Clinical Performance Indicators

Union Hospital’s performance against the Australian Council on Healthcare Standards (ACHS) Clinical Indicators is described below:

44 quantifiable and comparable Clinical Indicators have been collected in the 1st half of 2025. There are 19 Indicators performed statistically significantly better than the International Peer Aggregate Rate:

Above International Aggregate Rate
On Par with International Aggregate Rate
Below International Aggregate Rate
SetClinical Indicator No.Indicator NameUnion Hospital's RateInternational Peer Aggregate Rate
Anaesthesia3.5Unplanned stay in recovery room >2 hours0.02% 0.76%
Anaesthesia4.1Unplanned ICU admission ≤24 hours after procedure0.03% 0.17%
Day Patient5.1Unplanned return to operating room on same day as initial procedure0.00% 0.06%
Emergency Medicine1.1Australasian Triage Scale Category 1 - medically assessed and treated immediately100.00% 97.33%
Emergency Medicine1.2Australasian Triage Scale Category 2 - medically assessed and treated within 10 minutes100.00% 77.10%
Emergency Medicine1.3Australasian Triage Scale Category 3 - medically assessed and treated within 30 minutes99.02% 74.91%
Emergency Medicine1.4Australasian Triage Scale Category 4 - medically assessed and treated within 60 minutes84.44% 78.55%
Emergency Medicine1.5Australasian Triage Scale Category 5 - medically assessed and treated within 120 minutes99.73% 88.93%
Gynaecology2.1Injury to a major viscus during endoscopic surgery0.00% 0.49%
Gynaecology2.2Injury to a major viscus during non-endoscopic surgery0.00% 0.19%
Hospital Wide2.1Unplanned return to the operating room during the same admission0.14% 0.23%
Hospital Wide3.1Inpatients who develop ≥1 pressure injuries0.00% 0.02%
Hospital Wide4.1Inpatient falls0.02% 0.28%
Hospital Wide4.2Inpatient falls resulting in fracture or closed head injury0.00% 0.01%
Hospital Wide5.2Deaths in adult patients who do not have a resuscitation plan0.02% 0.02%
Hospital Wide6.1Significant adverse blood transfusion events0.00% 0.06%
Hospital Wide9.2Laparoscopic cholecystectomy - bile duct injury requiring operative intervention0.00% 0.01%
Hospital Wide9.3Tonsillectomy - significant reactionary haemorrhage0.00% 0.02%
Infection Control1.1Deep or organ/space surgical site infection - hip prosthesis procedure0.00% 0.41%
Infection Control1.2Deep or organ/space surgical site infection - knee prosthesis procedure0.00% 0.35%
Infection Control6.1Reported parenteral exposures sustained by staff0.00% 0.03%
Infection Control6.2Reported non-parenteral exposures sustained by staff0.00% 0.01%
Intensive Care1.1ICU adult non-admission due to inadequate resources11.43% 2.11%
Intensive Care1.2ICU - elective adult surgical cases deferred or cancelled due to unavailability of bed3.13% 0.13%
Intensive Care1.3ICU - adult transfer to another facility / ICU due to unavailability of bed6.06% 0.58%
Intensive Care1.4ICU - adult discharge delay more than 12 hours0.00% 23.15%
Intensive Care2.1Rapid response system calls to adult ICU patients within 48 hours of ICU discharge0.00% 1.76%
Intensive Care3.1Venous thromboembolism prophylaxis in adult patients within 24 hours of ICU admission100.00% 96.87%
Intensive Care4.1Adult ICU-associated centrally inserted central line-associated bloodstream infection0.00% 0.13%
Maternity7.1Term neonates - Apgar score less than 7 at 5 minutes post-delivery0.00% 0.84%
Maternity8.1Admissions of term neonate to a neonatal intensive care nursery or special care nursery at birth whose length of stay exceeds 24 hours0.53% 6.09%
Medication Safety6.3Medication errors - adverse event requiring intervention0.00% 0.00%
Ophthalmology1.1Cataract surgery - unplanned readmissions within 28 days0.00% 0.18%
Oral Health1.1Restorative treatment - teeth retreated within 6 months0.29% 2.55%
Paediatrics1.1Registered nurses with paediatric basic life support qualifications100.00% 100.00%
Paediatrics2.1Medication errors0.02% 0.02%
Paediatrics2.3Adverse events in a paediatric ward/area0.00% 0.04%
Pathology1.1Serum / plasma potassium for emergency department - in lab to validated time <40 minutes100.00% 62.43%
Pathology1.3Serum / plasma troponin for emergency department - in lab to validated time <50 minutes100.00% 74.91%
Pathology2.1Haemoglobin for emergency department - in lab to validated time <35 minutes96.08% 86.59%
Pathology6.1Misidentified episodes0.00% 1.39%
Radiology1.1Number of Severity Assessment Code (SAC) 1 or Incident Severity Rating (ISR) 1 incidents - interventional radiology examinations0.00% 0.00%
Radiology1.6Contrast extravasation during an IV contrast enhanced CT procedure requiring medical review0.10% 0.09%
Radiology1.9Image-guided percutaneous core biopsy of internal organ that led to an unexpected adverse event1.84% 1.08%
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