13. Monthly Performance Report - Southern Health and Social Care ...

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Health Care Acquired Infection – Related DeathsMonitoring of HCAI deaths SHSCT, is now based on the date the death is registered and is fully aligned with the CentralServices Agency / NI Stats & Research Agency reporting.As part of the review of arrangements for monitoring death related data, processes have been established with AssociateMedical Directors to take forward issues arising from the morbidity & mortality meetings, including providing assurances thatcases where HCAI was recorded on the death certificate are discussed.Clostridium Difficile – Annual trend by hospital site and breakdown by Quarter for 2009No deaths were recorded for Jan 2010Number of SHSCT deaths with MRSA mentioned and recorded as the underlying causeof death certificate, 2002 – 2008 (validated)Number of SHSCT deaths with Clostridium Difficile mentioned and recorded as theunderlying cause on death certificate:Jan – Dec 2009 P& 1st – 31st Jan 2010 P (unvalidated)January – December 2009 P (unvalidated)12104Primary1a Primary1b Primary1c SecondaryClassification of C.DIFF on death certificate836241200Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4200220032004200520062007200820092010200220032004200520062007200820092010200220032004200520062007200820092010200220032004200520062007200820092010200220032004200520062007200820092010200220032004200520062007200820092010200220032004200520062007200820092010Craigavon Area Daisy Hill Hospital Lurgan Hospital Mullinure Hospital South Tyrone St Luke's Hospital All Other PlacesHospitalHospitalP – Provisional data pending publication of the Registrar General’s Annual Report for 2009 & 2010.NB Excludes deaths in all other places between 2002 – 2008, as this information is aggregated regionally in the Registrar General’s Annual Report.CAH(n=7) DHH(n=4) Lurgan(n=0) Mullinure(n=0) STH(n=1) SLH(n=0) All othern=12P – Provisional data pending publication of the Registrar General’s Annual Report for 2009Source: NI Stats & Research Agency and Central Services Agency combined weekly submission of HCAI death related dataplaces(n=0)This graph shows a significant drop in the number of deaths with Clostridium Difficile mentioned on the death certificate in 2009 (n=12), incomparison to 19 hospital CDI deaths in 2008, as demonstrated in the following graph.42
MRSA – Annual trend by hospital site and breakdown by Quarter for 2009No deaths were recorded for Jan 2010Number of SHSCT deaths with MRSA mentioned and recorded as the underlying causeof death certificate, 2002 – 2008 (validated)Number of SHSCT deaths with MRSA mentioned and recorded as the underlying cause ondeath certificate, Regional overview:Jan – Dec 2009 P& 1st – 31st Jan 2010 P (unvalidated)January – December 2009 P (unvalidated)121086432These 11 cases will be included inthe discussions on 30-day HCAIMortality, which is scheduled for 15 thJan 2010Primary1a Primary1b Primary1c SecondaryClassification of MRSA on death certificate41202002200320042005200620072008200920102002200320042005200620072008200920102002200320042005200620072008200920102002200320042005200620072008200920102002200320042005200620072008200920102002200320042005200620072008200920102002200320042005200620072008200920100Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4CAH(n=4) DHH(n=2) Lurgan(n=0) Mullinure(n=1) STH(n=0) SLH(n=0) All otherplaces(n=4)n=11Craigavon Area Daisy Hill Hospital Lurgan Hospital Mullinure Hospital South Tyrone St Luke's Hospital All Other PlacesHospitalHospitalP – Provisional data pending publication of the Registrar General’s Annual Report for 2009 & 2010.NB Excludes deaths in all other places between 2002 – 2008, as this information is aggregated regionally in the Registrar General’s Annual Report.This dataset is provisional pending publication of the Registrar General’s Annual Report for 200911 MRSA related deaths in SHSCT in 2008 & 2009.In this update, there has been no additional cases where MRSA was recorded as a cause of death on the death certificate.43
Page 4 and 5: CONTENTPage1.0 Context 52.0 Reporti
Page 6: 3 SUMMARY REPORT3.1 DOMAIN: EFFICIE
Page 9: KPI : %DischargesCoded-cumulativeco
Page 12 and 13: PFA AHP AccessBy March 2010-no pati
Page 14 and 15: PSA 5.4: CareleaversBy March 2010in
Page 16 and 17: 3.3 DOMAIN: CLINICAL AND SOCIAL CAR
Page 18 and 19: PSA 5.2FamilysupportinterventionsOc
Page 20 and 21: SSI rate (Hipsonly)BundleCompliance
Page 22 and 23: -%compliancewith riskassessment-%co
Page 24 and 25: Priority 5(Target 7)PFA -Assessment
Page 26 and 27: 3.4 DOMAIN: WORKFORCETarget/Indicat
Page 28 and 29: • Re-admission Rates with Peer co
Page 30 and 31: Monthly Performance Report 16 Febru
Page 32: Renal - dialysis via fistula: This
Page 35 and 36: 0.400.350.300.250.200.150.100.05MSS
Page 37 and 38: MRSA AnalysisNew cases of MRSA2009
Page 39 and 40: Hand Hygiene Compliance AuditsHand
Page 41: Compliance with AntibioticsHospital
Page 45 and 46: % Bundle Compliance100%90%80%70%60%
Page 47 and 48: CHILDREN AND YOUNG PEOPLE REPORTING
Page 49 and 50: Appendix I - Daycase Rates by Proce
Page 51 and 52: Hydrocele exc IS 9 10 47.4%PROCEDUR
Page 53 and 54: STH 3 0 100.0%Varicose Veins exc IS
Page 55 and 56: ContentsSection1 Introduction2 Depa
Page 57 and 58: The overall score is an average of
Page 59 and 60: 3. Departmental Audit Results - Bre
Page 61 and 62: St Luke's Hospital1009590Score85807
Page 63 and 64: 4. ICNA Audit Results143 audits hav
Page 65 and 66: Daisy Hill Rehab Environment 24/06/
Page 67 and 68: 5. Action PlanThis Action Plan was
Page 69 and 70: MonthHospitalRisk CategoryDepartmen
Page 77 and 78: and nurses station.EC Departmental

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