Catholic Health Services of Long Island Network Composite Scores for Specified Health Conditions

Heart Attack Composite Score

Represents the aggregate result from the following standard performance measures:

• Aspirin given at arrival
• Aspirin prescribed at discharge
• ACE Inhibitor or ARB given for Left Ventricular Systolic Dysfunction (LVSD)
• Smoking Cessation advice/counseling provided
• Beta Blocker prescribed at discharge
• Fibrinolytic medication given within 30 minutes of arrival
• Percutaneous Coronary Intervention within 90 minutes of arrival

Heart Failure Composite Score

Represents the aggregate result from the following standard performance measures:

• Discharge Instructions provided
• Evaluation of Left Ventricular Systolic (LVS) Function provided
• ACE Inhibitor or ARB given for Left Ventricular Systolic Dysfunction (LVSD)
• Smoking Cessation advice/counseling provided

Pneumonia Composite Score

Represents the aggregate result from the following standard performance measures:

• Oxygen assessment provided
• Pneumococcal Vaccination assessment and administration
• Blood cultures performed prior to administration of first dose of antibiotics
• Smoking Cessation advice/counseling provided
• Initial antibiotics provided within 6 hours after arrival
• Most appropriate initial antibiotic provided
• Influenza Vaccination assessment and administration

Surgical Infection Composite Score

Represents the aggregate result from the following standard performance measures:

• Preventative antibiotic given within 1 hour of surgery
• Most appropriate preventative antibiotic administered
• Preventative antibiotic discontinued within 24 hours of surgery
• Blood sugar kept under control after surgery
• Hair removed from surgical area utilizing a safer method
• Treatments to prevent blood clots ordered
• Treatments to prevent blood clots received within 24 hours of surgery
• Beta blocker prior to admission and perioperatively (New as of 1Q09)

Stroke Care

A stroke is a type of disease that affects the blood vessels leading to and within the brain. A stroke occurs when the blood supply to the brain is interrupted due to a clot or leakage of a blood vessel into the brain. When this happens, brain cells quickly begin to die. Treating stroke quickly and effectively is the difference between ability and disability or even life and death. The first step in this process is to be taken to a hospital that is experienced and fully equipped to provide an accurate diagnosis and rapid treatment. Your brain is your body’s most vital and delicate organ. Immediate response is crucial because every minute lost, from the onset of symptoms to the time of emergency contact, cuts into the limited window of opportunity for intervention.

The most common stroke symptoms are:

• Sudden numbness or weakness of face, arm or leg, especially on one side of the body
• Sudden confusion, trouble speaking or understanding
• Sudden trouble seeing in one or both eyes
• Sudden trouble walking, dizziness, loss of balance or coordination
• Sudden severe headache with no known cause

If you see someone having these symptoms or experience any of these symptoms yourself, call 911 immediately. Treatment can be more effective if given quickly. Every minute counts. These common symptoms of stroke can be remembered by the acronym FAST. If you think someone may be having a stroke, act FAST and do this simple test:

• F = Face: Ask the person to smile. Is one side of the face drooping down?
• A = Arms: Ask the person to raise both arms. Does one arm drift downward?
• S = Speech: Ask the person to repeat a simple sentence. Are the words slurred? Can he/she repeat the sentence correctly?
• T = Time: If the person shows any sign of these symptoms, time is important. Call 911 or get to a hospital fast. Brain cells are dying.

Catholic Health Services of Long Island is committed to optimizing the care of stroke patients through the implementation of evidence-based clinical practice guidelines. To sustain continuous improvement and monitor performance, our hospitals participate in the American Heart Association’s Get-With-the-Guidelines program which ensures stroke patients are treated appropriately from admission to discharge. Appropriate recommended care for stroke patients includes timely administration of specific medications, advising smokers to quit, and giving written instructions and education upon discharge from the hospital. A composite score is a single score that reflects the following aspects of Stroke care when appropriate: The care measures that have been implemented and monitored include:

• Timely administration of Intravenous Tissue Plasminogen Activator (IV t-PA) “clot-busting” medication
• Early administration of antithrombotic therapy to help prevent blood clots and to reduce the risk of early recurrent stroke
• Early administration of deep vein thrombosis (DVT) therapy to help reduce the risk of developing blood clots in the legs
• Prescribing antithrombotic therapy at discharge to help lower the risk of future strokes
• Prescribing anticoagulation therapy at discharge for patients with an irregular heart rate (Atrial Fibrillation or AF) to help lower the risk of blood clotting
• Prescribing cholesterol-reducing medication at discharge to help lower Low Density Lipoprotein (LDL) to less than 100
• Provide advice and/or counseling to stop smoking
• Perform a Swallow or Dysphagia screen before being given any food, fluids or medication by mouth
• Provide Stroke Education or education materials prior to discharge
• Assess the need for Rehabilitation services

Heart Attack

A Heart Attack (also called an acute myocardial infarction) happens when the blood vessels leading to the heart become blocked and the blood supply is slowed or stopped. When the heart muscle can’t get the oxygen and nutrients it needs, the part of the heart tissue that is affected may die. The symptoms of a heart attack can include:

• Chest pain (often described as a crushing, squeezing or burning pain in the center of the chest and may radiate to the arm or jaw)
• Shortness of breath
• Dizziness or faintness
• Sweating
• Nausea
• Cold or clammy skin
• A gray or very ill appearance

Sometimes there may be no symptoms, especially if you have diabetes. Appropriate recommended care includes giving aspirin and beta blockers on arrival to hospital, advising smokers to quit, and prescribing specific medications upon discharge from the hospital. A composite score is a single score that reflects the following aspects of Heart Attack care when appropriate.

Process Measure/ Why it is Important

Percent of Heart Attack Patients Given Aspirin at Arrival - Aspirin can help keep blood clots from forming and dissolve blood clots that can cause heart attacks.

Percent of Heart Attack Patients Given Aspirin at Dischargen - Taking aspirin may help prevent further heart attacks.

Percent of Heart Attack Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) - ACE (angiotensin converting enzyme) inhibitors and ARBs (angiotensin receptor blockers) are medicines used to treat heart attacks, heart failure, or a decreased function of the heart. There may be reasons not to prescribe these medications based on other conditions affecting a patient’s health.

Percent of Heart Attack Patients Given Smoking Cessation Advice/Counseling - Smoking is linked to heart attacks. Quitting may help prevent another heart attack.

Percent of Heart Attack Patients Given Beta Blocker at Discharge - Beta blockers are a type of medicine used to lower blood pressure, treat chest pain (angina) and heart failure, and to help prevent a heart attack. There may be reasons not to prescribe these medications based on other conditions affecting a patient’s health.

Percent of Heart Attack Patients Given Fibrinolytic Medication Within 30 Minutes Of Arrival - Blood clots can cause heart attacks. Doctors may give this medicine, or perform a procedure to open the blockage, and in some cases, may do both.

Percent of Heart Attack Patients Given PCI Within 90 Minutes Of Arrival - The procedures called Percutaneous Coronary Interventions (PCI) are among those that are the most effective for opening blocked blood vessels that cause heart attacks. Doctors may perform PCI, or give medicine to open the blockage, and in some cases, may do both. Not every organization offers PCI in their scope of services.

Heart Failure

Heart failure is a weakening of the heart’s ability to pump enough blood to meet the nutrient and oxygen needs of the body’s other organs. This can cause fluid to build up in the body, which is seen as swelling (edema), most commonly in the lower legs and ankles. Fluid can also collect in the lungs and interfere with breathing, causing shortness of breath. Your heart tries to pump more blood, but the muscle walls become weaker over time.

Symptoms of heart failure may include:

• Shortness of breath from fluid in the lungs
• Swelling (such as in legs, ankles or abdomen)
• Dizziness
• Fatigue
• Weakness
• Cold or clammy skin
• A rapid or irregular heartbeat.

Heart failure can be a result of heart condition due to:

• hardening of the arteries, also known as coronary artery disease,
• a heart attack,
• cardiomyopathy (heart muscle damage from infection or alcohol or drug abuse),
• or an overworked heart (caused over time by conditions like high blood pressure, kidney disease, diabetes, or a defect from birth).

Appropriate recommended care for Heart Failure includes assessing heart function, advising smokers to quit, and prescribing specific medications and giving written instructions upon discharge from the hospital. A composite score is a single score that reflects the following aspects of Heart Failure care when appropriate:

• Heart Failure Care Measure
• Brief Explanation
• Providing Discharge Instructions

The staff at the hospital should provide you with information to help you manage your heart failure symptoms when you are discharged.

• Evaluation of Left Ventricular Systolic (LVS)
• Function: An evaluation of the LVS function checks how the left chamber of the heart is pumping. Prescribing ACE Inhibitor or ARB (heart medication) for Left Ventricular Systolic
• Dysfunction (LVSD): ACE (angiotensin converting enzyme) inhibitors and ARBs (angiotensin receptor blockers) are medicines used to treat heart attacks, heart failure, or a decreased function of the heart.
• Smoking Cessation Advice/Counseling. Smoking is linked to heart failure. Quitting may help improve your condition.

Surgical Infection

Hospitals can improve surgical care and reduce the risk of wound infection after surgery by providing the right medicines at the right time on the day of surgery. There are also steps that you, as a patient, can take to make sure the surgery is as safe as possible. For example, your doctor or nurse can tell you how to wash with an antibiotic soap the day before surgery. You can also give your doctor or nurse a list of all your medications, including vitamins, herbal medicines, and over-the-counter medications. You should also tell your doctor or nurse about any allergies and bad reactions to anesthesia.

Sometimes patients get an infection after surgery, even if the hospital took steps to prevent it. Here are signs to look out for:

• The surgical wound is red, hot, and swollen.
• You have a fever of over 100 degrees after you go home.
• A smelly or yellow/green fluid is coming out of the wound.
• Your pain is increasing even though you are taking pain medication.

Call your doctor or local hospital immediately if you have any of these signs.

A composite score is a single score that reflects the following aspects of surgical care when appropriate.

SURGICAL CARE IMPROVEMENT PROJECT CARE MEASURE

PREVENTING BLOOD CLOTS

• Treatment ordered to prevent blood clots after certain types of surgeries
• Certain types of surgery can increase patients’ risk of having blood clots after surgery. For these types of surgery, this measure tells how often treatment to help prevent blood clots was ordered by the doctor.
• Treatment ordered at the right time (within 24 hours before or after their surgery) to help prevent blood clots after certain types of surgery
• This measure tells how often patients having certain types of surgery received treatment to prevent blood clots in the period from 24 hour s before surgery to 24 hours after surgery.

Pneumonia

Pneumonia is a serious infection and/or inflammation of the lungs. It is caused by a viral or bacterial infection that fills your lungs with mucus. This lowers the oxygen level in your blood and can cause your body’s cells to not work properly. Symptoms of pneumonia can include the following:

• Difficulty breathing
• "Wet" cough. Your mucus may look green or bloody.
• Chest pain
• Fever and chills
• Fatigue

Appropriate recommended care for pneumonia includes:

• Performing blood cultures when indicated
• Oxygen assessment
• Selecting and administering antibiotics in the Emergency Department within 4 hours of arrival
• Assessing vaccination status
• And advising patients to quit smoking.

A composite score is a single score that reflects the following aspects of Pneumonia care when appropriate: Pneumonia Care Measure Brief Explanation

• Oxygenation assessment : Having enough oxygen in your blood is important to your health.
• Pneumococcal vaccination: A pneumonia (pneumococcal) shot can help prevent pneumonia in the future, even for patients who have been hospitalized for pneumonia.
• Blood Culture performed prior to the administration of the first hospital dose of antibiotics: A blood culture tells what kind of medicine will work best to treat your pneumonia.
• Smoking Cessation Advice/Counseling: Smoking is linked to pneumonia. Quitting may help prevent you from getting pneumonia again.
• Initial Antibiotic(s) within 6 Hours after arrival: Timely use of antibiotics can improve the treatment of pneumonia caused by bacteria.
• Appropriate initial antibiotic(s): Antibiotics are medicines that treat infection, and each one is different. Hospitals should choose the antibiotics that best treat the infection type for each pneumonia patient.
• Percent of Pneumonia Patients Assessed and Given Influenza Vaccination: An influenza shot can help prevent influenza in the future, even for patients who have been hospitalized for pneumonia.

Ventilator-Associated Pneumonia

Weakened by critical illness or surgical trauma, many patients in hospital intensive care units (ICUs) are unable to breathe without the aid of mechanical ventilators. These machines pump air into struggling lungs through tubes inserted into airways, giving severely stressed patients time to regain the energy and strength to breathe on their own.

Though often vital and life-sustaining, ventilators can turn into a hazard for patients when the tubes delivering air also allow bacteria or secretions to enter the lungs. As many as 15 percent of ICU patients on breathing machines develop ventilator-associated pneumonia (VAP). Already debilitated by their medical conditions, patients often have little ability to fight off the added assault.

Content source: Institute for Healthcare Improvement

Central Line-Associated Bloodstream Infection

Central lines are commonly used in the inpatient and outpatient settings to provide long-term venous access. Central lines disrupt the integrity of the skin, making infection with bacteria and/or fungi possible. Infection may spread to the bloodstream (bacteremia) and hemodynamic changes and organ dysfunction (severe sepsis) may ensue possibly leading to death. Approximately 90 percent of the catheter-related bloodstream infections are related to central lines.

Forty-eight percent of ICU patients have central lines according to the IHI. Care bundles, in general, are groupings of best practices with respect to a disease process that individually improve care, but when applied together result in substantially greater improvement. The science supporting the bundle components is sufficiently established to be considered standard of care.

The Central Line Bundle is a group of evidence-based interventions for patients with intravascular central catheters that, when implemented together, result in better outcomes than when implemented individually.

The key components of the Central Line Bundle are:

• Hand Hygiene
• Maximal Barrier Precautions Upon Insertion
• Chlorhexidine Skin Antisepsis
• Optimal Catheter Site Selection, with Avoidance of the Femoral Vein for Central Venous Access in Adult Patients
• Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines

Content Source: Institute for Healthcare Improvement

*Note: NHSN revised CLAB definition in 2008 (wider scope) which resulted in an increase in identified infections. Benchmark Source: National Health Safety Network (NHSN) 2006-2007 Data Summary Medical ICU Median (50th Percentile) Published in American Journal of Infection Control (AJIC), Issued November 2008