NSW Health WSLHD Safety & Quality Account 2020-21

A review of performance indicators against 2021-22 NSWHealth Key Performance Indicators

Hospital Acquired Complications Measure Results Actual (per 10,000 episodes of care)

Upper limit (per 10,000 episodes of care)

Performance Green line = WSLHD Upper Limit Blue line = WSLHD performance per month

38.3

27.3

Hospital Acquired Endocrine Complication (per 10,000 episodes of care)

July 2021

December

June 2022

Hospital Acquired Endocrine Complications’ is when patient has low blood sugar levels that require treatment. It also includes malnutrition.

40.9

30

Hospital Acquired Cardiac Complication ( per 10,000 episodes of care) A ‘Cardiac Complication’ is a problem with the heart.

July 2021

December

June 2022

305.3

375.4

3rd and 4th degree perineal lacerations that occur whilst giving birth vaginally (per 10,000 episodes of care) A ‘Perineal Laceration’ is a tear of the skin surrounding a women’s vagina that occurs during childbirth.

July 2021

December

June 2022

46

96.6

Hospital Acquired Neonatal Birth Trauma (per 10,000 episodes of care) Neonatal Birth Trauma’ is an injury to a newborn baby. Examples of injuries include bruising or swelling.

July 2021

December

June 2022

SOURCE: QIDS 24th August 2022

Quality and Safety Strategies

WSLHD has implemented a range of strategies to drive continuous improvement in reducing hospital acquired complications. The table outlines strategies in places against each quality area.

Quality Area

Strategies in place

Pressure Injury Prevention

Clinical Excellence Commission* Intentional Rounding program Clinical Excellence Commission* Pressure Injury Prevention Bundles Intensive Care pressure injury prevention project Clinical Excellence Commission* Intentional Rounding program Implementation of Falls Risk Assessment Management Plan in the electronic medical record Clinical Excellence Commission* Safe and Early Mobilisation program

Fall-related Injuries

Healthcare Acquired Infection Surgical site infection bundle at Westmead- ERAS program (see page 51) Clinical Excellence Commission* urine specimen collection tools

Respiratory Compilation

Early dysphagia screening, improve oral care and early mobilisation programs ICU patient care bundle- positioning, oral care, ventilation

Venous Thromboembolism (VTE)

Game of thrombosis- VTE prevention program at Auburn Hospital

Medication complication

Mental Health reducing polypharmacy in psychoactive medications project

Delirium

Delirium screening in Emergency Department across WSLHD Safer ways to care program- geriatric medicine at Westmead Hospital BUMP behavior management program at Blacktown (see page 49)

3rd and 4th degree perineal laceration

Clinical Excellence Commission* Perineal Protection Bundle

Neonatal Birth Trauma

Clinical Excellence Commission* Safer baby bundle (see page 47)

*More information on the Clinical Excellence Commission programs can be found at www.cec.health.nsw.gov.au

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