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September 30, 2010 To Healthcare Partners and the Citizens of Oklahoma, Quality of health care remains an ongoing concern for patients, payers, and policy makers in Oklahoma. While there are a number of initiatives to measure and to improve the quality of care in our state and nationally, variations in quality continue to exist. Patients and other consumers of health care increasingly understand that the quality of their care is often compromised by medical errors, failure to deliver care consistent with the best evidence of effectiveness, and the lack of coordination of care between health care settings. The following document represents the second annual Oklahoma Hospital Report which provides a summary of nationally standardized, hospital-specific quality indicators. This report fulfills requirements set forth by the Oklahoma Legislature to publish an annual report of hospital-specific quality measures. In addition to providing details of hospital-specific performance on the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators, this year’s report now includes information on hospital-acquired infections as mandated by the Legislature. In a recent report on health system performance, Oklahoma ranked 50th in the nation based on 38 indicators of access to healthcare, health care quality, costs of care, and health outcomes. As noted in the Oklahoma Health Improvement Plan, there is an urgent need to improve health outcomes and health care quality. We continue to hope that providing the information detailed in this report to the citizens of Oklahoma will motivate leaders in health care to continue to identify opportunities to improve patient safety and health care quality, and to allow patients to use the information to make informed decisions when choosing their healthcare provider. Sincerely, Dale W. Bratzler, DO, MPH, Chair Hospital Advisory Council Oklahoma Hospital Annual Report 2009 2 (This page left blank) Oklahoma Hospital Annual Report 2009 3 Table of Content Services Offered………………………………………………………………………………………………………….5 Public Report AHRQ Patient Safety Indicators…………………………………………..13 Tier One PSI 4 Death among Surgical In- patients with Complications.17 PSI 6 Iatrogenic Pneumothorax……………………………………………………………21 PSI 11Postoperative Respiratory Failure………………………………………..25 PSI 12 Postoperative Pulmonary Embolism or DVT………………….29 PSI 14 Postoperative Wound Dehiscence……………………………………..33 PSI 15 Accidental Puncture or Laceration………………………………………37 PSI 17 Birth Trauma – Injury to Neonate………………………………………….41 PSI 18 Obstetric Trauma – Vaginal Delivery with Instrument…43 PSI 19 Obstetric Trauma – Vaginal Delivery w/o Instrument….47 Tier 1-B PSI 2 Death in Low Mortality DRGs…………………………………………………..51 PSI 8 Postoperative Hip Fracture……………………………………………………….55 National Healthcare Safety Network Central Line Associated Bloodstream Infection……………………………57 Ventilator Associated Pneumonia……………………………………………………..119 Hospital Compare…………………………………………………………………………………………………….181 References………………………………………………………………………………………………………………….182 **This document was revised May 10, 2011 Oklahoma Hospital Annual Report 2009 4 (This page left blank) Oklahoma Hospital Annual Report 2009 5 Services Offered Licensure Hospitals in Oklahoma are required by state statute to be licensed except those hospitals operated by the federal government, state mental hospitals, and community-based structured crisis centers. Licensing Authority - The Medical Facilities Service, within Protective Health Services of the Oklahoma State Department of Health (OSDH), is charged with the responsibility of assessing compliance with statute and administrative rule for hospital licensure. Rules – Chapter 667 Hospital Standards, Title 310, of the Oklahoma Administrative Code (OAC) outlines construction standards and rules for operation in order for an entity to be licensed as a hospital in Oklahoma. Fees – The licensure fee is set but statute and is based on the total number of beds licensed by the facility multiplied by ten dollars. Renewals – A license is valid for one year, therefore, facilities must apply annually for renewal. Facility Description Hospital – Any institution, place, building or agency, public or private, whether organized for profit or not, devoted primarily to the maintenance and operation of facilities for the diagnosis, treatment or care of patients admitted for overnight stay or longer in order to obtain medical care, surgical care, obstetrical care, or nursing care for illness, disease, injury, infirmity, or deformity {63 O.S. § 1-701}. In addition, Oklahoma Statutes provide that the term ―hospital‖ includes general medical surgical hospitals, specialized hospitals, critical access and emergency hospitals, and birthing centers. General Medical Surgical Hospital – A hospital maintained for the purpose of providing care in a broad category of illness and injury. Specialized Hospital – A hospital maintained for the purpose of providing care in a certain category, or categories, of illness and injury. The OSDH currently recognizes psychiatric, rehabilitation, and abortion facilities as specialized hospitals. Critical Access Hospital – A hospital that the OSDH determines to be a necessary provider of health care services to residents of a rural community. Oklahoma Hospital Annual Report 2009 6 Emergency Hospital – A hospital that provides emergency treatment and stabilization services on a 24-hour basis and has the ability to admit and treat patients for short period time. Birthing Center – Any hospital, place, or institution which is maintained or established primarily for the purpose of providing the services of a certified nurse midwife or licensed medical doctor to assist or attend in the delivery or birth and where a woman is scheduled in advance to give birth following a normal, uncomplicated, low-risk pregnancy. Licensure of birthing centers is voluntary. Medicare Certification OSDH contracts with the Centers for Medicare & Medicaid Services (CMS) to conduct administrative and inspection activities related to certification of hospitals for participation in the federal Medicare program. Although participation in the Medicare program is voluntary, facilities opting to apply must: 1) meet the requirements outlined in the Code of Federal Regulations (CFR); Conditions of Participation for Hospitals (42 CFR part 482), and for Critical Access Hospitals, CFR Part 485; subpart F - Conditions of Participation for Critical Access Hospitals (CAHs); and 2) comply with the Emergency Medical Treatment and Labor Act found in the Social Security Act, Sections 1866 and 1867, and associated regulations at CFR 42 part 489.24. OSDH makes recommendations regarding Medicare certification issues; however the CMS Region VI Office in Dallas, Texas has authority to make all final certification decisions. Accreditation Several national organizations offer programs for accrediting hospitals, or parts of a hospital’s operation, by meeting the respective organizations published standards. Participation in such accreditation programs is voluntary. Some private accrediting bodies have been granted ―deemed status‖ by Federal authorities. Hospitals accredited by one or more of these accrediting bodies are ―deemed― to meet the applicable federal standards without undergoing an on-site inspection by agents of CMS. There is no similar provision in Oklahoma law to grant ―deemed status‖ to third party accrediting organization for the purpose of state licensure. Oklahoma Hospital Annual Report 2009 7 Complaint Investigations OSDH conducts complaint investigation when allegations have been made that a licensed hospital is non-complaint with Chapter 667 Hospital Standards. In addition, the OSDH can investigate complaints against non-accredited hospitals regarding compliance with the Medicare Conditions of Participation; however, such investigations in accredited hospitals must be authorized by the CMS. Prior authorization from the CMS is also required before the OSDH can conduct an investigation of compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA) requirements. Construction Reviews Licensed hospitals wishing to alter existing buildings or build a new facility, must submit design plans and related documents to the OSDH for review and approval prior to construction. A review fee, based on the project’s estimated cost for design and construction, is assessed. Final inspection and approval of the facility must be granted by the OSDH prior to occupancy. Hospital Classifications Oklahoma Statutes require the OSDH to ―develop a classification system for all hospitals that treat emergency patients. The classification system shall identify stabilizing and definitive emergency services provided by each hospital‖ {63 O.S. § 1-2511}. The system is designed to classify the level of emergency services each hospital in Oklahoma provides in ten clinical categories. Within each category, the rules identify the practitioners, hospital personnel, equipment, and support services necessary for each level of care. It should be emphasized that the classification system is not designed to be a hospital ―report card.‖ Rather, it is intended to help direct emergency response providers and patients to the most appropriate facility based on the type and severity of their injury or illness. The ten clinical categories and levels of service follow: Trauma & Emergency Operative Services: Levels I – IV Cardiology: Levels I – III Pediatric Medicine and Trauma: Levels I-IV Dental: Levels I-III Obstetrics/Gynecology: Levels I-IV Ophthalmology: Levels I-III Neurology: Levels I-III Psychiatry: Levels I-III General Medicine: Levels I-I Stroke: Primary – Secondary Oklahoma Hospital Annual Report 2009 8 The most comprehensive services are offered by hospitals classified as Level I in a specific clinical category. These facilities are equipped and staffed to provide definitive treatment for severe emergency conditions in the classified clinical category. The hospital emergency classification system was developed with the assistance of the Oklahoma State Trauma Advisory Council, Oklahoma Emergency Response Systems Development Advisory Council, and numerous industry and professional associations. The classification system was promulgated in rule as Subchapter 59 of Chapter 667 Hospital Standards and became effective on July 13, 2000. By May 2001, each hospital in the State that offers emergency services had received an on-site visit by OSDH representatives to verify the level of service provided in each clinical category. In an effort to facilitate proper treatment of strokes, Governor Brad Henry signed the Oklahoma Administrative Code, Title 310, Chapter 667 Hospital Standards in 2009, which established classification standards for "Primary Stroke Centers" and "Secondary Stroke Facilities." These standards are intended to stratify hospitals into those hospitals willing and able to administer a federal Food and Drug Administration approved intravenous thrombolytic agent to appropriate patients within one hour of arriving at the emergency department and within three hours of the onset of ischemic stroke symptoms. A Primary Stroke Center shall provide emergency medical services with an organized emergency department. A physician shall be on call and immediately available to respond to the emergency department and nursing staff with special capability in emergent stroke care shall be on site twenty-four hours a day. A Secondary Stroke Facility shall provide services with at least a licensed independent practitioner, registered nurse, licensed practical nurse, or intermediate or paramedic level emergency medical technician on site twenty-four hours a day. Complete hospital standards of the rules can be found in OAC 310:667- 59-20.1 Those hospitals that are not able or choose not to provide this therapeutic intervention for stroke are classified as a Secondary Stroke Facility. 1 OSDH link. Oklahoma Hospital Annual Report 2009 9 Emergency Systems In August 2009, the Emergency Medical Services (EMS) Division and Trauma Division reorganized into a single work unit, Emergency Systems. The rationale for the consolidation of these areas into a single work unit includes: maximizing staff resources while achieving common goals in emergency system development, aligning and streamlining fiscal processes for the disbursements of the Oklahoma Emergency Response Systems Stabilization and Improvement Revolving Fund and the Trauma Care Assistance Revolving, and for further development of systems of care for patients with time-sensitive trauma and medical emergency conditions. Statistics at a Glance Fiscal Year 2009 152 Licensed Hospitals currently in operation: 97 General Medical Surgical Hospitals 35 Critical Access Hospitals 11 Specialized Hospitals, Psychiatric 6 Specialized Hospitals, Rehabilitation 3 Specialized Hospitals, Abortion Facility 115 Medicare Certification Surveys performed: 25 Re-certification surveys 1 Follow-up Surveys 57 Complaint Investigations 1 Validation Survey 0 Initial Surveys 26 Life Safety 35 Licensure Surveys performed, including: 28 Re-licensure Surveys 0 Follow-up Surveys 4 Complaint Investigations 3 Initial Surveys $163,020.00 Fees collected (Note: The total dollar amount of fee collections shown above includes the fees for the Ambulatory Surgical Centers, Birthing Centers, and Workplace Drug and Alcohol Testing Facilities program areas.) Oklahoma Hospital Annual Report 2009 10 Hospital Advisory Council The Hospital Advisory Council is authorized by Oklahoma Statute (63 O.S., Section 1-707) to serve as an advisory body to the Board of Health, Commissioner and Department. The Advisory Council is composed of nine members appointed by the Commissioner with the advice and consent of the Board of Health. The membership of the Advisory Council is a follows: two members are hospital administrators of licensed hospitals; two members are licensed physicians or practitioners who have current privileges to provide services in hospitals; two members are hospital employees; and three members are citizens representing the public who: are not hospital employees, do not hold hospital staff appointments, and are not members of hospital governing boards. Members are appointed for a three-year term. The Board must meet at least quarterly, and may hold such special meetings as may be necessary. Advisory Board Members: Dale Bratzler, D.O., Chair Gloria Caldwell Nancy Cooper, MS, ARNP Starla Givens, R.N. Gary W. Mitchell, D.Ph. FACHE Ken Rose, Ed. D. Betty Selby Dale Harris 1 Vacancy Authority The Advisory Council has the duty and authority to: (1) review and approve in its advisory capacity rules and standards for hospital licensure; (2) evaluate, review and make recommendations regarding Department licensure activities, provided, however, the Advisory Council shall not make recommendations regarding scope of practice for any health care providers or practitioners regulated pursuant to Title 59 of the Oklahoma Statues, and (3) recommended and approve: quality indicators and data submission requirements for hospitals, to include: Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators available as part of the standard inpatient discharge data set, and for acute care intensive care patients ventilator associated pneumonia and device –related blood stream infections, and the indicators and data to be used by the Department to monitor compliance with licensure requirements and to publish an annual report of hospital performance to include the facility specific quality indicators required by this section. The Council has recommended the Department designate the National Healthcare Safety Network, supported by the Centers for Disease Control and Prevention, as the data collection and analysis tool licensed hospitals shall use for public reporting purposes. Oklahoma Hospital Annual Report 2009 11 Public Reporting The Oklahoma Hospital Annual Report 2009 is a publication required by statute at 63 O.S., Section 1-707. This report is intended to increase the availability of quality data related to hospital services and to improve patient care in Oklahoma. The annual report displays hospital-specific quality indicators and a brief outline of services provided by the Medical Facilities Service of the Oklahoma State Department of Health. There are three sources for the data included in this report: 1. Detailed hospital-specific performance measures outlined by the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators for care provided during the 2007 calendar year. These measures are calculated from the standard hospital discharge data set reported to the OSDH Health Care Information Division 2. The National Healthcare Safety Network (NHSN) data system. NHSN is a secure, internet-based surveillance system that integrates patient and healthcare personnel safety surveillance systems data and is managed by the Division of Healthcare Quality Promotion (DHQP) at the Centers for Disease Control and Prevention (CDC). In July 2008 Hospital Infection Preventionist in Oklahoma began collecting and reporting data for events related to central line associated bloodstream infections (CLABSI) and ventilator associated pneumonias (VAP). Adult patients in an Intensive Care Unit (ICU) who were on a ventilator or who had at least one central line inserted who subsequently develop an infection meeting the strict case definition criteria defined by CDC are reported to NHSN. 3. Hospital Compare. The Hospital Compare website is maintained by The Centers for Medicare & Medicaid Services (CMS) and the Hospital Quality Alliance (HQA). The nation's hospitals are working together to create and publicly report hospital quality information as related to care. This information measures how well hospitals care for their patients, whether the care was paid for by Medicare, Medicaid, or a private health insurance plan. Oklahoma Hospital Annual Report 2009 12 (This page left blank) Oklahoma Hospital Annual Report 2009 13 Patient Safety Indicators The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators are measures used to screen for adverse events that patients experience as a result of exposure to the health care system; these events are likely amenable to prevention by changes at the system or provider level. The Patient Safety Indicators (PSIs) are used with the hospital inpatient discharge data, which is uploaded to the Oklahoma State Department of Health annually. Improving patient safety is a critical part of efforts to provide high quality healthcare in Oklahoma. This report is intended to facilitate such efforts. Comparative reporting of hospital performance data is encouraged by the Agency for Healthcare Research and Quality (AHRQ). AHRQ considers comparative reporting an important strategy to advance the quality improvement agenda in healthcare. Public reporting has been supportive evidence that comparative performance data by hospital is a key element that promotes enhanced patient care. AHRQ is an active participant and works closely with the Hospital Quality Alliance (HQA), the Ambulatory Care Quality Alliance (AQA) alliance, the National Quality Forum (NQF) and others. The combined effort in comparative reporting AHRQ Quality Indicators are submitted to the National Quality Forum endorsement process. Based on an extensive analysis of each indicator by these partners, NQF has determined the appropriateness of each indicator for comparative reporting. For the purpose of this report only the indicators classified as Tier 1 will be reported. Tier 1 has the strongest evidence base, with established evidence in several or most evidentiary areas and no substantial evidence suggesting that the indicator may not be useful for comparative reporting. Additional data from Tier 1 B will also be reported as these events are serious reportable events but may not be as useful for hospital comparison. 2 The PSIs are a set of measures that can be used with hospital inpatient discharge administrative data to provide perspective on patient safety. This data is taken from the medical record billing ICD-9 codes. Specifically, PSIs screen for problems that patients experience as a result of exposure to the healthcare system and that are likely amenable to prevention by changes at the healthcare system (hospital) or provider level. These are referred to as complications or adverse events. PSIs are defined for this report as Provider level Indicators. Provider level Indicators provide a measure of the potentially preventable complication for patients who received their initial care and the complication of care within the same hospitalization. Provider level Indicators include only those cases where a secondary diagnosis code 2 AHRQ Quality Indications, Guidance on Using the AHRQ QI” for Hospital-Level Comparative Reporting , June 2009. Oklahoma Hospital Annual Report 2009 14 flags a potentially preventable complication. Detailed information on the methods of identifying, selecting and evaluating these quality indicators can be found at the AHRQ Quality Indicator Web Site: http://www.qualityindicators.ahrq.gov Limitations Because of limitations related to the use of administrative data, many important concerns and potentially confounding factors cannot currently be monitored, such as adverse drug events. Using this data tends to favor specific types of indicators. The PSIs mainly focus on surgical indicators rather than medical or psychiatric conditions because medical complications are often difficult to distinguish from co-morbidities that are present on admission. However, the careful use of administrative data holds promise for screening to target further data collection analysis. In small hospitals, the mathematical formula may be difficult to compute due to sample size or the number of patients (denominator) who have had the procedures. Therefore charts in this report are noted to reflect when the denominator for the specific indicator is less than ideal, because the true population at risk could not be identified from the discharge data. Data Charts The hospitals are grouped into peer groups by hospital state licensure and the number of licensed beds. Some hospitals may not be represented since the data is representative of 2007; hospital ownership may have changed or a hospital may have closed since the data was collected. Also, the numbers represented on the charts are the number of patients affected for an event per 1000 patient discharges or with PSI # 17 through 19, it would be per 1000 live births. Therefore the lower the bar is on the chart the fewer events have occurred which is a favorable representation. The ultimate goal is to have zero events for each of the Patient Safety Indicators. It is also important to note that if a hospital does not have incidents of the event, then no data is reported and the name of the hospital maybe displayed without a bar on the chart. If a peer group of hospitals does not have data for a specific PSI, a chart may not be displayed. Oklahoma Hospital Annual Report 2009 15 Long Term Acute Care Hospitals Long Term Acute Care Hospitals (LTCH) are designed to provide extended medical and rehabilitative care for patients who are clinically complex and have multiple acute or chronic conditions. These hospitals are licensed in Oklahoma as Acute Care Hospitals and are ranked in this report with hospitals of similar bed size; however the patients within these facilities may be more acutely ill. Most patients in LTCHs have several diagnosis codes on their Medicare claims, which indicate that they have multiple co-morbidities and are probably less stable on admission than patients admitted to other post-acute care settings (Prospective Payment Assessment Commission, 1996). Approximately one-half of the patients have five or more diagnoses noted on their claims. LTCHs generally provide a range of services, including comprehensive rehabilitation, cancer treatment, head trauma treatment, and pain management (Medicare Payment Advisory Commission, 1998b). The typical Medicare patient in a LTCH is admitted following an acute care hospital stay. As of 1997, about 200 facilities were certified by Medicare as LTCHs. For the purposes of this report, data maybe reported that appears to fall beyond expected limits due to the small number of patients in the sample many of whom also have complex conditions that result in less than optimal outcomes. The following facilities are designated as LTCH by the Centers for Medicare & Medicaid Services (CMS): Continuous Care Center of Bartlesville Continuous Care Center of Tulsa Edmond Specialty Hospital Integris Bass Pavilion Kindred Hospital Lane Frost Health and Rehabilitation Center Meadowbrook Specialty Hospital of Tulsa Norman Specialty Hospital Select Specialty Hospital – Oklahoma City Select Specialty Hospital – Tulsa/Midtown Solara Hospital Muskogee Solara Hospital Shawnee Specialty Hospital of Midwest City Oklahoma Hospital Annual Report 2009 16 AHRQ Tier 1 Patient Safety Indicators (PSI) in this tier has the strongest evidence base. The National Quality Forum has endorsed these indicators. The following PSIs are included in Tier 1: PSI #04 Death among Surgical In-patients with Treatable Serious Complications PSI #06 Iatrogenic Pneumothorax PSI #11 Postoperative Respiratory Failure PSI #12 Postoperative Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE) PSI #14 Postoperative Wound Dehiscence PSI #15 Accidental Puncture or Laceration PSI #17 Birth Trauma PSI #18 OB Trauma-Vaginal Delivery with Instrument-assisted Delivery PSI #19 OB Trauma-Vaginal Delivery without Instrument-assisted Delivery Oklahoma Hospital Annual Report 2009 17 PSI 4 Deaths among Surgical Inpatients with Treatable Serious Complications Description: Rate of in-hospital death per 1000 surgical discharges, defined by specific Diagnosis Related Group codes and an ICD-9-CM code of major operating room procedure in any procedure field, age 18 years and older and with a principal procedure within 2 days of admission OR admission type of elective and with an ICD-9-CM code of potential complications of care (e.g., pneumonia, DVT/PE, sepsis, shock/cardiac arrest, or GI hemorrhage/acute ulcer) in any secondary diagnosis field. HealthGrades translated as ability to diagnose and treat in time.3 Critical Access Hospitals and Less than 50 Beds 3 HealthGrades Guiding America to Better Healthcare. Copyrighted 2009 Health Grades. Inc. - 100.00 200.00 300.00 400.00 500.00 600.00 Arbuckle Memorial Hospital Atoka Memorial Hospital Beaver County Memorial … Bristow Medical Center Carnegie Tri-County … Cimarron Memorial Hospital … Cleveland Area Hospital Cordell Memorial Hospital Fairfax Memorial Hospital Inc. Fairview Hospital Harmon Memorial Hospital Harper County Community … Healdton Municipal Hospital Holdenville General Hospital Integris Marshall Memorial … Jane Phillips Nowata Health … Jefferson County Hospital Johnston Memorial Hospital Kingfisher Regional Hospital Logan Medical Center Quartz Mountain Medical … Mary Hurley Hospital Mercy Health Love County Okeene Municipal Hospital Pawhuska Hospital, Inc. Physicians Hospital of … Prague Municipal Hospital Roger Mills Memorial Hospital Seiling Municipal Hospital St. John Sapulpa (AKA Bartlett) Stroud Regional Medical … Watonga Municipal Hospital Weatherford Regional Hospital Drumright Regional Hospital Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 18 PSI 4 Deaths among Surgical Inpatients with Treatable Serious Complications Medical Surgical Hospitals Licensed for less than 50 Beds Medical Surgical Hospitals Licensed for 50 to 99 Beds **Charts represent hospitals licensed as Acute Care Hospitals and may also be CMS Long-Term Acute Care Hospitals - 50.00 100.00 150.00 200.00 250.00 Choctaw Memorial Hospital Community Hospital Continuous Care Center of … Continuous Care Center of … Eastern Oklahoma Medical … Elkview General Hospital Foundation Bariatric Hospital … Haskell County Hospital Henryetta Medical Center Integris Bass Pavilion Integris Canadian Valley … Lakeside Women's Hospital Latimer County General … Lindsay Municipal Hospital Memorial Hospital & … Memorial Hospital of Texas … Northwest Surgical Hospital Oklahoma Center for … Oklahoma NeuroSpecialty … Oklahoma Spine Hospital, L.L.C. Orthopedic Hospital Park View Hospital Perry Memorial Center Purcell Municipal Hospital Pushmataha Hospital Sayre Memorial Hospital Sequoyah Memorial Hospital Share Memorial Hospital Solora Hospital Muskogee St John Owasso Surgical Hospital of … Tulsa Spine Hospital EPIC Medical Center Southwestern Regional … Solara Hospital Shawnee Hospital Rate State Rate - 50.00 100.00 150.00 200.00 250.00 300.00 350.00 Bailey Medical Center Claremore Regional Hospital Craig General Hospital Cushing Regional Hospital Grady Memorial Hospital Great Plains Regional Medical … Integris Blackwell Regional … Integris Clinton Regional … Integris Grove General Hospital Integris Mayes County … Memorial Hospital of Stilwell Newman Memorial Hospital Okmulgee Memorial Hospital Pauls Valley General Hospital Saint Francis Hospital South McBride Clinic Orthopedic … Oklahoma Surgical Hospital Edmond Medical Center Oklahoma Heart Hospital Select Specialty Hospital-… Select Specialty Hospital, Tulsa Woodward Regional Hospital Norman Specialty Hospital Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 19 PSI 4 Deaths among Surgical Inpatients with Treatable Serious Complications Medical Surgical Hospitals Licensed 100 to 249 Beds Medical Surgical Hospitals Licensed 250 to 499 Beds - 50.00 100.00 150.00 200.00 250.00 300.00 350.00 400.00 Integris Baptist Regional … McCurtain Memorial Hospital Medical Center of … OSU Medical Center Ponca City Medical Center St. Mary's Regional Medical … Unity Health Center Wagoner Community Hospital Duncan Regional Hospital, Inc. McAlester Regional Health … Mercy Memorial Health … Jackson County Memorial … SouthCrest Hospital Stillwater Medical Center Southwestern Medical Center Tahlequah City Hospital Integris Bass Baptist Health … Valley View Regional Hospital Jane Phillips Medical Center Hospital Rate State Rate - 50.00 100.00 150.00 200.00 250.00 Integris Southwest Medical Center of OK Mercy Health Center, Inc. Midwest Regional Medical Center Muskogee Regional Medical Center Deaconess Hospital Comanche County Memorial Hospital Hospital Rate State Rate T Oklahoma Hospital Annual Report 2009 20 PSI 4 Deaths among Surgical Inpatients with Treatable Serious Complications Medical Surgical Hospitals Licensed over 500 Beds Rehabilitation Hospitals - 50.00 100.00 150.00 200.00 250.00 Hillcrest Medical Center St. Anthony Hospital OU Medical Center Saint Francis Hospital, Inc. St. John Medical Center, Inc. Norman Regional Hospital Integris Baptist Medical Center, Inc. Hospital Rate State Rate - 100.00 200.00 300.00 400.00 500.00 600.00 Edmond Specialty Hospital George Nigh Rehabilitation Institute Hillcrest Specialty Hospital J. D. McCarty Center for Children with Developmental Disabil Specialty Hospital of Midwest City Valir Rehabilitation Hospital of OKC, LLC Lane Frost Health and Rehabilitation Center Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 21 PSI 6 Iatrogenic Pneumothorax Description: Rate of discharges with an ICD-9-CM code of iatrogenic pneumothorax in any secondary diagnosis field (not present on admission) among surgical and medical discharges, defined by specific DRG codes, age 18 years and older. An adverse condition caused by treatment by any health professional where a leak in the lung causes air to accumulate in the space around the lung (pleural cavity). This prevents the lung from expanding fully and hence a partial lung collapse occurs. For example, a doctor may accidentally puncture the lung during a surgical operation. This indicator is intended to flag cases of pneumothorax caused by medical care. Iatrogenic pneumothorax excludes all trauma patients because these patients may be more susceptible to non-preventable iatrogenic pneumothorax or may be miscoded for traumatic pneumothorax. Critical Access Hospitals and Less than 50 Beds - 1.00 2.00 3.00 4.00 5.00 6.00 7.00 Arbuckle Memorial Hospital Atoka Memorial Hospital Bristow Medical Center Carnegie Tri-County … Cimarron Memorial Hospital … Cleveland Area Hospital Cordell Memorial Hospital Drumright Regional Hospital Fairfax Memorial Hospital Inc. Fairview Hospital Harmon Memorial Hospital Harper County Community … Healdton Municipal Hospital Holdenville General Hospital Integris Marshall Memorial … Jane Phillips Nowata Health … Jefferson County Hospital Johnston Memorial Hospital Kingfisher Regional Hospital Logan Medical Center Quartz Mountain Medical … Mary Hurley Hospital Mercy Health Love County Okeene Municipal Hospital Pawhuska Hospital, Inc. Physicians Hospital of … Prague Municipal Hospital Roger Mills Memorial Hospital Seiling Municipal Hospital St. John Sapulpa (AKA Bartlett) Stroud Regional Medical … Watonga Municipal Hospital Weatherford Regional Hospital Beaver County Memorial … Hosp Rate State Rate Oklahoma Hospital Annual Report 2009 22 PSI 6 Iatrogenic Pneumothorax Medical Surgical Hospitals Licensed for less than 50 Beds Medical Surgical Hospitals Licensed for 50 to 99 Beds **Charts represent hospitals licensed as Acute Care Hospitals and may also be CMS Long-Term Acute Care Hospitals - 1.00 2.00 3.00 4.00 5.00 6.00 7.00 Choctaw Memorial Hospital Eastern Oklahoma Medical … Elkview General Hospital Foundation Bariatric Hospital … Haskell County Hospital Henryetta Medical Center Integris Bass Pavilion Integris Canadian Valley … Lakeside Women's Hospital Latimer County General … Lindsay Municipal Hospital Memorial Hospital & … Memorial Hospital of Texas … Northwest Surgical Hospital Oklahoma Center for … Oklahoma NeuroSpecialty … Oklahoma Spine Hospital, L.L.C. Orthopedic Hospital Park View Hospital Perry Memorial Hospital Purcell Municipal Hospital Pushmataha Hospital Sayre Memorial Hospital Sequoyah Memorial Hospital Share Memorial Hospital Solara Hospital Shawnee Solora Hospital Muskogee St John Owasso Surgical Hospital of … Tulsa Spine Hospital EPIC Medical Center Community Hospital Continuous Care Center of … Southwestern Regional … Continuous Care Center of … Hospital Rate State Rate - 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 Claremore Regional Hospital Craig General Hospital Cushing Regional Hospital Edmond Medical Center Great Plains Regional Medical … Integris Blackwell Regional … Integris Clinton Regional … Integris Mayes County … McBride Clinic Orthopedic … Meadow Brook Specialty … Memorial Hospital of Stilwell Newman Memorial Hospital Oklahoma Surgical Hospital Okmulgee Memorial Hospital Pauls Valley General Hospital Select Specialty Hospital, Tulsa Woodward Regional Hospital Integris Grove General Hospital Grady Memorial Hospital Saint Francis Hospital South Bailey Medical Center Select Specialty Hospital-… Norman Specialty Hospital Oklahoma Heart Hospital Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 23 PSI 6 Iatrogenic Pneumothorax Medical Surgical Hospitals Licensed for 100 to 249 Beds Medical Surgical Hospitals Licensed for 250 to 499 Beds - 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 1.80 2.00 Integris Baptist Regional … McCurtain Memorial Hospital Stillwater Medical Center Valley View Regional Hospital Wagoner Community Hospital Medical Center of … St. Mary's Regional Medical … McAlester Regional Health … Integris Bass Baptist Health … Ponca City Medical Center Jackson County Memorial … SouthCrest Hospital Mercy Memorial Health … Southwestern Medical Center Duncan Regional Hospital, Inc. Jane Phillips Medical Center Unity Health Center OSU Medical Center Tahlequah City Hospital Hospital Rate State Rate - 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 Mercy Health Center, Inc. Integris Southwest Medical Center of OK Muskogee Regional Medical Center Midwest Regional Medical Center Deaconess Hospital Comanche County Memorial Hospital Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 24 PSI 6 Iatrogenic Pneumothorax Medical Surgical Hospitals Licensed for over 500 Beds Rehabilitation Hospitals - 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 1.80 St. Anthony Hospital Norman Regional Hospital Integris Baptist Medical Center, Inc. Hillcrest Medical Center St. John Medical Center, Inc. Saint Francis Hospital, Inc. OU Medical Center Hospital Rate State Rate - 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 Edmond Specialty Hospital George Nigh Rehabilitation Institute J. D. McCarty Center for Children with Developmental Disabil Lane Frost Health and Rehabilitation Center Valir Rehabilitation Hospital of OKC, LLC Hillcrest Specialty Hospital Specialty Hospital of Midwest City Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 25 PSI 11 Postoperative Respiratory Failure Description: Rate of discharges with an ICD-9-CM code of acute respiratory failure in any secondary diagnosis field (not present on admission) or an ICD-9-CM code for re-intubation procedure in any procedure field that is zero, one or two or more days after the major operating room procedure (depending on the code) among elective surgical discharges, defined by specific DRG codes and an ICD-9-CM code of major operating room procedure in any procedure field, age 18 and older. The goal is to avoid respiratory failure following a surgery procedure. Medical Surgical Hospitals Licensed for less than 50 Beds **Charts represent hospitals licensed as Acute Care Hospitals and may also be CMS Long-Term Acute Care Hospitals - 50.00 100.00 150.00 200.00 250.00 Choctaw Memorial Hospital Elkview General Hospital Foundation Bariatric Hospital … Haskell County Hospital Lakeside Women's Hospital Lindsay Municipal Hospital Northwest Surgical Hospital Oklahoma Center for … Oklahoma Spine Hospital, L.L.C. Orthopedic Hospital Park View Hospital Perry Memorial Hospital Purcell Municipal Hospital Sayre Memorial Hospital Solora Hospital Muskogee St John Owasso Surgical Hospital of … Tulsa Spine Hospital Continuous Care Center of … Continuous Care Center of … Latimer County General … Memorial Hospital & … Oklahoma NeuroSpecialty … Pushmataha Hospital Sequoyah Memorial Hospital Share Memorial Hospital EPIC Medical Center Community Hospital Integris Canadian Valley … Henryetta Medical Center Southwestern Regional … Memorial Hospital of Texas … Eastern Oklahoma Medical … Solara Hospital Shawnee Integris Bass Pavilion Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 26 PSI 11 Postoperative Respiratory Failure Medical Surgical Hospitals Licensed for 50 to 99 Beds Medical Surgical Hospitals Licensed for100 to 249 Beds **Charts represent hospitals licensed as Acute Care Hospitals and may also be CMS Long-Term Acute Care Hospitals - 20.00 40.00 60.00 80.00 100.00 120.00 140.00 Claremore Regional Hospital Craig General Hospital Grady Memorial Hospital Integris Blackwell Regional … Integris Clinton Regional … Integris Mayes County … McBride Clinic Orthopedic … Meadow Brook Specialty … Memorial Hospital of Stilwell Newman Memorial Hospital Okmulgee Memorial Hospital Pauls Valley General Hospital Oklahoma Surgical Hospital Oklahoma Heart Hospital Great Plains Regional … Edmond Medical Center Saint Francis Hospital South Woodward Regional Hospital Cushing Regional Hospital Integris Grove General … Bailey Medical Center Norman Specialty Hospital Select Specialty Hospital-… Select Specialty Hospital, Tulsa Hospital rate State Rate - 5.00 10.00 15.00 20.00 25.00 30.00 35.00 Ponca City Medical Center McCurtain Memorial … Medical Center of … OSU Medical Center Wagoner Community … Stillwater Medical Center Southwestern Medical … Jackson County Memorial … St. Mary's Regional … Unity Health Center Jane Phillips Medical Center McAlester Regional Health … Duncan Regional Hospital, … Mercy Memorial Health … Tahlequah City Hospital Integris Baptist Regional … Valley View Regional … SouthCrest Hospital Integris Bass Baptist … Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 27 PSI 11 Postoperative Respiratory Failure Medical Surgical Hospitals Licensed for 250 to 499 Beds Medical Surgical Hospitals Licensed for over 500 Beds T - 5.00 10.00 15.00 20.00 25.00 30.00 35.00 St. John Medical Center, Inc. Saint Francis Hospital, Inc. St. Anthony Hospital Norman Regional Hospital OU Medical Center Integris Baptist Medical Center, Inc. Hillcrest Medical Center Hospital Rate State Rate - 5.00 10.00 15.00 20.00 25.00 30.00 35.00 St. John Medical Center, Inc. Saint Francis Hospital, Inc. St. Anthony Hospital Norman Regional Hospital OU Medical Center Integris Baptist Medical Center, Inc. Hillcrest Medical Center Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 28 (This page left blank) Oklahoma Hospital Annual Report 2009 29 PSI 12 Postoperative Pulmonary Embolism or Deep Vein Thrombosis Description: Rate of discharges with an ICD-9-CM code of deep vein thrombosis or pulmonary embolism in any secondary diagnosis field (not present on admission) among surgical discharges, defined by specific DRG codes and an ICD-9-CM code of major operating room procedure in any procedure field, age 18 and older. Deep vein thrombosis is a blood clot in a deep vein. The blood clot commonly occurs in the deeper veins in the thigh or calf, but may occur in the deep veins of the arms. A blood clot is also called a thrombus. The condition can be very painful and can lead to serious complications. Pulmonary embolism is a blocked lung blood vessel often from a blood clot. This indicator is intended to capture cases of postoperative venous thromboses and embolism – specifically, pulmonary embolism and deep venous thrombosis. It further excludes patients who have principal diagnosis of deep vein thrombosis, as these patients are likely to have a pulmonary embolism/deep vein thrombosis present on admission. Medical Surgical Hospitals Licensed for less than 50 Beds **Charts represent hospitals licensed as Acute Care Hospitals and may also be CMS Long-Term Acute Care Hospitals - 20.00 40.00 60.00 80.00 100.00 120.00 140.00 Choctaw Memorial Hospital Eastern Oklahoma Medical … Elkview General Hospital Foundation Bariatric … Haskell County Hospital Integris Bass Pavilion Lakeside Women's Hospital Lindsay Municipal Hospital Memorial Hospital & … Memorial Hospital of Texas … Northwest Surgical Hospital Oklahoma Center for … Park View Hospital Purcell Municipal Hospital Sayre Memorial Hospital Solora Hospital Muskogee St John Owasso Surgical Hospital of … EPIC Medical Center Latimer County General … Oklahoma NeuroSpecialty … Perry Memorial Hospital Sequoyah Memorial Hospital Oklahoma Spine Hospital, … Tulsa Spine Hospital Community Hospital Integris Canadian Valley … Orthopedic Hospital Henryetta Medical Center Solara Hospital Shawnee Pushmataha Hospital Continuous Care Center of … Share Memorial Hospital Southwestern Regional … Continuous Care Center of … Hospital Rate Oklahoma Hospital Annual Report 2009 30 PSI 12 Postoperative Pulmonary Embolism or Deep Vein Thrombosis Medical Surgical Hospitals Licensed for 50 to 99 Beds Medical Surgical Hospitals Licensed for 100 to 249 Beds - 10.00 20.00 30.00 40.00 50.00 60.00 70.00 80.00 Claremore Regional Hospital Great Plains Regional … Integris Blackwell Regional … Integris Clinton Regional … Integris Mayes County … Memorial Hospital of Stilwell Newman Memorial Hospital Pauls Valley General Hospital Oklahoma Surgical Hospital Saint Francis Hospital South Bailey Medical Center Cushing Regional Hospital Integris Grove General … Okmulgee Memorial Hospital Woodward Regional Hospital McBride Clinic Orthopedic … Oklahoma Heart Hospital Grady Memorial Hospital Edmond Medical Center Craig General Hospital Norman Specialty Hospital Select Specialty Hospital, … Meadow Brook specialty … Select Specialty Hospital-… Hospital Rate State Rate - 2.00 4.00 6.00 8.00 10.00 12.00 14.00 16.00 18.00 McCurtain Memorial Hospital Wagoner Community Hospital McAlester Regional Health … Unity Health Center Southwestern Medical Center Jackson County Memorial … Valley View Regional Hospital Jane Phillips Medical Center Duncan Regional Hospital, Inc. Tahlequah City Hospital Medical Center of … St. Mary's Regional Medical … Stillwater Medical Center Mercy Memorial Health … SouthCrest Hospital Ponca City Medical Center Integris Baptist Regional … OSU Medical Center Integris Bass Baptist Health … Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 31 PSI 12 Postoperative Pulmonary Embolism or Deep Vein Thrombosis Medical Surgical Hospitals Licensed for 250 to 499 Beds Medical Surgical Hospitals Licensed for over 500 Beds T - 5.00 10.00 15.00 20.00 25.00 30.00 35.00 40.00 St. Anthony Hospital Norman Regional Hospital Hillcrest Medical Center St. John Medical Center, Inc. Integris Baptist Medical Center, Inc. Saint Francis Hospital, Inc. OU Medical Center Hospital Rate State Rate - 5.00 10.00 15.00 20.00 25.00 30.00 35.00 40.00 St. Anthony Hospital Norman Regional Hospital Hillcrest Medical Center St. John Medical Center, Inc. Integris Baptist Medical Center, Inc. Saint Francis Hospital, Inc. OU Medical Center Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 32 PSI 12 Postoperative Pulmonary Embolism or Deep Vein Thrombosis Rehabilitation Hospitals - 20.00 40.00 60.00 80.00 100.00 120.00 J. D. McCarty Center for Children with Developmental Disabil Valir Rehabilitation Hospital of OKC, LLC Edmond Specialty Hospital George Nigh Rehabilitation Institute Specialty Hospital of Midwest City Hillcrest Specialty Hospital Lane Frost Health and Rehabilitation Center Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 33 PSI 14 Postoperative Wound Dehiscence Description: Rate of discharges with an ICD-9-CM code of reclosure of postoperative disruption of abdominal wall in any procedure field among abdominopelvic surgical discharges, defined by specific ICD-9-CM codes, age 18 and older. Wound dehiscence is the parting of the layers of a surgical wound. This indicator is intended to flag cases of wound dehiscence in patients who have undergone abdominal and pelvic surgery. Critical Access Hospitals and Less than 50 Beds - 10.00 20.00 30.00 40.00 50.00 60.00 70.00 80.00 90.00 Drumright Regional Hospital Fairfax Memorial Hospital Inc. Holdenville General Hospital Integris Marshall Memorial … Kingfisher Regional Hospital Logan Medical Center Pawhuska Hospital, Inc. Physicians Hospital of … St. John Sapulpa (AKA Bartlett) Stroud Regional Medical … Weatherford Regional … Arbuckle Memorial Hospital Atoka Memorial Hospital Beaver County Memorial … Bristow Medical Center Carnegie Tri-County … Cimarron Memorial Hospital … Cleveland Area Hospital Cordell Memorial Hospital Fairview Hospital Harmon Memorial Hospital Harper County Community … Healdton Municipal Hospital Jane Phillips Nowata Health … Jefferson County Hospital Johnston Memorial Hospital Quartz Mountain Medical … Mary Hurley Hospital Mercy Health Love County Prague Municipal Hospital Roger Mills Memorial Hospital Seiling Municipal Hospital Watonga Municipal Hospital Okeene Municipal Hospital Hosp Rate State Rate Oklahoma Hospital Annual Report 2009 34 PSI 14 Postoperative Wound Dehiscence Medical Surgical Hospitals Licensed for 100 to 249 Beds Medical Surgical Hospitals Licensed for 250 to 499 Beds - 2.00 4.00 6.00 8.00 10.00 12.00 14.00 Wagoner Community Hospital Integris Bass Baptist Health … Jackson County Memorial … McCurtain Memorial Hospital Mercy Memorial Health … Ponca City Medical Center SouthCrest Hospital Southwestern Medical Center St. Mary's Regional Medical … Stillwater Medical Center Tahlequah City Hospital Valley View Regional Hospital McAlester Regional Health … Duncan Regional Hospital, Inc. Unity Health Center Medical Center of … OSU Medical Center Jane Phillips Medical Center Integris Baptist Regional … Hospital Rate State Rate T - 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 Muskogee Regional Medical Center Midwest Regional Medical Center Deaconess Hospital Comanche County Memorial Hospital Integris Southwest Medical Center of OK Mercy Health Center, Inc. Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 35 PSI 14 Postoperative Wound Dehiscence Medical Surgical Hospitals Licensed for over 500 Beds - 1.00 2.00 3.00 4.00 5.00 6.00 Hillcres t Medic… OU Medical Center Saint Francis Hospi… Norma n Regio… St. John Medical Cente… Integris Baptist Medic… St. Anthon y … Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 36 (This page left blank) Oklahoma Hospital Annual Report 2009 37 PSI 15 Accidental Puncture or Laceration Description: Rate of discharges with an ICD-9-CM code of accidental cut, puncture, perforation or laceration during a procedure in any secondary diagnosis field (not present on admission) among surgical and medical discharges, defined by specific DRG codes, age 18 years and older. The event is an accidental cut or laceration, which occurred during a hospital stay while receiving medical care. This indicator is intended to flag cases of complications that arise due to technical difficulties in medical care – specifically, those involving an accidental puncture or laceration. Critical Access Hospitals and Less than 50 Beds - 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 Arbuckle Memorial Hospital Atoka Memorial Hospital Beaver County Memorial … Bristow Medical Center Carnegie Tri-County … Cimarron Memorial Hospital … Cleveland Area Hospital Cordell Memorial Hospital Fairview Hospital Harmon Memorial Hospital Harper County Community … Healdton Municipal Hospital Holdenville General Hospital Integris Marshall Memorial … Jane Phillips Nowata Health … Jefferson County Hospital Johnston Memorial Hospital Quartz Mountain Medical … Mary Hurley Hospital Mercy Health Love County Okeene Municipal Hospital Pawhuska Hospital, Inc. Physicians Hospital of … Prague Municipal Hospital Roger Mills Memorial Hospital Seiling Municipal Hospital St. John Sapulpa (AKA Bartlett) Stroud Regional Medical … Watonga Municipal Hospital Weatherford Regional … Kingfisher Regional Hospital Logan Medical Center Drumright Regional Hospital Fairfax Memorial Hospital Inc. Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 38 PSI 15 Accidental Puncture or Laceration Medical Surgical Hospitals Licensed for less than 50 Beds Medical Surgical Hospitals Licensed for 50 to 99 Beds **Charts represent hospitals licensed as Acute Care Hospitals and may also be CMS Long-Term Acute Care Hospitals - 5.00 10.00 15.00 20.00 25.00 30.00 Choctaw Memorial Hospital Continuous Care Center of … Continuous Care Center of … Eastern Oklahoma Medical … Henryetta Medical Center Integris Bass Pavilion Latimer County General … Lindsay Municipal Hospital Memorial Hospital & … Oklahoma NeuroSpecialty … Orthopedic Hospital Purcell Municipal Hospital Pushmataha Hospital Sayre Memorial Hospital Sequoyah Memorial Hospital Share Memorial Hospital Solora Hospital Muskogee Surgical Hospital of … Perry Memorial Hospital EPIC Medical Center Park View Hospital Elkview General Hospital Memorial Hospital of Texas … St John Owasso Haskell County Hospital Southwestern Regional … Integris Canadian Valley … Tulsa Spine Hospital Solara Hospital Shawnee Northwest Surgical Hospital Oklahoma Center for … Community Hospital Lakeside Women's Hospital Oklahoma Spine Hospital, … Foundation Bariatric … Hospital Rate State Rate - 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 Craig General Hospital Integris Clinton Regional … Norman Specialty Hospital Okmulgee Memorial Hospital Pauls Valley General Hospital Select Specialty Hospital, … Meadow Brook Specialty … Select Specialty Hospital-… Cushing Regional Hospital McBride Clinic Orthopedic … Great Plains Regional … Integris Blackwell Regional … Memorial Hospital of Stilwell Newman Memorial Hospital Saint Francis Hospital South Claremore Regional Hospital Integris Mayes County … Integris Grove General … Oklahoma Heart Hospital Edmond Medical Center Grady Memorial Hospital Oklahoma Surgical Hospital Woodward Regional Hospital Bailey Medical Center Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 39 PSI 15 Accidental Puncture or Laceration Medical Surgical Hospitals Licensed for 100 to 249 Beds Medical Surgical Hospitals Licensed for 250 to 499 Beds - 1.00 2.00 3.00 4.00 5.00 6.00 Wagoner Community Hospital Medical Center of … McCurtain Memorial Hospital Unity Health Center Valley View Regional Hospital Jackson County Memorial … Ponca City Medical Center St. Mary's Regional Medical … Duncan Regional Hospital, Inc. Integris Bass Baptist Health … Mercy Memorial Health … Stillwater Medical Center Southwestern Medical Center Integris Baptist Regional … SouthCrest Hospital McAlester Regional Health … Tahlequah City Hospital OSU Medical Center Jane Phillips Medical Center Hospital Rate State Rate T - 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 Integris Baptist Medical Center, Inc. Norman Regional Hospital Hillcrest Medical Center St. John Medical Center, Inc. St. Anthony Hospital Saint Francis Hospital, Inc. OU Medical Center Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 40 PSI 15 Accidental Puncture or Laceration Medical Surgical Hospitals Licensed for over 500 Beds Rehabilitation Hospitals - 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 Integris Baptist Medical Center, Inc. Norman Regional Hospital Hillcrest Medical Center St. John Medical Center, Inc. St. Anthony Hospital Saint Francis Hospital, Inc. OU Medical Center Hospital Rate State Rate - 0.50 1.00 1.50 2.00 2.50 3.00 3.50 Edmond Specialty Hospital George Nigh Rehabilitation Institute Hillcrest Specialty Hospital J. D. McCarty Center for Children with Developmental Disabil Lane Frost Health and Rehabilitation Center Specialty Hospital of Midwest City Valir Rehabilitation Hospital of OKC, LLC Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 41 PSI 17 Birth Trauma – Injury to Neonate Description: Rate of discharges with an ICD-9-CM code of birth trauma in any diagnosis field among newborns. This indicator is intended to flag cases of birth trauma for infants born alive in a hospital. The indicator excludes patients born pre-term, as birth trauma in these patients may be less preventable than for full-term infants. Medical Surgical Hospitals Licensed for 100 to 249 Beds T - 50.00 100.00 150.00 200.00 250.00 St. Mary's Regional Medical … Wagoner Community Hospital Integris Baptist Regional … Integris Bass Baptist Health … Jackson County Memorial … Jane Phillips Medical Center McCurtain Memorial Hospital Medical Center of … Mercy Memorial Health … OSU Medical Center Ponca City Medical Center SouthCrest Hospital Southwestern Medical Center Stillwater Medical Center Tahlequah City Hospital Unity Health Center Valley View Regional Hospital Duncan Regional Hospital, Inc. McAlester Regional Health … Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 42 (This page left blank) Oklahoma Hospital Annual Report 2009 43 PSI 18 Obstetric Trauma – Vaginal Delivery with Instrument Description: Rate of discharges with an ICD-9-CM code of 3rd and 4th degree obstetric laceration in any diagnosis field among vaginal delivery discharges, defined by DRG, with an ICD-9-CM code of instrument-assisted delivery in any procedure field. This event occurs during a vaginal delivery using an obstetric instrument and a severe laceration, such as a tear extending into the deep transverse perineal muscles and fibers of the anal sphincter (third degree) or rectal mucosa (fourth degree). This indicator is intended to flag cases of potentially preventable trauma during vaginal delivery with instrument. Critical Access Hospitals and Less than 50 Beds - 50.00 100.00 150.00 200.00 250.00 300.00 350.00 400.00 450.00 Harper County Community … Arbuckle Memorial Hospital Atoka Memorial Hospital Beaver County Memorial … Bristow Medical Center Carnegie Tri-County … Cimarron Memorial Hospital … Cleveland Area Hospital Cordell Memorial Hospital Drumright Regional Hospital Fairfax Memorial Hospital Inc. Fairview Hospital Harmon Memorial Hospital Healdton Municipal Hospital Holdenville General Hospital Integris Marshall Memorial … Jane Phillips Nowata Health … Jefferson County Hospital Johnston Memorial Hospital Logan Medical Center Quartz Mountain Medical … Mary Hurley Hospital Mercy Health Love County Okeene Municipal Hospital Pawhuska Hospital, Inc. Physicians Hospital of … Prague Municipal Hospital Roger Mills Memorial Hospital Seiling Municipal Hospital St. John Sapulpa (AKA Bartlett) Stroud Regional Medical … Watonga Municipal Hospital Weatherford Regional … Kingfisher Regional Hospital Hosp Rate State Rate Oklahoma Hospital Annual Report 2009 44 PSI 18 Obstetric Trauma – Vaginal Delivery with Instrument Medical Surgical Hospitals Licensed for less than 50 Beds Medical Surgical Hospitals Licensed for 50 to 99 Beds - 100.00 200.00 300.00 400.00 500.00 600.00 Memorial Hospital of … St John Owasso Choctaw Memorial … Community Hospital Continuous Care Center … Continuous Care Center … Foundation Bariatric … Haskell County Hospital Henryetta Medical … Integris Bass Pavilion Latimer County General … Lindsay Municipal … Memorial Hospital & … Northwest Surgical … Oklahoma Center for … Oklahoma … Oklahoma Spine … Orthopedic Hospital Perry Memorial Hospital Pushmataha Hospital Sayre Memorial Hospital Sequoyah Memorial … Share Memorial Hospital Solara Hospital Shawnee Solora Hospital … Southwestern Regional … Surgical Hospital of … Tulsa Spine Hospital EPIC Medical Center Eastern Oklahoma … Elkview General Hospital Lakeside Women's … Integris Canadian Valley … Park View Hospital Purcell Municipal … Hospital Rate State Rate - 100.00 200.00 300.00 400.00 500.00 600.00 Edmond Medical Center McBride Clinic Orthopedic … Meadow Brook Specialty … Newman Memorial Hospital Norman Specialty Hospital Oklahoma Heart Hospital Oklahoma Surgical Hospital Okmulgee Memorial Hospital Saint Francis Hospital South Select Specialty Hospital, … Select Specialty Hospital-… Bailey Medical Center Claremore Regional Hospital Pauls Valley General Hospital Integris Clinton Regional … Grady Memorial Hospital Integris Blackwell Regional … Integris Mayes County … Craig General Hospital Cushing Regional Hospital Integris Grove General … Great Plains Regional … Woodward Regional Hospital Memorial Hospital of Stilwell Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 45 PSI 18 Obstetric Trauma – Vaginal Delivery with Instrument Medical Surgical Hospitals Licensed for 100 to 249 Beds Medical Surgical Hospitals Licensed for 250 to 499 Beds - 50.00 100.00 150.00 200.00 250.00 300.00 350.00 Wagoner Community Hospital Tahlequah City Hospital Valley View Regional Hospital Jackson County Memorial … McCurtain Memorial Hospital Unity Health Center Medical Center of … Mercy Memorial Health … Integris Baptist Regional … SouthCrest Hospital Jane Phillips Medical Center Duncan Regional Hospital, Inc. Southwestern Medical Center Stillwater Medical Center Ponca City Medical Center St. Mary's Regional Medical … OSU Medical Center Integris Bass Baptist Health … McAlester Regional Health … Hospital Rate State Rate - 20.00 40.00 60.00 80.00 100.00 120.00 140.00 160.00 180.00 200.00 Muskogee Regional Medical Center Integris Southwest Medical Center of OK Midwest Regional Medical Center Comanche County Memorial Hospital Deaconess Hospital Mercy Health Center, Inc. Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 46 PSI 18 Obstetric Trauma – Vaginal Delivery with Instrument Medical Surgical Hospitals Licensed for over 500 Beds T - 50.00 100.00 150.00 200.00 250.00 300.00 350.00 St. Anthony Hospital Norman Regional Hospital OU Medical Center Hillcrest Medical Center Integris Baptist Medical Center, Inc. Saint Francis Hospital, Inc. St. John Medical Center, Inc. Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 47 PSI 19 Obstetric Trauma – Vaginal Delivery without Instrument Description: Rate of discharges with an ICD-9-CM code of 3rd and 4th degree obstetric trauma in any diagnosis field among vaginal delivery discharges, defined by DRG, without an ICD-9-CM code of instrument-assisted delivery in any procedure field. This event occurs during a vaginal delivery without the use of an obstetric instrument and a severe laceration, such as a tear extending into the deep transverse perineal muscles and fibers of the anal sphincter (third degree) or rectal mucosa (fourth degree). This indicator is intended to flag cases of potentially preventable trauma during vaginal delivery without instrument. Critical Access Hospitals and Less than 50 Beds - 10.00 20.00 30.00 40.00 50.00 60.00 70.00 Harper County Community … Okeene Municipal Hospital Watonga Municipal Hospital Arbuckle Memorial Hospital Atoka Memorial Hospital Beaver County Memorial … Bristow Medical Center Carnegie Tri-County … Cimarron Memorial Hospital … Cleveland Area Hospital Cordell Memorial Hospital Drumright Regional Hospital Fairfax Memorial Hospital Inc. Fairview Hospital Harmon Memorial Hospital Healdton Municipal Hospital Holdenville General Hospital Integris Marshall Memorial … Jane Phillips Nowata Health … Jefferson County Hospital Johnston Memorial Hospital Logan Medical Center Quartz Mountain Medical … Mary Hurley Hospital Mercy Health Love County Pawhuska Hospital, Inc. Physicians Hospital of … Prague Municipal Hospital Roger Mills Memorial Hospital Seiling Municipal Hospital St. John Sapulpa (AKA Bartlett) Stroud Regional Medical … Weatherford Regional … Kingfisher Regional Hospital Hosp Rate State Rate Oklahoma Hospital Annual Report 2009 48 PSI 19 Obstetric Trauma – Vaginal Delivery without Instrument Medical Surgical Hospitals Licensed for less than 50 Beds Medical Surgical Hospitals Licensed for 50 to 99 Beds **Charts represent hospitals licensed as Acute Care Hospitals and CMS Long –term Care Hospitals - 20.00 40.00 60.00 80.00 100.00 120.00 Choctaw Memorial Hospital Community Hospital Continuous Care Center of … Continuous Care Center of … Elkview General Hospital Memorial Hospital & … Foundation Bariatric … Haskell County Hospital Henryetta Medical Center Integris Bass Pavilion Latimer County General … Lindsay Municipal Hospital Northwest Surgical Hospital Oklahoma Center for … Oklahoma NeuroSpecialty … Oklahoma Spine Hospital, … Orthopedic Hospital Perry Memorial Hospital Pushmataha Hospital Sayre Memorial Hospital Sequoyah Memorial Hospital Share Memorial Hospital Solara Hospital Shawnee Solora Hospital Muskogee Southwestern Regional … Surgical Hospital of … Tulsa Spine Hospital EPIC Medical Center Memorial Hospital of Texas … Eastern Oklahoma Medical … Park View Hospital Lakeside Women's Hospital Integris Canadian Valley … St John Owasso Purcell Municipal Hospital Hospital Rate State Rate - 50.00 100.00 150.00 200.00 250.00 300.00 350.00 400.00 450.00 Edmond Medical Center McBride Clinic Orthopedic … Norman Specialty Hospital Oklahoma Heart Hospital Oklahoma Surgical Hospital Saint Francis Hospital South Select Specialty Hospital, Tulsa Select Specialty Hospital-… Integris Blackwell Regional … Memorial Hospital of Stilwell Meadow Brook Specialty … Okmulgee Memorial Hospital Grady Memorial Hospital Integris Mayes County … Integris Clinton Regional … Cushing Regional Hospital Newman Memorial Hospital Integris Grove General Hospital Craig General Hospital Great Plains Regional Medical … Pauls Valley General Hospital Claremore Regional Hospital Woodward Regional Hospital Bailey Medical Center Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 49 PSI 19 Obstetric Trauma – Vaginal Delivery without Instrument Medical Surgical Hospitals Licensed for 100 to 249 Beds Medical Surgical Hospitals Licensed for 250 to 499 Beds - 10.00 20.00 30.00 40.00 50.00 60.00 70.00 Wagoner Community Hospital Medical Center of … Tahlequah City Hospital Duncan Regional Hospital, Inc. Valley View Regional Hospital Integris Baptist Regional … St. Mary's Regional Medical … Ponca City Medical Center McCurtain Memorial Hospital SouthCrest Hospital Unity Health Center Mercy Memorial Health … Stillwater Medical Center Southwestern Medical Center Jane Phillips Medical Center OSU Medical Center Jackson County Memorial … Integris Bass Baptist Health … McAlester Regional Health … Hospital Rate State Rate T - 10.00 20.00 30.00 40.00 50.00 60.00 Integris Southwest Medical Center of OK Comanche County Memorial Hospital Midwest Regional Medical Center Muskogee Regional Medical Center Mercy Health Center, Inc. Deaconess Hospital Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 50 PSI 19 Obstetric Trauma – Vaginal Delivery without Instrument Medical Surgical Hospitals Licensed for over 500 Beds - 20.00 40.00 60.00 80.00 100.00 120.00 Norman Regional Hospital St. Anthony Hospital Hillcrest Medical Center OU Medical Center Saint Francis Hospital, Inc. Integris Baptist Medical Center, Inc. St. John Medical Center, Inc. Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 51 AHRQ Tier 1-B A subset of Tier 1, are serious reportable events that are most suitable for public accountability and root cause analysis, but for which comparisons between hospitals may not be useful. The National Quality Forum has endorsed the following PSIs which are included in Tier 1B: PSI #02 Death in Low Mortality Diagnosis Related Grouping (DRGs) PSI #08 Postoperative Hip Fracture PSI 2 Death in Low Mortality DRGs Description: Rate of in-hospital death among discharges with a DRG code for a low mortality DRG (defined as a mortality rate of less than 0.5%). Critical Access Hospitals and Less than 50 Beds - 10.00 20.00 30.00 40.00 50.00 60.00 70.00 Arbuckle Memorial Hospital Atoka Memorial Hospital Beaver County Memorial … Bristow Medical Center Carnegie Tri-County … Cimarron Memorial Hospital … Cleveland Area Hospital Cordell Memorial Hospital Drumright Regional Hospital Fairfax Memorial Hospital Inc. Fairview Hospital Harper County Community … Holdenville General Hospital Jane Phillips Nowata Health … Jefferson County Hospital Kingfisher Regional Hospital Quartz Mountain Medical … Okeene Municipal Hospital Pawhuska Hospital, Inc. Physicians Hospital of … Roger Mills Memorial Hospital Stroud Regional Medical … Weatherford Regional … St. John Sapulpa (AKA Bartlett) Logan Medical Center Integris Marshall Memorial … Harmon Memorial Hospital Mercy Health Love County Mary Hurley Hospital Prague Municipal Hospital Healdton Municipal Hospital Johnston Memorial Hospital Watonga Municipal Hospital Seiling Municipal Hospital Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 52 PSI 2 Death in Low Mortality DRGs Medical Surgical Hospitals Licensed for less than 50 Beds Medical Surgical Hospitals Licensed for 50 to 99 Beds **Charts represent hospitals licensed as Acute Care Hospitals and may also be CMS Long-Term Acute Care Hospitals - 100.00 200.00 300.00 400.00 500.00 600.00 Community Hospital Continuous Care Center of … Foundation Bariatric … Henryetta Medical Center Lakeside Women's Hospital Latimer County General … Lindsay Municipal Hospital Memorial Hospital & … Northwest Surgical Hospital Oklahoma Center for … Oklahoma NeuroSpecialty … Oklahoma Spine Hospital, … Orthopedic Hospital Park View Hospital Purcell Municipal Hospital Pushmataha Hospital Sayre Memorial Hospital Sequoyah Memorial … Southwestern Regional … St John Owasso Surgical Hospital of … Tulsa Spine Hospital EPIC Medical Center Integris Canadian Valley … Eastern Oklahoma Medical … Memorial Hospital of … Choctaw Memorial Hospital Elkview General Hospital Perry Memorial Hospital Share Memorial Hospital Haskell County Hospital Integris Bass Pavilion Continuous Care Center of … Solora Hospital Muskogee Solara Hospital Shawnee Hospital Rate State Rate - 100.00 200.00 300.00 400.00 500.00 600.00 700.00 Cushing Regional Hospital Integris Blackwell Regional … Integris Clinton Regional … McBride Clinic Orthopedic … Newman Memorial Hospital Norman Specialty Hospital Oklahoma Surgical Hospital Select Specialty Hospital, … Great Plains Regional … Claremore Regional … Woodward Regional … Craig General Hospital Memorial Hospital of … Integris Mayes County … Pauls Valley General … Grady Memorial Hospital Okmulgee Memorial … Integris Grove General … Edmond Medical Center Oklahoma Heart Hospital Saint Francis Hospital South Select Specialty Hospital-… Meadow Brook Specialty … Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 53 PSI 2 Death in Low Mortality DRGs Medical Surgical Hospitals Licensed for 100 to 249 Beds Medical Surgical Hospitals Licensed for 250 to 499 Beds - 1.00 2.00 3.00 4.00 5.00 6.00 Integris Baptist Regional … St. Mary's Regional … Wagoner Community … Medical Center of … Jackson County Memorial … Valley View Regional … McAlester Regional Health … Stillwater Medical Center Southwestern Medical … SouthCrest Hospital Mercy Memorial Health … Tahlequah City Hospital Unity Health Center Duncan Regional Hospital, … McCurtain Memorial … Jane Phillips Medical Center Integris Bass Baptist … Ponca City Medical Center OSU Medical Center Hospital Rate State Rate T - 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 Mercy Health Center, Inc. Midwest Regional Medical Center Muskogee Regional Medical Center Integris Southwest Medical Center of OK Deaconess Hospital Comanche County Memorial Hospital Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 54 PSI 2 Death in Low Mortality DRGs Medical Surgical Hospitals Licensed for over 500 Beds Rehabilitation Hospitals - 1.00 2.00 3.00 4.00 5.00 6.00 Hillcrest Medical Center St. Anthony Hospital OU Medical Center Norman Regional Hospital St. John Medical Center, Inc. Saint Francis Hospital, Inc. Integris Baptist Medical Center, Inc. Hospital Rate State Rate - 10.00 20.00 30.00 40.00 50.00 60.00 70.00 80.00 90.00 George Nigh Rehabilitation Institute Hillcrest Specialty Hospital J. D. McCarty Center for Children with Developmental Disabil Lane Frost Health and Rehabilitation Center Specialty Hospital of Midwest City Valir Rehabilitation Hospital of OKC, LLC Edmond Specialty Hospital Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 55 PSI 8 Postoperative Hip Fracture Description: Rate of discharges with an ICD-9-CM code of hip fracture in any secondary diagnosis field (not present on admission) among surgical discharges, defined by specific DRG codes and an ICD-9-CM code of major operating room procedure in any procedure field, age 18 and older. This event is when a patient while hospitalized as the result of a surgical procedure has fallen and has fractured a hip. This indicator is intended to capture cases of in hospital fracture—specifically, hip fractures. It further excludes any patients with musculoskeletal disorders and any patients with indication for trauma or cancer, or a principal diagnosis of seizure, syncope, stroke, coma, cardiac arrest, or poisoning, as these patients may have a fracture present on admission. This indicator is limited to surgical cases since previous research suggested that previously named medical patients often represent conditions present on admission. Medical Surgical Hospitals Licensed for less than 50 Beds **Charts represent hospitals licensed as Acute Care Hospitals and may also be CMS Long-Term Acute Care Hospitals - 2.00 4.00 6.00 8.00 10.00 12.00 Choctaw Memorial Hospital Community Hospital Continuous Care Center of … Continuous Care Center of … Eastern Oklahoma Medical … Elkview General Hospital Foundation Bariatric … Haskell County Hospital Henryetta Medical Center Integris Bass Pavilion Integris Canadian Valley … Lakeside Women's Hospital Lindsay Municipal Hospital Memorial Hospital & … Memorial Hospital of … Northwest Surgical Hospital Oklahoma Center for … Oklahoma Spine Hospital, … Orthopedic Hospital Park View Hospital Perry Memorial Hospital Purcell Municipal Hospital Pushmataha Hospital Sayre Memorial Hospital Share Memorial Hospital Solora Hospital Muskogee Southwestern Regional … St John Owasso Surgical Hospital of … Tulsa Spine Hospital EPIC Medical Center Latimer County General … Oklahoma NeuroSpecialty … Sequoyah Memorial … Solara Hospital Shawnee Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 56 PSI 8 Postoperative Hip Fracture Medical Surgical Hospitals Licensed for 100 to 249 Beds Medical Surgical Hospitals Licensed for 250 to 499 Beds - 0.50 1.00 1.50 2.00 2.50 Integris Baptist Regional … Integris Bass Baptist … Jackson County Memorial … McAlester Regional … McCurtain Memorial … Medical Center of … Mercy Memorial Health … Ponca City Medical Center SouthCrest Hospital Southwestern Medical … St. Mary's Regional … Stillwater Medical Center Unity Health Center Valley View Regional … Wagoner Community … Duncan Regional Hospital, … OSU Medical Center Jane Phillips Medical Center Tahlequah City Hospital Hospital Rate State Rate T - 0.20 0.40 0.60 0.80 1.00 1.20 Comanche County Memorial Hospital Deaconess Hospital Integris Southwest Medical Center of OK Midwest Regional Medical Center Muskogee Regional Medical Center Mercy Health Center, Inc. Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 57 National Healthcare Safety Network Oklahoma currently has 152 licensed hospitals with 50 of those hospitals identified as having at least one adult intensive care unit. Hospitals with adult intensive care units are required to collect and report data monthly beginning July 2008. These hospitals were required to complete an orientation on how to utilize and enter data into the NHSN data system. Once the orientation was complete, the Infection Preventionist for the hospital initiated the enrollment process. Hospitals participating in NHSN must be a recognized healthcare entity in the United States, and be listed in or associated with a facility that is included in one of the following national databases: American Hospital Association (AHA), Centers for Medicare and Medicaid Services (CMS), or Veteran’s Affairs (VA). The implementation of the reporting process is based on data collected and reported to NHSN. Every effort has been made to correct data reporting errors. However, if data was not reported or errors could not be resolved, the data has been identified by an asterisk (*) as missing or having been reported inaccurately. It is estimated that 248,000 bloodstream infections occur each year in U.S. hospitals. These infections are very serious and usually result in longer hospital stays, which result in increased cost and increased risk of morbidity and mortality. With proper management these infections can be prevented. The second most common nosocomial infection in the United States is pneumonia. Patients who require mechanical assistance with a ventilator are at a higher risk of developing nosocomial pneumonia. Central Line Associated Bloodstream Infection (CLABSI) The definition of a central line is an intravascular catheter that terminates at or close to the heart or in one of the great vessels such as aorta, pulmonary artery, superior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, external iliac veins, and common femoral veins which is used for infusion, withdrawal of blood, or hemodynamic monitoring. A pacemaker wire and other non-lumenated devices inserted into central blood vessels or the heart are not considered central lines, because fluids are not infused, pushed, nor withdrawn through such devices. Central Line Associated Bloodstream Infection is a primary bloodstream infection (BSI) in a patient that had a central line within the 48-hour period before the development of the BSI. There is no minimum period of time that the central line must be in place in order for the BSI to be considered central line-associated. Laboratory-confirmed bloodstream infection (LCBI) must meet one of the following criteria: Oklahoma Hospital Annual Report 2009 58 Criterion 1: Patient has a recognized pathogen cultured from one or more blood cultures and organism cultured from blood is not related to an infection at another site. Criterion 2: Patient has at least one of the following signs or symptoms: fever (>38C), chills, or hypotension and signs and symptoms and positive laboratory results are not related to an infection at another site and common skin contaminant (i.e., diphtheroids [Corynebacterium spp.], Bacillus [not B. anthracis] spp., Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridans group streptococci, Aerococcus spp., Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions. The data collected in NHSN are used for improving patient safety at the local and national levels. In aggregate, CDC analyzes and publishes surveillance data to estimate and characterize the national burden of healthcare-associated infections. At the local level, the data analysis features of NHSN are available to participating facilities range from rate tables and graphs to statistical analysis that compares the healthcare facility’s rates with the national aggregate metrics. Two factors are use to analyze the data. The first is numerator data, when a CLABSI is identified during the month the patient demographic information on whether a central line was present, and, if so, the type of central line the patient had as appropriate to the location is entered into the NHSN database. The data will be used to calculate line-specific infection rates. Additional data include the specific criteria met for identifying the primary BSI, whether the patient died, and the organisms isolated from blood cultures, and the organisms’ antimicrobial susceptibili-ties. The second is denominator data, which is the total device days and patient days, collected daily, at the same time each day, during the month. Only the totals for the month are entered into NHSN. If a patient has both a temporary and a permanent central line, only the temporary line is counted. The statistical graph charts are displayed by individual hospital facility. Some larger hospital facilities may have more than one intensive care unit; therefore, more than one chart may be shown. The data for this report is for the last six months of 2008 (July through December). Oklahoma Hospital Annual Report 2009 59 Central Line Associated Blood Stream Infections for State This chart depicts the reports of all hospitals who reported to the NHSN for the time period from July through December 2008. The total number of central line associated blood stream infections for the month is then divided by the number of central line days, which is then multiplied by 1000 patient days. The average for 2008 for the state as a whole was 1.01 infections per 1000 device days. 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 CLABSI State Rate for 2008 by Month per 1000 Device Days Oklahoma Hospital Annual Report 2009 60 Central Line Associated Blood Stream Infections for State by Unit Type An intensive care unit is a nursing care area that provides intensive observation, diagnosis and therapeutic procedures for adults who are critically ill. The following definitions better define the specific care units. If a hospital has more than one unit, it is more common for the units to provide specialized care as related to the primary diagnosis. Coronary is a critical care area specializing in the care of patients with serious heart problems that do not require heart surgery. Surgical Cardiothoracic is a critical care area specializing in the care of patients following cardiac and thoracic surgery. Medical Surgical is a critical care area for patients who are being treated for nonsurgical conditions. Neurosurgical is a critical care area specializing in the surgical management of patients with severe neurological diseases or those at risk for neurological injury as a result of surgery. Surgical is a critical care area for the evaluation and management of patients with serious illness before and /or after surgery. Trauma is a critical care area specializing in the care of patients who require a high level of monitoring and/or intervention following trauma or during critical illness related to trauma. Coronar y Surgical Cardioth oracic Medical/ Surgical Neurosu rgical Surgical Trauma Rate of CLABSI/1,000 Central Line Days 0.14 1.70 1.06 1.48 0.10 1.06 NHSN Rate 2.00 1.40 1.80 2.50 2.30 3.60 0.00 1.00 2.00 3.00 4.00 CLABSI Rate Comparison of CLABSI Rates in OK Hospitals by Selected Critical Care Locations at Baseline (2008) to Available NHSN Rate from 2006 through 2008 Oklahoma Hospital Annual Report 2009 61 Central Line Associated Blood Stream Infections for hospitals by peer groups This report shows the initial results from a new reporting system. The Oklahoma State Department of Health and the Hospital Advisory Council recommend users of these data not draw definitive conclusions from the limited information that is currently available. Facilities vary in the types of patients treated, and a facility that treats a high volume of severely ill patients may have higher infection rates. The following charts are hospitals separated by licensure peer groups. If the hospital reported zero infections or no data was reported, there will not be a bar graft for representation of the infections. The goal is that all hospitals will have a rate of zero. The hospitals are listed in order of NHSN facility identification however, that number is not disclosed. 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 Integris Canadian Valley Regional Hospital Community Hospital Memorial Hospital of Texas County CTCA at Southwestern Regional Medical Center CLABSI Rate for Hospitals with less than 50 Beds CLABSI per 1000 Oklahoma Hospital Annual Report 2009 62 0 0.5 1 1.5 2 2.5 3 3.5 Integris Clinton Regional … Oklahoma Heart Hospital Integris Grove General … St.Francis Hospital South Claremore Regional … Grady Memorial Hospital Edmond Medical Center Great Plains Regional … Eastern Oklahoma … Bailey Medical Center Pauls Valley General … Newman Regional Hospital Woodward Regional … Cushing Regional Hospital CLABSI Rate for Hospitals 50-99 Beds CLABSI per 1000 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 Valley View Reg Hosp Integris Baptist Regional �� Integris Bass Baptist … OSU Medical Center Duncan Regional Hosp. Tahlequah City Hosp. Medical Center of … Stillwater Medical Center McAlester Regional … Southwestern Medical … McCurtain Memorial … Jane Phillips Medical … St. Mary's Regional Hospital Ponca City Medical Center Unity Health Center Jackson County Memorial … Mercy Memorial Health … CLABSI Rate for Hospitals 100-249 Beds CLABSI per 1000 Oklahoma Hospital Annual Report 2009 63 0 0.5 1 1.5 2 2.5 3 3.5 4 Integris Southwest Medical Center Mercy Health Center Midwest Regional Medical Center Deaconess Muskogee Regional Medical Center Comanche Co Memorial Hospital CLABSI Rate for Hospitals 250-499 Beds CLABSI per 1000 0 1 2 3 4 5 6 St Anthony Hospital-3N St Anthony Hospital-4N Integris Baptist Medical … Integris Baptist Medical … Integris Baptist Medical … Integris Baptist Medical … Integris Baptist Medical … St John Medical … St John Medical … St John Medical … St Francis Hospital-CCU St Francis Hospital-ICU4 St Francis Hospital-… OU Medical Center-ICUS OU Medical Center-… OU Medical Center-ICUN Norman Regional … Hillcrest Medical … Hillcrest Medical … Hillcrest Medical … CLABSI Rate by Units in Hospitals with 500 + Beds CLABSI Per 1000 Oklahoma Hospital Annual Report 2009 64 Central Line Associated Blood Stream Infections by individual hospital The following charts are listed in alphabetical order and represent each facility’s infection by intensive care units. If the facility has more than one unit the numbers will be listed by the identifier the infection control preventionist has labeled the individual unit in the NHSN database. Each facility page has a brief explanation about the facility, such as the number of licensed beds, the number of beds in the unit, and the type of patients which are admitted to the units. Data charts definitions: Year Month: This represents the year 2008 and the month by number for the reported data. CLABSI Infections: Actual infections that occur during a month on a particular intensive care unit. Number of Central Line Days: For each day of the month, at the same time each day, record the number of patients on the selected unit who have a central line. This number is summed at the end of the month. CLABSI Rate: The number of Central Line Associated Blood Stream infections divided by the number of central line days multiplied by 1000. Number of Patient Days: For each day of the month, at the same time each day, record the number of patients on the selected unit. Central Line Utilization Ratio: The number of central line days divided by the number of patient days for a given month. Oklahoma Hospital Annual Report 2009 65 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ration 2008M07 0 10 0.0 26 0.38 2008M08 0 6 0.0 22 0.27 2008M09 0 5 0.0 16 0.31 2008M10 0 10 0.0 19 0.53 2008M11 0 3 0.0 14 0.21 2008M12 0 5 0.0 20 0.25 Data is per 1000 device days and is from July 2008 through December 2008. Bailey Medical Center –This hospital is located in Owasso. Data was collected from an inpatient acute critical care medical surgical unit, consisting of five setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 73. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Bailey Medical Center Oklahoma Hospital Annual Report 2009 66 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 48 0.0 112 0.43 2008M08 0 6 0.0 1324* 0.00 2008M09 0 72 0.0 147 0.49 2008M10 0 36 0.0 1197* 0.03 2008M11 0 44 0.0 131 0.34 2008M12 0 37 0.0 116 0.32 Data is per 1000 device days and is from July 2008 through December 2008. *Data reported number of patient days for entire facility Claremore Regional Hospital – This hospital is located in Claremore. Data was collected from an inpatient acute critical care medical unit, consisting of six setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 81. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Claremore Regional Hospital Oklahoma Hospital Annual Report 2009 67 Year Month CLABSI Infection Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 157 0.0 428 0.37 2008M08 1 147 6.8 453 0.32 2008M09 1 152 6.6 446 0.34 2008M10 1 221 4.5 442 0.50 2008M11 1 224 4.5 474 0.47 2008M12 0 246 0.0 503 0.49 Data is per 1000 device days and is from July 2008 through December 2008. Comanche County Memorial Hospital – This Hospital is located in Lawton. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 20 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 283. 0 1 2 3 4 5 6 7 8 July August September October November December Comanche County Memorial Hospital Oklahoma Hospital Annual Report 2009 68 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 6 0.0 535* 0.01 2008M08 0 5 0.0 413* 0.01 2008M09 0 23 0.0 528* 0.04 2008M10 0 11 0.0 550* 0.02 2008M11 0 8 0.0 430* 0.02 2008M12 0 15 0.0 525* 0.03 Data is per 1000 device days and is from July 2008 through December 2008. *Data reported number of patient days for entire facility, maximum number of ICU patient days would be 90 or less. Community Hospital – This hospital is located in Oklahoma City. Data was collected from an inpatient acute critical care medical surgical unit, consisting of three setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 49. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Community Hospital Oklahoma Hospital Annual Report 2009 69 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 4 0.0 39 0.10 2008M08 0 4 0.0 18 0.22 2008M09 0 2 0.0 38 0.05 2008M10 0 6 0.0 46 0.13 2008M11 0 0 . 19 0.00 2008M12 0 4 0.0 29 0.14 Data is per 1000 device days and is from July 2008 through December 2008. Cushing Regional Hospital – This hospital is located in Cushing. Data was collected from an inpatient acute critical care medical surgical unit, consisting of four setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 95. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Cushing Regional Hospital Oklahoma Hospital Annual Report 2009 70 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 314 0.0 5185* 0.06 2008M08 0 292 0.0 4822* 0.06 2008M09 0 232 0.0 5091* 0.05 2008M10 0 186 0.0 279 0.67 2008M11 0 261 0.0 375 0.70 2008M12 0 279 0.0 361 0.77 Data is per 1000 device days and is from July 2008 through December 2008. *Data reported number of patient days for entire facility, maximum number of ICU patient days would be 870 or less. Deaconess Hospital – This hospital is located in Oklahoma City. Data was collected from an inpatient acute critical care medical unit, consisting of 29 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 313. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Deaconess Hospital Oklahoma Hospital Annual Report 2009 71 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 63 0.0 135 0.47 2008M08 0 49 0.0 156 0.31 2008M09 0 55 0.0 134 0.41 2008M10 0 63 0.0 150 0.42 2008M11 0 49 0.0 154 0.32 2008M12 0 23 0.0 141 0.16 Data is per 1000 device days and is from July 2008 through December 2008. Duncan Regional Hospital – This hospital is located in Duncan. Data was collected from an inpatient acute critical care medical surgical unit, consisting of nine setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 167. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Duncan Regional Hospital Oklahoma Hospital Annual Report 2009 72 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 12 0.0 134 0.09 2008M08 0 17 0.0 182 0.09 2008M09 0 38 0.0 176 0.22 2008M10 0 60 0.0 211 0.28 2008M11 0 52 0.0 190 0.27 2008M12 0 26 0.0 162 0.16 Data is per 1000 device days and is from July 2008 through December 2008. Eastern Oklahoma Medical Center –This hospital is located in Poteau. Data was collected from an inpatient acute critical care medical surgical unit, consisting of eight setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 84. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Eastern Oklahoma Medical Center Oklahoma Hospital Annual Report 2009 73 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 1 144 6.9 161 0.89 2008M08 1 115 8.7 139 0.83 2008M09 0 98 0.0 116 0.84 2008M10 0 93 0.0 135 0.69 2008M11 0 106 0.0 159 0.67 2008M12 0 99 0.0 159 0.62 Data is per 1000 device days and is from July 2008 through December 2008. Edmond Medical Center – This hospital is located in Edmond. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 12 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 94. 0 1 2 3 4 5 6 7 8 9 10 July August September October November December Edmond Medical Center Oklahoma Hospital Annual Report 2009 74 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 28 0.0 72 0.39 2008M08 0 32 0.0 138 0.23 2008M09 0 40 0.0 103 0.39 2008M10 0 31 0.0 110 0.28 2008M11 0 38 0.0 122 0.31 2008M12 0 31 0.0 111 0.28 Data is per 1000 device days and is from July 2008 through December 2008. Grady Memorial Hospital – This hospital is located in Chickasha. Data was collected from an inpatient acute critical care medical surgical unit, consisting of seven setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 99. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Grady Memorial Hospital Oklahoma Hospital Annual Report 2009 75 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 0 . 85 0.00 2008M08 0 8 0.0 87 0.09 2008M09 0 10 0.0 112 0.09 2008M10 0 0 . 86 0.00 2008M11 0 3 0.0 67 0.04 2008M12 0 3 0.0 110 0.03 Data is per 1000 device days and is from July 2008 through December 2008. Great Plains Regional Medical Center – This hospital is located in Elk City. Data was collected from an inpatient acute critical care medical unit, consisting of six setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 62. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Great Plains Regional Medical Center Oklahoma Hospital Annual Report 2009 76 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 July August September October November December CCU ICU MICU Hillcrest Medical Center Oklahoma Hospital Annual Report 2009 77 Hillcrest Medical Center Unit Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio CCU 2008M07 0 284 0.0 296 0.96 CCU 2008M08 1 243 4.1 292 0.83 CCU 2008M09 0 188 0.0 269 0.70 CCU 2008M10 1 218 4.6 280 0.78 CCU 2008M11 0 198 0.0 227 0.87 CCU 2008M12 0 262 0.0 303 0.86 ICU 2008M07 0 249 0.0 357 0.70 ICU 2008M08 0 269 0.0 363 0.74 ICU 2008M09 0 244 0.0 331 0.74 ICU 2008M10 0 235 0.0 365 0.64 ICU 2008M11 0 251 0.0 341 0.74 ICU 2008M12 1 285 3.5 369 0.77 MICU 2008M07 0 82 0.0 120 0.68 MICU 2008M08 0 80 0.0 131 0.61 MICU 2008M09 0 79 0.0 137 0.58 MICU 2008M10 0 103 0.0 151 0.68 MICU 2008M11 0 106 0.0 138 0.77 MICU 2008M12 0 129 0.0 163 0.79 Data is per 1000 device days and is from July 2008 through December 2008. Hillcrest Medical Center– This hospital is located in Tulsa. Data was collected from three inpatient acute critical care units, two of which were Medical Surgical Units, and one Cardiac Vascular Care Unit. All three ICUs total 31 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 691. Oklahoma Hospital Annual Report 2009 78 Data is per 1000 device days and is from July 2008 through December 2008. Integris Baptist Medical Center – This hospital is located in Oklahoma City. Data was collected from five inpatient acute critical care medical surgical units, consisting of 60 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 640. 0 1 2 3 4 5 6 7 July August September October November December ICU 501 ICU 601 ICU 701 ICU 801 ICU 901 Integris Baptist Medical Center Oklahoma Hospital Annual Report 2009 79 Integris Baptist Medical Center Unit Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 501 2008M07 0 131 0.0 167 0.78 501 2008M08 0 158 0.0 204 0.77 501 2008M09 0 180 0.0 243 0.74 501 2008M10 1 161 6.2 219 0.74 501 2008M11 0 202 0.0 260 0.78 501 2008M12 0 245 0.0 299 0.82 601 2008M07 0 248 0.0 329 0.75 601 2008M08 0 249 0.0 302 0.82 601 2008M09 0 244 0.0 315 0.77 601 2008M10 0 251 0.0 316 0.79 601 2008M11 0 241 0.0 325 0.74 601 2008M12 0 228 0.0 323 0.71 701 2008M07 0 297 0.0 308 0.96 701 2008M08 0 250 0.0 284 0.88 701 2008M09 0 278 0.0 291 0.96 701 2008M10 0 280 0.0 281 1.00 701 2008M11 0 286 0.0 304 0.94 701 2008M12 0 309 0.0 315 0.98 801 2008M07 1 304 3.3 304 1.00 801 2008M08 1 270 3.7 285 0.95 801 2008M09 0 268 0.0 269 1.00 801 2008M10 0 269 0.0 269 1.00 801 2008M11 0 255 0.0 257 0.99 801 2008M12 0 275 0.0 293 0.94 901 2008M07 0 261 0.0 306 0.85 901 2008M08 0 241 0.0 293 0.82 901 2008M09 0 178 0.0 266 0.67 901 2008M10 0 156 0.0 244 0.64 901 2008M11 0 183 0.0 294 0.62 901 2008M12 1 248 4.0 334 0.74 Oklahoma Hospital Annual Report 2009 80 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 5 0.0 81 0.06 2008M08 0 32 0.0 118 0.27 2008M09 0 23 0.0 100 0.23 2008M10 0 13 0.0 92 0.14 2008M11 0 16 0.0 70 0.23 2008M12 0 33 0.0 109 0.30 Data is per 1000 device days and is from July 2008 through December 2008. Integris Baptist Regional Health Center– This hospital is located in Miami. Data was collected from an inpatient acute critical care medical surgical unit, consisting of five setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 117. 0 0.2 0.4 0.6 0.8 1 1.2 July August September October November December Integris Baptist Regional Health Center Oklahoma Hospital Annual Report 2009 81 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 41 0.0 80 0.51 2008M08 0 65 0.0 108 0.60 2008M09 0 63 0.0 100 0.63 2008M10 0 100 0.0 139 0.72 2008M11 0 102 0.0 139 0.73 2008M12 0 68 0.0 127 0.54 Data is per 1000 device days and is from July 2008 through December 2008. Integris Bass Baptist Health Center – This hospital is located in Enid. Data was collected from an inpatient acute critical care medical surgical unit, consisting of seven setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 183. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Integris Bass Baptist Health Center Oklahoma Hospital Annual Report 2009 82 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 40 0.0 73 0.55 2008M08 0 48 0.0 102 0.47 2008M09 0 37 0.0 95 0.39 2008M10 0 24 0.0 101 0.24 2008M11 0 60 0.0 101 0.59 2008M12 0 46 0.0 107 0.43 Data is per 1000 device days and is from July 2008 through December 2008. Integris Canadian Valley Hospital – This hospital is located in Yukon. Data was collected from an inpatient acute critical care medical surgical unit, consisting of four setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 48. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Integris Canadian Valley Hospital Oklahoma Hospital Annual Report 2009 83 Data is per 1000 device days and is from July 2008 through December 2008. Integris Clinton Regional Hospital – This hospital is located in Clinton. Data was collected from an inpatient acute critical care medical surgical unit, consisting of four setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 56. 0 0.2 0.4 0.6 0.8 1 1.2 July August September October November December Integris Clinton Regional Hospital Year Month CLASI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 9 0.0 14 0.64 2008M08 0 2 0.0 14 0.14 2008M09 0 20 0.0 25 0.80 2008M10 0 8 0.0 44 0.18 2008M11 0 6 0.0 44 0.14 2008M12 0 5 0.0 35 0.14 Oklahoma Hospital Annual Report 2009 84 Year Month CLABSI Infection Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 24 0.0 62 0.39 2008M08 0 6 0.0 31 0.19 2008M09 0 0 . 21 0.00 2008M10 0 0 . 31 0.00 2008M11 0 14 0.0 40 0.35 2008M12 0 3 0.0 49 0.06 Data is per 1000 device days and is from July 2008 through December 2008. Integris Grove General Hospital – This hospital is located in Grove. Data was collected from an inpatient acute critical care medical surgical unit, consisting of four setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 68. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Integris Grove General Hospital Oklahoma Hospital Annual Report 2009 85 Data is per 1000 device days and is from July 2008 through December 2008. Integris Southwest Medical Center – This hospital is located in Oklahoma City. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 20 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 406. 0 1 2 3 4 5 6 7 8 July August September October November December Integris Southwest Medical Center Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 1 253 4.0 490 0.52 2008M08 1 233 4.3 459 0.51 2008M09 0 224 0.0 469 0.48 2008M10 0 231 0.0 449 0.51 2008M11 1 190 5.3 484 0.39 2008M12 2 297 6.7 535 0.56 Oklahoma Hospital Annual Report 2009 86 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 23 0.0 135 0.17 2008M08 0 26 0.0 26 1.00 2008M09 0 16 0.0 113 0.14 2008M10 0 32 0.0 104 0.31 2008M11 0 11 0.0 100 0.11 2008M12 0 0 . 96 0.00 Data is per 1000 device days and is from July 2008 through December 2008. Jackson County Memorial Hospital – This hospital is located in Altus. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 12 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 156. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Jackson County Memorial Hospital Oklahoma Hospital Annual Report 2009 87 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 67 0.0 180 0.37 2008M08 0 46 0.0 119 0.39 2008M09 0 67 0.0 157 0.43 2008M10 0 38 0.0 144 0.26 2008M11 0 24 0.0 85 0.28 2008M12 0 27 0.0 128 0.21 Data is per 1000 device days and is from July 2008 through December 2008. Jane Phillips Medical Center – This hospital is located in Bartlesville. Data was collected from an inpatient acute critical care medical surgical unit, consisting of eight setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 137. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Jane Phillips Medical Center Oklahoma Hospital Annual Report 2009 88 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 4 0.0 30 0.13 2008M08 0 44 0.0 146 0.30 2008M09 0 45 0.0 153 0.29 2008M10 0 77 0.0 218 0.35 2008M11 0 20 0.0 197 0.10 2008M12 0 38 0.0 188 0.20 Data is per 1000 device days and is from July 2008 through December 2008. McAlester Regional Health Center – Data was collected from an inpatient acute critical care medical surgical unit, consisting of 14 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 171. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December McAlester Regional Health Center Oklahoma Hospital Annual Report 2009 89 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 0 . 43 0.00 2008M08 0 6 0.0 57 0.11 2008M09 0 2 0.0 69 0.03 2008M10 0 0 . 50 0.00 2008M11 0 0 . 63 0.00 2008M12 0 0 . 57 0.00 Data is per 1000 device days and is from July 2008 through December 2008. McCurtain Memorial Hospital – This hospital is located in Idabel. Data was collected from an inpatient acute critical care medical surgical unit, consisting of six setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 106. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December McCurtain Memorial Hospital Oklahoma Hospital Annual Report 2009 90 Year Month CLABSI Infections Number of Central Line Days CLABSI Number of Patient Days Central Line Utilization Ratio 2008M07 0 92 0.0 231 0.40 2008M08 0 69 0.0 200 0.35 2008M09 0 56 0.0 213 0.26 2008M10 0 88 0.0 223 0.39 2008M11 0 86 0.0 213 0.40 2008M12 0 28 0.0 220 0.13 Data is per 1000 device days and is from July 2008 through December 2008. Medical Center of Southeastern Oklahoma – This hospital is located in Durant. Data was collected from an inpatient acute critical care medical surgical unit, consisting of eight setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 148. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Medical Center of Southeastern Oklahoma Oklahoma Hospital Annual Report 2009 91 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 6 0.0 314* 0.86 2008M08 0 1 0.0 270* 0.00 2008M09 0 6 0.0 326* 0.02 2008M10 0 0 . 392* 0.00 2008M11 0 0 . 308* 0.00 2008M12 0 0 . 288* 0.00 Data is per 1000 device days and is from July 2008 through December 2008. *Data reported number of patient days for entire facility, maximum number of ICU patient days would be 120 or less. Memorial Hospital of Texas County – This hospital is located in Guymon. Data was collected from an inpatient acute critical care medical surgical unit, consisting of four setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 47. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Memorial Hospital of Texas County Oklahoma Hospital Annual Report 2009 92 Year Month CLABSI Infection Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 1 428 2.3 757 0.57 2008M08 0 563 0.0 878 0.64 2008M09 0 490 0.0 875 0.56 2008M10 0 556 0.0 893 0.62 2008M11 1 623 1.6 970 0.64 2008M12 1 686 1.5 984 0.70 Data is per 1000 device days and is from July 2008 through December 2008. Mercy Health Center – This hospital is located in Oklahoma City. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 54 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 380. 0 0.5 1 1.5 2 2.5 July August September October November December Mercy Health Center Oklahoma Hospital Annual Report 2009 93 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 47 0.0 203 0.23 2008M08 0 64 0.0 236 0.27 2008M09 0 100 0.0 269 0.37 2008M10 1 91 11.0 249 0.37 2008M11 0 104 0.0 234 0.44 2008M12 0 104 0.0 255 0.41 Data is per 1000 device days and is from July 2008 through December 2008. Mercy Memorial Health Center – This hospital is located in Ardmore. Data was collected from an inpatient acute critical care medical surgical unit, consisting of ten setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 175. 0 2 4 6 8 10 12 July August September October November December Mercy Memorial Health Center Oklahoma Hospital Annual Report 2009 94 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 176 0.0 261 0.67 2008M08 0 183 0.0 231 0.79 2008M09 0 151 0.0 226 0.67 2008M10 0 148 0.0 236 0.63 2008M11 0 143 0.0 210 0.68 2008M12 0 162 0.0 256 0.63 Data is per 1000 device days and is from July 2008 through December 2008. Midwest Regional Medical Center – This hospital is located in Midwest City. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 24 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 255. 0 0.2 0.4 0.6 0.8 1 1.2 July August September October November December Midwest Regional Medical Center Oklahoma Hospital Annual Report 2009 95 Year Month CLABSI Infections Number of CLABSI Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 70 0.0 493 0.14 2008M08 0 37 0.0 503 0.07 2008M09 0 45 0.0 516 0.09 2008M10 0 73 0.0 569 0.13 2008M11 0 49 0.0 640 0.08 2008M12 0 45 0.0 649 0.07 Data is per 1000 device days and is from July 2008 through December 2008. Muskogee Regional Medical Center – Data was collected from an inpatient acute critical care medical surgical unit, consisting of 24 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 275 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Muskogee Regional Medical Center Oklahoma Hospital Annual Report 2009 96 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 0 . 221* 0.00 2008M08 0 0 . 280* 0.00 2008M09 0 15 0.0 287* 0.05 2008M10 0 2 0.0 264* 0.01 2008M11 0 0 . 300* 0.00 2008M12 0 0 . 259* 0.00 Data is per 1000 device days and is from July 2008 through December 2008. *Data reported number of patient days for entire facility, maximum number of ICU patient days would be 62 or less. Newman Memorial Hospital – This hospital is located in Shattuck. Data was collected from an inpatient acute critical care medical surgical unit, consisting of two setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 79. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December NewmanMemorial Hospital Oklahoma Hospital Annual Report 2009 97 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 384 0.0 502 0.76 2008M08 0 454 0.0 589 0.77 2008M09 0 394 0.0 612 0.64 2008M10 0 471 0.0 565 0.83 2008M11 0 445 0.0 608 0.73 2008M12 1 669 1.5 773 0.87 Data is per 1000 device days and is from July 2008 through December 2008. Norman Regional Hospital – This hospital is located in Norman. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 43 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 518. 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 July August September October November December Norman Regional Hospital Oklahoma Hospital Annual Report 2009 98 Year Month CLABSI Infections 2008M07 0 2008M08 0 2008M09 0 2008M10 0 2008M11 0 2008M12 1 Data is per 1000 device days and is from July 2008 through December 2008. **Data report incomplete due to data entry error. Oklahoma Heart Hospital – This hospital is located in Oklahoma City. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 54 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 99. 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 July August September October November December Oklahoma Heart Hospital Oklahoma Hospital Annual Report 2009 99 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 630 0.0 673 0.94 2008M08 1 509 2.0 604 0.84 2008M09 0 367 0.0 523 0.70 2008M10 0 468 0.0 546 0.86 2008M11 0 348 0.0 479 0.73 2008M12 0 372 0.0 481 0.77 Data is per 1000 device days and is from July 2008 through December 2008. Oklahoma State University Medical Center – This hospital is located in Tulsa. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 54 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 249. 0 0.5 1 1.5 2 2.5 July August September October November December Oklahoma State University Medical Center Oklahoma Hospital Annual Report 2009 100 0 2 4 6 8 10 12 14 July August September October November December ICUS ICUW ICUN OUMedical Center Oklahoma Hospital Annual Report 2009 101 OU Medical Center Unit Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio ICUS 2008M07 0 272 0.0 471 0.58 ICUS 2008M08 0 204 0.0 406 0.50 ICUS 2008M09 0 301 0.0 422 0.71 ICUS 2008M10 0 263 0.0 455 0.58 ICUS 2008M11 0 315 0.0 467 0.67 ICUS 2008M12 1 344 2.9 488 0.70 ICUW 2008M07 1 259 3.9 474 0.55 ICUW 2008M08 1 227 4.4 416 0.55 ICUW 2008M09 0 315 0.0 477 0.66 ICUW 2008M10 3 245 12.2 476 0.51 ICUW 2008M11 0 337 0.0 516 0.65 ICUW 2008M12 4 344 11.6 514 0.67 ICUN 2008M07 1 261 3.8 455 0.57 ICUN 2008M08 0 274 0.0 437 0.63 ICUN 2008M09 0 339 0.0 427 0.79 ICUN 2008M10 0 294 0.0 449 0.65 ICUN 2008M11 1 390 2.6 458 0.85 ICUN 2008M12 0 333 0.0 458 0.73 Data is per 1000 device days and is from July 2008 through December 2008. OU Medical Center – This hospital is located in Oklahoma City. Data was collected from two inpatient acute critical care units, two of which were Medical Surgical Units, and one Trauma Critical Care Unit. All three ICUs total 151 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 689. Oklahoma Hospital Annual Report 2009 102 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 0 . 19 0.00 2008M08 0 0 . 11 0.00 2008M09 0 0 . 4 0.00 2008M10 0 0 . 23 0.00 2008M11 0 0 . 14 0.00 2008M12 0 0 . 13 0.00 Data is per 1000 device days and is from July 2008 through December 2008. Pauls Valley General Hospital – This hospital is located in Pauls Valley. Data was collected from an inpatient acute critical care medical surgical unit, consisting of three setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 64. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Pauls Valley General Hospital Oklahoma Hospital Annual Report 2009 103 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 29 0.0 153 0.19 2008M08 0 28 0.0 102 0.27 2008M09 0 9 0.0 144 0.06 2008M10 0 45 0.0 141 0.32 2008M11 0 37 0.0 153 0.24 2008M12 0 27 0.0 124 0.22 Data is per 1000 device days and is from July 2008 through December 2008. Ponca City Medical Center – This hospital is located in Ponca City. Data was collected from an inpatient acute critical care medical unit, consisting of ten setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 140. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Ponca City Medical Center Oklahoma Hospital Annual Report 2009 104 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 1 89 11.2 152 0.59 2008M08 0 114 0.0 142 0.80 2008M09 0 68 0.0 99 0.69 2008M10 0 78 0.0 140 0.56 2008M11 0 76 0.0 103 0.74 2008M12 0 94 0.0 112 0.84 Data is per 1000 device days and is from July 2008 through December 2008. Southwestern Medical Center – This hospital is located in Lawton. Data was collected from an inpatient acute critical care medical surgical unit, consisting of ten setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 199. 0 2 4 6 8 10 12 July August September October November December SouthwesternMedical Center Oklahoma Hospital Annual Report 2009 105 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 1 36 27.8 166 0.22 2008M08 0 49 0.0 139 0.35 2008M09 1 77 13.0 132 0.58 2008M10 0 75 0.0 152 0.49 2008M11 0 150 0.0 168 0.89 2008M12 0 107 0.0 149 0.72 Data is per 1000 device days and is from July 2008 through December 2008. Southwestern Regional Medical Center– (Cancer Treatment Center of America)- This hospital is located in Tulsa. Data was collected from an inpatient acute critical care medical surgical unit, consisting of seven setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 43. 0 5 10 15 20 25 30 July August September October November December Southwestern Regional Medical Center Oklahoma Hospital Annual Report 2009 106 0 1 2 3 4 5 6 7 8 9 10 July August September October November December 3 N 4 N St. Anthony Hospital Oklahoma Hospital Annual Report 2009 107 Unit Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 3N 2008M07 0 130 0.0 303 0.43 3N 2008M08 0 210 0.0 302 0.70 3N 2008M09 1 209 4.8 307 0.68 3N 2008M10 0 160 0.0 335 0.48 3N 2008M11 0 225 0.0 342 0.66 3N 2008M12 2 225 8.9 326 0.69 4N 2008M07 0 223 0.0 397 0.56 4N 2008M08 0 209 0.0 382 0.55 4N 2008M09 1 259 3.9 397 0.65 4N 2008M10 2 267 7.5 410 0.65 4N 2008M11 0 287 0.0 395 0.73 4N 2008M12 0 216 0.0 402 0.54 Data is per 1000 device days and is from July 2008 through December 2008. St. Anthony Hospital – This hospital is located in Oklahoma City. Data was collected from two inpatient acute critical care medical surgical units, consisting of 29 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 686. Oklahoma Hospital Annual Report 2009 108 0 0.5 1 1.5 2 2.5 3 3.5 4 July August Septembe r October Novembe r Decembe r CCU ICU-4 Trauma ICU Saint Francis Hospital Oklahoma Hospital Annual Report 2009 109 Saint Francis Hospital Unit Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio CCU 2008M07 0 473 0.0 701 0.67 CCU 2008M08 0 436 0.0 651 0.67 CCU 2008M09 0 356 0.0 539 0.66 CCU 2008M10 0 288 0.0 460 0.63 CCU 2008M11 1 276 3.6 454 0.61 CCU 2008M12 0 286 0.0 458 0.62 ICU-4 2008M07 2 670 3.0 877 0.76 ICU-4 2008M08 0 681 0.0 889 0.77 ICU-4 2008M09 0 602 0.0 843 0.71 ICU-4 2008M10 0 668 0.0 882 0.76 ICU-4 2008M11 0 637 0.0 861 0.74 ICU-4 2008M12 1 708 1.4 885 0.80 TRAUMA ICU 2008M07 379 0.0 469 0.81 0 TRAUMA ICU 2008M08 0 372 0.0 464 0.80 TRAUMA ICU 2008M09 1 352 2.8 437 0.81 TRAUMA ICU 2008M10 0 365 0.0 459 0.80 TRAUMA ICU 2008M11 0 351 0.0 436 0.81 TRAUMA ICU 2008M12 0 347 0.0 455 0.76 Data is per 1000 device days and is from July 2008 through December 2008. Saint Francis Hospital – This hospital is located in Tulsa. Data was collected from three inpatient acute critical care units, Medical Surgical Critical Care, Cardiac Critical Care, and Trauma Critical Care. All three ICUs total to 139 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 928. Oklahoma Hospital Annual Report 2009 110 0 1 2 3 4 5 6 7 July August September October November December AICU NSICU SICU Oklahoma Hospital Annual Report 2009 111 St. John Medical Center Unit Year Month CLABSI Infection Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization AICU 2008M07 1 221 4.5 323 0.68 AICU 2008M08 1 447 2.2 623 0.72 AICU 2008M09 1 397 2.5 558 0.71 AICU 2008M10 1 479 2.1 638 0.75 AICU 2008M11 2 462 4.3 631 0.73 AICU 2008M12 1 391 2.6 623 0.63 NSICU 2008M07 1 205 4.9 317 0.65 NSICU 2008M08 0 309 0.0 343 0.90 NSICU 2008M09 2 319 6.3 407 0.78 NSICU 2008M10 1 371 2.7 452 0.82 NSICU 2008M11 1 377 2.7 477 0.79 NSICU 2008M12 0 349 0.0 443 0.79 SICU 2008M07 0 226 0.0 323 0.70 SICU 2008M08 0 232 0.0 343 0.68 SICU 2008M09 0 225 0.0 308 0.73 SICU 2008M10 0 258 0.0 357 0.72 SICU 2008M11 0 214 0.0 407 0.53 SICU 2008M12 0 227 0.0 350 0.65 Data is per 1000 device days and is from July 2008 through December 2008. St. John Medical Center – This hospital is located in Tulsa. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 54 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 703. Oklahoma Hospital Annual Report 2009 112 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 81 0.0 139 0.58 2008M08 0 93 0.0 180 0.52 2008M09 1 105 9.5 176 0.60 2008M10 0 156 0.0 206 0.76 2008M11 0 114 0.0 156 0.73 2008M12 0 83 0.0 165 0.50 Data is per 1000 device days and is from July 2008 through December 2008. St. Mary’s Regional Medical Center – This hospital is located in Enid. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 11 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 245. 0 1 2 3 4 5 6 7 8 9 10 July August September October
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Title | Oklahoma Hospital Report 2009 Hospital AR complete |
OkDocs Class# | H940.3 H828r 2009 |
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ODL electronic copy | Downloaded from agency website: http://www.ok.gov/health/documents/2009%20Hospital%20Annual%20Report%205-10-11.pdf |
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Language | English |
Full text | September 30, 2010 To Healthcare Partners and the Citizens of Oklahoma, Quality of health care remains an ongoing concern for patients, payers, and policy makers in Oklahoma. While there are a number of initiatives to measure and to improve the quality of care in our state and nationally, variations in quality continue to exist. Patients and other consumers of health care increasingly understand that the quality of their care is often compromised by medical errors, failure to deliver care consistent with the best evidence of effectiveness, and the lack of coordination of care between health care settings. The following document represents the second annual Oklahoma Hospital Report which provides a summary of nationally standardized, hospital-specific quality indicators. This report fulfills requirements set forth by the Oklahoma Legislature to publish an annual report of hospital-specific quality measures. In addition to providing details of hospital-specific performance on the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators, this year’s report now includes information on hospital-acquired infections as mandated by the Legislature. In a recent report on health system performance, Oklahoma ranked 50th in the nation based on 38 indicators of access to healthcare, health care quality, costs of care, and health outcomes. As noted in the Oklahoma Health Improvement Plan, there is an urgent need to improve health outcomes and health care quality. We continue to hope that providing the information detailed in this report to the citizens of Oklahoma will motivate leaders in health care to continue to identify opportunities to improve patient safety and health care quality, and to allow patients to use the information to make informed decisions when choosing their healthcare provider. Sincerely, Dale W. Bratzler, DO, MPH, Chair Hospital Advisory Council Oklahoma Hospital Annual Report 2009 2 (This page left blank) Oklahoma Hospital Annual Report 2009 3 Table of Content Services Offered………………………………………………………………………………………………………….5 Public Report AHRQ Patient Safety Indicators…………………………………………..13 Tier One PSI 4 Death among Surgical In- patients with Complications.17 PSI 6 Iatrogenic Pneumothorax……………………………………………………………21 PSI 11Postoperative Respiratory Failure………………………………………..25 PSI 12 Postoperative Pulmonary Embolism or DVT………………….29 PSI 14 Postoperative Wound Dehiscence……………………………………..33 PSI 15 Accidental Puncture or Laceration………………………………………37 PSI 17 Birth Trauma – Injury to Neonate………………………………………….41 PSI 18 Obstetric Trauma – Vaginal Delivery with Instrument…43 PSI 19 Obstetric Trauma – Vaginal Delivery w/o Instrument….47 Tier 1-B PSI 2 Death in Low Mortality DRGs…………………………………………………..51 PSI 8 Postoperative Hip Fracture……………………………………………………….55 National Healthcare Safety Network Central Line Associated Bloodstream Infection……………………………57 Ventilator Associated Pneumonia……………………………………………………..119 Hospital Compare…………………………………………………………………………………………………….181 References………………………………………………………………………………………………………………….182 **This document was revised May 10, 2011 Oklahoma Hospital Annual Report 2009 4 (This page left blank) Oklahoma Hospital Annual Report 2009 5 Services Offered Licensure Hospitals in Oklahoma are required by state statute to be licensed except those hospitals operated by the federal government, state mental hospitals, and community-based structured crisis centers. Licensing Authority - The Medical Facilities Service, within Protective Health Services of the Oklahoma State Department of Health (OSDH), is charged with the responsibility of assessing compliance with statute and administrative rule for hospital licensure. Rules – Chapter 667 Hospital Standards, Title 310, of the Oklahoma Administrative Code (OAC) outlines construction standards and rules for operation in order for an entity to be licensed as a hospital in Oklahoma. Fees – The licensure fee is set but statute and is based on the total number of beds licensed by the facility multiplied by ten dollars. Renewals – A license is valid for one year, therefore, facilities must apply annually for renewal. Facility Description Hospital – Any institution, place, building or agency, public or private, whether organized for profit or not, devoted primarily to the maintenance and operation of facilities for the diagnosis, treatment or care of patients admitted for overnight stay or longer in order to obtain medical care, surgical care, obstetrical care, or nursing care for illness, disease, injury, infirmity, or deformity {63 O.S. § 1-701}. In addition, Oklahoma Statutes provide that the term ―hospital‖ includes general medical surgical hospitals, specialized hospitals, critical access and emergency hospitals, and birthing centers. General Medical Surgical Hospital – A hospital maintained for the purpose of providing care in a broad category of illness and injury. Specialized Hospital – A hospital maintained for the purpose of providing care in a certain category, or categories, of illness and injury. The OSDH currently recognizes psychiatric, rehabilitation, and abortion facilities as specialized hospitals. Critical Access Hospital – A hospital that the OSDH determines to be a necessary provider of health care services to residents of a rural community. Oklahoma Hospital Annual Report 2009 6 Emergency Hospital – A hospital that provides emergency treatment and stabilization services on a 24-hour basis and has the ability to admit and treat patients for short period time. Birthing Center – Any hospital, place, or institution which is maintained or established primarily for the purpose of providing the services of a certified nurse midwife or licensed medical doctor to assist or attend in the delivery or birth and where a woman is scheduled in advance to give birth following a normal, uncomplicated, low-risk pregnancy. Licensure of birthing centers is voluntary. Medicare Certification OSDH contracts with the Centers for Medicare & Medicaid Services (CMS) to conduct administrative and inspection activities related to certification of hospitals for participation in the federal Medicare program. Although participation in the Medicare program is voluntary, facilities opting to apply must: 1) meet the requirements outlined in the Code of Federal Regulations (CFR); Conditions of Participation for Hospitals (42 CFR part 482), and for Critical Access Hospitals, CFR Part 485; subpart F - Conditions of Participation for Critical Access Hospitals (CAHs); and 2) comply with the Emergency Medical Treatment and Labor Act found in the Social Security Act, Sections 1866 and 1867, and associated regulations at CFR 42 part 489.24. OSDH makes recommendations regarding Medicare certification issues; however the CMS Region VI Office in Dallas, Texas has authority to make all final certification decisions. Accreditation Several national organizations offer programs for accrediting hospitals, or parts of a hospital’s operation, by meeting the respective organizations published standards. Participation in such accreditation programs is voluntary. Some private accrediting bodies have been granted ―deemed status‖ by Federal authorities. Hospitals accredited by one or more of these accrediting bodies are ―deemed― to meet the applicable federal standards without undergoing an on-site inspection by agents of CMS. There is no similar provision in Oklahoma law to grant ―deemed status‖ to third party accrediting organization for the purpose of state licensure. Oklahoma Hospital Annual Report 2009 7 Complaint Investigations OSDH conducts complaint investigation when allegations have been made that a licensed hospital is non-complaint with Chapter 667 Hospital Standards. In addition, the OSDH can investigate complaints against non-accredited hospitals regarding compliance with the Medicare Conditions of Participation; however, such investigations in accredited hospitals must be authorized by the CMS. Prior authorization from the CMS is also required before the OSDH can conduct an investigation of compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA) requirements. Construction Reviews Licensed hospitals wishing to alter existing buildings or build a new facility, must submit design plans and related documents to the OSDH for review and approval prior to construction. A review fee, based on the project’s estimated cost for design and construction, is assessed. Final inspection and approval of the facility must be granted by the OSDH prior to occupancy. Hospital Classifications Oklahoma Statutes require the OSDH to ―develop a classification system for all hospitals that treat emergency patients. The classification system shall identify stabilizing and definitive emergency services provided by each hospital‖ {63 O.S. § 1-2511}. The system is designed to classify the level of emergency services each hospital in Oklahoma provides in ten clinical categories. Within each category, the rules identify the practitioners, hospital personnel, equipment, and support services necessary for each level of care. It should be emphasized that the classification system is not designed to be a hospital ―report card.‖ Rather, it is intended to help direct emergency response providers and patients to the most appropriate facility based on the type and severity of their injury or illness. The ten clinical categories and levels of service follow: Trauma & Emergency Operative Services: Levels I – IV Cardiology: Levels I – III Pediatric Medicine and Trauma: Levels I-IV Dental: Levels I-III Obstetrics/Gynecology: Levels I-IV Ophthalmology: Levels I-III Neurology: Levels I-III Psychiatry: Levels I-III General Medicine: Levels I-I Stroke: Primary – Secondary Oklahoma Hospital Annual Report 2009 8 The most comprehensive services are offered by hospitals classified as Level I in a specific clinical category. These facilities are equipped and staffed to provide definitive treatment for severe emergency conditions in the classified clinical category. The hospital emergency classification system was developed with the assistance of the Oklahoma State Trauma Advisory Council, Oklahoma Emergency Response Systems Development Advisory Council, and numerous industry and professional associations. The classification system was promulgated in rule as Subchapter 59 of Chapter 667 Hospital Standards and became effective on July 13, 2000. By May 2001, each hospital in the State that offers emergency services had received an on-site visit by OSDH representatives to verify the level of service provided in each clinical category. In an effort to facilitate proper treatment of strokes, Governor Brad Henry signed the Oklahoma Administrative Code, Title 310, Chapter 667 Hospital Standards in 2009, which established classification standards for "Primary Stroke Centers" and "Secondary Stroke Facilities." These standards are intended to stratify hospitals into those hospitals willing and able to administer a federal Food and Drug Administration approved intravenous thrombolytic agent to appropriate patients within one hour of arriving at the emergency department and within three hours of the onset of ischemic stroke symptoms. A Primary Stroke Center shall provide emergency medical services with an organized emergency department. A physician shall be on call and immediately available to respond to the emergency department and nursing staff with special capability in emergent stroke care shall be on site twenty-four hours a day. A Secondary Stroke Facility shall provide services with at least a licensed independent practitioner, registered nurse, licensed practical nurse, or intermediate or paramedic level emergency medical technician on site twenty-four hours a day. Complete hospital standards of the rules can be found in OAC 310:667- 59-20.1 Those hospitals that are not able or choose not to provide this therapeutic intervention for stroke are classified as a Secondary Stroke Facility. 1 OSDH link. Oklahoma Hospital Annual Report 2009 9 Emergency Systems In August 2009, the Emergency Medical Services (EMS) Division and Trauma Division reorganized into a single work unit, Emergency Systems. The rationale for the consolidation of these areas into a single work unit includes: maximizing staff resources while achieving common goals in emergency system development, aligning and streamlining fiscal processes for the disbursements of the Oklahoma Emergency Response Systems Stabilization and Improvement Revolving Fund and the Trauma Care Assistance Revolving, and for further development of systems of care for patients with time-sensitive trauma and medical emergency conditions. Statistics at a Glance Fiscal Year 2009 152 Licensed Hospitals currently in operation: 97 General Medical Surgical Hospitals 35 Critical Access Hospitals 11 Specialized Hospitals, Psychiatric 6 Specialized Hospitals, Rehabilitation 3 Specialized Hospitals, Abortion Facility 115 Medicare Certification Surveys performed: 25 Re-certification surveys 1 Follow-up Surveys 57 Complaint Investigations 1 Validation Survey 0 Initial Surveys 26 Life Safety 35 Licensure Surveys performed, including: 28 Re-licensure Surveys 0 Follow-up Surveys 4 Complaint Investigations 3 Initial Surveys $163,020.00 Fees collected (Note: The total dollar amount of fee collections shown above includes the fees for the Ambulatory Surgical Centers, Birthing Centers, and Workplace Drug and Alcohol Testing Facilities program areas.) Oklahoma Hospital Annual Report 2009 10 Hospital Advisory Council The Hospital Advisory Council is authorized by Oklahoma Statute (63 O.S., Section 1-707) to serve as an advisory body to the Board of Health, Commissioner and Department. The Advisory Council is composed of nine members appointed by the Commissioner with the advice and consent of the Board of Health. The membership of the Advisory Council is a follows: two members are hospital administrators of licensed hospitals; two members are licensed physicians or practitioners who have current privileges to provide services in hospitals; two members are hospital employees; and three members are citizens representing the public who: are not hospital employees, do not hold hospital staff appointments, and are not members of hospital governing boards. Members are appointed for a three-year term. The Board must meet at least quarterly, and may hold such special meetings as may be necessary. Advisory Board Members: Dale Bratzler, D.O., Chair Gloria Caldwell Nancy Cooper, MS, ARNP Starla Givens, R.N. Gary W. Mitchell, D.Ph. FACHE Ken Rose, Ed. D. Betty Selby Dale Harris 1 Vacancy Authority The Advisory Council has the duty and authority to: (1) review and approve in its advisory capacity rules and standards for hospital licensure; (2) evaluate, review and make recommendations regarding Department licensure activities, provided, however, the Advisory Council shall not make recommendations regarding scope of practice for any health care providers or practitioners regulated pursuant to Title 59 of the Oklahoma Statues, and (3) recommended and approve: quality indicators and data submission requirements for hospitals, to include: Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators available as part of the standard inpatient discharge data set, and for acute care intensive care patients ventilator associated pneumonia and device –related blood stream infections, and the indicators and data to be used by the Department to monitor compliance with licensure requirements and to publish an annual report of hospital performance to include the facility specific quality indicators required by this section. The Council has recommended the Department designate the National Healthcare Safety Network, supported by the Centers for Disease Control and Prevention, as the data collection and analysis tool licensed hospitals shall use for public reporting purposes. Oklahoma Hospital Annual Report 2009 11 Public Reporting The Oklahoma Hospital Annual Report 2009 is a publication required by statute at 63 O.S., Section 1-707. This report is intended to increase the availability of quality data related to hospital services and to improve patient care in Oklahoma. The annual report displays hospital-specific quality indicators and a brief outline of services provided by the Medical Facilities Service of the Oklahoma State Department of Health. There are three sources for the data included in this report: 1. Detailed hospital-specific performance measures outlined by the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators for care provided during the 2007 calendar year. These measures are calculated from the standard hospital discharge data set reported to the OSDH Health Care Information Division 2. The National Healthcare Safety Network (NHSN) data system. NHSN is a secure, internet-based surveillance system that integrates patient and healthcare personnel safety surveillance systems data and is managed by the Division of Healthcare Quality Promotion (DHQP) at the Centers for Disease Control and Prevention (CDC). In July 2008 Hospital Infection Preventionist in Oklahoma began collecting and reporting data for events related to central line associated bloodstream infections (CLABSI) and ventilator associated pneumonias (VAP). Adult patients in an Intensive Care Unit (ICU) who were on a ventilator or who had at least one central line inserted who subsequently develop an infection meeting the strict case definition criteria defined by CDC are reported to NHSN. 3. Hospital Compare. The Hospital Compare website is maintained by The Centers for Medicare & Medicaid Services (CMS) and the Hospital Quality Alliance (HQA). The nation's hospitals are working together to create and publicly report hospital quality information as related to care. This information measures how well hospitals care for their patients, whether the care was paid for by Medicare, Medicaid, or a private health insurance plan. Oklahoma Hospital Annual Report 2009 12 (This page left blank) Oklahoma Hospital Annual Report 2009 13 Patient Safety Indicators The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators are measures used to screen for adverse events that patients experience as a result of exposure to the health care system; these events are likely amenable to prevention by changes at the system or provider level. The Patient Safety Indicators (PSIs) are used with the hospital inpatient discharge data, which is uploaded to the Oklahoma State Department of Health annually. Improving patient safety is a critical part of efforts to provide high quality healthcare in Oklahoma. This report is intended to facilitate such efforts. Comparative reporting of hospital performance data is encouraged by the Agency for Healthcare Research and Quality (AHRQ). AHRQ considers comparative reporting an important strategy to advance the quality improvement agenda in healthcare. Public reporting has been supportive evidence that comparative performance data by hospital is a key element that promotes enhanced patient care. AHRQ is an active participant and works closely with the Hospital Quality Alliance (HQA), the Ambulatory Care Quality Alliance (AQA) alliance, the National Quality Forum (NQF) and others. The combined effort in comparative reporting AHRQ Quality Indicators are submitted to the National Quality Forum endorsement process. Based on an extensive analysis of each indicator by these partners, NQF has determined the appropriateness of each indicator for comparative reporting. For the purpose of this report only the indicators classified as Tier 1 will be reported. Tier 1 has the strongest evidence base, with established evidence in several or most evidentiary areas and no substantial evidence suggesting that the indicator may not be useful for comparative reporting. Additional data from Tier 1 B will also be reported as these events are serious reportable events but may not be as useful for hospital comparison. 2 The PSIs are a set of measures that can be used with hospital inpatient discharge administrative data to provide perspective on patient safety. This data is taken from the medical record billing ICD-9 codes. Specifically, PSIs screen for problems that patients experience as a result of exposure to the healthcare system and that are likely amenable to prevention by changes at the healthcare system (hospital) or provider level. These are referred to as complications or adverse events. PSIs are defined for this report as Provider level Indicators. Provider level Indicators provide a measure of the potentially preventable complication for patients who received their initial care and the complication of care within the same hospitalization. Provider level Indicators include only those cases where a secondary diagnosis code 2 AHRQ Quality Indications, Guidance on Using the AHRQ QI” for Hospital-Level Comparative Reporting , June 2009. Oklahoma Hospital Annual Report 2009 14 flags a potentially preventable complication. Detailed information on the methods of identifying, selecting and evaluating these quality indicators can be found at the AHRQ Quality Indicator Web Site: http://www.qualityindicators.ahrq.gov Limitations Because of limitations related to the use of administrative data, many important concerns and potentially confounding factors cannot currently be monitored, such as adverse drug events. Using this data tends to favor specific types of indicators. The PSIs mainly focus on surgical indicators rather than medical or psychiatric conditions because medical complications are often difficult to distinguish from co-morbidities that are present on admission. However, the careful use of administrative data holds promise for screening to target further data collection analysis. In small hospitals, the mathematical formula may be difficult to compute due to sample size or the number of patients (denominator) who have had the procedures. Therefore charts in this report are noted to reflect when the denominator for the specific indicator is less than ideal, because the true population at risk could not be identified from the discharge data. Data Charts The hospitals are grouped into peer groups by hospital state licensure and the number of licensed beds. Some hospitals may not be represented since the data is representative of 2007; hospital ownership may have changed or a hospital may have closed since the data was collected. Also, the numbers represented on the charts are the number of patients affected for an event per 1000 patient discharges or with PSI # 17 through 19, it would be per 1000 live births. Therefore the lower the bar is on the chart the fewer events have occurred which is a favorable representation. The ultimate goal is to have zero events for each of the Patient Safety Indicators. It is also important to note that if a hospital does not have incidents of the event, then no data is reported and the name of the hospital maybe displayed without a bar on the chart. If a peer group of hospitals does not have data for a specific PSI, a chart may not be displayed. Oklahoma Hospital Annual Report 2009 15 Long Term Acute Care Hospitals Long Term Acute Care Hospitals (LTCH) are designed to provide extended medical and rehabilitative care for patients who are clinically complex and have multiple acute or chronic conditions. These hospitals are licensed in Oklahoma as Acute Care Hospitals and are ranked in this report with hospitals of similar bed size; however the patients within these facilities may be more acutely ill. Most patients in LTCHs have several diagnosis codes on their Medicare claims, which indicate that they have multiple co-morbidities and are probably less stable on admission than patients admitted to other post-acute care settings (Prospective Payment Assessment Commission, 1996). Approximately one-half of the patients have five or more diagnoses noted on their claims. LTCHs generally provide a range of services, including comprehensive rehabilitation, cancer treatment, head trauma treatment, and pain management (Medicare Payment Advisory Commission, 1998b). The typical Medicare patient in a LTCH is admitted following an acute care hospital stay. As of 1997, about 200 facilities were certified by Medicare as LTCHs. For the purposes of this report, data maybe reported that appears to fall beyond expected limits due to the small number of patients in the sample many of whom also have complex conditions that result in less than optimal outcomes. The following facilities are designated as LTCH by the Centers for Medicare & Medicaid Services (CMS): Continuous Care Center of Bartlesville Continuous Care Center of Tulsa Edmond Specialty Hospital Integris Bass Pavilion Kindred Hospital Lane Frost Health and Rehabilitation Center Meadowbrook Specialty Hospital of Tulsa Norman Specialty Hospital Select Specialty Hospital – Oklahoma City Select Specialty Hospital – Tulsa/Midtown Solara Hospital Muskogee Solara Hospital Shawnee Specialty Hospital of Midwest City Oklahoma Hospital Annual Report 2009 16 AHRQ Tier 1 Patient Safety Indicators (PSI) in this tier has the strongest evidence base. The National Quality Forum has endorsed these indicators. The following PSIs are included in Tier 1: PSI #04 Death among Surgical In-patients with Treatable Serious Complications PSI #06 Iatrogenic Pneumothorax PSI #11 Postoperative Respiratory Failure PSI #12 Postoperative Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE) PSI #14 Postoperative Wound Dehiscence PSI #15 Accidental Puncture or Laceration PSI #17 Birth Trauma PSI #18 OB Trauma-Vaginal Delivery with Instrument-assisted Delivery PSI #19 OB Trauma-Vaginal Delivery without Instrument-assisted Delivery Oklahoma Hospital Annual Report 2009 17 PSI 4 Deaths among Surgical Inpatients with Treatable Serious Complications Description: Rate of in-hospital death per 1000 surgical discharges, defined by specific Diagnosis Related Group codes and an ICD-9-CM code of major operating room procedure in any procedure field, age 18 years and older and with a principal procedure within 2 days of admission OR admission type of elective and with an ICD-9-CM code of potential complications of care (e.g., pneumonia, DVT/PE, sepsis, shock/cardiac arrest, or GI hemorrhage/acute ulcer) in any secondary diagnosis field. HealthGrades translated as ability to diagnose and treat in time.3 Critical Access Hospitals and Less than 50 Beds 3 HealthGrades Guiding America to Better Healthcare. Copyrighted 2009 Health Grades. Inc. - 100.00 200.00 300.00 400.00 500.00 600.00 Arbuckle Memorial Hospital Atoka Memorial Hospital Beaver County Memorial … Bristow Medical Center Carnegie Tri-County … Cimarron Memorial Hospital … Cleveland Area Hospital Cordell Memorial Hospital Fairfax Memorial Hospital Inc. Fairview Hospital Harmon Memorial Hospital Harper County Community … Healdton Municipal Hospital Holdenville General Hospital Integris Marshall Memorial … Jane Phillips Nowata Health … Jefferson County Hospital Johnston Memorial Hospital Kingfisher Regional Hospital Logan Medical Center Quartz Mountain Medical … Mary Hurley Hospital Mercy Health Love County Okeene Municipal Hospital Pawhuska Hospital, Inc. Physicians Hospital of … Prague Municipal Hospital Roger Mills Memorial Hospital Seiling Municipal Hospital St. John Sapulpa (AKA Bartlett) Stroud Regional Medical … Watonga Municipal Hospital Weatherford Regional Hospital Drumright Regional Hospital Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 18 PSI 4 Deaths among Surgical Inpatients with Treatable Serious Complications Medical Surgical Hospitals Licensed for less than 50 Beds Medical Surgical Hospitals Licensed for 50 to 99 Beds **Charts represent hospitals licensed as Acute Care Hospitals and may also be CMS Long-Term Acute Care Hospitals - 50.00 100.00 150.00 200.00 250.00 Choctaw Memorial Hospital Community Hospital Continuous Care Center of … Continuous Care Center of … Eastern Oklahoma Medical … Elkview General Hospital Foundation Bariatric Hospital … Haskell County Hospital Henryetta Medical Center Integris Bass Pavilion Integris Canadian Valley … Lakeside Women's Hospital Latimer County General … Lindsay Municipal Hospital Memorial Hospital & … Memorial Hospital of Texas … Northwest Surgical Hospital Oklahoma Center for … Oklahoma NeuroSpecialty … Oklahoma Spine Hospital, L.L.C. Orthopedic Hospital Park View Hospital Perry Memorial Center Purcell Municipal Hospital Pushmataha Hospital Sayre Memorial Hospital Sequoyah Memorial Hospital Share Memorial Hospital Solora Hospital Muskogee St John Owasso Surgical Hospital of … Tulsa Spine Hospital EPIC Medical Center Southwestern Regional … Solara Hospital Shawnee Hospital Rate State Rate - 50.00 100.00 150.00 200.00 250.00 300.00 350.00 Bailey Medical Center Claremore Regional Hospital Craig General Hospital Cushing Regional Hospital Grady Memorial Hospital Great Plains Regional Medical … Integris Blackwell Regional … Integris Clinton Regional … Integris Grove General Hospital Integris Mayes County … Memorial Hospital of Stilwell Newman Memorial Hospital Okmulgee Memorial Hospital Pauls Valley General Hospital Saint Francis Hospital South McBride Clinic Orthopedic … Oklahoma Surgical Hospital Edmond Medical Center Oklahoma Heart Hospital Select Specialty Hospital-… Select Specialty Hospital, Tulsa Woodward Regional Hospital Norman Specialty Hospital Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 19 PSI 4 Deaths among Surgical Inpatients with Treatable Serious Complications Medical Surgical Hospitals Licensed 100 to 249 Beds Medical Surgical Hospitals Licensed 250 to 499 Beds - 50.00 100.00 150.00 200.00 250.00 300.00 350.00 400.00 Integris Baptist Regional … McCurtain Memorial Hospital Medical Center of … OSU Medical Center Ponca City Medical Center St. Mary's Regional Medical … Unity Health Center Wagoner Community Hospital Duncan Regional Hospital, Inc. McAlester Regional Health … Mercy Memorial Health … Jackson County Memorial … SouthCrest Hospital Stillwater Medical Center Southwestern Medical Center Tahlequah City Hospital Integris Bass Baptist Health … Valley View Regional Hospital Jane Phillips Medical Center Hospital Rate State Rate - 50.00 100.00 150.00 200.00 250.00 Integris Southwest Medical Center of OK Mercy Health Center, Inc. Midwest Regional Medical Center Muskogee Regional Medical Center Deaconess Hospital Comanche County Memorial Hospital Hospital Rate State Rate T Oklahoma Hospital Annual Report 2009 20 PSI 4 Deaths among Surgical Inpatients with Treatable Serious Complications Medical Surgical Hospitals Licensed over 500 Beds Rehabilitation Hospitals - 50.00 100.00 150.00 200.00 250.00 Hillcrest Medical Center St. Anthony Hospital OU Medical Center Saint Francis Hospital, Inc. St. John Medical Center, Inc. Norman Regional Hospital Integris Baptist Medical Center, Inc. Hospital Rate State Rate - 100.00 200.00 300.00 400.00 500.00 600.00 Edmond Specialty Hospital George Nigh Rehabilitation Institute Hillcrest Specialty Hospital J. D. McCarty Center for Children with Developmental Disabil Specialty Hospital of Midwest City Valir Rehabilitation Hospital of OKC, LLC Lane Frost Health and Rehabilitation Center Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 21 PSI 6 Iatrogenic Pneumothorax Description: Rate of discharges with an ICD-9-CM code of iatrogenic pneumothorax in any secondary diagnosis field (not present on admission) among surgical and medical discharges, defined by specific DRG codes, age 18 years and older. An adverse condition caused by treatment by any health professional where a leak in the lung causes air to accumulate in the space around the lung (pleural cavity). This prevents the lung from expanding fully and hence a partial lung collapse occurs. For example, a doctor may accidentally puncture the lung during a surgical operation. This indicator is intended to flag cases of pneumothorax caused by medical care. Iatrogenic pneumothorax excludes all trauma patients because these patients may be more susceptible to non-preventable iatrogenic pneumothorax or may be miscoded for traumatic pneumothorax. Critical Access Hospitals and Less than 50 Beds - 1.00 2.00 3.00 4.00 5.00 6.00 7.00 Arbuckle Memorial Hospital Atoka Memorial Hospital Bristow Medical Center Carnegie Tri-County … Cimarron Memorial Hospital … Cleveland Area Hospital Cordell Memorial Hospital Drumright Regional Hospital Fairfax Memorial Hospital Inc. Fairview Hospital Harmon Memorial Hospital Harper County Community … Healdton Municipal Hospital Holdenville General Hospital Integris Marshall Memorial … Jane Phillips Nowata Health … Jefferson County Hospital Johnston Memorial Hospital Kingfisher Regional Hospital Logan Medical Center Quartz Mountain Medical … Mary Hurley Hospital Mercy Health Love County Okeene Municipal Hospital Pawhuska Hospital, Inc. Physicians Hospital of … Prague Municipal Hospital Roger Mills Memorial Hospital Seiling Municipal Hospital St. John Sapulpa (AKA Bartlett) Stroud Regional Medical … Watonga Municipal Hospital Weatherford Regional Hospital Beaver County Memorial … Hosp Rate State Rate Oklahoma Hospital Annual Report 2009 22 PSI 6 Iatrogenic Pneumothorax Medical Surgical Hospitals Licensed for less than 50 Beds Medical Surgical Hospitals Licensed for 50 to 99 Beds **Charts represent hospitals licensed as Acute Care Hospitals and may also be CMS Long-Term Acute Care Hospitals - 1.00 2.00 3.00 4.00 5.00 6.00 7.00 Choctaw Memorial Hospital Eastern Oklahoma Medical … Elkview General Hospital Foundation Bariatric Hospital … Haskell County Hospital Henryetta Medical Center Integris Bass Pavilion Integris Canadian Valley … Lakeside Women's Hospital Latimer County General … Lindsay Municipal Hospital Memorial Hospital & … Memorial Hospital of Texas … Northwest Surgical Hospital Oklahoma Center for … Oklahoma NeuroSpecialty … Oklahoma Spine Hospital, L.L.C. Orthopedic Hospital Park View Hospital Perry Memorial Hospital Purcell Municipal Hospital Pushmataha Hospital Sayre Memorial Hospital Sequoyah Memorial Hospital Share Memorial Hospital Solara Hospital Shawnee Solora Hospital Muskogee St John Owasso Surgical Hospital of … Tulsa Spine Hospital EPIC Medical Center Community Hospital Continuous Care Center of … Southwestern Regional … Continuous Care Center of … Hospital Rate State Rate - 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 Claremore Regional Hospital Craig General Hospital Cushing Regional Hospital Edmond Medical Center Great Plains Regional Medical … Integris Blackwell Regional … Integris Clinton Regional … Integris Mayes County … McBride Clinic Orthopedic … Meadow Brook Specialty … Memorial Hospital of Stilwell Newman Memorial Hospital Oklahoma Surgical Hospital Okmulgee Memorial Hospital Pauls Valley General Hospital Select Specialty Hospital, Tulsa Woodward Regional Hospital Integris Grove General Hospital Grady Memorial Hospital Saint Francis Hospital South Bailey Medical Center Select Specialty Hospital-… Norman Specialty Hospital Oklahoma Heart Hospital Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 23 PSI 6 Iatrogenic Pneumothorax Medical Surgical Hospitals Licensed for 100 to 249 Beds Medical Surgical Hospitals Licensed for 250 to 499 Beds - 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 1.80 2.00 Integris Baptist Regional … McCurtain Memorial Hospital Stillwater Medical Center Valley View Regional Hospital Wagoner Community Hospital Medical Center of … St. Mary's Regional Medical … McAlester Regional Health … Integris Bass Baptist Health … Ponca City Medical Center Jackson County Memorial … SouthCrest Hospital Mercy Memorial Health … Southwestern Medical Center Duncan Regional Hospital, Inc. Jane Phillips Medical Center Unity Health Center OSU Medical Center Tahlequah City Hospital Hospital Rate State Rate - 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 Mercy Health Center, Inc. Integris Southwest Medical Center of OK Muskogee Regional Medical Center Midwest Regional Medical Center Deaconess Hospital Comanche County Memorial Hospital Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 24 PSI 6 Iatrogenic Pneumothorax Medical Surgical Hospitals Licensed for over 500 Beds Rehabilitation Hospitals - 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 1.80 St. Anthony Hospital Norman Regional Hospital Integris Baptist Medical Center, Inc. Hillcrest Medical Center St. John Medical Center, Inc. Saint Francis Hospital, Inc. OU Medical Center Hospital Rate State Rate - 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 Edmond Specialty Hospital George Nigh Rehabilitation Institute J. D. McCarty Center for Children with Developmental Disabil Lane Frost Health and Rehabilitation Center Valir Rehabilitation Hospital of OKC, LLC Hillcrest Specialty Hospital Specialty Hospital of Midwest City Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 25 PSI 11 Postoperative Respiratory Failure Description: Rate of discharges with an ICD-9-CM code of acute respiratory failure in any secondary diagnosis field (not present on admission) or an ICD-9-CM code for re-intubation procedure in any procedure field that is zero, one or two or more days after the major operating room procedure (depending on the code) among elective surgical discharges, defined by specific DRG codes and an ICD-9-CM code of major operating room procedure in any procedure field, age 18 and older. The goal is to avoid respiratory failure following a surgery procedure. Medical Surgical Hospitals Licensed for less than 50 Beds **Charts represent hospitals licensed as Acute Care Hospitals and may also be CMS Long-Term Acute Care Hospitals - 50.00 100.00 150.00 200.00 250.00 Choctaw Memorial Hospital Elkview General Hospital Foundation Bariatric Hospital … Haskell County Hospital Lakeside Women's Hospital Lindsay Municipal Hospital Northwest Surgical Hospital Oklahoma Center for … Oklahoma Spine Hospital, L.L.C. Orthopedic Hospital Park View Hospital Perry Memorial Hospital Purcell Municipal Hospital Sayre Memorial Hospital Solora Hospital Muskogee St John Owasso Surgical Hospital of … Tulsa Spine Hospital Continuous Care Center of … Continuous Care Center of … Latimer County General … Memorial Hospital & … Oklahoma NeuroSpecialty … Pushmataha Hospital Sequoyah Memorial Hospital Share Memorial Hospital EPIC Medical Center Community Hospital Integris Canadian Valley … Henryetta Medical Center Southwestern Regional … Memorial Hospital of Texas … Eastern Oklahoma Medical … Solara Hospital Shawnee Integris Bass Pavilion Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 26 PSI 11 Postoperative Respiratory Failure Medical Surgical Hospitals Licensed for 50 to 99 Beds Medical Surgical Hospitals Licensed for100 to 249 Beds **Charts represent hospitals licensed as Acute Care Hospitals and may also be CMS Long-Term Acute Care Hospitals - 20.00 40.00 60.00 80.00 100.00 120.00 140.00 Claremore Regional Hospital Craig General Hospital Grady Memorial Hospital Integris Blackwell Regional … Integris Clinton Regional … Integris Mayes County … McBride Clinic Orthopedic … Meadow Brook Specialty … Memorial Hospital of Stilwell Newman Memorial Hospital Okmulgee Memorial Hospital Pauls Valley General Hospital Oklahoma Surgical Hospital Oklahoma Heart Hospital Great Plains Regional … Edmond Medical Center Saint Francis Hospital South Woodward Regional Hospital Cushing Regional Hospital Integris Grove General … Bailey Medical Center Norman Specialty Hospital Select Specialty Hospital-… Select Specialty Hospital, Tulsa Hospital rate State Rate - 5.00 10.00 15.00 20.00 25.00 30.00 35.00 Ponca City Medical Center McCurtain Memorial … Medical Center of … OSU Medical Center Wagoner Community … Stillwater Medical Center Southwestern Medical … Jackson County Memorial … St. Mary's Regional … Unity Health Center Jane Phillips Medical Center McAlester Regional Health … Duncan Regional Hospital, … Mercy Memorial Health … Tahlequah City Hospital Integris Baptist Regional … Valley View Regional … SouthCrest Hospital Integris Bass Baptist … Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 27 PSI 11 Postoperative Respiratory Failure Medical Surgical Hospitals Licensed for 250 to 499 Beds Medical Surgical Hospitals Licensed for over 500 Beds T - 5.00 10.00 15.00 20.00 25.00 30.00 35.00 St. John Medical Center, Inc. Saint Francis Hospital, Inc. St. Anthony Hospital Norman Regional Hospital OU Medical Center Integris Baptist Medical Center, Inc. Hillcrest Medical Center Hospital Rate State Rate - 5.00 10.00 15.00 20.00 25.00 30.00 35.00 St. John Medical Center, Inc. Saint Francis Hospital, Inc. St. Anthony Hospital Norman Regional Hospital OU Medical Center Integris Baptist Medical Center, Inc. Hillcrest Medical Center Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 28 (This page left blank) Oklahoma Hospital Annual Report 2009 29 PSI 12 Postoperative Pulmonary Embolism or Deep Vein Thrombosis Description: Rate of discharges with an ICD-9-CM code of deep vein thrombosis or pulmonary embolism in any secondary diagnosis field (not present on admission) among surgical discharges, defined by specific DRG codes and an ICD-9-CM code of major operating room procedure in any procedure field, age 18 and older. Deep vein thrombosis is a blood clot in a deep vein. The blood clot commonly occurs in the deeper veins in the thigh or calf, but may occur in the deep veins of the arms. A blood clot is also called a thrombus. The condition can be very painful and can lead to serious complications. Pulmonary embolism is a blocked lung blood vessel often from a blood clot. This indicator is intended to capture cases of postoperative venous thromboses and embolism – specifically, pulmonary embolism and deep venous thrombosis. It further excludes patients who have principal diagnosis of deep vein thrombosis, as these patients are likely to have a pulmonary embolism/deep vein thrombosis present on admission. Medical Surgical Hospitals Licensed for less than 50 Beds **Charts represent hospitals licensed as Acute Care Hospitals and may also be CMS Long-Term Acute Care Hospitals - 20.00 40.00 60.00 80.00 100.00 120.00 140.00 Choctaw Memorial Hospital Eastern Oklahoma Medical … Elkview General Hospital Foundation Bariatric … Haskell County Hospital Integris Bass Pavilion Lakeside Women's Hospital Lindsay Municipal Hospital Memorial Hospital & … Memorial Hospital of Texas … Northwest Surgical Hospital Oklahoma Center for … Park View Hospital Purcell Municipal Hospital Sayre Memorial Hospital Solora Hospital Muskogee St John Owasso Surgical Hospital of … EPIC Medical Center Latimer County General … Oklahoma NeuroSpecialty … Perry Memorial Hospital Sequoyah Memorial Hospital Oklahoma Spine Hospital, … Tulsa Spine Hospital Community Hospital Integris Canadian Valley … Orthopedic Hospital Henryetta Medical Center Solara Hospital Shawnee Pushmataha Hospital Continuous Care Center of … Share Memorial Hospital Southwestern Regional … Continuous Care Center of … Hospital Rate Oklahoma Hospital Annual Report 2009 30 PSI 12 Postoperative Pulmonary Embolism or Deep Vein Thrombosis Medical Surgical Hospitals Licensed for 50 to 99 Beds Medical Surgical Hospitals Licensed for 100 to 249 Beds - 10.00 20.00 30.00 40.00 50.00 60.00 70.00 80.00 Claremore Regional Hospital Great Plains Regional … Integris Blackwell Regional … Integris Clinton Regional … Integris Mayes County … Memorial Hospital of Stilwell Newman Memorial Hospital Pauls Valley General Hospital Oklahoma Surgical Hospital Saint Francis Hospital South Bailey Medical Center Cushing Regional Hospital Integris Grove General … Okmulgee Memorial Hospital Woodward Regional Hospital McBride Clinic Orthopedic … Oklahoma Heart Hospital Grady Memorial Hospital Edmond Medical Center Craig General Hospital Norman Specialty Hospital Select Specialty Hospital, … Meadow Brook specialty … Select Specialty Hospital-… Hospital Rate State Rate - 2.00 4.00 6.00 8.00 10.00 12.00 14.00 16.00 18.00 McCurtain Memorial Hospital Wagoner Community Hospital McAlester Regional Health … Unity Health Center Southwestern Medical Center Jackson County Memorial … Valley View Regional Hospital Jane Phillips Medical Center Duncan Regional Hospital, Inc. Tahlequah City Hospital Medical Center of … St. Mary's Regional Medical … Stillwater Medical Center Mercy Memorial Health … SouthCrest Hospital Ponca City Medical Center Integris Baptist Regional … OSU Medical Center Integris Bass Baptist Health … Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 31 PSI 12 Postoperative Pulmonary Embolism or Deep Vein Thrombosis Medical Surgical Hospitals Licensed for 250 to 499 Beds Medical Surgical Hospitals Licensed for over 500 Beds T - 5.00 10.00 15.00 20.00 25.00 30.00 35.00 40.00 St. Anthony Hospital Norman Regional Hospital Hillcrest Medical Center St. John Medical Center, Inc. Integris Baptist Medical Center, Inc. Saint Francis Hospital, Inc. OU Medical Center Hospital Rate State Rate - 5.00 10.00 15.00 20.00 25.00 30.00 35.00 40.00 St. Anthony Hospital Norman Regional Hospital Hillcrest Medical Center St. John Medical Center, Inc. Integris Baptist Medical Center, Inc. Saint Francis Hospital, Inc. OU Medical Center Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 32 PSI 12 Postoperative Pulmonary Embolism or Deep Vein Thrombosis Rehabilitation Hospitals - 20.00 40.00 60.00 80.00 100.00 120.00 J. D. McCarty Center for Children with Developmental Disabil Valir Rehabilitation Hospital of OKC, LLC Edmond Specialty Hospital George Nigh Rehabilitation Institute Specialty Hospital of Midwest City Hillcrest Specialty Hospital Lane Frost Health and Rehabilitation Center Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 33 PSI 14 Postoperative Wound Dehiscence Description: Rate of discharges with an ICD-9-CM code of reclosure of postoperative disruption of abdominal wall in any procedure field among abdominopelvic surgical discharges, defined by specific ICD-9-CM codes, age 18 and older. Wound dehiscence is the parting of the layers of a surgical wound. This indicator is intended to flag cases of wound dehiscence in patients who have undergone abdominal and pelvic surgery. Critical Access Hospitals and Less than 50 Beds - 10.00 20.00 30.00 40.00 50.00 60.00 70.00 80.00 90.00 Drumright Regional Hospital Fairfax Memorial Hospital Inc. Holdenville General Hospital Integris Marshall Memorial … Kingfisher Regional Hospital Logan Medical Center Pawhuska Hospital, Inc. Physicians Hospital of … St. John Sapulpa (AKA Bartlett) Stroud Regional Medical … Weatherford Regional … Arbuckle Memorial Hospital Atoka Memorial Hospital Beaver County Memorial … Bristow Medical Center Carnegie Tri-County … Cimarron Memorial Hospital … Cleveland Area Hospital Cordell Memorial Hospital Fairview Hospital Harmon Memorial Hospital Harper County Community … Healdton Municipal Hospital Jane Phillips Nowata Health … Jefferson County Hospital Johnston Memorial Hospital Quartz Mountain Medical … Mary Hurley Hospital Mercy Health Love County Prague Municipal Hospital Roger Mills Memorial Hospital Seiling Municipal Hospital Watonga Municipal Hospital Okeene Municipal Hospital Hosp Rate State Rate Oklahoma Hospital Annual Report 2009 34 PSI 14 Postoperative Wound Dehiscence Medical Surgical Hospitals Licensed for 100 to 249 Beds Medical Surgical Hospitals Licensed for 250 to 499 Beds - 2.00 4.00 6.00 8.00 10.00 12.00 14.00 Wagoner Community Hospital Integris Bass Baptist Health … Jackson County Memorial … McCurtain Memorial Hospital Mercy Memorial Health … Ponca City Medical Center SouthCrest Hospital Southwestern Medical Center St. Mary's Regional Medical … Stillwater Medical Center Tahlequah City Hospital Valley View Regional Hospital McAlester Regional Health … Duncan Regional Hospital, Inc. Unity Health Center Medical Center of … OSU Medical Center Jane Phillips Medical Center Integris Baptist Regional … Hospital Rate State Rate T - 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 Muskogee Regional Medical Center Midwest Regional Medical Center Deaconess Hospital Comanche County Memorial Hospital Integris Southwest Medical Center of OK Mercy Health Center, Inc. Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 35 PSI 14 Postoperative Wound Dehiscence Medical Surgical Hospitals Licensed for over 500 Beds - 1.00 2.00 3.00 4.00 5.00 6.00 Hillcres t Medic… OU Medical Center Saint Francis Hospi… Norma n Regio… St. John Medical Cente… Integris Baptist Medic… St. Anthon y … Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 36 (This page left blank) Oklahoma Hospital Annual Report 2009 37 PSI 15 Accidental Puncture or Laceration Description: Rate of discharges with an ICD-9-CM code of accidental cut, puncture, perforation or laceration during a procedure in any secondary diagnosis field (not present on admission) among surgical and medical discharges, defined by specific DRG codes, age 18 years and older. The event is an accidental cut or laceration, which occurred during a hospital stay while receiving medical care. This indicator is intended to flag cases of complications that arise due to technical difficulties in medical care – specifically, those involving an accidental puncture or laceration. Critical Access Hospitals and Less than 50 Beds - 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 Arbuckle Memorial Hospital Atoka Memorial Hospital Beaver County Memorial … Bristow Medical Center Carnegie Tri-County … Cimarron Memorial Hospital … Cleveland Area Hospital Cordell Memorial Hospital Fairview Hospital Harmon Memorial Hospital Harper County Community … Healdton Municipal Hospital Holdenville General Hospital Integris Marshall Memorial … Jane Phillips Nowata Health … Jefferson County Hospital Johnston Memorial Hospital Quartz Mountain Medical … Mary Hurley Hospital Mercy Health Love County Okeene Municipal Hospital Pawhuska Hospital, Inc. Physicians Hospital of … Prague Municipal Hospital Roger Mills Memorial Hospital Seiling Municipal Hospital St. John Sapulpa (AKA Bartlett) Stroud Regional Medical … Watonga Municipal Hospital Weatherford Regional … Kingfisher Regional Hospital Logan Medical Center Drumright Regional Hospital Fairfax Memorial Hospital Inc. Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 38 PSI 15 Accidental Puncture or Laceration Medical Surgical Hospitals Licensed for less than 50 Beds Medical Surgical Hospitals Licensed for 50 to 99 Beds **Charts represent hospitals licensed as Acute Care Hospitals and may also be CMS Long-Term Acute Care Hospitals - 5.00 10.00 15.00 20.00 25.00 30.00 Choctaw Memorial Hospital Continuous Care Center of … Continuous Care Center of … Eastern Oklahoma Medical … Henryetta Medical Center Integris Bass Pavilion Latimer County General … Lindsay Municipal Hospital Memorial Hospital & … Oklahoma NeuroSpecialty … Orthopedic Hospital Purcell Municipal Hospital Pushmataha Hospital Sayre Memorial Hospital Sequoyah Memorial Hospital Share Memorial Hospital Solora Hospital Muskogee Surgical Hospital of … Perry Memorial Hospital EPIC Medical Center Park View Hospital Elkview General Hospital Memorial Hospital of Texas … St John Owasso Haskell County Hospital Southwestern Regional … Integris Canadian Valley … Tulsa Spine Hospital Solara Hospital Shawnee Northwest Surgical Hospital Oklahoma Center for … Community Hospital Lakeside Women's Hospital Oklahoma Spine Hospital, … Foundation Bariatric … Hospital Rate State Rate - 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 Craig General Hospital Integris Clinton Regional … Norman Specialty Hospital Okmulgee Memorial Hospital Pauls Valley General Hospital Select Specialty Hospital, … Meadow Brook Specialty … Select Specialty Hospital-… Cushing Regional Hospital McBride Clinic Orthopedic … Great Plains Regional … Integris Blackwell Regional … Memorial Hospital of Stilwell Newman Memorial Hospital Saint Francis Hospital South Claremore Regional Hospital Integris Mayes County … Integris Grove General … Oklahoma Heart Hospital Edmond Medical Center Grady Memorial Hospital Oklahoma Surgical Hospital Woodward Regional Hospital Bailey Medical Center Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 39 PSI 15 Accidental Puncture or Laceration Medical Surgical Hospitals Licensed for 100 to 249 Beds Medical Surgical Hospitals Licensed for 250 to 499 Beds - 1.00 2.00 3.00 4.00 5.00 6.00 Wagoner Community Hospital Medical Center of … McCurtain Memorial Hospital Unity Health Center Valley View Regional Hospital Jackson County Memorial … Ponca City Medical Center St. Mary's Regional Medical … Duncan Regional Hospital, Inc. Integris Bass Baptist Health … Mercy Memorial Health … Stillwater Medical Center Southwestern Medical Center Integris Baptist Regional … SouthCrest Hospital McAlester Regional Health … Tahlequah City Hospital OSU Medical Center Jane Phillips Medical Center Hospital Rate State Rate T - 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 Integris Baptist Medical Center, Inc. Norman Regional Hospital Hillcrest Medical Center St. John Medical Center, Inc. St. Anthony Hospital Saint Francis Hospital, Inc. OU Medical Center Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 40 PSI 15 Accidental Puncture or Laceration Medical Surgical Hospitals Licensed for over 500 Beds Rehabilitation Hospitals - 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 Integris Baptist Medical Center, Inc. Norman Regional Hospital Hillcrest Medical Center St. John Medical Center, Inc. St. Anthony Hospital Saint Francis Hospital, Inc. OU Medical Center Hospital Rate State Rate - 0.50 1.00 1.50 2.00 2.50 3.00 3.50 Edmond Specialty Hospital George Nigh Rehabilitation Institute Hillcrest Specialty Hospital J. D. McCarty Center for Children with Developmental Disabil Lane Frost Health and Rehabilitation Center Specialty Hospital of Midwest City Valir Rehabilitation Hospital of OKC, LLC Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 41 PSI 17 Birth Trauma – Injury to Neonate Description: Rate of discharges with an ICD-9-CM code of birth trauma in any diagnosis field among newborns. This indicator is intended to flag cases of birth trauma for infants born alive in a hospital. The indicator excludes patients born pre-term, as birth trauma in these patients may be less preventable than for full-term infants. Medical Surgical Hospitals Licensed for 100 to 249 Beds T - 50.00 100.00 150.00 200.00 250.00 St. Mary's Regional Medical … Wagoner Community Hospital Integris Baptist Regional … Integris Bass Baptist Health … Jackson County Memorial … Jane Phillips Medical Center McCurtain Memorial Hospital Medical Center of … Mercy Memorial Health … OSU Medical Center Ponca City Medical Center SouthCrest Hospital Southwestern Medical Center Stillwater Medical Center Tahlequah City Hospital Unity Health Center Valley View Regional Hospital Duncan Regional Hospital, Inc. McAlester Regional Health … Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 42 (This page left blank) Oklahoma Hospital Annual Report 2009 43 PSI 18 Obstetric Trauma – Vaginal Delivery with Instrument Description: Rate of discharges with an ICD-9-CM code of 3rd and 4th degree obstetric laceration in any diagnosis field among vaginal delivery discharges, defined by DRG, with an ICD-9-CM code of instrument-assisted delivery in any procedure field. This event occurs during a vaginal delivery using an obstetric instrument and a severe laceration, such as a tear extending into the deep transverse perineal muscles and fibers of the anal sphincter (third degree) or rectal mucosa (fourth degree). This indicator is intended to flag cases of potentially preventable trauma during vaginal delivery with instrument. Critical Access Hospitals and Less than 50 Beds - 50.00 100.00 150.00 200.00 250.00 300.00 350.00 400.00 450.00 Harper County Community … Arbuckle Memorial Hospital Atoka Memorial Hospital Beaver County Memorial … Bristow Medical Center Carnegie Tri-County … Cimarron Memorial Hospital … Cleveland Area Hospital Cordell Memorial Hospital Drumright Regional Hospital Fairfax Memorial Hospital Inc. Fairview Hospital Harmon Memorial Hospital Healdton Municipal Hospital Holdenville General Hospital Integris Marshall Memorial … Jane Phillips Nowata Health … Jefferson County Hospital Johnston Memorial Hospital Logan Medical Center Quartz Mountain Medical … Mary Hurley Hospital Mercy Health Love County Okeene Municipal Hospital Pawhuska Hospital, Inc. Physicians Hospital of … Prague Municipal Hospital Roger Mills Memorial Hospital Seiling Municipal Hospital St. John Sapulpa (AKA Bartlett) Stroud Regional Medical … Watonga Municipal Hospital Weatherford Regional … Kingfisher Regional Hospital Hosp Rate State Rate Oklahoma Hospital Annual Report 2009 44 PSI 18 Obstetric Trauma – Vaginal Delivery with Instrument Medical Surgical Hospitals Licensed for less than 50 Beds Medical Surgical Hospitals Licensed for 50 to 99 Beds - 100.00 200.00 300.00 400.00 500.00 600.00 Memorial Hospital of … St John Owasso Choctaw Memorial … Community Hospital Continuous Care Center … Continuous Care Center … Foundation Bariatric … Haskell County Hospital Henryetta Medical … Integris Bass Pavilion Latimer County General … Lindsay Municipal … Memorial Hospital & … Northwest Surgical … Oklahoma Center for … Oklahoma … Oklahoma Spine … Orthopedic Hospital Perry Memorial Hospital Pushmataha Hospital Sayre Memorial Hospital Sequoyah Memorial … Share Memorial Hospital Solara Hospital Shawnee Solora Hospital … Southwestern Regional … Surgical Hospital of … Tulsa Spine Hospital EPIC Medical Center Eastern Oklahoma … Elkview General Hospital Lakeside Women's … Integris Canadian Valley … Park View Hospital Purcell Municipal … Hospital Rate State Rate - 100.00 200.00 300.00 400.00 500.00 600.00 Edmond Medical Center McBride Clinic Orthopedic … Meadow Brook Specialty … Newman Memorial Hospital Norman Specialty Hospital Oklahoma Heart Hospital Oklahoma Surgical Hospital Okmulgee Memorial Hospital Saint Francis Hospital South Select Specialty Hospital, … Select Specialty Hospital-… Bailey Medical Center Claremore Regional Hospital Pauls Valley General Hospital Integris Clinton Regional … Grady Memorial Hospital Integris Blackwell Regional … Integris Mayes County … Craig General Hospital Cushing Regional Hospital Integris Grove General … Great Plains Regional … Woodward Regional Hospital Memorial Hospital of Stilwell Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 45 PSI 18 Obstetric Trauma – Vaginal Delivery with Instrument Medical Surgical Hospitals Licensed for 100 to 249 Beds Medical Surgical Hospitals Licensed for 250 to 499 Beds - 50.00 100.00 150.00 200.00 250.00 300.00 350.00 Wagoner Community Hospital Tahlequah City Hospital Valley View Regional Hospital Jackson County Memorial … McCurtain Memorial Hospital Unity Health Center Medical Center of … Mercy Memorial Health … Integris Baptist Regional … SouthCrest Hospital Jane Phillips Medical Center Duncan Regional Hospital, Inc. Southwestern Medical Center Stillwater Medical Center Ponca City Medical Center St. Mary's Regional Medical … OSU Medical Center Integris Bass Baptist Health … McAlester Regional Health … Hospital Rate State Rate - 20.00 40.00 60.00 80.00 100.00 120.00 140.00 160.00 180.00 200.00 Muskogee Regional Medical Center Integris Southwest Medical Center of OK Midwest Regional Medical Center Comanche County Memorial Hospital Deaconess Hospital Mercy Health Center, Inc. Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 46 PSI 18 Obstetric Trauma – Vaginal Delivery with Instrument Medical Surgical Hospitals Licensed for over 500 Beds T - 50.00 100.00 150.00 200.00 250.00 300.00 350.00 St. Anthony Hospital Norman Regional Hospital OU Medical Center Hillcrest Medical Center Integris Baptist Medical Center, Inc. Saint Francis Hospital, Inc. St. John Medical Center, Inc. Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 47 PSI 19 Obstetric Trauma – Vaginal Delivery without Instrument Description: Rate of discharges with an ICD-9-CM code of 3rd and 4th degree obstetric trauma in any diagnosis field among vaginal delivery discharges, defined by DRG, without an ICD-9-CM code of instrument-assisted delivery in any procedure field. This event occurs during a vaginal delivery without the use of an obstetric instrument and a severe laceration, such as a tear extending into the deep transverse perineal muscles and fibers of the anal sphincter (third degree) or rectal mucosa (fourth degree). This indicator is intended to flag cases of potentially preventable trauma during vaginal delivery without instrument. Critical Access Hospitals and Less than 50 Beds - 10.00 20.00 30.00 40.00 50.00 60.00 70.00 Harper County Community … Okeene Municipal Hospital Watonga Municipal Hospital Arbuckle Memorial Hospital Atoka Memorial Hospital Beaver County Memorial … Bristow Medical Center Carnegie Tri-County … Cimarron Memorial Hospital … Cleveland Area Hospital Cordell Memorial Hospital Drumright Regional Hospital Fairfax Memorial Hospital Inc. Fairview Hospital Harmon Memorial Hospital Healdton Municipal Hospital Holdenville General Hospital Integris Marshall Memorial … Jane Phillips Nowata Health … Jefferson County Hospital Johnston Memorial Hospital Logan Medical Center Quartz Mountain Medical … Mary Hurley Hospital Mercy Health Love County Pawhuska Hospital, Inc. Physicians Hospital of … Prague Municipal Hospital Roger Mills Memorial Hospital Seiling Municipal Hospital St. John Sapulpa (AKA Bartlett) Stroud Regional Medical … Weatherford Regional … Kingfisher Regional Hospital Hosp Rate State Rate Oklahoma Hospital Annual Report 2009 48 PSI 19 Obstetric Trauma – Vaginal Delivery without Instrument Medical Surgical Hospitals Licensed for less than 50 Beds Medical Surgical Hospitals Licensed for 50 to 99 Beds **Charts represent hospitals licensed as Acute Care Hospitals and CMS Long –term Care Hospitals - 20.00 40.00 60.00 80.00 100.00 120.00 Choctaw Memorial Hospital Community Hospital Continuous Care Center of … Continuous Care Center of … Elkview General Hospital Memorial Hospital & … Foundation Bariatric … Haskell County Hospital Henryetta Medical Center Integris Bass Pavilion Latimer County General … Lindsay Municipal Hospital Northwest Surgical Hospital Oklahoma Center for … Oklahoma NeuroSpecialty … Oklahoma Spine Hospital, … Orthopedic Hospital Perry Memorial Hospital Pushmataha Hospital Sayre Memorial Hospital Sequoyah Memorial Hospital Share Memorial Hospital Solara Hospital Shawnee Solora Hospital Muskogee Southwestern Regional … Surgical Hospital of … Tulsa Spine Hospital EPIC Medical Center Memorial Hospital of Texas … Eastern Oklahoma Medical … Park View Hospital Lakeside Women's Hospital Integris Canadian Valley … St John Owasso Purcell Municipal Hospital Hospital Rate State Rate - 50.00 100.00 150.00 200.00 250.00 300.00 350.00 400.00 450.00 Edmond Medical Center McBride Clinic Orthopedic … Norman Specialty Hospital Oklahoma Heart Hospital Oklahoma Surgical Hospital Saint Francis Hospital South Select Specialty Hospital, Tulsa Select Specialty Hospital-… Integris Blackwell Regional … Memorial Hospital of Stilwell Meadow Brook Specialty … Okmulgee Memorial Hospital Grady Memorial Hospital Integris Mayes County … Integris Clinton Regional … Cushing Regional Hospital Newman Memorial Hospital Integris Grove General Hospital Craig General Hospital Great Plains Regional Medical … Pauls Valley General Hospital Claremore Regional Hospital Woodward Regional Hospital Bailey Medical Center Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 49 PSI 19 Obstetric Trauma – Vaginal Delivery without Instrument Medical Surgical Hospitals Licensed for 100 to 249 Beds Medical Surgical Hospitals Licensed for 250 to 499 Beds - 10.00 20.00 30.00 40.00 50.00 60.00 70.00 Wagoner Community Hospital Medical Center of … Tahlequah City Hospital Duncan Regional Hospital, Inc. Valley View Regional Hospital Integris Baptist Regional … St. Mary's Regional Medical … Ponca City Medical Center McCurtain Memorial Hospital SouthCrest Hospital Unity Health Center Mercy Memorial Health … Stillwater Medical Center Southwestern Medical Center Jane Phillips Medical Center OSU Medical Center Jackson County Memorial … Integris Bass Baptist Health … McAlester Regional Health … Hospital Rate State Rate T - 10.00 20.00 30.00 40.00 50.00 60.00 Integris Southwest Medical Center of OK Comanche County Memorial Hospital Midwest Regional Medical Center Muskogee Regional Medical Center Mercy Health Center, Inc. Deaconess Hospital Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 50 PSI 19 Obstetric Trauma – Vaginal Delivery without Instrument Medical Surgical Hospitals Licensed for over 500 Beds - 20.00 40.00 60.00 80.00 100.00 120.00 Norman Regional Hospital St. Anthony Hospital Hillcrest Medical Center OU Medical Center Saint Francis Hospital, Inc. Integris Baptist Medical Center, Inc. St. John Medical Center, Inc. Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 51 AHRQ Tier 1-B A subset of Tier 1, are serious reportable events that are most suitable for public accountability and root cause analysis, but for which comparisons between hospitals may not be useful. The National Quality Forum has endorsed the following PSIs which are included in Tier 1B: PSI #02 Death in Low Mortality Diagnosis Related Grouping (DRGs) PSI #08 Postoperative Hip Fracture PSI 2 Death in Low Mortality DRGs Description: Rate of in-hospital death among discharges with a DRG code for a low mortality DRG (defined as a mortality rate of less than 0.5%). Critical Access Hospitals and Less than 50 Beds - 10.00 20.00 30.00 40.00 50.00 60.00 70.00 Arbuckle Memorial Hospital Atoka Memorial Hospital Beaver County Memorial … Bristow Medical Center Carnegie Tri-County … Cimarron Memorial Hospital … Cleveland Area Hospital Cordell Memorial Hospital Drumright Regional Hospital Fairfax Memorial Hospital Inc. Fairview Hospital Harper County Community … Holdenville General Hospital Jane Phillips Nowata Health … Jefferson County Hospital Kingfisher Regional Hospital Quartz Mountain Medical … Okeene Municipal Hospital Pawhuska Hospital, Inc. Physicians Hospital of … Roger Mills Memorial Hospital Stroud Regional Medical … Weatherford Regional … St. John Sapulpa (AKA Bartlett) Logan Medical Center Integris Marshall Memorial … Harmon Memorial Hospital Mercy Health Love County Mary Hurley Hospital Prague Municipal Hospital Healdton Municipal Hospital Johnston Memorial Hospital Watonga Municipal Hospital Seiling Municipal Hospital Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 52 PSI 2 Death in Low Mortality DRGs Medical Surgical Hospitals Licensed for less than 50 Beds Medical Surgical Hospitals Licensed for 50 to 99 Beds **Charts represent hospitals licensed as Acute Care Hospitals and may also be CMS Long-Term Acute Care Hospitals - 100.00 200.00 300.00 400.00 500.00 600.00 Community Hospital Continuous Care Center of … Foundation Bariatric … Henryetta Medical Center Lakeside Women's Hospital Latimer County General … Lindsay Municipal Hospital Memorial Hospital & … Northwest Surgical Hospital Oklahoma Center for … Oklahoma NeuroSpecialty … Oklahoma Spine Hospital, … Orthopedic Hospital Park View Hospital Purcell Municipal Hospital Pushmataha Hospital Sayre Memorial Hospital Sequoyah Memorial … Southwestern Regional … St John Owasso Surgical Hospital of … Tulsa Spine Hospital EPIC Medical Center Integris Canadian Valley … Eastern Oklahoma Medical … Memorial Hospital of … Choctaw Memorial Hospital Elkview General Hospital Perry Memorial Hospital Share Memorial Hospital Haskell County Hospital Integris Bass Pavilion Continuous Care Center of … Solora Hospital Muskogee Solara Hospital Shawnee Hospital Rate State Rate - 100.00 200.00 300.00 400.00 500.00 600.00 700.00 Cushing Regional Hospital Integris Blackwell Regional … Integris Clinton Regional … McBride Clinic Orthopedic … Newman Memorial Hospital Norman Specialty Hospital Oklahoma Surgical Hospital Select Specialty Hospital, … Great Plains Regional … Claremore Regional … Woodward Regional … Craig General Hospital Memorial Hospital of … Integris Mayes County … Pauls Valley General … Grady Memorial Hospital Okmulgee Memorial … Integris Grove General … Edmond Medical Center Oklahoma Heart Hospital Saint Francis Hospital South Select Specialty Hospital-… Meadow Brook Specialty … Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 53 PSI 2 Death in Low Mortality DRGs Medical Surgical Hospitals Licensed for 100 to 249 Beds Medical Surgical Hospitals Licensed for 250 to 499 Beds - 1.00 2.00 3.00 4.00 5.00 6.00 Integris Baptist Regional … St. Mary's Regional … Wagoner Community … Medical Center of … Jackson County Memorial … Valley View Regional … McAlester Regional Health … Stillwater Medical Center Southwestern Medical … SouthCrest Hospital Mercy Memorial Health … Tahlequah City Hospital Unity Health Center Duncan Regional Hospital, … McCurtain Memorial … Jane Phillips Medical Center Integris Bass Baptist … Ponca City Medical Center OSU Medical Center Hospital Rate State Rate T - 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 Mercy Health Center, Inc. Midwest Regional Medical Center Muskogee Regional Medical Center Integris Southwest Medical Center of OK Deaconess Hospital Comanche County Memorial Hospital Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 54 PSI 2 Death in Low Mortality DRGs Medical Surgical Hospitals Licensed for over 500 Beds Rehabilitation Hospitals - 1.00 2.00 3.00 4.00 5.00 6.00 Hillcrest Medical Center St. Anthony Hospital OU Medical Center Norman Regional Hospital St. John Medical Center, Inc. Saint Francis Hospital, Inc. Integris Baptist Medical Center, Inc. Hospital Rate State Rate - 10.00 20.00 30.00 40.00 50.00 60.00 70.00 80.00 90.00 George Nigh Rehabilitation Institute Hillcrest Specialty Hospital J. D. McCarty Center for Children with Developmental Disabil Lane Frost Health and Rehabilitation Center Specialty Hospital of Midwest City Valir Rehabilitation Hospital of OKC, LLC Edmond Specialty Hospital Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 55 PSI 8 Postoperative Hip Fracture Description: Rate of discharges with an ICD-9-CM code of hip fracture in any secondary diagnosis field (not present on admission) among surgical discharges, defined by specific DRG codes and an ICD-9-CM code of major operating room procedure in any procedure field, age 18 and older. This event is when a patient while hospitalized as the result of a surgical procedure has fallen and has fractured a hip. This indicator is intended to capture cases of in hospital fracture—specifically, hip fractures. It further excludes any patients with musculoskeletal disorders and any patients with indication for trauma or cancer, or a principal diagnosis of seizure, syncope, stroke, coma, cardiac arrest, or poisoning, as these patients may have a fracture present on admission. This indicator is limited to surgical cases since previous research suggested that previously named medical patients often represent conditions present on admission. Medical Surgical Hospitals Licensed for less than 50 Beds **Charts represent hospitals licensed as Acute Care Hospitals and may also be CMS Long-Term Acute Care Hospitals - 2.00 4.00 6.00 8.00 10.00 12.00 Choctaw Memorial Hospital Community Hospital Continuous Care Center of … Continuous Care Center of … Eastern Oklahoma Medical … Elkview General Hospital Foundation Bariatric … Haskell County Hospital Henryetta Medical Center Integris Bass Pavilion Integris Canadian Valley … Lakeside Women's Hospital Lindsay Municipal Hospital Memorial Hospital & … Memorial Hospital of … Northwest Surgical Hospital Oklahoma Center for … Oklahoma Spine Hospital, … Orthopedic Hospital Park View Hospital Perry Memorial Hospital Purcell Municipal Hospital Pushmataha Hospital Sayre Memorial Hospital Share Memorial Hospital Solora Hospital Muskogee Southwestern Regional … St John Owasso Surgical Hospital of … Tulsa Spine Hospital EPIC Medical Center Latimer County General … Oklahoma NeuroSpecialty … Sequoyah Memorial … Solara Hospital Shawnee Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 56 PSI 8 Postoperative Hip Fracture Medical Surgical Hospitals Licensed for 100 to 249 Beds Medical Surgical Hospitals Licensed for 250 to 499 Beds - 0.50 1.00 1.50 2.00 2.50 Integris Baptist Regional … Integris Bass Baptist … Jackson County Memorial … McAlester Regional … McCurtain Memorial … Medical Center of … Mercy Memorial Health … Ponca City Medical Center SouthCrest Hospital Southwestern Medical … St. Mary's Regional … Stillwater Medical Center Unity Health Center Valley View Regional … Wagoner Community … Duncan Regional Hospital, … OSU Medical Center Jane Phillips Medical Center Tahlequah City Hospital Hospital Rate State Rate T - 0.20 0.40 0.60 0.80 1.00 1.20 Comanche County Memorial Hospital Deaconess Hospital Integris Southwest Medical Center of OK Midwest Regional Medical Center Muskogee Regional Medical Center Mercy Health Center, Inc. Hospital Rate State Rate Oklahoma Hospital Annual Report 2009 57 National Healthcare Safety Network Oklahoma currently has 152 licensed hospitals with 50 of those hospitals identified as having at least one adult intensive care unit. Hospitals with adult intensive care units are required to collect and report data monthly beginning July 2008. These hospitals were required to complete an orientation on how to utilize and enter data into the NHSN data system. Once the orientation was complete, the Infection Preventionist for the hospital initiated the enrollment process. Hospitals participating in NHSN must be a recognized healthcare entity in the United States, and be listed in or associated with a facility that is included in one of the following national databases: American Hospital Association (AHA), Centers for Medicare and Medicaid Services (CMS), or Veteran’s Affairs (VA). The implementation of the reporting process is based on data collected and reported to NHSN. Every effort has been made to correct data reporting errors. However, if data was not reported or errors could not be resolved, the data has been identified by an asterisk (*) as missing or having been reported inaccurately. It is estimated that 248,000 bloodstream infections occur each year in U.S. hospitals. These infections are very serious and usually result in longer hospital stays, which result in increased cost and increased risk of morbidity and mortality. With proper management these infections can be prevented. The second most common nosocomial infection in the United States is pneumonia. Patients who require mechanical assistance with a ventilator are at a higher risk of developing nosocomial pneumonia. Central Line Associated Bloodstream Infection (CLABSI) The definition of a central line is an intravascular catheter that terminates at or close to the heart or in one of the great vessels such as aorta, pulmonary artery, superior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, external iliac veins, and common femoral veins which is used for infusion, withdrawal of blood, or hemodynamic monitoring. A pacemaker wire and other non-lumenated devices inserted into central blood vessels or the heart are not considered central lines, because fluids are not infused, pushed, nor withdrawn through such devices. Central Line Associated Bloodstream Infection is a primary bloodstream infection (BSI) in a patient that had a central line within the 48-hour period before the development of the BSI. There is no minimum period of time that the central line must be in place in order for the BSI to be considered central line-associated. Laboratory-confirmed bloodstream infection (LCBI) must meet one of the following criteria: Oklahoma Hospital Annual Report 2009 58 Criterion 1: Patient has a recognized pathogen cultured from one or more blood cultures and organism cultured from blood is not related to an infection at another site. Criterion 2: Patient has at least one of the following signs or symptoms: fever (>38C), chills, or hypotension and signs and symptoms and positive laboratory results are not related to an infection at another site and common skin contaminant (i.e., diphtheroids [Corynebacterium spp.], Bacillus [not B. anthracis] spp., Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridans group streptococci, Aerococcus spp., Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions. The data collected in NHSN are used for improving patient safety at the local and national levels. In aggregate, CDC analyzes and publishes surveillance data to estimate and characterize the national burden of healthcare-associated infections. At the local level, the data analysis features of NHSN are available to participating facilities range from rate tables and graphs to statistical analysis that compares the healthcare facility’s rates with the national aggregate metrics. Two factors are use to analyze the data. The first is numerator data, when a CLABSI is identified during the month the patient demographic information on whether a central line was present, and, if so, the type of central line the patient had as appropriate to the location is entered into the NHSN database. The data will be used to calculate line-specific infection rates. Additional data include the specific criteria met for identifying the primary BSI, whether the patient died, and the organisms isolated from blood cultures, and the organisms’ antimicrobial susceptibili-ties. The second is denominator data, which is the total device days and patient days, collected daily, at the same time each day, during the month. Only the totals for the month are entered into NHSN. If a patient has both a temporary and a permanent central line, only the temporary line is counted. The statistical graph charts are displayed by individual hospital facility. Some larger hospital facilities may have more than one intensive care unit; therefore, more than one chart may be shown. The data for this report is for the last six months of 2008 (July through December). Oklahoma Hospital Annual Report 2009 59 Central Line Associated Blood Stream Infections for State This chart depicts the reports of all hospitals who reported to the NHSN for the time period from July through December 2008. The total number of central line associated blood stream infections for the month is then divided by the number of central line days, which is then multiplied by 1000 patient days. The average for 2008 for the state as a whole was 1.01 infections per 1000 device days. 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 CLABSI State Rate for 2008 by Month per 1000 Device Days Oklahoma Hospital Annual Report 2009 60 Central Line Associated Blood Stream Infections for State by Unit Type An intensive care unit is a nursing care area that provides intensive observation, diagnosis and therapeutic procedures for adults who are critically ill. The following definitions better define the specific care units. If a hospital has more than one unit, it is more common for the units to provide specialized care as related to the primary diagnosis. Coronary is a critical care area specializing in the care of patients with serious heart problems that do not require heart surgery. Surgical Cardiothoracic is a critical care area specializing in the care of patients following cardiac and thoracic surgery. Medical Surgical is a critical care area for patients who are being treated for nonsurgical conditions. Neurosurgical is a critical care area specializing in the surgical management of patients with severe neurological diseases or those at risk for neurological injury as a result of surgery. Surgical is a critical care area for the evaluation and management of patients with serious illness before and /or after surgery. Trauma is a critical care area specializing in the care of patients who require a high level of monitoring and/or intervention following trauma or during critical illness related to trauma. Coronar y Surgical Cardioth oracic Medical/ Surgical Neurosu rgical Surgical Trauma Rate of CLABSI/1,000 Central Line Days 0.14 1.70 1.06 1.48 0.10 1.06 NHSN Rate 2.00 1.40 1.80 2.50 2.30 3.60 0.00 1.00 2.00 3.00 4.00 CLABSI Rate Comparison of CLABSI Rates in OK Hospitals by Selected Critical Care Locations at Baseline (2008) to Available NHSN Rate from 2006 through 2008 Oklahoma Hospital Annual Report 2009 61 Central Line Associated Blood Stream Infections for hospitals by peer groups This report shows the initial results from a new reporting system. The Oklahoma State Department of Health and the Hospital Advisory Council recommend users of these data not draw definitive conclusions from the limited information that is currently available. Facilities vary in the types of patients treated, and a facility that treats a high volume of severely ill patients may have higher infection rates. The following charts are hospitals separated by licensure peer groups. If the hospital reported zero infections or no data was reported, there will not be a bar graft for representation of the infections. The goal is that all hospitals will have a rate of zero. The hospitals are listed in order of NHSN facility identification however, that number is not disclosed. 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 Integris Canadian Valley Regional Hospital Community Hospital Memorial Hospital of Texas County CTCA at Southwestern Regional Medical Center CLABSI Rate for Hospitals with less than 50 Beds CLABSI per 1000 Oklahoma Hospital Annual Report 2009 62 0 0.5 1 1.5 2 2.5 3 3.5 Integris Clinton Regional … Oklahoma Heart Hospital Integris Grove General … St.Francis Hospital South Claremore Regional … Grady Memorial Hospital Edmond Medical Center Great Plains Regional … Eastern Oklahoma … Bailey Medical Center Pauls Valley General … Newman Regional Hospital Woodward Regional … Cushing Regional Hospital CLABSI Rate for Hospitals 50-99 Beds CLABSI per 1000 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 Valley View Reg Hosp Integris Baptist Regional �� Integris Bass Baptist … OSU Medical Center Duncan Regional Hosp. Tahlequah City Hosp. Medical Center of … Stillwater Medical Center McAlester Regional … Southwestern Medical … McCurtain Memorial … Jane Phillips Medical … St. Mary's Regional Hospital Ponca City Medical Center Unity Health Center Jackson County Memorial … Mercy Memorial Health … CLABSI Rate for Hospitals 100-249 Beds CLABSI per 1000 Oklahoma Hospital Annual Report 2009 63 0 0.5 1 1.5 2 2.5 3 3.5 4 Integris Southwest Medical Center Mercy Health Center Midwest Regional Medical Center Deaconess Muskogee Regional Medical Center Comanche Co Memorial Hospital CLABSI Rate for Hospitals 250-499 Beds CLABSI per 1000 0 1 2 3 4 5 6 St Anthony Hospital-3N St Anthony Hospital-4N Integris Baptist Medical … Integris Baptist Medical … Integris Baptist Medical … Integris Baptist Medical … Integris Baptist Medical … St John Medical … St John Medical … St John Medical … St Francis Hospital-CCU St Francis Hospital-ICU4 St Francis Hospital-… OU Medical Center-ICUS OU Medical Center-… OU Medical Center-ICUN Norman Regional … Hillcrest Medical … Hillcrest Medical … Hillcrest Medical … CLABSI Rate by Units in Hospitals with 500 + Beds CLABSI Per 1000 Oklahoma Hospital Annual Report 2009 64 Central Line Associated Blood Stream Infections by individual hospital The following charts are listed in alphabetical order and represent each facility’s infection by intensive care units. If the facility has more than one unit the numbers will be listed by the identifier the infection control preventionist has labeled the individual unit in the NHSN database. Each facility page has a brief explanation about the facility, such as the number of licensed beds, the number of beds in the unit, and the type of patients which are admitted to the units. Data charts definitions: Year Month: This represents the year 2008 and the month by number for the reported data. CLABSI Infections: Actual infections that occur during a month on a particular intensive care unit. Number of Central Line Days: For each day of the month, at the same time each day, record the number of patients on the selected unit who have a central line. This number is summed at the end of the month. CLABSI Rate: The number of Central Line Associated Blood Stream infections divided by the number of central line days multiplied by 1000. Number of Patient Days: For each day of the month, at the same time each day, record the number of patients on the selected unit. Central Line Utilization Ratio: The number of central line days divided by the number of patient days for a given month. Oklahoma Hospital Annual Report 2009 65 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ration 2008M07 0 10 0.0 26 0.38 2008M08 0 6 0.0 22 0.27 2008M09 0 5 0.0 16 0.31 2008M10 0 10 0.0 19 0.53 2008M11 0 3 0.0 14 0.21 2008M12 0 5 0.0 20 0.25 Data is per 1000 device days and is from July 2008 through December 2008. Bailey Medical Center –This hospital is located in Owasso. Data was collected from an inpatient acute critical care medical surgical unit, consisting of five setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 73. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Bailey Medical Center Oklahoma Hospital Annual Report 2009 66 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 48 0.0 112 0.43 2008M08 0 6 0.0 1324* 0.00 2008M09 0 72 0.0 147 0.49 2008M10 0 36 0.0 1197* 0.03 2008M11 0 44 0.0 131 0.34 2008M12 0 37 0.0 116 0.32 Data is per 1000 device days and is from July 2008 through December 2008. *Data reported number of patient days for entire facility Claremore Regional Hospital – This hospital is located in Claremore. Data was collected from an inpatient acute critical care medical unit, consisting of six setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 81. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Claremore Regional Hospital Oklahoma Hospital Annual Report 2009 67 Year Month CLABSI Infection Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 157 0.0 428 0.37 2008M08 1 147 6.8 453 0.32 2008M09 1 152 6.6 446 0.34 2008M10 1 221 4.5 442 0.50 2008M11 1 224 4.5 474 0.47 2008M12 0 246 0.0 503 0.49 Data is per 1000 device days and is from July 2008 through December 2008. Comanche County Memorial Hospital – This Hospital is located in Lawton. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 20 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 283. 0 1 2 3 4 5 6 7 8 July August September October November December Comanche County Memorial Hospital Oklahoma Hospital Annual Report 2009 68 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 6 0.0 535* 0.01 2008M08 0 5 0.0 413* 0.01 2008M09 0 23 0.0 528* 0.04 2008M10 0 11 0.0 550* 0.02 2008M11 0 8 0.0 430* 0.02 2008M12 0 15 0.0 525* 0.03 Data is per 1000 device days and is from July 2008 through December 2008. *Data reported number of patient days for entire facility, maximum number of ICU patient days would be 90 or less. Community Hospital – This hospital is located in Oklahoma City. Data was collected from an inpatient acute critical care medical surgical unit, consisting of three setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 49. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Community Hospital Oklahoma Hospital Annual Report 2009 69 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 4 0.0 39 0.10 2008M08 0 4 0.0 18 0.22 2008M09 0 2 0.0 38 0.05 2008M10 0 6 0.0 46 0.13 2008M11 0 0 . 19 0.00 2008M12 0 4 0.0 29 0.14 Data is per 1000 device days and is from July 2008 through December 2008. Cushing Regional Hospital – This hospital is located in Cushing. Data was collected from an inpatient acute critical care medical surgical unit, consisting of four setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 95. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Cushing Regional Hospital Oklahoma Hospital Annual Report 2009 70 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 314 0.0 5185* 0.06 2008M08 0 292 0.0 4822* 0.06 2008M09 0 232 0.0 5091* 0.05 2008M10 0 186 0.0 279 0.67 2008M11 0 261 0.0 375 0.70 2008M12 0 279 0.0 361 0.77 Data is per 1000 device days and is from July 2008 through December 2008. *Data reported number of patient days for entire facility, maximum number of ICU patient days would be 870 or less. Deaconess Hospital – This hospital is located in Oklahoma City. Data was collected from an inpatient acute critical care medical unit, consisting of 29 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 313. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Deaconess Hospital Oklahoma Hospital Annual Report 2009 71 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 63 0.0 135 0.47 2008M08 0 49 0.0 156 0.31 2008M09 0 55 0.0 134 0.41 2008M10 0 63 0.0 150 0.42 2008M11 0 49 0.0 154 0.32 2008M12 0 23 0.0 141 0.16 Data is per 1000 device days and is from July 2008 through December 2008. Duncan Regional Hospital – This hospital is located in Duncan. Data was collected from an inpatient acute critical care medical surgical unit, consisting of nine setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 167. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Duncan Regional Hospital Oklahoma Hospital Annual Report 2009 72 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 12 0.0 134 0.09 2008M08 0 17 0.0 182 0.09 2008M09 0 38 0.0 176 0.22 2008M10 0 60 0.0 211 0.28 2008M11 0 52 0.0 190 0.27 2008M12 0 26 0.0 162 0.16 Data is per 1000 device days and is from July 2008 through December 2008. Eastern Oklahoma Medical Center –This hospital is located in Poteau. Data was collected from an inpatient acute critical care medical surgical unit, consisting of eight setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 84. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Eastern Oklahoma Medical Center Oklahoma Hospital Annual Report 2009 73 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 1 144 6.9 161 0.89 2008M08 1 115 8.7 139 0.83 2008M09 0 98 0.0 116 0.84 2008M10 0 93 0.0 135 0.69 2008M11 0 106 0.0 159 0.67 2008M12 0 99 0.0 159 0.62 Data is per 1000 device days and is from July 2008 through December 2008. Edmond Medical Center – This hospital is located in Edmond. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 12 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 94. 0 1 2 3 4 5 6 7 8 9 10 July August September October November December Edmond Medical Center Oklahoma Hospital Annual Report 2009 74 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 28 0.0 72 0.39 2008M08 0 32 0.0 138 0.23 2008M09 0 40 0.0 103 0.39 2008M10 0 31 0.0 110 0.28 2008M11 0 38 0.0 122 0.31 2008M12 0 31 0.0 111 0.28 Data is per 1000 device days and is from July 2008 through December 2008. Grady Memorial Hospital – This hospital is located in Chickasha. Data was collected from an inpatient acute critical care medical surgical unit, consisting of seven setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 99. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Grady Memorial Hospital Oklahoma Hospital Annual Report 2009 75 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 0 . 85 0.00 2008M08 0 8 0.0 87 0.09 2008M09 0 10 0.0 112 0.09 2008M10 0 0 . 86 0.00 2008M11 0 3 0.0 67 0.04 2008M12 0 3 0.0 110 0.03 Data is per 1000 device days and is from July 2008 through December 2008. Great Plains Regional Medical Center – This hospital is located in Elk City. Data was collected from an inpatient acute critical care medical unit, consisting of six setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 62. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Great Plains Regional Medical Center Oklahoma Hospital Annual Report 2009 76 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 July August September October November December CCU ICU MICU Hillcrest Medical Center Oklahoma Hospital Annual Report 2009 77 Hillcrest Medical Center Unit Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio CCU 2008M07 0 284 0.0 296 0.96 CCU 2008M08 1 243 4.1 292 0.83 CCU 2008M09 0 188 0.0 269 0.70 CCU 2008M10 1 218 4.6 280 0.78 CCU 2008M11 0 198 0.0 227 0.87 CCU 2008M12 0 262 0.0 303 0.86 ICU 2008M07 0 249 0.0 357 0.70 ICU 2008M08 0 269 0.0 363 0.74 ICU 2008M09 0 244 0.0 331 0.74 ICU 2008M10 0 235 0.0 365 0.64 ICU 2008M11 0 251 0.0 341 0.74 ICU 2008M12 1 285 3.5 369 0.77 MICU 2008M07 0 82 0.0 120 0.68 MICU 2008M08 0 80 0.0 131 0.61 MICU 2008M09 0 79 0.0 137 0.58 MICU 2008M10 0 103 0.0 151 0.68 MICU 2008M11 0 106 0.0 138 0.77 MICU 2008M12 0 129 0.0 163 0.79 Data is per 1000 device days and is from July 2008 through December 2008. Hillcrest Medical Center– This hospital is located in Tulsa. Data was collected from three inpatient acute critical care units, two of which were Medical Surgical Units, and one Cardiac Vascular Care Unit. All three ICUs total 31 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 691. Oklahoma Hospital Annual Report 2009 78 Data is per 1000 device days and is from July 2008 through December 2008. Integris Baptist Medical Center – This hospital is located in Oklahoma City. Data was collected from five inpatient acute critical care medical surgical units, consisting of 60 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 640. 0 1 2 3 4 5 6 7 July August September October November December ICU 501 ICU 601 ICU 701 ICU 801 ICU 901 Integris Baptist Medical Center Oklahoma Hospital Annual Report 2009 79 Integris Baptist Medical Center Unit Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 501 2008M07 0 131 0.0 167 0.78 501 2008M08 0 158 0.0 204 0.77 501 2008M09 0 180 0.0 243 0.74 501 2008M10 1 161 6.2 219 0.74 501 2008M11 0 202 0.0 260 0.78 501 2008M12 0 245 0.0 299 0.82 601 2008M07 0 248 0.0 329 0.75 601 2008M08 0 249 0.0 302 0.82 601 2008M09 0 244 0.0 315 0.77 601 2008M10 0 251 0.0 316 0.79 601 2008M11 0 241 0.0 325 0.74 601 2008M12 0 228 0.0 323 0.71 701 2008M07 0 297 0.0 308 0.96 701 2008M08 0 250 0.0 284 0.88 701 2008M09 0 278 0.0 291 0.96 701 2008M10 0 280 0.0 281 1.00 701 2008M11 0 286 0.0 304 0.94 701 2008M12 0 309 0.0 315 0.98 801 2008M07 1 304 3.3 304 1.00 801 2008M08 1 270 3.7 285 0.95 801 2008M09 0 268 0.0 269 1.00 801 2008M10 0 269 0.0 269 1.00 801 2008M11 0 255 0.0 257 0.99 801 2008M12 0 275 0.0 293 0.94 901 2008M07 0 261 0.0 306 0.85 901 2008M08 0 241 0.0 293 0.82 901 2008M09 0 178 0.0 266 0.67 901 2008M10 0 156 0.0 244 0.64 901 2008M11 0 183 0.0 294 0.62 901 2008M12 1 248 4.0 334 0.74 Oklahoma Hospital Annual Report 2009 80 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 5 0.0 81 0.06 2008M08 0 32 0.0 118 0.27 2008M09 0 23 0.0 100 0.23 2008M10 0 13 0.0 92 0.14 2008M11 0 16 0.0 70 0.23 2008M12 0 33 0.0 109 0.30 Data is per 1000 device days and is from July 2008 through December 2008. Integris Baptist Regional Health Center– This hospital is located in Miami. Data was collected from an inpatient acute critical care medical surgical unit, consisting of five setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 117. 0 0.2 0.4 0.6 0.8 1 1.2 July August September October November December Integris Baptist Regional Health Center Oklahoma Hospital Annual Report 2009 81 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 41 0.0 80 0.51 2008M08 0 65 0.0 108 0.60 2008M09 0 63 0.0 100 0.63 2008M10 0 100 0.0 139 0.72 2008M11 0 102 0.0 139 0.73 2008M12 0 68 0.0 127 0.54 Data is per 1000 device days and is from July 2008 through December 2008. Integris Bass Baptist Health Center – This hospital is located in Enid. Data was collected from an inpatient acute critical care medical surgical unit, consisting of seven setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 183. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Integris Bass Baptist Health Center Oklahoma Hospital Annual Report 2009 82 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 40 0.0 73 0.55 2008M08 0 48 0.0 102 0.47 2008M09 0 37 0.0 95 0.39 2008M10 0 24 0.0 101 0.24 2008M11 0 60 0.0 101 0.59 2008M12 0 46 0.0 107 0.43 Data is per 1000 device days and is from July 2008 through December 2008. Integris Canadian Valley Hospital – This hospital is located in Yukon. Data was collected from an inpatient acute critical care medical surgical unit, consisting of four setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 48. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Integris Canadian Valley Hospital Oklahoma Hospital Annual Report 2009 83 Data is per 1000 device days and is from July 2008 through December 2008. Integris Clinton Regional Hospital – This hospital is located in Clinton. Data was collected from an inpatient acute critical care medical surgical unit, consisting of four setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 56. 0 0.2 0.4 0.6 0.8 1 1.2 July August September October November December Integris Clinton Regional Hospital Year Month CLASI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 9 0.0 14 0.64 2008M08 0 2 0.0 14 0.14 2008M09 0 20 0.0 25 0.80 2008M10 0 8 0.0 44 0.18 2008M11 0 6 0.0 44 0.14 2008M12 0 5 0.0 35 0.14 Oklahoma Hospital Annual Report 2009 84 Year Month CLABSI Infection Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 24 0.0 62 0.39 2008M08 0 6 0.0 31 0.19 2008M09 0 0 . 21 0.00 2008M10 0 0 . 31 0.00 2008M11 0 14 0.0 40 0.35 2008M12 0 3 0.0 49 0.06 Data is per 1000 device days and is from July 2008 through December 2008. Integris Grove General Hospital – This hospital is located in Grove. Data was collected from an inpatient acute critical care medical surgical unit, consisting of four setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 68. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Integris Grove General Hospital Oklahoma Hospital Annual Report 2009 85 Data is per 1000 device days and is from July 2008 through December 2008. Integris Southwest Medical Center – This hospital is located in Oklahoma City. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 20 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 406. 0 1 2 3 4 5 6 7 8 July August September October November December Integris Southwest Medical Center Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 1 253 4.0 490 0.52 2008M08 1 233 4.3 459 0.51 2008M09 0 224 0.0 469 0.48 2008M10 0 231 0.0 449 0.51 2008M11 1 190 5.3 484 0.39 2008M12 2 297 6.7 535 0.56 Oklahoma Hospital Annual Report 2009 86 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 23 0.0 135 0.17 2008M08 0 26 0.0 26 1.00 2008M09 0 16 0.0 113 0.14 2008M10 0 32 0.0 104 0.31 2008M11 0 11 0.0 100 0.11 2008M12 0 0 . 96 0.00 Data is per 1000 device days and is from July 2008 through December 2008. Jackson County Memorial Hospital – This hospital is located in Altus. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 12 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 156. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Jackson County Memorial Hospital Oklahoma Hospital Annual Report 2009 87 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 67 0.0 180 0.37 2008M08 0 46 0.0 119 0.39 2008M09 0 67 0.0 157 0.43 2008M10 0 38 0.0 144 0.26 2008M11 0 24 0.0 85 0.28 2008M12 0 27 0.0 128 0.21 Data is per 1000 device days and is from July 2008 through December 2008. Jane Phillips Medical Center – This hospital is located in Bartlesville. Data was collected from an inpatient acute critical care medical surgical unit, consisting of eight setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 137. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Jane Phillips Medical Center Oklahoma Hospital Annual Report 2009 88 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 4 0.0 30 0.13 2008M08 0 44 0.0 146 0.30 2008M09 0 45 0.0 153 0.29 2008M10 0 77 0.0 218 0.35 2008M11 0 20 0.0 197 0.10 2008M12 0 38 0.0 188 0.20 Data is per 1000 device days and is from July 2008 through December 2008. McAlester Regional Health Center – Data was collected from an inpatient acute critical care medical surgical unit, consisting of 14 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 171. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December McAlester Regional Health Center Oklahoma Hospital Annual Report 2009 89 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 0 . 43 0.00 2008M08 0 6 0.0 57 0.11 2008M09 0 2 0.0 69 0.03 2008M10 0 0 . 50 0.00 2008M11 0 0 . 63 0.00 2008M12 0 0 . 57 0.00 Data is per 1000 device days and is from July 2008 through December 2008. McCurtain Memorial Hospital – This hospital is located in Idabel. Data was collected from an inpatient acute critical care medical surgical unit, consisting of six setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 106. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December McCurtain Memorial Hospital Oklahoma Hospital Annual Report 2009 90 Year Month CLABSI Infections Number of Central Line Days CLABSI Number of Patient Days Central Line Utilization Ratio 2008M07 0 92 0.0 231 0.40 2008M08 0 69 0.0 200 0.35 2008M09 0 56 0.0 213 0.26 2008M10 0 88 0.0 223 0.39 2008M11 0 86 0.0 213 0.40 2008M12 0 28 0.0 220 0.13 Data is per 1000 device days and is from July 2008 through December 2008. Medical Center of Southeastern Oklahoma – This hospital is located in Durant. Data was collected from an inpatient acute critical care medical surgical unit, consisting of eight setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 148. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Medical Center of Southeastern Oklahoma Oklahoma Hospital Annual Report 2009 91 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 6 0.0 314* 0.86 2008M08 0 1 0.0 270* 0.00 2008M09 0 6 0.0 326* 0.02 2008M10 0 0 . 392* 0.00 2008M11 0 0 . 308* 0.00 2008M12 0 0 . 288* 0.00 Data is per 1000 device days and is from July 2008 through December 2008. *Data reported number of patient days for entire facility, maximum number of ICU patient days would be 120 or less. Memorial Hospital of Texas County – This hospital is located in Guymon. Data was collected from an inpatient acute critical care medical surgical unit, consisting of four setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 47. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Memorial Hospital of Texas County Oklahoma Hospital Annual Report 2009 92 Year Month CLABSI Infection Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 1 428 2.3 757 0.57 2008M08 0 563 0.0 878 0.64 2008M09 0 490 0.0 875 0.56 2008M10 0 556 0.0 893 0.62 2008M11 1 623 1.6 970 0.64 2008M12 1 686 1.5 984 0.70 Data is per 1000 device days and is from July 2008 through December 2008. Mercy Health Center – This hospital is located in Oklahoma City. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 54 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 380. 0 0.5 1 1.5 2 2.5 July August September October November December Mercy Health Center Oklahoma Hospital Annual Report 2009 93 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 47 0.0 203 0.23 2008M08 0 64 0.0 236 0.27 2008M09 0 100 0.0 269 0.37 2008M10 1 91 11.0 249 0.37 2008M11 0 104 0.0 234 0.44 2008M12 0 104 0.0 255 0.41 Data is per 1000 device days and is from July 2008 through December 2008. Mercy Memorial Health Center – This hospital is located in Ardmore. Data was collected from an inpatient acute critical care medical surgical unit, consisting of ten setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 175. 0 2 4 6 8 10 12 July August September October November December Mercy Memorial Health Center Oklahoma Hospital Annual Report 2009 94 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 176 0.0 261 0.67 2008M08 0 183 0.0 231 0.79 2008M09 0 151 0.0 226 0.67 2008M10 0 148 0.0 236 0.63 2008M11 0 143 0.0 210 0.68 2008M12 0 162 0.0 256 0.63 Data is per 1000 device days and is from July 2008 through December 2008. Midwest Regional Medical Center – This hospital is located in Midwest City. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 24 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 255. 0 0.2 0.4 0.6 0.8 1 1.2 July August September October November December Midwest Regional Medical Center Oklahoma Hospital Annual Report 2009 95 Year Month CLABSI Infections Number of CLABSI Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 70 0.0 493 0.14 2008M08 0 37 0.0 503 0.07 2008M09 0 45 0.0 516 0.09 2008M10 0 73 0.0 569 0.13 2008M11 0 49 0.0 640 0.08 2008M12 0 45 0.0 649 0.07 Data is per 1000 device days and is from July 2008 through December 2008. Muskogee Regional Medical Center – Data was collected from an inpatient acute critical care medical surgical unit, consisting of 24 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 275 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Muskogee Regional Medical Center Oklahoma Hospital Annual Report 2009 96 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 0 . 221* 0.00 2008M08 0 0 . 280* 0.00 2008M09 0 15 0.0 287* 0.05 2008M10 0 2 0.0 264* 0.01 2008M11 0 0 . 300* 0.00 2008M12 0 0 . 259* 0.00 Data is per 1000 device days and is from July 2008 through December 2008. *Data reported number of patient days for entire facility, maximum number of ICU patient days would be 62 or less. Newman Memorial Hospital – This hospital is located in Shattuck. Data was collected from an inpatient acute critical care medical surgical unit, consisting of two setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 79. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December NewmanMemorial Hospital Oklahoma Hospital Annual Report 2009 97 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 384 0.0 502 0.76 2008M08 0 454 0.0 589 0.77 2008M09 0 394 0.0 612 0.64 2008M10 0 471 0.0 565 0.83 2008M11 0 445 0.0 608 0.73 2008M12 1 669 1.5 773 0.87 Data is per 1000 device days and is from July 2008 through December 2008. Norman Regional Hospital – This hospital is located in Norman. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 43 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 518. 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 July August September October November December Norman Regional Hospital Oklahoma Hospital Annual Report 2009 98 Year Month CLABSI Infections 2008M07 0 2008M08 0 2008M09 0 2008M10 0 2008M11 0 2008M12 1 Data is per 1000 device days and is from July 2008 through December 2008. **Data report incomplete due to data entry error. Oklahoma Heart Hospital – This hospital is located in Oklahoma City. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 54 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 99. 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 July August September October November December Oklahoma Heart Hospital Oklahoma Hospital Annual Report 2009 99 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 630 0.0 673 0.94 2008M08 1 509 2.0 604 0.84 2008M09 0 367 0.0 523 0.70 2008M10 0 468 0.0 546 0.86 2008M11 0 348 0.0 479 0.73 2008M12 0 372 0.0 481 0.77 Data is per 1000 device days and is from July 2008 through December 2008. Oklahoma State University Medical Center – This hospital is located in Tulsa. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 54 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 249. 0 0.5 1 1.5 2 2.5 July August September October November December Oklahoma State University Medical Center Oklahoma Hospital Annual Report 2009 100 0 2 4 6 8 10 12 14 July August September October November December ICUS ICUW ICUN OUMedical Center Oklahoma Hospital Annual Report 2009 101 OU Medical Center Unit Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio ICUS 2008M07 0 272 0.0 471 0.58 ICUS 2008M08 0 204 0.0 406 0.50 ICUS 2008M09 0 301 0.0 422 0.71 ICUS 2008M10 0 263 0.0 455 0.58 ICUS 2008M11 0 315 0.0 467 0.67 ICUS 2008M12 1 344 2.9 488 0.70 ICUW 2008M07 1 259 3.9 474 0.55 ICUW 2008M08 1 227 4.4 416 0.55 ICUW 2008M09 0 315 0.0 477 0.66 ICUW 2008M10 3 245 12.2 476 0.51 ICUW 2008M11 0 337 0.0 516 0.65 ICUW 2008M12 4 344 11.6 514 0.67 ICUN 2008M07 1 261 3.8 455 0.57 ICUN 2008M08 0 274 0.0 437 0.63 ICUN 2008M09 0 339 0.0 427 0.79 ICUN 2008M10 0 294 0.0 449 0.65 ICUN 2008M11 1 390 2.6 458 0.85 ICUN 2008M12 0 333 0.0 458 0.73 Data is per 1000 device days and is from July 2008 through December 2008. OU Medical Center – This hospital is located in Oklahoma City. Data was collected from two inpatient acute critical care units, two of which were Medical Surgical Units, and one Trauma Critical Care Unit. All three ICUs total 151 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 689. Oklahoma Hospital Annual Report 2009 102 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 0 . 19 0.00 2008M08 0 0 . 11 0.00 2008M09 0 0 . 4 0.00 2008M10 0 0 . 23 0.00 2008M11 0 0 . 14 0.00 2008M12 0 0 . 13 0.00 Data is per 1000 device days and is from July 2008 through December 2008. Pauls Valley General Hospital – This hospital is located in Pauls Valley. Data was collected from an inpatient acute critical care medical surgical unit, consisting of three setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 64. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Pauls Valley General Hospital Oklahoma Hospital Annual Report 2009 103 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 29 0.0 153 0.19 2008M08 0 28 0.0 102 0.27 2008M09 0 9 0.0 144 0.06 2008M10 0 45 0.0 141 0.32 2008M11 0 37 0.0 153 0.24 2008M12 0 27 0.0 124 0.22 Data is per 1000 device days and is from July 2008 through December 2008. Ponca City Medical Center – This hospital is located in Ponca City. Data was collected from an inpatient acute critical care medical unit, consisting of ten setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 140. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 July August September October November December Ponca City Medical Center Oklahoma Hospital Annual Report 2009 104 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 1 89 11.2 152 0.59 2008M08 0 114 0.0 142 0.80 2008M09 0 68 0.0 99 0.69 2008M10 0 78 0.0 140 0.56 2008M11 0 76 0.0 103 0.74 2008M12 0 94 0.0 112 0.84 Data is per 1000 device days and is from July 2008 through December 2008. Southwestern Medical Center – This hospital is located in Lawton. Data was collected from an inpatient acute critical care medical surgical unit, consisting of ten setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 199. 0 2 4 6 8 10 12 July August September October November December SouthwesternMedical Center Oklahoma Hospital Annual Report 2009 105 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 1 36 27.8 166 0.22 2008M08 0 49 0.0 139 0.35 2008M09 1 77 13.0 132 0.58 2008M10 0 75 0.0 152 0.49 2008M11 0 150 0.0 168 0.89 2008M12 0 107 0.0 149 0.72 Data is per 1000 device days and is from July 2008 through December 2008. Southwestern Regional Medical Center– (Cancer Treatment Center of America)- This hospital is located in Tulsa. Data was collected from an inpatient acute critical care medical surgical unit, consisting of seven setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 43. 0 5 10 15 20 25 30 July August September October November December Southwestern Regional Medical Center Oklahoma Hospital Annual Report 2009 106 0 1 2 3 4 5 6 7 8 9 10 July August September October November December 3 N 4 N St. Anthony Hospital Oklahoma Hospital Annual Report 2009 107 Unit Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 3N 2008M07 0 130 0.0 303 0.43 3N 2008M08 0 210 0.0 302 0.70 3N 2008M09 1 209 4.8 307 0.68 3N 2008M10 0 160 0.0 335 0.48 3N 2008M11 0 225 0.0 342 0.66 3N 2008M12 2 225 8.9 326 0.69 4N 2008M07 0 223 0.0 397 0.56 4N 2008M08 0 209 0.0 382 0.55 4N 2008M09 1 259 3.9 397 0.65 4N 2008M10 2 267 7.5 410 0.65 4N 2008M11 0 287 0.0 395 0.73 4N 2008M12 0 216 0.0 402 0.54 Data is per 1000 device days and is from July 2008 through December 2008. St. Anthony Hospital – This hospital is located in Oklahoma City. Data was collected from two inpatient acute critical care medical surgical units, consisting of 29 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 686. Oklahoma Hospital Annual Report 2009 108 0 0.5 1 1.5 2 2.5 3 3.5 4 July August Septembe r October Novembe r Decembe r CCU ICU-4 Trauma ICU Saint Francis Hospital Oklahoma Hospital Annual Report 2009 109 Saint Francis Hospital Unit Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio CCU 2008M07 0 473 0.0 701 0.67 CCU 2008M08 0 436 0.0 651 0.67 CCU 2008M09 0 356 0.0 539 0.66 CCU 2008M10 0 288 0.0 460 0.63 CCU 2008M11 1 276 3.6 454 0.61 CCU 2008M12 0 286 0.0 458 0.62 ICU-4 2008M07 2 670 3.0 877 0.76 ICU-4 2008M08 0 681 0.0 889 0.77 ICU-4 2008M09 0 602 0.0 843 0.71 ICU-4 2008M10 0 668 0.0 882 0.76 ICU-4 2008M11 0 637 0.0 861 0.74 ICU-4 2008M12 1 708 1.4 885 0.80 TRAUMA ICU 2008M07 379 0.0 469 0.81 0 TRAUMA ICU 2008M08 0 372 0.0 464 0.80 TRAUMA ICU 2008M09 1 352 2.8 437 0.81 TRAUMA ICU 2008M10 0 365 0.0 459 0.80 TRAUMA ICU 2008M11 0 351 0.0 436 0.81 TRAUMA ICU 2008M12 0 347 0.0 455 0.76 Data is per 1000 device days and is from July 2008 through December 2008. Saint Francis Hospital – This hospital is located in Tulsa. Data was collected from three inpatient acute critical care units, Medical Surgical Critical Care, Cardiac Critical Care, and Trauma Critical Care. All three ICUs total to 139 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 928. Oklahoma Hospital Annual Report 2009 110 0 1 2 3 4 5 6 7 July August September October November December AICU NSICU SICU Oklahoma Hospital Annual Report 2009 111 St. John Medical Center Unit Year Month CLABSI Infection Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization AICU 2008M07 1 221 4.5 323 0.68 AICU 2008M08 1 447 2.2 623 0.72 AICU 2008M09 1 397 2.5 558 0.71 AICU 2008M10 1 479 2.1 638 0.75 AICU 2008M11 2 462 4.3 631 0.73 AICU 2008M12 1 391 2.6 623 0.63 NSICU 2008M07 1 205 4.9 317 0.65 NSICU 2008M08 0 309 0.0 343 0.90 NSICU 2008M09 2 319 6.3 407 0.78 NSICU 2008M10 1 371 2.7 452 0.82 NSICU 2008M11 1 377 2.7 477 0.79 NSICU 2008M12 0 349 0.0 443 0.79 SICU 2008M07 0 226 0.0 323 0.70 SICU 2008M08 0 232 0.0 343 0.68 SICU 2008M09 0 225 0.0 308 0.73 SICU 2008M10 0 258 0.0 357 0.72 SICU 2008M11 0 214 0.0 407 0.53 SICU 2008M12 0 227 0.0 350 0.65 Data is per 1000 device days and is from July 2008 through December 2008. St. John Medical Center – This hospital is located in Tulsa. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 54 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 703. Oklahoma Hospital Annual Report 2009 112 Year Month CLABSI Infections Number of Central Line Days CLABSI Rate Number of Patient Days Central Line Utilization Ratio 2008M07 0 81 0.0 139 0.58 2008M08 0 93 0.0 180 0.52 2008M09 1 105 9.5 176 0.60 2008M10 0 156 0.0 206 0.76 2008M11 0 114 0.0 156 0.73 2008M12 0 83 0.0 165 0.50 Data is per 1000 device days and is from July 2008 through December 2008. St. Mary’s Regional Medical Center – This hospital is located in Enid. Data was collected from an inpatient acute critical care medical surgical unit, consisting of 11 setup and staffed beds. The total number of beds that this facility is licensed to operate by the Oklahoma State Department of Health is 245. 0 1 2 3 4 5 6 7 8 9 10 July August September October |
Date created | 2011-06-14 |
Date modified | 2011-10-27 |
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