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The Maine Hospital Quality Snapshots Web Site Methods

 

Overview

The Maine Quality Forum (MQF) created the Maine Hospital Quality Snapshots Web site to make information on the quality of care in Maine hospitals easily available to users and providers of health care. The Web site presents simple meters and tables on how hospitals perform in caring for patients with specific clinical conditions. This information can assist you in making choices about hospital care.

The information is contained in a large number of measures of hospital quality. The typical measure describes a “best clinical practice” and percent of patients receiving that practice. For example, of patients admitted to a hospital with a heart attack, the percent who receive aspirin at admission is a “best practice” measure for heart attack. One challenge of the information is the overwhelming number of measures that are available so the Web site also combines several measures into one summary measure.

This document explains the background data and methods used to create the Web site information. It describes:

This is the first release of the Maine Hospital Quality Snapshots. It includes many ideas that were collected through public forums, as well as insights offered by various advisors to the MQF.

Two companies helped the MQF to develop this Web site: Thomson Reuters (formerly Thomson Healthcare) and Rapid Application Development, Corporation (RADCorp). This Web site modifies the State Snapshots from the National Healthcare Quality Report (NHQR), developed by Thomson Reuters and RADCorp for the Agency for Healthcare Research and Quality (http://statesnapshots.ahrq.gov/snaps07/index.jsp). The NHQR State Snapshots offer a visual summary of the quality of health care for hospital and other settings at the State level. The Maine Hospital Quality Snapshots present an overview of quality at the hospital level.

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Summary Measures

The summary measures you will see in this document combine individual measures of quality of care. Hospitals have been voluntarily reporting this information to state-wide organizations, known as Quality Improvement Organizations (QIOs). The QIOs are funded mainly by the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (DHHS). Those QIO/CMS measures are reported individually by hospital on the CMS Hospital Compare Web site (http://www.hospitalcompare.hhs.gov). The data for the Maine Hospital Quality Snapshots Web site were developed by the Maine Quality Forum. They have been collected and provided by the Maine Health Data Organization.

In general, individual measures are the proportion of a hospital’s patients with a specific clinical condition that receive a “best practice” in the hospital for a given condition. That best practice is based on evidence that the process improves patient outcomes (National Quality Forum, 2002) 1 .

The Maine Hospital Quality Snapshots combine individual best-practice measures into clinical summary measures. Hospital Compare measures were grouped into six clinical summary measures. The clinical areas are:

  • Heart Disease
  • Heart Attack
  • Heart Failure
  • Pneumonia Care
  • Preventing Infections in General Surgery
  • Preventing Infections in Cardiac/Vascular Surgery

How do these summary measures work, and why are they useful? A summary measure on the Maine Hospital Quality Snapshots is the proportion of all of the hospital’s opportunities to provide “best practice” care that the hospital achieved in a given clinical area. For example, if a patient came to the hospital with a heart attack, the hospital might have eight opportunities (eight individual heart-attack-related quality measures) to provide the best care for that patient. The hospital would receive credit for each best practice opportunity relevant to a patient, if the best practice was delivered. (A different approach would credit the hospital for achieving best practice only if all of the best practices were given when relevant to the patient. In this approach, best practices are viewed as an “all-or-nothing” concept and would thus be counted one time, rather than eight times. This approach would result in lower, more conservative, estimates of achieved best practice and is the approach used for the Healthcare Associated Infection Processes of Care Measures).

Appendix Table A.1 lists all measures considered for the Web site. Appendix Table A.2 shows which individual clinical measures are combined into each summary measure.

For the clinical area summary measures, two types of tools were created to evaluate hospitals:

  • Proportion of opportunities, in which a best practice that was performed in each hospital is summarized on a “meter”; and
  • Hospital performance, rated as “outstanding,” “average,” or “needs improvement” in the clinical area, is noted in a text box below the meter.

These two evaluation tools are summarized in the section that follows.

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Proportion of Opportunities. The proportion of opportunities where a best practice was performed across relevant measures in a clinical area was calculated as the sum of all the best practices performed, divided by the sum of all the opportunities for best practices. Those proportions are marked on a “meter” (Figure 1), which displays:

Figure 1

Figure 1: Performance Meter: Overall Heart Disease Care.

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Hospital Performance. The arrows on the meter tell you how often the hospital applied best practices for the current and previous years. But they do not tell you whether that performance should be considered “outstanding,” “average,” or “needing improvement.” The discussion below describes a way to make that judgment. For a technical description, please go to Regression Analysis in Technical Terms.

A statistical test was used to identify the lower and higher performers from the middle or average group. A standard technique, known as regression analysis, was used. This technique allows us to compare one hospital’s performance on all individual measures in a clinical area to all hospitals’ performance on the same measures. Regressions were estimated for each clinical area. The results of the regression estimated the average effect across all the measures of each hospital’s difference from the “average of all hospitals.” The regression results also provided a statistical test of that difference. The performance rankings of hospitals were determined in the following ways:

  • If the estimate was positive (that is, the hospital was better than the average of hospitals) and the test indicated statistical significance (that is, the estimate of the difference only has a 1 percent likelihood of being due to chance error), then the hospital was considered better than average or “outstanding.”
  • If the estimate was negative (that is, the hospital was worse than the average) and the test indicated statistical significance, then the hospital was considered worse than average or “needing improvement.”
  • If the estimate was greater than, equal to, or less than the average, but did not have statistical significance, then the hospital was considered “average.”

The result of this analysis for the current year is described in a text box on the Web page below each summary “meter.” The text box (example below) says whether the hospital is “outstanding,” “average,” or “needs improvement” in terms of its performance in the clinical area, as compared to other hospitals.

For the current
year <Hospital> is
an <Outstanding>
Performer in <Heart 
Failure Care>

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Regression Analysis in Technical Terms. A multilevel logistic regression was estimated for each clinical area (Snijders and Bosker, 1999)2. First-level measures were nested within hospitals at the second level. For each regression, the dependent variable was the log-odds of success (measured as the percentage of patients that received the best practice) for each measure within each clinical area. The regression was adjusted for each of the individual measures within each clinical area. That is, the independent variables were indicators (0, 1), one for each measure, within the clinical area. For example, the regression for heart attack adjusted for each of the individual heart attack measures (e.g., giving the patient aspirin at arrival, giving a beta blocker at arrival, etc.).

The logistic regressions estimated each hospital’s deviation from the average hospital by combining the information on measure-specific deviations across all of the measures in each clinical area. In other words, it estimated the average difference between the hospital’s success rate and the "average” of all hospitals’ success rates. Please note that each hospital's distance from the average is based on the measures that were not missing for that hospital. Thus, these results assume that each hospital's average deviation would have been the same for missing measures as it was for its non-missing measures. A p-value of <0.01 was used to gauge statistical significance of the results.

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Individual Nursing Measures

Maine’s hospitals submit individual nursing-sensitive measures to the Maine Health Data Organization, and this organization provides them for the Web site.

The individual nursing measures are nursing-related patient outcomes and nursing availability and experience. The relationship between nursing availability and experience and patient outcomes has been documented in past research studies (Kane et al., 2007)3.

The Maine Hospital Quality Snapshots report the nursing measures separately, rather than combining them into summary measures. Because the individual nursing measures reflect different concepts, they are difficult to interpret when combined.

Twelve nursing measures were collected by the hospitals. Two additional measures were calculated from those:

  • NSPC 2b:
    Number of inpatient falls without injury per 1000 patient days =
    NSPC 2 (Inpatient falls per 1000 patient days)
    – NSPC 3 (Inpatient falls with injury per 1000 patient days)
  • NSSC 7c:
    (Staff turnover) =
    [NSSC 7a (RN + APN voluntary separations)
    + NSSC 7b (LVN+LPN+UAP voluntary separations)]
    / Total number of staff at beginning of period

where, RN = registered nurse, APN = advanced practice nurse; LVN = licensed vocational nurse; LPN = licensed practical nurse; UAP = unlicensed assistive personnel.

In all, fourteen measures relate to nursing care on the MQF Web site. Appendix Table A.3 shows how the 14 measures are organized by Nursing Care Outcomes and Nursing Availability and Experience. All 14 measures are in downloadable tables on the Web site.

Five measures relate either to adverse events that should be low with good nursing practices such as pressure ulcers and patient falls (with or without injury) or relate to practices that should be rare during good nursing care (use of patient restraints). Nine measures relate to nursing availability and experience: RN, LPN, UAP and contract nursing hours as a percent of total nursing hours, RN hours and total nursing hours per patient day, and nursing turnover rate.

The nursing-related tables on the Web pages include, for each measure, the hospital’s value and the hospital peer group value for two time periods: the most recent four quarters (current year) and the previous four quarters (previous year).

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Individual Healthcare Associated Infection Measures

Healthcare associated infection measures can be used to evaluate how well hospitals prevent infections in their facilities. Maine's hospitals submit measures of actual infection rates (e.g. central line associated bloodstream infections) and measures showing their ability to consistently implement groups (or bundles) of evidence-based practices shown to prevent infections. These measures are reported to the Maine Health Data Organization which provides them for the Maine Quality Forum Web site.

Preventing Infections Associated with Central Lines

Central line associated bloodstream infections rates are a measurement of how effectively hospitals prevent infections in patients with catheters inserted in larger blood vessels to provide long term access to the bloodstream (used for giving medications and fluids, for withdrawing blood, or for monitoring their condition). Any disruption of the skin makes infection with bacteria or fungi possible. Rates are reported as the number of infections divided by the number of days that patients had central lines inserted multiplied by 1000 (per 1000 central line days). A central line day is each day that any patient has a central line in place.

Preventing Infections - Processes of Care Measures

Adherence to infection prevention practices can also be measured by a hospital's ability to implement "best practice" processes of care. For example, if a hospitalized patient had a central line catheter inserted, the hospital might have five opportunities (five individual central line infection prevention quality measures) to prevent infections in that patient (Berenholtz et al, 20044). For these measures, the hospital will receive credit for achieving the best practice only if all of the best practices were given when relevant to the patient. In this approach, best practices are viewed as an "all-or-nothing" concept and would thus be counted one time, rather than five times. Process of care measures are also reported on hospital efforts to prevent ventilator associated pneumonia in patients on mechanical ventilation (assistance for breathing) ( Drakulovic et al, 19995 and Kress et al, 20006).

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A Consistency of Performance Indicator

To provide an overall view of the hospital’s performance across clinical areas and nursing, a measure called “consistency of performance” was developed. This measure indicates how often (on what percent of measures) a hospital appears among the following tiers of performance of Maine general acute care hospitals:

  • Best: Top 10 percent of hospitals
  • Like most other hospitals: Middle 80 percent of hospitals
  • Worst: Bottom 10 percent of hospitals.

Ten individual measures (8 clinical and 2 nursing) were selected for this view. They were chosen because they were important measures available for all 36 general acute care hospitals:

Measure Description
AMI-1 Aspirin at arrival for heart attack
AMI-6 Beta blocker at arrival for heart attack
HF-2 Evaluation of left ventricular function for heart failure
HF-3 ACEI or ARB at discharge for heart failure with LVSD
PN-2 Pneumococcal vaccination or screen
PN-5c Antibiotics for pneumonia within 6 hours of arrival – all patients
SCIP-1a Antibiotic within 1 hour prior to any surgery
SCIP-3a Antibiotics discontinued within 24 hours after any surgery
NSPC-2 Number of inpatient falls per 1000 inpatient days
NSSC-7c Staff turnover

The pie chart below shows the distribution of the percent of a hospital’s measures in the three tiers of performance.

Figure 2: Distribution of the percent of a hospital’s measures in the three tiers of performance

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Hospital Comparison Groups

All summary measures and individual nursing measures are presented both for the hospital and for at least one comparison group. The comparison groups differ by type of measure:

Maine Hospital Peer Groups

The peer groups were established by the Maine Hospital Association (MHA). The MHA considers these peer groupings to be similar hospitals.

Peer Group   Hospital Location Beds
Peer Group A   4 Hospitals
    Central Maine Medical Center Lewiston 250
    Eastern Maine Medical Center Bangor 411
    MaineGeneral Medical Center Augusta/Waterville 304
    Maine Medical Center Portland 606
Peer Group B   8 Hospitals
    Aroostook Medical Center Presque Isle 105
    Mercy Hospital Portland 230
    Mid Coast Hospital Brunswick 104
    Penobscot Bay Medical Center Rockport 109
    Southern Maine Medical Center Biddeford 150
    St. Joseph Hospital Bangor 112
    St. Mary's Regional Medical Center Lewiston 233
    York Hospital York 79
Peer Group C   4 Hospitals
    Cary Medical Center Caribou 65
  *  Franklin Memorial Hospital Farmington 70
    Goodall Hospital Sanford 53
  *  Maine Coast Memorial Hospital Ellsworth 64
Peer Group D   5 Hospitals
    Inland Hospital Waterville 48
  *  Miles Memorial Hospital Damariscotta 38
    Northern Maine Medical Center Fort Kent 49
    Parkview Adventist Medical Center Brunswick 55
  *  Stephens Memorial Hospital Norway 50
Peer Group E   15 Hospitals (Critical Access Hospitals)
    Blue Hill Memorial Hospital Blue Hill 25
    Bridgton Hospital Bridgton 25
    Calais Regional Hospital Calais 25
    Charles A. Dean Memorial Hospital Greenville 14
    Down East Community Hospital Machias 25
    Houlton Regional Hospital Houlton 25
    Mayo Regional Hospital Dover-Foxcroft 25
    Millinocket Regional Hospital Millinocket 25
    Mount Desert Island Hospital Bar Harbor 25
    Penobscot Valley Hospital Lincoln 25
    Redington-Fairview General Hospital Skowhegan 25
    Rumford Hospital Rumford 25
    St. Andrews Hospital Boothbay Harbor 25
    Sebasticook Valley Hospital Pittsfield 25
    Waldo County General Hospital Belfast 25
Peer Group F   4 Hospitals (Private and State Psychiatric)
    Acadia Hospital Bangor 100
    Dorothea Dix Psychiatric Center Bangor 100
    Riverview Psychiatric Center Augusta 92
    Spring Harbor Hospital Westbrook 100
Peer Group G   1 Hospital (Rehabilitation)
    New England Rehabilitation Hospital Portland 100

* Qualified Swing Bed Hospital

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Appendix A: List of Individual and Summary Measures for Clinical Areas and Nursing

Table A.1. Individual Measures of Hospital Quality of Care for the MQF Web Site
MQF Measure Acronym Short Name Description
AMI-1 Aspirin at arrival for heart attack Percent of acute myocardial infarction (heart attack) patients without aspirin contraindications who received aspirin within 24 hours before or after hospital arrival.
AMI-2 Aspirin at discharge for heart attack Percent of acute myocardial infarction (heart attack) patients without aspirin contraindications who are prescribed aspirin at hospital discharge.
AMI-3 ACEI or ARB at discharge for heart attack with LVSD Percent of acute myocardial infarction (heart attack) patients with left ventricular systolic dysfunction (LVSD) and without contraindications who are prescribed angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) at discharge.
AMI-4 Smoking cessation advice for heart attack Percent of acute myocardial infarction (heart attack) patients with a history of smoking cigarettes (in last year) who are given smoking cessation advice or counseling during hospital stay.
AMI-5 Beta blocker at discharge for heart attack Percent of acute myocardial infarction (heart attack) patients without beta blocker contraindications who are prescribed a beta blocker at hospital discharge.
AMI-6 Beta blocker at arrival for heart attack Percent of acute myocardial infarction (heart attack) patients without beta blocker contraindications who received a beta blocker within 24 hours after hospital arrival.
AMI-7a Thrombolytics at arrival for heart attack Percent of acute myocardial infarction (heart attack) patients who received thrombolytic therapy (for discharges prior to April 1, 2006) or fibrinolytic therapy (for discharges as of April 1, 2006) within 30 minutes or less of arrival at hospital.
AMI-8a Percutaneous coronary intervention at arrival for heart attack Percent of acute myocardial infarction (heart attack) patients who received percutaneous coronary intervention (PCI) within 120 minutes or less of arrival at hospital (for discharges prior to July 1, 2006) or 90 minutes or less of arrival at hospital (for discharges as of July 1, 2006).
HF-1 Discharge instructions for heart failure Percent of heart failure patients discharged home with written instructions or educational material given to patient or caregiver at discharge or during the hospital stay, addressing all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen.
HF-2 Evaluation of left ventricular function for heart failure Percent of heart failure patients with documentation in the hospital record that left ventricular function (LVF) was evaluated before arrival, during hospitalization, or is planned after discharge.
HF-3 ACEI or ARB at discharge for heart failure with LVSD Percent of heart failure patients with left ventricular systolic dysfunction (LVSD) and without both angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) contraindications who are prescribed an ACEI or ARB at hospital discharge.
HF-4 Smoking cessation advice for heart failure Percent of heart failure patients with a history of smoking cigarettes (in last year) who are given smoking cessation advice or counseling during hospital stay.
PN-1 Oxygenation assessment for pneumonia Percent of pneumonia patients who had an assessment of arterial oxygenation by arterial blood gas measurement or pulse oximetry within 24 hours prior to or after arrival at the hospital.
PN-2 Pneumococcal vaccination or screen Percent of pneumonia patients 65 or older who were screened for pneumococcal vaccine status and were administered the vaccine prior to discharge, if indicated.
PN-4 Smoking cessation advice for pneumonia Percent of pneumonia patients with a history of smoking cigarettes (in last year) who are given smoking cessation advice or counseling during hospital stay.
PN-5b Antibiotics for pneumonia within 4 hours of arrival - All patients Percent of pneumonia patients who received their first dose of antibiotics within 4 hours after arrival at hospital (for discharges prior to April 1, 2008).
PN-5c Antibiotics for pneumonia within 6 hours of arrival - All patients (replaces PN-5b) Percent of pneumonia patients who received their first dose of antibiotics within 6 hours after arrival at hospital (for discharges beginning April 1, 2008).
PN-6 Appropriate antibiotics for pneumonia within 24 hours of arrival - All patients Percent of immunocompetent patients with community-acquired pneumonia who received initial antibiotic regimen during the first 24 hours that is consistent with current guidelines.
PN-6a Appropriate antibiotics for pneumonia within 24 hours of arrival - ICU patients Percent of immunocompetent ICU patients with community-acquired pneumonia who received initial antibiotic regimen during the first 24 hours that is consistent with current guidelines.
PN-6b Appropriate antibiotics for pneumonia within 24 hours of arrival - non-ICU patients Percent of immunocompetent non-ICU patients with community-acquired pneumonia who received initial antibiotic regimen during the first 24 hours that is consistent with current guidelines.
PN-7 Flu vaccination or screen for pneumonia Percent of pneumonia patients age 50 and older, hospitalized any time between October and February, who were screened for flu vaccine status and vaccinated prior to discharge, if indicated.
SCIP-1a Antibiotic within 1 hour prior to any surgery Percent of seven types of surgical patients that received prophylactic antibiotic within one hour prior to surgical incision.
SCIP-1b Antibiotic within 1 hour prior to CABG surgery Percent of CABG surgery patients that received prophylactic antibiotic within one hour prior to surgical incision.
SCIP-1c Antibiotic within 1 hour prior to other cardiac surgery Percent of other cardiac surgery patients that received prophylactic antibiotic within one hour prior to surgical incision.
SCIP-1d Antibiotic within 1 hour prior to hip arthroplasty Percent of hip arthroplasty patients that received prophylactic antibiotic within one hour prior to surgical incision.
SCIP-1e Antibiotic within 1 hour prior to knee arthroplasty Percent of knee arthroplasty patients that received prophylactic antibiotic within one hour prior to surgical incision.
SCIP-1f Antibiotic within 1 hour prior to colon surgery Percent of colon surgery patients that received prophylactic antibiotic within one hour prior to surgical incision.
SCIP-1g Antibiotic within 1 hour prior to hysterectomy Percent of hysterectomy patients who received prophylactic antibiotic within one hour prior to surgical incision.
SCIP-1h Antibiotic within 1 hour prior to vascular surgery Percent of vascular surgery patients who received prophylactic antibiotic within one hour prior to surgical incision.
SCIP-2a Antibiotic guideline compliance for all surgery Percent of seven types of surgical patients who received prophylactic antibiotics consistent with current guidelines for specific procedure.
SCIP-2b Antibiotic guideline compliance for CABG surgery Percent of CABG surgical patients who received prophylactic antibiotic consistent with current guidelines for specific procedure.
SCIP-2c Antibiotic guideline compliance for other cardiac surgery Percent of other cardiac surgery patients who received prophylactic antibiotic consistent with current guidelines for specific procedure.
SCIP-2d Antibiotic guideline compliance for hip arthroplasty Percent of hip arthroplasty surgical patients who received prophylactic antibiotic consistent with current guidelines for specific procedure.
SCIP-2e Antibiotic guideline compliance for knee arthroplasty Percent of knee arthroplasty surgical patients who received prophylactic antibiotic consistent with current guidelines for specific procedure.
SCIP-2f Antibiotic guideline compliance for colon surgery Percent of colon surgery patients who received prophylactic antibiotic consistent with current guideline for specific procedure.
SCIP-2g Antibiotic guideline compliance for hysterectomy Percent of hysterectomy patients who received prophylactic antibiotic consistent with current guidelines for specific procedure.
SCIP-2h Antibiotic guideline compliance for vascular surgery Percent of vascular surgery patients who received prophylactic antibiotic consistent with current guidelines for specific procedure.
SCIP-3a Antibiotics discontinued within 24 hours after any surgery Percent of seven types of surgical patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time.
SCIP-3b Antibiotics discontinued soon after CABG surgery Percent of CABG surgery patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time (for discharges prior to January 1, 2006) and within 48 hours after surgery end time (for discharges as of January 1, 2006).
SCIP-3c Antibiotics discontinued soon after other cardiac surgery Percent of other cardiac surgery patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time (for discharges prior to January 1, 2006) and within 48 hours after surgery end time (for discharges as of January 1, 2006).
SCIP-3d Antibiotics discontinued within 24 hours of hip arthroplasty Percent of hip arthroplasty patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time.
SCIP-3e Antibiotics discontinued within 24 hours of knee arthroplasty Percent of knee arthroplasty patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time.
SCIP-3f Antibiotics discontinued within 24 hours of colon surgery Percent of colon surgery patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time.
SCIP-3g Antibiotics discontinued within 24 hours of hysterectomy Percent of hysterectomy patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time.
SCIP-3h Antibiotics discontinued within 24 hours of vascular surgery Percent of vascular surgery patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time.
SCIP-4 Controlled post-operative serum glucose Percent of cardiac surgery patients with controlled 6 AM post-operative serum glucose.
SCIP-6 Appropriate hair removal Rate of surgery patients with appropriate hair removal.
SCIP-7 Postoperative normothermia Rate of colorectal surgery patients with immediate postoperative normothermia.
SCIP-VTE-1 Venous Thromboembolism (VTE) prophylaxis ordered Rate of surgery patients with recommended venous thromboembolism (VTE) prophylaxis ordered.
SCIP-VTE-2 Timely initiation and discontinuation of venous thromboembolism (VTE) prophylaxis Rate of surgery patients who received appropriate venous thromboembolism (VTE) prophylaxis within 24 hours prior to surgery to 24 hours after surgery.
HAI-1 CLABSI rate for ICU patients Central-line-associated blood stream infection (CLABSI) rate per 1,000 central-line catheter days, for ICU patients.
HAI-2 CLABSI rate for ICU neonates Central-line-associated blood stream infection (CLABSI) rate per 1,000 central-line catheter days, for ICU neonates.
HAI-3 Documented central line bundle compliance to prevent infection in ICUs

Percent of ICU patients with central line catheters for whom all five of "central line bundle" elements are documented daily (except where element is contraindicated):
1. Hand hygiene
2. Maximal barrier precautions
3. Chlorhexidine skin antisepsis
4. Optimal catheter site selection, with subclavian vein as the preferred site for non-tunneled catheters
5. Daily review of line necessity, with prompt removal of unnecessary lines
HAI-4 Documented central line bundle compliance to prevent infection in surgical suites

Percent of patients in pre-operative areas, operating rooms, and recovery areas with central line catheters for whom the four insertion related elements of "central line bundle" compliance are documented (except where element is contraindicated):
1. Hand hygiene
2. Maximal barrier precautions
3. Chlorhexidine skin antisepsis
4. Optimal catheter site selection, with subclavian vein as the preferred site for non-tunneled catheters

HAI-5 Documented ventilator bundle compliance to prevent pneumonia in ICUs

Percent of patients on ventilators in ICUs for whom "ventilator bundle" compliance is documented on all four evidence-based interventions (except where element is contraindicated):
1. Elevation of the head of the bed to between 30 and 45 degrees
2. Daily “sedative interruption” and daily assessment of readiness to extubate
3. Peptic ulcer disease (PUD) prophylaxis
4. Deep venous thrombosis (DVT) prophylaxis
NSPC – 1 Hospital-acquired pressure ulcer rate Percent of patients who have a hospital-acquired pressure ulcer (stage1 or greater prior to July 1, 2006; stage 2 or greater thereafter) on day of prevalence study.
NSPC – 2 Inpatient Falls Rate Number of inpatient falls per 1000 inpatient days.
NSPC – 2b Inpatient Falls without Injury Rate Number of inpatient falls without injury per 1000 inpatient days.
NSPC – 3 Inpatient Falls with Injury Rate Number of inpatient falls with injuries per 1000 inpatient days.
NSPC – 4 Use of physical restraints Percent of patients who have a vest or limb restraint on day of prevalence study.
NSSC – 1 RN to total nursing hours Percent of registered nurse (RN) care hours to total nursing care hours.
NSSC – 2 LVN+LPN to total nursing hours Percent of license vocational nurse/license practical nurse (LVN/LPN) care hours to total nursing care hours.
NSSC – 3 UAP to total nursing hours Percent of unlicensed assistive personnel (UAP) care hours to total nursing care hours.
NSSC – 4 Contract to total nursing hours Percent of contract care hours (RN, LVN/LPN, and UAP) to total nursing care hours.
NSSC – 5 RN care hours per patient day Number of RN care hours per patient day.
NSSC – 6 Total nursing care hours per patient day Number of total nursing care hours (RN, LVN/LPN, and UAP, employed and under contract) per patient day.
NSSC – 7a RN + APN voluntary separations Rate of voluntary uncontrolled separations for RNs and advanced practice nurses (APN) during the quarter relative to the number employed at beginning of quarter.
NSSC – 7b LVN+LPN+UAP voluntary separations Rate of voluntary uncontrolled separations during the quarter for LVN/LPN and nurse assistants/aides (NA) relative to the number employed at beginning of quarter.
NSSC – 7c Staff turnover/voluntary separations Rate of voluntary uncontrolled separations during the quarter for RN/APN/LVN/LPN and nurse assistants/aides (NA) relative to the number employed at beginning of quarter.


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Table A.2. Summary Measures of Hospital Quality of Care, by Clinical Area
Summary Measures Included Individual Measures*
Heart Disease AMI 1-6, 7a, 8a, HF 1-4
   Heart Attack AMI 1-6, 7a, 8a
   Heart Failure HF 1-4
Pneumonia Care PN 1, 2, 4, 5b, 6a, 6b, 7
Preventing Infections  
   In General Surgery SCIP 1d-1g, SCIP 2d-2g, SCIP 3d-3g, (SCIP-6, SCIP-7, SCIP-VTE-1, SCIP-VTE-2)
   In Cardiac/Vascular Surgery SCIP 1b-1c, 1h; SCIP 2b-2c, 2h; SCIP 3b-3c, 3h; SCIP-4

* See Appendix Table A.1 for a description of individual measures.


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Table A.3. Individual Nursing Measures, Grouped by Type
Types of Nursing Measure Included Individual Measures*
Nursing Care Outcomes NSPC 1, 2b, 3, 4
Nursing Availability & Experience NSSC 1-6, 7a, 7b

* See Appendix Table A.1 for a description of individual measures.


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Table A.4. Individual Healthcare Associated Infection Measures, Grouped by Type
Types of Healthcare Associated Infection Measure Included Individual Measures
Associated with Central Lines HAI-1
Processes of Care Measures HAI-3, -4, and -5

* See Appendix Table A.1 for a description of individual measures.


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References

1 National Quality Forum (2002). A National Framework for Healthcare Quality Measurement and Reporting: A Consensus Report. Washington DC: National Quality Forum. Available from: http://input.qualityforum.org/publications/reports/.

2 Snijders, T. and Bosker, R. (1999). Multilevel Analysis. Thousand Oaks, CA: Sage Publications.

3 Kane RL, Shamliyan T, Mueller C, Duval S, Wilt T (2007). Nursing Staffing and Quality of Patient Care. Evidence Report/Technology Assessment No. 151 (Prepared by the Minnesota Evidence based Practice Center under Contract No. 290-02-0009.) AHRQ Publication No. 07-E005. Rockville, MD: Agency for Healthcare Research and Quality, March 2007. Available from: http://www.ahrq.gov/downloads/pub/evidence/pdf/nursestaff/nursestaff.pdf.

4 Berenholtz SM, Pronovost PJ, Lipset PA, et al. Eliminating catheter-related bloodstream infection in the intensive care unit. Critical care Medicine, 2004;32:2014-2020.

5 Drakulovic MB, Torres A, Bauer TT, et al. Supine body position as a risk factor for nosocomial pnuemonia in mechanically ventilated patients: a randomized trial. Lancet. 1999;354(9193):1851-1858.

6 Kress JP, Pohlman AS, O'Connor MF, et al. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342(20):1471-1477.

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