Indicator Area 4: Electroconvulsive therapy; Indicator Area 5: Use of seclusion and restraint; Indicator Area 6: critical incidents; Indicator Area 7: Length of stay Indicator Area 10: Community care; A. ACHS Clinical Indicator Report: Attach the relevant ACHS clinical indicator comparison reports for the most recent 12 month period; this will involve two ACHS reports. B. Complete only if the ACHS indicator equivalent has not been reported to ACHS. Hospitals use internal systems to collect data and monitor results. Please review your hospital’s clinical/quality report and if the above indicators are not submitted to ACHS, report hospital collected data on the following pages for the most recent 12 month time period. SECTION 2B: CLINICAL INDICATORS ACHS Mental Health Inpatient Clinical Indicators – Version 7 ACHS Mental Health – Inpatient Clinical Indicators Reporting Period Previous Period ACHS Aggregate Rates Indicator Number Indicator Description Numerator (Please replace description with your number) Denominator (Please replace description with your number) Your Rate % Your Sector % All Orgs. % Your Rate % INDICATOR AREA 1: DIAGNOSIS AND CARE PLANNING 1.1 Individual care plan Number of consumers with an individual care plan, during the 12 reporting period Number of consumers to whom care is provided, during the 12 reporting period. 1.2 Individual care plan signed by consumer Number of consumers who signed individual care plan, during the 12 month reporting period. Number of consumers to whom care is provided, during the 12 month reporting period. 1.3 Individual care plan signed by carer Number of nominated carers who signed the individual care plan, during the 12 month reporting period Number of consumers to whom care is provided that have a nominated carer, during the 12 month reporting period. INDICATOR AREA 2: PHYSICAL EXAMINATION OF PATIENTS 2.1 Physical examination documented within 24 of admission Number of inpatients with a complete documented physical examination within 24 of admission, during the 12 month reporting period. Number of inpatients admitted with a length of stay of 24 hours or more, during the 12 month reporting period.
INDICATOR AREA 3: PRESCRIBING PATTERNS 3.1 Discharged on 2 or more psychotropic medications from 1 category (excluding antipsychotics) Number of consumers on 2 or more psychotropic medications from 1 category (listed above) at the time of discharge, during the 12 month reporting period. Number of consumers on psychotropic medication at the time of discharge, during the 12 month reporting period. INDICATOR AREA 4: ELECTROCONVULSIVE THERAPY 4.1 Mean number of ECT treatments Total number of ECT treatments for courses of ECT which were completed, during the 12 month reporting period. Total number of consumers with a course of ECT which were completed, during the 12 month reporting period. 4.2 Major medical complications while undergoing ECT Number of inpatients experiencing major medical complications while undergoing ECT, during the 12 month reporting period. Number of inpatients undergoing a course of nonmaintenance ECT, during the 12 month reporting period. INDICATOR AREA 5: USE OF SECLUSION AND RESTRAINT 5.1 Rate of seclusion (Seclusion episodes per 1,000 bed days) Number of seclusion episodes in unit, during the 12 month reporting period. Number of occupied bed days in unit, during the 12 month reporting period. 5.2 Average duration of seclusion episodes (Hours per episode) Total duration of seclusion episodes in unit, during the 12 month reporting period. Number of seclusion episodes in unit, during the 12 month reporting period. 5.3 Percent of persons secluded Number of persons secluded at least once during a hospital stay, during the 12 month reporting period. persons in unit, during the 12 month reporting period.
5.4 Seclusion – > 4 hours in 1 episode Number of inpatient separations who had seclusion for more than 4 in 1 episode, in an admission, during the 12 month reporting period. Number of inpatient separations having seclusion, during the 12 month reporting period. 5.4 Seclusion > 4 hours in 1 episode Number of completed episodes who had seclusion for more than 4 hours in 1 episode, during the 12 month reporting period. Number of completed episodes having seclusion, during the 12 month reporting period. 5.5 Physical restraint ≥ 1 episode Number of completed episodes with at least one episode of physical restraint, during the 12 month reporting period. Number of completed episodes, during the 12 month reporting period. 5.6 Mechanical restraint ≥ 1 episode Number of completed episodes with at least one episode of mechanical restraint, during the 12 month reporting period. Number of completed episodes, during the 12 month reporting period. INDICATOR AREA 6: MAJOR CRITICAL INCIDENTS 6.1 Suicide Number of consumers who commit suicide, during the 12 reporting period. Number of consumers, during the 12 month reporting period. 6.2 Consumers who assault Number of consumers who assault in an admission, during the 12 month reporting period. Number of consumers, during the 12 month reporting period. 6.3 Consumers assaulted Number of consumers assaulted by visitors or other inpatients in an admission, during the 12 month reporting period. Number of consumers, during the 12 month reporting period. 6.4 Sexual assault Number of reported sexual assaults on consumers, during the 12 month reporting period. Number of consumers assaulted by visitors or inpatients in an admission (Numerator CI 6.3), during the 12 month reporting period. 6.5 Significant Number of consumers who undertake significant in an admission, during the 12 month reporting period. Number of consumers, during the 12 month reporting period. INDICATOR AREA 7: LENGTH OF STAY
7.1 Acute unit - length of stay > 28 days Number of completed episodes in an inpatient unit with a length of stay greater than 28 days, during the 12 month reporting period. Number of completed episodes in the acute inpatient unit, during the 12 month reporting period. INDICATOR AREA 9: CONTINUITY OF CARE 9.1 Discharge summary / letter provided to consumer or nominated carer Number of completed episodes where the consumer or nominated carer is provided with a discharge summary / letter at the time of hospital discharge, during the 12 month reporting period. Number of completed episodes, during the 12 month reporting period. 9.2 Discharge summary / letter provided to service providing ongoing care Number of completed episodes the consumer’s discharge summary / letter is provided to the service providing ongoing care within 1 working day, during the 12 month reporting period. Number of completed episodes with a service providing ongoing care, during the 12 month reporting period. 9.3 Three-monthly multidisciplinary review Number of consumers who have a multidisciplinary review recorded every 3 months, during the 12 month reporting period. Number of consumers with a service episode greater than 3 months, during the 12 reporting period. INDICATOR AREA 10: COMMUNITY CARE 10.1 Consumers contacted by community service Number of registered consumers contacted by the community service, during the 12 month reporting period. Number of consumers registered with the community service, during the 12 month reporting period. SECTION 3: COLLECTION, ANALYSIS & REPORTING OF INDICATORS Provide comment on collection, analysis and any change in the reporting of all Clinical Indicators. If relevant, comment on reasons why certain clinical indicators have not been included in your report. Also, if the ACHS average rate of occurrence is exceeded for any indicator, please explain why and note any remedial actions undertaken (attachments are permitted, however please index those attachments below):