2014 Progress.

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Presentation transcript:

2014 Progress

Points to Remember Better Focus, Better Data Focusing the hospitals on an agreed upon measure set for 2014 has aligned data submission Comparisons and the AK State overall picture are easier to put together Not Every Measure, Not Every Month Data submission has improved across the board but there are still occasional months where hospitals fail to submit

CAUTI Rate of hospital-acquired CAUTI/1000 Cath Days N= 6 2 5 4 3 D= 1429 1574 1634 1511 1667 1533 1623 1320 1414 1396 963 Participating Hospitals: ANMC, AK Regional, Bartlett, Central Peninsula, Cordova, FMH, Maniilaq, Mt. Edgecumbe, PeaceHealth, Petersburg, South Peninsula, Wrangell

CLABSI Rate of hospital-acquired CLABSI /1000 Line Days 1 3 5 D= 1317 1165 1314 1157 1234 1343 1180 1167 1168 1306 849 631 Participating Hospitals: ANMC, AK Regional, Bartlett, Central Peninsula, FMH, Mt. Edgecumbe, PeaceHealth, South Peninsula

Falls Rate With, Without Injury /1000 Inpatient, Obs Days 24 26 27 18 22 19 25 14 12 D= 6466 5828 6790 6486 6291 6560 7041 5693 5793 5309 4545 4793 Participating Hospitals: ANMC, Bartlett, Central Peninsula, Cordova, FMH, Maniilaq, Mt. Edgecumbe, PeaceHealth, Petersburg, Sitka, South Peninsula, Wrangell

EEDs Rate of Elective Deliveries 37-39 Weeks /100 Patients 1 2 D= 29 33 24 40 27 30 31 22 26 25 34 Participating Hospitals: Central Peninsula, FMH, Mt. Edgecumbe, PeaceHealth, Sitka

Cesarean Frequency Rate/100 NTSV 12 7 10 13 15 6 9 8 14 D= 62 48 45 59 65 53 54 47 43 Participating Hospitals: Central Peninsula, FMH, Maniilaq, PeaceHealth, Sitka, South Peninsula

Pressure Ulcers Rate of hospital acquired stage III or greater ulcers /1000 discharges Participation dropped off in the last moths of the year N= 1 D= 1149 875 933 968 958 903 947 915 815 753 721 Participating Hospitals: Central Peninsula, Cordova, FMH, Maniilaq, Mt. Edgecumbe, PeaceHealth, Petersburg, Sitka, South Peninsula, Wrangell

Preventable Readmissions Rate of 30-day inpatient readmissions / 100 live discharges N= 130 120 141 131 122 129 114 128 163 151 D= 1707 1550 1706 1718 1738 1683 1715 1754 1639 1767 1660 Participating Hospitals: ANMC, Central Peninsula, Cordova, FMH, Maniilaq, Mt. Edgecumbe, PeaceHealth, Petersburg, Sitka, South Peninsula, Wrangell

Excessive Anticoagulation Rate of INR greater than 6 /100 patients on warfarin N= 10 3 1 7 5 8 4 D= 56 42 60 51 70 63 71 59 33 14 27 Participating Hospitals: AK Regional, Central Peninsula, Cordova, Maniilaq, Mt. Edgecumbe, PeaceHealth, Petersburg, South Peninsula, Wrangell

Hypoglycemia Among Inpatients Rate of hypoglycemia /100 inpatients receiving insulin N= 3 7 2 4 5 1 D= 143 157 153 142 144 150 137 140 114 86 74 Participating Hospitals: Central Peninsula, Cordova, PeaceHealth, Petersburg, Sitka, South Peninsula, Wrangell

ADEs Due to Opioids Rate of reversal agents needed /100 pts on opioids 7 8 9 3 4 2 1 D= 656 589 668 663 704 772 780 797 102 106 78 Participating Hospitals: Central Peninsula, Cordova, PeaceHealth, Petersburg, Wrangell

SSI Rate of Surgical Site Infections/ 100 Surg. Patients 2 4 1 3 D= 95 123 109 110 119 82 90 87 28 Participating Hospitals: ANMC, AK Regional, Bartlett, Central Peninsula, FMH, Mt. Edgecumbe, PeaceHealth, Petersburg, Sitka, South Peninsula

VAE Rate of Possible, Probable VAP / 1000 Vent Days 1 D= 403 448 347 331 427 451 393 299 330 Participating Hospitals: ANMC, AK Regional, Bartlett, Central Peninsula, FMH, Mt. Edgecumbe

VTE Rate of Non-Prophylaxis / 100 HAC-VTE Patients D= 8 14 10 3 2 1 4 Participating Hospitals: Bartlett, Central Peninsula, Mt. Edgecumbe, PeaceHealth, South Penn, Wrangell