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Saint Francis Hospital Wilmington, DE 19805 CMS Certification Number: 080003 |
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Quality Report |
Timely & Effective Care
Timely Heart Attack Care
| Measure | Number of Patients | Hospital Footnotes | Hospital Score | National Average | State Average |
|---|---|---|---|---|---|
| AMI-7a. Fibrinolytic Medication Within 30 Minutes Of Arrival | ### | ### | ### | ### | ### |
| AMI-8a. PCI Within 90 Minutes Of Arrival | ### | ### | ### | ### | ### |
| OP-2. Fibrinolytic Therapy received within 30 minutes | ### | ### | ### | ### | ### |
| OP-3b. Median Time to transfer patients for Acute Coronary Intervention | ### | ### | ### | ### | ### |
| OP-4. Aspirin at Arrival | ### | ### | ### | ### | ### |
| OP-5. Median Time to ECG | ### | ### | ### | ### | ### |
Effective Heart Attack Care
| Measure | Number of Patients | Hospital Footnotes | Hospital Score | National Average | State Average |
|---|---|---|---|---|---|
| AMI-2. Aspirin at Discharge | ### | ### | ### | ### | ### |
| AMI-10. Heart Attack Patients Given a Prescription for a Statin at Discharge | ### | ### | ### | ### | ### |
Effective Heart Failure Care
| Measure | Number of Patients | Hospital Footnotes | Hospital Score | National Average | State Average |
|---|---|---|---|---|---|
| HF-1. Discharge Instructions | ### | ### | ### | ### | ### |
| HF-2. Evaluation of Left Ventricular Systolic (LVS) Function | ### | ### | ### | ### | ### |
| HF-3. ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD) | ### | ### | ### | ### | ### |
Effective Pneumonia Care
| Measure | Number of Patients | Hospital Footnotes | Hospital Score | National Average | State Average |
|---|---|---|---|---|---|
| PN-3b. Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospita | ### | ### | ### | ### | ### |
| PN-6. Appropriate Initial Antibiotic Selection | ### | ### | ### | ### | ### |
Emergency Department: AMI Cardiac Care
| Measure | Number of Patients | Hospital Footnotes | Hospital Score | National Average | State Average |
|---|---|---|---|---|---|
| OP-1. Median Time to Fibrinolysis | ### | ### | ### | ### | ### |
Timely Surgical Care
| Measure | Number of Patients | Hospital Footnotes | Hospital Score | National Average | State Average |
|---|---|---|---|---|---|
| OP-6. Timing of Antibiotic Prophylaxis | ### | ### | ### | ### | ### |
| SCIP-INF-1. Prophylactic Antibiotic Received Within 1 Hour Prior to Surgical Incision | ### | ### | ### | ### | ### |
| SCIP-INF-3. Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time | ### | ### | ### | ### | ### |
| SCIP-VTE-2. Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery | ### | ### | ### | ### | ### |
Effective Surgical Care
| Measure | Number of Patients | Hospital Footnotes | Hospital Score | National Average | State Average |
|---|---|---|---|---|---|
| OP-7. Prophylactic Antiobiotic Selection | ### | ### | ### | ### | ### |
| SCIP-CARD-2. Patients on beta blocker at admission who received beta blocker during perioperative period | ### | ### | ### | ### | ### |
| SCIP-INF-2. Prophylactic Antibiotic Selection | ### | ### | ### | ### | ### |
| SCIP-INF-4. Blood glucose controlled in days following heart surgery | ### | ### | ### | ### | ### |
| SCIP-INF-9. Urinary catheter removed within two days following surgery | ### | ### | ### | ### | ### |
| SCIP-INF-10. Patients having surgery who were actively warmed in the operating room or whose body temperature was near normal by the end of surgery | ### | ### | ### | ### | ### |
| SCIP-VTE-1. Recommended Venous Thromboembolism Prophylaxis Ordered | ### | ### | ### | ### | ### |
Timely Emergency Department Care
| Measure | Footnotes | Hospital Score | National Average | State Average |
|---|---|---|---|---|
| ED-1b. Average (median) time patients spent in the emergency department, before they were admitted to the hospital as an inpatient | ### | ### | ### | ### |
| ED-2b. Average (median) time patients spent in the emergency department, after the doctor decided to admit them as an inpatient before leaving the emergency department for their inpatient room | ### | ### | ### | ### |
| OP-18b. Average time patients spent in the emergency department before being sent home | ### | ### | ### | ### |
| OP-20. Average time patients spent in the emergency department before they were seen by a healthcare professional | ### | ### | ### | ### |
| OP-21. Average time patients who came to the emergency department with broken bones had to wait before receiving pain medication | ### | ### | ### | ### |
| OP-23. Percentage of patients who came to the emergency department with stroke symptoms who received brain scan results within 45 minutes of arrival | ### | ### | ### | ### |
Preventive Care
| Measure | Footnotes | Hospital Score | National Average | State Average |
|---|---|---|---|---|
| IMM-1a. Patients assessed and given pneumonia vaccination | ### | ### | ### | ### |
| IMM-2. Patients assessed and given influenza vaccination | ### | ### | ### | ### |
Effective Children's Asthma Care
| Measure | Number of Patients | Hospital Footnotes | Hospital Score | National Average | State Average | |
|---|---|---|---|---|---|---|
| No Data are available for this hospital. | ||||||
Patient Survey Results
| Survey question | Measure | Percent | Measure | Percent | Measure | Percent |
|---|---|---|---|---|---|---|
| Nurses communicated well | ### | ### | ### | ### | ### | ### |
| Doctors communicated well | ### | ### | ### | ### | ### | ### |
| Help received quickly | ### | ### | ### | ### | ### | ### |
| Pain controlled well | ### | ### | ### | ### | ### | ### |
| Staff explained medicines | ### | ### | ### | ### | ### | ### |
| Room and bath kept clean | ### | ### | ### | ### | ### | ### |
| Area quiet at night | ### | ### | ### | ### | ### | ### |
| Given discharge instructions | ### | ### | ### | ### | ### | ### |
| Overall hospital rating | ### | ### | ### | ### | ### | ### |
| Would recommend hospital | ### | ### | ### | ### | ### | ### |
Readmissions, Complications and Deaths
30-Day Risk Adjusted Mortality Rates
| Measure | Hospital | Predicted Range | National Average | ||
|---|---|---|---|---|---|
| Number Patients | Mortality Rate | from | to | ||
| Heart Attack | ### | ### | ### | ### | ### |
| Heart Failure | ### | ### | ### | ### | ### |
| Pneumonia | ### | ### | ### | ### | ### |
30-Day Risk Adjusted Readmission Rates
| Measure | Hospital | Predicted Range | National Average | ||
|---|---|---|---|---|---|
| Number Patients | Readmission Rate | from | to | ||
| Heart Attack | ### | ### | ### | ### | ### |
| Heart Failure | ### | ### | ### | ### | ### |
| Pneumonia | ### | ### | ### | ### | ### |
Hospital Acquired Conditions
| Measure | Rate per Thousand | National Rate |
|---|---|---|
| HAC-1. Foreign object retained after surgery | ### | ### |
| HAC-2. Air embolism | ### | ### |
| HAC-3. Blood incompatibility | ### | ### |
| HAC-4. Pressure ulcer stages III and IV | ### | ### |
| HAC-5. Falls and trauma | ### | ### |
| HAC-6. Vascular catheter-associated infection | ### | ### |
| HAC-7. Catheter-associated urinary tract infection | ### | ### |
| HAC-8. Manifestations of poor glycemic control | ### | ### |
Serious Complications and Deaths
| Measure | Hospital | Predicted Range | National Average | ||
|---|---|---|---|---|---|
| Number Patients | Rate | from | to | ||
| IQI-11. Death after surgery to repair a weakness in the abdominal aorta | ### | ### | ### | ### | ### |
| IQI-19. Deaths after admission for a broken hip | ### | ### | ### | ### | ### |
| IQI-91. Deaths from Certain Conditions | ### | ### | ### | ### | ### |
| PSI-4. Death from serious treatable complications after surgery | ### | ### | ### | ### | ### |
| PSI-6. Collapsed lung due to medical treatment | ### | ### | ### | ### | ### |
| PSI-11. Breathing failure after surgery | ### | ### | ### | ### | ### |
| PSI-12. Serious blood clots after surgery | ### | ### | ### | ### | ### |
| PSI-14. A wound that splits open after surgery | ### | ### | ### | ### | ### |
| PSI-15. Accidental cuts and tears from medical treatment | ### | ### | ### | ### | ### |
| PSI-90. Serious Complications | ### | ### | ### | ### | ### |
Healthcare Associated Infections
| Measure | Hospital Score | State Score |
|---|---|---|
| HAI-1-SIR. Central Line Associated Blood Stream Infections (CLABSI) | ### | ### |
| HAI-2-SIR. Catheter Associated Urinary Tract Infections (CAUTI) | ### | ### |
| HAI-3-SIR. Surgical Site Infections from colon surgery (SSI: Colon) | ### | ### |
| HAI-4-SIR. Surgical Site Infections from abdominal hysterectomy (SSI: Hysterectomy) | ### | ### |
Efficiency Measures
Use of Medical Imaging
| Measure | Number of Patients | Hospital Footnotes | Hospital Score | National Average | State Average |
|---|---|---|---|---|---|
| OP-8. MRI Lumbar Spine for Low Back Pain | ### | ### | ### | ### | ### |
| OP-9. Mammography Follow-up Rates | ### | ### | ### | ### | ### |
| OP-10. Abdomen CT - Use of Contrast Material | ### | ### | ### | ### | ### |
| OP-11. Thorax CT - Use of Contrast Material | ### | ### | ### | ### | ### |
| OP-13. Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery | ### | ### | ### | ### | ### |
| OP-14. Outpatients with brain CT scans who got a sinus CT scan at the same time | ### | ### | ### | ### | ### |
Medicare Spending Per Patient
| Measure | Hospital Score |
|---|---|
| SPP-1. Spending per Hospital Patient with Medicare (displayed in ratio) | ### |
