Carolinas HealthCare System

Hospital Compare National Data

Instructions: Roll over the boxes with below average scores (in yellow) to see actions taken to improve those scores.

CMS Hospital Compare Data
Includes Discharges from October 2012 through September 2013
Carolinas Medical Center CMC-Mercy/
Pineville
CMC-University CMC-NorthEast Carolinas HealthCare System Lincoln CMC-Union US Avg NC Avg
Heart Attack (Acute Myocardial Infarction)

Percent of heart attack patients given Aspirin at discharge

99% 100% 100% 100% N/A 100% 99% 100%
Percent of heart attack patients given Fibrinolytic medication within 30 minutes of arrival N/A N/A N/A N/A N/A N/A 58% 67%
Percent of heart attack patients given PCI within 90 minutes of arrival 98% 100% N/A 99% N/A N/A 96% 98%
Percent of heart attack patients given a prescription for a Statin at discharge 99% 100% 100% 100% N/A 100% 98% 99%
Heart Failure
Percent of heart failure patients given discharge instructions 97% 100% 100% 97% 99% 99% 94% 96%
Percent of heart failure patients given an evaluation of left ventricular systolic (LVS) function 100% 100% 100% 100% 99%One-on-one intervention with physicians and review of fallouts for root cause and preventable actions. 100% 99% 100%
Percent of heart failure patients given ACE inhibitor or ARB for left ventricular systolic dysfunction (LVSD) 98% 99% 100% 98% 100% 95% Team led by Chief Medical Officer conducts a weekly review outliers. Any outliers are discussed with attending physician. 97% 98%
Pneumonia
Percent of pneumonia patients whose initial emergency room blood culture was performed prior to the administration of the first hospital dose of antibiotics 98% 99% 94%Focus on education to reduce opportunity for incorrect documentation of the time that the blood was drawn. 99% 98% 97%Revision of protocols and physician order sets. Cases that fall out are reviewed by nurse and physician. 98% 98%
Percent of pneumonia patients given the most appropriate initial antibiotic(s) 97% 99% 99% 96%Physician coaching on appropriate antibiotics; action plan shared with the department of Emergency Medicine. 96%Nurse and physician follow-up on missed opportunities. Morning team huddle now discusses core measure patients for concurrent opportunities. 96%Any outliers are reviewed by the Chief Medical Officer who discusses with physicians on an individual basis. Physicians are educated and re-educated as indicated. 95% 97%
Surgical Care Improvement
Percent of surgery patients who were given an antibiotic at the right time (within one hour before surgery) to help prevent infection 98%Daily rounding on post-surgical units. Nurse and physician follow-up on missed opportunities. 100% 100% 100% 100% 99% 98% 99%
Percent of surgery patients who were given the right kind of antibiotic to help prevent infection 99% 100% 100% 100% 99% 100% 99% 99%
Percent of surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery) 97%Daily rounding on post-surgical units. Nurse and physician follow-up on missed opportunities. Communication with department chiefs and MDs on individual and group compliance. 100% 98%One-on-one intervention with physicians and staff to include review of fallouts for root cause and preventable actions. 98%Pharmacy intervenes by revieingw charts post-operatively. 98%Nurse and physician follow-up on missed opportunities. Morning team huddle now discusses core measure patients for concurrent opportunities. 97%All missed cases reviewed and discussed with physician on individual basis. 98% 99%
Percent of all heart surgery patients whose blood sugar (blood glucose) is kept under good control in the days right after surgery 99% 100% N/A 98%Implemented the Endotool to improve blood sugar control. N/A N/A 97% 98%
Percent of surgery patients whose urinary catheters were removed on the first or second day after surgery 96%Initiated a urinary catheter protocol in the electronic medical record; daily rounding on post-surgical units. 100% 98%Initiated a urinary catheter protocol in the electronic medical record. 98%Initiated a urinary catheter protocol in the electronic medical record. 100% 98%Initiated a urinary catheter protocol in the electronic medical record. 97% 99%
Percent of surgery patients who were actively warmed in the operating room or whose body temperature was near normal by the end of surgery 100% 100% 100% 100% 100% 100% 100% 100%
Percent of surgery patients who were taking heart drugs called beta blockers before coming to the hospital, who were kept on the beta blockers during the period just before and after the surgery 98%Concurrent daily monitoring with intervention as needed. 100% 96%Utilize checklist to ensure patients on beta blockers are identified and follow-up administration. 98%Developed a report that lists patients on beta blockers prior to surgery. Pharmacy department uses the list to review patient records for administration of the beta blocker. 99% 98%Improve communication with surgical staff. Case review and follow up with nursing &medical staff, as needed. 98% 99%
Percent of patients who received treatment at the right time (within 24 hours before or after their surgery) to help prevent blood clots after certain types of surgery 98%Mandatory risk assessment initiated in electronic medical record. Weekly team meetings to review all missed cases and follow up with providers. 100% 98%Engage help from IT liaison with physician education. 98%Nursing follow-up to educate on best practice. Pharmacy intervention. 99% 99% 98% 99%

 

Key
Above the NC Average
  No different than the NC Average
  Below the NC Average
^ Number of cases is too small to be sure how well a hospital is performing.
N/A No patients met criteria for inclusion in the measure calculation.
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