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Downstate Times

The Newsletter for SUNY Downstate
University Hospital of Brooklyn

"All Care Measures" in Which Downstate
Scored First

The number after the slash represents the # of hospitals submitting data on this measure through the UHC consortium.

AMI (Acute Myocardial Infarction)
1. Aspirin at arrival - 1/153
2. Angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blocker (ARB) administered to prevent left ventricular systolic dysfunction (medications administered to block hormones that cause blood vessels to constrict, therefore reducing the risk of a heart attack) – 1/136
3. Beta blocker prescribed at discharge (beta blockers reduce blood pressure) - 1/151
4. Percutaneous Coronary Intervention (PCI) received within 90 mins of arrival - (PCI is the opening of a narrowed coronary artery using special tools. Doing so within 90 minutes of hospital arrival greatly increases the odds of survival) - 1/117

HF (Heart Failure)
5. Discharge instructions - 1/158
6. Evaluation of Left Ventricular Systolic function- this determines if the heart is pumping properly) - 1/158
7. Angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blocker (ARB) administered to prevent left ventricular systolic dysfunction - 1/155

PN (Pneumonia)
8. Blood culture within 24 hrs of arrival for patients transferred/admitted to ICU - 1/153
9. Blood cultures in the ED prior to antibiotic - 1/156
10. Antibiotic selection for Community Acquired Pneumonia (CAP) in immunocompetent patient (tracks patients in non-ICUs who were given the appropriate antibiotics) - 1/155
11. Antibiotic selection for CAP in immunocompetent ICU patient - 1/127
12. Antibiotic selection for CAP in immunocompetent non-ICU patient - 1/155 (same as above)

PC (Perinatal Care Conditions)
13. Health Care-Associated Bloodstream Infections in Newborns - 1/100


Surgical Care Improvement Project (SCIP):

SCIP-Card-2 (Surgical Care Improvement Project – Cardiology)
14. Surgery Patients on Beta Blocker Therapy Prior to Admission Who Received a Beta Blocker During the Perioperative Period - 1/161 SCIP-Inf-1 (Antibiotic Received One Hour Prior to Surgical Incision)
15. CABG (The appropriate antibiotic administered one hour prior to Coronary Artery Bypass Surgery) - - 1/98
16. Knee arthroplasty - 1/152
17. Colon surgery - 1/157
18. Vascular surgery - 1/123

SCIP-Inf-2 (Antibiotic Selection for Surgical Patients)
19. CABG (The appropriate antibiotic administered for Coronary Artery bypass Surgery) - 1/98
20. Other cardiac surgery - 1/97
21. Hip arthroplasty - 1/155
22. Knee arthroplasty - 1/152
23. Hysterectomy - 1/151
24. Vascular surgery - 1/123

SCIP-Inf-3 (Antibiotics Discontinued Within 24/48 Hours After Surgery End)
25. Overall - 1/162
26. CABG (Proportion of patients whose appropriate antibiotics were discontinued within 24 hours after anesthesia end time, or 48 hours after cardiac surgery end time) - 1/98

SCIP-Inf-3 (Antibiotics Discontinued Within 24/48 Hours After Surgery End)
27. Other cardiac surgery - 1/97
28. Hip arthroplasty - 1/155
29. Knee arthroplasty - 1/151
30. Colon surgery - 1/157
31. Hysterectomy - 1/151
32. Vascular surgery - 1/123

SCIP-Inf-4 (Cardiac Surgery Patients with Controlled 6 AM Postoperative Serum Glucose
33. Cardiac surgery patients with controlled 6 AM postoperative serum glucose - 1/99

SCIP-Inf-6 (Surgery Patients with Appropriate Hair Removal)
34. Surgery patients with appropriate hair removal - 1/164

SCIP-Inf-9 (Urinary catheter removed on postoperative day 1 or 2)
35. Urinary catheter removed on postoperative day - 1/162

SCIP-Inf-10 (Surgery patients with perioperative temperature management)
36. Surgery patients with perioperative temperature management - 1/163

SCIP-VTE-2 (Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery)
37. Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery - 1/163

STK (Stroke)
38. Venous Thromboembolism (VTE) Prophylaxis - 1/121
39. Discharged on Antithrombotic Therapy - 1/121
40. Anticoagulation Therapy for Atrial Fibrillation/Flutter - 1/111
41. Antithrombotic Therapy By End of Hospital Day - 1/120
42. Discharged on Statin Medication - 1/121
43. Assessed for Rehabilitation - 1/121

VTE (Venous Thromboembolism Prophylaxis)
44. Venous Thromboembolism Patients with Anticoagulation Overlap Therapy - 1/154
45. Venous Thromboembolism Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol - 1/147
46. Incidence of Potentially-Preventable Venous Thromboembolism - 1/139


Hospital-based Inpatient Psychiatric Services (HBIPS)

HBIPS-1 (Assessment of violence risk, substance use disorder, trauma and patient strengths completed)
47. Admission Screening- Overall Rate - 1/51
48. Admission Screening- Adult (18 through 64 years) - 1/49
49. Admission Screening- Older Adult - 1/45

HBIPS-4 (Patients discharged on multiple antipsychotic medications)
50. Multiple Antipsychotic Medications at Discharge- Older Adult (>65 years) - 1/64

HBIPS-5 (Multiple antipsychotic medications at discharge with appropriate justification)
51. Multiple Antipsychotic Medications at Discharge with Appropriate Justification- Overall Rate - 1/57
52. Multiple Antipsychotic Medications at Discharge with Appropriate Justification- Adult (18 through 64 years) - 1/53

HBIPS-6 (Post Discharge Continuing Care Plan)
53. Post Discharge Continuing Care Plan- Overall Rate - 1/72
54. Post Discharge Continuing Care Plan-Adult (18 through 64 years) - 1/70
55. Post Discharge Continuing Care Plan-Older Adult (>65 years) - 1/66

HBIPS-7 (Post Discharge Continuing Care Plan Transmitted)
56. Post Discharge Continuing Care Plan Transmitted - 1/72
57. Post Discharge Continuing Care Plan Transmitted - Adult (18 through 64 years) - 1/70
58. Post Discharge Continuing Care Plan Transmitted - Older Adult (>65 years) - 1/66


CMS Composite Measures

1. Hospital-based Inpatient Psychiatric Services Composite - 1/72
2. Heart Failure Composite - 1/158
3. Pneumonia Composite - 1/157


Value Based Purchasing Clinical Process of Care Measures

100% observed compliance was achieved on the following measures:
1. Surgical Care Improvement Project -Inf-9 Urinary catheter removed on postoperative day 1 or 2
2. AMI-8a PCI received within 90 minutes of arrival
3. Heart Failure-1 Discharge instructions
4. Pneumonia Blood cultures in the ED prior to antibiotic
5. Pneumonia Antibiotic selection for CAP in immunocompetent patient
6. Surgical Care Improvement Project -3a Antibiotics Discontinued Within 24/48 Hours After Surgery End
7. Surgical Care Improvement Project -4 Cardiac surgery patients with controlled 6 AM postoperative serum glucose
8. Surgical Care Improvement Project -2 Surgery Patients on Beta Blocker Therapy Prior to Admission Who
Received a Beta Blocker During the Perioperative Period
9. Surgical Care Improvement Project Venous Thrombosis -2 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery


The full 2nd quarter 2013 results »

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