Post-discharge surgical site surveillance: does patient education improve reliability of diagnosis?

Post-discharge surgical infection surveillance by patients remains an integral part of many infection control programmes despite proven unreliability. We attempted to improve the validity of patient recognition of signs and symptoms of wound infection and post-discharge postal questionnaire responses through specific education prior to discharge. In total, 588 patients were studied after random assignment into two intervention groups, one of which received relevant education. Both groups were followed for four weeks post-operatively, with features of infection assessed weekly by experienced infection control nurses (ICNs) and by patient responses to routine postal questionnaires. Those patients who received education demonstrated a significantly poorer correlation with ICN diagnosis compared to the non-educated group (Kappa 0.69 and 0.81 respectively, P=0.05). Both patient groups achieved the same sensitivity for recall (83.3%), with high specificity demonstrated by both groups [educated (93.7%); non-educated (98.1%)]. The positive predictive value was 65.2% for the educated group and 83.3% for the non-educated patient group. When infected wounds identified by patients were examined for the proportion that were overdiagnosed, the excess of SSI identified by the educated patient group was 44.4% and by the non-educated group 16.7%. These results suggest that pre-discharge education causes patients to overdiagnose clinical features of wound infection and fails to improve the validity of diagnosis. This outcome further questions the value of post-discharge infection rates obtained by patient self-assessment as a measure of quality of performance.

Post-discharge surveillance: can patients reliably diagnose surgical wound infections?

Post-discharge surgical wound infection surveillance is an important part of many infection control programs. It is frequently undertaken by patient self-assessment, prompted either by a telephone or postal questionnaire. To assess the reliability of this method, 290 patients were followed for six weeks postoperatively. Their wounds were photographed and also covertly assessed for signs of infection by two experienced infection control nurses (ICNs). Patients also responded to a postal questionnaire seeking evidence of infection at both week four and week six post-surgery. Correlation between the patient's assessment of their wound and the ICNs diagnosis was poor (r = 0.37) with a low positive predictive value (28.7%), although negative predictive value was high (98.2%). Assessment of photos for signs of infection by two experienced clinicians also correlated poorly with the ICNs diagnosis of infection (r = 0.54). The patient's recall of prescription of an antibiotic by their general practitioner (GP) for wound infection during the postoperative period correlated best with the ICNs diagnosis (r = 0.76). This latter measure, particularly when confirmed by the GP in those patients reporting an infection, appears to provide the most valid and resource efficient marker of post-discharge surgical wound infection.

Clinical indicators in accreditation: an effective stimulus to improve patient care.

The Australian Council on Healthcare Standards (ACHS) established the Care Evaluation Program (CEP) of clinical performance measures in its accreditation program to increase the clinical component of that program and to increase medical practitioner involvement in formal quality activities in their health care organizations. From the introduction of a set of generic indicators in 1993 the program expanded through all of the various medical disciplines and from January 2000 there will be 18 sets (well over 200 indicators) in the program. More than half of Australia's acute hospitals (covering the majority of patient separations) are monitoring the indicators and reporting clinical data twice yearly to the ACHS. In turn they receive a 6-monthly feedback of aggregate and peer comparative results. The ACHS policy had no specific requirement for a set number of indicators to be monitored and it was not mandatory to achieve any specific data threshold to be accredited. However, where an organization's results differed unfavorably from those of its peers some action was expected. Qualitative information is also sent to the CEP and this has enabled a determination of the effectiveness of the indicators. There is documented evidence of improved management and numerous examples of improved patient outcomes. The program remains unique in the scope of the medical disciplines covered and in the formal provider involvement with indicator development. Both the clinical component of accreditation and clinician involvement in quality activities have been increased in an educational process. However, not all of the indicators are of equal value and a reduction in the number of indicators to a 'core' group of the most reliable and responsive ones is in process.

Early experience with clinical indicators in surgery.

BACKGROUND: In 1997 a set of 53 clinical indicators developed by the Royal Australasian College of Surgeons (RACS) and the Australian Council on Healthcare Standards (ACHS) Care Evaluation Programme (CEP), was introduced into the ACHS Evaluation and Quality Improvement Programme (EQuIP). The clinical indicators covered 20 different conditions or procedures for eight specialty groups and were designed to act as flags to possible problems in surgical care. METHODS: The development process took several years and included a literature review, field testing, and revision of the indicators prior to approval by the College council. In their first year 155 health-care organizations (HCO) addressed the indicators and this rose to 210 in 1998. Data were received from all states and both public and private facilities. RESULTS: The collected data for 1997 and 1998 for some of the indicators revealed rates which were comparable with those reported in the international literature. For example, the rates of bile duct injury in laparoscopic cholecystectomy were 0.7 and 0.53%, respectively; the mortality rates for coronary artery graft surgery were 2.5 and 2.1%, respectively; the mortality rates after elective abdominal aortic aneurysm repair were 2.5 and 3.7%, respectively; and the post-tonsillectomy reactionary haemorrhage rates were 0.9 and 1.3%, respectively. Results for some indicators differed appreciably from other reports, flagging the need for further investigation; for example, the negative histology rates for appendectomy in children were 18.6 and 21.2%, respectively, and the rates for completeness of excision of malignant skin tumours were 90.7 and 90%, respectively. The significance of these figures, however, depends upon validation of the data and their reliability and reproducibility. Because reliability can be finally determined only at the hospital level they are of limited value for broader comparison. CONCLUSION: The process of review established for the indicator set has led to refinement of some indicators through improvement of definitions, and to a considerable reduction in the number of indicators to 29 (covering 18 procedures), for the second version of the indicators (which was introduced for use from January 1999). The clinical indicator programme, as it has with other disciplines, hopefully will provide a stimulus to the modification and improvement of surgical practice. Clinician ownership should enhance the collection of reliable data and hence their usefulness.

The ACHS Care Evaluation Program: a decade of achievement. Australian Council on Healthcare Standards.

In 1989 the Australian Council on Healthcare Standards (ACHS) embarked on a programme to develop acute health care clinical indicators in conjunction with the Australian medical colleges. Through a carefully structured stepwise process this collaboration established a 'World first' in 1993 with the introduction of the first set of indicators into the ACHS Accreditation programme. The programme remains unique in the formal involvement of providers in the development process and in the scope of the clinical areas covered in acute health care. From the year 2000 there will be 18 sets (and over 200 indicators) from which health care organisations (HCOs) can choose to monitor the major services they provide. There remains no compulsion to address a specific number of indicators. The growth of the programme has been considerable with more than half of the nations' acute HCOs reporting their clinical indicator data (twice yearly) and it provides a reflection of the care given for the majority of patient separations in acute care. This reporting process allows HCOs to receive feedback on the aggregate results together with comparative peer group information for each indicator they address. In addition to numerous publications in peer reviewed journals an annual aggregate report, 'the Measurement of Care in Australian Hospitals' is published. It reports both qualitative and quantitative data on all indicator sets for the preceding year. Validity of the indicators is strengthened each year with a review process and reliability and reproducibility of the data can now be demonstrated. The clinical response to the indicators has been overwhelming and there is now documented evidence of numerous actions taken by HCOs to improve both the processes and the outcomes of patient care. The nation wide database can be expected to reflect trends in care over the next few years. The process of indicator refinement, however, will continue and it is likely that a reduction in the total number of indicators will occur with a core group of the more 'robust' indicators remaining. Further directions in indicator development are likely to be in the area of multidisciplinary care and in the assessment of longer-term outcomes. In addition to measures of the quality of care, hopefully, in time, health care providers will also take part in the establishment of measures of the appropriateness of that care.

In-hospital mortality and associated complications after bowel surgery in Victorian public hospitals.

BACKGROUND: The purpose of the present paper was to determine the mortality rate and associated complications after large bowel resection and anastomosis in Victorian public hospitals. METHODS: A retrospective analysis of data from the Victorian Inpatient Minimum Database (VIMD) was undertaken. The data were collected from all Victorian public hospitals performing hemicolectomy and anterior resection (resection of the rectum with anastomosis) from 1987/88 to 1995/96. RESULTS: A total of 11036 patients underwent hemicolectomy or anterior resection in the time period studied, there being a 7% increase in the rate of operations performed over the 9 years. Two-thirds of these operations were for carcinoma of the large bowel. The anastomotic leak rate of 4.5% fell slightly but the in-hospital mortality rate of 6.5% did not change over the study period. The total morbidity recorded (mainly major complications) was 24.6%. The patients most at risk of death were the elderly with pre-existing cardiac or respiratory disease undergoing an emergency operation. CONCLUSIONS: Notwithstanding some inaccuracies of coding and reporting, the morbidity and mortality for surgery of the large intestine remains high, largely due to the comorbidities of the patients, although certain technical complications such as leakage of an anastomosis after anterior resection are still associated with a significantly increased risk of death. Consideration should be given to the routine use of high-dependency nursing units for these high-risk patients after major colorectal surgery, and support from physicians to reduce morbidity and mortality from associated medical conditions worsened by surgery.

Measuring the quality of hospital in the home care: a clinical indicator approach.

BACKGROUND: Hospital in the home (HIH) refers to the delivery of acute hospital care to patients at home. This includes the delivery of intravenous therapy, low molecular weight heparin, and complex wound care that would necessitate hospital admission. The development of quality assessment and improvement in HIH has been hampered by several factors. OBJECTIVE: To (i) develop clinical indicators for HIH care from an analysis of the current literature and test their suitability for implementation by HIH programmes; and (ii) make a preliminary assessment of the quality of HIH care delivered in several HIH units in Victoria, through an examination of clinical indicator data. DESIGN: Prospective descriptive study in 3 consecutive months of HIH admissions. PARTICIPANTS: Nine HIH units in Victoria, Australia. MAIN OUTCOME MEASURES/INTERVENTIONS: Five clinical indicators for HIH care: unexpected patient telephone calls; unplanned staff call-outs; unplanned return to hospital; medication administration errors; and patient refusal to consent to HIH care. RESULTS: Seven hundred and fifty-nine patient admissions over a 3-month period were included. On average, 10% of patients made an unexpected telephone call, 2.4% of patient admissions required an unplanned staff call-out, and 7.3% of admissions resulted in an unplanned return to hospital. Only one medication administration error was reported. Patient refusal of HIH was very uncommon. CONCLUSIONS: Clinical indicators relating to unexpected patient telephone calls, unplanned staff call-outs and returns to hospital are recommended for inclusion in Australia's hospital accreditation programme. On the basis of this study, it appears that HIH is a safe and acceptable form of care. However, the findings also suggest a minimum level of service provision, particularly in the area of after-hours support, for the safe management of acute hospital care at home.

Addressing adverse events through clinical indicators.

In an attempt to improve the reporting rate of adverse drug reactions the Adverse Drug Reaction Advisory Committee approached the Australian Council on Healthcare Standards Care Evaluation Program to develop a set of indicators to improve healthcare standards by heightening awareness amongst clinical staff of the morbidity, mortality and financial implications of adverse drug reactions. Ten clinical indicators addressing: (i) reporting of adverse drug reactions; (ii) adherence to treatment protocols for anaphylaxis; (iii) monitoring of warfarin; and (iv) monitoring of streptokinase, were field tested in ten Australian health-care organizations, to determine that the data were available, that the indicators were relevant to clinical practice and that the measures were achievable. Based on the results of this field test, six adverse drug reaction clinical indicators will be introduced into the Australian Council on Healthcare Standards Evaluation and Quality Improvement Program from January 1999.

Total colectomy for Crohn's disease.

BACKGROUND: Total colectomy for Crohn's disease of the colon may be restorative with ileorectal anastomosis or with an ileostomy and rectal stump. The present paper retrospectively audits the results of total colectomy and in particular assesses the number of patients who had a permanent ileostomy and whether this was related to disease in the rectum at the time of the original operation. METHODS: A retrospective case note review was undertaken of patients operated upon between 1968 and 1994. RESULTS: Thirty-eight patients were identified (mean age 35 years; range 17-65 years). One patient died perioperatively from an anastomotic leak. Median follow-up for the remaining patients was 7 years (range 1-29 years). Ileorectal anastomosis was performed in 17 patients and total colectomy and ileostomy in 20 patients. Indications for surgery were failure of medical treatment (61%); toxic colitis (18%); abscess (8%); perforation (5%); large bowel obstruction (5%); and colovesical fistula (3%). Subsequent proctectomy (14 patients, 38%) was more likely with subtotal colectomy and ileostomy (nine patients, 45%) than ileorectal anastomosis (five patients, 29%). This was not statistically significant (P = 0.33). Additionally, seven patients had diversion of the rectum making 21 with an ileostomy (57%). Rectal involvement at the time of the original procedure significantly increased the likelihood of permanent ileostomy (P = 0.001). The presence of anal disease did not increase the prospect of ileostomy. One patient died with advanced adeno carcinoma in a defunctioned rectum. CONCLUSIONS: A permanent ileostomy after total colectomy for Crohn's disease is common and significantly more likely with rectal involvement.

Health-care performance measurement systems and the ACHS Care Evaluation Program. Australian Council on Healthcare Standards.

The call for evidence-based medicine and information on health outcomes has brought with it performance measurement systems. The necessary attributes of these systems are now being addressed as are the attributes of the measures themselves. In this paper the Australian Council on Healthcare Standards Care Evaluation Program is reviewed in relation to these various attributes. The more focused systems should prove useful in achieving change in clinical practice.