Positive Patient Outcomes

Collecting and analyzing health care data is a critical means of assessing the quality of patient health care services. Care metrics help facilities identify opportunities for improvement, pinpoint areas that need targeted solutions, and help an organization keep a pulse on how it is performing, all with the ultimate goal of achieving and maintaining high quality performance and positive patient outcomes.

Care Metrics

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Sepsis is a life-threatening infection that materializes when the body’s present infection causes a series of events throughout the body. This can lead to tissue damage, organ failure and death if not treated on time.

One of the ways clinicians treat patients with sepsis is by utilizing an evidence based, standardized sepsis bundle. Bundles are made up of a group of clinical components such as lab tests, medications, fluids, etc. that have been identified to help treat the infection on-time and improve the outcome of the patient. The appropriate use of a sepsis bundle can help with achieving positive patient outcomes.

Given the high rate of sepsis in our community, Catholic Health has developed a system-wide Sepsis Program that uses evidence-based, best practice methods for early recognition and treatment in Sepsis prevention. Here at Catholic Health, one of our organizational goals is to become a High Reliability Organization, prioritizing safety practices and design workflows that decrease potential harm to our patients.

The Sepsis Program was designed to reduce poor outcomes, align with federal and state regulatory requirements, and move the organization toward the top tier, nation-wide, for outstanding care and treatment of the Septic patient.  The program is driven by an Executive Steering Committee that is lead by physicians, nurses, infection prevention and other clinical service disciplines.

Although NYSDOH suspended reporting of data for the sepsis program in 2020 due to the COVID pandemic, Catholic Health continued to treat patients according to best practices to help ensure the best possible health outcomes for this patient population.

Sepsis 3HR Graph

Sepsis 6HR Graph

Catholic Health 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. The performance 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 70
  • Provide advice and/or counseling to stop smoking
  • Perform a swallow or dysphagia screen before patient is given any food, fluids or medication by mouth
  • Provide stroke education or education materials prior to discharge
  • Assess the need for rehabilitation services

The following charts represent Catholic Health composite scores for the stroke condition. A composite score is an individual score that represents a hospital’s overall performance for the specified condition. It is calculated by adding together the results of all of the performance measures within the specified condition. Higher scores represent better performance.

Stroke Guidelines
Stroke Guidelines 2

Catholic Health's neuroscience team offers advanced treatments and care for stroke patients. Our six hospitals across Long Island are New York State Department of Health-designated stroke centers. All have been recognized by the American Heart Association/American Stroke Association’s Get With The Guidelines® program for meeting quality standards for rapid diagnosis and treatment of stroke.

A fall with injury is defined as an unplanned drop to the ground that can result in an injury. Catholic Health Falls Prevention Committee monitors all falls that happen within Catholic Health. This committee is made up of staff from our care teams. These committee members are dedicated subject matter experts in the prevention of falls whose goal is to keep all patients safe. The committee meets on a reoccurring basis to review all falls and fall prevention best practices. Committee focuses are:

  • Decreasing the number of falls with injury within all Catholic Health facilities
  • Providing education on falls prevention and systematizing our Falls Prevention Policy
  • Focusing on wellness and healthy approaches to falls prevention upon discharge of Catholic Health patients to home

Catholic Health continues to explore ways to reduce the number of falls at our facilities and keep our patients, families, and staff safe.

Falls with injury acute care graphic
Falls with injury skilled nursing graphic


falls with injury home care graphic
Falls with injury good shep hospice graphic


Central line-associated bloodstream infection (CLABSI)—Catholic Health Home Care

Central line-associated bloodstream infection (CLABSI) is a serious infection that occurs when germs (usually bacteria or viruses) enter the bloodstream through the central line. Health care providers must follow a strict protocol when inserting the line to make sure the line remains sterile and a CLABSI does not occur. In addition to inserting the central line properly, health care providers must use stringent infection control practices each time they check the line or change the dressing. Patients who get a CLABSI have a fever, and might also have red skin and soreness around the central line.

To address this issues and eliminate harm associated with CLABSI infections Catholic Health Home Care had adopted a strict policy and procedure on care and maintenance of central lines adopted from Infusion Nurse Society manual that sets the standards of practice for infusion in the healthcare industry. The procedure requires a strict maintenance of sterile technique by clinicians that is taught and consistently evaluated during the nursing competencies as well as supervisory visits.

As a result of strict adherence to best practices defined in policy and procedure, our infusion team is proud to sustain Zero Harm caused to our patients, or no reported CLABSI infections, from 2017 to present.



Antibiotic Stewardship—Skilled Nursing Facilities (SNF)

Antibiotic Stewardship became a focus in nursing homes with information from the CDC, “Core Elements of Antibiotic Stewardship for Nursing Homes,” which indicated that studies performed showed 40-75% of antibiotics prescribed maybe unnecessary or inappropriate.

Catholic Health skilled nursing facilities (SNFs) reviewed the materials and provided interdisciplinary education while initiating a focus on Antibiotic Stewardship. In 2018, the SNFs formulated protocols of care for the most common infectious processes indicating non-antibiotic management of symptoms and indicators of when there was acceptable use of antibiotics. Medical and nursing staff were educated on the protocols of care. Infection preventionists were provided with tracking tools for documentation of infection management, which also indicated whether the protocols of care were followed.

In 2018, the facilities added a new indicator tracking compliance with the antibiotic protocols. There has been progressive improvement in this indicator since 2018 with a current benchmark of 20% for Antibiotics Not Meeting Protocol.


Antibiotic Stewardship Graph