Overall
- Medical Center voluntarily submits data to CMS as well as Illinois Hospital Association & JCAHO
- Commitment to share information with our patients and community
- The medical center has multidisciplinary teams which work on continuous improvement strategies. This includes AMI, Heart Failure, and Pneumonia, and we also have teams on other topics which are not part of the national agenda- such as Stroke, Asthma, Surgical Prophylaxis, DVT Prophylaxis, and ICU Care.
AMI (Acute Myocardial Infarction or “Heart Attack”)
- Excellent rates for providing important medication treatment with beta blockers and aspirin at admission and discharge. This is a reflection not only of excellent care by our Cardiology service, but also a unique program of doctorate level pharmacists practicing on every inpatient service in collaboration with our doctors
- Our mortality rates for AMI are lower than national rates and mean rates for other academic medical centers which is an important outcome measure for this condition.
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Heart Failure
- For the past year, our rate of Ace Inhibitor treatment of heart failure has exceeded national rates.
- We have heart failure specialists in terms of both medical staff and advance practice nurses, who provide continuity between the hospital and our clinics.
- Although not published in this release, our QI team has worked aggressively at improving counseling of our patients to stop smoking, and documentation of this improved to 81% in 3rd quarter 2004. We established referrals of smokers to our Smoking Cessation Clinic.
Pneumonia
- For the past 2 quarters, we have exceeded national rates for both oxygen assessment and blood cultures as pneumonia patients present in our Emergency Room. This is the most important critical step in making an early diagnosis of pneumonia.
- Although our data does not show a high rate of giving antibiotics within the 4 hour window which is ideal, this is more of a gap in emergency room clinicians not properly documenting and writing down the medications given. We are working on education and documentation forms to improve this.
- We plan to offer vaccines for prevention of flu and pneumonia to our patients, and are exploring the optimal way to incorporate into our electronic medical record.
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