National Hospital Measures
	The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires accredited hospitals to collect and submit performance data on Heart Attack, Heart Failure, and Pneumonia. This requirement was established to improve the safety and quality of care and to support performance improvement in hospitals. PeaceHealth participates in this initiative not only to comply with the regulatory agencies, but also to demonstrate our commitment to exceptional medicine and compassionate care.
	Key ~ Data not yet available or measure not applicable to this hospital * Too few cases. Data hidden to protect patient confidentiality. Hospital Measure All PeaceHealth Sacred Heart Medical Center St. Joseph Hospital St. John Medical Center Peace Harbor Hospital Ketchikan General Hospital National Average National Top 10% Pneumonia  (7/1/2007 - 9/30/2007) Oxygenation Assessment 100% 100% 100% 100% 100% 100% 100% 100% Pneumococcal screening and/or vaccination 82% 86% 78% 77% 91% 75% 81% 96% Blood Culture in ED prior to initial antibiotic 96% 97% 92% 95% 100% 100% 90% 97% Blood Culture for Transfers to Intensive Care Unit (ICU) 97% 100% 92% 100% * * 92% 100% Adult Smoking Cessation Advice/Counseling 93% 97% 88% 91% * 83% 92% 100% Antibiotic timing 2:21 2:27 2:29 2:12 2:22 1:46 ~ ~ Antibiotic received within 8 hours 98% 99% 95% 98% 100% 100% 96% 100% Antibiotic received within 4 hours 85% 86% 87% 81% 73% 100% 81% 93% Antibiotic selection for patients in non-ICU 90% 96% 90% 78% 100% 86% 91% 97% Antibiotic selection for patients in ICU 73% 86% * ~ * * 64% 91% Influenza vaccine ~ ~ ~ ~ ~ ~ 79% 97% Heart Attack   (7/1/2007 - 9/30/2007) Aspirin at Arrival 99% 100% 98% 100% * ~ 97% 100% Aspirin Prescribed at Discharge 98% 98% 100% 95% * ~ 97% 100% ACEI or ARB for LVSD 96% 100% 94% 80% * ~ 89% 100% Adult Smoking Cessation Advice/Counseling 99% 100% 95% 100% ~ ~ 98% 100% Beta Blocker Prescribed at Discharge 100% 100% 100% 100% * ~ 97% 100% Beta Blocker at Arrival 96% 95% 100% 93% * ~ 94% 100% Time to Fibrinolysis ~ ~ ~ ~ ~ ~ 0:50 1:40 Fibrinolytic therapy within 30 minutes of arrival ~ ~ ~ ~ ~ ~ ~ ~ Time to PCI 1:09 1:07 1:15 ~ ~ ~ 1:05 1:28 PCI within 90 minutes of arrival 80% 88% 69% ~ ~ ~ ~ ~ Inpatient Mortality 3% 3% 4% 4% * ~ ~ ~ Heart Failure   (7/1/2007 - 9/30/2007) Discharge Instructions 82% 88% 80% 83% 92% 83% 74% 96% LVF Assessment 96% 100% 100% 96% 93% 43% 94% 100% ACEI or ARB for LVSD 98% 100% 100% 95% * * 88% 99% Adult Smoking Cessation Advice/Counseling 89% 100% 70% 94% * * 94% 100%
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