| Heart Attack (Acute Myocardial Infarction) |
|
Percent of heart attack patients given Aspirin at discharge
|
100% |
99% |
100%^ |
100% |
100^ |
96%One-on-one physician counseling for missed cases. Have been 100% compliance since July 2012. |
99% |
99% |
| 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 |
60% |
N/A |
| Percent of heart attack patients given PCI within 90 minutes of arrival |
99% |
97% |
N/A |
99% |
N/A |
N/A |
95% |
97% |
| Percent of heart attack patients given a prescription for a Statin at discharge |
99% |
99% |
100%^ |
99% |
100%^ |
100%^ |
98% |
99% |
| Heart Failure |
| Percent of heart failure patients given discharge instructions |
99% |
99% |
100% |
98% |
99% |
100% |
93% |
94% |
| Percent of heart failure patients given an evaluation of left ventricular systolic (LVS) function |
100% |
100%One-on-one physician counseling. Created Heart Failure patient list in electronic medical record for physician reference. |
100% |
100% |
100% |
99%Discharge nurse reviews for presence of documentation prior to discharge. |
99% |
100% |
| Percent of heart failure patients given ACE inhibitor or ARB for left ventricular systolic dysfunction (LVSD) |
96%Heart failure team reviews all cases. Medical Director follows up with physicians. |
95%One-on-one physician counseling. Created Heart Failure patient list in electronic medical record for physician reference. |
98% |
100% |
100% |
100% |
96% |
97% |
| Pneumonia |
| Percent of pneumonia patients whose initial emergency room blood culture was performed prior to the administration of the first hospital dose of antibiotics |
97% |
96%Chief Medical Officer enforced manadatory blood cultures. Created visual reminders for RNs to adjust blood culture draw time. |
97% |
97% |
97% |
97% |
97% |
97% |
| Percent of pneumonia patients given the most appropriate initial antibiotic(s) |
98% |
95%One-on-one counseling from Chief Medical Officer. Re-educated on list of approved antibiotics/pocket cards provided. |
97% |
98% |
92%Physician education. Morning team huddle now discusses core measure patients for concurrent opportunities. |
99% |
95% |
96% |
| 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%Nurse and physician follow up on missed opportunities. |
98%Instituted antibiotics administration only in the Operating Room. Physicians educated on new process. Physician one-on-one follow up as necessary. |
99% |
99% |
99% |
100% |
98% |
99% |
| Percent of surgery patients who were given the right kind of antibiotic to help prevent infection |
98%Nurse and physician follow-up on missed opportunities. |
100% |
98%RN/MD review missed opportunites. Monthly core measure team reviews. |
100% |
95%Physician follow-up on missed opportunities. Morning team huddle now discusses core measure patients for concurrent opportunities. |
99% |
99% |
99% |
| Percent of surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery) |
97%Nurse and physician follow-up on missed opportunities. Communication with department chiefs and MDs on individual and group compliance. |
98% |
96%Each missed opportunity is reviewed. Directed education on physician documentation. |
99% |
95%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. |
97% |
98% |
| Percent of all heart surgery patients whose blood sugar (blood glucose) is kept under good control in the days right after surgery |
100% |
98% |
N/A |
93%Revised physician order set. Process improvement team focus. |
N/A |
N/A |
96% |
97% |
| Percent of surgery patients whose urinary catheters were removed on the first or second day after surgery |
94%Daily electronic reminder developed for physicians to continue or discontinue urinary catheter. |
99% |
95%Daily electronic reminder developed for physicians to continue or discontinue urinary catheter. |
96%Focused assessment for concurrent review initiated by unit manager where greatest opportunity existed. Action plan initiated. |
99% |
98% |
95% |
97% |
| 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% |
97%Report created to list post-operative patients on beta blockers at home. Medication is either ordered and administered or appropriatlye documented as to why not. Additionally, focused nursing and physician education was completed. |
98% |
98% |
100% |
97%Improve communication with surgical staff. Case review and follow up with nursing medical staff, as needed. |
97% |
98% |
| Percent of surgery patients whose doctors ordered treatments to prevent blood clots after certain types of surgeries |
98%Team meets and reviews all cases that had missed opportunity. Follow up with attending physician. |
99% |
99% |
96%Physician follow-up to educate on best practice. Pharmacy intervention. |
95%Nurse and physician follow-up on missed opportunities. Morning team huddle now discusses core measure patients for concurrent opportunities. |
99% |
97% |
98% |
| 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% |
99% |
96%Engage help from IT liaison with physician education |
96%Nursing follow-up to educate on best practice. Pharmacy intervention. |
94%Nurse and physician follow-up on missed opportunities. Morning team huddle now discusses core measure patients for concurrent opportunities. |
98% |
97% |
98% |
