CCU Data Collection with MIDAS+

Transcription

1 May 22 24, 2006 Starr Pass Resort Tucson, Arizona CCU Data Collection with MIDAS+ This session will examine the task of collecting and aggregating CCU data and present the best method for accomplishing it successfully. Presented by: Laura Kelley MIDAS+ System Manager, QI Analyst Cooley Dickinson Hospital, Northhampton, MA Sharren Zetterholm, MS, RN, CPHQ QI Manager Cooley Dickinson Hospital, Northhampton, MA

2 Post-Symposium Availability Shortly after the conclusion of the Symposium, most General Session and Breakout Session presentations will be available for licensed MIDAS+ Clients to view and download from our Web site: The presentations will be available in read only format. For information about obtaining the native Microsoft PowerPoint presentations, please contact the presenter(s) directly. Contact us at: ACS Healthcare Solutions MIDAS North Pantano Road, Suite 200 Tucson, Arizona (520) (800) Visit our Web site at: MIDAS+, the MIDAS+ logo, DataVision, ReporTrack, Seeker, and SmarTrack are trademarks of MidasPlus, Inc. The ACS logo is a registered trademark of ACS, Inc. Third party trademarks, trade names, product names, and logos may be the trademarks or registered trademarks of their respective owners.

3 CCU Data Collection with MIDAS+ 1 CCU DATA COLLECTION WITH MIDAS+ Laura Kelley, MIDAS+ System Manager & Sharren Zetterholm, QI Manager Cooley Dickinson Hospital Northampton, MA COOLEY DICKINSON HOSPITAL Founded 1886 Located in Northampton, MA 125 Bed Community hospital Member of Dartmouth Hitchcock Alliance 50 specialty areas 300 primary care physicians & specialists DPH Stroke Center JCAHO accredited

4 2 CCU Data Collection with MIDAS+ OBJECTIVES By the end of this session, the participant will be able to: Develop a CCU Data Collection Tool Add extended user fields to the CCU module Develop user, data quality and outcome reports We Need Data CCU wants to implement the Ventilator Bundle, and needs a mechanism to track the compliance. CCU also wants to track: If bed alarms are set & on DVT prophylaxis Mobility Nutritional Support TPN Infection Control needs more accurate data: Central Line Days in CCU (vs. patient days) Foley Catheter Days in CCU (vs. patient days) Ventilator Days for calculating VAP rates TPN Days in CCU

5 CCU Data Collection with MIDAS+ 3 What Did We Do? 1. Developed a tool 2. Developed the MIDAS+ Critical Care module 3. Flowcharted the process 4. Trained employees on MIDAS+ data entry 5. Built profiles & created reports 6. Improved outcomes 1. Developed a Tool: CCU Quality Form Developed the CCU Quality Form Identified data needs Considered the person completing the form/ Needs of data entry person Took data quality issues into consideration (yes, no, n/a s) Developed the Definitions for CCU Quality Form

6 4 CCU Data Collection with MIDAS+ 2. Developed Critical Care Module: Extended User Fields Extended User Fields built See handout for all fields 3. Flowcharted the Process: Patient Admission to Data Entered into MIDAS+ CCU Quality Form is stamped as part of the admission paperwork CCU Quality Form is placed in daily rounds notebook CCU Quality Form is reviewed every day at rounds (same time every day) When patient is discharged or transferred, the CCU Quality Form is completed The Administrative Assistant enters the data from the CCU Quality Form into MIDAS+

7 CCU Data Collection with MIDAS Trained on MIDAS+ Data Entry Prepared Training Document (see handout) Performed 1:1 training Review of document Screen by screen Actual entry of a completed form Left Training Document & phone number as a reference 5. Built Profiles & Created Reports: User, Data Quality & Outcomes Example of a data quality report Conditional formatting Review of how to interpret the data quality report Missed data elements

8 6 CCU Data Collection with MIDAS+ SmarTrack Profile Outcome Reports CCU Measures User reports SmarTrack Profile

9 CCU Data Collection with MIDAS+ 7 CCU Measures CCU Measures/Rates for the month of: Oct-05 Nov-05 Dec-05 Mortality Rate 4.90 % 4.35 % 2.75 % LOS > 7 days Rate 3.92 % 2.61 % 3.67 % Average LOS 2.41 Days 2.13 Days 2.30 Days Average days on Mechanical Ventilation 2.00 Days 5.33 Days 3.11 Days Readmission Rate 0.98 % 3.48 % 1.83 % HOB > 30 degrees Rate % % % PUD Prophylaxis Rate % % % Oral Care Rate % % % Bed Alarms Set Correctly Rate % % % Mobility Rate % % % IHI VAP Bundle Rate % % % CDH VAP Bundle Rate % % % TPN Rate 9.79 % 9.79 % % Appropriate Sedation Rate % % % Appropriate DVT prophylaxis % % % Appropriate DVT prophylaxis - mech vent pts % % % Nutritional Support % % % 6. Improved Outcomes: VAP Bundle Data for Improvement Reviewed results monthly Composite compliance with VAP Bundle Head of bed up 30degrees (100% Q3 & Q4) Appropriate sedation vacation (100% 5/6 months Q3 & Q4) Peptic ulcer disease prophylaxis Deep Vein Thrombosis Prophylaxis Oral Care every 2 hours

10 8 CCU Data Collection with MIDAS+ Reviewed Results Monthly Composite Compliance with VAP Bundle (with Oral Care) VAP Bundle:Peptic Ulcer Disease (PUD) Propphylaxis Percent Compliance Benchmark Percent Compliance Benchmark Percent Compliance 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 83% 67% 57% 50% 67% 75% 100% 67% 67% 88% 67% 67% Percent Compliance 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 100% 91% 97% 90% 98% 97% 100% 100% 89% 94% 100% 97% 0% 0% Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month in 2005 Month in 2005 VAP Bundle: Deep Vein Thrombosis (DVT) Prophylaxis Oral Care Every 2 Hours Percent Compliance Benchmark Percent Compliance Benchmark Percent Compliance 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% % 69% 87% 100% 89% 100% 94% 100% 100% Percent Compliance 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 100% 91% 91% 90% 98% 97% 100% 95% 100% 100% 100% 89% Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month in 2005 Month in 2005 Identified Opportunities/ Root Causes OPPORTUNITIES ROOT CAUSES PUD Lack of Physician Order DVT Lack of Physician Order ORAL CARE Confusing Nursing Flow Sheet

11 CCU Data Collection with MIDAS+ 9 Improvements CCU Nursing Flow Sheet was revised so oral care every 2 hours could be easily documented Revised CCU Nursing Flow Sheet Documentation Oral Care every 2 Old CCU Nursing Flow Sheet Documentation Oral Care x Improvements Implementation of pre-printed ventilator order sheet to improve lack of physician orders for PUD & DVT Date/Time Diagnosis: Allergies: NKDA SEC Ventilator Settings: FIO2 Titrate to maintain O2 saturation at 92%... TV.. Mode.. PEEP Rate. Daily Weaning Parameters: Head of bed up 30 or higher Sedation:. Daily interruption of sedation drug infusion until patient is calm and cooperative (#4 on SAS scale) DVT prophylaxis.. Peptic Ulcer Disease prophylaxis. Nutrition Consult Physician Signature MD R N

12 10 CCU Data Collection with MIDAS+ 6. Improved Outcomes: Other Monitor that bed alarms are set and on - a NPSG Monitor DVT prophylaxis in all CCU patients - likely to soon be a Core Measure for at least surgical patients Monitor if central line is still needed, part of the IHI 100K Lives central line bundle Obtain denominators for Central Line, Foley Catheter and Ventilator Associated Pneumonia rates QUESTIONS Laura Kelley MIDAS+ System Manager Laura_Kelley@Cooley-Dickinson.org Sharren Zetterholm Quality Improvement Manager Sharren_Zetterholm@Cooley-Dickinson.org THANK YOU

13 CCU Data Collection with MIDAS+ 11 CCU QUALITY FORM Complete daily during DAILY ROUNDS Patient Label Here Admission/ Transfer to CCU Date: Admission/ Transfer to CCU Time: Admit/ Transfer From: W1 ; W2 ; W3 ; W5 ; Telemetry ; PACU ; ED Readmit to CCU within 48 hours of discharge? Y N Discharge/ Transfer from CCU Date: Discharge/ Transfer from CCU Time: Discharge/ Transfer to: W2 ; W3 ; Telemetry ; Home ; SNF ; Baystate Medical Center ; Expired ; Other (Please be specific) DAILY ROUNDS DATE Bed Alarms Set & On DVT Prophylaxis Mobility Nutritional Support Central Line Still Needed? Y N Y N N/A Y N N/A Y N N/A Y N N/A Y N Y N Y N Y N N/A Y N N/A Y N N/A Y N N/A Y N Y N Y N Y N N/A Y N N/A Y N N/A Y N N/A Y N Y N Y N Y N N/A Y N N/A Y N N/A Y N N/A Y N Y N Y N Y N N/A Y N N/A Y N N/A Y N N/A Y N Y N Y N Y N N/A Y N N/A Y N N/A Y N N/A Y N Y N Y N Y N N/A Y N N/A Y N N/A Y N N/A Y N Y N Y N Y N N/A Y N N/A Y N N/A Y N N/A Y N Y N Y N Y N N/A Y N N/A Y N N/A Y N N/A Y N Y N Y N Y N N/A Y N N/A Y N N/A Y N N/A Y N Y N Foley TPN MECHANICAL VENTILATION Complete This Section for All Ventilated Patients Vent order sheet used? Y N Date: MD ordering vent: Vent order sheet used? Y N Date: MD ordering vent: Date 1 DVT Prophylaxis 2 HOB > 30 degrees 3 SAS 4.0 (alert & following commands) 4 PUD Prophylaxis 5 Oral Care Q2 hours (REF= refused) All of #1 - #4 Yes or N/A All of #1 - #5 Yes or N/A Y N N/A Y N N/A Y N N/A Y N N/A Y N Ref Y N Y N Y N N/A Y N N/A Y N N/A Y N N/A Y N Ref Y N Y N Y N N/A Y N N/A Y N N/A Y N N/A Y N Ref Y N Y N Y N N/A Y N N/A Y N N/A Y N N/A Y N Ref Y N Y N Y N N/A Y N N/A Y N N/A Y N N/A Y N Ref Y N Y N Y N N/A Y N N/A Y N N/A Y N N/A Y N Ref Y N Y N Y N N/A Y N N/A Y N N/A Y N N/A Y N Ref Y N Y N Y N N/A Y N N/A Y N N/A Y N N/A Y N Ref Y N Y N Y N N/A Y N N/A Y N N/A Y N N/A Y N Ref Y N Y N Additional comments PRN (DO NOT ENTER): Data Entry Person: (enter name of month(s) and total number of days for each month) Total Central Line Days: Month 1 # Month 2 # Total Foley Days: Month 1 # Month 2 # Total TPN Days: Month 1 # Month 2 # Total Vent Days: Month 1 # Month 2 # Last Revised 3/1/2006

14 12 CCU Data Collection with MIDAS+ DEFINITIONS FOR CCU DATA COLLECTION TOOL CCU readmit within 48hrs of discharge (Y/N) = any patient readmitted to a CCU bed within 48 hours of being discharged or transferred from CCU Bedside monitor alarms set & on (Y/N) = alarms are turned on and individualized for heart rate Mobility = Y= documentation that patient has been out of bed in past 24 hours N= no documentation that patient has been out of bed in past 24 hours N/A= patient has a contraindication to getting out of bed Nutrition Support (Y/N) = patient is receiving oral, enteral or parenteral nutrition Nutrition Support (N/A) = NPO status is indicated for this patient up to a maximum of 7 days Central Line Still Needed (Y/N) = patient has a central line (Triple lumen catheter, PA catheter, or PICC line) in and it either is still needed or it is not (this daily assessment is required). If the line is not needed, it should be taken out. Central Line Still Needed (N/A) = patient does not have a central line in. Urinary Catheter = any urinary catheter that is in placed, or placed during this admission FOR MECHANICAL VENTILATION PATIENTS ONLY: Document the date of intubation, MD who wrote the orders and whether the order sheet was used. Complete the second box if the patient is extubated and re-intubated. Date(s) On Mechanical Ventilation = date patient was placed on the ventilator, and each day the patient remains on the ventilator. 1 DVT prophylaxis (Y/N) = patient is receiving coumadin, lovenox, heparin, or is wearing elastic stockings or pneumatic boots 1 DVT prophylaxis (N/A) = patient does not meet any risk criteria for therapy, or patient has contraindication to such therapy such as a coagulopathy or is actively bleeding. 2 HOB elevated >30 degrees (Y/N) = for any patient on a ventilator, is the patient s head of bed at an angle of 30 degrees or more at the time of data collection 2 HOB elevated >30 degrees (N/A) = there is a contraindication to using this position (I.E. hypotension, line placement) 3 Sedation Agitation Scale (SAS) 4 (Y/N) = for any patient receiving continuous sedation. Is the patient s SAS 4 showing that they are alert and following commands. 3 Sedation Agitation Scale (SAS) 4 (N/A) = If patient is not receiving continuous sedation during ventilation. 4 Peptic ulcer disease prophylaxis (Y/N) = for any patient on a ventilator, are they receiving an agent for PUD prophylaxis such as Protonix or Pepcid 4 Peptic ulcer disease prophylaxis (N/A) = for any patient on a ventilator, that may not be appropriate at the present time to receive an agent for PUD prophylaxis such as Protonix or Pepcid. I.E. Endoscopy, end of life. 5 Oral Care (Y/N) = oral care was provided & documented every 2 hours 5 Oral Care (REF) = oral care was attempted to be provided but the patient refused. Gray Fields All of #1 - #4 Yes or N/A = If the #1-4 fields are marked yes or N/A, then mark the Yes box. If any of the #1-4 fields are marked No, then mark this box No. All of #1 - #5 Yes or N/A = If the #1-5 fields are marked yes or N/A, then mark the Yes box. If any of the #1-5 fields are marked No, then mark this box No. ***Additional comments should be made, if needed, to support data. This is not data entered.

15 CCU Data Collection with MIDAS+ 13 4/3/2006 COOLEY DICKINSON HOSPITAL PAGE 1 15:13 Focus Criteria Definition List Criteria Response Mand Age Sex Subcriteria Name: CRITICAL CARE EXTENDED Type: EXTENDED Admit/Transfer to CCU TIME TIME Y Telemetry Overflow? SELECT SINGLE Y YES NO Admit/Transfer FROM SELECT SINGLE N W1 W2 W3 W5 TELEMETRY PACU ED Readmit to CCU w/in 48 hrs of discharge SELECT SINGLE N YES NO N/A Discharge/Transfer from CCU TIME TIME N Discharge/Transfer TO SELECT SINGLE N W2 W3 TELEMETRY HOME SNF BAYSTATE EXPIRED OTHER DAILY ROUNDS - number of days rounded NUMERIC N BED ALARMS Set & On - number of days YES NUMERIC N BED ALARMS Set & On - number of days NO NUMERIC N DVT Prophylaxis - number of days YES NUMERIC N DVT Prophylaxis - number of days NO NUMERIC N DVT Prophylaxis - number of days N/A NUMERIC N Mobility - number days YES NUMERIC N

16 14 CCU Data Collection with MIDAS+ Mobility - number days NO NUMERIC N Mobility - number days N/A NUMERIC N NUTRITIONAL SUPP - number of days YES NUMERIC N NUTRITIONAL SUPP - number of days NO NUMERIC N NUTRITIONAL SUPP - number of days N/A NUMERIC N Central Line still needed - # days YES NUMERIC N Central Line still needed - # days NO NUMERIC N Central Line still needed - # days N/A NUMERIC N Foley - number days YES NUMERIC N Foley - number days NO NUMERIC N TPN - number days YES NUMERIC N TPN - number days NO NUMERIC N Vent order sheet used? SELECT SINGLE N YES NO Physician name on vent order SELECT SINGLE N [PROVIDERS] Was patient mechanically ventilated? SELECT SINGLE N YES NO N/A Continued

17 CCU Data Collection with MIDAS+ 15 4/3/2006 COOLEY DICKINSON HOSPITAL PAGE 2 15:13 Focus Criteria Definition List Criteria Response Mand Age Sex Subcriteria CRITICAL CARE EXTENDED - Continued DVT Proph (M) - number days YES NUMERIC N DVT Proph (M) - number days NO NUMERIC N DVT Proph (M) - number days N/A NUMERIC N HOB>30 degrees - number days YES NUMERIC N HOB>30 degrees - number days NO NUMERIC N HOB>30 degrees - number days N/A NUMERIC N SAS gt/eq number days YES NUMERIC N SAS gt/eq number days NO NUMERIC N SAS gt/eq number days N/A NUMERIC N PUD Prophylaxis - number days YES NUMERIC N PUD Prophylaxis - number days NO NUMERIC N PUD Prophylaxis - number days N/A NUMERIC N ORAL CARE - number of days YES NUMERIC N ORAL CARE - number of days NO NUMERIC N ORAL CARE - number of days N/A NUMERIC N All 1-4 equals Yes or N/A - days YES NUMERIC N All 1-4 equals Yes or N/A - days NO NUMERIC N All 1-5 equals Yes or N/A - days YES NUMERIC N All 1-5 equals Yes or N/A - days NO NUMERIC N Central Line Month1 (name of month) TEXT N Total Central Line Days (month1) NUMERIC N Central Line Month2 (name of month) TEXT N Total Central Line Days (month2) NUMERIC N

18 16 CCU Data Collection with MIDAS+ Foley Month1 (name of month) TEXT N Total Foley Days (month1) NUMERIC N Foley Month2 (name of month) TEXT N Total Foley Days (month2) NUMERIC N TPN Month1 (name of month) TEXT N Total TPN Days (month1) NUMERIC N TPN Month2 (name of month) TEXT N Total TPN Days (month2) NUMERIC N Vent Month1 (name of month) TEXT N Total Vent Days (month1) NUMERIC N Vent Month2 (name of month) TEXT N Total Vent Days (month2) NUMERIC N

19 CCU Data Collection with MIDAS+ 17 MIDAS SYSTEM ENTRY INSTRUCTIONS CRITICAL CARE: EXTENDED USER FIELDS Laura Kelley MIDAS System Manager 7/14/05 Extension 2601 J:\Shared\Quality\MIDAS Reference\CCU Entry on MIDAS

20 18 CCU Data Collection with MIDAS+ Main Screen Function > Quality Management > Critical Care Entry The Critical Care Patient Lookup Screen will come up. Type the Account Number of the current Inpatient Encounter in the field labeled ID NUMBER and click OK: The Critical Care Entry Screen will come up. All bolded fields are mandatory entries in MIDAS (the entry can not be saved until these fields are entered): Critical Care Loc Admit Date Admit/Transfer to CCU Time (extended user fields) Telemetry Overflow? (extended user fields) These fields will all have been entered by the unit secretary upon the patient s arrival in CCU, as well as the remaining fields on the main entry screen. NOTE: If you do not already have a CCU entry for this encounter on the main screen, please check to make certain you have the correct account number. If the account number is correct and there is no entry yet, please check with the unit secretary to see if the main entry has been made yet. You can not enter on the extended user fields until you have the information for the main entry screens required fields (at least).

21 CCU Data Collection with MIDAS+ 19 Extended User Fields Click the button in the lower right corner of the mainscreen labeled User Fields. The Extended User Fields-Critical Care Entry screen will pop up. Enter the fields on this screen, based on the CCU Rounding form: **Notice in the bottom left corner of the full screen (above START) that the format required for each of the User Fields is displayed.** 1. Admit/Transfer FROM choose unit from which patient arrived 2. Readmit w/in 48 hrs choose yes or no 3. Discharge/Transfer from CCU Time enter time of discharge (ex: 1510 for 3:10 pm) 4. Discharge/Transfer TO choose unit/location to which patient has been discharged 5. Daily Rounds number of Days rounded 6. Bed Alarms Set & On Number of days YES 7. Bed Alarms Set & ON Number of days NO 8. DVT Prophylaxis Number of days YES 9. DVT Prophylaxis Number of days NO add the number of days the patient was rounded and enter it here add the YES check boxes and enter the number here add the NO check boxes and enter the number here add the YES check boxes and enter the number here add the NO check boxes and enter the number here

22 20 CCU Data Collection with MIDAS+ 10. DVT Prophylaxis Number of days N/A add the N/A check boxes and enter the number here 11. Mobility number of days YES add the YES check boxes and enter the number here 12. Mobility number of days NO add the NO check boxes and enter the number here 13. Mobility number of days N/A add the N/A check boxes and enter the number here 14. Nutr Support number of days YES add the YES check boxes and enter the number here 15. Nutr Support number of days NO add the NO check boxes and enter the number here 16. Nutr Support number of days N/A add the N/A check boxes and enter the number here 17. Central Line number of days YES add the YES check boxes and enter the number here 18. Central Line number of days NO add the NO check boxes and enter the number here 19. Central Line number of days N/A add the N/A check boxes and enter the number here 20. Foley number of days YES add the YES check boxes and enter the number here 21. Foley number of days NO add the NO check boxes and enter the number here 22. TPN number of days YES add the YES check boxes and enter the number here 23. TPN number of days NO add the NO check boxes and enter the number here 24. Vent Order sheet used? Choose Yes or No 25. Physician name on vent enter the name of the doctor ordering the vent 26. Was patient mechanically vented? Choose Yes or No 27. DVT Proph (M) number of days YES add the YES check boxes and enter the number here 28. DVT Proph (M) number of days NO add the NO check boxes and enter the number here 29. DVT Proph (M) number of days N/A add the N/A check boxes and enter the number here 30. HOB > 30 deg number of days YES add the YES check boxes and enter the number here 31. HOB > 30 deg number of days NO add the NO check boxes and enter the number here 32. HOB > 30 deg number of days N/A add the N/A check boxes and enter the number here 33. SAS 4.0 number of days YES add the YES check boxes and enter the number here 34. SAS 4.0 number of days NO add the NO check boxes and enter the number here

23 CCU Data Collection with MIDAS SAS 4.0 number of days N/A add the N/A check boxes and enter the number here 36. PUD Proph number of days YES add the YES check boxes and enter the number here 37. PUD Proph number of days NO add the NO check boxes and enter the number here 38. PUD Proph number of days N/A add the N/A check boxes and enter the number here 39. Oral Care number of days YES add the YES check boxes and enter the number here 40. Oral Care number of days NO add the NO check boxes and enter the number here 41. Oral Care number of days N/A add the Ref check boxes and enter the number here 42. All of #1-4 Yes or N/Adays YES add the YES check boxes and enter the number here 43. All of #1-4 Yes or N/A days NO add the NO check boxes and enter the number here 44. All of #1-5 Yes or N/Adays YES add the YES check boxes and enter the number here 45. All of #1-5 Yes or N/A days NO add the NO check boxes and enter the number here 46. Central Line Days Month1 enter name of first month in which pt had central line 47. Total central line days (m1) enter total of central line days YES and N/A checks for Month one 48. Central Line Days Month2 if applicable, enter name of second month in which pt had central line 49. Total central line days (m2) enter total of central line days YES and N/A checks for month two 50. Foley Days Month1 enter name of first month in which pt had foley 51. Total foley days (m1) enter total of foley days YES and N/A checks for Month one 52. Foley Days Month2 if applicable, enter name of second month in which pt had foley 53. Total foley days (m2) enter total of foley days YES and N/A checks for month two 54. TPN Days Month1 enter name of first month in which pt had TPN 55. Total TPN days (m1) enter total of TPN days YES and N/A checks for Month one 56. TPN Days Month2 if applicable, enter name of second month in which pt had TPN 57. Total TPN days (m2) enter total of TPN days YES and N/A checks for month two 58. Vent Days Month1 enter name of first month in which pt was on a vent 59. Total vent days (m1) enter total of vent days for month one 60. Vent Days Month2 if applicable, enter name of second month in which pt was on a vent 61. Total vent days (m2) enter total of vent days for month two

24 22 CCU Data Collection with MIDAS+ Click SAVE **Reminder your entry will not be saved if you do not click SAVE** Please call me with any questions regarding the MIDAS entry I am on extension 2601.

25 CCU Data Collection with MIDAS+ 23 Cooley Dickinson Hospital CCU Measures Data CCU Discharges through December 2005 CCU Data for the month of: Oct-05 Nov-05 Dec-05 TOTAL# of DISCHARGES TOTAL# of DEATHS Patients with LOS > 7 DAYS Patients on MECH VENT READMISSIONS within 48 hrs BED ALARMS Set & On # days YES DVT PROPH # days YES DVT PROPH # days N/A MOBILITY # days YES MOBILITY # days N/A NUTRITION SUPP # days YES NUTRITION SUPP # days N/A CENTRAL LINE # days YES CENTRAL LINE # days N/A FOLEY # days YES TPN # days YES DVT Mech Vent PROPH # days YES DVT Mech Vent PROPH # days NA HOB > 30 # of days YES HOB > 30 # of days N/A SED HELD # days YES SED HELD # days N/A PUD # days YES PUD # days NA IHI VAP Bundle (ALL 1-4) - # of patients ORAL CARE # days YES ORAL CARE # days Refused CDH VAP Bundle (ALL 1-5) - # of patients TOTAL ALL LOS (date admitted to CCU through date discharged) TOTAL ROUNDING DAYS (CCU patient days) Central Line Days (M1) Central Line Days (M2) Foley Days (M1) Foley Days (M2) Vent Days (M1) Vent Days (M2) TPN Days (M1) TPN Days (M2) Total Central Line Days for CCU discharges this month Total Foley Days for CCU discharges this month Total Vent Days for CCU discharges this month Total TPN Days for CCU discharges this month

26 24 CCU Data Collection with MIDAS+ Cooley Dickinson Hospital CCU Measures Data CCU Discharges through December 2005 CCU Measures/Rates for the month of: Oct-05 Nov-05 Dec-05 Mortality Rate 4.90 % 4.35 % 2.75 % LOS > 7 days Rate 3.92 % 2.61 % 3.67 % Average LOS 2.41 Days 2.13 Days 2.30 Days Average days on Mechanical Ventilation 2.00 Days 5.33 Days 3.11 Days Readmission Rate 0.98 % 3.48 % 1.83 % HOB > 30 degrees Rate % % % PUD Prophylaxis Rate % % % Oral Care Rate % % % Bed Alarms Set Correctly Rate % % % Mobility Rate % % % IHI VAP Bundle Rate % % % CDH VAP Bundle Rate % % % TPN Rate 9.79 % 9.79 % % Appropriate Sedation Rate % % % Appropriate DVT prophylaxis % % % Appropriate DVT prophylaxis - mech vent pts % % % Nutritional Support % % %

27 CCU Data Collection with MIDAS+ 25 CCU Measures Definitions MEASURE DEFINITION NUMERATOR SOURCE DENOMINATOR SOURCE Outcome Measures CCU Mortality Rate Percentage of CCU discharges who die in the CCU (no risk adjustment) CCU LOS > 7 days Percentage of CCU discharges with CCU LOS > 7 days Total number of CCU deaths MIDAS Total number of CCU discharges (including deaths & transfers) All CCU patients with CCU LOS > 7 days MIDAS Total number of CCU discharges (including deaths & transfers) MIDAS MIDAS Average CCU LOS Average CCU LOS Sum of CCU LOS for all discharges MIDAS Total number of CCU discharges (including deaths & transfers) Average days on mechanical ventilation Average days on mechanical ventilation based on days rounded Complication Measures CCU Readmissions Percentage of CCU patients readmitted within 48 hrs of discharge Sum of ventilator days out of days rounded MIDAS Total number of intubated/trached patients, who were mechanically vented Number of patients with CCU readmission within 48 hrs of discharge MIDAS Total number of CCU discharges (including deaths & transfers) MIDAS MIDAS MIDAS Rate of catheter-related blood stream infections Rate of catheter-related blood stream infections per 1,000 catheter days Number of patients with catheter-reloated BSI as defined by Centers for Disease Control INFECTION CONTROL Total number of catheter days in the CCU MIDAS Rate of resistant infections Rate of new onse resistant infections per CCU patient day Process Measures Appropriate deep venous thrombosis (DVT) prophylaxis (all patients) Prevention of ventilator-associated pneumonia (HOB>30) (ventilator patients) Appropriate sedation (ventilator patients) Appropriate peptic ulcer disease (PUD) prophylaxis (ventilator patients) Percent of CCU patient days where patient received DVT prophylaxis Percent of ventilator days where the HOB is elevated > 30 degrees for any patient on a ventilator, continuous sedative infusion stopped until the patient s SAS (Sedation Agitiation Score) was 4 at anytime in the last 24 hours Percent of ventilator days when patient received PUD prophylaxis Self Extubation Rates Percent of ventilator days when the patient self extubates Bed Alarms Correctly Set/On Percent of CCU days when bed alarms are properly set and on Proper Bed Rest Percent of CCU days when patients were on bed rest TPN Support Percent of CCU days when patients receiving TPN Nutritional Support Percent of CCU days when nutritional support was given up to a max of 7 days IHI VAP Bundle (ventilator patients) Percent of patients who received IHI VAP Bundle during mech ventilation CDH VAP Bundle (ventilator patients) Percent of patients who received CDH VAP Bundle during mech ventilation Number of patients who develop resistant infections in the CCU (MRSA or VRE) Number of CCU days patients received DVT prophylaxis Number of ventilator days when the HOB is elevated > 30 degrees Number of ventilator days in which infusion stopped until patient's SAS was 4 Number of ventilator days when patient received DVT prophylaxis Number of ventilator days when patient self extubates INFECTION CONTROL Total number of CCU patient days MIDAS MIDAS Total number of CCU days in which DVT was indicated (rounding days minus number of days DVT not indicated) MIDAS Total number of ventilator days minus the number of days not indicated MIDAS MIDAS MIDAS Total number of ventilator days MIDAS MIDAS Total number of ventilator days MIDAS MIDAS Total number of ventilator days MIDAS Number of CCU days with alarms correctly set MIDAS Total number of CCU days MIDAS Number of CCU days when patients were on bed rest Number of CCU days when patients were receiving TPN Number of CCU days when patients were receiving nutritional support Number of patients who received the IHI VAP Bundle each day mech vented (HOB>30, sed vacation, PUD, DVT) Number of patients who received the IHI VAP Bundle each day mech vented (HOB>30, sed vacation, PUD, DVT, and oral care q 2 hrs) MIDAS Total number of CCU days MIDAS MIDAS Total number of CCU days MIDAS MIDAS Total number of CCU days when nutritional support was indicated (rounding days minus number of days nutritional support not indicated) MIDAS MIDAS Total number of patients ventilated MIDAS MIDAS Total number of patients ventilated MIDAS

28 26 CCU Data Collection with MIDAS+ Cooley Dickinson Hospital CCU Quality Data January 2006 CCU LOS Days Rounded LOS = Rounded? Readmit? Alarms Yes Alarms No Total Alarms Total Alarms = Round Days DVT Yes DVT No DVT NA Total DVT Total DVT = Round Days? Mobility Yes Mobility No Mobility NA Total Mobility Total Mob = Round Days? NUTR Y NUTR No NUTR NA Total NUTR Total NUTR = Round Days? Central Line Needed Yes Central Line Needed No Central Line Needed NA CCU Disch Date Account Patient Name Disp Loc Phys ordering vent 1/1/ PATIENT,A 2 NO HOME YES YES YES YES 1/1/ PATIENT,B 1 1 YES NO W5 SMITH,JOHN YES YES YES YES /1/ PATIENT,C 1 1 YES NO WEST YES YES YES YES /1/ PATIENT,D 2 2 YES NO HOME YES YES YES YES /2/ PATIENT,E 1 NO HOME YES YES YES YES 1/2/ PATIENT,F 3 3 YES NO WEST YES YES YES YES /2/ PATIENT,G 1 NO HOME YES YES YES YES Total Central Line Total CL = Round Days? Foley Yes Foley No Total Foley Total Foley = Round Days? TPN Yes TPN No Total TPN Total TPN = Round Days? Mech Vented? Vent order sheet used? DVTM Yes DVTM No DVTM NA DVTM Yes/NA = Vent Days? HOB Yes HOB No HOB NA Total HOB Y/NA = Vent Days? SAS Y SAS N SAS NA Total SAS Y/NA = Vent Days? PUD Yes PUD No PUD NA Total PUD Y/NA = Vent Days? CCU Disch Date Account Patient Name 1/1/ PATIENT,A S YES YES 1/1/ PATIENT,B 1 S YES YES S S S NO NO NO 1/1/ PATIENT,C 1 S YES YES NO 1/1/ PATIENT,D 2 S YES YES NO 1/2/ PATIENT,E S YES YES 1/2/ PATIENT,F 3 S YES YES NO 1/2/ PATIENT,G S YES YES

29 CCU Data Collection with MIDAS+ 27 Cooley Dickinson Hospital CCU Quality Data January 2006 Oral Y Oral No Oral Refused Total Oral Y/NA = Vent Days? All 1-4 Yes All 1-4 No Total All 1-4 = Vent Days? All 1-5 Yes All 1-5 No Total All 1-5 Central Line Month 1 Central Line Days (Month 1) Central Line Month 2 Central Line Days (Month 2) Foley Month 1 Foley Days (Month 1) Foley Month 2 Foley Days (Month 2) TPN Month 1 TPN Days (Month 1) TPN Month 2 TPN Days (Month 2) Vent Month 1 Vent Days (Month 1) Vent Month 2 Vent Days (Month 2) CCU Disch Date Account Patient Name 1/1/ PATIENT,A YE 1/1/ PATIENT,B NO 0 1 S 0 1 YES Jan 1 1/1/ PATIENT,C Jan 1 1/1/ PATIENT,D Dec 1 Jan 1 1/2/ PATIENT,E 1/2/ PATIENT,F Dec 1 Jan 2 Dec 1 Jan 2 1/2/ PATIENT,G

30 28 CCU Data Collection with MIDAS+