Baylor Regional Medical Center at Grapevine

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Core Measures

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Fact Sheets

Baylor Regional Medical Center at Grapevine

How to Interpret the Data

Percentages listed in each column tell you how often a care process was put into practice during the indicated time period. For example, the AMI table may list the AMI Core Measure, "Percent of Heart Attack Patients Given Aspirin at Arrival," along with the following percentages: 100% for Baylor Grapevine, 99% for National and 99% for the State of Texas. This means that aspirin was administered within 24 hours of arrival for AMI patients 100% of the time at this hospital, 99% of the time in hospitals nationwide, 99% of the time in Texas hospitals.

Unless otherwise noted, these tables represent data as measured from January 1, 2011 through December 31, 2011. The definitions provided below each measure category title were retrieved from http://www.hospitalcompare.hhs.gov/. Please see the bottom of this page for an explanation of any symbols used in the below tables.

Acute Myocardial Infarction (AMI) Core Measures

An acute myocardial infarction (AMI), also called a heart attack, happens when one of the heart’s arteries becomes blocked and the supply of blood and oxygen to part of the heart muscle is slowed or stopped. When the heart muscle doesn’t get the oxygen and nutrients it needs, the affected heart tissue may die. These measures show some of the standards of care provided, if appropriate, for most adults who have had a heart attack.

AMI Quality Mesure	Description	Baylor Regional Medical Center at Grapevine	State of Texas Performance	National Performance
AMI-1	Percent of Heart Attack Patients Given Aspirin at Arrival	100%	99%	99%
AMI-2 ^‡	Percent of Heart Attack Patients Given Aspirin at Discharge	99%	99%	99%
AMI-3	Percent of Heart Attack Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)	100%	98%	97%
AMI-4	Percent of Heart Attack Patients Given Smoking Cessation Advice/Counseling	100%	100%	100%
AMI-5	Percent of Heart Attack Patients Given Beta Blocker at Discharge	99%	99%	99%
AMI-7a ^‡	Percent of Heart Attack Patients Given Fibrinolytic Medication Within 30 Minutes Of Arrival	0 patients	74%	60%
AMI-8a ^‡	Percent of Heart Attack Patients Given Percutaneous Coronary Intervention (PCI) Within 90 Minutes Of Arrival	98%	95%	95%
AMI-10 ^‡	Percent of Patients Who Were Prescribed a Statin at Discharge	99%	98%	98%
OP-1 ^‡	Median Time to Fibrinolysis	N/A***	30 minutes	28 minutes
OP-2 ^‡	Outpatients with chest pain or possible heart attack who got drugs to break up blood clots within 30 minutes of arrival (higher numbers are better)	N/A***	55%	59%
OP-3b ^‡	Average number of minutes before outpatients with chest pain or possible heart attack who needed specialized care were transferred to another hospital (a lower number of minutes is better)	N/A***	61 minutes	59 minutes
OP-4 ^‡	Outpatients with chest pain or possible heart attack who got aspirin within 24 hours of arrival (higher numbers are better)	100% *** ⁼	96%	97%
OP-5 ^‡	Average number of minutes before outpatients with chest pain or possible heart attack got an ECG (a lower number of minutes is better)	10 minutes *** ⁼	7 minutes	7 minutes

Pneumonia Core Measures

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

Pneumonia Quality Measure	Description	Baylor Regional Medical Center at Grapevine	State of Texas Performance	National Performance
PN-2	Percent of Pneumonia Patients Assessed and Given Pneumococcal Vaccination	96%	96%	95%
PN-3b ^‡	Percent of Pneumonia Patients Whose Initial Emergency Room Blood Culture Was Performed Prior To The Administration Of The First Hospital Dose Of Antibiotics	98%	98%	97%
PN-4	Percent of Pneumonia Patients Given Smoking Cessation Advice/Counseling	100%	98%	98%
PN-5c	Percent of Pneumonia Patients Given Initial Antibiotic(s) within 6 Hours After Arrival	100%	96%	96%
PN-6 ^‡	Percent of Pneumonia Patients Given the Most Appropriate Initial Antibiotic(s)	98%	95%	95%
PN-7	Percent of Pneumonia Patients Assessed and Given Influenza Vaccination	98%	95%	93%

Heart Failure (HF) Core Measures

Heart Failure 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 measures show some of the process of care provided for most adults with heart failure.

HF Quality Measure	Description	Baylor Regional Medical Center at Grapevine	State of Texas Performance	National Performance
HF-1 ^‡	Percent of Heart Failure Patients Given Discharge Instructions	100%	94%	93%
HF-2 ^‡	Percent of Heart Failure Patients Given an Evaluation of Left Ventricular Systolic (LVS) Function	100%	99%	99%
HF-3 ^‡	Percent of Heart Failure Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)	100%	97%	96%
HF-4	Percent of Heart Failure Patients Given Smoking Cessation Advice/Counseling	100%	99%	99 %

Surgical Care Improvement Project (SCIP) Core Measures

Hospitals can reduce the risk of infection after surgery by making sure they provide care that’s known to get the best results for most patients.

SCIP Quality Measure	Description	Baylor Regional Medical Center at Grapevine	State of Texas Performance	National Performance
SCIP- INF-1 ^‡	Percent of surgery patients who were given an antibiotic at the right time (within one hour before surgery) to help prevent infection	100% #	99%	98%
SCIP- INF-2 ^‡	Percent of surgery patients who were given the right kind of antibiotic to help prevent infection	99% #	99%	99%
SCIP- INF-3 ^‡	Percent of surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery)	99% #	98%	97%
SCIP- INF-4 ^‡	Percent of all heart surgery patients whose blood sugar (blood glucose) is kept under good control in the days right after surgery	97% #	95%	96%
SCIP- INF-6	Percent of surgery patients needing hair removed from the surgical area before surgery, who had hair removed using a safer method (electric clippers or hair removal cream – not a razor)	100%	100%	100%
SCIP- INF-9 ^‡	Percent of surgery patients with urinary catheter removal within 2 days of surgery	99% #	96%	95%
SCIP- INF-10 ^‡	Percent of surgery patients with Perioperative Temperature Management	100% #	100%	100%
SCIP- VTE-1 ^‡	Percent of surgery patients whose doctors ordered treatments to prevent blood clots after certain types of surgeries	100% #	98%	98%
SCIP- VTE-2 ^‡	Percent of patients who got treatment at the right time (within 24 hours before or after their surgery) to help prevent blood clots after certain types of surgery	100% #	97%	97%
SCIP- CARD-2 ^‡	Percent of surgery patients who were taking heart drugs called beta blockers before coming to the hospital, who were kept on the beta blockers during the period just before and after their surgery	99% #	97%	97%
OP-6 ^‡	Outpatients having surgery who got an antibiotic at the right time - within one hour before surgery (higher numbers are better)	99%	98%	97%
OP-7 ^‡	Outpatients having surgery who got the right kind of antibiotic (higher numbers are better)	100%	97%	97%

Explanation of Symbols Used

‡ Represents data as measured from July 1, 2011 through June 30, 2012

* No patients met the criteria for inclusion in the measure calculation

** There is not sufficient data to reliably determine performance

*** No data are available for publication from the hospital

= Rate reflects fewer than the maximum possible quarters of data

† Suppressed for one or more quarters by the CMS

0 patients = No patients met the criteria for inclusion in the measure calculation

# Reflects a submission based upon a sample of relevant discharges