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Quality Standards: Quality Report - 2008

Overall Summary of January '08 Preliminary Results

Heart Care

Meets or exceeds the national average in 9 core measures
Below the national average in 1 core measure

Pneumonia Care

Meets or exceeds the national average in 5 core measures
Below the national average in 2 core measures

Surgical Infection and Complication Prevention

Meets or exceeds the national average in 6 core measures

Indicators for Heart Attack Care

Heart attack, also called acute myocardial infarction (AMI) is a life-threatening event that is caused by insufficient oxygen reaching the heart. When a heart attack occurs, quick use of aspirin and other treatments can reduce damage to the heart and reduce the chance of death. The indicators in this section examine the initial care of heart attack patients and whether patients leave the hospital with medications known to be helpful after heart attack.

Core Measures	JPS Health Network January ‘08 Preliminary Results	National Average^*
Aspirin at arrival	100%	93%
Aspirin at discharge	88.9%	90%
ACE Inhibitor or ARB for LVSD	100%	85%
Adult: Smoking Cessation Advice	100%	91%
Beta Blocker at Discharge	100%	91%
Beta Blocker at Arrival	90.9%	88%

^*Source: Hospital Quality Alliance

ACE Inhibitor - any of a group of medications that relax arteries and help the body get rid of salt and water by affecting the activity of angiotensin converting enzyme (ACE). These medications are used to treat high blood pressure (hypertension).

Beta Blocker - medications that reduce the workload of the heart and lower blood pressure. They are commonly prescribed to relieve angina (a certain type of chest pain, pressure or discomfort) or to treat heart failure. They are also prescribed for people who have high blood pressure (hypertension).

Indicators for heart failure care

Heart failure, sometimes called congestive heart failure, is a long-term condition characterized by a weakening of the heart's pumping power. Heart failure becomes more common with age and has symptoms such as shortness of breath and a build up of fluid in the feet and legs. The indicators in this section measure the percent of heart failure patients getting all the recommended elements of care for heart failure.

Core Measures	JPS Health Network January ‘08 Preliminary Results	National Average^*
Discharge instructions	78.6%	66%
Evaluation of LVS function	100%	85%
ACEI or ARB for LVSD	87%	84%
Adult smoking cessation advice	100%	86%

^*Source: Hospital Quality Alliance

Indicators for pneumonia care

Data in this section reports on the initial care of pneumonia patients and the extent to which the hospital staff helps the patient prevent future lung problems.

Core Measures	JPS Health Network January ‘08 Preliminary Results	National Average^*
Oxygenation assessment	100%	99.6%
Pneumococcal vaccination	100%	75%
Blood cultures in ED before first abx	88.9%	90%
Adult smoking cessation advice	100%	84%
Antibiotic within 6 hours of hospital arrival	90%	82%
Initial antibiotic selection - nonICU patients	71.4%	86%
Influenza vaccine	93.3%	75%

^*Source: Hospital Quality Alliance

Indicators for surgical infection and complication prevention

This section reports on the hospital's overall performance for improving patient safety by reducing post-surgery complications.

Core Measures	JPS Health Network January ‘08 Preliminary Results	National Average^*
Prophylactic antibiotic received 1 hour prior to incision	89.8%	82%
Prophylactic antibiotic selection	97.9%	90%
Antibiotic discontinued within 24 hour post surgery end	91.7%	78%
Surgery patients with VTE prophylaxis ordered	92.2%	79%
Patients received appropriate VTE prophylaxis within 24 hours prior to surgery to 24 hours after surgery	84.3%	75%
Patients on beta blockers PTA who received beta blockers perioperatively	86.7%	83%

^*Source: Hospital Quality Alliance