AMR Antimicrobial resistance AMS Antimicrobial stewardship ANZASM Australian and New Zealand Audit of Surgical Mortality ANZDATA Australia and New Zealand Dialysis and Transplant Registry AOANJRR Australian Orthopaedic Association National Joint Replacement Registry AURA Antimicrobial Use and Resistance in Australia CBCT Cone beam computed tomography CT Computed tomography EMM Electronic medication management IT Information technology MBS Medicare Benefits Schedule MRSA Methicillin-resistant Staphylococcus aureus NSQHS National Safety and Quality Health Service OECD Organisation for Economic Co-operation and Development PBS Pharmaceutical Benefits Scheme RACS Royal Australasian College of Surgeons SAC Safety assessment code WHO World Health Organization Introduction Welcome to this fourth annual edition of Vital Signs, produced by the Australian Commission on Safety and Quality in Health Care (the Commission) to report on the state of safety and quality of health care in Australia in 2015–16. The Commission’s role is to lead and coordinate national improvements in the safety and quality of health care. The Commission works in partnership with patients, carers, clinicians, managers, policy makers and healthcare organisations
to achieve a sustainable, safe and health system. Key functions of the Commission include developing national safety and quality standards, developing clinical care standards to improve the implementation of evidence-based health care, coordinating work in specific areas to improve outcomes for patients, and providing information, publications and resources about safety and quality. The Commission works in four priority areas: 1. patient safety 2. partnering with patients, consumers and communities 3. quality, cost and value 4. supporting health professionals to provide care that is informed, supported and organised to deliver safe and health care. One of the Commission’s key functions is to report on the state of safety and quality in the Australian health system. This is important because it will inform how the health system is performing, and how successful efforts are at ensuring safety and quality health care for patients. This in turn assists the Commission and its partners to determine priorities for the future. This report, Vital Signs 2016, is structured around three important questions members of the public ask about their health care: Will my care be safe? Will I get the right care? Will I be a partner in my care? Australia performs very well in international comparisons about healthcare outcomes. The Australian population has high life expectancy, a relatively low rate of avoidable death and good survival rates from major cancer types and cardiovascular disease. However, measuring the safety and quality of care can be challenging. While there is information about surgery, emergency department attendances and visits to general practitioners, there is less complete information about safety and quality. Vital Signs 2016 brings together information from a range of sources to provide a snapshot of safety and quality outcomes in a number of patient care areas. Vital Signs 2016 also includes three case studies that provide an in-depth analysis of safety in the context of healthcare variation, clinical quality registries and reducing unnecessary radiation exposure to children and young people. The case studies illustrate the type of work that is needed to properly understand if we are improving the safety and quality of healthcare delivery.
What difference are the NSQHS Standards making to patient safety? The National Safety and Quality Health Service (NSQHS) Standards were developed by the Commission in collaboration with states and territories, clinical experts, patients and carers. The primary aims of the NSQHS Standards are to protect the public from harm and to improve the quality of health service provision. They provide a quality-assurance mechanism that tests whether relevant systems are in place to ensure expected standards of safety and quality are met. There are 10 NSQHS Standards, which cover high-prevalence adverse events, healthcare associated infections, medication safety, patient identification and procedure matching, clinical handover, the prevention and management of pressure injuries, the prevention of falls and responding to clinical deterioration. Importantly, these NSQHS Standards have provided, for the first time, a nationally consistent statement about the standard of care consumers can expect from their health service organisations. The implementation of the NSQHS Standards in hospitals and day procedure centres has contributed to significant improvements in patient safety. The NSQHS Standards have provided the impetus for new activities and they have led to increased priority being given to existing activities that aim to improve patient safety. Examples are an increased focus on the effective and appropriate use of antibiotics, better documentation of adverse drug reactions and medication history, and an increase in the number of hospitals reporting information nationally so that blood usage can be better monitored. How do the NSQHS Standards make a difference? People working in health services in Australia report that the NSQHS Standards are making a difference by enhancing: leadership for safety and quality – emphasising the responsibility of local hospital boards and executives for monitoring and taking action to improve safety and quality issues and encouraging a culture of safety clinical engagement – deepening the involvement of clinicians in designing and using safety and quality processes and tools that are focused on safe patient care effective systems – helping to ensure targeted systems and processes are used and continually monitored through clinical audits and other methods to evaluate effectiveness of interventions. The following sections provide examples of the some of the improvements that have been observed in the context of specific NSQHS Standards. Leadership for safety and quality –NSQHS Standard 1 The NSQHS Standards require that each health service organisation has an system that enables reporting of incidents of patient harm and ‘near misses’, and which is used by health service leaders to improve care. Incident monitoring helps
Ensuring that best-practice approaches are applied at the point of clinical care provision is an aspect of the Commission’s work – making sure that people get the right care. The Commission explores whether clinicians have the right information to assist in providing appropriate care to patients. It also examines if this knowledge is being applied, and if not, why not. This section of Vital Signs 2016 looks at the part of the Commission’s work that focuses on ensuring people get the right care in a range of clinical areas, including understanding resistance to and appropriate use of antibiotics in Australia, and supporting the safe use of online health resources. Antimicrobial resistance and appropriate use of antibiotics Antimicrobials are medicines designed to kill or slow the progress of infections, especially those caused by bacteria and fungi. There are many kinds of antimicrobials; the most common are antibiotics for treating bacterial infections. There are also antifungals, antivirals and anti-parasitics. These antimicrobials are essential to modern medicine. However, antimicrobials are losing their effectiveness because many organisms that were once successfully treated by antimicrobials have become resistant to them. Some organisms have become completely resistant to many different antimicrobials. This phenomenon is known as antimicrobial resistance (AMR). The development of resistance is a natural feature of bacterial evolution. However, as a community, we have been contributing to AMR by using antimicrobials too often, when they are not needed, or for the wrong types of infection. Resistance is spreading; once thought to be a problem only in hospitals, it is now found just as often in the community. AMR is a significant healthcare issue that can result in medical treatments becoming more complex and expensive, and in some patients needing to stay in hospitals longer. Some people may die because they have infections that can no longer be treated. Many health organisations around the world, including the World Health Organization, recognise AMR as a major threat to public health affecting every country.5 Australia is no exception. The Commission’s Antimicrobial Use and Resistance in Australia (AURA) Surveillance System, funded by the Australian Government Department of Health, will help prevent and slow the progress of AMR by increasing understanding of how antimicrobials are being used, and of patterns and trends in AMR.
What is Australia doing to fight AMR? In Australia, laboratories and surveillance programs detect and monitor AMR. Hospitals, residential aged-care facilities and some parts of the community use audit tools and systems to monitor antimicrobial use and its appropriateness. While these programs provide valuable surveillance data, a nationally coordinated approach was needed so that policy makers could see a clearer picture. The AURA Surveillance System, and the Commission’s work more broadly, supports a number of the objectives of the National Antimicrobial Resistance Strategy The Commission has been working with a range of partners to expand coverage by increasing the number of hospitals and laboratories that contribute data. It is also working to enhance analysis and reporting to system users, and will establish new systems where information gaps need to be filled. AURA Surveillance System program partners Australian Group on Antimicrobial Resistance National Centre for Antimicrobial Stewardship: National Antimicrobial Prescribing Survey South Australia Health National Antimicrobial Utilisation Surveillance Program National Neisseria Network National Notifiable Diseases Surveillance System NPS MedicineWise MedicineInsight Program Australian Government Pharmaceutical Benefits Scheme and Repatriation Pharmaceutical Benefits Scheme Queensland Health OrgTRx system Sullivan Nicolaides Pathology, Brisbane Mater Misericordiae Health Services, Brisbane States and territories. The First Australian Report on Antimicrobial Use and Resistance in Human Health The Commission has released the First Australian Report on Antimicrobial Use and Resistance in Human Health (AURA 2016) using data from the AURA Surveillance System.a AURA 2016 focuses on resistance rates for organisms that have been identified as priority organisms in Australia. If these organisms develop high resistance to the ‘last-line’ antimicrobials, it is likely that there will be significant increases in morbidity and mortality rates. Of the priority organisms, one of the Enterococcus species is most resistant to antimicrobials. Enterococcus species are opportunistic pathogens that cause a range of infections in patients whose immune system is already compromised due to surgery or invasive devices. The proportion of Enterococcus faecium strains that are resistant to the antimicrobial vancomycin is almost 50% – one of the highest rates in the world. Resistance to ampicillin was even higher in this species, at about 90% (see Figure 11). These resistances have a major impact on seriously ill patients in hospital and require significant efforts and investment of
Medicines, digital health and clinical safety: making sure technology supports clinicians to provide safe care to consumers Medicines are the most common treatment used in health care and contribute to significant improvements in health when used appropriately. However, medicine use can also be associated with harm, and the high use of medicines means they are associated with more errors and adverse events than any other aspect of health care. While rates of serious harm are low, errors do affect health outcomes for people and increase healthcare costs. For example, medication related hospital admissions in Australia account for about 2% to 3% of all admissions.7 The prevalence of medication errors is of particular concern because most of these errors are preventable. In order to improve the safety and quality of medicine use, we need to know how adverse medication events occur and how they can be prevented. This is true both at the level of individual practice and within systems for managing medicines. New technologies offer a promising avenue for improving medication safety. The role of digital health in this regard will be fundamental. There are clear benefits to implementing digital health systems that could reduce errors. For example, an electronic medication management (EMM) system can help reduce the frequency of medication-associated hospital admissions by: improving the legibility of medication information8 providing warnings to prescribers regarding adverse reactions with existing conditions or other medications the patient is taking. In addition, the increasing utilisation of the My Health Record system is also likely to help reduce medication errors and improve health outcomes. However, the rapid uptake and use of digital health systems can also cause new risks to clinical safety.9 The risks and the benefits of digital health must be balanced. The introduction of these systems needs to be accompanied by measures that ensure they are safe and are used in a way that protects patients. Steps being taken by the Commission to contribute to the safe use of digital health systems are discussed below. Safety issues with the use of digital health Clinical safety needs to be built into the planning and development phases of any system rollout if risks to patients are to be minimised. For example, hardware, software and the networks underpinning digital health systems must be robust and must recover quickly from breakdowns and failures with minimal impact. Digital health systems also need to be usable by and intuitive for clinicians. For example, a poorly designed interface might not display important clinical information in a manner that a clinician would expect, leading to an incorrect interpretation of patient data.