Our Commitment to Quality and Patient Safety Core Measures

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1 Calvert Memorial Hospital is committed to our community, with a focus on patient-centered care. High quality and safe patient care is not our goal, it is our priority. That means delivering the best possible care to every person, every time. We are dedicated to improving the way we do things on a continual basis. Calvert Memorial Hospital's "Six Pillars of Excellence" guides our decision making and shapes the culture of our organization. The first pillar that supports our outstanding organization is Quality. CMH provides responsible, safe, reliable and effective care and services. We take pride in what we do. What are? "Core measures" is the name of a nationwide study in which all accredited hospitals participate. It is designed to help hospitals provide the highest quality outcomes based on the latest research available. These standards were initially presented to hospitals in 2000 from the Center of Medicare and Medicaid Services (CMS). Hospitals began publicly reporting their outcomes in Calvert Memorial Hospital participates in five of these measures: Heart Attack (AMI), Pneumonia (PN), Heart Failure (HF), Surgical Care Improvement Project (SCIP), Children's Asthma Care (CAC), and Venous Thromboembolism (VTE). Calvert Memorial Hospital strives to achieve 100% compliance in all measures. We are constantly evaluating and improving on processes to meet and exceed our goals. We always put our patients first and are committed to providing the safest quality outcomes for our community. Heart Attack (AMI) A heart attack, also called an acute myocardial infarction (AMI), happening when one of the heart s arteries becomes blocked and the supply of blood and oxygen to part of the heart muscle is slowed or stopped. When the heart muscle doesn t get the oxygen and nutrients it needs, the affected heart tissue may die. Signs and symptoms of a heart attack can vary among individuals, especially those with a history of certain diseases. Some common signs and symptoms of a heart attack are: Chest pain Jaw pain Shoulder pain Feeling of indigestion Sweating Shortness of breath

2 Please remember, if you have any of these symptoms or a combination; you should call your provider or 911 to take you to the hospital. Percentage of heart attack patients that receive aspirin within 24 hours of arrival to the hospital Why is this Important? Blood clots can cause heart attacks. For many patients having a heart attack, taking aspirin soon after symptoms of a heart attached begin may help break up a clot and make the heart attack less severe. If patients have not taken aspirin themselves before going to the hospital, they should get aspirin when they arrive. Standards of care say that patients should get aspirin within 24 hours of arriving at the hospital. Percentage of heart attack patients that receive aspirin once they are discharged from the hospital Why is this Important? 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.

3 Percentage of heart attack patients given a prescription for a statin at discharge Why is this Important? Statins are drugs used to lower cholesterol. Cholesterol is a fat (also called a lipid) that your body needs to work properly. Cholesterol levels that are too high can increase your chance of getting heart disease, stroke, and other problems. For patients who have had one or more heart attacks and have high cholesterol, taking statin can lower the chance that they ll have another heart attack or die.

4 Percentage of heart attack patients that received and ACE inhibitor and/or angiotensin receptor blocker medication for Left Ventricular Systolic Dysfunction (LVSD) of the heart Why is this Important? 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 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. Standards of care say that if patients have a heart attack and/or heart failure, they should get a prescription for ACE inhibitors or ARBs if they have decreased heart function before leaving the hospital. Pneumonia Why is this Important? Pneumonia is an infection in the lungs that can be caused by bacteria, virus, or fungus. Signs and symptoms may vary among individuals, but the most common signs and symptoms are: Cough Fever Chills Trouble breathing/shortness of breath Chest pain

5 Percentage of pneumonia patients given the most appropriate initial antibiotics 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. Heart Failure Heart failure, or congestive heart failure, is a condition where the heart is no longer able to pump blood effectively to the rest of the body. Common symptoms include: Trouble breathing/shortness of breath with activity or lying down Cough Swelling in ankles and feet Weight gain Irregular or rapid pulse Percentage of heart failure patients that were given and evaluation for Left Ventricular Systolic Dysfunction (LVSD) Why is this Important? 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 and 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

6 Our Commitment to Quality and Patient Safety A physical examination Listening to your heart sounds; and Other tests as ordered by a physician (like an ECG (electrocardiogram), chest x-ray, blood work, and an echocardiogram) Percentage of heart failure patients that received and ACE inhibitor and/or angiotensin receptor blocker medication for Left Ventricular Systolic Dysfunction (LVSD) of the heart Why is this Important? 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 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. Standards of care say that if patients have a heart attack and/or heart failure, they should get a prescription for ACE inhibitors or ARBs if they have decreased heart function before leaving the hospital.

7 Surgical Care Improvement Project (SCIP) SCIP is a national quality partnership of organizations developed for the sole purpose of improving surgical care by reducing surgical complications. SCIP focuses on various surgical areas, such as: cardiac, vascular, colon, hysterectomy, knees, and hip surgeries. Of these, Calvert Memorial Hospital monitors colon surgeries, hysterectomies, knee, and hip surgeries. Percentage of surgical patients that received their antibiotic within 1 hour prior to surgery to prevent infection Why is this Important? Surgical wound infections can be prevented. Medical research shows that surgery patients who get antibiotics within the hour before their surgery are less likely to get wound infections. Getting an antibiotic earlier, or after surgery begins, is not as effective. Hospital staff should make sure surgery patients get antibiotics at the right time.

8 Percentage of surgical patients whose preventive antibiotics were stopped within 24 hours after surgery Why is this Important? Antibiotics are often given to patients before surgery to prevent infection. Taking these antibiotics for more than 24 hours after routine surgery is usually not necessary. Continuing the medication longer than necessary can increase the risk of side effects such as stomach aches and serious types of diarrhea. Also, when antibiotics are used for too long, patients can develop resistance to them and the antibiotics won't work as well.

9 Percentage of surgical patients who were given the right kind of antibiotic to help prevent infection Why is this Important? Surgical wound infections can be prevented. Medical research has shown that certain antibiotics work better to prevent wound infections for certain types of surgery. Percentage of surgical patients whose urinary catheters were removed on the first or second day after surgery Why is this Important? Sometimes surgical patients need to have a urinary catheter, or thin tube, inserted into their bladder to help drain the urine. Catheters are usually attached to a bag that collects the urine. Surgery patients can develop infections when urinary catheters are left in place too long after surgery. Standard of care say that most surgery patients should have their urinary catheters removed within in 2 days after survey to help prevent infection.

10 Percentage of surgical patients who were taking heart drugs called beta blockers before coming to the hospital, who were kept on the beta blockers during the period just before and after their surgery Why is this Important? It is often standard procedure to stop taking usual mediations for a while before and after surgery. But if patients who have been taking beta blockers suddenly stop taking them, they can have heart problems such as a fast heartbeat. For these patients, staying on beta blockers before and after surgery makes it less likely that they will have heart problems. Percentage of surgical patients who got treatment at the right time (within 24 hours before or after surgery) to help prevent blood clots after certain types of surgery.

11 Why is this Important? 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 the other parts of the body. If the blood clot gets into the lung, it is a serious problem that can sometimes cause death. Doctors can order treatments including 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. Children's Asthma Care (CAC) Asthma is a chronic lung condition that causes problems getting air in and out of the lungs. Children with asthma may experience wheezing, coughing, chest tightness, and trouble breathing Percentage of children who receive reliever medication while hospitalized for asthma Why is this Important? National guidelines for testing children with asthma recommend children with asthma recommend using relievers in the severe phase and gradually cutting down the dosage of medications to provide control of asthma symptoms. Although there are guidelines for medication therapy for children with asthma, there is evidence that these guidelines are not being consistently followed. Using the appropriate medications will lower the risk of severe illness and/or death.

12 Relievers are medications that relax the bands of muscle surrounding the airways and making breathing easier. Percentage of children who received systemic corticosteroid medication (oral and IV medication that reduces inflammation and controls symptoms) while hospitalized for asthma Why is this Important? Oral or IV steroid medications control severe asthma well. That is why they are important for hospital care. Unfortunately, they can cause serious side effects when used long-term. This is why they are mainly used for severe episodes or chronic severe asthma, which cannot be controlled with other medications (like inhaled or oral bronchodilators and anti-inflammatory medications). Percentage of children and their caregivers who received a home management plan of care document while hospitalized for asthma

13 Why is this Important? Because asthma is a chronic condition, controlling a child s asthma symptoms at home will help reduce the risk of further attacks. Knowledge about the disease and its treatment is the key to good asthma control. Asthma this is not managed effectively may lead to more visits to the hospital. Medications can help prevent asthma symptoms and attacks from starting in the first place and can reduce how often attacks happen and severity of the attacks. It is important for children with asthma and their caregivers to knowhow to prevent asthma symptoms and attacks before they happen. The home management plan of care helps children with asthma and their caregivers develop a plan to manage the child s asthma symptoms and to know when to take actions. It should address all of the following: Arrangements for follow-up care Environmental control and control of other triggers Method and timing of rescue actions Use of controller medications Use of reliever medications Venous Thromboembolism (VTE) Because hospital patients often have to stay in bed for long periods of time, any patient who is admitted to the hospital is at increased risk of developing a blood clot in the veins (known as venous thromboembolism). Blood clots can break off and travel to other parts of the body and cause serious problems, even death. Fortunately, there are safe, effective, and proven methods to prevent blood clots or to treat them when they occur. Percentage of patients who got treatment to prevent blood clots on the day of or day after hospital admission or surgery

14 Why is this Important? Hospitals can prevent blood clots by routinely evaluating patients for their risk of developing blood clots and using appropriate prevention and treatment procedures. Prevention can include compression stockings, blood thinners, and/or other medicines. Percentage of patients who got treatment to prevent blood clots on the day of or day after being admitted to the intensive care unit (ICU) Why is this Important? Patients in the Intensive Care Unit (ICU) are at increased risk for developing blood clots in their veins (venous thromboembolism, or VTE), because they are in bed for a long period of time. These clots can break off and travel to other parts of the body, causing serious harm. Hospitals can prevent blood clots by routinely evaluation all patients for their risk of developing blood clots and using appropriate preventions and treatment procedures. Prevention can include compression stockings, blood thinners, and/or other medicines.

15 Percentage of patients with blood clots who got the recommended treatment, which includes using two different blood thinner medicines at the same time Why is this Important? Patients who develop blood clots in their veins (also called venous thromboembolism, or VTE) need to get treatment that can break up the clots quickly and prevent others from forming. The recommended treatment is to first give a blood thinner that can get into the bloodstream quickly through an IV or injection (heparin), then give a slower-acting oral blood thinner medicine (warfarin), and continue giving both blood thinners for 5 days or until it is safe for the patient to transition off of the IV blood thinner and use only the oral blood thinner medicine. Percentage of patients with blood clots who were treated with an intravenous blood thinner, and then were check to determine if the blood thinner was putting the patient at an increased risk of bleeding Why is this Important? Patients who have been diagnosed with a blood clot (also called venous thromboembolism, or VTE) are usually treated with a blood thinner such as IV heparin. Some patients may be prescribed a type of IV heparin called unfractionated heparin. Unfractionated heparin carries a higher risk of increased bleeding than a different type of IV heparin (called low molecular weight heparin). Risk of bleeding increases because blood thinners increase the time it takes your blood to clot. The most common signs of increased bleeding include unusual bruising, nosebleeds, and bleeding gums. Because of their higher risk of bleeding, patients getting unfractionated heparin should be given regular blood tests to determine if they are at an increased risk of bleeding from getting the medication.

16 Percentage of patients with blood clots who were discharges on a blood thinner medicine and received written instructions about that medicine Why is this Important? Patients who have been diagnosed with blood clots (also called venous thromboembolism, or VTE) will usually be given blood thinner medicines to take when they leave the hospital. Educating patients about how to take the medicine and its possible side effects can help prevent problems that could bring them back to the hospital, patients with a blood clot, who are taking a blood thinner medicine, and their caregiver should receive information about the following topics: Compliance (how to follow medication instructions) Diet (how to eat a healthy diet and avoid foods that interfere with blood thinners) Monitoring their blood thinner medicine Adverse drug reactions (difficulty breathing, vomiting, and nausea) When to call your health care provider (dizziness or weakness, a fall, bright red bleeding)

17 Percentage of patients who developed a blood clot while in the hospital who did not get treatment that could have prevented it Why is this Important? Because hospital patients often have to stay in bed for long periods of time, all patients admitted to the hospital are at increased risk of developing blood clots in their veins (also called venous thromboembolism or VTE) that can break off and travel to other parts of the body, like the heart, brain, or lung. Hospital can prevent blood clots by routinely evaluating patients for their risk of developing blood clots and using appropriate prevention and treatment procedures. Prevention can include compression stockings, blood thinners, and/or other medicines.