Baylor All Saints Medical Center at Fort Worth

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: 97% for Baylor All Saints, 94% for National and 92% for the State of Texas. This means that aspirin was administered within 24 hours of arrival for AMI patients 97% of the time at this hospital, 94% of the time in hospitals nationwide, 92% of the time in Texas hospitals.

Unless otherwise noted, these tables represent data as measured from April 1, 2009 - March 31, 2010.

Acute Myocardial Infarction (AMI) Core Measures

Cardiovascular disease, including AMI (commonly called heart attack), is the leading cause of death in the United States. Each year, 900,000 Americans are diagnosed with AMI and 225,000 cases lead to death. For patients who are admitted with symptoms of heart attack, the following Core Measures are recommended care processes:

AMI Indicator	AMI Description	Baylor All Saints Medical Center at Fort Worth	National Average	State of Texas Average
AMI-1	Percent of Heart Attack Patients Given Aspirin at Arrival	98%	98%	98%
AMI-2	Percent of Heart Attack Patients Given Aspirin at Discharge	97%	98%	98%
AMI-3	Percent of Heart Attack Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)	96%	96%	95%
AMI-4	Percent of Heart Attack Patients Given Smoking Cessation Advice/Counseling	100%	99%	100%
AMI-5	Percent of Heart Attack Patients Given Beta Blocker at Discharge	97%	98%	98%
AMI-7a	Percent of Heart Attack Patients Given Fibrinolytic Medication Within 30 Minutes Of Arrival	N/A*	54%	62%
AMI-8a	Percent of Heart Attack Patients Given Percutaneous Coronary Intervention (PCI) Within 90 Minutes Of Arrival	94%	89%	87%
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*	54%	45%
OP-3**	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)	131 Minutes	62 Minutes	68 Minutes
OP-4	Outpatients with chest pain or possible heart attack who got aspirin within 24 hours of arrival (higher numbers are better)	100%	95%	93%
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)	9 Minutes	9 Minutes	8 Minutes

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

** Data Measured from 7/1/2009 - 3/31/2010

Community Acquired Pneumonia (CAP) Core Measures

Community-acquired pneumonia (CAP) is the sixth most common cause of death in the United States. Every year, there are an estimated two to three million cases of CAP resulting in 500,000 hospitalizations and 45,000 deaths. The following are the Core Measures recommended to treat this condition.

CAP Indicator	CAP Description	Baylor All Saints Medical Center at Fort Worth	National Average	State of Texas Average
PN-2	Percent of Pneumonia Patients Assessed and Given Pneumococcal Vaccination	99%	92%	93%
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	99%	95%	95%
PN-4	Percent of Pneumonia Patients Given Smoking Cessation Advice/Counseling	99%	97%	98%
PN-5c	Percent of Pneumonia Patients Given Initial Antibiotic(s) within 6 Hours After Arrival	97%	95%	95%
PN-6	Percent of Pneumonia Patients Given the Most Appropriate Initial Antibiotic(s)	90%	91%	91%
PN-7	Percent of Pneumonia Patients Assessed and Given Influenza Vaccination	99%	91%	93%

Heart Failure (HF) Core Measures

Heart failure is a condition in which the heart muscle weakens and can't pump blood efficiently. About five million patients in the United States have HF, and more than 550,000 patients are newly diagnosed with HF each year. It is primarily a condition of the elderly; more Medicare dollars are spent for the diagnosis and treatment of HF than for any other diagnosis. The following Core Measures are recommended to treat this condition.

HF Indicator	HF Description	Baylor All Saints Medical Center at Fort Worth	National Average	State of Texas Average
HF-1	Percent of Heart Failure Patients Given Discharge Instructions	91%	87%	88%
HF-2	Percent of Heart Failure Patients Given an Evaluation of Left Ventricular Systolic (LVS) Function	99%	98%	97%
HF-3	Percent of Heart Failure Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)	95%	94%	94%
HF-4	Percent of Heart Failure Patients Given Smoking Cessation Advice/Counseling	100%	98%	98%

Surgical Care Improvement Project (SCIP) Core Measures

Surgical site infections account for 15% of all hospital-acquired infections. Patients who develop surgical site infections are twice as likely to die as other surgical patients. The following Core Measures are recommended to treat this condition.

SCIP Indicator	SCIP Description	Baylor All Saints Medical Center at Fort Worth	National Average	State of Texas Average
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%	96%	97%
INF-2	Percent of surgery patients who were given the right kind of antibiotic to help prevent infection	98%	97%	97%
INF-3	Percent of surgery patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery)	97%	94%	93%
INF-4	Percent of all heart surgery patients whose blood sugar (blood glucose) is kept under good control in the days right after surgery	91%	93%	90%
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%	99%	99%
INF-9	Percent of surgery patients with unrinary catheter removal within 2 days of surgery	88%	89%	87%
INF-10	Percent of surgery patients with Perioperative Temperature Management	N/A
VTE-1	Percent of surgery patients whose doctors ordered treatments to prevent blood clots after certain types of surgeries	94%	94%	93%
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	91%	92%	90%
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%	92%	92%
OP-6**	Outpatients having surgery who got an antibiotic at the right time - within one hour before surgery (higher numbers are better)	95%	92%	92%
OP-7**	Outpatients having surgery who got the right kind of antibiotic (higher numbers are better)	92%	94%	93%

** Data Measured from 7/1/2009 - 3/31/2010

References