Clinical Performance Indicators

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

54 Clinical Indicators have been collected in the 2nd half of 2024. There are 26 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 hours0.01% 0.65%
Anaesthesia4.1Unplanned ICU admission ≤24 hours after procedure0.02% 0.14%
Day Patient5.1Unplanned return to operating room on same day as initial procedure0.00% 0.03%
Emergency Medicine1.1Australasian Triage Scale Category 1 - medically assessed and treated immediately100.00% 99.20%
Emergency Medicine1.2Australasian Triage Scale Category 2 - medically assessed and treated within 10 minutes100.00% 60.55%
Emergency Medicine1.3Australasian Triage Scale Category 3 - medically assessed and treated within 30 minutes98.45% 62.09%
Emergency Medicine1.4Australasian Triage Scale Category 4 - medically assessed and treated within 60 minutes85.10% 74.61%
Emergency Medicine1.5Australasian Triage Scale Category 5 - medically assessed and treated within 120 minutes99.86% 89.54%
Gastrointestinal Endoscopy1.1Failure to reach caecum due to inadequate bowel preparation0.00% 0.31%
Gastrointestinal Endoscopy1.2Failure to reach caecum due to pathology encountered0.21%  0.18%
Gastrointestinal Endoscopy2.1Treatment for possible perforation post-polypectomy0.00% 0.01%
Gastrointestinal Endoscopy2.2Treatment for possible perforation post-colonoscopy0.00% 0.01%
Gastrointestinal Endoscopy2.3Post-polypectomy haemorrhage0.00% 0.02%
Gastrointestinal Endoscopy3.1Adenoma detection rate43.28% 34.52%
Gynaecology2.1Injury to a major viscus during endoscopic surgery0.18% 0.37%
Gynaecology2.2Injury to a major viscus during non-endoscopic surgery0.10% 0.22%
Hospital Wide2.1Unplanned return to the operating room during the same admission0.03% 0.15%
Hospital Wide3.1Inpatients who develop ≥1 pressure injuries0.00% 0.02%
Hospital Wide4.1Inpatient falls0.01% 0.18%
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 plan0.03% 0.14%
Hospital Wide6.1Significant adverse blood transfusion events0.00% 0.09%
Hospital Wide8.1Rapid response system calls to adult patients0.00% 6.74%
Hospital Wide8.2Rapid response system calls to adult patients within 24 hours of admission0.00% 1.59%
Hospital Wide9.2Laparoscopic cholecystectomy - bile duct injury requiring operative intervention0.00% 0.20%
Hospital Wide9.3Tonsillectomy - significant reactionary haemorrhage0.00% 0.26%
Infection Control1.1Deep or organ/space surgical site infection – hip prosthesis procedure0.00% 0.44%
Infection Control1.2Deep or organ/space surgical site infection – knee prosthesis procedure0.00% 0.25%
Infection Control6.1Reported parenteral exposures sustained by staff0.00%  0.02%
Infection Control6.2Reported non-parenteral exposures sustained by staff0.00%  0.01%
Intensive Care1.1ICU adult non-admission due to inadequate resources6.25%  3.36%
Intensive Care1.2ICU - elective adult surgical cases deferred or cancelled due to unavailability of bed0.00%  0.19%
Intensive Care1.3ICU - adult transfer to another facility / ICU due to unavailability of bed3.23%  0.86%
Intensive Care1.4ICU - adult discharge delay more than 12 hours0.00%  20.88%
Intensive Care2.1Rapid response system calls to adult ICU patients within 48 hours of ICU discharge0.00%  2.66%
Intensive Care3.1Venous thromboembolism prophylaxis in adult patients within 24 hours of ICU admission100.00%  81.46%
Intensive Care4.1Adult ICU-associated centrally inserted central line-associated bloodstream infection0.00%  0.10%
Maternity7.1Term neonates - Apgar score less than 7 at 5 minutes post-delivery0.00%  0.96%
Maternity8.1Admissions of term neonate to a neonatal intensive care nursery or special care nursery at birth whose length of stay exceeds 24 hours0.56%  6.23%
Medication Safety6.3Medication errors - adverse event requiring intervention0.00%  0.00%
Ophthalmology1.1Cataract surgery – unplanned readmissions within 28 days0.00%  0.19%
Oral Health1.1Restorative treatment - teeth retreated within 6 months1.15%  2.52%
Paediatrics1.1Registered nurses with paediatric basic life support qualifications100.00%  100.00%
Paediatrics2.1Medication errors0.00%  0.00%
Paediatrics2.3Adverse events in a paediatric ward/area0.00%  0.00%
Pathology1.1Serum / plasma potassium for emergency department – in lab to validated time <40 minutes97.67%  44.21%
Pathology1.3Serum / plasma troponin for emergency department – in lab to validated time <50 minutes100.00%  80.91%
Pathology2.1Haemoglobin for emergency department – in lab to validated time <35 minutes97.06%  88.54%
Pathology3.1Anatomic Pathology complexity level 4 Medicare Benefits Schedule item – received to validated time <4 working days97.75%  74.71%
Pathology3.2Anatomic Pathology complexity level 6 & 7 Medicare Benefits Schedule item – received to validated time <7 working days within a calendar month97.78%  94.14%
Pathology6.1Misidentified episodes0.00%  0.30%
Radiology1.1Number of Severity Assessment Code (SAC) 1 or Incident Severity Rating (ISR) 1 incidents - interventional radiology examinations0.00%  0.00%
Radiology1.5Contrast extravasation during an IV contrast enhanced CT procedure requiring specialist review0.00%  0.07%
Radiology1.6Contrast extravasation during an IV contrast enhanced CT procedure requiring medical review0.02%  0.06%
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