Evaluating the effectiveness of patient care and support for selected surgical procedures at SMHS

The rate of unplanned hospital readmissions is considered a global healthcare measure as it potentially helps hospitals identify issues with the overall functioning of the service. Appropriate intervention and effective treatment together with good discharge planning decreases the likelihood of unplanned hospital readmissions.

Higher hospital readmission rates may be the result of patients being discharged prematurely and/or ineffective discharge planning and communication.  Reducing avoidable or unplanned hospital readmissions supports better health outcomes, improves patient safety and leads to greater efficiency in the health system. By measuring and monitoring this indicator the level of hospital readmissions can be assessed in order to identify key areas for improvement.

A hospital readmission occurs when a patient has been discharged from hospital and is admitted again within a certain time period. Generally, hospital readmissions can be considered in two broad categories:

  • Readmissions that relate to routine care (planned), for example those that relate to necessary treatments such as chemotherapy or dialysis, and are required to ensure safe clinical care.
  • Readmissions that are potentially avoidable (unplanned).

The unplanned hospital readmission rate is calculated by dividing the number of patients experiencing an unplanned hospital readmission within 28-days of discharge, by the number of patients discharged within the period for the same procedure. The results are expressed as a rate per 1,000 separations (discharges).  

The surgeries selected to be measured by this indicator are based on the seven surgery types in the current National Health Agreement Unplanned Readmission performance indicator (NHA PI 23).

Established benchmark rates for each procedure are detailed in the table below.

Table: Established benchmark rates
Surgical Procedure
Benchmark
Knee replacement
≤26.2 per 1,000 separations
Hip replacement
≤17.1 per 1,000 separations
Tonsillectomy and adenoidectomy
≤61 per 1,000 separations
Hysterectomy
≤41.3 per 1,000 separations
Prostatectomy
≤38.8 per 1,000 separations
Cataract surgery
≤1.1 per 1,000 separations
Appendicectomy
≤25.7 per 1,000 separations
Knee replacement

The SMHS rate for unplanned readmissions following a knee replacement varied; however, the overall rate for 2017-18 was 26.3 per 1,000 separations, which is 0.1 above the benchmark. For the first three quarters of 2018-19 the overall SMHS rate achieved a rate below the benchmark at 24.3 per 1,000 separations.

Figure 1: SMHS rate of unplanned readmissions following a knee replacement per 1,000 separations, quarterly results July 2017 to March 2019


Hip replacement

For 2017–18 SMHS unplanned readmission rate for hip replacements was 23.6 per 1,000 separations, placing it above the benchmark of ≤17.1.

A review of unplanned readmission cases contributing to this rate was undertaken be relevant sites, and whilst known complications had occurred with the majority of these cases, no issues were identified with the clinical care provided. In one readmission case the patient had developed a serious hip prosthesis infection despite continuing on antibiotics, and a Severity Assessment Code 1 (SAC1) Clinical incident investigation was undertaken. The SAC1 investigation found all clinical care was appropriate, and the patient was covered by appropriate antibiotics throughout their inpatient stay and outpatient care.

A review was undertaken in 2019 of the patient journey of all hip and knee surgical site infections reported in 2018-19 for Fiona Stanley Hospital. An action plan was developed and implemented, including updates to the clinical pathways; confirmation of current best practice in wound management and dressings; documentation of wound care management; and changes to patient discharge information.

Figure 2: SMHS rate of unplanned readmissions following a hip replacement per 1,000 separations, quarterly results July 2017 to March 2019


Tonsillectomy and adenoidectomy

The overall rate of unplanned readmissions for tonsillectomy and adenoidectomy procedures remained above the benchmark at 105.1 per 1,000 separations for 2017–18 and increased to 118.4 for the first three quarters of 2018–19.

A review of the cases found no issues identified with clinical care processes as the majority of cases were a result of known complications.  However, a number of quality improvement activities were initiated to help reduce the rates. Initiatives included changes to the type of analgesia provided post-operatively; a review of the discharge information/advice provided to patients; and review of readmissions every quarter at the departmental Clinical Review Committee.

In view of SMHS continuing to have an elevated unplanned readmission rate for tonsillectomy and adenoidectomy, further analysis was undertaken in 2017-18 and then again in 2018–19 using Health Roundtable (HRT) data. This analysis involved a comparison of readmission rates for Fiona Stanley Hospital with state tertiary hospitals and with HRT Australasian peer hospitals.

Comparisons with the readmission rates compared favourably with Australasian peer hospitals.

Figure 3: SMHS rate of unplanned readmissions following tonsillectomy and adenoidectomy per 1,000 separations, quarterly results July 2018 to March 2019


Hysterectomy

The overall unplanned readmission rate following a hysterectomy for 2017-18 was 62.8 per 1,000 separations which increased to a rate of 77.5 for the first three quarters of 2018–19.

As SMHS continued to be above the benchmark, the cases were reviewed by relevant clinical teams at SMHS sites. The reviews found a number of the readmissions were for known complications such as small bleeds, haematoma and wound infection and appropriate care was provided.

Figure 4: SMHS rate of unplanned readmissions following hysterectomy per 1,000 separations, quarterly results July 2018 to March 2019


Prostatectomy

The overall SMHS rate of unplanned readmissions following prostatectomy for 2017–18 was 40.4 per 1,000 separations, marginally above the benchmark of ≤ 38.8. This rate subsequently decreased during the first three quarters of 2018–19 to achieve an overall rate below the benchmark at 36.8

Figure 5: SMHS rate of unplanned readmissions following prostatectomy per 1,000 separations, quarterly results July 2017 to March 2019


Cataract surgery

For unplanned readmissions following cataract surgery the 2017–18 overall SMHS rate was 4.29, a result above the benchmark of ≤1.1 per 1,000 separations. Whilst the overall SMHS rate dropped in the following three quarters (Q1-Q3 of 2018–19) to 4.01 per 1,000 separations, it still remained above the benchmark.  

Clinical review of the cases found no issues were identified and appropriate care was provided.

Figure 6: SMHS rate of unplanned readmissions following cataract surgery per 1,000 separations, quarterly results July 2017 to March 2019


Appendicectomy

For 2017-18 SMHS achieved an overall rate below the benchmark of 25.7 for unplanned readmissions following appendicectomy with a result of 20.8 per 1,000 separations. However, this overall rate increased in the first three quarters of 2018-19 to 29.7.

Clinical review revealed the patients involved in the four cases were readmitted due to known minor complications and no issues were identified with the clinical care provided.

Figure 7: SMHS rate of unplanned readmissions following appendicectomy per 1,000 separations, quarterly results July 2017 to March 2019