The King's Daughters' Hospital and Health Services

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KDH Quality Data

Process of care measures

King's Daughters' Hospital and Health Services (KDHHS) is proud to participate in the Centers for Medicare and Medicaid (CMS) program for public reporting of quality data. The measures below are selected by CMS and each indicator represents a key process of care measure. These measures are determined by CMS to be national standards of quality care. The information below is updated to show the most current KDHHS data available compared to national and state averages. An NA indicates there were not enough qualifying patients for that particular Quality Measure during the quarter involved. Data is updated as the next quarter's data becomes available.

MEASURE 1: ACUTE MYCARDIAL INFARCTION (AMI - heart attack)

AMI-1: Aspirin at arrival
What does this care measure mean?

The heart is a muscle that gets oxygen through blood vessels. Sometimes blood clots can block these blood vessels, and the heart can’t get enough oxygen. This can cause a heart attack. Chewing an aspirin as soon as symptoms of a heart attack begin may help reduce the severity of the attack. This chart shows the percent of heart attack patients who were given (or took) aspirin within 24 hours of arrival at the hospital.

National Average
July '09 - June '10
99%

State Average
July '09 - June '10
98%

KDHHS
1^st Q 2011
100%

4^th Q 2010
100%

3^rd Q 2010
100%

2^nd Q 2010
100%

AMI-2: Aspirin at discharge
What does this care measure mean?

Blood clots can block blood vessels. Aspirin can help prevent blood clots from forming or help dissolve blood clots that have formed. Following a heart attack, continued use of aspirin may help reduce the risk of another heart attack. Aspirin can have side effects like stomach inflammation, bleeding, or allergic reactions. Talk to your health care provider before using aspirin on a regular basis to make sure it’s safe for you.

National Average
July '09 - June '10
98%

State Average
July '09 - June '10
99%

KDHHS
1^st Q 2011
100%

4^th Q 2010
100%

3^rd Q 2010
100%

2^nd Q 2010
NA

AMI-3: ACEI or ARB for LVSD
What does this care measure mean?

ACE (angiotensin converting enzyme) inhibitors and ARBs (angiotensin receptor blockers) are medicines used to treat patients with heart failure and are particularly beneficial in those patients with heart failure and decreased function of the left side of the heart. Early treatment with ACE inhibitors and ARBs in patients who have heart failure symptoms or decreased heart function after a heart attack can also reduce their risk of death from future heart attacks. ACE inhibitors and ARBs work by limiting the effects of a hormone that narrows blood vessels, and may thus lower blood pressure and reduce the work the heart has to perform. Since the ways in which these two kinds of drugs work are different, your doctor will decide which drug is most appropriate for you. If you have a heart attack and/or heart failure, you should get a prescription for ACE inhibitors or ARBs if you have decreased heart function before you leave the hospital.

National Average
July '09 - June '10
96%

State Average
July '09 - June '10
96%

KDHHS
1^st Q 2011
100%

4^th Q 2010
NA

3^rd Q 2010
NA

2^nd Q 2010
NA

AMI-4: Adult Smoking Cessation
What does this care measure mean?

Smoking increases your risk for developing blood clots and heart disease that can result in a heart attack, heart failure or stroke. Smoking causes your arteries to thicken and your blood vessels to narrow. Fat and plaque stick to the walls of your arteries, which makes it harder for blood to flow. Reduced blood flow to your heart may result in chest pain, high blood pressure, and an increased heart rate. Smoking is also linked to lung disease and cancer, and can cause premature death. It is important that you get information to help you quit smoking before you leave the hospital. Quitting may help prevent another heart attack.

National Average
July '09 - June '10
99%

State Average
July '09 - June '10
99%

KDHHS
1^st Q 2011
NA

4^th Q 2010
NA

3^rd Q 2010
100%

2^nd Q 2010
NA

AMI-5: Beta Blocker at discharge
What does this care measure mean?

Beta blockers are a type of medicine that is used to lower blood pressure, treat chest pain (angina) and heart failure, and to help prevent a heart attack. Beta blockers relieve the stress on your heart by slowing the heart rate and reducing the force with which your heart muscles contract to pump blood. They also help keep blood vessels from constricting in your heart, brain, and body. If you have a heart attack, you should get a prescription for a beta blocker before you leave the hospital.

National Average
July '09 - June '10
98%

State Average
July '09 - June '10
98%

KDHHS
1^st Q 2011
100%

4^th Q 2010
83%

3^rd Q 2010
75%

2^nd Q 2010
NA

MEASURE 2: HEART FAILURE

HF-1: Discharge Instructions
What does this care measure mean?

Heart failure is a chronic condition. It results in symptoms such as shortness of breath, dizziness, and fatigue. Before you leave the hospital, the staff at the hospital should provide you with information to help you manage the symptoms after you get home. The information should include your activity level (what you can and can't do), diet (what you should, and shouldn't eat or drink), medications, follow-up appointment, watching your daily weight, what to do if your symptoms get worse.

National Average
July '09 - June '10
88%

State Average
July '09 - June '10
84%

KDHHS
1^st Q 2011
100%

4^th Q 2010
96%

3^rd Q 2010
100%

2^nd Q 2010
99%

HF-2: LVF Assessment
What does this care measure mean?

The proper treatment for heart failure depends on what area of your heart is affected. An important test is to check how your heart is pumping, called an “evaluation of the left ventricular systolic function.” It can tell your health care provider whether the left side of your heart is pumping properly. Other ways to check on how your heart is pumping include: your medical history, a physcial examination, listening to your heart sounds, other tests as ordered by a physicain (like an ECG (electrocardiogram), chest x-ray, blood work, and an echocardiogram), what to do if your symptoms get worse.

National Average
July '09 - June '10
98%

State Average
July '09 - June '10
98%

KDHHS
1^st Q 2011
100%

4^th Q 2010
100%

3^rd Q 2010
100%

2^nd Q 2010
99%

HF-3: ACEI or ARB for LVSD
What does this care measure mean?

National Average
July '09 - June '10
94%

State Average
July '09 - June '10
92%

KDHHS
1^st Q 2011
100%

4^th Q 2010
100%

3^rd Q 2010
NA

2^nd Q 2010
97%

HF-4: Adult Smoking Counseling
What does this care measure mean?

Smoking increases your risk for developing blood clots and heart disease, which can result in a heart attack, heart failure or stroke. Smoking causes your blood vessels to thicken. Fat and plaque then stick to the wall of your blood vessels, which makes it harder for blood to flow. Reduced blood flow to your heart may result in chest pain, high blood pressure, and an increased heart rate. Smoking is linked to lung disease and cancer, and can cause premature death. It is important for your health that you get information to help you quit smoking before you leave the hospital.

National Average
July '09 - June '10
98%

State Average
July '09 - June '10
99%

KDHHS
1^st Q 2011
100%

4^th Q 2010
100%

3^rd Q 2010
100%

2^nd Q 2010
100%

MEASURE 3: PNEUMONIA

PN-2: Pneumococcal Screen/Vaccination
What does this care measure mean?

The pneumococcal vaccine may help you prevent, or lower the risk of complications of pneumonia caused by bacteria. It may also help you prevent future infections. Patients with pneumonia should be asked if they have been vaccinated recently for pneumonia and, if not, should be given the vaccine.

National Average
July '09 - June '10
93%

State Average
July '09 - June '10
94%

KDHHS
1^st Q 2011
100%

4^th Q 2010
100%

3^rd Q 2010
100%

2^nd Q 2010
100%

PN-3B: Blood Cultures
What does this care measure mean?

Different types of bacteria can cause pneumonia. A blood culture is a test that can help your health care provider identify which bacteria may have caused your pneumonia, and which antibiotic should be prescribed. A blood culture is not always needed, but for patients who are first seen in the hospital emergency department, it is important for the accuracy of the test that blood culture be conducted before any antibiotics are started. It is also important to start antibiotics as soon as possible.

National Average
July '09 - June '10
96%

State Average
July '09 - June '10
95%

KDHHS
1^st Q 2011
100%

4^th Q 2010
100%

3^rd Q 2010
100%

2^nd Q 2010
99%

PN-4: Adult Smoking Counseling
What does this care measure mean?

Smoking damages your lungs and can make it hard to breath. Smoking increases your chances of getting pneumonia or other chronic lung diseases like emphysema and bronchitis. Smoking is also linked to lung cancer, heart disease, and stroke, and can cause premature death. It is important for you to get information to help you quit smoking before you leave the hospital. Quitting may reduce your chance of getting pneumonia again.

National Average
July '09 - June '10
97%

State Average
July '09 - June '10
98%

KDHHS
1^st Q 2011
100%

4^th Q 2010
100%

3^rd Q 2010
100%

2^nd Q 2010
100%

PN-5C: Initial Antibiotic Received within 6 hours
What does this care measure mean?

Antibiotics are used to treat adults with pneumonia caused by bacteria. Early treatment with antibiotics can cure bacterial pneumonia and reduce the possibility of complications. This information shows the percent of patients who were given their first dose of antibiotics within 6 hours of arrival at the hospital. Patients who get pneumonia during their stay at the hospital are not counted in this measure.

National Average
July '09 - June '10
95%

State Average
July '09 - June '10
96%

KDHHS
1^st Q 2011
100%

4^th Q 2010
98%

3^rd Q 2010
97%

2^nd Q 2010
99%

PN-6B: Initial Antibiotic Selection for Immunization (non-ICU)
What does this care measure mean?

Pneumonia is a lung infection that is usually caused by bacteria or a virus. If pneumonia is caused by bacteria, hospitals will treat the infection with antibiotics. Different bacteria are treated with different antibiotics. To learn about how hospitals use a blood test to choose the most effective treatment for pneumonia patients, refer to the Process of Care measure named 'Percent of Pneumonia Patients Whose Initial Emergency Room Blood Culture Was Performed Prior To The Administration Of The First Hospital Dose Of Antibiotics'.

National Average
July '09 - June '10
92%

State Average
July '09 - June '10
90%

KDHHS
1^st Q 2011
100%

4^th Q 2010
91%

3^rd Q 2010
95%

2^nd Q 2010
95%

PN-7: Pneumonia Patients Assessed and Given Influenza Vaccination
What does this care measure mean?

Flu shots reduce the risk of influenza, a serious and sometimes deadly lung infection that can spread quickly in a community or facility. Hospitals should check to make sure that pneumonia patients, particularly those who are age 50 or older, get a flu shot during flu season to protect them from another lung infection and to help prevent the spread of influenza. Since a flu shot is effective for just one flu season, the period of time used to calculate this rate is the flu season (from approximately November through March), in contrast to other measures on Hospital Compare, which are generally collected throughout the year. Higher percentages are better.

National Average
July '09 - June '10
91%

State Average
July '09 - June '10
93%

KDHHS
1^st Q 2011
100%

4^th Q 2010
100%

3^rd Q 2010
NA

2^nd Q 2010
100%

MEASURE 4: SCIP - SURGICAL INFECTION PREVENTION

SCIP-1: Prophylactic Antibiotic within 1 hour of cut
What does this care measure mean?

Antibiotics are medicines to prevent and treat infections. Research shows that surgery patients who get antibiotics within the hour before their operation are less likely to get wound infections. Getting an antibiotic earlier, or after surgery begins, is not as effective. This shows how often hospitals make sure surgery patients get antibiotics at the right time.

National Average
July '09 - June '10
97%

State Average
July '09 - June '10
97%

KDHHS
1^st Q 2011
100%

4^th Q 2010
100%

3^rd Q 2010
94%

2^nd Q 2010
99%

SCIP-2: Antibiotic Selection
What does this care measure mean?

Certain antibiotics are recommended to help prevent wound infection for particular types of surgery. This measure looks at how often hospital surgical patients get the appropriate antibiotic in order to prevent a surgical wound infection. Infections continue to be the main preventable complication of most surgical procedures. Antibiotics are medicines to prevent and treat infections. By following the standard guidelines for timing and giving you the correct antibiotic drug, hospitals can reduce your risk of getting a wound infection after surgery. Hospitals can reduce the risk of wound infection after surgery by making sure patients get the right medicines at the right time on the day of their surgery. These quality measures show some of the standards of care.

National Average
July '09 - June '10
97%

State Average
July '09 - June '10
98%

KDHHS
1^st Q 2011
100%

4^th Q 2010
93%

3^rd Q 2010
94%

2^nd Q 2010
100%

SCIP-3: Prophylactic Antibiotic discontinued 24 hours post close
What does this care measure mean?

Antibiotics are medicines to prevent and treat infections. While the likelihood of infection after surgery can be reduced by giving patients preventative antibiotics, taking these antibiotics for more than 24 hours after routine surgery is usually not necessary and can increase the risk of side effects such as stomach aches, serious types of diarrhea, and antibiotic resistance (when antibiotics are used too much, they will not work anymore.) There are exceptions – for example, where the surgical site has been contaminated (making the surgery not routine).Talk to your doctor if you have questions about how long you should take antibiotics after surgery.

National Average
July '09 - June '10
94%

State Average
July '09 - June '10
95%

KDHHS
1^st Q 2011
100%

4^th Q 2010
93%

3^rd Q 2010
94%

2^nd Q 2010
96%

SCIP-C2: Patients who were taking heart drugs called beta blockers before coming to the hospital
What does this care measure mean?

It is often standard procedure to stop patients’ usual medications for awhile before and after their surgery. But if patients who have been taking beta blockers suddenly stop taking them, they can have heart problems such as a fast heart beat. For these patients, staying on beta blockers before and after surgery makes it less likely that they will have heart problems. Higher percentages are better.

National Average
July '09 - June '10
93%

State Average
July '09 - June '10
93%

KDHHS
1^st Q 2011
100%

4^th Q 2010
93%

3^rd Q 2010
100%

2^nd Q 2010
NA

SCIP-6: Patients needing hair removed from the surgical area before surgery
What does this care measure mean?

Preparing a patient for surgery may include removing body hair from skin in the area where the surgery will be done. Medical research has shown that shaving with a razor can increase the risk of infection. It is safer to use electric clippers or hair removal cream. Higher percentages are better.

National Average
July '09 - June '10
99%

State Average
July '09 - June '10
100%

KDHHS
1^st Q 2011
96%

4^th Q 2010
100%

3^rd Q 2010
100%

2^nd Q 2010
100%

SCIP-V1: Patients whose doctors ordered treatments to prevent blood clots after certain types of surgeries
What does this care measure mean?

Certain surgeries increase the risk that the patient will develop a blood clot (venous thromboembolism). When patients stay still for a long time after some types of surgery, they are more likely to develop a blood clot in the veins of the legs, thighs, or pelvis. A blood clot slows down the flow of blood, causing swelling, redness, and pain. A blood clot can also break off and travel to other parts of the body. If the blood clot gets into the lung, it is a serious problem that can cause death. To help prevent blood clots from forming after surgery, doctors can order treatments to be used just before or after the surgery. These include blood-thinning medications, elastic support stockings, or mechanical air stockings that help with blood flow in the legs. Higher percentages are better.

National Average
July '09 - June '10
94%

State Average
July '09 - June '10
92%

KDHHS
1^st Q 2011
93%

4^th Q 2010
100%

3^rd Q 2010
100%

2^nd Q 2010
96%

SCIP-V2: Patients who got treatment at the right time (within 24 hours before or after their surgery)
What does this care measure mean?

Many factors influence a surgery patient’s risk of developing a blood clot, including the type of surgery. When patients stay still for a long time after some types of surgery, they are more likely to develop a blood clot in the veins of the legs, thighs, or pelvis. A blood clot slows down the flow of blood, causing swelling, redness, and pain. A blood clot can also break off and travel to other parts of the body. If the blood clot gets into the lung, it is a serious problem that can sometimes cause death. Treatments to help prevent blood clots from forming after surgery include blood-thinning medications, elastic support stockings, or mechanical air stockings that help with blood flow in the legs. These treatments need to be started at the right time, which is typically during the period that begins 24 hours before surgery and ends 24 hours after surgery. Higher percentages are better.

National Average
July '09 - June '10
92%

State Average
July '09 - June '10
90%

KDHHS
1^st Q 2011
93%

4^th Q 2010
100%

3^rd Q 2010
100%

2^nd Q 2010
96%

*NA - The number of cases is too small (less than 25) to reliably tell how well a hospital is performing

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