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  (10/1/2007 - 12/31/2007) Oxygenation Assessment 100% 100% 100% 100% 100% 100% 100% 100% Pneumococcal screening and/or vaccination 86% 82% 87% 85% 100% 100% 82% 97% Blood Culture in ED prior to initial antibiotic 95% 100% 97% 93% 86% 89% 91% 97% Blood Culture for Transfers to Intensive Care Unit (ICU) 93% 100% 100% 81% * 100% 93% 100% Adult Smoking Cessation Advice/Counseling 96% 100% 83% 100% * 100% 93% 100% Antibiotic timing 2:20 2:34 2:16 2:02 1:59 2:14 ~ ~ Antibiotic received within 8 hours 96% ~ ~ 94% 100% 100% 96% 100% Antibiotic received within 4 hours 86% 83% 85% 88% 100% 89% 82% 93% Antibiotic selection for patients in non-ICU 90% 96% 89% 82% * * 92% 98% Antibiotic selection for patients in ICU 61% 86% * 20% * * 66% 100% Influenza vaccine 61% 60% 72% 39% 83% 62% 79% 97% Heart Attack   (10/1/2007 - 12/31/2007) Aspirin at Arrival 97% 98% 97% 100% * ~ 97% 100% Aspirin Prescribed at Discharge 97% 98% 95% 100% * ~ 97% 100% ACEI or ARB for LVSD 98% 96% 100% 100% ~ ~ 90% 100% Adult Smoking Cessation Advice/Counseling 95% 97% 90% * ~ ~ 98% 100% Beta Blocker Prescribed at Discharge 98% 98% 99% 100% * ~ 97% 100% Beta Blocker at Arrival 95% 97% 92% 92% * ~ 94% 100% Time to Fibrinolysis ~ ~ ~ ~ ~ ~ ~ ~ Fibrinolytic therapy within 30 minutes of arrival ~ ~ ~ ~ ~ ~ 50% 100% Time to PCI 1:15 1:09 1:22 ~ ~ ~ 1:17 1:05 PCI within 90 minutes of arrival 69% 71% 67% ~ ~ ~ 69% 89% Inpatient Mortality 3% 1% 6% 0% * ~ 4% ~ Heart Failure   (10/1/2007 - 12/31/2007) Discharge Instructions 75% 85% 57% 83% 88% ~ 76% 97% LVF Assessment 97% 100% 99% 90% 100% * 95% 100% ACEI or ARB for LVSD 94% 96% 91% 91% 100% * 89% 100% Adult Smoking Cessation Advice/Counseling 93% 96% 75% 100% * ~ 95% 100%
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