Title
Microbiology: percentage of validated CSF results from ED with a microscopy (+/- gram stain) with a turnaround time (received to validated time) less than 40 minutes, during the 1 to 2 month time period.
Source(s)
| Australian Council on Healthcare Standards (ACHS). ACHS clinical indicator users' manual 2011. ULTIMO NSW: Australian Council on Healthcare Standards (ACHS); 2011 Jan. |
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Primary Measure Domain
Clinical Quality Measures: Process
Secondary Measure Domain
Does not apply to this measure
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Description
This measure is used to assess percentage of validated cerebrospinal fluid (CSF) results from emergency department (ED) with a microscopy (+/- gram stain) with a turnaround time (received to validated time) less than 40 minutes, during the 1 to 2 month time period.
Rationale
Cerebrospinal fluid (CSF) is usually considered to be a critical specimen. Timely information on the results of CSF samples is important for patient management, quality control and cost effectiveness.
Evidence for Rationale
| Australian Council on Healthcare Standards (ACHS). ACHS clinical indicator users' manual 2011. ULTIMO NSW: Australian Council on Healthcare Standards (ACHS); 2011 Jan. |
Primary Health Components
Cerebrospinal fluid (CSF); microscopy; gram stain; emergency department (ED); turnaround time
Denominator Description
Total number of all cerebrospinal fluid (CSF) samples received by the laboratory from emergency department (ED), during the 1 to 2 month time period (see the related "Denominator Inclusions/Exclusions" field)
Numerator Description
Total number of validated cerebrospinal fluid (CSF) results from emergency department (ED) with a microscopy (+/- gram stain) with a turnaround time (received to validated time) less than 40 minutes, during the 1 to 2 month time period (see the related "Numerator Inclusions/Exclusions" field)
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Evidence Supporting the Measure
Type of Evidence Supporting the Criterion of Quality for the Measure
- A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
Additional Information Supporting Need for the Measure
The Australian Council on Healthcare Standards (ACHS) Australasian Clinical Indicator Report 2001-2009 shows the trends in the rates for each clinical indicator (CI) (if four or more years of data are available) and three measures of the variation in rates between healthcare organisations (HCOs). The variations in clinical practice are quantified by the differences between the 20th and 80th centiles, the differences between the strata (states/territories in Australia and New Zealand, public/private sector HCOs, metropolitan and non-metropolitan HCOs), and the rates for the HCOs that are outliers.
This report also estimates the potential improvement if:
- The mean rate were shifted to the better centile rate,
- The mean rate were shifted to the best stratum rate, and
- The outlier HCOs with less desirable rates were to shift their rate to the mean rate.
Evidence for Additional Information Supporting Need for the Measure
| Australian Council on Healthcare Standards (ACHS). Australasian clinical indicator report 2001-2009. Determining the potential to improve quality of care: 11th edition. Executive summary. ULTIMO NSW: Australian Council on Healthcare Standards (ACHS); 2010 Nov. 64 p. |
| Australian Council on Healthcare Standards (ACHS). Australasian clinical indicator report 2001-2009. Determining the potential to improve quality of care: 11th edition. ULTIMO NSW: Australian Council on Healthcare Standards (ACHS); 2010 Nov. 680 p. |
Extent of Measure Testing
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State of Use of the Measure
State of Use
Current routine use
Current Use
Accreditation
Internal quality improvement
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Application of the Measure in its Current Use
Measurement Setting
Hospitals
Professionals Involved in Delivery of Health Services
Allied Health Personnel
Physicians
Least Aggregated Level of Services Delivery Addressed
Single Health Care Delivery or Public Health Organizations
Statement of Acceptable Minimum Sample Size
Unspecified
Target Population Gender
Either male or female
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National Strategy for Quality Improvement in Health Care
National Quality Strategy Aim
Better Care
National Quality Strategy Priority
Prevention and Treatment of Leading Causes of Mortality
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Institute of Medicine (IOM) National Health Care Quality Report Categories
IOM Care Need
Getting Better
IOM Domain
Effectiveness
Timeliness
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Data Collection for the Measure
Denominator Sampling Frame
Patients associated with provider
Denominator (Index) Event or Characteristic
Diagnostic Evaluation
Encounter
Denominator Inclusions/Exclusions
Inclusions
Total number of all cerebrospinal fluid (CSF) samples* received by the laboratory from emergency department (ED), during the 1 to 2 month time period
*A CSF sample refers to a separately collected cerebrospinal fluid specimen where microscopy and culture are requested. Sample may include a single tube or a set of 3 tubes, collected at a single episode.
Exclusions
Unspecified
Exclusions/Exceptions
Unspecified
Numerator Inclusions/Exclusions
Inclusions
Total number of validated* cerebrospinal fluid (CSF) results from emergency department (ED) with a microscopy (+/- gram stain) with a turnaround time (received to validated time) less than 40 minutes, during the 1 to 2 month time period
*A validated report refers to the time at which the laboratory first releases the results of analysis to the referrer or clinical staff of the health care organisation. Note that, for the purpose of determining turnaround time, this validation time might be whichever is appropriate (i.e., time at which the report is printed, faxed or telephoned, or the time at which the result is available via the Laboratory Information System).
Exclusions
Unspecified
Numerator Search Strategy
Fixed time period or point in time
Data Source
Administrative clinical data
Laboratory data
Paper medical record
Instruments Used and/or Associated with the Measure
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Computation of the Measure
Measure Specifies Disaggregation
Does not apply to this measure
Interpretation of Score
Desired value is a higher score
Allowance for Patient or Population Factors
Unspecified
Standard of Comparison
External comparison at a point in, or interval of, time
External comparison of time trends
Internal time comparison
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Original Title
Indicator area 4: microbiology CI 4.1.
Submitter
Australian Council on Healthcare Standards - Health Care Accreditation Organization
Developer
Australian Council on Healthcare Standards - Health Care Accreditation Organization
Funding Source(s)
Funding is direct Australian Council on Healthcare Standards (ACHS) funding sourced through our membership. ACHS does not receive external funding from the government or other sources.
Composition of the Group that Developed the Measure
Our terms of reference dictate the composition of the working parties that develop our indicators and include the following:
- Two Clinicians -- nominated by the relevant specialty college/association/society, one nominated to be the chair of the working party
- Private Hospital Representative -- nominated by the Australian Private Hospital Association
- Consumer Representative -- nominated by the Consumer Health Forum of Australia
- Coding Representative -- nominated by the National Centre for Clinical Classification on Health
- Quality Health New Zealand, nominated by QHNZ (if applicable)
- Epidemiological/Clinical Research Representative, Director of Health Services Research Group, University of Newcastle
- Australian Council on Healthcare Standards (ACHS) Representatives -- Clinical Director, Coordinator, Administrative Assistant
- Other Expert Stakeholders, as required
Financial Disclosures/Other Potential Conflicts of Interest
Adaptation
This measure was not adapted from another source.
Date of Most Current Version in NQMC
2011 Jan
Date of Next Anticipated Revision
Measure Status
Please note: This measure has been updated. The National Quality Measures Clearinghouse is working to update this summary.
Source(s)
| Australian Council on Healthcare Standards (ACHS). ACHS clinical indicator users' manual 2011. ULTIMO NSW: Australian Council on Healthcare Standards (ACHS); 2011 Jan. |
Measure Availability
The individual measure, "Indicator Area 4: Microbiology CI 4.1," is published in "ACHS Clinical Indicator Users' Manual 2011."
For more information contact, the Australian Council on Healthcare Standards (ACHS), 5 Macarthur Street, ULTIMO NSW 2007; Phone: (02) 9281 9955; Fax: (02) 9211 9633; E-mail: pos@achs.org.au; Web site: www.achs.org.au  .
Companion Documents
The following are available:
- Australian Council on Healthcare Standards (ACHS). Australasian clinical indicator report 2001-2009. Determining the potential to improve quality of care: 11th edition. ULTIMO NSW: Australian Council on Healthcare Standards (ACHS); 2010 Nov. 680 p. This document is available in Portable Document Format (PDF) from the Australian Council on Healthcare Standards (ACHS) Web site .
- Australian Council on Healthcare Standards (ACHS). Australasian clinical indicator report 2001-2009. Determining the potential to improve quality of care: 11th edition. Executive summary. ULTIMO NSW: Australian Council on Healthcare Standards (ACHS); 2010 Nov. 64 p. This document is available in PDF from the ACHS Web site .
NQMC Status
This NQMC summary was completed by ECRI Institute on July 29, 2008. This NQMC summary was updated by ECRI Institute on June 30, 2009 and again on December 13, 2010. This NQMC summary was retrofitted into the new template on June 23, 2011. This NQMC summary was updated again by ECRI Institute on January 6, 2012.
Copyright Statement
This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions. This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without written permission from The Australian Council on Healthcare Standards (ACHS).
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