround
time (Collected to Validated
time) less than 96 hours, during
the 1-2 week time period.

3.4

Turnaround time of
As described above.
requests for large biopsies

4.1

Turnaround time of
requests for cerebrospinal
fluid (CSF) samples from
the Emergency
Department (ED)

4.2

Turnaround time of
requests for cerebrospinal
fluid (CSF) samples from As described above.
the Emergency
Department (ED)

1.1

Wait of more than 14 days

Undue delay in treatment may adversely
to commence
influence the outcome.
radiotherapy treatment

1.2

Informed consent is
recorded in the patients
medical record before
receiving radiotherapy

Total number of patients who

have informed consent recorded
Patients should be fully informed before receiving
in the medical record before
radiotherapy.
receiving radiotherapy, during 1
week in May or November.

Patients entry on
prospective clinical trials

Total number of patients having

megavoltage external beam
radiotherapy, entered on
prospective clinical trials, during
1 week in May or November.

1.3

2.1

2.2

CSF is usually considered to be a critical

specimen. Timely information on the results of
CSF samples is important for patient
management, quality control and cost
effectiveness.

Trial participation results in improved patient

outcomes and quality of care.

Total number of validated CSF

results from ED with a
microscopy (gram +/- stain) with
a turnaround time (Received to
validated time) less than 40
minutes, during the 1-2 month
time period.
Total number of validated CSF
results from ED for microscopy
(gram +/- stain) with a
turnaround time (Collected to
validated time) less than 60
minutes during the 1-2 month
time period.
Total number of patients waiting
more than 14 days, from the
date 'ready for care', to the
date of commencing
radiotherapy, during 1 week in
May or November.

Total number of patients with

SCC of the oral cavity,
Wait longer than 6 weeks
oropharynx,hypopharynx and
for post operative
Delays longer than 6 weeks result in poorer
larynx who wait longer than 6
radiotherapy for head and outcomes.
weeks from their definitive
neck cancer
surgery to commencing their
radiotherapy.
Total number of patients who
receive curative
Curative
The omission of chemotherapy, that is, the use of
chemoradiotherapy for SCC of
chemoradiotherapy for
radiotherapy alone, results in poorer outcomes.
the cervix in the definitive or the
SCC of the cervix
post-operative setting.

ACHS Clinical Indicator Summary Guide 2012

Denominator

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Dimension of
Quality

EQuIP5
Criterion

Total number of all large

biopsies received by the
laboratory, during the 1-2
week time period.

Yes

High

40.2

31.4

77.0

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of all CSF

samples received by the
laboratory from ED, during
the 1-2 month time period.

Yes

High

71.6

41.6

85.8

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of all CSF

samples received by the
laboratory from ED, during
the 1-2 month time period.

Yes

High

69.7

46.8

80.9

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of patients

commencing radiotherapy,
during 1 week in May or
November.

Yes

Total number of patients

receiving radiotherapy,
during 1 week in May or
November.

Total number of megavoltage external beam

radiotherapy courses
undertaken, during 1 week
in May or November.

Total number of patients

receiving post-operative
radiotherapy for SCC of the
oral cavity, oropharynx,
hypopharynx and larynx.
Total number of patients
who receive curative
radiotherapy or
chemoradiotherapy for
cancer of the cervix.

Yes

Low

29.3

10.8

42.9

Continuity of Care,
1.1.2, 1.1.4,
Accessibility,
1.2.2, 1.3.1,
Process
Appropriateness,
1.4.1
Effectiveness

High

97.7

99.8

99.9

Continuity of Care, 1.1.2, 1.1.3,

Process Appropriateness, 1.1.4, 1.1.8,
Effectiveness
1.3.1, 1.4.1

High

2.97

0.44

3.34

Continuity of Care,
Accessbility,
1.1.2, 1.1.4,
Appropriateness,
1.1.8, 1.2.2,
Process Effectiveness,
1.3.1, 1.4.1,
Quality
2.5.1
Improvement and
Risk

Low

28.6

22.2

31.6

Process

Continuity of Care,
1.1.2, 1.1.4,
Accessbility,
1.2.2, 1.3.1,
Appropriateness,
1.4.1
Effectiveness

High

69.4

67.7

74.3

Process

Continuity of Care,
1.1.2, 1.1.4,
Accessbility,
1.2.2, 1.3.1,
Appropriateness,
1.4.1
Effectiveness

42

Indicator Set

Version CI No.

Topic

Rationale

Numerator

Radiation
Oncology

2.3

Megavoltage radiotherapy MLCs result in more accurate shielding and

using Multi-leaf
better occupational health and safety for
collimators (MLC)
radiation therapists and improved efficiency.

Total number of patients

receiving megavoltage
radiotherapy using MLC.

Radiation
Oncology

2.4

Curative megavoltage
radiotherapy courses
provided where CT
planning was utilised

2.5

The letter is addressed to

the referring doctor and
It is important to have high levels of
general practitioner and
communication with the referring doctors and
contains information
GPs.
relevant to the current
course of treatment

Total number of curative

megavoltage radiotherapy
courses provided, where CT
planning was utilised.
Total number of patients who
have a letter on file to the
referring doctor and general
practitioner, regarding the
current radiotherapy course,
during 1 week in May or
November.

3.1

Radiotherapy treatment
for glottic cancer (T 1-2
NO MO) with complete
follow up

Radiation
Oncology

Radiation
Oncology

Radiation
Oncology

Radiology

Radiology

Radiology

Radiology

CT planning results in improved accuracy.

Complete or near complete follow-up after

cancer treatment is essential to assess the quality
and effectiveness of radiotherapy. Laryngectomy
rate reflects the efficacy of the radiotherapy.

Denominator

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Total number of patients

who receive megavoltage
radiotherapy.
Total number of curative
megavoltage radiotherapy
courses provided.

Yes

Total number of patients

receiving radiotherapy,
during 1 week in May or
November.

Dimension of
Quality

EQuIP5
Criterion

High

89.3

77.7

94.0

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

High

98.9

98.3

100

Continuity of Care,
1.1.2, 1.1.4,
Structure Appropriateness,
1.3.1, 1.4.1
Effectiveness

High

90.6

89.6

99.8

1.1.2, 1.1.4,
Continuity of Care,
1.1.5, 1.1.6,
Process Appropriateness,
1.1.8, 1.3.1,
Effectiveness
1.4.1

Total number of patients who

had radiotherapy for glottic
cancer (T1-2N0M0), who had
complete follow-up.

Total number of patients

who receive radiotherapy
for glottic cancer.

Yes

High

94.6

95.7

97.8

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

3.2

Radiotherapy treatment
for breast conservation
Follow up is essential to assess quality and
(pT 1- 3, any nodal staging,
effectiveness of radiotherapy.
M0) with complete follow
up

Total number of patients who

had radiotherapy for breast
conservation (pT 1- 3, any nodal
staging, M0), who had complete
follow-up.

Total number of patients

who receive radiotherapy
for breast conservation (pT13, any nodal staging, M0).

Yes

High

74.8

57.5

96.1

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

1.1

Reports on radiographic
examinations not available If a radiological study is to have any impact on
to the referring doctor
patient management, it should be available to the
within 24 hours of
referring doctor within 24 hours.
completion

Total number of
radiographic examination
requests, during the 7 day
time period.

Yes

Low

24.2

3.56

43.6

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

2.1

Percutaneous trans
pleural biopsy of lung or
mediastinum pneumothorax or
haemothorax

Total number of reports on

radiographic examinations not
available to the referring doctor
within 24 hours of completion,
during the 7 day time period.
Total number of patients
undergoing percutaneous trans
pleural biopsy of the lung or
mediastinum, for whom there is
documented evidence of
pneumothorax and/or
haemothorax requiring
intervention following the
procedure.

Low

8.06

5.04

14.0

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.1.8,
Effectiveness
1.3.1, 1.4.1

These procedures may be associated with

significant morbidity and may reflect possible
problems in the performance of the procedure.

Total number of patients

undergoing percutaneous
trans pleural biopsy of the
lung or mediastinum.

2.2

Peripheral embolic
complications during limb As described above.
angioplasty

Total number of peripheral

embolic complications during
angioplasty of the arteries in
upper or lower limbs.

2.3

Iodinated contrast
extravasation during an IV
As described above.
contrast enhanced CT
procedure

Total number of patients

experiencing iodinated contrast Total number of IV contrast
extravasation requiring medical enhanced CT scans
review during an IV contrast
performed.
enhanced CT procedure.

ACHS Clinical Indicator Summary Guide 2012

Total number of peripheral

angioplasties performed by a
radiologist or proceduralist.

Yes

Yes

Low

0.74

0.51

0.82

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

Yes

Low

0.27

0.21

0.33

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

43

Indicator Set

Radiology

Rehabilitation
Medicine

Rehabilitation
Medicine

Rehabilitation
Medicine

Version CI No.

Topic

2.4

Puncture site
complications during or
following angiography.

1.1

Timely assessment of
function within 72 hours
of patient admission.

2.1

3.1

Rehabilitation
Medicine

4.1

Rehabilitation
Medicine

5.1

Rationale

As described above.

Numerator

Total number of puncture site

complications during or
following angiography.

Total number of patients

admitted to a rehabilitation
unit/facility for whom there is
documented evidence of a
functional assessment within 72
hours of patient admission.
Total number of inpatients for
whom there is documented
evidence of a functional
Functional assessment prior to episode end is
Documented evidence of a
assessment within 72 hours of
required so that the patients functional
functional assessment
cessation of an inpatient
improvement during the rehabilitation program
within 72 hours prior to
rehabilitation program
can be measured. Ideally this assessment should
cessation of an inpatient
(excluding deaths and those
be carried out no more than 72 hours prior to
rehabilitation program.
cases where a suspension of
episode end.
rehabilitation treatment leads to
a care type change to acute
care)
Total number of patients
admitted to a rehabilitation
unit/facility for whom there is a
Timely establishment of a The establishment of a rehabilitation plan with
multi-disciplinary team
regular review is necessary for effective patient documented established multidisciplinary rehabilitation plan
rehabilitation plan.
rehabilitation.
within 7 days of patient
admission.
Total number of separations for
which there is an appropriate
An effective rehabilitation program should
discharge plan for a patient
contain a discharge plan to maximise the
(excluding deaths and those
Appropriate discharge
potential for fullest possible recovery and ensure
cases with a suspension of
plan on separation
community support services, if relevant, are in
rehabilitation treatment leads to
place prior to discharge.
a care type change to acute
care).
Rehabilitation programs aim to provide the
highest level of independence (physically,
Total number of patients
Functional gain achieved
psychologically and socially) to people with loss of discharged from a completed
by patients discharged
function or ability due to injury or disease. This
rehabilitation program for
from a completed
indicator serves as a broad measure that the unit whom there is documented
rehabilitation program
is achieving functional gain on behalf of their
evidence of functional gain.
patients.

ACHS Clinical Indicator Summary Guide 2012

The implementation of an effective rehabilitation

program is dependent upon the early assessment
of patient function. Such an assessment also
provides a baseline from which functional
improvement can be measured.

Denominator

Total number of angiograms

performed.

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Yes

Dimension of
Quality

EQuIP5
Criterion

Low

0.97

0.33

1.75

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

Total number of patients

admitted to the
rehabilitation unit/facility
with a minimum length of
stay of 72 hours.

Yes

High

96.3

92.3

99.9

Continuity of Care, 1.1.1, 1.1.2,

Process Appropriateness, 1.1.4, 1.1.8,
Effectiveness
1.3.1, 1.4.1

Total number of inpatients

who cease an inpatient
rehabilitation program
(excluding deaths and those
cases where a suspension of
rehabilitation treatment
leads to a care type change
to acute care).

Yes

High

96.7

93.5

99.9

Continuity of Care, 1.1.1, 1.1.2,

Process Appropriateness, 1.1.4, 1.1.8,
Effectiveness
1.3.1, 1.4.1

Total number of patients

admitted to a rehabilitation
unit/facility with a minimum
length of stay of 7 days.

Yes

High

97.2

94.3

99.9

Continuity of Care, 1.1.2, 1.1.4,

Process Appropriateness, 1.1.8, 1.3.1,
Effectiveness
1.4.1

High

98.6

98.4

100

1.1.2, 1.1.4,
Continuity of Care,
1.1.5, 1.1.6,
Process Appropriateness,
1.1.8, 1.3.1,
Effectiveness
1.4.1

High

95.0

90.4

99.1

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.1.8,
Effectiveness
1.3.1, 1.4.1

Total number of separations

(excluding deaths and those
cases with a suspension of
rehabilitation treatment
leads to a care type change
to acute care).

Total number of patients

discharged from a
completed rehabilitation
program.

Yes

44

Indicator Set

Version CI No.

Topic

Rationale

Numerator

Total number of patients

discharged from a completed
rehabilitation program to their
pre-episode form of
accommodation, or a form of
accommodation that allows for
greater independence, after
completion of rehabilitation
program.
Total number of patients having
Skilful surgery should avoid mucosal perforation, a pyloromyotomy in which
which may give rise to other complications, such mucosal perforation occurs and
is detected at the time of
as wound infection.
operation or later.
One measure of an effective rehabilitation
program is that the patient returns to their preepisode accommodation or a form of
accommodation that allows for greater
independence. Measuring the destination of a
patient subsequent to discharge from a
rehabilitation program is both an outcome
measure and a quality measure.

Denominator

Rehabilitation
Medicine

6.1

Patients return to their

pre-episode
accommodation or a form
of accommodation that
allows for greater
independence

Surgical

1.1

Pyloromyotomy in which
mucosal perforation
occurs

1.2

Appendicectomy is a commonly performed

Pre-operative diagnosis of
operation in childhood. Good management
acute appendicitis, with
should achieve a low rate of negative (normal)
normal histology.
histology.

Total number of children with a

pre-operative diagnosis of acute
appendicitis, who undergo
appendicectomy with normal
histology.

Total number of children

with a pre-operative
diagnosis of acute
appendicitis who undergo
appendicectomy.

Total number of children with a

pre-operative diagnosis of acute
appendicitis who undergo
appendicectomy with normal
histology, but significant other
intra abdominal pathology.

Total number of children

with a pre-operative
diagnosis of acute
appendicitis who undergo
appendicectomy.

Surgical

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Total number of patients

discharged from a
completed rehabilitation
program.

Total number of patients

having a pyloromyotomy
performed.

Dimension of
Quality

EQuIP5
Criterion

High

89.3

80.6

96.9

Continuity of Care, 1.1.2, 1.1.4,

Outcome Appropriateness, 1.1.6, 1.3.1,
Effectiveness
1.4.1

Low

1.20

1.20

1.20

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Yes

Low

18.9

13.4

25.0

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Yes

Low

5.64

2.36

8.23

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Yes

Yes

Surgical

1.3

Appendicectomy with
normal histology but
significant other intra
abdominal pathology

Surgical

2.1

This is a commonly performed major procedure.

Urology, TUR for benign
Compliance in these indicators would be a
prostatomegaly - average
reasonable measure of the care provided in a
operating time
urological service.

Total operating time (minutes) Total number of patients

for all patients undergoing a TUR having a TUR for benign
for benign prostatomegaly.
prostatomegaly.

Not
specified

Mean =
48.2

39.5

60.9

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of patients days

(from the first day after surgery)
for all patients having a TUR for
benign prostatomegaly
(excluding patients having other
procedures).

Total number of patients

having a TUR for benign
prostatomegaly (excluding
patients having other
procedures).

Not
specified

Mean =
3.08

2.30

3.32

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of patients

having a TUR for benign
prostatomegaly.

Not
specified

Mean =
22.8

17.7

26.7

Continuity of Care,
1.1.2, 1.1.4,
Process Appropriateness,
1.3.1, 1.4.1
Effectiveness

Low

3.23

1.63

3.72

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

As described above.

Surgical

2.2

Urology, TUR for benign

prostatomegaly - average As described above.
length of stay

Surgical

2.3

Urology, TUR for benign

prostatomegaly - average As described above.
weight of tissue

Total weight of tissue (grams)

removed from all patients
undergoing TUR for benign
prostatomegaly.

2.4

Urology, TUR for benign

prostatomegaly - blood
transfusion

Total number of patients having

a TUR for benign
Total number of patients
prostatomegaly, who have a
having a TUR for benign
blood transfusion (intraprostatomegaly.
operatively or post-operatively)
within the same admission.

Surgical

ACHS Clinical Indicator Summary Guide 2012

As described above.

Yes

45

Indicator Set

Version CI No.

Topic

Rationale

Numerator

Total number of patients having

an unplanned readmission
within 28 days of discharge
As described above.
following TUR for benign
prostatomegaly.
Orthopaedics Total Hip
Total number of patients
If infection occurs following primary total hip joint
Joint Replacement (THJR) undergoing primary THJR having
replacement (THJR) the risk of removal of the
postoperative in hospital
a post-operative in-hospital
prosthesis is considerable.
infection
infection.
Good surgical practice should achieve a low
Plastic surgery incidence of incomplete excisions.
Total number of completely
completely excised
excised malignant skin tumours.
malignant skin tumours
Urology, TUR for benign
prostatomegaly unplanned readmission
within 28 days

Surgical

2.5

Surgical

3.1

Surgical

4.1

Surgical

5.1

Coronary Artery Graft

Surgery (CAGS) - death

Coronary artery graft surgery (CAGS) is the most Total number of patients who
commonly performed cardiac operation in adults. die in the same admission as
Low mortality is now achievable.
having CAGS.

Surgical

5.2

Elective Coronary Artery

Graft Surgery (CAGS) death

As described above.

5.3

Surgical

Denominator

Low

5.17

2.49

8.38

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

Total number of patients

undergoing primary THJR
operation.

Yes

Low

1.16

0.79

1.53

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

High

90.4

83.7

94.5

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of excised

malignant skin tumours.

Yes

Low

1.71

1.64

1.75

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Total number of elective

patients who die in the same
admission as having CAGS.

Total number of patients

having CAGS as an elective
procedure.

Yes

Low

1.33

1.33

1.33

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

Coronary Artery Graft

Surgery (CAGS) patients
As described above.
aged 71 years or greater death

Total number of patients aged

71 years or greater who die in
the same admission as CAGS.

Total number of patients

aged 71 years or greater
having CAGS performed.

Yes

Low

2.98

2.98

2.98

Continuity of Care,
1.1.2, 1.1.4,
Outcome Appropriateness,
1.3.1, 1.4.1
Effectiveness

The occurrence of infection following

neurosurgery may have undesirable effects.

Total number of patients having

a neurosurgical infection in
hospital, during time period
Total number of patients
under study excluding superficial having a neurosurgical
wound infections requiring
procedure performed.
nothing more than a single short
course of antibiotics.

6.1

Surgical

6.2

Neurosurgery - new
neurological deficit
following procedure

Total number of patients with a

Total number of patients
Neurological deficit after surgery may imply a less new neurological deficit
undergoing a neurosurgery
following a neurosurgery
than optimal technique.
procedure.
procedure.

7.1

Laparoscopic
cholecystectomy - bile
duct injury requiring
operative intervention

Total number of patients having

Laparoscopic cholecystectomy is a relatively new
Total number of patients
a laparoscopic cholecystectomy
procedure, which is associated with an increased
having a laparoscopic
with a bile duct injury requiring
risk of injury to the extra hepatic biliary system.
cholecystectomy performed.
operative intervention.

8.1

Vascular surgery, elective Abdominal aortic aneurysm repair is major

abdominal aortic
surgery and is associated with a significant
aneurysm (AAA) - death
mortality.

Yes

Total number of patients

having CAGS

Surgical

EQuIP5
Criterion

Yes

Surgical

Dimension of
Quality

Total number of patients

discharged as having a TUR
for benign prostatomegaly
(excluding deaths).

Neurosurgery neurosurgical infection

Surgical

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

ACHS Clinical Indicator Summary Guide 2012

Total number of patients having

Total number of patients
an elective AAA repair
having and elective AAA
performed, who die within the
repair performed.
same admission.

Yes

Low

1.14

0.79

1.54

Continuity of Care,
1.1.1, 1.1.2,
Appropriateness,
1.1.4, 1.3.1,
Outcome
Effectiveness,
1.4.1, 1.5.2
Safety

Yes

Low

1.08

0.69

1.49

Continuity of Care, 1.1.1, 1.1.2,

Outcome Appropriateness, 1.1.4, 1.3.1,
Effectiveness
1.4.1

0.69

Continuity of Care,
Appropriateness,
1.1.2, 1.1.4,
Effectiveness,
1.3.1, 1.4.1,
Outcome
Quality
2.1.3
Improvement and
Risk

1.24

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

Yes

Yes

Low

Low

0.50

1.29

0.30

0.89

46

Indicator Set

Surgical

Surgical

Version CI No.

Topic

Rationale

Carotid endarterectomy is undertaken as a

prophylactic measure to reduce the occurrence
of stroke. A minimal rate of postoperative stroke
is desirable.

8.2

Vascular surgery, carotid

endarterectomy - stroke

9.1

Otolaryngology,
Tonsillectomy is a commonly performed
tonsillectomy - significant discretionary procedure with a low, but definite,
reactionary haemorrhage morbidity.

ACHS Clinical Indicator Summary Guide 2012

Numerator

Denominator

Total number of patients having

Total number of patients
a carotid endarterectomy who
having a carotid
have a stroke within the same
endarterectomy performed.
admission.

Total number of patients who

have a significant reactionary
haemorrhage following
tonsillectomy.

Total number of patients

who have a tonsillectomy
performed.

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Centile Centile Indicator
Undersirable
Rate
Outcome
Outcome

Yes

Yes

Low

Low

4.05

0.64

0.81

0.28

Dimension of
Quality

EQuIP5
Criterion

6.70

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

0.66

Continuity of Care,
Appropriateness,
1.1.1, 1.1.2,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Quality
1.4.1, 2.1.3
Improvement and
Risk

47