NOTICE - Kaweah Delta Medical Center · Kaweah Delta Health Care District 1 Q1 Q2 Q3 Q4 AVG. or...

400 West Mineral King Avenue · Visalia, CA · (559) 624 2000 · www.kaweahdelta.org

March 8, 2019 NOTICE

The Board of Directors of the Kaweah Delta Health Care District will meet in an open Quality Council Committee meeting at 7:00AM on Thursday March 14, 2019, in the Kaweah Delta Medical Center – Acequia Wing – Executive Office Conference Room {400 W. Mineral King, Visalia}. The Board of Directors of the Kaweah Delta Health Care District will meet in a Closed Quality Council Committee meeting immediately following the 7:00AM Open Quality Council Committee meeting on Thursday March 14, 2019, in the Kaweah Delta Medical Center – Acequia Wing – Executive Office Conference Room {400 W. Mineral King, Visalia} pursuant to Health and Safety Code 32155 & 1461.

All Kaweah Delta Health Care District regular board meeting and committee meeting notices and agendas are posted 72 hours prior to meetings in the Kaweah Delta Medical Center, Mineral King Wing entry corridor between the Mineral King lobby and the Emergency Department waiting room.

The disclosable public records related to agendas are available for public inspection at the Kaweah Delta Medical Center – Acequia Wing, Executive Offices (Administration Department) {1st floor}, 400 West Mineral King Avenue, Visalia, CA and on the Kaweah Delta Health Care District web page http://www.kaweahdelta.org.

KAWEAH DELTA HEALTH CARE DISTRICT Nevin House, Secretary/Treasurer

Cindy Moccio Board Clerk, Executive Assistant to CEO

DISTRIBUTION: Governing Board Legal Counsel Executive Team Chief of Staff http://www.kaweahdelta.org/

http://www.kaweahdelta.org/

Thursday March 14, 2019 – Quality Council Page 1 of 2 Herb Hawkins – Zone I ⃰⃰ Lynn Havard Mirviss – Zone II ⃰⃰ John Hipskind, MD – Zone III ⃰⃰ David Francis– Zone IV ⃰⃰ Nevin House– Zone V Board Member President Vice President Board Member Secretary/Treasurer

KAWEAH DELTA HEALTH CARE DISTRICT BOARD OF DIRECTORS

QUALITY COUNCIL

Thursday, March 14, 2019

Kaweah Delta Medical Center – Acequia Wing 400 W. Mineral King Avenue, Visalia, CA Executive Conference Room

ATTENDING: Herb Hawkins – Committee Chair, Board Member; Nevin House, Board Member; Gary Herbst, CEO; Regina Sawyer, RN, VP & CNO; Harry Lively, MD, Chief of Staff; Byron Mendenhall, MD, Professional Staff Quality Committee Chair; Monica Manga, MD, Secretary/Treasurer; Dan Boken, MD, Past Chief of Staff; Lori Winston, MD, DIO; Tom Gray, MD, Quality and Patient Safety Medical Director; Sandy Volchko, Director of Quality and Patient Safety; Evelyn McEntire, Director of Risk Management; Ben Cripps, Compliance and Privacy Officer, and Heather Goyer, Recording.

OPEN MEETING – 7:00AM

Call to order – Herb Hawkins, Committee Chair & Board Member

Public / Medical Staff participation – Members of the public wishing to address the Committee concerning items not on the agenda and within the subject matter jurisdiction of the Committee may step forward and are requested to identify themselves at this time. Members of the public or the medical staff may comment on agenda items after the item has been discussed by the Committee but before a Committee recommendation is decided. In either case, each speaker will be allowed five minutes.

1. Written Quality Reports – A review of key quality metrics and actions associated with the following populations:

1.1. Infection Prevention – Shawn Elkin, Manager of Infection Prevention 1.2. Patient Experience - Ed Largoza, Director of Patient Experience

2. Emergency Department Performance – A review of key performance measures and actions for the Emergency Department. Kona Seng, OD, Tom Siminski, RN Director of Emergency Services.

3. Update: Fiscal Year 2019 Clinical Quality Goals - A review of current performance and actions focused on the FY 2019 clinical quality goals. Sandy Volchko, RN, Director of Quality and Patient Safety.

4. Cardiac Service Line Quality Report – A review of key quality indicators and actions associated with the care of cardiac patient population 4.1. Dr. Sergio Caminha, Department Chair of Cardiac Surgery 4.2. Dr. Ashok Verma, MD, Medical Director of Cardiac Cath Lab

1/166

Thursday March 14, 2019 – Quality Council Page 2 of 2 Herb Hawkins – Zone I ⃰⃰ Lynn Havard Mirviss – Zone II ⃰⃰ John Hipskind, MD – Zone III ⃰⃰ David Francis– Zone IV ⃰⃰ Nevin House– Zone V Board Member President Vice President Board Member Secretary/Treasurer

5. Approval of Quality Council Closed Meeting Agenda – Kaweah Delta Medical Center Executive Conference Room – immediately following the open Quality Council meeting

o Quality Assurance pursuant to Health and Safety Code 32155 and 1461, report of Professional Staff Quality Committee (Pro-Staff) – Byron Mendenhall, MD, and Professional Staff Quality Committee Chair;

o Quality Assurance pursuant to Health and Safety Code 32155 and 1461, report of Professional Staff Quality Committee (Pro-Staff) – Evelyn McEntire, Director of Risk Management.

Adjourn Open Meeting – Herb Hawkins, Committee Chair & Board Member

CLOSED MEETING – Immediately following the 7:00AM open meeting

Call to order – Herb Hawkins, Committee Chair & Board Member

1. Quality Assurance pursuant to Health and Safety Code 32155 and 1461, report of Professional Staff Quality Committee (Pro-Staff) – Byron Mendenhall, MD, and Professional Staff Quality Committee Chair

2. Quality Assurance pursuant to Health and Safety Code 32155 and 1461, report of Professional Staff Quality Committee (Pro-Staff) – Evelyn McEntire, Director of Risk Management.

Adjourn Open Meeting – Herb Hawkins, Committee Chair & Board Member

In compliance with the Americans with Disabilities Act, if you need special assistance to participate at this meeting, please contact the Board Clerk (559) 624-2330. Notification 48 hours prior to the meeting will enable the District to make reasonable arrangements to ensure accessibility to the Kaweah Delta Health Care District Board of Directors committee meeting.

2/166

Kaweah Delta Health Care District 1

Q1 Q2 Q3 Q4AVG. or

TOTAL YTDSUMMARY / ACTION

I. Overall Surgical Site Infections (SSI) IR/SIR SSIs calculated internally though standard incidence

rate and externally through Standardized Infection

Ratio (SIR) from National Health and Safety Network

(NHSN).

A. #Total Procedure Count 1042 1270 1168 1478 4958 Annual running total: 4,953

B. Total Infection Count

[note: SSI events can be identified up to 90 days from

the last day of the month in each quarter]

3 12 12 6 33 1st QTR: 2 Predicted: 10.5

2nd QTR: 10 Predicted: 14.3

3rd QTR: 12 Predicted: 12.428

4th QTR: 6 Predicted: 16.891

C. Incidence Rate (IR)

[# of total SSI infections/# total procedures x 100]

Internal

0.70 Goal

0.287 0.945 0.794 0.41 0.609

D. SIR Confidence Interval

(CI-KDHCD predicted range, based on risks)

0.071 -

0.764

0.444 -

1.393

0.523 -

1.641

0.144 -

0.739

1st QTR: Better than California 2016 Total SSI

Benchmark of 0.971

2nd QTR: Better than California 2016 Total SSI

Benchmark of 0.971

3rd QTR: Better than California 2016 Total SSI

Benchmark of 0.971

4th QTR: Better than California 2016 Total SSI

Benchmark of 0.971E. Standardized Infection Ratio (SIR) NHSN 0.622 0.819 0.966 0.356 0.69 1st QTR: 62% of predicted, doing o.k. No CMS VBP

procedures. (1 FUSN; 1 CSEC; 1 CRAN).

2nd QTR: 82% of predicted, could do better. 3 CMS

VBP procedures. (2 APPY; 5 COLO; 1 CRAN; 1

CSEC; 2 PVBY; 1 SB).

3rd QTR: 97% of predicted, too close for comfort. 1

CMS VBP procedure. (1 APPY; 1 CBGB; 1 COLO; 5

CSEC;1 FUSN;1 FX; 1 HER; 1 HPRO)

4th QTR: 36% of predicted, doing well. 1 CMS VBP

procedure. (1 COLO; 1 CSEC; 1 FX; 1 FUSN; 1

KPRO; 1 SB)

ANNUAL SUMMARY: Overall SSI rates remain low.

However, opportunities for improvement exist with

COLO; CSEC, and FUSN procedures.

Infection Prevention and Control Committee - IP Quality Improvement Dashboard CY 2018

3/166


Q1 Q2 Q3 Q4AVG. or



F. Action Plan for Improvement 1st QTR: Working with Anesthesia to administer pre-

op antibiotics in an effective manner, chiefly

appropriate timing well before cut-time and right

dosing/re-dosing based on patient BMI and length of

surgery.

2nd QTR: Assembled a meeting with surgery,

anesthesia, pharmacy, infectious disease, infection

prevention, and quality to determine a single process

that best ensures pre-op antibiotic administration 60

minutes prior to cut-time, right dosing and re-dosing

based of BMI and length of surgery.

3rd QTR: Two meetings with Pre-op antibiotic

Taskforce. Redesigning pre-op antibiotic delivery

process making it more effective. Submitted CSEC

cases to OB for review. Submitted all non-OB cases

to ASC for review. Units received cases with time

spent on unit. Clean-closure practices identified as

area needing improvement.

4th QTR: Continued work on ensuring timely and

appropriate pre-op antibiotic administration. Glucose

management needs more attention. Literature review

underway regarding Clean-closure (IP and nursing in

support of this activity). Door entry rates less of an

issue. Patient teaching may need to be enhanced.

ANNUAL SUMMARY: Recommend removal of

HYST procedures from the Dashboard. Continue to

monitor COLO; CSEC; FUSN closely.

II. Specific Surgical Review SIR

A. Colon Surgery (COLO) CMS/VBP

1. #Total Procedure Count 26 34 23 56 139 Annual running total: 139

2. Total Infection Count 0

[0]

3

[3]

1

[0]

1

[1]

5

[4]

1st QTR: 0 Predicted: 0.748.




4/166


Q1 Q2 Q3 Q4AVG. or



3. SIR CI (KDHCD predicted range, based on risks) 0 - 2.655 0.680 -

5.164

0.041 -

4.039

0.030 -

2.936

1st QTR: Better than 2018 National Benchmark of

0.781. Value is within the lower limit of 2017

confidence interval (0.881-1.019)

2nd QTR: Worse than 2018 National Benchmark of

0.781. Value exceeds upper limit of 2017 confidence

interval.

3rd QTR: Better than 2018 National Benchmark of

0.781. Value is within the lower limit of 2017

confidence interval.

4th QTR: Better than 2018 National Benchmark of

0.781. Value is less than the lower limit of 2017

confidence interval. 4. SIR (Standardized Infection Ration) total

Value Based Purchasing (VBP) SIR = [ ]

0

[0]

2.942

[3.14]

0.819

[0]

0.349

[0.686]

1.028

[0.957]

1st QTR: 0% of predicted, very good! No CMS VBP

procedures.

2nd QTR: 194%, [214%] above predicted,

unacceptable. These 3 events are both CMS VBP

procedures. (Note: the SIR was manually calculated

as the predicted value is less than 1 and not provided

by NHSN) .

3rd QTR: 22% below predicted, very good. No CMS

VBP procedure.

4th QTR: 35% of predicted [69% of predicted],

acceptable. One event that involved a patient from

the CMS population. Clean-closure was not

performed on this case.

ANNUAL SUMMARY: Must advocate that Clean-

closure continue to be performed for all GI

procedures. Tighter glucose control required. Monitor

pre-op antibiotic selection now that a reference

document is available. B. Cesarean Section (CSEC)

1. #Total Procedure Count 370 359 412 392 1533 Annual running total: 1,533

2. Total Infection Count 1 1 5 1 8 1st QTR: 1 Predicted: 3.073




5/166


Q1 Q2 Q3 Q4AVG. or



3. SIR CI (KDHCD predicted range, based on risks) 0.016 -

1.605

0.015-

1.512

0.502 -

3.039

0.015 -

1.472

1st QTR: No different than California 2016 CSEC

Benchmark of 0.96.

2nd QTR: No different than California 2016 CSEC

Benchmark of 0.96.

3rd QTR: No different than California 2016 CSEC

Benchmark of 0.96.

4th QTR: No different than California 2016 CSEC

Benchmark of 0.96. 4. SIR (Standardized Infection Ration) total 0.325 0.307 1.371 0.30 0.58 1st QTR: 33% of predicted, good. Not a CMS VBP

procedure.

2nd QTR: 31% of predicted, good. Not a CMS VBP

procedure.

3rd QTR: 37% above predicted, must do better. Not a

CMS VBP procedure.

4th QTR: 30% of predicted, good. Not a CMS VBP

procedure.

ANNUAL SUMMARY: CSEC procedures have been

difficult due to very short time between pre-op

antibiotic administration and cut-time. Additionally, in

some CSEC procedures Clean Closure might apply if

a hysterectomy is done simultaneously. C. Spinal Fusion (FUSN)






3. SIR CI (KDHCD predicted range, based on risks) NA NA NA NA NA 1st QTR: Worse than California 2016 FUSN

Benchmark of 0.78.

2nd QTR: Better than California 2016 FUSN

Benchmark of 0.78.

3rd QTR: Worse than California 2016 FUSN

Benchmark of 0.78.

4th QTR: Worse than California 2016 FUSN

Benchmark of 0.78.

6/166


Q1 Q2 Q3 Q4AVG. or



4. SIR (Standardized Infection Ration) total 2.43 0 2.35 2.959 1.94 1st QTR: 143% above predicted. Low volume of

procedures and 1 infection results in high SIR.

2nd QTR: 0% above predicted. Excellent!

3rd QTR: 135% above predicted. The 1 infection is a

superficial surgical site infection that occurred 15

days post-op.

4th QTR: Nearly 200% above predicted. Low volume

of procedures none-the-less there is an SSI each

quarter. Considering patient teaching and MRSA

screening for this patient population.

ANNUAL SUMMARY: Too many infections for this

low volume procedure. Must consider different

options for this patient population. Two procedures

were superficial and one deep with an abscess.

Consider patient discharge teaching and MRSA

screening for this population. D. Hysterectomy (HYST) CMS/VBP





4th QTR: 0 Predicated: 0.2983. SIR CI (KDHCD predicted range, based on risks) NA NA NA NA NA 1st QTR: Better than 2018 Benchmark of 0.722.

2nd QTR: Better than 2018 National Benchmark of

0.772.


0.772.


0.772. 4. SIR (Standardized Infection Ration) total


0

[0]

0

[0]

0

[0]

0

[0]

0

[0]

1st QTR: 0% of predicted, very good! This is a CMS

VBP procedure.

2nd QTR: 0% of predicted, excellent! This is a CMS

VBP procedure.

3rd QTR: 0% of predicted, excellent keep up the

great work!. This is a CMS VBP procedure.

4th QTR: 0% of predicted, wonderful job! This is a

CMS VBP procedure.

ANNUAL SUMMARY: Recommend removing this

metric from dashboard. II. Ventilator Associated Events (VAE) SIR

7/166


Q1 Q2 Q3 Q4AVG. or



A. Ventilator Device Use

SUR (standardized utilization ratio)

2.118 1.225 1.435 1.64 1.6 1st QTR: 1022 ventilator days (vd) Predicted: 482.5

2nd QTR: 632 ventilator days (vd) Predicted: 515.9

3rd QTR: 548 ventilator days (vd) Predicted: 381.9

4th QTR: 941 ventilator days (vd) Predicted: 573.64

B. Total VAEs ICU (NHSN Reportable) Includes

IVAC Plus

3 4 3 4 14 1st QTR: 3 Predicted: 6.945

2nd QTR: 4 Predicted:4.295



1. SIR Total VAE CI

(KDHCD predicted range, based on risks)

0.110 -

1.176

0.296 -

2.247

0.205 -

2.193

0.199 -

1.509

This is an internal quality driven metric. A State or

National benchmark has not been made available.

2. Total VAEs SIR 0.432 0.931 0.806 0.626 0.7 1st QTR: 43% of predicted, good.

2nd QTR: 93% of predicted, cutting it a little close.

3rd QTR: 80% of predicted, better still room for

improvement.

4th QTR: 63% of predicted, good. C. Total IVAC Plus -ICU 1 2 0 2 5 1st QTR: 1 Predicted: 2.572

2nd QTR: 2 Predicted:1.591



1. Total IVAC Plus CI

(KDHCD predicted range, based on risks)

0.019 -

1.917

0.211 -

4.154

0 -

1.560

0.142 -

2.790

1st QTR: Reported in NHSN. Ensuring that the VAP

prevention bundle is being implemented and

documented.

2nd QTR: Number of events has increased compared

to 1st QTR. Initiated installation of a small laminated

reference card on ventilators that displays critieria for

a VAE. Rationale: often ventilator settings are

changed indiscriminately and patient has a change

with antibiotics this results in an IVAC. Will offer

information to residents during 3rd QTR.

3rd QTR: The third quarter does reflect the start of a

new group of residents. VAE subcommittee has

contacted two physicians on the subcommittee to

attend the meetings and support tighter controls over

ventilator settings. There were no VAP events

identified during 3rd QTR.

4th QTR: 50% of events were related to adjustments

made to the ventilator and 50% of events were due to

the patient developing a pneumonia.

8/166


Q1 Q2 Q3 Q4AVG. or



2. Total IVAC Plus ICU SIR 0.389 1.591 0 0.844 0.706 1st QTR: 39% of predicted, good.

2nd QTR: 59% above predicted, unacceptable.

3rd QTR: 0% of predicted, excellent job!!

4th QTR: 84% of predicted, ok but room for

improvement.

D. CVICU/KDHCD Total VAEs (not NHSN/Internal) 2 1 3 0 6 1st QTR: Not reported to State or Federal

government. Yet there is room for improvement from

a quality perspective. 1 IVAC; 1 PVAP.

2nd QTR: There was 1 IVAC.

3rd QTR: Total of 2 VAC; 1 IVAC.

4th QTR: No VAE in CVICU.

E. Total VAEs-Both Units 5 6 6 4 21 1st QTR: 2 VAC and 2 IVAC, 1 VAP events. Carefully

monitor PEEP and FiO2 parameter variations after

stability has been met.

2nd QTR: 2 PVAP, 1 IVAC, 2 VAC.

3rd QTR: 1 IVAC, 6 VAC.

4th QTR: 2 VAC, 1 IVAC, 1 PVAP

ANNUAL SUMMARY: Total of 3 PVAP. VAE

Subcommittee pursuing subglottic suction and oral

care interventions. Will continue to encourage

compliance with all other aspects of VAE prevention

bundle. III. Central Line Associated Blood Stream Infections

(CLABSI) CMS/VBP

NHSN SIR

A. Total number of Central Line Days (CLD) 4162 3486 3382 3313 14343 Annual running total: 14,343

B. Central Line Device Use SUR

(standardized utilization ratio)

0.899 0.738 0.713 0.696 0.762 1st QTR: 4,162 CLD Predicted: 4,627.7 CLD

2nd QTR: 3,486 CLD Predicted: 4,723.49 CLD

3rd QTR: 3,382 CLD Predicted: 4,740.04 CLD

4th QTR: 3,313 CLD Predicted: 4,761.998 CLD

C. Total Infection Count

Valule Based Purchasing (VBP) # events = [ ]

7

[3]

3

[3]

9

[3]

9

[6]

28

[15]

1st QTR: 7 total Predicted: 3.658

2nd QTR: 3 total Predicted: 3.028

3rd QTR: 9 total Predicted: 3.007

4th QTR: 9 total Predicted: 2.912D. SIR Confidence Interval 0.837 -

3.786

0.252 -

2.697

0.690 -

0.738

1.507 -

5.671

1st QTR: Worse than 2018 National Benchmark of

0.784


0.784.

3rd QTR: Worse than 2018 National Benchmark of

0.784.

4th QTR: Worse than 2018 National Benchmark of

0.784. 9/166


Q1 Q2 Q3 Q4AVG. or



E. SIR (Standardized Infection Ratio) total


1.914

[1.209]

0.991

[1.553]

2.993

[1.573]

3.09

[2.651]

2.247

[1.75]

1st QTR: 91%, [20%] above predicted. Expired

peripheral IV lines and poor central IV line

maintenance/infection prevention practice

contributing to this increase. Current Actions: Focus

studies on central line maintenance; blood collection

from lines; medication administration through lines;

third party central line prevalence study; daily

reminders to remove expired peripheral IV lines;

reminders about relocating femoral access central

venous catheters ;implementation of new dressing kit

and application of a CHG impregnated patch at

insertion of central lines.

2nd QTR: 0.9% below predicted, [55%] above

predicted. Similar issues identified during 1st QTR

exist during 2nd QTR. New Actions: Full

implementation of new Bard All Points dressing kit

and GuardIVa CHG patch. Active Train-the-trainer

and active training on the units. Nursing Safety

Summit started 7/25/18 with an onsite eduction

module related to CLABSI. CLABSI Focus Study and

now Manager's HAI Prevention Focus Study being

completed routinely.

3rd QTR: 199% [57%] above predicted. Manager HAI

Audit Tool; CLABSI Focus Study; Nursing Safety

Summit on CLABSI Prevention are all underway

continuously. Train-the-trainer on "All Points Dressing

kit and GuardIVa patch" completed. Training for all

nursing staff near completion. New residency group

started June.

10/166


Q1 Q2 Q3 Q4AVG. or



Recent CLABSI events are occuring earlier (3-5 days

post insertion). Will be requesting physician support

at CLABSI prevention subcommittee. Providers need

to understand prevention activities. Additionally,

provider insertion documentation needs to improve

and CLIP form completion needs to be performed by

nursing.

4th QTR: 231% [187%] above predicted. Central

Venous Catheter utilization rates are decreasing

steadily which does help reduce the risk of CLABSI

events. However, management of the central lines

indicated and in use must be better. IV Safety Team

service line initiated 1/7/19. The team alerts, instructs,

and facilitates policy (evidence based practice) driven

actions to decrease CLABSI and improve patient

outcomes.

ANNUAL SUMMARY: Several interventions of the

CLABSI prevention bundle implemented. Results

have been discourage throughout the year. Initiated

an IV Safety Team that started January 2019 with the

goal of significantly decreasing CLABSI rate.

IV. Catheter Associated Urinary Tract Infections

(CAUTI) CMS/VBP NHSN SIR

A. Total number of Catheter Device Days (CDD) 4500 4806 4518 4164 17988 Annual running total: 17,988

B. Catheter Device Days SUR

(Standardized Utilization Ratio)

0.892 0.938 0.921 0.799 0.888 1st QTR: 4500 CCD Predicted: 5043.6 CDD

2nd QTR: 4806 CDD Predicted: 5,122.64 CDD

3rd QTR: 3232 CDD Predicted: 3,507.83 CDD

4th QTR: 4164 CDD Predicted: 5,210.741 CDDC. Total Infection Count

Value Based Purchasing (VBP) # of events = [ ]

1

[1]

9

[4]

8

[6]

6

[2]

24

[13]

1st QTR: 1 Predicted: 4.444

2nd QTR:9 Predicted: 4.794



D. SIR Confidence Interval 0.011 -

1.110

0.916 -

3.445

0.816 -

3.336

0.582 -

2.986

1st QTR: No Different than 2018 National Benchmark

of 0.828


0.828 and the 2017 upper limit confidence interval of

1.104.

3rd QTR: Worse than 2018 National Benchmark of

0.828 and the 2017 upper limit confidence interval of

1.104.


0.828 and the 2017 upper limit of confidence interval

of 1.104.

11/166


Q1 Q2 Q3 Q4AVG. or



E. SIR (Standardized Infection Ratio) total


0.225

[0.331]

1.87

[1.284]

1.76

[2.286]

1.436

[0.821]

1.32

[1.18]

1st QTR: 27% [39%] of predicted, good. This is a

CMS VBP procedure.

2nd QTR: 125% [55%] above predicted,

unacceptable. This is a CMS VBP procedure.

Reviewing catheter utilization rates. Determining why

catheters are not being removed when no longer

indicated. Also looking at documentation to determine

whether the switch over to Cerner has resulted in an

increase in CAUTI events.

3rd QTR: 112% [176%] above predicted,

unacceptable. Urinary catheter utilization continues to

hover around 90-95% of predicted. Removal of

indwelling catheter and patient bathing are some

improvement efforts underway.

4th QTR: 73% above predicted total CAUTI. [CMS

population = 0.01% below predicted]. Indwelling

urinary catheter utilization is declining slowly.

ANNUAL SUMMARY: CAUTI increased through the

latter part of the year. Current measures involve

encouraging patient bathing and pericare, and

discouraging "the culture-of-culturing" practices.

Physician's order for urine culture is being revised to

guide providers in the direction of testing

appropriateness.

V. Clostridium difficile Infection (CDI) CMS/VBP SIR

A. Total Infection Count All units 12 4 4 8 28 1st QTR: 12 Predicted: 17.661



4th QTR: 8 Predicted: 14.604B. SIR CI (KDHCD predicted range, based on risks) 0.368 -

1.155

0.077 -

0.588

0.112 -

0.847

0.254 -

1.040

1st QTR: No Different than 2018 National Benchmark

of 0.852


0.852 and Better than 2017 lower limit confidence

interval of 0.891.



interval of 0.891.


0.852 and No different than 2017 lower limit

confidence interval of 0.891.

12/166


Q1 Q2 Q3 Q4AVG. or



C. SIR (Standardized Infection Ratio) total


0.679

[0.679]

0.244

[0.244]

0.351

[0.351]

0.548

[0.548]

0.456

[0.454]

1st QTR: 68% of predicted, doing o.k., certainly

improving. This is a CMS VBP procedure.

2nd QTR: 24% of predicted, doing much better!!. This

is a CMS VBP procedure. ID Pharmacist is working

on modifying the order for C. difficile testing to

automatically discontinue after 24 hours. This action

should help keep our C. difficle rates consistently low.

3rd QTR: 0% of predicted, excellent job!!!! Still

working on modifying order for C. difficile testing to

automatically discontinue after 24 hours.

4th QTR: 55% of predicted, doing o.k., must continue

to keep a tight control on appropriateness for C.

difficile testing.

ANNUAL SUMMARY: By far our best metric for the

year! Hospital-onset Clostrdium diffcile rates remain

low. Still educating staff and providers not to perform

C. diff. testing for patients receiving a bowel regimen

and/or Lactulose.

VI. Hand Hygiene 95%

13/166


Q1 Q2 Q3 Q4AVG. or



A. All units

Percentage of correct Hand Hygiene

observations/opportunities (30 observations/month/unit)

92% 89% 87% 89% 91% 1st QTR: 92%, just under our 95% goal. Current

actions to increase hand hygiene include review of

technology for monitoring complaince. Continued

secret shopper and Infection Prevention hand

hygiene monitoring. IP Liaison committee is

generating ideas to enhance hand hygiene through a

campaign and other measures to ensure greater

complaince.

2nd QTR: 89%, well under our 95% goal. IP Liaison

committee provided a list of barriers to hand hygiene

compliance and a list of potential solutions to poor

hand hygiene compliance. Need IP Committee and

Executive Leadership to support a higher standard

and accountability to better hand hygiene compliance.

3rd QTR: 87%, consistently decreasing compliance

and way off the mark of the now 90% compliance

goal. Of 3,519 observations, 3,071 were compliant

and 448 were not compliant. Will need to re-evaluate

our current hand hygiene campaign.

4th QTR: 89%, improving slightly. 3N CUSP team is

evaluating the best methods to increase hand

hygiene compliance on their unit. BioVigil electronic

hand hygiene monitoring will be trialed x 12 months

on 4N and ICU. IP Liaison continues actively perform

hand hygiene observations throughout the district.

ANNUAL SUMMARY: Capturing more accurate

results with employment of the IP Liaisons performing

"secret-shopper" hand hygiene audits. Waiting on

exective team approval for deployment of an

electronic hand hygiene surveillance trial to be

performed in the ICU and on 4N for 12 months.

Reinforcing with all healthcare personnel that hand

hygiene is the primary method to reduce disease

transmission.

VII. VRE (HAI) Blood-Hospital Onset (HO) BM

A. Total Infection Count 0 0 0 0 0 1st QTR: 0 Predicted: 0

2nd QTR: 0 Predicted: 0

3rd QTR: 0 Predicted: 0

4th QTR: 0 Predicted: 0

14/166


Q1 Q2 Q3 Q4AVG. or



B. Prevalence Rate (x100) 0 0 0 0 0 1st QTR: 0

2nd QTR: 0

3rd QTR: 0

4th QTR: 0

ANNUAL SUMMARY: Recommend removal of this

metric from the dashboard. C. Number Admissions 6179 5832 6126 18,137 admissionsVIII. MRSA (HAI) Blood CMS/VBP SIR

A. Total Infection Count (IP Facility-wide) 7 1 3 4 15 1st QTR: 7 Predicted 1.406



4th QTR: 4 Predicted: 1.452B. SIR CI (KDHCD predicted range, based on risks) 2.177 -

9.846

0.037 -

3.673

0.566-

6.061

0.875 -

6.644

1st QTR: Worse than 2018 National Benchmark of

0.815.



interval of 0.867.

3rd QTR: No different than 2018 National Benchmark

of 0.815.


0.815.

15/166


Q1 Q2 Q3 Q4AVG. or



C. SIR (Standardized Infection Ration) total


4.977

[4.977]

0.745

[0.745]

2.227

[2.227]

2.75

[2.754]

2.67

[2.67]

1st QTR: 416% above predicted, unacceptable.

MDRO-Committee meets monthy to address issues

related to Hospital Onset MRSA BSI prevalence.

Infection Prevention is working with Antimicrobial

Stewardship Pharmacist to ensure right drug/bug

match. However, added focus is being made recently

toward shifting cultural awareness toward meticulous

hand hygiene and cooperative environmental

cleaning practices.

2nd QTR: 75% of predicted, on the right track.

Infection Prevention continues to be tenacious

pushing for removal of expire peripheral IVs.

Pharmacy is looking at enhancing Antimicrobial

Stewardship Committee (increasing meeting

frequency, using assistance from Pharmacy

Residents) and continues to work closely with

Infectious Disease and Infection Prevention.

3rd QTR: 141% above predicted. Will be trialing

remote hand hygiene compliance sensor system

(BioVigil) in February 2019. Emphasizing removal of

peripheral IVs that remain as "just-in-case" access.

Performing surveillance on expired peripheral IV

lines. Changed peripheral IV replacement frequency

back to Q72 hours.

4th QTR: 194% above predicted number of events,

unacceptable. Majority of these events are associated

with an expired or infiltrated peripheral IV in the

presence of a central line. CLABSI and MRSA BSI

are closely associated because of this relationship.

ANNUAL SUMMARY: MRSA BSI rates are elevated

in-part to expired peripheral IV lines. IP staff pursue

the nursing units daily to remove/replace expired PIV.

IV Safety Team will be doing the same.

IX. Influenza Rates (Year 2017-2018) NHSN

A. All Healthcare Workers

4,844 working/4,769 total vaccination (75 declined)

98.5%Season 2017-2018: 98.5%. Slight Improvement from

year 2016/2017- 98%. Reported to CDHP/NHSN.

Action: MS and HR implemented processes to

assure increased gathering of information.

Season 2018-2019: Will not be available until the end

of March 2019. 16/166


Q1 Q2 Q3 Q4AVG. or



Approved IPC: March 21, 2018 approved

Approved IPC: June 20, 2018 approved

Approved IPC: December, 19, 2018 approved

Approved IPC:

Prepared by Shawn Elkin, MPA, BSN, RN, PHN, CIC

Infection Prevention Manager

17/166

Excellent Service / Patient Experience HCAHPS The data is for patients discharged: Second Quarter 2017 through First Quarter 2018. 1557 surveys completed with a 20% response rate. HCAHPS Composites Adjusted Score State Avg National Avg Comments/Improvement Efforts

Communication with Nurses (FY19 79%)

76%

76% 80% Bedside report

Patient communication boards

‘About Us’ flyers to inform patients of how to reach department leaders

Nurse leaders rounding on patients

Communication with Doctors (FY19 80%)

74%

77% 81% Review data & best practices routinely with Hospitalists, ACTS, FHCN, ED providers

Responsiveness of Hospital Staff (FY19 66%)

63%

64% 70% Hourly rounding

Proactive toileting

Communication about Medicines (FY19 65%)

60%

63% 66% Patient Medicine Guide

Cleanliness of Environment (FY19 79%)

68%

72% 75% EVS leaders rounding on patients

Rework of laundry supply and utilization

Culture of Cleanliness – Review refurbishment possibilities of high traffic areas in the MK wing, hardwire hygiene/bathing standards, evaluate availability of trash receptacles

Quietness of Environment (FY19 55%)

47%

51% 62% Evaluate vendors with noise masking solutions

Discharge Information (FY19 85%)

85% (Yes)

85% 87% Re-build discharge instructions to make them more patient-friendly

Hardwire use of Patient Medicine Guide

Evaluate solutions for discharge phone calls

Address patient “preferences” prior to discharge

Care Transition (FY19 47%)

47% (Strongly Agree)

50% 53% Same as above

Overall Rating of Hospital (0 = worst; 10 = best) (FY19 73%)

71% (9 or 10)

69% 73% Acts of Kindness Campaign

Support work of REC to improve discharge effectiveness and throughput

Badge visitors to enhance patient and staff safety

Provide assistance to visitor traveling between Acequia and Mineral King wings

Launch new patient menu

Willingness to Recommend (FY19 72%)

69% (Definitely Recommend)

70% 72% Same as above

Legend: Above or at benchmark Within 3% of benchmark Greater than 3% below benchmark

18/166

19/166

Sepsis is a potentially life-threatening complication of an infection. It's most dangerous in

older adults or those with weakened immune systems. Early treatment of sepsis, usually with antibiotics and large amounts of intravenous fluids, improves chances for survival.

OCTOBER 2018HIGHER IS BETTER

Percent of patients with this serious infection that received “perfect care”. Perfect care is the right treatment at the right time for our sepsis patients.

Methicillin-resistant Staphylococcus aureus (MRSA) is a type of staph bacteria that is

resistant to certain antibiotics. More severe or potentially life-threatening MRSA infections occur most frequently among patients in healthcare settings.

OCT-DEC 2018LOWER IS BETTER

DEC 2018NUMBER OF PATIENTS WHO ACQUIRED MRSA

Standardized Infection Ratio (SIR)The number of patients who acquired MRSA while in the hospital divided by the number of patients who were expected.

A catheter-associated urinary tract infection (CAUTI) is one of the most common infections a

person can contract in the hospital. Indwelling urinary catheters are the cause of this infection.

Standardized Infection Ratio: The number of patients who acquired a CAUTI while in the hospital divided by the number of patients who were expected.


DEC 2018NUMBER OF PATIENTS WHO ACQUIRED CAUTI

A central line-associated bloodstream infection (CLABSI) is a serious infection

that occurs when germs (usually bacteria or viruses) enter the bloodstream through the central line.


Standardized Infection Ratio (SIR) The number of patients who acquired a CLABSI while in the hospital divided by the number of patients who were expected.

DEC 2018NUMBER OF PATIENTS WHO

ACQUIRED CLABSI

<.86

PREVIOUSMONTH

63%

PREVIOUSQUARTER

NO SIR

PREVIOUSQUARTER

2.15

PREVIOUSQUARTER

2.99

CLINICAL QUALITY

62% 2.75

1

1

3.092

1.4420/166

Cardiac Surgery Data2018Q2

DATA ANALYSES OF THE SOCIETY OF THORACIC SURGEONS

NATIONAL ADULT CARDIAC SURGERY DATABASE

*Comparison reporting period 01/01/2018 through 06/30/201821/166

The Medical Staff Officers have reviewed the CV Services report and noted that the report is exemplary or has shown improvement in many areas, notably:

• From the STS Report:

• CABG Post Op Sternal Wound Infection, Deep and Superficial

• CABG Operative Mortality

• Post-Op Renal Failure

• CABG Prolonged Ventilation

• CABG Post Op Permanent Stroke

22/166

0.0% 0.0% 0.0% 0.0%

0.3% 0.3%

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

2015n=0/192

2016n=0/172

2017n=0/182

2018 Q1-Q2n=0/94

Like Hospitals STS*

Pe

rce

nt

of

Pat

ien

tsCABG Post Op Deep Sternal Wound Infection

Risk Adjusted

Kaweah Delta Medical Center

Goal

2018 O/E = 0


3.0%

1.0%1.2%

0.0%

2.3%2.4%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

2015n=2

2016n=2

2017n=4

2018n=0

Like Hospitals STS*

Pe

rce

nt

of

Pat

ien

tsCABG Post Op Sternal Wound Infection

Superficial


Goal

2018 O/E = 0


0.9%

2.2%

1.5%

1.9%

2.5%

2.3%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

2015n=2/192

2016n=4/172

2017n=4/182

2018 Q1-Q2n=2/94

Like Hospitals STS*

Pe

rce

nt

of

Pat

ien

tsCABG Operative Mortality

Risk Adjusted


Goal

2018 O/E = 0.8


0.6%

3.2%

1.2%

2.4%2.5%

2.3%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

2015n=1/178

2016n=5/164

2017n=2/159

2018 Q1-Q2n=2/86

Like Hospitals STS*

Pe

rce

nt

of

Pat

ien

tsCABG Post-Op Renal Failure1

Risk Adjusted


Goal

2018 O/E = 1.0*Comparison reporting period 01/01/2018 through 06/30/20181 – Excludes patients with preoperative dialysis or preoperative Creatinine ≥ 4

26/166

8.5%

13.6%

6.5%

8.0% 8.3%7.7%

0.0%

5.0%

10.0%

15.0%

20.0%

2015n=20/192

2016n=29/172

2017n=19/182

2018 Q1-Q2n=11/94

Like Hospitals STS*

Pe

rce

nt

of

Pat

ien

tsCABG Prolonged Ventilation

Risk Adjusted


Goal

2018 O/E = 1.0


1.9%

1.7%

0.0%

1.9%

1.4% 1.4%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

2015n=4/192

2016n=3/172

2017n=0/182

2018 Q1-Q2n=2/94

Like Hospitals STS*

Pe

rce

nt

of

Pat

ien

ts

CABG Post Op Permanent StrokeRisk Adjusted


Goal

2018 O/E = 1.33


Opportunities for improvement and / or documentation of compliance with improvement plans were also noticed in several

areas.

The Officers have asked for a brief summary addressing the following questions to be presented at the ProStaff meeting

?29/166

2.6%2.3%

3.3%

2.1%1.9% 1.9%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

2015n=5/193

2016n=4/172

2017n=6/182

2018 Q1-Q2n=2/94

Like Hospitals STS*

Pe

rce

nt

of

Pat

ien

ts

CABG Re-Op Bleed


Goal

2018 O/E = 1.2


37.2%41.3%

29.7%

34.0%

25.7% 25.9%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

2015n=67/193

2016n=71/172

2017n=54/182

2018 Q1-Q2n=32/94

Like Hospitals STS*

Pe

rce

nt

of

Pat

ien

ts

CABG Intra-operative Blood Product Usage1


Goal

2018 O/E = 1.3*Comparison reporting period 01/01/2018 through 06/30/20181Surgeries where at least one unit blood product (RBC, Plasma, Platelet) was given intra-operatively31/166

Quality Initiative: Bleeding, blood usage

• Quarterly review of blood usage throughout Pt. stay

• TEG coagulation monitoring

• Antifibrinolytic agents

• Heparin monitoring

• Heparin coated circuits

• Hemostasis achieved during procedure

• Cell saver utilized during surgery

• Restrictive transfusion criteria

• Surgeon approval of each transfusion

• Treatment of pre-operative anemia or transfusion as needed

Have any opportunities for

improvement been identified?

32/166

7.9

9.5

8.5

9.3

6.9 7.0

2.0

4.0

6.0

8.0

10.0

12.0

2015 2016 2017 2018 Q1-Q2 Like Hospitals STS*

Po

st-O

pe

rati

ve D

ays

in H

osp

ital

CABG Post Op Length of StayMean


Goal

2018 O/E = 1.3

*Comparison reporting period 01/01/2018 through 06/30/2018

Are there action plans to address these elements?

33/166

269

295

316327

243 238

100

150

200

250

300

350

400


Min

ute

s

CABG Skin to Skin Duration 1


Goal

2018 O/E = 1.4



34/166

126

134143

151

98 96

50

70

90

110

130

150

170


Min

ute

s

CABG Pump Time Duration 1


Goal

2018 O/E = 1.6

*Comparison reporting period 01/01/2018 through 06/30/20181- Excludes Off-Pump procedures


35/166

Kaweah Delta Pt. Populations

42.6%

9.7%

5.7%

10.1%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

Radial Artery Usage Readmission w/in 30 days

KaweahDelta

STSNationalRate


Why is Radial Artery Usage so high? Is it related to the low

radial artery usage for PCI in the ACC report?

36/166

2017 Q2 - 2018 Q1 Data


PCI Data Quality Analysis


Green – At the ACC 90th % GOALPurple - At the ACC 50th %

Red - Worse than ACC 50th %

37/166

The Medical Staff Officers have reviewed the CV

Services report and noted that the report is exemplary

or has shown improvement in many areas, notably:

• From the ACC/PCI Report:o Stroke Post PCI

o Vascular Access Site Injury

o P2Y12 Inhibitor Prescribed at Discharge

38/166

Stroke Post PCI1

0.0%

0.34%0.35%

0.0%

0.17% 0.17%

0.0%0.0%

0.1%

0.2%

0.3%

0.4%

0.5%

0.6%

Q2 2017

n=0/306

Q3 2017

n=1/296

Q4 2017

n=1/284

Q1 2018

n=0/295

KD R4Q ACC 50th

percentile

ACC 90th

percentile

GOAL

R4Q O/E = 1.01 Patients without CABG during this admission. (ref: 1811)*Comparison reporting period is 4/01/17 through 03/31/18

39/166

Vascular Access Site InjuryBleeding Event w/in 72 Hours1

0.3%

1.7%

3.2%

1.4%

1.6% 1.6%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

Q2 2017

n=1/306

Q3 2017

n=5/296

Q4 2017

n=9/284

Q1 2018

n=4/295

KD R4Q ACC

Average

GOAL

R4Q O/E = 1.01 Requiring treatment/ major bleeding; Pt.’s w/out CABG during admission defined as: Bleeding at access site, hematoma at access

site, or retroperitoneal bleed that occur within 72 hours of procedure. To qualify, event must be associated with Hgb drop >=3 g/dL;

transfusion, or a procedural intervention/surgery to reverse/stop or correct the bleeding. Excludes GI, GU, Other bleeds. (ref: 1848)*Comparison reporting period is 4/01/17 through 03/31/18

What Led to the Q1

Improvements?

40/166

P2Y12 Inhibitor Prescribed at DC1

100.0%

99.6%

98.4%

100.0%

99.5%

99.8%

100.0%

97.5%

98.0%

98.5%

99.0%

99.5%

100.0%

Q2 2017

n=0

Q3 2017

n=1

Q4 2017

n=4

Q1 2018

n=0

KD R4Q ACC 50th

percentile

ACC 90th

percentile

GOAL

R4Q O/E = 1.01 Proportion of pts (without a documented contraindication) with a stent implanted that had a thienopyridine/P2Y12 inhibitor

prescribed at discharge; excludes patients that were discharged to "Other acute care hospital", "Hospice", or “Left against medical

advice (AMA)“. (ref: 2005)*Comparison reporting period is 4/01/17 through 03/31/18

41/166

Opportunities for improvement and / or

documentation of compliance with improvement

plans were also noticed in several areas.

The Officers have asked for a brief summary

addressing the following questions to be presented at

the ProStaff meeting

?42/166

PCI In-Hospital Mortality Rate1

Risk Adjusted (STEMI patients)

6.7%

8.2%

11.7%

8.1%

9.2%

7.1%

3.8%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

Q2 2017

n=2/48

Q3 2017

n=4/52

Q4 2017

n=9/60

Q1 2018

n=4/46

KD R4Q

n=19/206

ACC 50th

percentile

ACC 90th

percentile

GOAL

R4Q RA O/E = 1.58 1 PCI in-hospital mortality rate for STEMI Pt.’s. (ref: 2044)*Comparison reporting period is 4/01/17 through 03/31/18

43/166

PCI In-Hospital Mortality Rate1

Risk Adjusted (NSTEMI, USA, stable angina, electives)

1.1%

0.8% 0.7%

2.0%

1.1% 1.1%

0.5%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

Q2 2017

n=3/251

Q3 2017

n=2/243

Q4 2017

n=2/218

Q1 2018

n=5/243

KD R4Q

n=12/955

ACC 50th

percentile

ACC 90th

percentile

R4Q RA O/E = 1.421 PCI in-hospital mortality rate for all patients Excluding STEMI. Exclusions include patients with a discharge location of “other

acute care hospital.” (ref: 2053)*Comparison reporting period is 4/01/17 through 03/31/18

GOAL

44/166

PCI Mortality1 Rate by PhysicianRolling 4 Quarters (Q2 2017 – Q1 2018)

0.0%

0.0%

0.0%

4.7%

6.3%

0.0%

2.7%

3.7%

0.0%

5.7%

2.1%

1.5%

1.1%

MD #1

MD #2

MD #3

MD #4

MD #5

MD #6

MD #7

MD #8

MD #9

MD #10

MD #11

MD #12

ACC 90th %

GOAL

1 PCI in-hospital mortality rate for all patients for that MD. Exclusions include patients with a discharge location of “other acute

care hospital.” (ref: NCDR/ACC Physician Dashboard)

Is there an explanation for the

variation in PCI Mortality by Physician?

45/166

STEMI Triage

Thoughtful Pause Guidelines

• Should possibly go to CVICU First, not the Cath Lab

o Cardiac Arrest with CPR ≥ 20 minutes and un/minimally responsive

o Cardiogenic Shock, age ≥ 80

o STEMI ≥ 24 hours without Chest Pain

o Excess risk of bleeding (e.g. active internal bleed, ICH<3 mos, Hct<22, PLT<30K)

o Altered Mental Status

o Apparent sepsis or other conditions (other than pure cardiogenic shock) that would markedly increase the risk of dying within 30 days

o Pre-existing DNR / No Code Status

Consider lytic agents for symptoms < 3 hours, anticipated DTB time > 120 minutes and low risk of bleeding

These are intended as guidelines, not to supersede clinical judgement

Adopted from The Cleveland Clinic Heart Institute: Triage Guidelines for STEMI patients.

Are these Thoughtful Pause Guidelines being

utilized by all MD’s?

Is this being Documented in the Record?

46/166

Quality Initiative:

Vitally Important Steps• Physician collaboration & coordination between departments is required

• Cardiologist must participate in all thoughtful pause discussions

• ED physician and Cardiologist will consult with an Intensivist as needed for difficult cases

• Intensivist will respond to the ED for thoughtful pauses as requested

• Thoughtful pause must be documented in patient’s EMR by a physician

• ED staff will transport patients to the Cath Lab for Cardiac Alerts after hours with the Cath Lab RN

• Families must be given aggressive treatment options

with their corresponding prognosis or futility

• Honest communication between all parties required

to maintain transparency and trust

Rab, Tanveer, and Karl B. Kern. “Cardiac Arrest A Treatment Algorithm for Emergent Invasive Cardiac Procedures in the Resuscitated Comatose Patient.” Journal of the American College of Cardiology 66.1 (2015): 62-73.

Are patients and families presented with the options for care considering prognosis and futility?

47/166

Ethical Issues pertinent to Care

• Ethical issues are unavoidable in the care of

critically ill patients but we must maximize the

ethical decision-making regarding angiography

and PCI in these patient populationso Clinical judgments of the multidisciplinary physicians must be observed whenever possible

o Diagnostic tools and data must be readily available for discussion in real time so that decisions can

be made

o Additional research into emerging data on this topic and diagnostic tools to keep our patients

receiving state of the art care

o Transparent discussions at the practice and policy making levels about what characterizes

appropriate or futile care

o Assessing patient wishes, respecting DNR and advanced directives even in times of family crisis

and proxy decision makers

o Lastly and importantly, a frank and honest discussion with families as to

what is futile care

Rab, Tanveer, and Karl B. Kern. “Cardiac Arrest A Treatment Algorithm for Emergent Invasive Cardiac Procedures in the Resuscitated Comatose Patient.” Journal of the American College of Cardiology 66.1 (2015): 62-73.

How frequently does this occur, by whom?

48/166

Immediate PCI for

STEMI (in minutes)1

65 67

5458

62 60

49

0

10

20

30

40

50

60

70

80

90

Q2 2017

n=27

Q3 2017

n=27

Q4 2017

n=48

Q1 2018

n=33

KD R4Q ACC 50th

percentile

ACC 90th

percentile

GOAL

R4Q O/E = 1.31 Median time frame from hospital arrival to immediate PCI for STEMI pts in minutes. Exclusions: Patients transferred in from

another acute care facility; Reasons for delay does not equal none. (ref:1502)*Comparison reporting period is 4/01/17 through 03/31/18

Have Thoughtful Pause or risk stratification concerns/discussions

contributed to the time?

49/166

Quality Initiative:Best Practice in Door to Balloon

• ED staff and CathLab RN to bring patients to Cath Lab in Cardiac

Alerts after 9:00pm

• Cardiac Alerts to be called at the time of leaving transferring

hospitals

• ED EKG to be placed in EMR or Tracemaster

• Cath Lab on call crew response time of 20 minutes

• Fallouts are reviewed promptly and in every case

• Cardiac Alerts called within 10 minutes of ED arrival unless Thoughtful

Pause is documented in the EMR

Has review of the Fallouts provided insight into potential opportunities

for improvement?

50/166

Radial Arterial Access Use

0.0%2.6%

5.2%8.4%

4.0%

40.7%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

Q2 2017

n=0/315

Q3 2017

n= 8/304

Q4 2017

n= 15/287

Q1 2018

n=25/299

KD R4Q ACC

Average

GOALThis is increasing but remains far below the ACC average. Is there a plan to

increase radial artery access?

R4Q O/E = 0.1

(ref:1658)*Comparison reporting period is 4/01/17 through 03/31/18 51/166

Acute Kidney Injury1 Post PCIRisk Adjusted

9.6%

6.1%

7.9%

9.3%

8.3%

5.7%

2.7%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

Q2 2017

n=30/280

Q3 2017

n=17/240

Q4 2017

n=21/226

Q1 2018

n=28/249

KD R4Q ACC 50th

percentile

ACC 90th

percentile

GOAL

R4Q O/E = 1.11 Proportion of patients who had a rise of serum creatinine of > 50% over the pre-procedure baseline (excluding patients on dialysis

pre-procedure). Inclusions: >= 90% of patients with a pre and post creatinine coded; LOS >= 1 day. (ref: 1959)*Comparison reporting period is 4/01/17 through 03/31/18

52/166

Have the monthly audits of order set usage

revealed an opportunity for improvement?

Has investigation of the Dialaflow IV pumps been

helpful?

53/166

Transfusion of RBCs1

3.0%

1.7%

2.5%2.4% 2.4%

1.1%

0.0%0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

Q2 2017

n=9/304

Q3 2017

n=5/295

Q4 2017

n=7/280

Q1 2018

n=7/295

KD R4Q ACC 50th

percentile

ACC 90th

percentile

GOAL

R4Q O/E = 2.2 1 Proportion of patients who received a transfusion of whole blood or RBCs after PCI procedure. Exclusions: Patients having CABG

or other major surgery during the same admission; Pt.'s with a pre-procedure hemoglobin ≤8g/dL or no value. (ref: 1852)*Comparison reporting period is 4/01/17 through 03/31/18

54/166

Do we know how often blood transfusions are given outside

of the Blood Transfusion Guide algorithm?

Is the reason Blood was

given documented?

55/166

ASA Prescribed at DC1

99.3%

97.2%

98.5%

99.6%

98.7%

99.3%

100.0%

95.5%

96.0%

96.5%

97.0%

97.5%

98.0%

98.5%

99.0%

99.5%

100.0%

Q2 2017

n=2

Q3 2017

n=8

Q4 2017

n=4

Q1 2018

n=1

KD R4Q ACC 50th

percentile

ACC 90th

percentile

GOAL

R4Q O/E = 1.01 Proportion of pts (without a documented contraindication) with a stent attempted or implanted that were prescribed aspirin at

discharge; excludes patients that were discharged to "Other acute care hospital", "Hospice", or “Left against medical advice (AMA)“

(ref: 1996)*Comparison reporting period is 4/01/17 through 03/31/18

Are the orders hardwired into the Discharge

order set?

56/166

Statins Prescribed at DC1

98.3%

96.5%

97.4%

99.6%

98.0% 98.0%

100.0%

94.0%

95.0%

96.0%

97.0%

98.0%

99.0%

100.0%

Q2 2017

n=5

Q3 2017

n=10

Q4 2017

n=7

Q1 2018

n=1

KD R4Q ACC 50th

percentile

ACC 90th

percentile

GOAL

R4Q O/E = 1.01 Proportion of pts (without a documented contraindication) with stent attempted or implanted that were prescribed statin at discharge;

excludes patients that were dc’ed to "Other acute care hospital", "Hospice", or “Left against medical advice (AMA)“ (ref: 2001)

*Comparison reporting period is 4/01/17 through 03/31/18

Are the orders hardwired into the Discharge

order set?

57/166

Post-PCI Length of Stay1

– with STEMI

4.03.7

4.6

3.94.1

3.7

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

Q2 2017

n=50

Q3 2017

n=51

Q4 2017

n=61

Q1 2018

n=45

KD R4Q ACC

Average

GOAL

R4Q O/E = 1.11 Mean Post-procedure length of stay in STEMI patients. Exclusions: Patients having CABG or other major surgery during the

same admission. (ref:2134)*Comparison reporting period is 4/01/17 through 03/31/18

Are there additional measures under

consideration for reducing the LOS or impediments

that need to be addressed by the medical staff?

58/166

Post-PCI Length of Stay1

– w/out STEMI

2.8

2.0 2.0

2.62.4

1.8

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

Q2 2017

n=257

Q3 2017

n=246

Q4 2017

n=220

Q1 2018

n=246

KD R4Q ACC

Average

GOAL

R4Q O/E = 1.31 Mean Post-procedure length of stay in patients without STEMI. Exclusions: Patients having CABG or other major surgery

during the same admission. (ref:2173)*Comparison reporting period is 4/01/17 through 03/31/18

Are there additional measures under

consideration for reducing the LOS or impediments that need to be addressed by the

medical staff?

59/166

Date post:	24-Mar-2020
Category:	Documents
Upload:	others
View:	6 times
Download:	0 times

NOTICE - Kaweah Delta Medical Center · Kaweah Delta Health Care District 1 Q1 Q2 Q3 Q4 AVG. or...

Documents