Quality Committee Core Measures Report |AMI 2011 Acute Myocardial Infarction Quality Committee Core Measures Report ASPIRIN AT ARRIVAL: A higher number is better. What this means: This measure shows the percentage of heart attack patients who receive aspirin within 24 hrs of arrival at hospital. Why this is important: Aspirin is a drug that can help reduce the severity of the heart attack and improve survival rates by lowering the tendency of blood to clot in the vessels. AMI1 - Aspirin at arrival 100% 100% State, 99% 80% 90% 60% 2011 YTD, 92% 80% 40% 20% 0% Natl, 98% 0 Cases 0Cases 70% N=13 60% AMI1 - Aspirin at arrival ASPIRIN PRESCRIBED AT DISCHARGE: A higher number is better. What this means: This measure shows how often aspirin was prescribed to heart attack patients at the time they are discharged from the hospital. Why this is important: Aspirin is a drug that can help improve survival rates by lowering the tendency of blood to clot in the vessels. AMI2 - Aspirin prescribed at discharge 100% 80% 60% 40% 20% 0% 100% 90% 2011 YTD, 100% State, 98% Natl, 98% 80% 0 Cases 0Cases 70% 60% AMI2 - Aspirin prescribed at discharge 1_AMI Quality Committee Core Measures Report ACE INHIBITOR, or ARB PRESCRIBED FOR LVSD (left ventricular systolic dysfunction): A higher number is better. What this means: ACE (angiotensin converting enzyme) inhibitors and ARBs(angiotensin receptor blockers) are medicines used in Heart attack, high blood pressure and heart failure. They are also frequently used for a condition called ‘systolic dysfunction’, which is A decrease in the function of the left side of the heart. This measure shows the percentage of heart attack patients prescribed these drugs at discharge from hospital. Heart attack patients are prescribed this medicine to help improve the pumping of the heart. Why this is important: Patients who have had heart attacks can have better results if they take this medicine AMI3 - ACEI or ARB for LVSD 100% 80% 60% 40% 20% 0% 100% 90% 2011 YTD, 100% State, 96% Natl, 96% 80% 0 Cases 0 Cases 0Cases 70% 60% AMI3 - ACEI or ARB for LVSD AMI3 - ACEI or ARB for LVSD BETA BLOCKER PRESCRIBED AT DISCHARGE: A higher score is better. What this means: This measure shows the percentage of patients with heart attacks that have been prescribed a medicine called a beta blocker, on discharge from the hospital. Why this is important: This medicine can help reduce the amount of damage to the heart muscle in heart attack patients. AMI5 - Beta blocker prescribed at discharge 100% 80% 60% 40% 20% 0% 100% 90% 2011 YTD, 100% State, 98% Natl, 98% 80% 0 Cases 0Cases 70% 60% AMI5 - Beta blocker prescribed at discharge 2_AMI Quality Committee Core Measures Report |Heart Failure 2011 Heart Failure Quality Committee Core Measures Report **DISCHARGE INSTRUCTIONS : A higher score is better. (** Used in Value Based Purchasing (VBP) scoring) What does this mean: The percentage of patients that receive the patient education instructions about heart failure management at the time of discharge from the hospital. Why this is important: Heart failure is a chronic condition that can result in different symptoms such as shortness of breath, dizziness and water weight gain. Before discharge, the staff at the hospital should provide education materials to help manage these potential symptoms. HF1-All Discharge Instructions 100% 100% 2011 YTD, 88% 80% 80% Natl, 87% 60% 60% 40% 40% n=25 20% 0% State, 90% 0 Cases 20% 0% Core HF1 - All Discharge Instructions . LEFT VENTRICULAR FUNCTION (LVF) ASSESSMENT: A higher score is better. What does this mean: The percentage of patients given an LVF assessment. Why this is important: The proper treatment for heart failure must account for what area of your heart is affected. With heart failure, the pumping mechanism is affected and an important test to assess the pumping ability of your heart is the ‘left ventricular function assessment’. The results of this test will tell your provider how well your heart is pumping. HF2- Evaluation of LVS Function 100% 100% 80% 80% 2011 YTD, 94% State, 98% Natl, 98% 60% 60% 40% 40% 20% 0% 0 Cases 20% 0% Core HF2 - Evaluation of LVS Function 1_HF Quality Committee Core Measures Report ACE INHIBITOR, or ARB PRESCRIBED FOR LVSD (left ventricular systolic dysfunction): A higher number is better. What this means: ACE (angiotensin converting enzyme) inhibitors and ARBs(angiotensin receptor blockers) are medicines used in Heart attack, high blood pressure and heart failure. They are also frequently used for a condition called ‘systolic dysfuntion’, which is a decrease in the function of the left side of the heart. This measure shows the percentage of heart attack patients prescribed these drugs at discharge from hospital. Heart attack patients are prescribed this medicine to help improve the pumping of the heart. Why this is important: Patients who have had heart attacks can have better results if they take this medicine HF3-ACEI or ARB for LVSD 100% 100% 80% 80% State, 95% 2011 YTD, 87% Natl, 94% 60% 60% 40% 40% 20% 0% 0 Cases 0 Cases 0 Cases 20% 0% Core HF3 - ACEI or ARB for LVSD 2_HF Quality Committee Core Measures Report |PNA 2011 Community Acquired Pneumonia Quality Committee Core Measures Report PNEUMONIA VACCINATION GIVEN: A higher score is better. What this means: This is a measure that shows how well the hospital has documented that pneumonia patients over the age of 65years have been screened for or asked if they wish vaccination. Why this is important: Scientific literature has shown that people over the age of 65 years of age are more at risk for pneumonia. PN2 - Pneumococcal Vaccination 100% 100% 80% 80% 60% 2011 YTD, 91% State, 92% Natl, 92% 60% 40% 40% 20% 0% 20% 0% PN2 - Pneumococcal Vaccination Blood Culture within 24 hours before or after arrival-ICU: A higher number is better. What this means: This measure shows how timely a blood culture was obtained for patients admitted to ICU Why this is important: Pretreatment cultures are recommended because the yield of clinically useful information is greater if the culture is collected before antibiotics are administered. PN3a -Blood culture 24 hrs prior to/after arrival-ICU 100% 80% 100% 80% 2011 YTD, 89% State, 95% Natl, 95% 60% 60% 40% 40% 20% 0% 0 Cases 20% 0% PN3a -Blood culture 24 hrs prior to/after arrival-ICU 1_PNA Quality Committee Core Measures Report **Blood Cultures in ED before first antibiotic: A higher score is better. (** Used in Value Based Purchasing (VBP) scoring) What this means: This is the measure that shows the percentage of pneumonia patients who had blood cultures in the emergency before the first antibiotic was administered. Why this is important: Patients who receive blood cultures before the first antibiotic administration has been shown to be very effective in treating community acquired pneumonia PN3b - Blood culture in ED prior to initial antibiotic 100% 2011 YTD, 100% 80% 100% 80% State, 95% Natl, 95% 60% 60% 40% 40% 20% 20% 0% 0% PN3b - Blood culture in ED prior to initial antibiotic Initial Antibiotic received within 6 hours of arrival: A higher score is better. What this means: This measure shows the percentage of patients with community acquired pneumonia who receive their first dose of antibiotics within 6 hours after arrival at the hospital. Why this is important: Timely administration (Within 6 hours) of first antibiotic dose for community-acquired pneumonia (CAP) has been shown to lower mortality rate PN5c - Antibiotic within 6 hours of arrival 100% 100% 80% 2011 YTD, 98% State, 92% Natl, 95% 80% 60% 40% 60% 40% 20% 0% 20% 0% PN5c - Antibiotic within 6 hours of arrival 2_PNA Quality Committee Core Measures Report **Antibiotic selection for Community Acquired Pneumonia in an Immunocompetent Patient: A higher score is better. (** Used in Value Based Purchasing (VBP) scoring) What this means: This is the measure that shows the percentage of community acquired pneumonia patients who were given appropriate antibiotics within 24 hours of their hospital admission. Why this is important: Patients who receive appropriate antibiotics within 24 hours of their hospital admission has been shown to be very effective in treating community acquired pneumonia. 100% PN6 - Antibiotic Selection for ICU/non ICU patients 2011 YTD, 98% 80% State, 92% Natl, 91% 100% 80% 60% 60% 40% 40% 20% 20% 0% 0% PN6 - Antibiotic selection for ICU/non-ICU patients Influenza Vaccine for patients over age 50: A higher score is better. What this means: This is the measure that shows the percentage of patients who were who were screened for influenza vaccine status and were vaccinated prior to discharge, if indicated Why this is important: Influenza vaccination is indicated for people age 50 years and older, because it is highly effective in preventing influenzarelated pneumonia, hospitalization, and death. PN7 - Influenza vaccination 100% 80% 100% 80% 60% State, 91% Natl, 91% 2011 YTD, 83% 60% 40% 40% 20% 20% 0 cases n=36 0% 0% PN7 - Influenza vaccination (measure retired in 2012) 3_PNA Quality Committee Core Measures Report |SCIP 2011 Surgical Care Infection Prevention Quality Committee Core Measures Report **PROPHYLACTIC ANTIBIOTIC RECEIVED WITHIN ONE HOUR PRIOR TO SURGERY: A higher score is better. (** Used in Value Based Purchasing (VBP) scoring) What this means: This is a measure that shows the percentage of surgical patients that received prophylactic antibiotics within 1 hour prior to surgical incision. Why this is important: Scientific studies show that patients who receive prophylactic antibiotics within 1 hour of surgery incision time can have reduced numbers of post operative infections. SCIP Inf 1a- ABX within 1 hour of incision 100% 100% 80% 2011 YTD, 98% State, 96% Natl, 96% 80% 60% 60% 40% 40% 20% N=102 20% 0% 0% Core SCIP/SIP-Inf-1a - Antibiotic within 1 hr of incision-Overall **ANTIBIOTIC SELECTION OVERALL: A higher score is better. (** Used in Value Based Purchasing (VBP) scoring) What this means: This is a measure that shows the percentage of surgical patients that received appropriate antibiotics . Why this is important: A goal of prophylaxis with antibiotics is to use an agent that is safe, cost-effective, and has a spectrum of action that covers most of the probable intraoperative contaminants for the operation. SCIP/SIP-Inf-2a - ABX selection-Overall 100% 100% 80% 2011 YTD, 99% State, 97% Natl, 97% 80% 60% 40% 60% 40% N=103 20% 0% 20% 0% SCIP/SIP-Inf-2a - Antibiotic selection-Overall 1_SCIP Quality Committee Core Measures Report **PROPHYLACTIC ANTIBIOTICS DISCONTINUED WITHIN 24 HOURS OF SURGERY END TIME: a higher score is better. (** Used in Value Based Purchasing (VBP) scoring) What this means: This is a measure that shows the percentage of surgical patients that had their prophylactic antibiotics discontinued within 24 hours of surgery end time. Why this is important: Scientific studies show that the administration of prophylactic antibiotics for more than a few hours after the surgical incision is closed offers no additional benefit to the surgical patient. Prolonged administration can result in resistant strain bacteria. SCIP/SIP-Inf-3a - ABX Discontinued within 24 hours-Overall 100% 2011 YTD, 92% 80% 100% 80% State, 92% Natl, 94% 60% 60% 40% 40% N=100 20% 20% 0% 0% SCIP/SIP-Inf-3a - Antibiotic disc. within 24 hrs-Overall Urinary Catheter removed POD 1 or POD 2 : a higher score is better. What this means: This is a measure that shows the percentage of surgical patients that had their urinary catheter removed by end of Post Op Day 2. Why this is important: Studies show that postoperative catheterization of > 2 days is associated with: Increased in-hospital urinary tract infection  Increased 30-day mortality  Increased length of stay SCIP-Inf-9 - Urinary catheter removed POD 1 or POD 2 100% 80% 100% 80% 60% 40% 20% 2011 YTD, 94% State, 89% Natl, 89% 60% 40% N=90 20% 0% 0% Core SCIP-Inf-9 - Urinary catheter removed POD 1 or POD 2 2_SCIP Quality Committee Core Measures Report Surgery Patients with Appropriate Hair Removal: a higher score is better. What this means: This is a measure that shows the percentage of surgery patients with surgical site hair removal with clippers or depilatory or with no surgical site hair removal. Why this is important: Studies show that shaving causes multiple skin abrasions that later may become infected SCIP-Inf-6 - Appropriate hair removal 100% 100% 80% 2011 YTD, 100% State, 99% Natl, 99% 80% 60% 60% N=144 40% 40% 20% 20% 0% 0% Core SCIP-Inf-6 - Appropriate hair removal **Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who Received a Beta-Blocker During the Perioperative Period: a higher score is better. (** Used in Value Based Purchasing (VBP) scoring) What this means: This is a measure that shows the percentage of surgery patients on beta-blocker therapy prior to arrival who receive a beta-blocker during the perioperative period Why this is important: Studies show that continuous beta-blocker use remains significantly associated with a lower 1-year mortality than among nonusers. SCIP-CARD-2 - Beta blocker prior to admission and periop 100% 80% 100% 80% State, 91% Natl, 92% 60% 60% 40% 40% 20% 0% 2011 YTD, 100% N=18 20% 0 Cases 0 Cases 0% Core SCIP-CARD-2 - Beta blocker prior to admission and periop 3_SCIP Quality Committee Core Measures Report Surgery Patients with Perioperative Temperature Management: a higher score is better. What this means: This is a measure that shows the percentage of surgery patients for whom either active warming was used intraoperatively for the purpose of maintaining normothermia or who had at least one body temperature equal to or greater than 96.8° Fahrenheit. Why this is important: Studies show that core temperatures outside the normal range pose a risk in all patients undergoing surgery. Core SCIP-Inf-10 - Surgery patients w/perioperative temperature mgmt 100% 80% 100% 80% 2011 YTD, 99% State, 90% Natl, 92% 60% 60% 40% 40% 20% 20% N=161 0% 0% Core SCIP-Inf-10 - Surgery patients w/perioperative temperature mgmt **Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered: a higher score is better. (** Used in Value Based Purchasing (VBP) scoring) What this means: This is a measure that shows the percentage of surgery patients with recommended Venous Thromboembolism (VTE) prophylaxis ordered anytime from hospital arrival to 24 hours after Anesthesia End Time. Why this is important: Despite the evidence that VTE is one of the most common postoperative complications and prophylaxis is the most effective strategy to reduce morbidity and mortality, it is often underused. Core SCIP-VTE-1 - VTE prophylaxis ordered 100% 100% 80% 2011 YTD, 96% State, 91% Natl, 94% 80% 60% 40% 60% 40% N=108 20% 0% 20% 0% Core SCIP-VTE-1 - VTE prophylaxis ordered 4_SCIP Quality Committee Core Measures Report |HOP AMI/CP 2011 HOP AMI/Chest Pain Quality Committee Core Measures Report Aspirin at Arrival: A higher score is better. What this means: This is a measure that shows the percentage of Emergency Department acute myocardial infarction (AMI) patients or chest pain patients (with Probable Cardiac Chest Pain) who received aspirin within 24 hours before ED arrival or prior to transfer. Why this is important: The early use of aspirin in patients with AMI results in a significant reduction in adverse events and subsequent mortality. 100% OP 4a- Aspirin at Arrival 100% 80% 2011 YTD, 100% State, 96% 80% 60% 60% 40% 40% National, 95% n=47 20% 0 Cases 0% 20% 0% OP-4a - Aspirin at Arrival Median Time to Transfer to Another Facility for Acute Coronary Intervention: A lower time is better. What this means: Median time from emergency department arrival to time of transfer to another facility for acute coronary intervention. Why this is important: The early use of primary angioplasty in patients with ST-segment myocardial infarction (STEMI) results in a significant reduction in mortality and morbidity. Current recommendations support a door-to-balloon time of 90 minutes or less. OP-3b - Median Time to Txfer to Fac for Acute Coronary Intervention 1,451.0 250 200 150 2011 YTD, 200.09 1005 100 505 96.0 5 15.0 17.0 112.5 85.0 25.0 95.0 50 0 Cases n=11 Lower is better! State, 66 National, 62 0 OP-3b - Median Time (minutes) to Txfer to Fac for Acute Coronary Intervention 1_HOP AMI & Chest Pain Quality Committee Core Measures Report Median Time to Transfer to ECG: A lower time is better. What this means: Median time from emergency department arrival to ECG (performed in the ED prior to transfer) for acute myocardial infarction (AMI) or Chest Pain patients (with Probable Cardiac Chest Pain) Why this is important: Guidelines recommend patients presenting with chest discomfort or symptoms suggestive of ST-segment elevation myocardial infarction (STEMI) have a 12-lead electrocardiogram (ECG) performed within a target of 10 minutes of emergency department arrival. 25 OP-5a - Median Time to ECG 80 20 62.0 15 60 40 20 0 31.0 10 20.8 10.5 11.1 7.3 12.5 6.0 7.3 0 cases 6.3 7.5 5 2011 YTD, 20.45 n=47 Lower is better! State, 8 National, 9 0 OP-5a - Median Time to ECG 2_HOP AMI & Chest Pain Quality Committee Core Measures Report |HOP Surgery 2011 HOP Surgery Quality Committee Core Measures Report PROPHYLACTIC ANTIBIOTIC RECEIVED WITHIN ONE HOUR PRIOR TO SURGERY: A higher score is better. What this means: This is a measure that shows the percentage of outpatient surgical patients that received prophylactic antibiotics within 1 hour prior to surgical incision. Why this is important: Scientific studies show that patients who receive prophylactic antibiotics within 1 hour of surgery incision time can have reduced numbers of post operative infections. OP 6- Antibiotic Timing 100% 100% 80% 80% 60% 60% 40% National, 92% State, 90% n=28 40% 20% 0% 2011 YTD, 89% 0 Cases 0 Cases 20% 0% OP 6-Antibiotic Timing ANTIBIOTIC SELECTION OVERALL: A higher score is better. What this means: This is a measure that shows the percentage of outpatient surgical patients that received appropriate antibiotics . Why this is important: A goal of prophylaxis with antibiotics is to use an agent that is safe, cost-effective, and has a spectrum of action that covers most of the probable intraoperative contaminants for the operation. 100% OP 7- Antibiotic Selection 100% 80% 2011 YTD, 96% State, 92% National, 94% 80% 60% 60% 40% n=28 40% 20% 0% 0 Cases 0 Cases 20% 0% OP 7-Antibiotic Selection 1_HOP Surgery Quality Committee Core Measures Report **Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery: a higher score is better. (** Used in Value Based Purchasing (VBP) scoring) What this means: This is a measure that shows the percentage of surgery patients who received appropriate Venous Thromboembolism (VTE) prophylaxis within 24 hours prior to Anesthesia Start Time to 24 hours after Anesthesia End Time. Why this is important: Timing of prophylaxis is based on the type of procedure, prophylaxis selection, and clinical judgment regarding the impact of patient risk factors---24 hours prior to surgery to 24 hours post surgery was recommended by consensus of the SCIP Technical Expert Panel in order to establish a timeframe that would encompass most procedures. Core SCIP-VTE-1 - VTE prophylaxis timing 100% 100% 80% 2011 YTD, 94% State, 90% Natl, 92% 80% 60% 40% 60% N=108 40% 20% 0% 20% 0% Core SCIP-VTE-2 - VTE prophylaxis timing 5_SCIP