Public Reporting Data
Process of Care Measures
King's Daughters' Hospital and Health Services (KDHHS) is proud to participate in the Centers for Medicare and Medicaid (CMS) program for public reporting of quality data. The measures below are selected by CMS and each indicator represents a key process of care measure. These measures are determined by CMS to be national standards of quality care. The information below is updated to show the most current KDHHS data available compared to national and state averages. An NA indicates there were not enough qualifying patients for that particular Quality Measure during the quarter involved. Data is updated as the next quarter's data becomes available.
MEASURE 1: ACUTE MYCARDIAL INFARCTION (AMI - heart attack)
AMI-1: Aspirin at arrival
What does this care measure mean?
The heart is a muscle that gets oxygen through blood vessels. Sometimes blood clots can block these blood vessels, and the heart can't get enough oxygen. This can cause a heart attack. Chewing an aspirin as soon as symptoms of a heart attack begin may help reduce the severity of the attack. This chart shows the percent of heart attack patients who were given (or took) aspirin within 24 hours of arrival at the hospital.
National Average |
State Average |
KDHHS |
2nd Q 2007 |
1st Q 2007 |
4th Q 2006 |
AMI-2: Aspirin at discharge
What does this care measure mean?
Blood clots can block blood vessels. Aspirin can help prevent blood clots from forming or help dissolve blood clots that have formed. Following a heart attack, continued use of aspirin may help reduce the risk of another heart attack. Aspirin can have side effects like stomach inflammation, bleeding, or allergic reactions. Talk to your health care provider before using aspirin on a regular basis to make sure it's safe for you.
National Average |
State Average |
KDHHS |
2nd Q 2007 |
1st Q 2007 |
4th Q 2006 |
AMI-3: ACEI or ARB for LVSD
What does this care measure mean?
ACE (angiotensin converting enzyme) inhibitors and ARBs (angiotensin receptor blockers) are medicines used to treat patients with heart failure and are particularly beneficial in those patients with heart failure and decreased function of the left side of the heart. Early treatment with ACE inhibitors and ARBs in patients who have heart failure symptoms or decreased heart function after a heart attack can also reduce their risk of death from future heart attacks. ACE inhibitors and ARBs work by limiting the effects of a hormone that narrows blood vessels, and may thus lower blood pressure and reduce the work the heart has to perform. Since the ways in which these two kinds of drugs work are different, your doctor will decide which drug is most appropriate for you. If you have a heart attack and/or heart failure, you should get a prescription for ACE inhibitors or ARBs if you have decreased heart function before you leave the hospital.
National Average |
State Average |
KDHHS |
2nd Q 2007 |
1st Q 2007 |
4th Q 2006 |
AMI-4: Adult Smoking Cessation
What does this care measure mean?
Smoking increases your risk for developing blood clots and heart disease that can result in a heart attack, heart failure or stroke. Smoking causes your arteries to thicken and your blood vessels to narrow. Fat and plaque stick to the walls of your arteries, which makes it harder for blood to flow. Reduced blood flow to your heart may result in chest pain, high blood pressure, and an increased heart rate. Smoking is also linked to lung disease and cancer, and can cause premature death. It is important that you get information to help you quit smoking before you leave the hospital. Quitting may help prevent another heart attack.
National Average |
State Average |
KDHHS |
2nd Q 2007 |
1st Q 2007 |
4th Q 2006 |
AMI-5: Beta Blocker at discharge
What does this care measure mean?
Beta blockers are a type of medicine that is used to lower blood pressure, treat chest pain (angina) and heart failure, and to help prevent a heart attack. Beta blockers relieve the stress on your heart by slowing the heart rate and reducing the force with which your heart muscles contract to pump blood. They also help keep blood vessels from constricting in your heart, brain, and body. If you have a heart attack, you should get a prescription for a beta blocker before you leave the hospital.
National Average |
State Average |
KDHHS |
2nd Q 2007 |
1st Q 2007 |
4th Q 2006 |
AMI-5: Beta Blocker at arrival
What does this care measure mean?
Beta blockers are a type of medicine that is used to lower blood pressure, treat chest pain (angina) and heart failure, and to help prevent a heart attack. Beta blockers relieve the stress on the heart by slowing the heart rate and reducing the force with which the heart muscle contracts (to pump blood). Most heart attack patients should be given a beta blocker within 24 hours of arriving at the hospital.
National Average |
State Average |
KDHHS |
2nd Q 2007 |
1st Q 2007 |
4th Q 2006 |
MEASURE 2: HEART FAILURE
HF-1: Discharge Instructions
What does this care measure mean?
Heart failure is a chronic condition. It results in symptoms such as shortness of breath, dizziness, and fatigue. Before you leave the hospital, the staff at the hospital should provide you with information to help you manage the symptoms after you get home. The information should include your activity level (what you can and can't do), diet (what you should, and shouldn't eat or drink), medications, follow-up appointment, watching your daily weight, what to do if your symptoms get worse.
National Average |
State Average |
KDHHS |
2nd Q 2007 |
1st Q 2007 |
4th Q 2006 |
HF-2: LVF Assessment
What does this care measure mean?
The proper treatment for heart failure depends on what area of your heart is affected. An important test is to check how your heart is pumping, called an Òevaluation of the left ventricular systolic function.Ó It can tell your health care provider whether the left side of your heart is pumping properly. Other ways to check on how your heart is pumping include: your medical history, a physical examination, listening to your heart sounds, other tests as ordered by a physician (like an ECG (electrocardiogram), chest x-ray, blood work, and an echocardiogram), what to do if your symptoms get worse.
National Average |
State Average |
KDHHS |
2nd Q 2007 |
1st Q 2007 |
4th Q 2006 |
HF-3: ACEI or ARB for LVSD
What does this care measure mean?
ACE (angiotensin converting enzyme) inhibitors and ARBs (angiotensin receptor blockers) are medicines used to treat patients with heart failure and are particularly beneficial in those patients with heart failure and decreased function of the left side of the heart. Early treatment with ACE inhibitors and ARBs in patients who have heart failure symptoms or decreased heart function after a heart attack can also reduce their risk of death from future heart attacks. ACE inhibitors and ARBs work by limiting the effects of a hormone that narrows blood vessels, and may thus lower blood pressure and reduce the work the heart has to perform. Since the ways in which these two kinds of drugs work are different, your doctor will decide which drug is most appropriate for you. If you have a heart attack and/or heart failure, you should get a prescription for ACE inhibitors or ARBs if you have decreased heart function before you leave the hospital.
National Average |
State Average |
KDHHS |
2nd Q 2007 |
1st Q 2007 |
4th Q 2006 |
HF-4: Adult Smoking Counseling
What does this care measure mean?
Smoking increases your risk for developing blood clots and heart disease, which can result in a heart attack, heart failure or stroke. Smoking causes your blood vessels to thicken. Fat and plaque then stick to the wall of your blood vessels, which makes it harder for blood to flow. Reduced blood flow to your heart may result in chest pain, high blood pressure, and an increased heart rate. Smoking is linked to lung disease and cancer, and can cause premature death. It is important for your health that you get information to help you quit smoking before you leave the hospital.
National Average |
State Average |
KDHHS |
2nd Q 2007 |
1st Q 2007 |
4th Q 2006 |
MEASURE 3: PNEUMONIA
PN-1: Oxygenation Assessment
What does this care measure mean?
Pneumonia can lower the oxygen in your blood because the air spaces in your lungs fill with mucus. The oxygen you breathe does not get into your bloodstream. It is important that the amount of oxygen in your blood be measured within 24 hours of arriving at the hospital to see if you need oxygen therapy. The assessment may include an ABG (arterial blood gas) or pulse oximetry (electrodes attached to a part of your body like a finger, earlobe, or skin fold).
National Average |
State Average |
KDHHS |
2nd Q 2007 |
1st Q 2007 |
4th Q 2006 |
PN-2: Pneumococcal Screen/Vaccination
What does this care measure mean?
The pneumococcal vaccine may help you prevent, or lower the risk of complications of pneumonia caused by bacteria. It may also help you prevent future infections. Patients with pneumonia should be asked if they have been vaccinated recently for pneumonia and, if not, should be given the vaccine.
National Average |
State Average |
KDHHS |
2nd Q 2007 |
1st Q 2007 |
4th Q 2006 |
PN-3B: Blood Cultures
What does this care measure mean?
Different types of bacteria can cause pneumonia. A blood culture is a test that can help your health care provider identify which bacteria may have caused your pneumonia, and which antibiotic should be prescribed. A blood culture is not always needed, but for patients who are first seen in the hospital emergency department, it is important for the accuracy of the test that blood culture be conducted before any antibiotics are started. It is also important to start antibiotics as soon as possible.
National Average |
State Average |
KDHHS |
2nd Q 2007 |
1st Q 2007 |
4th Q 2006 |
PN-4: Adult Smoking Counseling
What does this care measure mean?
Smoking damages your lungs and can make it hard to breath. Smoking increases your chances of getting pneumonia or other chronic lung diseases like emphysema and bronchitis. Smoking is also linked to lung cancer, heart disease, and stroke, and can cause premature death. It is important for you to get information to help you quit smoking before you leave the hospital. Quitting may reduce your chance of getting pneumonia again.
National Average |
State Average |
KDHHS |
2nd Q 2007 |
1st Q 2007 |
4th Q 2006 |
PN-5B: Initial Antibiotic Received within 4 hours
What does this care measure mean?
Antibiotics are used to treat adults with pneumonia caused by bacteria. Early treatment with antibiotics can cure bacterial pneumonia and reduce the possibility of complications. This information shows the percent of patients who were given their first dose of antibiotics within 4 hours of arrival at the hospital. Patients who get pneumonia during their stay at the hospital are not counted in this measure.
National Average |
State Average |
KDHHS |
2nd Q 2007 |
1st Q 2007 |
4th Q 2006 |
PN-6B: Initial Antibiotic Selection for Immunization (non-ICU)
What does this care measure mean?
Pneumonia is a lung infection that is usually caused by bacteria or a virus. If pneumonia is caused by bacteria, hospitals will treat the infection with antibiotics. Different bacteria are treated with different antibiotics. To learn about how hospitals use a blood test to choose the most effective treatment for pneumonia patients, refer to the Process of Care measure named 'Percent of Pneumonia Patients Whose Initial Emergency Room Blood Culture Was Performed Prior To The Administration Of The First Hospital Dose Of Antibiotics'.
National Average |
State Average |
KDHHS |
2nd Q 2007 |
1st Q 2007 |
4th Q 2006 |
MEASURE 4: SCIP - SURGICAL INFECTION PREVENTION
SCIP-1: Prophylactic Antibiotic within 1 hour of cut
What does this care measure mean?
Antibiotics are medicines to prevent and treat infections. Research shows that surgery patients who get antibiotics within the hour before their operation are less likely to get wound infections. Getting an antibiotic earlier, or after surgery begins, is not as effective. This shows how often hospitals make sure surgery patients get antibiotics at the right time.
National Average |
State Average |
KDHHS |
2nd Q 2007 |
1st Q 2007 |
4th Q 2006 |
SCIP-2: Antibiotic Selection
What does this care measure mean?
Certain antibiotics are recommended to help prevent wound infection for particular types of surgery. This measure looks at how often hospital surgical patients get the appropriate antibiotic in order to prevent a surgical wound infection. Infections continue to be the main preventable complication of most surgical procedures. Antibiotics are medicines to prevent and treat infections. By following the standard guidelines for timing and giving you the correct antibiotic drug, hospitals can reduce your risk of getting a wound infection after surgery. 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. These quality measures show some of the standards of care.
National Average |
State Average |
KDHHS |
2nd Q 2007 |
1st Q 2007 |
4th Q 2006 |
SCIP-3: Prophylactic Antibiotic discontinued 24 hours post close
What does this care measure mean?
Antibiotics are medicines to prevent and treat infections. While the likelihood of infection after surgery can be reduced by giving patients preventative antibiotics, taking these antibiotics for more than 24 hours after routine surgery is usually not necessary and can increase the risk of side effects such as stomach aches, serious types of diarrhea, and antibiotic resistance (when antibiotics are used too much, they will not work anymore.) There are exceptions Ð for example, where the surgical site has been contaminated (making the surgery not routine).Talk to your doctor if you have questions about how long you should take antibiotics after surgery.
National Average |
State Average |
KDHHS |
2nd Q 2007 |
1st Q 2007 |
4th Q 2006 |