Security of care may be defined as “the degree to which the system does not harm the patient”. The four types of indicators used for assessing security of care in this report are related to:
- Hospital-aquired infections (QS-1, QS-2, QS-7, QS-8)
- Post-surgical complications (QS-3, QS-4)
- Complications related to nursing care (QS-5)
- Multiple medication in elderly people (QS-6)
(1) Excluding Denmark and Sweden, (2) OECD Health at a Glance 2017, (3) Belgium has an intermediate position across EU-15 countries for a similar indicator (see appendix of the report for details), *This indicator will be updated on the website when recent results become available, (a) Patient safety indicators on hospital discharge data.
Some of the indicators analysed in other sections of this report may also be interpreted in terms of security of care:
- Among appropriateness of care indicators, indicators on antibiotic consumption (QA-3 to QA-5) and inappropriate use of medical imaging (QA-6). These two forms of inappropriate use of care can have an impact in terms of patient security.
- Among care for the elderly indicators, particularly care in residential facilities, the incidence of bed sores (ELD-8) and MRSA carrier prevalence (ELD-9), inappropriate prescriptions of neuroleptics and anticholinergic medicines (ELD-10 to ELD-12).
Infections acquired during a stay in hospital (nosocomial infections) are a subject of growing concern in today’s context of increasing antibiotic resistance. These infections are a serious threat to patient security, as they can lead to severe complications, or even death. They also represent a significant financial burden for the community due to the extended duration of hospital stays and the treatment costs involved.
Infections due to methicillin-resistant Staphylococcus aureus (MRSA), bacteria which are present on the skin, have been subject to mandatory controls by hospitals since 2007. Infections due to multi-resistant gram-negative intestinal bacteria (Escherichia coli) have been subject to such controls since 2015. These bacteria are primary indicators of antibiotic resistance for human bacteria. The results of these surveillance controls are centralised by a specific unit within Sciensano. MRSA surveillance can provide information about the effectiveness of infection prevention and control measures (including hand hygiene), while E. coli surveillance is also a source of information about antibiotic consumption.
In this report, we have selected four indicators which can help define the problem of hospital-acquired infections:
- Proportion of hospitalised patients acquiring a nosocomial infection (QS-1)
- Incidence of hospital-acquired infections due to methicillin-resistant Staphylococcus aureus (MRSA) (QS-2)
- Proportion of hospital-acquired infections due to methicillin-resistant Staphylococcus aureus (MRSA) (QS-7)
- Proportion of hospital-acquired infections due to 3rd and 4th-generation cephalosporin-resistant E.coli. 3rd-generation cephalosporins are large-spectrum antibiotics which are often used because they are effective and have few side effects. 4th-generation cephalosporins are effective against certain entero-bacteria which are resistant against 3rd-generation cephalosporins (QS-8).
Proportion of hospitalised patients acquiring a nosocomial infection (QS-1)
- In 2017, the number of patients with at least one nosocomial infection on a given day was estimated at 7.3% of hospitalised people. This figure has been stable compared to 2011 results (7.1%), but remains above the EU-15 average (6.4%). (Figure 1)
- The three most commonly reported combined nosocomial infections are pneumonia (22%), urinary tract infections (21%), and surgical site infections (17%).
- The three most commonly reported bacteria are Escherichia coli (18%), Staphylococcus aureus (9%) and Pseudomonas aeruginosa (5%).
Source: Suetens et al., 2018
Incidence of hospital-acquired infections due to MRSA (QS-2)
- Since 2005, the incidence of hospital-acquired MRSA infections has been slowly decreasing (Figure ).
- This improvement can probably be attributed in part to the recommendations issued in 2003, national hand hygiene campaigns, and the rationalisation of antibiotic use. It is, however, essential to maintain a high level of vigilance toward MRSA infections, despite additional efforts which are necessary to prevent the emergence of new multi-resistant micro-organisms.
Source: Latour et al., 2018
Proportion of hospital-acquired infections due to MRSA (QS-7)
- In 2016, the proportion of methicillin-resistant staphylococci (MRSA) was 15.0% in Belgian hospitals, with significantly higher figures in Wallonia (21.2%) compared to Flanders (10.9%) and Brussels (10.3%). These figures have been consistently decreasing since 2004.
- On an international scale (EARS-Net [European Antimicrobial Resistance Surveillance Network] data), Belgium has an intermediary position among the EU-15 countries.
Source: Latour et al., 2018
Proportion of hospital-acquired infections due to 3rd and 4th-generation cephalosporin-resistant E.coli (QS-8)
- In 2016, the proportion of E. Coli resistant to 3rd and 4th- generation cephalosporins was 9.1% in Belgian hospitals (median). No statistically significant difference could be observed between regions. These figures have been increasing: from an average 8.1% in 2014 to 9.8% in 2016.
Source: EARS-net annual report 2017
Any surgical procedure involves risks which are impossible to avoid at 100%. However, in all hospitals, preventive measures (prophylaxis) are implemented in order to reduce as much as possible the occurrence of such risks. The two indicators in this section assess the effectiveness of these security measures for all hospitals combined.
The first indicator relates to pulmonary embolism or deep-vein thrombosis after a hip or knee prosthesis placement. Measures taken against these complications include administering anticoagulants in the weeks following surgery, early mobilisation of the operated patients, wearing compression stockings, etc.
The second indicator relates to post-operative sepsis conditions, which can be extremely serious. These cases can be prevented by administering prophylactic antibiotics, ensuring the sterility of surgical techniques, and providing high-quality post-operative care.
All of these complications are (ideally) subject to notifications in the hospital files (‘RHMs’ - Minimum Hospital Summaries), which means that the data can then be fed into the security indicators of the OECD (OECD Health Quality of Care Indicators (HCQI)), allowing for international comparisons.
- The incidence of pulmonary embolism and deep-vein thrombosis after a hip or knee surgery has slightly decreased between 2009 and 2014 (Figures 5 and 6).
- As for the incidence of post-operative sepsis conditions, it has strongly decreased during the same period (Figure 7).
- By comparison with other European countries, Belgium has obtained good results, but this may be due to major differences in coding practices de among different countries – in particular to better reporting of complications in some countries than others.
Data source: RHM - MZG
Data source: RHM - MZG
Data source: OECD health statistics 2018
Data source: OECD health statistics 2018
Bed sores (skin ulcers occurring at pressure points in people who stay in bed for long periods of time) are one example of complications for which there are preventive measures within the scope of nursing care. They are classified in 4 categories (I to IV) of increasing severity.
Measuring the prevalence of bed sores in different hospital departments can help in targeting preventive action and evaluating the effectiveness of previously implemented preventive procedures. A national survey organised in 2012 by the Belgian Federal Council on Nursing Activity Quality (CFQAI) collected various indicators in 70 general hospitals. This report is the most recent source of data for this indicator; it will be updated as soon as new results become available.
- In 2012, 7.8% of patients hospitalised in general hospitals had Cat I-to-IV bed sores (5.1% for Categories II to IV alone).
- These figures have slightly decreased since the previous national survey (2008), whose methodology was somewhat different. It is therefore difficult to compare these results.
- Comparing the Belgian data with other European countries is also difficult due to differences in the definitions, data collection methods, and patient populations. Considering these limitations, Belgium shows the lowest bed sore prevalence among the surveys organised in France, Germany, Italy, Sweden and the Netherlands.
Many elderly people take a great number of different medicines, particularly when they suffer from chronic diseases. However, the more medicines one takes, the higher the risk of adverse effects, drug interactions, non-compliance, deterioration of functional status, and increased frailty in people of very old age. A sound balance must therefore be determined between taking a reasonable amount of medicines and polymedication.
There is no clear limit above which a number of medicines would be considered as excessive, but an increasing number of studies have been addressing this question. A list of criteria named STOPP/START helps general practitioners and geriatricians detect potentially inappropriate or unnecessary prescriptions.
In this section, polymedication is defined as the administration of at least 5 different medicines/day.
- 39% of people aged over 65 years have used at least 5 different medicines (for over 80 DDD = chronic use) during the past year (2016 figures). Polymedication is more common in Wallonia (44%) than in Brussels (35%) and in Flanders (37%) (Figure 9).
- Polymedication is most common in 'very old people’ (aged 85 and over), which requires special attention as these individuals are at a higher risk for adverse effects, particularly due to decreased kidney and liver function.
- Over 90% of people aged over 65 years affected by polymedication take medicines for the cardiovascular system.
- Belgium ranks fourth in terms of polymedication among the 18 countries which participated in the SHARE 2015 Survey (Survey of Health, Ageing and Retirement in Europe) (Figure 10).
Data source: Pharmanet (RIZIV - INAMI)
Data source: SHARE 2015