Erlanger Hospital Quality Indicators

National Quality Improvement Goals

Why these measures are important

These goals represent optimal care for treating patients with the following common conditions: heart attack, heart failure, pneumonia, and preventing surgical infection. Together, these conditions affect hundreds of thousands of patients each year. Patients who are treated according to these guidelines are more likely to improve and/or have good outcomes of care.

Health care providers and practitioners recognize these as "desirable goals" for treating patients with the identified conditions.

Erlanger's approach to improving quality

Every day Erlanger strives to provide exceptional care...every time. We are continually working toward improving our scores. Process and quality oversight teams made up of doctors, nurses, product line administrators, and process improvement experts actively measure and assess day-to-day operations.

Higher number is better.

Heart Attack (AMI):

A heart attack (also called an AMI, acute MI, or acute myocardial infarction) happens when the arteries leading to the heart become blocked and the blood supply is slowed or stopped. These quality measures show some of the standards of care provided, if appropriate, to someone who has a heart attack.

Erlanger’s Heart and Vascular Center is the region’s leader in complete cardiac care. The Heart and Vascular Center offers the latest technology for diagnosing and treating heart diseases, including a full range of diagnostic testing. Our services address the needs of adults, as well as children, working with the pediatric cardiologists at T.C. Thompson Children’s Hospital.

This chart shows the average of the percentages reported on the following recommended processes of care measures:

Percent of Heart Attack Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)
Percent of Heart Attack Patients Given Aspirin at Discharge
Percent of Heart Attack Patients Given Beta Blocker at Arrival
Percent of Heart Attack Patients Given Beta Blocker at Discharge
Percent of Heart Attack Patients Given Fibrinolytic Medication Within 30 Minutes Of Arrival
Percent of Heart Attack Patients Given PCI Within 90 Minutes Of Arrival
Percent of Heart Attack Patients Given Smoking Cessation Advice/Counseling

View this information in greater detail at www.hospitalcompare.hhs.gov

More information about Heart Attack: [+/-]

Each year over a million people in the U.S. have a heart attack. About half of them die. Many people have permanent heart damage or die because they don't get help immediately. It's important to know the symptoms of a heart attack and call 9-1-1 if someone is having them. Those symptoms include:

Chest discomfort - pressure, squeezing, or pain
Shortness of breath
Discomfort in the upper body - arms, shoulder, neck, back
Nausea, vomiting, dizziness, lightheadedness, sweating

These symptoms can sometimes be different in women. What exactly is a heart attack? Most heart attacks happen when a clot in the coronary artery blocks the supply of blood and oxygen to the heart. Often this leads to an irregular heartbeat – called an arrhythmia - that causes a severe decrease in the pumping function of the heart. A blockage that is not treated within a few hours causes the affected heart muscle to die.
Source:National Library of Medicine

Higher number is better.

Heart Failure (CHF):

Heart failure (also called Cardiac failure, Congestive Heart Failure(CHF)) is a weakening of the heart’s pumping power. With heart failure your body doesn’t get enough oxygen and nutrients to meet its needs. These quality measures show some of the standards of care provided, if appropriate, to someone who has heart failure.

This chart shows the average of the percentages reported on the following recommended processes of care measures:

Percent of Heart Failure Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)
Percent of Heart Failure Patients Given an Evaluation of Left Ventricular Systolic (LVS) Function
Percent of Heart Failure Patients Given Discharge Instructions
Percent of Heart Failure Patients Given Smoking Cessation Advice/Counseling

View this information in greater detail at www.hospitalcompare.hhs.gov

More information about Heart Failure: [+/-]

Heart failure is a condition in which the heart can't pump enough blood throughout the body. Heart failure does not mean that your heart has stopped or is about to stop working. It means that your heart is not able to pump blood the way it should. The weakening of the heart's pumping ability causes Blood and fluid to back up into the lungs The buildup of fluid in the feet, ankles and legs - called edema Tiredness and shortness of breath The leading causes of heart failure are coronary artery disease, high blood pressure and diabetes. Treatment includes treating the underlying cause of your heart failure, medicines, and heart transplantation if other treatments fail. Heart failure is a serious condition. About 5 million people in the U.S. have heart failure. It contributes to 300,000 deaths each year.
Source:National Library of Medicine

Higher number is better.

Pneumonia:

Pneumonia (also called bronchopneumonia) is a serious lung infection that causes difficulty breathing, fever, cough, and fatigue. These quality measures show some of the recommended treatments for pneumonia.

This chart shows the average of the percentages reported on the following recommended processes of care measures:

Percent of Pneumonia Patients Assessed and Given Influenza Vaccination
Percent of Pneumonia Patients Assessed and Given Pneumococcal Vaccination
Percent of Pneumonia Patients Given Initial Antibiotic(s) within 4 Hours After Arrival
Percent of Pneumonia Patients Given Oxygenation Assessment
Percent of Pneumonia Patients Given Smoking Cessation Advice/Counseling
Percent of Pneumonia Patients Given the Most Appropriate Initial Antibiotic(s)
Percent of Pneumonia Patients Whose Initial Emergency Room Blood Culture Was Performed Prior To The Administration Of The First Hospital Dose Of Antibiotics

View this information in greater detail at www.hospitalcompare.hhs.gov

More information about Pneumonia: [+/-]

Pneumonia is an inflammation of the lung, usually caused by an infection. Three common causes are bacteria, viruses and fungi. You can also get pneumonia by accidentally inhaling a liquid or chemical. People most at risk are older than 65 or younger than 2 years of age, or already have health problems.
If you have pneumonia, you may have difficulty breathing and have a cough and a fever. A physical exam and history can help determine if you have pneumonia. Chest x-rays and blood tests can help determine what is wrong. Treatment depends on what made you sick. If bacteria are the cause, antibiotics should help. Viral pneumonia may get better with rest and drinking liquids.
Preventing pneumonia is always better than treating it. The best preventive measures include washing your hands frequently, not smoking, and wearing a mask when cleaning dusty or moldy areas. There is a vaccine for pneumococcal pneumonia, a bacterial infection which accounts for up to a quarter of all pneumonias.
Source:National Library of Medicine

Higher number is better.

Surgical Infection Prevention:

Hospitals can reduce the risk of wound infection after surgery by making sure patients get the right medicines at the right time on the day of their surgery.

This chart shows the average of the percentages reported on the following recommended processes of care measures:

Percent of surgery patients who received preventative antibiotic(s) one hour before incision.
Percent of surgery patients who received the appropriate preventative antibiotic(s) for their surgery .
Percent of surgery patients whose preventative antibiotic(s) are stopped within 24 hours after surgery.

View this information in greater detail at www.hospitalcompare.hhs.gov

More information about Surgical Infection Prevention: [+/-]

A heart attack (also called an AMI, acute MI, or acute myocardial infarction) happens when the arteries leading to the heart become blocked and the blood supply is slowed or stopped. These quality measures show some of the standards of care provided, if appropriate, to someone who has a heart attack. Receive aspirin within 24 hours before or after hospital arrival. Assure that the patient is discharged from the hospital on aspirin. Receive ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) Give the patient advice and education to stop smoking. Give the patient a prescription for a beta blocker.
Source:National Library of Medicine