Oklahoma hospital report

              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
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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
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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
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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
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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