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 2011 through September 2012
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%Daily rounding. Review missed cases and follow up with physician champions and their colleagues. 99%One-on-one physician counseling for missed cases. 100%^ 100% N/A 95%^One-on-one physician counseling for missed cases. Have been 100% compliance since July 2012. 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 61% N/A
Percent of heart attack patients given PCI within 90 minutes of arrival 99% 100% N/A 99% N/A N/A 95% 98%
Percent of heart attack patients given a prescription for a Statin at discharge 99% 99% 100%^ 99% N/A 100%^ 98% 99%
Heart Failure
Percent of heart failure patients given discharge instructions 99% 99% 100% 98% 100% 100% 93% 95%
Percent of heart failure patients given an evaluation of left ventricular systolic (LVS) function 100% 100% 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) 95%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. 99% 99% 96%Nurse and physician follow-up on missed opportunities. 100% 97% 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% 97% 97% 98% 96%Nurse and physician follow-up on missed opportunities. Initiated concurrent review of blood culture documentation before the patient leaves the ED by the charge nurse. 98% 97% 97%
Percent of pneumonia patients given the most appropriate initial antibiotic(s) 96% 98% 97% 98% 96% 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% 99% 100% 99% 99% 99% 97% 98%
Percent of surgery patients who were given the right kind of antibiotic to help prevent infection 98%Daily rounding on post-surgical units. Nurse and physician follow-up on missed opportunities. 100% 99% 100% 96%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) 96%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. 98% 97%Each missed opportunity is reviewed. Directed education on physician documentation. 98% 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% 99% N/A 96%Revised physician order set. Process improvement team focus. N/A N/A 96% 98%
Percent of surgery patients whose urinary catheters were removed on the first or second day after surgery 93%Initiated a urinary catheter protocol in the electronic medical record; daily rounding on post-surgical units. 99% 97%Daily electronic reminder developed for physicians to continue or discontinue urinary catheter. 97%Focused assessment for concurrent review initiated by unit manager where greatest opportunity existed. Action plan initiated. 99% 97%Initiated a urinary catheter protocol in the electronic medical record. 96% 98%
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 97%Concurrent daily monitoring with intervention as needed. 98% 98% 99% 100% 97%Improve communication with surgical staff. Case review and follow up with nursing and 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. 100% 98%Post-surgical staff monitor for blood clot prevention treatment and follow up with physicain if it is not ordered. IT liasison consults with individual physician on missed opportunities. 97%Physician follow-up to educate on best practice. Pharmacy intervention. 97%Nurse and physician follow-up on missed opportunities. Morning team huddle now discusses core measure patients for concurrent opportunities. 99% 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 97%Mandatory risk assessment initiated in electronic medical record. Weekly team meetings to review all missed cases and follow up with providers. 99% 95%Engage help from IT liaison with physician education 96%Nursing follow-up to educate on best practice. Pharmacy intervention. 96%Nurse and physician follow-up on missed opportunities. Morning team huddle now discusses core measure patients for concurrent opportunities. 97%Weekly review of all missed cases. 98% 98%

 

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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