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	98% 7/1/2011 - 6/30/2012	98% 7/1/2011 - 6/30/2012	99.6% 10/1/2011 - 9/30/2012
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	99% 7/1/2011 - 6/30/2012	98% 7/1/2011 - 6/30/2012	99.8% 10/1/2011 - 9/30/2012
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	97% 7/1/2011 - 6/30/2012	97% 7/1/2011 - 6/30/2012	99.6% 10/1/2011 - 9/30/2012
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	96% 7/1/2011 - 6/30/2012	96% 7/1/2011 - 6/30/2012	96.5% 10/1/2011 - 9/30/2012
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.
Inpatients whose urinary catheters were removed within 2 days after surgery to reduce the risk of infections.	95% 7/1/2011 - 6/30/2012	94% 7/1/2011 - 6/30/2012	99.1% 10/1/2011 - 9/30/2012
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	97% 7/1/2011 - 6/30/2012	96% 7/1/2011 - 6/30/2012	99% 10/1/2011 - 9/30/2012
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	98% 7/1/2011 - 6/30/2012	98% 7/1/2011 - 6/30/2012	99.8% 10/1/2011 - 9/30/2012
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	97% 7/1/2011 - 6/30/2012	97% 7/1/2011 - 6/30/2012	99.8% 10/1/2011 - 9/30/2012
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.
Surgery Patients with Perioperative Temperature Management	100% 7/1/2011 - 6/30/2012	99% 7/1/2011 - 6/30/2012	99.7% 10/1/2011 - 9/30/2012
Patients having surgery who were actively warmed in the operating room or whose body temperature was near normal by the end of surgery Why is this important? Hospitals can prevent surgical wound infections and other complications by keeping the patient’s body temperature near normal during surgery. Medical research has shown that patients whose body temperatures drop during surgery have a greater risk of infection and their wounds may not heal as quickly. Hospital staff should make sure that patients are actively warmed during and immediately after surgery to prevent drops in body temperature.