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Heart Attack

A heart attack is a life-threatening situation that occurs when a blood vessel to the heart is blocked by a clot or plaque. When this occurs, heart muscle is deprived of oxygen and the damage causes pain, and reduces the heart's ability to pump blood. Without prompt treatment through the use of drugs like aspirin or a "clot buster" medication, or interventions to open the vessel, patients can become disabled or even die. Our goal is to quickly restore blood flow to the heart to prevent more damage and prevent future heart attacks by reducing blood pressure, maintaining heart rate/beats, and preventing clots.

We measure six quality indicators:
  • Was an aspirin given on arrival at the hospital?
  • How quickly (within 90 minutes of arrival at the hospital) was cardiac catheterization (PCI) performed on appropriate patients?
  • Were appropriate medications (aspirin, beta-blocker, ACEI/ARB, and statin) prescribed at discharge?
Heart Attack Measures
( Higher is Better )

Measures
Performance Total
Performance Target
Graph & Details
Measure: Aspirin on Arrival
Performance Total: 100 %
Performance Target: 100 %
Measure: Aspirin at Discharge
Performance Total: 100 %
Performance Target: 100 %
Measure: ACE inhibitor (or ARB) for LVSD
Performance Total: 100 %
Performance Target: 100 %
Measure: Beta blockers at discharge
Performance Total: 100 %
Performance Target: 100 %
Measure: PCI within 90 minutes of arrival at the hospital
Performance Total: No patient population for this measure.
Performance Target: 100 %

Heart Failure

Heart failure, also known as congestive heart failure, is a chronic condition caused by the inability of the heart (specifically, the ventricle) to pump as much blood as the body needs. When the heart is unable to pump blood, fluid backs up and affects patients’ lungs and other organs. Heart failure is one of the most common reasons for hospitalization. Our goal is to correctly identify the degree of heart failure, help the heart pump more effectively, and reduce the strain on the heart through medications and dietary modifications that can reduce fluid.

We measure three quality indicators:
  • Was left ventricular (LV) function assessed?
  • Were written instructions given at discharge?
  • Was an appropriate medication (ACEI/ARB) prescribed at discharge?
Heart Failure Measures
( Higher is Better )

Measures
Performance Total
Performance Target
Graph & Details
Measure: ACE Inhibitor at discharge
Performance Total: 100 %
Performance Target: 100 %
Measure: Assessment of the left ventricle
Performance Total: 100 %
Performance Target: 100 %
Measure: Written Instructions at discharge
Performance Total: 100 %
Performance Target: 100 %

Pneumonia

Pneumonia is an infection of the lungs that can range from mild to severe. It is usually due to bacteria or viruses. Pneumonia causes more deaths worldwide than any other type of infection. Making sure that we provide appropriate treatment to those who develop this infection is the goal of these quality indicators.

We measure two quality indicators:
  • Were blood cultures done before the first dose of antibiotic was given?
  • Was the appropriate antibiotic(s) prescribed, according to national guidelines, for "community-acquired" pneumonia?

Pneumonia Measures
( Higher is Better )

Measures
Performance Total
Performance Target
Graph & Details
Measure: Blood cultures before first dose of antibiotic
Performance Total: 88 %
Performance Target: 100 %
Measure: Initial antibiotic selection according to national guidelines
Performance Total: 88 %
Performance Target: 100 %

Surgical Care Improvement Measures

Postoperative wound infection is a significant complication of surgery, and the use of antibiotics before surgery can prevent such infections. In addition, practices such as hair removal help prevent infection, and assessing risk of blood clots and administering medication to prevent clots are very important to preventing complications of surgery. The measures reported here examine when antibiotics are given and whether we have followed national guidelines in administering them.
We measure ten quality indicators:
- Were antibiotics administered within 1 hour prior to incision?
- Was the appropriate antibiotic(s) prescribed, according to national guidelines, for infection prevention?
- Were antibiotics discontinued within 24 hours after surgery?
- Was the blood sugar well controlled for cardiac surgery patients?
- Was hair removal done appropriately prior to surgery?
- Was the appropriate therapy to prevent blood clots ordered?
- Was the appropriate therapy to prevent blood clots given at the appropriate time?
- Was beta-blocker therapy continued for approprate patients?
- Was the urinary catheter removed within 2 days after surgery?
- Was the patient's temperature well controlled during surgery?

Surgical Care Improvement Measures Measures
( Higher is Better )

Measures
Performance Total
Performance Target
Graph & Details
Measure: Antibiotic discontinuation after surgery
Performance Total: 100 %
Performance Target: 100 %
Measure: Antibiotic selection appropriate for surgery
Performance Total: 100 %
Performance Target: 100 %
Measure: Antibiotics administered within 1 hour prior to incision
Performance Total: 100 %
Performance Target: 100 %
Measure: Appropriate Hair Removal
Performance Total: 100 %
Performance Target: 100 %
Measure: Beta-blocker Therapy
Performance Total: 100 %
Performance Target: 100 %
Measure: Temperature Management during Surgery
Performance Total: 100 %
Performance Target: 100 %
Measure: Urinary Catheter Removal
Performance Total: 100 %
Performance Target: 100 %
Measure: VTE Prevention Received
Performance Total: 100 %
Performance Target: 100 %