3 Inpatient management - Health Systems Trust Health Barometers/Distri… · 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 Pe r centage Inpatient bed utilisation rate (district

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Section A: Inpatient management

3 Inpatient management Naomi Massyn, Edwina Mabuela

The district hospital plays a pivotal role in the functioning of the district health system as it supports primary health care (PHC) and serves as an entry to more specialist care. District hospitals treat and admit patients with acute, relatively uncomplicated illnesses. Complicated cases are referred to a regional or tertiary hospital.

The purpose of this chapter is to provide feedback on district hospital performance from which district and hospital management teams can learn and identify where support or interventions are needed to improve performance.

The sheer volume of people in South Africa that make use of public health services coupled with the shortage of human, physical and financial resources places an immense strain on the public health system.

While stays in district hospitals are typically shorter than at regional or tertiary hospitals, it is difficult to predict how long patients will remain in hospital or the treatment they will require, as new information on their health, complications and demise all impact on their management and length of stay.

In order to match a patient to a bed, a set of bed allocation rules are normally followed. These rules go beyond simply taking into account the impact on bed utilisation but also the comfort and protection of the patient. General rules include the following:

✦ Male and female adult patients are usually separated and allocated to wards according to their needs

✦ Children and babies are separated from adult patients and are assigned to the correct wards to receive specialised care

✦ Preference is given to emergency patients but beds can also be reserved for elective patients

✦ Rooms can be used for isolation purposes to protect other patients from infections or diseases.

This chapter covers the following indicators:

✦ Inpatient bed utilisation rate (IBUR) (district hospitals)

✦ Average length of stay (ALOS) (district hospitals)

✦ Outpatient department (OPD) new client not referred rate (district hospitals)

✦ Inpatient crude death rate (all hospitals)

✦ Expenditure per patient day equivalent (PDE) (district hospitals).

3.1 Inpatient bed utilisation rate (district hospitals)The inpatient bed utilisation rate measures the inpatient bed days used as a proportion of maximum inpatient bed days (inpatient beds times days in period) available. It is calculated by dividing the number of inpatient days plus half-day patients (numerator) by inpatient bed days available (inpatient beds multiplied by 30.42) (denominator) and is expressed as a percentage.

High bed occupancy rates have been considered a matter of reduced patient comfort and privacy and an indicator of high productivity for hospitals. Hospitals with bed occupancy rates of above 85 per cent are generally considered to have bed shortages.a A study conducted in Danish hospitals’ departments of medicine for the period 1995–2012b found that high bed occupancy rates were associated with a significant nine per cent increase in rates of in-hospital mortality and thirty-day mortality, compared to low bed occupancy rates. Being admitted into a hospital outside of normal working hours or on a weekend or holiday was also significantly associated with increased mortality.

A shortage of beds causes the allocation of patients to beds to become problematic. Cases have been reported where patients share beds, are allocated to mattresses in hallways, or simply cannot be admitted.a

a Bloem C. Improving hospital bed utilisation through simulation and optimisation in South African Public Hospitals. 2014. University of Pretoria. Available from: https://repository.up.ac.za/bitstream/handle/2263/45144/FinalReport_Connie%20Bloem.pdf?sequence=1. [Accessed 29 October 2018].

b Madsen F, Ladelund S, Linneberg A. High levels of bed occupancy associated with increased inpatient and thirty-day hospital mortality in Denmark. July 2014. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25006151. [Accessed 29 October 2018].

67.3

66.365.8

65.3

63.9 64.1

62.0

63.0

64.0

65.0

66.0

67.0

68.0

2012/13 2013/14 2014/15 2015/16 2016/17 2017/18

Perc

enta

ge

Inpatient bed utilisation rate (district hospitals) by province, 2017/18

Percentage [Source: DHIS]

NC

EC

KZNFS

NW

GP

MP

LP

WC

20 40 60 80 100

57.0

88.3

69.5

54.7

60.2

72.7

63.0

66.9

54.6

SA: 64.1

ProvincesECFSGPKZNLPMPNCNWWC

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National overview

The national IBUR for district hospitals in 2017/18 was 64.1%, a slight increase from 63.9% in 2016/17 (Figure 1). However, the IBUR has been consistently below 70% for the past six years.

Figure 1: National inpatient bed utilisation rate (district hospitals), 2012/13–2017/18

Source: DHIS.

Provincial overview

Figure 2 shows that there is a great inter-provincial variation between the highest IBUR in Western Cape (WC) (88.3%) and the lowest IBUR in the Northern Cape (NC) (54.6%).

Figure 2: Inpatient bed utilisation rate by province, 2017/18

CPT

NMA

BUF

ETH

EKUJHB

DC10

DC12

DC13

DC14

DC15

DC44

DC16

DC18DC19

DC20

MAN

DC42DC48

TSH

DC21

DC22

DC23

DC24

DC25 DC26 DC27

DC28

DC29

DC43

DC33

DC34

DC35

DC36

DC47

DC30

DC31

DC32

DC45

DC6DC7

DC8DC9

DC37

DC38

DC39DC40

DC1

DC2

DC3

DC4

DC5

LegendProvinceDistrict

BUR_DH36.5 - 50.050.1 - 58.258.3 - 65.565.6 - 73.773.8 - 96.0

EKUJHB

DC42

DC48

TSH

Gauteng

37


District overview

Map 1 and Figure 3 show the IBUR for district hospitals in 2017/18 by district. The three districts with the highest IBUR were from Western Cape, all with an IBUR of over 80%, namely Cape Town (96.0%), Eden (83.9%) and West Coast (81.9%). The three districts with the lowest IBUR were from Northern Cape, KwaZulu-Natal (KZN) and Eastern Cape (EC), namely, Frances Baard (NC) (36.5%), King Cetshwayo (KZN) (42.3%) and Chris Hani (EC) (45.5%). Only 25 districts (48.1%) had an IBUR that exceeded the national average of 64.1%.

Map 1: Inpatient bed utilisation rate (district hospitals) by district, 2017/18

Source: DHIS.

Inpatient bed utilisation rate (district hospitals) by district, 2017/18


Frances Baard: DC9King Cetshwayo: DC28

C Hani: DC13ZF Mgcawu: DC8

iLembe: DC29uMzinyathi: DC24

T Mofutsanyana: DC19Ngaka Modiri Molema: DC38

Joe Gqabi: DC14Amathole: DC12O Tambo: DC15

Lejweleputswa: DC18eThekwini: ETH

J T Gaetsewe: DC45Pixley ka Seme: DC7

Buffalo City: BUFuMkhanyakude: DC27N Mandela Bay: NMA

Xhariep: DC16Harry Gwala: DC43

Sarah Baartman: DC10A Nzo: DC44

Zululand: DC26Johannesburg: JHBDr K Kaunda: DC40

uThukela: DC23Amajuba: DC25

West Rand: DC48Waterberg: DC36

Tshwane: TSHFezile Dabi: DC20

Ugu: DC21Sekhukhune: DC47

Overberg: DC3G Sibande: DC30

Ruth Segomotsi Mompati: DC39Ehlanzeni: DC32Mangaung: MANNkangala: DC31

Central Karoo: DC5Capricorn: DC35

Bojanala Platinum: DC37uMgungundlovu: DC22

Sedibeng: DC42Vhembe: DC34Namakwa: DC6

City of Ekurhuleni: EKUMopani: DC33

Cape Winelands: DC2West Coast: DC1

Eden: DC4Cape Town: CPT

20 40 60 80 100

50.049.2

42.3

67.0

75.5

61.5

56.6

64.0

57.7

63.3

58.2

79.181.9

70.5

96.083.9

69.069.2

69.4

70.3

54.3

57.7

55.854.9

45.5

60.260.6

57.4

65.5

70.1

57.9

56.0

51.9

71.8

77.9

68.9

76.7

64.9

73.7

69.2

62.3

52.1

77.8

61.5

65.0

64.5

75.9

36.5

56.9

77.1

57.3

46.4

SA: 64.1


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Figure 3: Inpatient bed utilisation rate (district hospitals) by district, 2017/18

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Table 1 presents the IBUR trends for district hospitals over time for the period 2013/14 – 2017/18. The IBUR of most of the districts remained relatively stable. Only two districts had an increase of more than 10 percentage points between 2013/14 – 2017/18, namely Amajuba (KZN) (19.7 percentage points) and Capricorn (Limpopo (LP)) (23.3 percentage points). Nine districts had a decrease of more than 10 percentage points between 2013/14 – 2017/18, with the highest decrease in Zwelentlanga Fatman Mgcawu (NC) (31.2 percentage points), Fezile Dabi (Free State (FS)) (29.6 percentage points) and eThekwini (KZN) (26.6 percentage points). Namakwa (NC) also showed a decrease of 60.3 percentage points, but the reason is due to data quality issues with denominators for Calvinia Hospital for most of 2013/14 missing.c Eastern Cape, Free State, Gauteng (GP) and Northern Cape had a decrease of more than 10 percentage points in the IBUR between 2013/14 – 2017/18.

Table 1: Annual trends: inpatient bed utilisation rate (district hospitals), 2013/14 – 2017/18

Province Local municipality 2013/14 2014/15 2015/16 2016/17 2017/18Eastern Cape Alfred Nzo 60.7 65.8 60.2 58.4 60.6

Amathole 59.1 59.0 55.1 55.0 54.9Buffalo City 64.9 56.6 53.4 58.4 57.4Chris Hani 53.6 50.2 49.7 48.4 45.5Joe Gqabi 70.7 70.4 64.3 58.7 54.3Nelson Mandela Bay 58.5 60.5 62.1 56.5 57.7OR Tambo 58.8 55.5 56.4 57.6 55.8Sarah Baartman 59.4 63.9 66.6 63.0 60.2

Eastern Cape 70.7 70.4 66.6 63.0 60.6Free State Fezile Dabi 95.1 68.7 68.9 68.3 65.5

Lejweleputswa 50.1 49.6 54.2 60.9 56.0Mangaung 74.3 67.2 69.5 64.2 70.1Thabo Mofutsanyana 51.9 50.6 50.1 52.2 51.9Xhariep 71.2 80.8 63.8 72.8 57.9

Free State 95.1 80.8 69.5 72.8 70.1Gauteng City of Ekurhuleni 89.2 69.0 69.2 73.7 77.8

Johannesburg 52.9 45.1 66.3 65.5 61.5Sedibeng 67.1 69.5 73.9 76.1 75.9Tshwane 67.5 62.4 63.7 62.7 65.0West Rand 70.3 66.7 60.5 56.8 64.5

Gauteng 89.2 69.5 73.9 76.1 77.8KwaZulu-Natal Amajuba 44.3 62.6 60.8 71.5 64.0

eThekwini 83.2 74.5 68.5 58.7 56.6Harry Gwala 66.8 64.9 63.6 52.8 58.2iLembe 56.7 56.5 56.9 49.2 49.2King Cetshwayo 47.2 50.0 46.9 44.4 42.3Ugu 72.0 69.4 66.3 59.5 67.0uMgungundlovu 74.6 79.6 80.5 78.9 75.5uMkhanyakude 60.7 60.2 56.0 58.4 57.7uMzinyathi 63.6 53.6 54.4 51.9 50.0uThukela 63.4 63.7 61.7 60.4 63.3Zululand 67.5 67.0 62.7 57.6 61.5

KwaZulu-Natal 83.2 79.6 80.5 78.9 75.5Limpopo Capricorn 48.5 69.5 73.0 74.9 71.8

Mopani 74.2 78.8 71.4 72.1 77.9Sekhukhune 64.9 63.3 61.4 68.1 68.9Vhembe 73.7 69.0 75.4 69.4 76.7Waterberg 61.8 63.1 62.1 62.6 64.9

Limpopo 74.2 78.8 75.4 74.9 77.9Mpumalanga Ehlanzeni 73.5 73.8 72.6 80.9 69.4

G Sibande 65.8 66.7 68.1 69.3 69.2Nkangala 72.6 72.8 73.5 73.3 70.3

Mpumalanga 73.5 73.8 73.5 80.9 70.3Northern Cape Frances Baard 51.9 36.3 38.4 38.3 36.5

John Taolo Gaetsewe 54.3 58.7 57.2 60.9 56.9Namakwa 137.4 97.6 89.5 80.5 77.1Pixley Ka Seme 57.6 64.8 65.6 61.8 57.3Zwelentlanga Fatman Mgcawu 77.6 74.1 72.4 51.4 46.4

Northern Cape 137.4 97.6 89.5 80.5 77.1

c Massyn N, Day C, Peer N, Padarath A, Barron P, English R, editors. District Health Barometer 2013/14. Durban: Health Systems Trust; October 2014.

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Province Local municipality 2013/14 2014/15 2015/16 2016/17 2017/18North West Bojanala Platinum 78.4 76.4 74.8 75.8 73.7

Dr K Kaunda 70.6 67.4 77.0 78.2 62.3Ngaka Modiri Molema 49.2 55.5 49.3 56.4 52.1Dr Ruth Segomotsi Mompati 60.3 63.3 62.7 65.4 69.2

North West 78.4 76.4 77.0 78.2 73.7Western Cape Cape Town 97.6 99.4 93.9 91.8 96.0

Cape Winelands 76.1 74.2 77.9 74.7 79.1Central Karoo 72.6 70.6 73.6 69.7 70.5Eden 83.4 83.1 86.0 83.0 83.9Overberg 75.3 73.3 75.7 68.9 69.0West Coast 83.2 81.4 79.4 77.4 81.9

Western Cape 97.6 99.4 93.9 91.8 96.0South Africa 137.4 99.4 93.9 91.8 96.0

Source: DHIS.

Orange indicates a decrease in the IBUR of more than 10 percentage points. Green indicates an increase in the IBUR of more than 10 percentage.

Twenty-four district hospitals had an IBUR below 40% in 2017/18. Most of the district hospitals were in the Eastern Cape (13), Free State (five), Northern Cape (four) and KwaZulu-Natal (two).

3.2 Average length of stay (district hospitals)Average length of stay is defined as the average number of days an admitted patient spends in hospital before separation. It is calculated by dividing the number of inpatient days plus half-day patients by the number of inpatient separations and this is expressed as a number of days. Inpatient separations are the sum of inpatient deaths, inpatient discharges and inpatient transfers out.

When a patient is admitted to hospital, not all the necessary medical treatments are always known at the start of the patient’s stay.a New findings during the patient’s treatment might change the priority group of the patient, giving rise to more treatments or complications. This causes variability in the ALOS of the patient.

A relatively high bed utilisation rate and low average length of stay are indicative of a well-functioning district hospital. The ALOS is a proxy measure of the efficiency of the hospital.c

If the ALOS is persistently high it suggests that patients spend too much time in hospital either because they are not discharged when they should be or not appropriately treated resulting in longer recovery times. Reasons for this might be a shortage of doctors, patients discharged do not have transport to go home, and are therefore not administratively discharged and admitted as boarders, and district hospitals with dedicated tuberculosis and psychiatric wards. Admission, treatment and discharge procedures should therefore be adhered to all the time. The persistently low ALOS (less than 1.5 days), could mean that patients are discharged earlier than they should be, due to high IBUR where demand for beds might lead to patients getting discharged too soon. It can also be because referral rates to levels of care are high.

National overview

The national ALOS decreased annually from 4.7 days in 2013/14 to 4.3 days in 2017/18 (Figure 4).

4.2

4.7

4.6

4.5

4.4

4.3

3.9

4.0

4.1

4.2

4.3

4.4

4.5

4.6

4.7

4.8

2012/13 2013/14 2014/15 2015/16 2016/17 2017/18

Day

s

Average length of stay (district hospitals) by province, 2017/18

Days [Source: DHIS]

KZN

EC

GP

LP

MP

NW

WC

FS

NC

1 2 3 4 5 6

3.2

4.4

5.4

4.3

4.1

4.9

4.2

3.3

3.3

SA: 4.3


41


Figure 4: National average length of stay (district hospitals), 2012/13–2017/18

Source: DHIS.

Provincial overview

Figure 5 shows that KwaZulu-Natal had the longest ALOS at 5.4 days followed by Eastern Cape at 4.9 days. The ALOS in the Northern Cape, Free State and Western Cape was on average three days shorter than in KwaZulu-Natal and two days shorter than in the Eastern Cape.

Figure 5: Average length of stay (district hospitals) by province, 2017/18

District overview

Map 2 and Figure 6 show the district ALOS for district hospitals by district in 2017/18. uMzinyathi (KZN) had the longest ALOS at 6.3 days and Namakwa (NC) had the shortest ALOS at 2.6 days. Of the 25 districts with an ALOS longer than the national average of 4.3 days were all 11 districts in KwaZulu-Natal and six of the eight districts in Eastern Cape.

CPT

NMA

BUF

ETH

EKUJHB

DC10

DC12

DC13

DC14

DC15

DC44

DC16

DC18DC19

DC20

MAN

DC42DC48

TSH

DC21

DC22

DC23

DC24

DC25 DC26 DC27

DC28

DC29

DC43

DC33

DC34

DC35

DC36

DC47

DC30

DC31

DC32

DC45

DC6DC7

DC8DC9

DC37

DC38

DC39DC40

DC1

DC2

DC3

DC4

DC5


ALOS_DH 2.6 - 3.23.3 - 4.14.2 - 4.84.9 - 5.65.7 - 6.3

EKUJHB

DC42

DC48

TSH

Gauteng

42


Map 2: Average length of stay by district, 2017/18

Source: DHIS.

Average length of stay (district hospitals) by district, 2017/18

Days [Source: DHIS]

uMzinyathi: DC24O Tambo: DC15

King Cetshwayo: DC28Buffalo City: BUF

Ugu: DC21uMkhanyakude: DC27

Zululand: DC26iLembe: DC29

uThukela: DC23uMgungundlovu: DC22

Joe Gqabi: DC14Amathole: DC12

A Nzo: DC44Harry Gwala: DC43Johannesburg: JHB

Nkangala: DC31C Hani: DC13Mopani: DC33

eThekwini: ETHBojanala Platinum: DC37

City of Ekurhuleni: EKUNgaka Modiri Molema: DC38

Vhembe: DC34Amajuba: DC25Tshwane: TSH

G Sibande: DC30West Rand: DC48

Sekhukhune: DC47Capricorn: DC35Waterberg: DC36Ehlanzeni: DC32

Sarah Baartman: DC10Sedibeng: DC42

Xhariep: DC16J T Gaetsewe: DC45

Cape Town: CPTMangaung: MAN

N Mandela Bay: NMARuth Segomotsi Mompati: DC39

Fezile Dabi: DC20Dr K Kaunda: DC40

ZF Mgcawu: DC8T Mofutsanyana: DC19

Frances Baard: DC9Pixley ka Seme: DC7

Central Karoo: DC5West Coast: DC1

Eden: DC4Cape Winelands: DC2

Overberg: DC3Lejweleputswa: DC18

Namakwa: DC6

1 2 3 4 5 6

3.8

2.6

3.0

3.2

3.0

4.5

4.8

4.4

4.0

4.3

5.45.4

5.9

5.6

5.3

5.5

6.3

5.4

4.4

5.0

4.6

4.2

4.6

4.2

4.4

4.1

3.2

4.4

4.5

3.73.7

6.1

4.0

5.0

5.6

5.2

4.0

4.7

5.0

4.6

4.3

3.5

2.6

3.0

3.7

3.8

2.8

2.9

3.7

2.8

2.7

2.8

SA: 4.3


43


Figure 6: Average length of stay (district hospitals) by district, 2017/18

Annual trends: Average length of stay (district hospitals)

Day

s

2

4

6

8EC FS

● ● ●●

●

● ● ●● ●

GP

2

4

6

8KZN

●● ●

●● ● ● ● ● ●

LP MP

2

4

6

8

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

2013

/14

2014

/15

2015

/16

2016

/17

2017

/18

NC

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

2013

/14

2014

/15

2015

/16

2016

/17

2017

/18

NW

2008

/09

2009

/10

2010

/11

2011

/12

2012

/13

2013

/14

2014

/15

2015

/16

2016

/17

2017

/18

●

●● ● ●

● ●● ● ●

WC

EC A NzoEC AmatholeEC Buffalo CityEC C HaniEC Joe GqabiEC N Mandela BayEC O TamboEC Sarah BaartmanFS Fezile DabiFS LejweleputswaFS MangaungFS T MofutsanyanaFS Xhariep

GP City of Ekurhuleni GP Johannesburg GP SedibengGP TshwaneGP West RandKZN AmajubaKZN eThekwiniKZN Harry GwalaKZN iLembeKZN King Cetshwayo KZN UguKZN uMgungundlovu KZN uMkhanyakude

KZN uMzinyathi KZN uThukelaKZ ZululandLP CapricornLP MopaniLP Sekhukhune LP VhembeLP Waterberg MP Ehlanzeni MP G Sibande MP Nkangala NC Frances Baard NC J T Gaetsewe

NC NamakwaNC Pixley ka SemeNC ZF MgcawuNW Bojanala PlatinumNW Dr K KaundaNW Ngaka Modiri MolemaNW Ruth Segomotsi MompatiWC Cape TownWC Cape WinelandsWC Central KarooWC EdenWC OverbergWC West Coast

●

●

●

44


Figure 7 shows annual trends in ALOS for district hospitals between 2008/09 – 2017/18. Districts in Eastern Cape show variations in ALOS ranging from around three days to above six days. OR Tambo (EC) had the longest ALOS since 2013/14. There are also variations in ALOS for districts in KwaZulu-Natal ranging between four to six days. Cape Town is the only district in Western Cape which had an ALOS around 4 days even with a decrease in the ALOS from 2015/16.

Figure 7: Annual trends: Average length of stay (district hospitals), 2008/09 – 2017/18 (days)

Source: DHIS.

PrimaryHealth Care

Community Health Centres

District Hospitals

RegionalHospitals

Tertiary Hospitals

Emergency Care

Emergency Care

Emergency Care

Level of Specialised Care

45


Twenty-five district hospitals had an ALOS of six days or more. Of the 25 hospitals, 14 are in the Eastern Cape and nine in KwaZulu-Natal. Only two hospitals with a long ALOS also had a low IBUR, namely Mjanyana Hospital in Chris Hani (EC) and St Lucy’s Hospital in OR Tambo (EC).

3.3 OPD new client not referred rate (district hospitals)The OPD new client not referred rate is defined as new OPD clients not referred as a proportion of the total OPD new clients seen at a hospital. It monitors utilisation trends of clients by-passing PHC facilities and the effect of PHC re-engineering on OPD utilisation. It does not include OPD follow-up and emergency clients in the denominator. It therefore monitors clients that access hospitals directly for PHC services including the treatment of minor ailments.

The South African public health sector has a hierarchical referral structure between the hospitals and clinicsa as shown in Figure 8.

Figure 8: Hierarchical referral structure of public hospitalsa

All patients must first receive primary care at a clinic or health centre where initial diagnosis and treatments are conducted.a If required, patients are then referred to a district hospital to be admitted. If patients require specialised care, they are transferred to a regional or tertiary hospital. The district, regional and tertiary hospitals all have an emergency department through which patients can also be admitted.

National overview

The national OPD new client not referred rate declined from 64.1% in 2012/13 to 58.4% in 2015/16, but then increased to 59.3% in 2016/17 and to 60.4% in 2017/18 (Figure 9).

64.1

61.560.7

58.4

59.3

60.4

55.0

56.0

57.0

58.0

59.0

60.0

61.0

62.0

63.0

64.0

65.0

2012/13 2013/14 2014/15 2015/16 2016/17 2017/18

Perc

enta

ge

OPD new client not referred rate (district hospitals) by province, 2017/18


LP

NC

FS

MP

GP

EC

NW

KZN

WC

20 40 60 80

13.6

55.9

71.3

72.4

67.5

66.7

50.4

63.1

71.7

SA: 60.4


46


Figure 9: National OPD new client not referred rate (district hospitals), 2012/13–2017/18

Source: DHIS.

Provincial overview

Figure 10 shows that Western Cape was the province with the lowest OPD new client not referred rate at 13.6% in 2017/18. The OPD new client not referred rate for the other provinces ranged between 50.4% in KwaZulu-Natal to 72.4% in Limpopo. The Northern Cape and Free State also had OPD new client not referred rates above 70% in 2017/18 at 71.7% and 71.3% respectively.

Figure 10: OPD new client not referred rate (district hospitals) by province, 2017/18

CPT

NMA

BUF

ETH

EKUJHB

DC10

DC12

DC13

DC14

DC15

DC44

DC16

DC18DC19

DC20

MAN

DC42DC48

TSH

DC21

DC22

DC23

DC24

DC25 DC26 DC27

DC28

DC29

DC43

DC33

DC34

DC35

DC36

DC47

DC30

DC31

DC32

DC45

DC6DC7

DC8DC9

DC37

DC38

DC39DC40

DC1

DC2

DC3

DC4

DC5


OPDNNRR_DH1.5 - 14.614.7 - 43.543.6 - 60.660.7 - 72.973.0 - 83.6

EKUJHB

DC42

DC48

TSH

Gauteng

47


District overview

Map 3 and Figure 11 show the OPD new client not referred rate by district for 2017/18. The five districts with lowest OPD new client not referred rate were Central Karoo (WC) (1.5%), Overberg (WC) (4.6%), Nelson Mandela Bay (EC) (9.3%), Eden (WC) (9.5%) and West Coast (WC) (11.4%). All six districts in the Western Cape were among the districts with the lowest OPD new client not referred rate.

The five districts with the highest OPD new client not referred rate were Waterberg (LP) (83.6%), Frances Baard (NC) (81.7%), Sekhukhune (LP) (81.1%), Thabo Mofutsanyana (FS) (80.5%) and Tshwane (GP) (75.6%).

Map 3: OPD new client not referred rate by district, 2017/18

Source: DHIS.

OPD new client not referred rate (district hospitals) by district, 2017/18


Waterberg: DC36Frances Baard: DC9Sekhukhune: DC47

T Mofutsanyana: DC19Tshwane: TSH

Pixley ka Seme: DC7Joe Gqabi: DC14

J T Gaetsewe: DC45West Rand: DC48

C Hani: DC13King Cetshwayo: DC28

Sedibeng: DC42Capricorn: DC35

Xhariep: DC16uMzinyathi: DC24

Mopani: DC33Nkangala: DC31Ehlanzeni: DC32

Johannesburg: JHBBuffalo City: BUF

Fezile Dabi: DC20ZF Mgcawu: DC8

Vhembe: DC34Mangaung: MAN

G Sibande: DC30Sarah Baartman: DC10

Ngaka Modiri Molema: DC38iLembe: DC29

Amathole: DC12Namakwa: DC6

Lejweleputswa: DC18A Nzo: DC44

Ruth Segomotsi Mompati: DC39O Tambo: DC15

Harry Gwala: DC43Amajuba: DC25Zululand: DC26

City of Ekurhuleni: EKUuMkhanyakude: DC27

Ugu: DC21Bojanala Platinum: DC37

uThukela: DC23eThekwini: ETH

Dr K Kaunda: DC40uMgungundlovu: DC22Cape Winelands: DC2

Cape Town: CPTWest Coast: DC1

Eden: DC4N Mandela Bay: NMA

Overberg: DC3Central Karoo: DC5

20 40 60 80

1.5

9.5

4.6

11.4

23.914.6

40.9

30.9

55.9

62.0

70.4

67.3

59.3

64.8

80.5

69.3

64.8

83.6

71.0

81.1

68.9

63.9

69.1

47.2

75.6

45.7

69.7

72.1

72.9

51.2

34.6

52.3

28.5

56.9

60.6

67.5

72.7

67.9

36.6

50.5

53.9

74.6

71.1

61.8

43.5

9.3

62.8

81.7

74.4

75.5

60.5

66.1

SA: 60.4


48


Figure 11: OPD new client not referred rate (district hospitals) by district, 2017/18

Annual trends: OPD new client not referred rate (district hospitals)

Perc

enta

ge

0

20

40

60

80

100EC FS

●

●

●

● ●

●●

●

GP

0

20

40

60

80

100KZN

● ● ● ● ●

●●

●

LP MP

0

20

40

60

80

100

2010

/11

2011

/12

2012

/13

2013

/14

2014

/15

2015

/16

2016

/17

2017

/18

NC

2010

/11

2011

/12

2012

/13

2013

/14

2014

/15

2015

/16

2016

/17

2017

/18

NW

2010

/11

2011

/12

2012

/13

2013

/14

2014

/15

2015

/16

2016

/17

2017

/18

●

●

●

●

●

WC



KZN uMzinyathi KZN uThukelaKZN ZululandLP CapricornLP MopaniLP Sekhukhune LP VhembeLP Waterberg MP Ehlanzeni MP G Sibande MP Nkangala NC Frances Baard NC J T Gaetsewe


●

●

●

49


Figure 12 shows annual trends per province per district for the period 2010/11 – 2017/18. In the Free State, Xhariep shows an annual increase in the rate over the years from 32.7% in 2013/14 to 70.4% in 2017/18 and needs to be investigated. In the Northern Cape, the OPD new client not referred rate in John Taolo Gaetsewe increased from 35.4% in 2016/17 to 74.4% in 2017/18 and also needs to be investigated.

Figure 12: Annual trends: OPD new client not referred rate (district hospitals), 2010/11 – 2017/18 (%)

Source: DHIS.

50


Twenty-one district hospitals had an OPD new client not referred rate above 90%. In three hospitals all clients seen at the OPD/casualty unit bypassed the PHC facilities and accessed the hospitals directly for PHC services. These hospitals were in Joe Gqabi (EC), Capricorn (LP) and Pixley Ka Seme (NC) districts.

3.4 Inpatient crude death rate (all hospitals)The inpatient crude death rate is defined as, clients who died during hospital stay as a proportion of inpatient separations – total. It monitors trends in inpatient deaths and provides an indication of the quality of inpatient care.

The factors that influence the quality of cared include the following:

✦ effective clinical care

✦ end of life care

✦ documentation and informatics

✦ leadership

✦ reliable care systems.

In recent years, monitoring deaths in hospital has become a standard part of assessing the performance of our hospitals and the quality of their care. There are two ways to consider in-hospital mortality rates. It can be done by looking at either crude mortality rates or standardised mortality ratios (SMRs). Both are a valid measure of mortality and are constructed from numbers of deaths. Together, they provide an indication that there may be cause for concern, but do not definitively demonstrate that there is.d For SMRs, the number of deaths within a given time period is divided by the expected numbers of deaths. Expected deaths has a specific meaning in the context of SMRs. The term is used to provide an indication of how likely a patient was to die of the symptoms they had when they came into hospital.

The methodology used to calculate the expected number of in-hospital deaths is complex. It involves using a range of variables to ‘adjust’ or ‘standardise’ the data to reflect the risk (or likelihood) of death. These factors consider aspects such as:

✦ Whether the patient was an emergency or an elective admission.

✦ Their age and gender.

✦ The diagnosis they were given when they were first admitted to hospital.

✦ Important co-morbidities the patient may have.

✦ Whether they are a palliative care patient.

✦ The relative affluence of the area in which they live.

In contrast, crude mortality rates do not consider these factors. For this reason crude rates are not appropriate for comparisons of organisations with different catchment areas as the cohort of people who are admitted to the hospital will have a different case-mix, age and gender profiles.d

d Advancing Quality Alliance. Reducing In-hospital Mortality. Observations arising from AQuA’s work. May 2013. Available from https://www.aquanw.nhs.uk/resources/analytics/Reducing-In-hospital-Mortality.pdf. [Accessed 1 November 2018].

5.85.4 5.2 5.0 4.9 4.8

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

2012/13 2013/14 2014/15 2015/16 2016/17 2017/18

Perc

enta

ge

Inpatient crude death rate by province, 2017/18


EC

NW

GP

KZNFS

NC

MP

LP

WC

2 4 6

5.1

4.9

4.8

4.9

3.0

5.0

4.8

6.2

6.1

SA: 4.8


51


National overview

The national inpatient crude death rate decreased annually from 5.8% in 2012/13 to 4.8% in 2017/18 (Figure 13).

Figure 13: National inpatient crude death rate (all hospitals), 2012/13–2017/18

Source: DHIS.

Provincial overview

Figure 14 shows the inpatient crude death rate by province for 2017/18. The three provinces with the lowest inpatient crude death rate were Western Cape (3.0%), Limpopo and Mpumalanga (MP) (both at 4.8%). The province with the highest inpatient crude death rate was Eastern Cape (6.2%) followed by North West (NW) (6.1%). Eastern Cape had the second longest ALOS (4.9 days) as well as the second lowest IBUR (54.7%) among the provinces.

Figure 14: Inpatient crude death rate by province, 2017/18

CPT

NMA

BUF

ETH

EKUJHB

DC10

DC12

DC13

DC14

DC15

DC44

DC16

DC18DC19

DC20

MAN

DC42DC48

TSH

DC21

DC22

DC23

DC24

DC25 DC26 DC27

DC28

DC29

DC43

DC33

DC34

DC35

DC36

DC47

DC30

DC31

DC32

DC45

DC6DC7

DC8DC9

DC37

DC38

DC39DC40

DC1

DC2

DC3

DC4

DC5


CRUDEATH2.6 - 3.33.4 - 4.54.6 - 5.35.4 - 6.06.1 - 6.9

EKUJHB

DC42

DC48

TSH

Gauteng

52


District overview

The four districts with the lowest inpatient crude death rate in 2017/18 were from Western Cape, namely, Overberg (2.6%), Cape Winelands (3.0%), Cape Town (3.0%) and Eden (3.0%) (Map 4 and Figure 15). Namakwa (NC) (3.1%) and Central Karoo (WC) (3.1%) also had an inpatient crude death rate around 3%.

The five districts with the highest inpatient crude death rate were Chris Hani (EC) (6.9%), Joe Gqabi (EC) (6.9%), OR Tambo (EC) (6.5%), Nkangala (MP) (6.5%) and Fezile Dabi (FS) (6.4%).

Map 4: Inpatient crude death rate by district, 2017/18

Source: DHIS.

Inpatient crude death rate by district, 2017/18


C Hani: DC13Joe Gqabi: DC14O Tambo: DC15Nkangala: DC31

Fezile Dabi: DC20Amathole: DC12

Ngaka Modiri Molema: DC38A Nzo: DC44

Bojanala Platinum: DC37Xhariep: DC16

Dr K Kaunda: DC40Buffalo City: BUFuThukela: DC23

Ruth Segomotsi Mompati: DC39King Cetshwayo: DC28

Harry Gwala: DC43Amajuba: DC25

N Mandela Bay: NMACapricorn: DC35Sedibeng: DC42Zululand: DC26

uMzinyathi: DC24West Rand: DC48ZF Mgcawu: DC8

Ugu: DC21Frances Baard: DC9

Lejweleputswa: DC18Pixley ka Seme: DC7

Sarah Baartman: DC10T Mofutsanyana: DC19

Johannesburg: JHBCity of Ekurhuleni: EKU

iLembe: DC29uMgungundlovu: DC22uMkhanyakude: DC27

Mopani: DC33Tshwane: TSHVhembe: DC34

Ehlanzeni: DC32Waterberg: DC36Mangaung: MAN

G Sibande: DC30eThekwini: ETH

Sekhukhune: DC47J T Gaetsewe: DC45

West Coast: DC1Central Karoo: DC5

Namakwa: DC6Eden: DC4

Cape Town: CPTCape Winelands: DC2

Overberg: DC3

2 4 6

5.15.1

4.8

5.6

5.5

5.3

4.2

3.1

5.2

5.4

5.6

4.9

4.2

4.7

4.5

5.2

6.2

5.1

6.4

4.4

3.0

3.1

3.03.0

2.6

3.3

5.0

4.5

6.5

5.75.7

4.9

5.9

5.7

5.3

4.9

4.2

5.5

4.2

5.5

6.9

5.6

6.3

6.06.1

6.5

5.1

6.36.3

6.9

6.2

5.8

SA: 4.8


53


Figure 15: Inpatient crude death rate by district, 2017/18

Annual trends: Inpatient crude death rate

Perc

enta

ge

2

4

6

8

10

EC FS

● ● ●● ●

●● ●

●

GP

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4

6

8

10

KZN

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10

2009

/10

2010

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2013

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NC

2009

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2012

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2013

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NW

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/18

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WC



KZN uMzinyathi KZN uThukelaKZN ZululandLP CapricornLP MopaniLP Sekhukhune LP VhembeLP Waterberg MP Ehlanzeni MP G Sibande MP Nkangala NC Frances Baard NC J T Gaetsewe


●

●

●

54


Figure 16 shows annual trends per province and districts for the period 2009/10 – 2017/18. The inpatient crude death rate remained relatively stable in most of the districts in this period. Two districts in Eastern Cape had a decrease of more than 1 percentage point in the period, namely, Alfred Nzo (1.2 percentage points) and OR Tambo (1.3 percentage points). The same applies to Limpopo (Capricorn and Mopani (both 1.2 percentage points), Mpumalanga (Ehlanzeni,1.1 percentage points) and Gert Sibande (1.3 percentage points) and Northern Cape (Frances Baard,1.0 percentage point) and John Taolo Gaetsewe (1.9 percentage points). Lejweleputswa in the Free State had the highest decrease of 2.1 percentage points in the rate in the same period.

Figure 16: Annual trends: Inpatient crude death rate (district hospitals), 2009/10 – 2017/18

Source: DHIS.

2 3622 405

2 497

2 602

2 690

2 803

2 100

2 200

2 300

2 400

2 500

2 600

2 700

2 800

2 900

2012/13 2013/14 2014/15 2015/16 2016/17 2017/18

Ran

d

55


Twenty district hospitals had an inpatient crude death rate of more than eight per cent in 2017/18. Twelve of the 20 hospitals were in the Eastern Cape, four in North West and three in the Free State.

3.5 Expenditure per patient day equivalent (district hospitals)Expenditure per PDE is defined as average cost per patient day equivalent. Patient day equivalent is the sum of inpatient days total plus half of day patients, plus one-third of outpatients and emergency headcount total. Expenditure per PDE connects financial data with service-related data from the hospital admissions and outpatient records. This indicator measures how the resources available to the hospital are being spent and is a marker of efficiency. This indicator is calculated by dividing the total expenditure of the hospital by the PDE and is expressed as Rand (R) per PDE.

District health services (DHS) budgets are divided into nine sub-programmes. District hospitals remain the largest sub-programme, and in 2016/17 made up 35.3% of total DHS expenditure.e Historical expenditure in this section has been adjusted for inflation and is presented in real 2017/18 prices.

Comparative analysis of costs involved to perform the same activity across facilities is important in monitoring performance efficiency. It is assumed that the average cost of one inpatient day is equivalent to that of three outpatient visits. Historically, under-utilisation of hospital services, and over-staffing with fixed costs like salaries, are common causes of high PDEs. This results in high expenditures with low utilisation. As expenditure per PDE is a ratio between costs and services, improved performance is possible if costs are reduced or utilisation increased.f

Expenditure per PDE can be compared across similar hospitals within or between districts. Rural hospitals, particularly those located in more remote areas, struggle to attract and retain staff for many reasons, including poor hospital infrastructure, lack of staff accommodation, uneven remuneration of staff working in different rural locations, and poor road and transport networks.g

Consequently, some of these hospitals are poorly utilised, with a low IBUR, and may have high expenditure per PDE since almost all fixed costs remain the same even if facilities are not fully utilised. Certain district hospitals, particularly in KwaZulu-Natal and the Eastern Cape, offer some regional and tertiary hospital services. This may result in higher expenditure per PDE since expenditure per PDE generally increases with the level of care, as the category of staff (e.g. medical specialists), and commodities for such levels of care are expensive and in most cases not adequately budgeted for.f

National overview

National expenditure per PDE for district hospitals increased from R2 362 in 2012/13 to R2 803 in 2017/18 (figure 17).

Figure 17: National expenditure per patient day equivalent (district hospitals), 2012/13–2017/18

Source: DHIS.

e Massyn N, Padarath A, Peer N, Day C, editors. District Health Barometer 2016/17. Durban: Health Systems Trust; 2017.

f Massyn N, Peer N, English R, Padarath A, Barron P, Day C, editors. District Health Barometer 2015/16. Durban: Health Systems Trust; 2016.

g Barron P, Monticelli F. Key district health indicators. Volume 1. Durban: Health Systems Trust, 2007.

Expenditure per patient day equivalent (district hospitals) by province, 2017/18

Rand (real prices) [Source: DHB 2017/18]

WC

MP

EC

NC

FSKZN

LP

GP

NW

1000 2000 3000 4000 5000

2609

2647

3265

2904

2469

3495

2632

3032

2450

SA: 2803


CPT

NMA

BUF

ETH

EKUJHB

DC10

DC12

DC13

DC14

DC15

DC44

DC16

DC18DC19

DC20

MAN

DC42DC48

TSH

DC21

DC22

DC23

DC24

DC25 DC26 DC27

DC28

DC29

DC43

DC33

DC34

DC35

DC36

DC47

DC30

DC31

DC32

DC45

DC6DC7

DC8DC9

DC37

DC38

DC39DC40

DC1

DC2

DC3

DC4

DC5


EXPPDE_DH1862 - 22622263 - 26982699 - 30543055 - 36093610 - 4732

EKUJHB

DC42

DC48

TSH

Gauteng

56


Provincial overview

Figure 18 shows expenditure per PDE by province for 2017/18. The province with the highest expenditure per PDE was North West at R3 495, much higher than the national average of R2 803. The province with the lowest expenditure per PDE was Western Cape at R2 450.

Figure 18: Expenditure per patient day equivalent (district hospitals) by province, 2017/18

District overview

Map 5 and Figure 19 show expenditure per PDE by district in 2017/18. The five districts with the highest expenditure per PDE were Amajuba (KZN) (R4 732), Frances Baard (NC) (R4 087), iLembe (KZN) (R3 894), Ngaka Modiri Molema (NW) (R3 854) and Waterberg (LP) (R3 828). Five districts with the lowest expenditure per PDE were Zwelentlanga Fatman Mgcawu (NC) (R1 862), Cape Winelands (WC) (R1 961), Eden (WC) (R2 119), John Taolo Gaetsewe (NC) (R2 245) and West Coast (WC) (R2 262).

Map 5: Expenditure per patient day equivalent by district, 2017/18

Source: DHIS.

Expenditure per patient day equivalent (district hospitals) by district, 2017/18

Rand (real prices) [Source: DHB 2017/18]

ZF Mgcawu: DC8Cape Winelands: DC2

Eden: DC4JT Gaetsewe: DC45

West Coast: DC1eThekwini: ETH

Ehlanzeni: DC32Mopani: DC33

A Nzo: DC44G Sibande: DC30Amathole: DC12

Sarah Baartman: DC10Lejweleputswa: DC18

Central Karoo: DC5uMgungundlovu: DC22

C Hani: DC13Cape Town: CPT

T Mofutsanyana: DC19Fezile Dabi: DC20

Ugu: DC21City of Ekurhuleni: EKU

Buffalo City: BUFO Tambo: DC15

Mangaung: MANPixley ka Seme: DC7

Nkangala: DC31King Cetshwayo: DC28

Namakwa: DC6Vhembe: DC34

Joe Gqabi: DC14Overberg: DC3

uMzinyathi: DC24Zululand: DC26uThukela: DC23

Sekhukhune: DC47Dr K Kaunda: DC40

Tshwane: TSHuMkhanyakude: DC27

Xhariep: DC16Harry Gwala: DC43

Bojanala Platinum: DC37Capricorn: DC35Sedibeng: DC42

Johannesburg: JHBRS Mompati: DC39

West Rand: DC48N Mandela Bay: NMA

Waterberg: DC36NM Molema: DC38

iLembe: DC29Frances Baard: DC9

Amajuba: DC25

1000 2000 3000 4000 5000

2928

2412

2625

25162425

2566

2642

3778

2518

2608

3173

3432

3685

3553

3894

3158

2536

3047

2953

4732

2995

2419

23522329

2698

2605

2623

3140

2622

3253

28302759

3275

3854

3609

3108

2245

2867

2752

4087

1862

3054

2395

3326

2875

3828

2522

2578

2262

1961

2941

2119

SA: 2803


57


Figure 19: Expenditure per patient day equivalent by district, 2017/18

58


Figure 20 shows annual trends in provinces per district for the period 2008/09 to 2017/18. Nelson Mandela district in the Eastern Cape is the only district in the province with an expenditure per PDE of R3 000 and above since 2009/10. The reason is that Uitenhage hospital offers some regional and tertiary hospital services. The expenditure per PDE in Xhariep district (FS) exceeded the rest of the districts in the province since 2015/16 and was the only district in 2017/18 with an expenditure per PDE above R3 000.

In KwaZulu-Natal the expenditure per PDE of iLembe was much higher than the rest of the districts since 2013/14 and the expenditure per PDE of Amajuba increased on average much more than the rest of the districts since 2015/16. The increase in these two districts needs to be investigated. The expenditure per PDE of Frances Baard (NC) was much higher than the rest of the districts in the province since 2012/13 and had almost double the expenditure per PDE of the other districts in 2017/18 at R4 087.

Annual trends: Expenditure per patient day equivalent (district hospitals)

Ran

d (re

al p

rices

)

1000

2000

3000

4000

EC FS

● ●

●●

●●

● ●●

●

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1000

2000

3000

4000

KZN

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2008

/09

2009

/10

2010

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2011

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2012

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2013

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2014

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2016

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2017

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NC

2008

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2009

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2010

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2011

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2012

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2013

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2014

/15

2015

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2016

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2017

/18

NW20

08/0

920

09/1

020

10/1

120

11/1

220

12/1

320

13/1

420

14/1

520

15/1

620

16/1

720

17/1

8●

●

●

●●

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●

WC



KZN uMzinyathi KZN uThukelaKZN ZululandLP CapricornLP MopaniLP Sekhukhune LP VhembeLP Waterberg MP Ehlanzeni MP G Sibande MP Nkangala NC Frances Baard NC JT Gaetsewe

NC NamakwaNC Pixley ka SemeNC ZF MgcawuNW Bojanala PlatinumNW Dr K KaundaNW NM MolemaNW RS MompatiWC Cape TownWC Cape WinelandsWC Central KarooWC EdenWC OverbergWC West Coast

●

●

●

59


Figure 20: Annual trends: expenditure per patient day equivalent (district hospitals), 2008/09 – 2017/18

Source: DHIS.

60


Twenty-three district hospitals had an expenditure per PDE of more than R4 000 in 2017/18. Some district hospitals had unrealistic values for expenditure per PDE of more than R100 000 which might be due to poor data quality with regard to financial or inpatient data. There is no specific trend between the higher expenditure per PDE, IBUR and ALOS to make comparisons and the high expenditure per PDE needs to be investigated.

Key findings

Inpatient bed utilisation rate:

✦ The national IBUR for district hospitals in 2017/18 was 64.1% and has been consistently below 70% for the past six years. Western Cape was the only province with an IBUR above 80% in the same period. Eastern Cape has had the lowest rate among the provinces since 2012/13.

✦ The three districts with the lowest IBUR were from Northern Cape, KwaZulu-Natal and Eastern Cape, namely, Frances Baard (NC) (36.5%), King Cetshwayo (KZN) (42.3%) and Chris Hani (EC) (45.5%). Only 25 districts (48.1%) had an IBUR that exceeded the national average of 64.1%.

✦ Only two districts had an increase of more than 10 percentage points between 2013/14 – 2017/18, namely Amajuba (KZN) (19.7 percentage points) and Capricorn (Limpopo (LP)) (23.3 percentage points).

✦ Nine districts had a decrease of more than 10 percentage points between 2013/14 – 2017/18, with the highest dec-rease in Zwelentlanga Fatman Mgcawu (NC) (31.2 percentage points).

✦ Of the district hospitals with an IBUR below 40% in 2017/18, the majority were in the Eastern Cape (13), Free State (five), Northern Cape (four) and KwaZulu-Natal (two).

Average length of stay:

✦ The national ALOS decreased annually from 4.7 days in 2013/14 to 4.3 days in 2017/18.

✦ KwaZulu-Natal had the longest ALOS at 5.4 days followed by Eastern Cape at 4.9 days. These provinces have mostly rural districts with specific challenges. Reasons for this might be that patients are not discharged when they should be due to a shortage of doctors, or that patients discharged do not have transport to go home. Another reason might be that patients admitted in district hospitals with dedicated tuberculosis and psychiatric wards usually have longer stays in hospital.

✦ The ALOS in the Northern Cape, Free State and Western Cape was on average three days shorter than in KwaZulu-Natal and two days shorter than in the Eastern Cape.

✦ uMzinyati (KZN) had the longest ALOS at 6.3 days and Namakwa (NC) had the shortest ALOS at 2.6 days. Of the 25 districts with an ALOS longer than the national average of 4.3 days, 11 were districts in KwaZulu-Natal and six of the eight districts in Eastern Cape.

✦ Only two hospitals with a long ALOS also had low IBUR, namely Mjanyana Hospital in Chris Hani (EC) and St Lucy’s Hospital in OR Tambo (EC).

OPD new client not referred rate:

✦ The national OPD new client not referred rate declined from 64.1% in 2012/13 to 58.4% in 2015/16 but then increased to 59.3% in 2016/17 and to 60.4% in 2017/18.

✦ Western Cape was the province with the lowest OPD new client not referred rate at 13.6% in 2017/18. The OPD new client not referred rate for the other provinces ranged between 50.4% in KwaZulu-Natal to 72.4% in Limpopo.

✦ The five districts with the highest OPD new client not referred rate were Waterberg (LP) (83.6%), Frances Baard (NC) (81.7%), Sekhukhune (LP) (81.1%), Thabo Mofutsanyana (FS) (80.5%) and Tshwane (GP) (75.6%).

✦ Twenty-one district hospitals had an OPD new client not referred rate above 90%. In three hospitals all clients seen at the OPD/casualty unit bypass the PHC facilities and access the hospitals directly for PHC services. These hospitals were in Joe Gqabi (EC), Capricorn (LP) and Pixley Ka Seme (NC) districts.

Inpatient crude death rate:

✦ The national inpatient crude death rate decreased annually from 5.8% in 2012/13 to 4.8% in 2017/18.

✦ The province with the highest inpatient crude death rate was Eastern Cape (6.2%) followed by North West (NW) (6.1%). Eastern Cape had the second longest ALOS (4.9 days) as well as the second lowest IBUR (54.7%) among the provinces.

✦ The five districts with the highest inpatient crude death rate were Chris Hani (EC) (6.9%), Joe Gqabi (EC) (6.9%), OR Tambo (EC) (6.5%), Nkangala (MP) (6.5%) and Fezile Dabi (FS) (6.4%).

✦ Twenty district hospitals had an inpatient crude death rate of more than eight per cent in 2017/18. Twelve of the 20 hospitals were in the Eastern Cape, four in North West and three in the Free State.

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Expenditure per patient day equivalent:

✦ The national expenditure per PDE for district hospitals increased from R2 362 in 2012/13 to R2 803 in 2017/18.

✦ The province with the highest expenditure per PDE was North West at R3 495 and Western Cape had the lowest expenditure per PDE at R2 450.

✦ Twenty-three district hospitals had an expenditure per PDE of more than R4 000 in 2017/18. Some district hospitals had unrealistic values for expenditure per PDE of more than R100 000 and it might be due to poor data quality with regard to financial or inpatient data. This resulted in incorrect expenditure per PDEs by district, province and national levels. There is no specific trend between the higher expenditure per PDE, IBUR and ALOS to make comparisons and the high expenditure per PDE needs to be investigated.

General:

✦ Poor data quality might be the reason for some of the relatively high or low inpatient indicator values and effects decision-making and inpatient management.

Recommendations ✦ To improve the quality of data, the data collection tools for hospitals that do not use an electronic data collection

system should be standardised.

✦ The low IBUR and long ALOS at some hospitals should be investigated and proper actions taken to address the abnormal trends.

✦ The District Health System must be strengthened to enable all patients to first receive primary care at a clinic or health centre where initial diagnosis and treatments are conducted.

✦ The District Health Management Offices together with the district hospital management, must work on plans to discourage the use OPD and emergency units for PHC services and treatment of minor ailments.

✦ The district hospitals must do outreach services to support the local primary health care facilities. This can be done by working together with the District Clinical Specialist Teams, where they are available.

✦ The relatively high inpatient crude death rate at some hospitals should be investigated.

✦ Reasons for the unrealistic values for expenditure per PDE at some hospitals should be determined and be corrected.

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Documents

3 Inpatient management - Health Systems Trust Health Barometers/Distri… · 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 Pe r centage Inpatient bed utilisation rate (district