The head of the Orthopaedic Surgery Department in Sydney’s Liverpool Hospital chose to investigate variation in management of hip fracture because it makes up a large part of the department’s activity, and it is a high-risk condition. Providing surgery within 48 hours of presentation if no clinical contraindication exists, and the patient prefers surgery, was identified as the first priority for attention because it improves clinical outcomes, and it is part of the Australian Clinical Care Standard for hip fracture. 

Addressing this issue also helps the hospital meet Action 1.7 of the NSQHS Governance Standard because it involves following a Clinical Care Standard.

The department already contributes data to the Australian and New Zealand Hip Fracture Registry (ANZHFR), which monitors practice according to the Hip Fracture Care Clinical Care Standard. The Registry online portal includes a dashboard showing the hospital’s results in seven aspects of care specified in the clinical care standard, and the annual report of the ANZHFR shows each contributing hospital’s performance, as well as the state/territory and national averages. 

As a starting point, the head of department asked the orthopaedic registrar to present the hospital’s Registry results, and the state and national averages from the latest annual report, at the monthly department meeting.

Review of three month’s data showed that only 50% of the hospital’s patients with hip fracture underwent surgery within 48 hours, compared to the national average of 77%. The department felt this poor result needed to be addressed urgently, and a team made up of orthopaedic surgeons, nurses, and geriatricians was created to investigate the issue and find potential solutions.

The department also noted that their total length of stay for hip fracture patients was well above average, and it was possible that the delays to theatre were contributing to the overall increase in total length of stay.

After the Clinical Nurse Consultant ruled out errors in data entry as a factor, the team met to discuss the possible reasons for the delays in surgery. A comparison of the reasons for delay in the hospital, compared with national averages in the registry annual report, showed that:

• The proportion of delays due to patients being medically unfit for surgery, or lack of surgeon availability, were similar to those in other hospitals
• Length of stay in the emergency department was also similar 
• A lack of theatre availability was substantially higher than the national average. 

A discussion about theatre access highlighted a number of areas for improvement. Patients presenting on Fridays or the weekend had the greatest delays because no theatre time was allocated on Saturdays or Sundays for hip fracture surgery. The group also noted that patients with hip fracture often had their surgery cancelled when cases seen as more urgent were brought into the hospital. This contributed to delays, and also led to prolonged and unnecessary fasting for patients.

The group made a case to the hospital manager for introducing a Sunday morning theatre list dedicated to hip fracture surgery. They presented the hospital’s performance compared with the national average, and against the clinical care standard quality statements.

The hospital manager determined that reducing delays in surgery for hip fracture was a priority for improving patient care, and introduced the additional, dedicated theatre time.

Follow up monitoring showed a reduction in delays to surgery, and the hospital became close to the national average. Reports generated from the hip fracture registry portal are discussed at a quarterly meeting between the orthopaedic surgery and geriatric departments, and are included in the hospital’s regular safety and quality reports to the Board. 

The department continues to check that delays to surgery are minimised, and is focussing on the quality indicators for pain management in the hip fracture clinical care standard next.

The head of the stroke unit selected discharge planning as a priority after a patient was readmitted with a second stroke following discharge without secondary prevention medication.

Apart from reducing the risk of another stroke, formal discharge planning can improve the coordination of services and reduce long-term unmet needs for people who have had a stroke. It is also part of the Clinical Guidelines for Stroke Management and the Acute Stroke Clinical Care Standard, so improving practice in this area would help the hospital meet Action 1.27 of the NSQHS Clinical Governance Standard. 

The hospital already contributes to the Australian Stroke Clinical Registry (AuSCR), so no new data collection would be needed. Benchmark, national and state data are also available for comparison, from sources including AuSCR and The Stroke Foundation.

The Stroke Unit’s Head of Department and Clinical Nurse Consultant decided to review the hospital’s AuSCR data for the previous year, along with national and state data. They chose two of the indicators related to discharge planning as their initial focus:

• Care plan provided at discharge
• Discharged on an antihypertensive medicine.

The Clinical Nurse Consultant generated a report from the online AuSCR portal. The hospital was close to average for most indicators but performed poorly on the measures of discharge planning. 

Only 49% of patients had a care plan on discharge after a stroke, compared to the national average of 59% and the benchmark of 95%. And 60% were discharged on antihypertensive medication, compared to the national average of 70%.

After ruling out data errors as a factor, the Clinical Nurse Consultant presented the results at a meeting of clinical staff who contribute to discharge planning for stroke patients. The group included medical, nursing, pharmacy and allied health staff.

The group decided differences in case mix, structure or resources of the hospital did not explain the poor results. They identified several aspects of processes and practice that were contributing to inconsistent discharge care planning:

• Lack of awareness, compounded by rotation of staff
• Lack of an appropriate template
• Inconsistent prescribing of secondary prevention medication.

At a follow up meeting to discuss strategies to improve discharge planning, the group agreed to a range of changes:

• Senior medical, nursing and allied health staff to raise discharge care planning for stroke patients on all ward rounds over the following two weeks, and to lead education sessions on the importance of discharge care planning in the following month
• Discharge care planning to be included in orientation of new staff
• The checklist for leaving hospital in the Stroke Foundation booklet ‘My stroke journey’ to be used as a template for discharge planning
• Recommendations and evidence for secondary prevention medication to be added to bedside charts as a reminder
• Pharmacy staff to alert the medical team if secondary prevention medications are not included in discharge medications.

Follow up after three months showed a small improvement in both indicators, but the hospital was still below the national averages. To improve discharge planning further, a stroke ‘in-reach’ team of medical and allied health practitioners was formed to review all stroke patients before discharge.

Review after a further three months showed that the hospital had reached the national averages for percentage of stroke patients with a discharge plan and for prescription of secondary prevention medication. Results for all indicators from the registry are reviewed every quarter at a multidisciplinary stroke meeting. Priorities for new quality improvement initiatives are also discussed in light of the hospital’s performance in comparison to national and state data.

The head of the cardiology department chose to investigate the prescribing of secondary preventive medicines for patients with acute coronary syndrome. This aspect of care was chosen because it is relevant to a large proportion of patients and it is important for reducing the risk of further cardiac events.

The department head knew of the Acute Coronary Syndromes Clinical Care Standard, and the cardiac registrar found a published audit of Australian hospitals that included rates of prescribing secondary preventive medicines. The same patient inclusion and exclusion criteria from the audit were used for the hospital’s variation project so the data could be directly compared.

The resident medical officer extracted the data from the electronic records for all patients who met the criteria for each of the previous three months. The percentage of patients who were prescribed secondary preventive medicines was 60%, 70% and 65% for each of the three months. This gave an average of 65% in this snapshot period.

The published audit found an average rate of 71% across Australian hospitals, which showed the department that they were performing below average on this aspect of care.

The team also compared practice with the Acute Coronary Syndromes Clinical Care Standard, which includes this statement:

Quality Statement 6 – Individualised care plan: Before a patient with an acute coronary syndrome leaves the hospital, they are involved in the development of an individualised care plan. This plan identifies the lifestyle modifications and medicines needed to manage their risk factors.

The data were presented to the cardiology department teams, who could see they were not meeting this aspect of the standard for up to 35% of their patients over the past three months.

The department decided that this gap in care was unacceptable and required urgent action. They decided to make the Australian average rate of 71% their initial goal, and to aim for a higher benchmark in the long term.

Medical, nursing, pharmacy and allied health staff met to discuss possible reasons for the poor performance in prescribing secondary prevention medicines. A lack of a standardised process and lack of awareness of the effectiveness of secondary prevention were thought to be the main contributors.

Education sessions on recommended secondary prevention medicines were held at the regular department meetings and a discharge checklist that included prescribing secondary prevention medicines was introduced. The hospital pharmacist also provided one-on-one education sessions with medical staff.

The department used the relevant indicators in the Acute Coronary Syndromes Clinical Care Standard to monitor performance going forward. The department head also collaborated with several other similar hospitals to compare data every quarter and exchange lessons learned.

The Clinical Director of Obstetrics and Gynaecology in the ACT had been concerned by Australia’s rising rate of preterm births (before 37 weeks gestation), and early planned births (38-39 weeks gestation) without a medical indication, for many years. The recent success of the WA ‘Whole Nine Months’ initiative in reducing early births was the impetus for targeting this issue at the Centenary Hospital for Women and Children, Canberra, which is the sole tertiary referral hospital for high-risk pregnancies in the ACT and surrounding areas of NSW. Emerging evidence of the adverse long- and short-term effects of early term birth (37-38+6 weeks) was a further prompt to examine the hospital’s performance in this clinical area.

The team, made up of two obstetricians and a midwife, decided to use data from The Birth Outcome System electronic medical record of the Canberra Hospital and compare with rates from WA.

The percentage of babies born preterm in the ACT pre-intervention was 9.7% (average 2014-2018), compared to 7.0% in WA over the same period.

The percentage of planned births with no medical indication between 37 to 38 weeks plus 6 days was 18.8% in the ACT (average 2014-2018).

The team identified contributing factors, including:

• Inconsistent use of interventions to prevent preterm birth
• A large proportion of high-risk pregnancies due to the hospital’s status as a tertiary referral service
• High rates of smoking
• Variable continuity of care for women with high-risk pregnancies
• Lack of a consistent screening process for women at high risk of preterm births.

The ACT preterm birth prevention initiative, based on the WA Whole Nine Months initiative, was introduced in 2019 with funding provided by the Canberra Hospital Foundation. The initiative included:

• Developing a guideline for management of women with low-, medium- and high-risk pregnancies, followed by three months of outreach education for general practitioners, obstetricians, sonographers, and midwives
• Establishing a dedicated multidisciplinary preterm birth prevention clinic
• Appointment of a dedicated midwife for the service, supported by two obstetricians with an interest in preterm birth prevention
• Universal screening of cervical length at the 18-20 week ultrasound scan
• Progesterone pessaries for women with a shortened cervix or a history of preterm birth, and consideration of cervical cerclage (suture) in some cases
• A structured smoking cessation program

Strategies to avoid planned birth before 39 weeks unless medically indicated were also introduced. These included a streamlined booking process for induction of labour and timing of elective caesarean sections for 39 weeks unless there was an obstetric indication for an earlier delivery.

After 16 months of the intervention, preterm births were reduced by 10% compared to the previous five years; planned early term births with no medical indication were reduced by 35% compared with the previous five years, with no increase in the stillbirth rate. Rates of preterm birth and early term birth continue to be monitored and reported to the department’s Quality and Safety Committee. The Unit is a member of the Australian Preterm Birth Prevention Alliance, and reports data to it also.

Education for obstetricians, midwives and ultrasonographers is ongoing. Further quality improvement activities are also continuing, including smoking cessation, and screening for infection projects.