Mediclinic Newcastle - Clinical Indicator Report PDF

CLINICAL INDICATOR REPORT MEDICLINIC NEWCASTLE RESULTS FOR THE PERIOD ENDING: JANUARY 2025 SECTION A: CLINICAL PERFORMANCE INDICATOR DETAIL OPERATIONAL OVERVIEW 12 Month Rolling Comparisons...

CLINICAL INDICATOR REPORT MEDICLINIC NEWCASTLE RESULTS FOR THE PERIOD ENDING: JANUARY 2025 SECTION A: CLINICAL PERFORMANCE INDICATOR DETAIL OPERATIONAL OVERVIEW 12 Month Rolling Comparisons Curr. Yr Previous Current 24 Month Indicator Target Change (%) Total Total Trend Number of Hospital Admissions 12 027 12 573 4,54% Number of Daycases 1 202 1 168 -2,83% Number of Inpatient (Overnight) Cases 10 825 11 405 5,36% Daycase/Inpatient Split (%) 10/90% 9/91% Number of Medical Cases 6 821 7 000 2,62% Number of Surgical Cases 5 206 5 573 7,05% Medical/Surgical Split (%) 57/43% 56/44% Number of Emergency Centre Cases 10 113 9 492 -6,14% Number of Ambulatory/Outpatient Cases 134 90 -32,84% Number of Vaccines Administered 0 0 Number of Outpatient Cases (Excl. Vaccinations) 134 90 -32,84% Volumes for Selected Acute Care Procedures/Diagnosis Hospital ( Medical Admissions: Adm Abortions/Miscarriages 106 137 29,25% Acute Bronchitis 171 143 -16,37% Acute Myocardial Infarctions 124 96 -22,58% Depression 934 929 -0,54% Gastroenteritis Infections 955 958 0,31% Normal Deliveries 196 226 15,31% Pneumonia 922 943 2,28% Septicaemia/Sepsis 927 918 -0,97% Strokes 179 160 -10,61% Haemorrhagic 27 20 -25,93% Ischaemic 84 79 -5,95% Not specified as haemorhage or infarction 22 22 0,00% Transient ischaemic attacks 44 38 -13,64% Occlusion of cerebral and precerebral arteries 2 1 -50,00% Surgical Admissions: Arthroscopy Knee 117 142 21,37% Arthroscopy Shoulder 19 27 42,11% Caesarean Sections 678 636 -6,19% Cardiac Catheterization Procedures 0 0 Cardiac EPS and Ablation 0 0 Cataract Surgery 0 0 Cholecystectomies 109 143 31,19% Circumcisions 20 22 10,00% Colonoscopies 512 577 12,70% Coronary Artery Bypass Grafts 0 0 Cystoscopies 283 350 23,67% Gastroscopies 960 1 035 7,81% Elective Hip Replacements 44 41 -6,82% Emergency Hip Replacements 16 11 -31,25% Hysterectomies 180 192 6,67% Knee Replacements 35 32 -8,57% Myringotomies 0 0 Radical Prostatectomy 0 1 Spinal Fusions 80 87 8,75% Spinal Laminectomies 67 48 -28,36% Tonsil & Adenoid Surgery 4 3 -25,00% Transurethral Resection of Prostate (TURP) 80 83 3,75% Valve Replacement (AVR) 0 0 Valve Implantation (TAVI) 0 0 INFORMATION AND DATA EMBODIED IN THIS DOCUMENT SHOULD BE TREATED AS CONFIDENTIAL ANALYTICS AND REPORTING DEPARTMENT - MEDICLINIC INTERNATIONAL MEDICLINIC NEWCASTLE 12 Month Rolling Comparisons Curr. Yr Previous Current 24 Month Indicator Target Change (%) Total Total Trend Volumes for Selected Chronic Diseases Hypertension 4 027 4 374 8,62% Diabetes Mellitus - Type 1 318 324 1,89% Diabetes Mellitus - Type 2 1 489 1 607 7,92% Hyperlipidaemia 1 633 1 614 -1,16% Asthma 745 764 2,55% Coronary Artery Disease 530 534 0,75% Cardiac Failure 1 037 1 073 3,47% Hypothyroidism 325 412 26,77% Epilepsy 685 751 9,64% COPD 416 423 1,68% Rheumatoid Arthritis 158 174 10,13% Tuberculosis 130 119 -8,46% HIV 854 691 -19,09% Malaria 2 1 -50,00% Hepatitis A,B,C,E 98 46 -53,06% Pertussis 3 0 -100,00% Measles 1 1 0,00% Meningococcal Meningitis 0 1 Age Population Profile Neonates [0-28 days] 127 142 11,81% Infants [29 days - 1 year] 171 171 0,00% Children [>1 years - 12 years] 851 932 9,52% Adolescents [13 years - 18 years] 490 477 -2,65% Adults [>18 years - 64 years] 8 321 8 665 4,13% Geriatrics [>65 years] 2 067 2 186 5,76% Body Mass Index (BMI) Categories Underweight (BMI ≤ 18.5) 160 166 3,75% Normal Weight (18.5 < BMI ≤ 25.0) 1 654 1 458 -11,85% Overweight (25.0 < BMI ≤ 30.0) 2 245 2 063 -8,11% Obese (30.0 < BMI ≤ 40.0) 2 936 2 936 0,00% Morbidly Obese (BMI > 40.0) 975 1 076 10,36% Unclassified 1 617 2 344 44,96% INFORMATION AND DATA EMBODIED IN THIS DOCUMENT SHOULD BE TREATED AS CONFIDENTIAL ANALYTICS AND REPORTING DEPARTMENT - MEDICLINIC INTERNATIONAL PATIENT SAFETY INFORMATION 12 Month Rolling Comparisons Curr. Yr Previous Current 24 Month Indicator Target Change (%) Total Total Trend Overall Patient Safety Reporting Indicators Number of Patient Days * 53 838 55 095 2,33% Serious Reportable Events (SRE) 91 93 2,20% Rate per 1,000 Patient Days 1,66 1,69 1,69 -0,13% Harm Levels Near Misses per 1,000 PD 1,36 1,31 -3,62% No Harm Events per 1,000 PD 9,34 10,29 10,15% Low Harm Events per 1,000 PD 5,07 4,12 -18,75% Moderate Harm Events per 1,000 PD 2,69 3,41 26,70% Severe Harm Events per 1,000 PD 0,11 0,13 14,00% Events Resulting in Death per 1,000 PD 1,26 1,14 -9,47% Surgical Safety Ward based checks (%) 87% 84% -2,92% Handover from ward to theatre staff (%) 100% 100% -0,28% Sign in Step (%) 97% 96% -1,00% Time out Step (%) 97% 97% -0,48% Sign out Step (%) 95% 95% -0,70% Theatre based checks (%) 98% 97% -0,64% Never Events Reported Never Events Reported 1 0 -100,00% Rate per 1,000 Patient Days 0,00 0,02 0,00 -100,00% Foreign Object(s) Left Behind in Patient 0 0 Incorrect Patient (Correct Surgery) 0 0 Incorrect Surgery (Correct Patient) 0 0 Incorrect Prosthesis/Implant 0 0 Surgery On Wrong Side/Site Performed 1 0 -100,00% Never Events Other 0 0 Unrecognized Abdominopelvic Accidental Puncture/Lacerations 2 3 50,00% Number of Abdominopelvic Surgery Cases 2 824 2 938 4,04% Rate per 1,000 Cases 1,06 0,71 1,02 44,18% * Patient Days per month reported on Invoice Date Medication Errors Number of Medication Errors 61 45 -26,23% Rate per 1,000 Patient Days 1,07 1,13 0,82 -27,91% Prescription Errors per 1,000 PD 0,09 0,02 -80,46% Dispensing Errors per 1,000 PD 0,26 0,13 -51,14% Administration Errors per 1,000 PD 0,78 0,67 -13,91% Number of Falls (with/without injuries) 73 63 -13,70% Number of Falls (with injuries) 10 11 10,00% Rate per 1,000 Patient Days 0,19 0,20 7,49% Hospital Associated Skin Lesions 26 37 42,31% Rate per 1,000 Patient Days 0,48 0,67 39,06% Hospital Associated Pressure Injuries 20 26 30,00% Pressure Injuries Rate per 1,000 Patient Days 0,34 0,90 1,31 0,00 -100,00% 0,37 0,47 27,03% Pressure Injuries (Grade 1) 5 3 -40,0% Pressure Injuries (Grade 2) 13 15 15,4% Pressure Injuries (Grade 3) 0 1 Pressure Injuries (Grade 4) 0 0 Pressure Injuries (Unstageable / Unclassified) 0 0 Suspected Deep Tissue Injury 2 7 >100.0% Pressure Injuries (Grade 1) per 1,000 PD (n) 0,09 0,05 -41,37% Pressure Injuries (Grade 2) per 1,000 PD (n) 0,24 0,27 12,75% Pressure Injuries (Grade 3) per 1,000 PD (n) 0,00 0,02 Pressure Injuries (Grade 4) per 1,000 PD (n) 0,00 0,00 Pressure Injuries (Unstageable / Unclassified) per 1,000 PD (n) 0,00 0,00 Suspected Deep Tissue Injury per 1,000 PD (n) 0,04 0,13 >100.0% Rate per 1,000 Patient Days 2,25 2,24 Number of IV Line Harm Cases 132 92 -30,30% ANALYTICS AND REPORTING DEPARTMENT - MEDICLINIC INTERNATIONAL INFORMATION AND DATA EMBODIED IN THIS DOCUMENT SHOULD BE TREATED AS CONFIDENTIAL 2,10 1,25 -40,66% 2,45 1,67 -31,89% INFECTION PREVENTION & CONTROL MEDICLINIC NEWCASTLE 12 Month Rolling Comparisons (%) Curr. Yr Previous Current 24 Month Indicator Target Change (%) Total Total Trend Total Actions 938 784 -16,42% Total Opportunities 1 076 941 -12,55% Hand Hygiene Compliance Rate (%) 88,49% 83,31% -5,86% Healthcare Associated Infections 34 47 38,24% HAI Rate per 1,000 Patient Days 0,58 1,12 1,84 0,62 -66,09% 0,63 0,85 35,08% Device Associated Infections (Overall Indicators) Ventilator Associated Pneumonia Infections 5 3 -40,00% Ventilator Days 1 483 964 -35,00% VAP Rate per 1,000 Ventilator Days 3,08 14,93 0,00 -100,00% 3,37 3,11 -7,70% Central Line Associated Bloodstream Infections 3 5 66,67% Central Line Days 5 114 6 074 18,77% CLABSI Rate per 1,000 Central Line Days 0,45 3,19 0,00 0,00 0,59 0,82 40,32% Catheter Associated Urinary Tract Infections 3 2 -33,33% Catheter Days 10 306 9 865 -4,28% CAUTI Rate per 1,000 Catheter Days 0,34 2,85 0,00 0,00 0,29 0,20 -30,35% Surgical Site Infections (Overall & Targeted Indicators) Surgical Site Infections 19 22 15,79% Operative Procedures 5 333 5 689 6,68% SSI Rate per 1,000 Operative Cases 3,12 6,42 5,00 3,72 -25,51% 3,56 3,87 8,54% Surgical Site Infections (Abdom. Hysterectomies) Rate per 1,000 Hysterectomies Surgical Site Infections (CABG) Rate per 1,000 CABG Surgical Site Infections (Knee Replacements) Rate per 1,000 Knee Replacements Surgical Site Infections (Hip Replacements) Rate per 1,000 Hip Replacements Surgical Site Infections (Caesarean Sections) Rate per 1,000 Caesarean Sections Alert Organisms Methicillin Resistant Staph. Aureus (MRSA) MRSA (Healthcare Associated) MRSA (Community & Healthcare Associated) Health. Ass. MRSA Rate per 100,000 PD's INFORMATION AND DATA EMBODIED IN THIS DOCUMENT SHOULD BE TREATED AS CONFIDENTIAL ANALYTICS AND REPORTING DEPARTMENT - MEDICLINIC INTERNATIONAL MEDICLINIC NEWCASTLE Month-on-Month Comparisons 12 Month Rolling Comparisons Curr. Yr. Previous Current 24 Month Indicator Target Change (%) Change (%) Nov '24 Dec '24 Jan '25 Total Total Trend Antimicrobial Stewardship Inappropriate Prophylaxis Cases 2 4 5 25,00% 26 35 34,62% Theatre Cases with Prophylaxis 211 187 228 21,93% 2 222 2 364 6,39% Inappropriate Prophylaxis Rate (%) 0,95% 2,14% 2,19% 2,52% 1,17% 1,48% 26,53% Prolonged/Extended Treatment Cases 4 2 2 0,00% 40 42 5,00% Exposures of Selected Antimicrobials 1 218 1 161 1 280 10,25% 14 373 15 232 5,98% Prolonged Treatm. Rate per 1,000 Exposures 3,28 1,72 1,56 -9,30% 2,78 2,76 -0,92% Total Antimicrobial Usage (DDD's) 3 191 2 835 3 649 28,71% 40 579 41 107 1,30% Total Antimicrobial Usage Rate per 100 PD's 73,73 71,61 74,53 75,90 1,83% 75,37 74,61 -1,01% Targeted Defined Daily Doses (DDD's) Utilisation: Polymyxin (Colistin and Polymyxin B) (DDD's) 198 200 0,79% Rate per 100 Patient Days 0,37 0,36 -1,51% Carbapenems (DDD's) 3 846 4 079 6,06% Rate per 100 Patient Days 7,14 7,40 3,64% Third Generation Cephalosporins (DDD's) 5 025 5 631 12,06% Rate per 100 Patient Days 9,33 10,22 9,50% Fluoroquinolone (DDD's) 2 573 2 518 -2,15% Rate per 100 Patient Days 4,78 4,57 -4,38% Echinocandins (DDD's) 992 1 130 13,95% Rate per 100 Patient Days 1,84 2,05 11,35% INFORMATION AND DATA EMBODIED IN THIS DOCUMENT SHOULD BE TREATED AS CONFIDENTIAL ANALYTICS AND REPORTING DEPARTMENT - MEDICLINIC INTERNATIONAL CLINICAL EFFECTIVENESS INDICATORS Month-on-Month Comparisons 12 Month Rolling Comparisons Curr. Yr. Previous Current 24 Month Indicator Target Change (%) Change (%) Nov '24 Dec '24 Jan '25 Total Total Trend Overall Mortality Indicators Number of Inpatient Mortalities 201 241 19,90% Inpatient Mortality Rate (%) 1,86% 2,11% 13,80% Number of Inpatient Adult Mortalities 195 233 19,49% Inpatient Adult Mortality Rate (%) 2,08% 2,36% 13,34% Hospital Standardized Adult Mortality Index 1,00 0,91 0,62 0,92 48,41% 0,74 0,85 14,50% Number of Surgical Mortalities (Inpatients) 5 2 12 >100.0% 71 79 11,27% Surgical Mortality Rate (%) 1,06% 0,50% 2,37% >100.0% 1,36% 1,42% 3,94% Number of Emergency Centre Mortalities 3 4 0 -100,00% 18 21 16,67% Emergency Centre Mortality Rate (%) 0,45% 0,44% 0,00% -100,00% 0,18% 0,22% 24,30% Number of Patients Transferred In 3 1 1 0,00% 28 44 57,14% Mortalities on Transferred In Patients 0 0 0 1 0 -100,00% Mortality Rate on Transferred In Patients (%) 0,00% 0,00% 0,00% 3,57% 0,00% -100,00% Number of Patients Admitted via EC 362 441 444 0,68% 4 300 4 606 7,12% Mortalities on Patients Admitted via EC 13 10 21 >100.0% 128 153 19,53% Mortality Rate on Patients via EC (%) 3,59% 2,27% 4,73% >100.0% 2,98% 3,32% 11,59% Maternal Mortality (WHO Definition) 0 0 0 0 1 1 0,00% Maternal Mortality Rate per 100,000 Live Births *126.83 0,00 0,00 0,00 122,40 122,25 -0,12% *As Per WHO 2020 benchmark Adult Critical Care Mortality Indicators Currently the SAPS3 model is used to measure critical care utcomes. o Number of Cases Captured on SAPS3 46 43 55 27,91% 519 533 2,70% Number of Critical Care Mortalities 14 13 21 61,54% 130 167 28,46% Crude Mortality Rate - Critical Care (%) 30,43% 30,23% 38,18% 26,29% 25,05% 31,33% 25,09% Number of Expected Mortality Cases 7 5 13 >100.0% 104 95 -8,16% Expected Mortality Rate - Critical Care (%) 16,12% 10,59% 23,93% >100.0% 19,97% 17,85% -10,58% Mortality Index (SAPS3) 1,00 1,89 2,85 1,60 -44,12% 1,25 1,75 39,88% INFORMATION AND DATA EMBODIED IN THIS DOCUMENT SHOULD BE TREATED AS CONFIDENTIAL ANALYTICS AND REPORTING DEPARTMENT - MEDICLINIC INTERNATIONAL  Month-on-Month Comparisons 12 Monthly Comparisons Network Curr. Yr. Previous Current 24 Month Indicator Change (%) Change (%) 2022 Nov '24 Dec '24 Jan '25 Total Total Trend Neonatal Critical Care Indicators The Vermont Oxford Network database is currently used to easure outcomes in the Neonatal Critical Care Unit m Please note that the figures are reported on date of birth and therefore will hange retrospectively when ses are captured on VON after discharge. c ca Expanded Birth Weight Indicators (All Eligible Cases) Number of Cases Captured on VON 6 4 3 -25,00% 106 101 -4,72% Number of Mortality Cases 0 0 0 8 4 -50,00% Number of Mortality Cases (Excl. Early Deaths) 0 0 0 7 4 -42,86% Mortality Rate (%) 2,9% 0,00% 0,00% 0,00% 7,55% 3,96% -47,52% Death or Morbidity Cases 0 0 0 8 6 -25,00% Death or Morbidity Rate (%) 10,8% 0,00% 0,00% 0,00% 7,55% 6,00% -20,50% Any Late Infections 0 0 0 1 1 0,00% Any Late Infection Rate (%) 2% 0,00% 0,00% 0,00% 1,06% 1,10% 3,30% Necrotizing Enterocolitis 0 0 0 0 2 Necrotizing Enterocolitis (%) 1% 0,00% 0,00% 0,00% 0,00% 1,98% Chronic Lung Disease (< 33 weeks gestation) 0 0 0 0 0 Chronic Lung Disease (%) 21,2% 0,00% 0,00% 0,00% Pneumothorax Cases 0 0 0 0 0 Pneumothorax (%) 3,3% 0,00% 0,00% 0,00% 0,00% 0,00% Severe Intraventricular Hemorrhage (IVH) 0 0 0 0 0 Severe IVH Rate (%) 4,2% 0,00% 0,00% 0,00% Cystic Periventricular Leukomalacia (PVL) 0 0 0 0 0 Cystic PVL Rate (%) 1,2% 0,00% 0,00% 0,00% Retinal Examination (VLBW) 0 0 0 0 0 Retinal Examination (VLBW) (%) 87% 0,00% 0,00% 0,00% Severe Retinopathy of Prematurity (ROP) 0 0 0 0 0 Severe ROP Rate (%) 5,2% INFORMATION AND DATA EMBODIED IN THIS DOCUMENT SHOULD BE TREATED AS CONFIDENTIAL ANALYTICS AND REPORTING DEPARTMENT - MEDICLINIC INTERNATIONAL MEDICLINIC NEWCASTLE 12 Monthly Comparisons Curr. Yr. Previous Current 24 Month Indicator Weight Change (%) Change (%) Nov '24 Dec '24 Jan '25 Total Total Trend Obstetric Indicators Number of Deliveries 57 73 74 1,37% 837 826 -1,31% Number of Live Births 58 72 73 1,39% 817 818 0,12% Caesarean Section (%) 70,2% 76,7% 73,0% -4,87% 76,6% 72,8% -4,99% Weighted Adverse Outcome Score (WAOS) 0,85 0,00 1,85 0,81 -56,16% 1,92 0,79 -58,65% Adverse Outcome Index (AOI) 1,8% 4,1% 4,1% -1,35% 3,3% 2,7% -20,38% Severity Index (SI) 0,0 45,0 20,0 -55,56% 57,3 29,8 -48,06% Number of Neonatal Mortalities 400 0 0 0 0 0 Neonatal Mortality Rate per 1,000 Live Births 0,00 0,00 0,00 0,00 0,00 Delivery Patient Mortalities 750 0 0 0 1 0 -100,00% Delivery Mortality Rate per 100,000 Live Births 0,00 0,00 0,00 122,40 0,00 -100,00% Uterine Ruptures 100 0 0 0 0 0 Uterine Ruptures (%) 0,00% 0,00% 0,00% 0,00% 0,00% Unplanned Maternal Admissions to ICU 65 0 1 0 -100,00% 4 3 -25,00% Unplanned Maternal Admission to ICU (%) 0,00% 1,37% 0,00% -100,00% 0,48% 0,36% -24,00% Birth Trauma Cases (≥37wks, ≥2.5kg) 60 0 0 0 0 0 Birth Trauma (%) 0,00% 0,00% 0,00% 0,00% 0,00% Unanticipated Operative Procedures 40 0 0 0 0 0 Unanticipated Operative Procedure (%) 0,00% 0,00% 0,00% 0,00% 0,00% Neonatal Admissions to NICU (≥37wks, ≥2.5kg, ≥24h) 35 0 2 0 -100,00% 7 5 -28,57% Neonatal Admissions to NICU (%) 0,00% 2,74% 0,00% -100,00% 0,84% 0,61% -27,62% APGAR score