Program Status Measures

This hospital has a Maternity Safety Program in place. A maternity safety program provides a coordinated approach and emergency response to risks associated with pregnancy and childbirth.

This hospital has a Sepsis Protocol in place. A sepsis protocol provides guidance for a coordinated approach to identification and treatment of an infection and inflammatory response which is present throughout the body.

This hospital has a Respiratory Monitoring program in place. Respiratory monitoring provides guidance for assessment of risk of respiratory depression, and includes continuous monitoring of breathing and functioning of the lungs and circulatory system when indicated.

Outcome Measure Definitions

CLABSI - Central line-Associated Blood Stream Infection: A serious infection that occurs when germs enter the bloodstream through a central line. A central line is a special intravenous catheter (IV) that allows access to a major vein close to the heart and can stay in place for weeks or months. The value shown above is a Standardized Infection Ratio (SIR), which is the ratio of observed-to-expected infections during the measure period. SIRs below 1.00 indicate that the observed number of infections during the measure period was lower than would be expected under normal conditions, whereas values above 1.00 indicate that the observed number of infections was higher than expected. Limitations: In the calculation of the Standardized Infection Ratio (SIR), the CDC adjusts for differences between hospitals. However, patient risk factors are not taken into account. These patient-specific variables (e.g., poor skin integrity, immunosuppression) can increase the risk of developing a central line infection. Hence, the SIR for hospitals that care for more medically complex or immunosuppressed patients may not be adequately adjusted to account for those patient-specific risk factors.

Colon SSI - Colon Surgical Site Infection: An infection (usually bacteria) that occurs after a person has colorectal surgery that occurs at the body site where the surgery took place. While some involve only the skin, others are more serious and can involve tissues under the skin, organs, or implanted material. The value shown above is a Standardized Infection Ratio (SIR), which is the ratio of observed-to-expected infections during the measure period. SIRs below 1.00 indicate that the observed number of infections during the measure period was lower than would be expected under normal conditions, whereas values above 1.00 indicate that the observed number of infections was higher than expected. Limitations: Some, but not all patient-specific risk factors are included in the adjustment of the SIR for these types of infections. However, not all relevant risk factors are included (e.g., trauma, emergency procedures). Hence, the SIRs for hospitals performing more complex procedures or with larger volumes of trauma or emergency procedures may not be adequately adjusted to account for those patient-specific risk factors.

NTSV - Nulliparous, Term, Singleton, Vertex Cesarean Birth Rate: The percentage of cesarean (surgical) births among first-time mothers who are at least 37 weeks pregnant with one baby in a head down position (not breech or transverse). Lower values indicate that fewer cesareans were performed in the hospital among primarily low risk, first-time mothers. Limitations: NTSV rates do not take into account certain obstetric conditions, such as placenta previa, that may make Cesarean delivery the safer route for both mother and infant.

Sepsis Mortality: Percent of patients, with a severe infection, who die in the hospital. Most sepsis cases (over 90%) start outside the hospital. Lower percentage of death indicates better survival. Limitations: Use of discharge/administrative data is limiting since such data has lower specificity for diagnoses than clinical data. In addition, without risk adjustment for differences in patient-specific factors, comparing rates among hospitals is difficult.

VTE - Venous thromboembolism: The measure of patients who develop deep vein clots who had not received potentially preventive treatment. Limitations: Although not adjusted to account for patient-specific risk factors, this rate is helpful in distinguishing a hospital’s adherence to the best practice of administration of appropriate VTE prophylaxis to all appropriate patients.

Release Date: 08/15/2018