Table 3 Clinical indicators

Fall with injury

A fall is an event that results in a person coming to rest inadvertently on the ground or floor or other lower level. If a client is found on the floor or ground, it should be assumed that they have fallen (unless they are cognitively unimpaired and indicate that they put themselves there on purpose). Signs of injury may include fracture, bruises, skin tears, sprains, lacerations, reddened areas or aggravation of pre-existing complaints such as back pain.

New urinary track infection

If the resident does not have an indwelling catheter, they must have at least three of the following signs or symptoms:

1. Fever (greater than 38°C) or chills;

2. New or increased burning pain on urination, frequency or urgency;

3. New flank or suprapubic pain or tenderness;

4. Change in the character of urine;

5. Worsening of mental or functional status;

6. New or increased incontinence.

If the resident has an indwelling catheter, they must have at least two of the following signs or symptoms:

1. Fever (greater than 38°C) or chills;

2. New flank or suprapubic pain or tenderness;

3. Change in the character of urine;

4. Worsening of mental or functional status.

New pressure areas

A pressure ulcer is defined as ‘any lesion caused by unrelieved pressure, resulting in damage of the skin and underlying tissue.’ Alternative terms include ‘bed sore’ and ‘decubitus ulcer.’ The record is kept for occurrences of new pressure areas regardless of their staging or severity.

Unintentional weight loss

Weight loss is captured for unintentional weight loss of over 2 kg in any given month. A baseline weight measurement on a specified day within the month needs to be taken before commencing data collection, and then the person is reweighed every month from that date to assess unintentional weight loss. Where a client is on a weight loss diet, due to health reasons, they are not included in this data capture, as we are interested in only unplanned/unintentional weight loss.

Hospital admissions

The number of unplanned client transfers (not the number of clients) to hospital where the client has been admitted to hospital. This refers to an unexpected admission for an unexpected event. For example, fracture of neck of femur, post fall, chest infection. This excludes admission to hospital for management of a chronic disease or condition or elective surgery.