3 Summary Guide Clinical Indicators 2012 (ACHS)

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,
1.3.1, 1.4.1
Effectiveness

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

attendance, during the time
period under study
High
97.0
93.9
100

Effectiveness
1.4.1
Low
0.063
0.016
0.085

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

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.

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

receiving anaesthesia care
who have a history of PONV,
study
3.1
3.2

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.
study
undergo a procedure with an
Compliance of anaesthesia
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
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

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.

receiving post-anaesthesia
care who are admitted to
the post anaesthesia
recovery room during the

recovery room, during the
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
Numerator

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
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,
study
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
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
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

Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Undersirable
Rate
Outcome
Outcome
Yes
Dimension of
Quality
EQuIP5
Criterion
Low
0.18
0.012
0.22

Effectiveness
1.4.1

Yes
Low
0.34
0.068
0.49

Effectiveness
1.4.1

Yes
Low
1.03
0.089
1.13
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness
Low
0.17
0.025
0.20
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness

receiving anaesthesia care,
study
Yes
Total number of surgical

patients staying at least one
night who receive acute pain
management, during the
Yes
High
95.3
89.0
100

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

epidural analgesia, during
the time period under study
Yes
High
99.9
99.9
100

Process,
Outcome
Effectiveness
1.3.1, 1.4.1
Low
0.46
0.29
0.47

Effectiveness
1.4.1
Total number of obstetric

patients receiving
patients who experience a postepidural/spinal analgesia,
dural puncture headache, during
the time period under study.
study.
Yes
Indicator Set
Anaesthesia
Version CI No.
5.1
Topic
Rationale
6.2

commence surgery within 30
minutes of request for
immediate lower segment
cesarian section (LSCS), during

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

patients who have
documentation of risks and
benefits of spinal
analgesia/epidural, during the
time period under study.
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

due to an acute medical
condition
Day Surgery
1.4

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.

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.

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

facility, whose procedure is
cancelled after their arrival at
the facility due to a pre-existing
medical condition.
the facility due to an acute
medical condition.
the facility due to
administrative/organisational
reasons.
Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
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,
1.3.1, 1.4.1
Effectiveness

patients receiving
epidural/spinal analgesia,
study.
High
57.7
28.4
99.8

Effectiveness
1.3.1, 1.4.1

facility.
Low
0.93
0.023
1.08
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness

who arrive at the day
procedure facility for a
booked procedure.
Low
0.24
0.040
0.28

Effectiveness
1.4.1

booked procedure.
Low
0.26
0.060
0.42

Effectiveness
1.4.1
Low
0.54
0.041
1.03
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness
Low
0.049
0.016
0.067
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness
Yes

booked procedure.

who have an operation/
an unplanned return to the
procedure performed in the
operating/procedure room.
day procedure facility.
Yes
Yes

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

Yes
Low
1.23
0.090
1.99
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness

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

Yes
Low
0.57
0.020
0.46
Continuity of Care,
1.1.2, 1.1.4,
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
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.

attending the emergency
department triaged to ATS
Category 1.
As described above.

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

Category 2.
As described above.

allocated to ATS Category 3 who
minutes.

Category 3.
As described above.

minutes.

Category 4.
Category 5.
1.1
ATS Category 1 patients

attended to immediately
1.2

attended to within 10
minutes
1.3

minutes
1.4

minutes
1.5

minutes
As described above.

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.

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.

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.

admitted or planned for
admission, transferred to
another hospital, or died in
the ED, during the 6 month
time period.
Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
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
Undersirable
Rate
Outcome
Outcome
As described above.
Total number of mental health

admitted patients (as defined in
the manual) whose total ED
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
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.

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
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
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.

65 years or older discharged
from the ED to home or
residential accommodation,
period.

65 years or older discharged
from the ED to home or
residential accommodation,
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
Undersirable
Rate
Outcome
Outcome
Low
High
High
High
Dimension of
Quality
EQuIP5
Criterion
New
indicator
for
2H2011

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

who presented to the ED with
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

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
internationally. Level I evidence reveals that
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.

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.

limb pain, during the 6
month time period.
7.4
Paediatric patients who

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
primary diagnosis of limb
fracture (ICD-10 code),
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.
As described above.
The number of patients

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

mental health complaint,
period.
Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
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
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

possible perforation not
related to polypectomy
Patients who have

bleeding.

related to dilation.
Denominator
As described above.
As described above.
Total number of
colonoscopies less total
treated for possible perforation
number of colonoscopy with
not related to polypectomy.
polypectomies.
A low complication rate is desirable.

have bleeding.
Low
Total number of
colonoscopies.

Total number of
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
Undersirable
Rate
Outcome
Outcome
Yes
Yes
Yes
Total number of
colonoscopy with
polypectomies.

Total number of
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

secondary to instrument
related causes
2.3
As described above.

Total number of upper GIT
polypectomies.
related to polypectomy.
3.1
Patients having an
overnight stay as a result
of aspiration.

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

related to upper GIT
polypectomy
1.1
Gynaecology
Numerator
As described above.
Rationale

Total number of
gastroscopies less dilatations
secondary to instrument related
and polypectomies.
causes.
Gynaecology
Gynaecology
Topic
2.1

who have an endoscopy
procedure (involving
sedation).
Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Undersirable
Rate
Outcome
Outcome
Yes
Yes
This indicator has been included as an index of

unintentional intra-operative morbidity
associated with gynaecological procedures.

suffering injury to a major viscus
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.

receiving an injury to a major
viscus with repair, during a
undergoing laparoscopic
laparoscopic gynaecological
operative procedure or
procedure.
subsequently up to 2 weeks postoperatively.
3.2
Laparoscopic
gynaecological surgery for As described above.
a ureter injury

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

receiving an unplanned blood
Blood transfusion for
This indicator is included as a general measure of transfusion during their hospital
gynaecological surgery for
admission for any type of
surgical management.
benign disease
surgery for benign disease.
gynaecological surgery for
benign disease.
Blood transfusion for
undergoing gynaecology surgery
surgery for malignant
malignant disease
for malignant disease.
disease.
Injury to a major viscus,
with repair during a
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

receiving a bladder injury at the
time of a laparoscopic
hysterectomy with repair during
hysterectomy.
Total number of patients having Total number of patients
laparoscopic management
presenting with an ectopic
following an ectopic pregnancy. pregnancy.
Gynaecology
3.3
Laparoscopic
a bladder injury
Gynaecology
4.1
Laparoscopic
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.

receiving injury to a major viscus
with repair, during a pelvic floor
undergoing a pelvic floor
repair procedure or
repair procedure.
subsequently up to 2 weeks postoperatively.
As described above.

receiving a ureter injury at the
time of a pelvic floor repair
procedure with repair during
repair procedure.
Gynaecology
Gynaecology
5.2
Urogynaecology
Urogynaecology
Gynaecology
5.3
Urogynaecology
As described above.

receiving a bladder injury at the
time of a pelvic floor repair
procedure with repair during
repair procedure.
Gynaecology
6.1
Antibiotic prophylaxis in
hysterectomy

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

undergo hysterectomy who
receive antibiotic prophylaxis
prior to surgery.

who undergo hysterectomy.
7.1
Thromboprophylaxis in
moderate to high risk
women having
hysterectomy

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
Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
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,
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

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

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
Undersirable
Rate
Outcome
Outcome
The number of patients making

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

Effectiveness
1.4.1
Yes
Low
0.24
0.11
0.46

Effectiveness
1.4.1
2.07
4.45

Outcome,
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

an unplanned return to hospital
(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.

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

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.

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

commenced on a HITH
program.

Effectiveness
1.4.1
Hospital in the
Home
2.2
Unplanned return to
hospital - back to HITH
program

Outcome,
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.

commenced on a HITH
program.
Low
New
indicator
for 2011
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness

commenced on a HITH
program.
Low
New
indicator
for 2011
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness
2.79
7.99

Outcome,
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

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

Effectiveness
1.4.1
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

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.
As described above.
Total number of inpatient falls

where the patients condition
requires intervention.
Dimension of
Quality
EQuIP5
Criterion

having an operation or
procedure in the operating
room.
Yes
Low
0.32
0.12
0.39

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,
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,
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

are admitted with one or more Total number of admissions.
pressure ulcers.
Identification of pressure
ulcers.
Denominator
Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Undersirable
Rate
Outcome
Outcome
Yes
Total number of occupied

bed days.

bed days
As described above.
Total number of fractures or

closed head injuries that result
because of an inpatient fall.

bed days.
As described above.
Total number of falls in

inpatients aged 65 years and
older.

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
transfusion.
6.3
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,
1.3.1, 1.4.1
Effectiveness
0.31
Continuity of Care,
Effectiveness,
1.1.4, 1.3.1,
Outcome
Safety, Quality
1.4.1, 1.5.5,
Improvement and
2.1.3
Risk
10.9

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.

episodes where informed
patient consent was not
documented.

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,
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

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.
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).
Numerator
Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Undersirable
Rate
Outcome
Outcome

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

knee prosthesis
As described above.
procedures
Total number of superficial

Total number of knee
incisional SSI in knee prosthesis
prosthesis procedures.
1.4
Deep incisional SSI in knee

As described above.
Total number of deep incisional

Total number of knee
SSI in knee prosthesis
prosthesis procedures.
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
space SSI (donor incision
site) in CABG
As described above.

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

performed.
Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
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
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

artery bypass graft
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

artery bypass graft
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

artery by pass graft
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

As described above.
elective colectomy
Numerator

incisional SSI in elective partial
or total colectomy procedures
(where there is an anastomosis
but no stoma formed)
performed.
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
Undersirable
Rate
Outcome
Outcome
Dimension of
Quality
EQuIP5
Criterion

partial or total colectomy
procedures (where there is
an anastomosis but no
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

partial or total colectomy
procedures (where there is
an anastomosis but no
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
1.10 space SSI in elective
colectomy
3.1

1.11
As described above.
femoro-popliteal bypass

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
performed.
3.1

1.13 open abdominal aortic
As described above.
aneurysm

incisional SSI in open abdominal Total number open AAA
aortic aneurysm (AAA)
Infection Control
3.1
space SSI in open
1.14
abdominal aortic
aneurysm

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

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

1.15 lower segment caesarean As described above.
section

incisional SSI in lower segment
caesarean section procedures.
Total number of lower

segment caesarean section
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

lower segment caesarean
section procedures.
Total number of lower

segment caesarean section
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

As described above.
abdominal hysterectomy

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
1.18 space SSI in abdominal
hysterectomy

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
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
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.

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.
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
centrally-inserted CLUR
Infection Control
3.1
2.5
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
peripherally-inserted
CLUR
As described above.
Total number of PI central line


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
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
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 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 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

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

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
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
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

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.

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

infection rate - neonates
of > 1000g birth weight
4.5

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

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
(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

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

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
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
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
days.
in a non-sterile site.
6.1
6.2
Reported parenteral
exposures sustained by
staff
Reported non-parenteral
exposures sustained by
staff
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
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
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

Effectiveness
1.4.1
Yes
High
Modified
indicator
for 2011

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

discharged from the ICU
between 6pm and 6am

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

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.

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

admissions into the ICU.
EQuIP5
Criterion
Low
1.1

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

line-days in Adult ICU.

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

Effectiveness
1.4.1
Not
specified
Modified
indicator
for 2011

Effectiveness
1.4.1
Not
specified
New
indicator
for 2011

Effectiveness
1.3.1, 1.4.1
Total number of rapid response

system calls to adult patients
within 24 hours of admission to hospital admissions.
hospital.
Not
specified
New
indicator
for 2011

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.
Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
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
Undersirable
Rate
Outcome
Outcome
Dimension of
Quality
EQuIP5
Criterion
Intensive Care
6.3
As described above.
As described above.

who have experienced a
cardiopulmonary arrest.

Low
New
indicator
for 2011
Continuity of Care,
1.1.2, 1.1.4,
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,
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.
Low
New
indicator
for 2011
Continuity of Care,
1.1.2, 1.1.4,
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.

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

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,
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.

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

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,
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.

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

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,
1.3.1, 1.4.1
Effectiveness
Internal Medicine
Internal Medicine
Internal Medicine
22
Indicator Set
Internal Medicine
Internal Medicine
Internal Medicine
Internal Medicine
Internal Medicine
Internal Medicine
Version CI No.
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.

discharged with any diagnosis of
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.

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

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

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).

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

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.
Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Undersirable
Rate
Outcome
Outcome
Dimension of
Quality
EQuIP5
Criterion
High
N/A
N/A
N/A

Effectiveness
1.4.1
High
80.8
76.5
87.5
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness
Yes
High
96.5
95.6
98.3
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness
Yes
Low
0.17
0.087
0.20
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness
High
89.3
89.3
89.3

Effectiveness
1.4.1
High
95.9
90.6
98.7
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness
Yes
Yes
23
Indicator Set
Internal Medicine
Internal Medicine
Internal Medicine
Internal Medicine
Internal Medicine
Version CI No.
Numerator
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.
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
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,
1.3.1, 1.4.1
Effectiveness

separated from hospital with
stroke (ICD-10 Code).
High
85.0
71.6
96.0

Effectiveness
1.3.1, 1.4.1

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

High
93.4
91.6
99.1

Effectiveness
1.4.1

documented physiotherapy
assessment within 48 hours of
presentation to hospital.

High
72.6
70.3
72.7

Effectiveness
1.3.1, 1.4.1

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

a diagnosis of ischaemic
stroke (ICD-10 Code),
without contraindication for
aspirin.
High
60.4
39.1
86.2

Effectiveness
1.4.1
Yes
24
Indicator Set
Internal Medicine
Internal Medicine
Internal Medicine
Internal Medicine
Version CI No.
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
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.

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.

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

Effectiveness
1.4.1
Appropriate discharge
planning for stroke.
Good discharge planning is crucial for successful

reintegration into the community as well as
effective and efficient use of limited hospital
resources. A care plan is normally completed
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.

discharged to a private
residence from hospital with
High
67.0
55.1
83.5

Effectiveness
1.3.1, 1.4.1
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.

stroke (ICD-10 Code) who are
prescribed and administered
antihypertensive medication
prior to discharge.

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,
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.

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

High
86.9
75.8
91.7

Effectiveness
1.4.1
25
Indicator Set
Internal Medicine
Internal Medicine
Internal Medicine
Internal Medicine
Internal Medicine
Version CI No.
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
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

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.

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.

admitted to a geriatric
medicine or geriatric
rehabilitation unit.
High
94.7
87.1
99.9

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

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.

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

discharged from a general
medical unit with any
diagnosis of COPD.
High
10.9
10.9
10.9

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.

admitted to hospital with a
diagnosis of acute asthma for
whom there is documented
diagnosis of acute asthma
objective assessment of severity
on initial presentation.
High
98.1
99.1
99.8

Effectiveness
1.3.1, 1.4.1
4.1
5.1
5.2
26
Indicator Set
Internal Medicine
Internal Medicine
Internal Medicine
Internal Medicine
Internal Medicine
Internal Medicine
Version CI No.
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.
Rationale
As described above.
Numerator

objective assessment of
severity, in addition to the initial
assessment, which facilitates
ongoing inpatient management.

As described above.
evidence of an appropriate
discharge plan.
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.
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
Undersirable
Rate
Outcome
Outcome

transfusion, for whom there is
documented evidence that a
member of surgical staff has
been notified of their condition.
transfusion, and have an
operation, during the same
admission.


blood transfusion.
Dimension of
Quality
EQuIP5
Criterion
High
84.5
62.4
98.9

Effectiveness
1.3.1, 1.4.1
High
70.8
33.8
82.4

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

blood transfusion.
High
83.1
78.1
88.0
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness

blood transfusion.
High
16.3
16.5
16.5

Effectiveness
1.4.1

blood transfusion.
Not
specified
4.64
3.52
5.17
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness
Yes
27
Indicator Set
Internal Medicine
Version CI No.
6.5
Topic
As described above.
Rationale
Numerator

melaena, having both blood
As described above.
transfusion and endoscopic
therapy, who subsequently have
an operation, during the same
admission.
As described above.
transfusion and subsequently
die.
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

blood transfusion.

having a renal biopsy.
Yes
Low
5.04
2.65
8.01

Effectiveness
1.4.1
High
93.2
92.8
93.9

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
event requiring intervention
bed days.
beyond routine observation and
monitoring.
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness
Continuity of Care,
1.1.2, 1.1.4,
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

blood transfusion.
Internal Medicine
Internal Medicine
Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
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
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
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.
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

Effectiveness
1.4.1
Yes
Low
Modified
indicator
for 2011
Continuity of Care,
1.1.2, 1.1.4,
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,
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 non samedischarged on warfarin who
day separations receiving
receive written drug information
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.

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

initiated on warfarin
High
New
indicator
for 2011
Total number of non sameday separations receiving

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
Undersirable
Rate
Outcome
Outcome

toxic aminoglycoside
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

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
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

consumers with the mental
health service during the
reporting period

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

Effectiveness
1.4.1
High
86.2
55.4
99.9

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 carers involved
consumers with the mental
in developing care plans
health service
High
83.8
13.2
100

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.

allocated a diagnosis within 24
hours of admission.
High
93.3
90.7
99.6

Effectiveness
1.4.1
Mental Health
Inpatient
1.2
Inpatients - diagnosis
recorded on hospital
discharge
As described above.

a diagnosis on hospital discharge Total number of inpatient
which is recorded in the medical separations.
record.
High
89.6
80.3
99.7

Effectiveness
1.4.1
1.3
Inpatient with an
individual care plan, which
is constructed and
As described above.
regularly reviewed with
the consumer

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

Effectiveness
1.4.1
Mental Health
Inpatient

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
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.

having at least 2 episodes of
seclusion, in an admission or in a
1 month period of an extended
admission.
having seclusion for more than 4
hours in 1 episode, in an
admission.
EQuIP5
Criterion
Yes
High
83.0
74.1
99.3

Effectiveness
1.3.1, 1.4.1

on psychotropic medications
on discharge.
Yes
Low
4.07
0.23
6.8
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness

undergoing a course of
E.C.T.
Yes
Low
8.80
5.56
16.2
Continuity of Care,
1.1.2, 1.1.4,
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

separations.
Low
8.45
3.41
13.3
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness

separations having
seclusion.
Low
35.6
32.7
39.4
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness

separations having
seclusion.
Low
52.7
23.1
70.2
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness
Low
0.096
0.096
0.096

Effectiveness
1.4.1
Yes
Total number of inpatients in

seclusion who were not
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.

experiencing major
separations having
complications while in seclusion. seclusion.
Mental Health
Inpatient
5.6
Inpatients having
seclusion
As described above.

having seclusion.
Dimension of
Quality

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

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

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

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
Undersirable
Rate
Outcome
Outcome

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,
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

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

separations having physical
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
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
Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Undersirable
Rate
Outcome
Outcome

separations.

Total number of inpatients.
assault in an admission.

assault twice or more in an
who assault in an admission.
admission.

undertake significant selfTotal number of inpatients.
mutilation in an admission.
As described above.

suffering significant other
injuries in an admission.
As described above.

assaulted by staff / visitors /
other inpatients in an admission.
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,
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
for psychiatric patients in an inpatient psychiatric
Inpatient death
deaths.
service or a medical / surgical ward of an
attached hospital only.
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.
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

separations.
Yes
Low
6.92
2.60
10.10

Effectiveness
1.4.1,
Yes
Low
0.058
0.042
0.055
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1,
Effectiveness
High
69.1
52.0
96.0

Effectiveness
1.3.1, 1.4.1,

separations.

separations.
Yes
High
78.7
61.0
99.1

Effectiveness
1.3.1, 1.4.1,
Total number of inpatient who

have a multidisciplinary review
recorded every 3 months.

with the stay of greater than
3 months.
Yes
High
94.2
90.0
98.5

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,
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,
1.3.1, 1.4.1
Effectiveness
High
45.8
36.4
57.7
Continuity of Care,
1.1.2, 1.1.4,
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.
primipara who undergo
As described above.
induction of labour.
Obstetrics
1.1
Selected primipara who

have a spontaneous
vaginal birth.
Obstetrics
1.2

undergo induction of
labour.
Obstetrics
1.3

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.

primipara undergoing caesarean
primipara who give birth.
section.
Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Undersirable
Rate
Outcome
Outcome


Yes
Low
29.1
22.8
34.0
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness

Yes
Low
24.3
19.2
27.8
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness
Low
28.0
22.4
33.9
Continuity of Care,
1.1.2, 1.1.4,
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

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.

primipara with an intact
primipara delivering
perineum or unsutured perineal
vaginally.
tear.
Yes
High
Modified
indicator
for 2011
As described above.

primipara undergoing
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.

primipara sustaining a perineal
tear AND no episiotomy.

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.

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

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.

primipara undergoing surgical
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.

primipara undergoing surgical
repair of the perineum for
fourth degree tear.
Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Undersirable
Rate
Outcome
Outcome

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

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
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,
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

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,
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.

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,
1.3.1, 1.4.1
Effectiveness

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,
1.3.1, 1.4.1
Effectiveness

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

Effectiveness
1.4.1
Obstetrics
Obstetrics
9.1
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
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

Effectiveness
1.4.1
High
84.2
94.6
99.1
Continuity of Care,
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.

having cataract surgery.
Yes
Low
0.35
0.058
0.49

Effectiveness
1.4.1
As described above.

a re-admission within 28 days of
discharge following cataract
surgery, due to endophthalmitis
in the operated eye.
Yes
Low
0.041
0.029
0.038

Effectiveness
1.4.1
Yes
Low
0.44
0.034
0.59
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness
Yes
Low
0.62
0.18
0.76
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness
Ophthalmology
1.3
Cataract surgery unplanned overnight

admission
As described above.

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

an anterior vitrectomy at the
time of cataract surgery.
Ophthalmology
2.1
Glaucoma surgery readmission within 28

days

should be associated with a low morbidity and a

following glaucoma surgery.

having glaucoma surgery.
Yes
Low
3.07
1.88
2.79

Effectiveness
1.4.1
Yes
Low

Effectiveness
1.4.1
Low
4.16
0.50
1.68
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness
Ophthalmology
2.2
Glaucoma surgery readmission within 28

days due to
endophthalmitis
As described above.

discharge following glaucoma
Ophthalmology
2.3
Glaucoma surgery - Length

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

LOS greater than 3 days
following glaucoma surgery.
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.

should be associated with a low morbidity and a
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

Effectiveness
1.4.1

an unplanned re-admission
having retinal detachment
following retinal detachment
surgery.
Yes
Low

Effectiveness
1.4.1
Low
1.13
1.03
1.31
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness
Low
1.78
1.63
1.71

Effectiveness
1.4.1
Low

Effectiveness
1.4.1
Low

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

should be associated with low morbidity and a

discharge following refractive
having refractive surgery.
Dimension of
Quality

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
Undersirable
Rate
Outcome
Outcome

LOS greater than 4 days,
surgery.
an unplanned re-operation on
the same eye within 28 days,
surgery.
following refractive surgery.

surgery.
surgery.
Yes
Yes

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.

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,
1.3.1, 1.4.1
Effectiveness
Ophthalmology
4.4
Refractive surgery anterior vitrectomy
As described above.

an anterior vitrectomy at the
time of refractive surgery.
Yes
Low
Continuity of Care,
1.1.2, 1.1.4,
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.

a complication (medical or
having excimer laser
surgical) within 28 days
surgery.
following excimer laser surgery.
Low
0.065
0.065
0.065

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,
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

Effectiveness
1.4.1

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
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

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,
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.

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,
1.3.1, 1.4.1
Effectiveness
3.1
Children's Dental Care Retreatment following

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
Low
New
indicator
for 2012
Continuity of Care,
1.1.2, 1.1.4,
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,
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,
1.3.1, 1.4.1
Effectiveness
Oral Health
Oral Health
Oral Health
Oral Health
Oral Health
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,
1.3.1, 1.4.1
Effectiveness
1.26
5.84
Continuity of Care,
1.1.2, 1.1.4,
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.

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.

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
Undersirable
Rate
Outcome
Outcome
Dimension of
Quality
EQuIP5
Criterion
High
Modified
indicator
for 2012
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness
Yes
High
91.2
81.3
98.7

Effectiveness
1.4.1
Yes
High
60.2
33.4
84.6

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
asthma.
Yes
Low
Mean =
1.64
1.40
1.91
Continuity of Care,
1.1.2, 1.1.4,
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
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,
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,
1.3.1, 1.4.1
Effectiveness
High
72.5
0.055
100

Effectiveness
1.4.1
3.1
Entry onto the Australian

and New Zealand
Paediatric Intensive Care
Registry
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

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

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

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)
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)

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
Undersirable
Rate
Outcome
Outcome
Yes
Yes
Yes
Yes
Dimension of
Quality
EQuIP5
Criterion

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

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

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,
1.3.1, 1.4.1
Effectiveness

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
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,
1.3.1, 1.4.1
Effectiveness

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,
1.3.1, 1.4.1
Effectiveness

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,
1.3.1, 1.4.1
Effectiveness

Coag results received by the
laboratory from ED during
Yes
High
58.4
40.9
86.8
Continuity of Care,
1.1.2, 1.1.4,
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
time period.
Total number of Coag validated
report results from ED with a
turnaround time (Collected to
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
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,
1.3.1, 1.4.1
Effectiveness
3.2
Turnaround time of
As described above.
requests for large biopsies
Total number of validated large

time (Received to Validated
Total number of all large

week time period.
Yes
High
52.8
32.7
76.0
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness
3.3
Turnaround time of
As described above.
requests for small biopsies
Total number of validated small

time (Collected to Validated
Total number of all small

week time period.
Yes
High
49.8
17.4
76.4
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness
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

time (Collected to Validated
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

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

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.

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.
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.
Denominator
Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Undersirable
Rate
Outcome
Outcome
Dimension of
Quality
EQuIP5
Criterion
Total number of all large

week time period.
Yes
High
40.2
31.4
77.0
Continuity of Care,
1.1.2, 1.1.4,
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,
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,
1.3.1, 1.4.1
Effectiveness

commencing radiotherapy,
during 1 week in May or
November.
Yes

receiving radiotherapy,
November.
Total number of megavoltage external beam

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

radiotherapy for SCC of the
oral cavity, oropharynx,
hypopharynx and larynx.
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

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.

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.
have a letter on file to the
referring doctor and general
practitioner, regarding the
current radiotherapy course,
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
Undersirable
Rate
Outcome
Outcome

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

receiving radiotherapy,
November.
Dimension of
Quality
EQuIP5
Criterion
High
89.3
77.7
94.0
Continuity of Care,
1.1.2, 1.1.4,
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,
1.1.8, 1.3.1,
Effectiveness
1.4.1

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

who receive radiotherapy
for glottic cancer.
Yes
High
94.6
95.7
97.8
Continuity of Care,
1.1.2, 1.1.4,
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

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

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,
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,
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.
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

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.

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

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

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.

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
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)
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
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,
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
is achieving functional gain on behalf of their
evidence of functional gain.
patients.
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
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

admitted to the
rehabilitation unit/facility
with a minimum length of
stay of 72 hours.
Yes
High
96.3
92.3
99.9

Effectiveness
1.3.1, 1.4.1

who cease an inpatient
cases where a suspension of
rehabilitation treatment
leads to a care type change
to acute care).
Yes
High
96.7
93.5
99.9

Effectiveness
1.3.1, 1.4.1

unit/facility with a minimum
length of stay of 7 days.
Yes
High
97.2
94.3
99.9

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,
1.1.8, 1.3.1,
Effectiveness
1.4.1
High
95.0
90.4
99.1

Effectiveness
1.3.1, 1.4.1
Total number of separations

cases with a suspension of
rehabilitation treatment
leads to a care type change
to acute care).

discharged from a
completed rehabilitation
program.
Yes
44
Indicator Set
Version CI No.
Topic
Rationale
Numerator

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.
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.

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.

pre-operative diagnosis of acute
appendicectomy with normal
histology, but significant other
intra abdominal pathology.
Total number of children

with a pre-operative
diagnosis of acute
appendicectomy.
Surgical
Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
Undersirable
Rate
Outcome
Outcome

discharged from a
completed rehabilitation
program.

having a pyloromyotomy
performed.
Dimension of
Quality
EQuIP5
Criterion
High
89.3
80.6
96.9

Effectiveness
1.4.1
Low
1.20
1.20
1.20
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness
Yes
Low
18.9
13.4
25.0

Effectiveness
1.4.1
Yes
Low
5.64
2.36
8.23
Continuity of Care,
1.1.2, 1.1.4,
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,
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).

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,
1.3.1, 1.4.1
Effectiveness

prostatomegaly.
Not
specified
Mean =
22.8
17.7
26.7
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness
Low
3.23
1.63
3.72
Continuity of Care,
1.1.2, 1.1.4,
1.3.1, 1.4.1
Effectiveness
As described above.
Surgical
2.2

prostatomegaly - average As described above.
length of stay
Surgical
2.3

prostatomegaly - average As described above.
weight of tissue
Total weight of tissue (grams)

removed from all patients
undergoing TUR for benign
prostatomegaly.
2.4

prostatomegaly - blood
transfusion

a TUR for benign
prostatomegaly, who have a
blood transfusion (intraprostatomegaly.
operatively or post-operatively)
within the same admission.
Surgical
As described above.
Yes
45
Indicator Set
Version CI No.
Topic
Rationale
Numerator

an unplanned readmission
As described above.
following TUR for benign
prostatomegaly.
Orthopaedics Total Hip
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
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

Effectiveness
1.4.1

undergoing primary THJR
operation.
Yes
Low
1.16
0.79
1.53

Effectiveness
1.4.1
High
90.4
83.7
94.5
Continuity of Care,
1.1.2, 1.1.4,
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,
1.3.1, 1.4.1
Effectiveness

patients who die in the same
admission as having CAGS.

having CAGS as an elective
procedure.
Yes
Low
1.33
1.33
1.33
Continuity of Care,
1.1.2, 1.1.4,
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.

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,
1.3.1, 1.4.1
Effectiveness
The occurrence of infection following

neurosurgery may have undesirable effects.

a neurosurgical infection in
hospital, during time period
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

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

Laparoscopic cholecystectomy is a relatively new
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

having CAGS
Surgical
EQuIP5
Criterion
Yes
Surgical
Dimension of
Quality

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
Undersirable
Rate
Outcome
Outcome

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

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.
Numerator
Denominator

a carotid endarterectomy who
having a carotid
have a stroke within the same
endarterectomy performed.
admission.

have a significant reactionary
haemorrhage following
tonsillectomy.

who have a tonsillectomy
performed.
Associated
Associated
with a
2010
with an
Desirable
20
80
Type of
Potentially
Aggregate
Adverse
Rate
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

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Clinical Indicator Summary Guide 2012

Total number of patients with a

Total number of patients

Continuity of Care, 1.1.2, 1.1.3,

Total number of patients

Total number of patients

Continuity of Care, 1.1.2, 1.1.4,

Continuity of Care, 1.1.1, 1.1.2,

Consent for anaesthesia is a separate process

Total number of patients who

Total number of patients

PONV is a frequent and distressing consequence

Total number of patients with a

Total number of patients

Total number of patients who

ACHS Clinical Indicator Summary Guide 2012

Consultation by an anaesthetist is essential for

Total number of patients

Total number of patients

Total number of patients

Established protocol for

Unplanned recovery room

Unplanned admission to an intensive care unit

Analgesic efficacy and the occurrence of clinical

At least daily review by an

These indicators have been included to monitor

ACHS Clinical Indicator Summary Guide 2012

Total number of patients

Total number of patients

Continuity of Care, 1.1.1, 1.1.2,

Total number of patients

Continuity of Care, 1.1.1, 1.1.2,

Total number of patients

Total number of patients

Total number of surgical

Continuity of Care, 1.1.1, 1.1.2,

Total number of patients

Continuity of Care, 1.1.1, 1.1.2,

Continuity of Care, 1.1.1, 1.1.2,

Total number of obstetric

Total number of patients who

Total number of patients

Total number of obstetric

This indicator provides evidence of the

Cancellation after arrival

This indicator provides evidence of the

Cancellation after arrival

Cancellation after arrival

Unplanned return to the

This indicator may reflect possible problems in

This indicator may reflect possible problems in

ACHS Clinical Indicator Summary Guide 2012

Total number of patients

Total number of obstetric

Continuity of Care, 1.1.2, 1.1.3,

Total number of patients

Total number of patients

Continuity of Care, 1.1.1, 1.1.2,

Total number of patients