Surgery Quality Measures at Strong Memorial Hospital

Surgical Care Improvement Project

	State Average	National Average	Strong Memorial Hospital
Prophylactic Antibiotic Received Within 1 Hour Prior to Surgical Incision	97% 10/1/2009 - 9/30/2010	97% 10/1/2009 - 9/30/2010	100% 10/1/2010 - 12/31/2010
Surgery patients who were given an antibiotic at the right time (within one hour before surgery) to help prevent infection Why is this important? Getting an antibiotic within one hour before surgery reduces the risk of wound infections. This measure shows how often hospital staff make sure surgery patients get antibiotics at the right time.
Prophylactic Antibiotic Selection for Surgical Patients	97% 10/1/2009 - 9/30/2010	97% 10/1/2009 - 9/30/2010	100% 10/1/2010 - 12/31/2010
Surgery patients who were given the right kind of antibiotic to help prevent infection Why is this important? Some antibiotics work better than others to prevent would infections for certain types of surgery. This measure shows how often hospital staff make sure patients get the right kind of preventative antibiotic medication for their surgery.
Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time	94% 10/1/2009 - 9/30/2010	95% 10/1/2009 - 9/30/2010	99% 10/1/2010 - 12/31/2010
Surgery patients whose preventative antibiotics were stopped at the right time (within 24 hours after surgery) Why is this important? Taking preventative antibiotics for more than 24 hours after routine surgery is usually not necessary. This measure shows how often hospital stopped giving antibiotics to surgery patients when they were no longer needed to prevent surgical infection.
Cardiac Surgery Patients with Controlled 6 A.M Postoperative Blood Glucose	94% 10/1/2009 - 9/30/2010	94% 10/1/2009 - 9/30/2010	93% 10/1/2010 - 12/31/2010
Cardiac surgery patients with controlled 6 A.M. blood glucose (ó 200 mg/dL) on postoperative day one (POD1) and postoperative day two (POD 2) with Surgery End Date being postoperative day zero (POD 0). Why is this important? CABG patients with uncontrolled blood glucose have significantly higher infection rates. Deep wound infections in diabetic cardiac surgery patients were reduced by controlling mean blood glucose levels below 200mg/dL.
Surgery Patients with Appropriate Hair Removal	100% 10/1/2009 - 9/30/2010	100% 10/1/2009 - 9/30/2010	100% 10/1/2010 - 12/31/2010
Surgery patients with appropriate surgical site hair removal. No hair removal, or hair removal with clippers or depilatory is considered appropriate. Shaving is considered inappropriate Why is this important? Shaving with a razor creates small nicks at the surgical site that can become infected. Hair removal with clippers or depilatories results in significantly lower infection rates
Inpatients whose urinary catheters were removed within 2 days after surgery to reduce the risk of infections.	90% 10/1/2009 - 9/30/2010	91% 10/1/2009 - 9/30/2010	98% 10/1/2010 - 12/31/2010
Shows the percent of surgery patients whose urinary catheters were removed on the first or second day after surgery. Why is this important? The longer a urinary catheter stays in place, the greater the risk for Catheter-Acquired Urinary Tract Infection (CAUTI).
Surgery Patients on Beta-Blocker Therapy Prior to Admission Who Received a Beta-Blocker During Perioperative Period	92% 10/1/2009 - 9/30/2010	93% 10/1/2009 - 9/30/2010	97% 10/1/2010 - 12/31/2010
Surgery 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? Beta Blockers cause vasodilation and reduce peripheral vascular resistance Beta Blockers have been shown to significantly reduce morbidity and mortality in AMI patients
Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered	96% 10/1/2009 - 9/30/2010	94% 10/1/2009 - 9/30/2010	100% 10/1/2010 - 12/31/2010
Surgery patients with recommended venous thromboembolism (VTE) prophylaxis ordered anytime from hospital arrival to 48 hours after Surgery End Time Why is this important? Certain types of surgery can increase a patients' risk of having blood clots after surgery. For these types of surgery, this measures tells how often treatment to help prevent blood clots was ordered by the doctor.
Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery	94% 10/1/2009 - 9/30/2010	93% 10/1/2009 - 9/30/2010	98% 10/1/2010 - 12/31/2010
Surgery patients who received appropriate venous thromboembolism (VTE) prophylaxis within 24 Hours prior to Surgical Incision Time to 24 Hours after Surgery End Time. Why is this important? This measure tells how often patients having certain types of surgery received treatement to prevent blood clots in the period from 24 hours before surgery to 24 hours after surgery.