Table of Contents Executive Summary

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					                                                    Table of Contents



Executive Summary ............................................................................................................. 2

Report from Subcommittee .................................................................................................. 4-11

Department of Health’s Summary of Recommendations .................................................... 12-14




Appendix I. Public Chapter 323, Senate Bill 441

Appendix II. Copy of Centers for Medicare and Medicaid Hospital Compare Website with example

Appendix III. Sub-Committee Membership List




                                                                                                                                    1
                                  Executive Summary
In response to Public Chapter 323, the Tennessee Department of Health and the Tennessee
Improving Patient Safety Coalition invited a group of infection control nurses and physicians and
other health care personnel to assist with the review of issues relating to public reporting of
hospital acquired infections. This group was composed of nine (9) infection control nurses, two
(2) hospital physician epidemiologists, one (1) hospital administrator, one (1) Tennessee
Hospital Association representative, and three (3) Department of Health representatives.

Surgical Site Infections (SSIs) are the second most common type of adverse events occurring in
hospitalized patients. Surgical site infections have been shown to increase mortality,
readmission rate, length of stay, and cost for patients who incur them. An estimated 2.6 percent
of nearly 30 million operations are complicated by surgical site infections each year. In
Tennessee, post-operative wound infections are the second most reported adverse events in
hospitals. The total number of post-operative wound infections reported by hospitals in 2005
was three hundred ninety-two (392). Thirty-four (34) hospitals out of one hundred forty-five
(145) acute care hospitals (23%) reported post-operative wound infections during 2005.

According to The Center for Disease Control and Prevention’s (CDC) National Nosocomial
Infections Surveillance (NNIS) system, which monitors reported trends in nosocomial infections
in participating US acute care hospitals:

   •   38 percent of all nosocomial (hospital acquired) infections in surgical patients are SSIs
   •   4 to 16 percent of all nosocomial infections among all hospitalized patients are SSIs
   •   2 to 5 percent of operated patients will develop SSIs
   •   SSIs increase length of stay in a hospital by an average of 7.5 days
   •   $2,734 to $26,019 extra cost per SSI (1985, US dollars)
   •   $130 million to $845 million per year estimated national costs in the United States

Currently there are six (6) states that require mandatory public reporting of hospital-acquired
infections and thirty-two (32) others are considering legislation. Many Tennessee hospitals track
their own infections, and some of these infections are reportable to the Tennessee Department of
Health through the Unusual Incident Reporting System. However, as noted during 2005, only
thirty-four (34) hospitals out of one hundred forty-five (145) acute care hospitals reported post-
operative wound infections to the Department. Ten (10) hospitals reported one (1) infection. Six
(6) hospitals reported three (3) or less. Thirty-nine percent (39%) of those reported events
required the patient to return to the operating room for additional surgery. One (1) death was
reported as a secondary impact of the reported post-operative wound infection.

The subcommittee not only reviewed oversight activities and legislative actions of other states
but made some very good recommendations which are categorized by outcome measures and
process measures. These recommendations are summarized in spreadsheet format for ease of
review.

The Department of Health supports the reporting of adverse events or unusual events. As stated
in the 2004 Patient Safety Report, the Department, licensed health care facilities and health care


                                                                                                   2
professionals continue to face an enormous challenge in the area of reporting unusual events both
internally and externally. The magnitude of this challenge strongly supports the necessity for a
change in culture and human behavior concerning patient safety. This identified area for
improvement has been adopted as a 2006 objective for the Tennessee Improving Patient Safety
Coalition and the Department of Health. Many health care organizations and consumers believe
strongly that public accountability (i.e. informing the public of the numbers) may be an
important key to improving health care outcomes. Many feel that public reporting is a great
incentive for health care facilities to respond to consumers’ concerns about the quality of care
provided in health care facilities.




                                                                                               3
  Report to TIPS from Subcommittee on Mandatory Reporting of Health Care Acquired
                                     Infections

        It is estimated by the Institute of Medicine (IOM) that 2 million Americans acquire health
care associated infections (HAI) annually. The Centers for Disease Control and Prevention
(CDC) in Atlanta states that about one third of these infections are preventable. Until now,
hospitals across Tennessee and the United States do not report infection rates publicly. Various
consumer groups have highlighted these facts urging legislators to pass legislation mandating
public reporting of these infections.

Current quality measures and programs
        Nearly all licensed health care institutions in Tennessee have been accredited by the Joint
Commission for the Accreditation of Health Care Organizations (JCAHO). As part of this
accreditation process, hospitals submit to triennial inspections, also called surveys, and must
have an Infection Control Program that is managed by a qualified person, usually the Infection
Control Practitioner (ICP). Hospitals must systematically review health care acquired infections
and have a plan in place to reduce those infections. One of the National Patient Safety goals
promoted by the JCAHO is to reduce health care acquired infections by adhering to the CDC
guidelines for hand hygiene and to report health care acquired infections that result in death or
significant loss of function as sentinel events. In 2007/2008 surveys, JCAHO anticipates adding
a central line associated blood stream infection component examining not only infection rates but
also adherence to CDC guidelines when vascular infusion devices terminate at or close to the
heart or in one of the great vessels. The JCAHO publishes institutional performance on quality
measures and compliance with patient safety goals on their website at www.jcaho.org.

        In accordance with the JCAHO requirements, hospitals identifying a health care acquired
infection that results in death or loss of function must conduct a root cause analysis. This is a
systematic way of analyzing an event or problem to determine why it occurred and how to
prevent it in the future. The infection, the root cause analysis, and the findings of the
investigation are voluntarily reported to the JCAHO.

         Hand hygiene is one of the least expensive and most effective ways to reduce health care
acquired infections. Infection Control Practitioners (ICP) have been instructing doctors and
nurses for years on the benefits of this one simple task. Yet, in today’s modern institutions, this
one critical task is often ignored. The JCAHO National Patient Safety Goals focus on
monitoring hand hygiene in an effort to encourage hand washing. The JCAHO does not mandate
how an institution monitors hand hygiene just that it is indeed monitored. Some institutions
monitor the volume of soaps and alcohol based hand sanitizers that are used over time. Some
institutions actually monitor care givers washing their hands or using the alcohol based hand
sanitizer. The subcommittee agreed to not make hand hygiene a publicly reportable process
measure at this time, because there is currently no standard method for collection, validating or
reporting this measure.

       The Centers for Medicare and Medicaid Services (CMS) is the federal agency that
insures that hospitals treating Medicare patients meet high standards. Among the many
mandates and performance measures that CMS requires for Medicare reimbursement, health care



                                                                                                 4
acquired infections are well represented. In April 2005, CMS unveiled a consumer oriented
website “Hospital Compare” at www.medicare.gov to provide consumers with information on
their local area hospitals and quality of care. CMS and the Hospital Quality Alliance (HQA)
partners continue to update the website and expand the reported measures. CMS has joined with
several other organizations in a national quality partnership entitled “The Surgical Care
Improvement Project” (SCIP). This initiative examines surgical complications including
surgical site infections, post-operative myocardial infarction (heart attack), post-operative blood
clots, and post-operative pneumonia. Institutions seeking Medicare reimbursement are
encouraged to participate in this initiative and report their compliance on the CMS website.

        In addition to the JCAHO and CMS, hospitals voluntarily join various quality groups that
publicly report the results of their performance measures on their web sites by hospital. The
Leapfrog Group and others encourage adoption of the National Quality Forum ((NQF) safe
practices. Among the 27 safe practices, several are aimed at preventing or reducing infections
such as hand hygiene protocols, central line blood stream infection avoidance and influenza
vaccines for patients and health care workers. There are a myriad of other excellent quality
groups that health care institutions volunteer to join. The Institutes of Healthcare Improvement’s
(IHI) 100,000 lives campaign, the National Quality Forum, and Hospital’s Pursing Magnet
Status are all active, rigorous quality programs with health care acquired infection reporting
components.

Background for public reporting
        The National Nosocomial Infection Surveillance (NNIS) system is the largest and oldest
monitoring system for health care acquired infections in the United States. Since it began in
1970 with 62 hospitals, NNIS has grown substantially to over 350 hospitals. Under the old
Hospitals Infections Program of the Centers for Disease Control and Prevention (CDC), one of
the key functions of NNIS was to establish definitions for hospital acquired infections.
Consistent use of uniform definitions insures comparability of collected data. Most, if not all,
Infection Control Practitioners (ICP) in Tennessee and throughout the United States use NNIS
definitions to identify nosocomial infections. NNIS is currently evolving into a more
comprehensive and patient safety focused program to be reborn as the National Healthcare
Safety Network (NHSN). NHSN will not only track health care acquired infections for both
inpatients and outpatients, but also antibiotic resistance, dialysis related infections, and health
care worker injuries such as disease exposure and needle stick injuries.

        Along with establishing definitions of infections, NNIS also provides benchmarks for
both member and non-member hospitals to compare. These benchmarks are not only used in the
United States, but throughout the world as reference points. NNIS hospitals share a few
distinguishing characteristics that make the program unique. These hospital’s Infection Control
Practitioners (ICP) collect data in the same way and there have to be a minimum number of ICPs
in the hospital doing data collection; the definitions are uniform; and the data are risk adjusted
and validated. These standardized components assure uniformity and comparability among
participating providers.




                                                                                                 5
Current reportable events
         In Tennessee, health care institutions have infection control programs and track their
infections. As part of state law, they must also track and report unusual events according to the
Health Data Reporting Act 2002 (T.C.A. 68-11-211). This law requires that health care
institutions report unusual events to the Department of Health to ensure the delivery of the best
medical care for the citizens of Tennessee by minimizing the frequency and severity of
unexpected events and improving the delivery of health care services through the collection of
meaningful health care data. Unusual events are defined by this law as an unexpected
occurrence resulting in death or life threatening or serious injury to a patient that is not related to
the natural course of the patient’s illness or underlying condition. Every health care facility must
report unusual events to the Tennessee Department of Health within seven business days of
identifying the event. The event is reported and a corrective action plan, similar to the JCAHO
root cause analysis, must also be reported to the Tennessee Department of Health. There are
thirty seven (37) event categories that must be reported. Infection related events, as defined by
this law, requires reporting unusual events related to Clean (Class I) and Clean-contaminated
(Class II) surgical site infections.

        In addition to the unusual events reporting, Tennessee health care institutions are also
required to report communicable diseases pursuant to T.C.A. 68-10-101. There are a number of
diseases that require telephone reporting followed by written reporting. This list also includes
agents of concern for Bio-terrorism and resistant organisms such as invasive MRSA (methicillin
resistant Staphylococcus aureus), VRSA (vancomycin resistant Staphylococcus aureus), and
VRE (Vancomycin resistant enterococci). Often, identifying a communicable disease brought
into a facility by a patient requires contact tracing by the facility to identify health care workers
and visitors that were exposed to the disease in question.

Summary of current legislation
       Since 2002, six states have enacted legislation that requires health care organizations to
publicly disclose health care associated infections (HAI). To date, there are six additional states
that have required a study of such legislation and many other states with pending legislation.
Groups supporting public reporting believe if hospitals report infections publicly, consumers and
employers can select the safest hospitals and competition among the hospitals will quickly force
the worst to improve.

        Illinois was one of the first states to pass legislation for mandatory reporting of health
care acquired infections. Measures approved in Illinois included Class I surgical site infections,
ventilator associated pneumonia rates and central line associated blood stream infections all
using standard CDC/NNIS definitions for infections. Lessons learned from Illinois include the
fact that if Class I surgical site infections are reported, this limits participation by institutions that
do not perform Class I surgeries. Illinois and many other states also have border hospitals faced
with meeting different state mandates. The Chicago Hospital Association has pointed out how
difficult the entire process is going to be. Illinois has not yet begun receiving data.

       Missouri was the third state to approve legislation and serves as a model for other states.
Missouri enacted the Missouri Nosocomial Infection Control Act of 2004 guided by an advisory
panel. Over time, Missouri health care facilities will report resistant organisms such as MRSA



                                                                                                        6
and VRE, surgical site infections, ventilator associated pneumonia and central line associated
bloodstream infections. Reporting requirements are consistent with CDC and CMS with
hospitals having the option to participate in the CDC’s NNIS/NHSN program. Missouri wisely
excluded Burn Units and Trauma Units from data collection sets. Burn and trauma patients, due
to the very nature of their injuries (smoke inhalation, burned skin, glass, dirt and debris in
wounds), are more prone to infections. They also limited certain data sets to intensive care units.

        The fourth state to enact legislation was Pennsylvania through the Pennsylvania Health
Care Cost Containment Council (PHC4). Of all the states that have enacted legislation,
Pennsylvania is a model of how not to enact legislation for mandatory reporting. PHC4 did not
engage the infection control community when crafting their laws. Thus the laws that were
passed are without sound epidemiological basis; they yield faulty data. PHC4 also chose to look
at administrative billing codes rather that reports generated by trained infection control persons.
In the first report from July 2005, a gap between the number of infections identified through
billing codes (115,631) and infections identified by the hospitals (11,668) was noted. The
disparity between using billing codes, also known as ICD-9 codes, and infection control
practitioner surveillance data based upon the CDC/NNIS definitions is that any kind of data
abstraction using diagnostic codes examines key words or phrases (content) noted in the medical
record billing records to define the presence of a health care associated infections where as
infection control surveillance is based upon patient symptoms, laboratory reports, physician and
nurses notes, and radiological studies. Studies have noted the limitations in using administrative
billing data to diagnose health care associated infections. This method is prone to misclassify
non-infectious illnesses as infections and is rarely able to distinguish between infections acquired
in the community and infections acquired in the health care facility.

CDC guidance on public reporting
        The Healthcare Infection Control Practices Advisory Committee (HICPAC) is a federal
committee associated with the CDC. Fourteen experts in infection control meet three (3) times
yearly at the CDC to advise the Department of Health and Human Services (HHS) on various
aspects of infection control. In February 2005, HICPAC published a guideline on mandatory
public reporting of health care acquired infections to assist Infection Control Practitioners and
persons involved in developing legislation. In March 2005, the Association for Practitioners in
Infection Control (APIC) and the Society for Hospital Epidemiologists of America (SHEA)
conducted a joint caucus to examine and debate the issues surrounding public reporting of health
care acquired infections. In October 2005, HICPAC formed a working group to develop a
standardized approach for mandatory reporting of health care acquired infections.

        HICPAC’s guideline concluded that there is insufficient evidence to recommend for or
against public reporting of health care acquired infections. There are potential benefits from
public reporting of HAIs that include a better informed public and better informed providers. In
addition, potential benefits include greater accountability, more focus on infection control
programs and thus possibly more resources for those programs.

       Conversely, there are potential unintended consequences of mandatory public reporting
of health care acquired infections. These consequences include misinformation if the study is
not properly designed. With a major focus on reporting infections, valuable and often scarce



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infection control resources could be diverted to data collection and away from bedside
prevention of these infections. Infection control programs may focus only on those elements
requiring public reporting and not on other items. Finally, institutions may avoid those patients
at highest risk of infection. This phenomenon has already been seen in the state of New York
where surgeon specific mortality rates for coronary artery bypass graft surgery were reported
publicly. In an effort to reduce their mortality rates, many surgeons refused to operate on
patients at highest risk of death or complications. Often those are patients that would benefit the
most from cardiac surgery. Thus an unintended consequence was a higher death rate among
these patients, and increased health care costs associated with increased hospitalization rates and
medical treatment.

Subcommittee recommendations
        After reviewing the data, this subcommittee for Tennessee Improving Patient Safety finds
that there is no evidence for or against using mandatory public reporting of health care acquired
infections to reduce such infections. The subcommittee recognizes that the consumers want this
information available publicly, and the subcommittee further recognizes the need to display data
the consumers will be able to comprehend. The subcommittee recommends that any action taken
by the legislature or the state be in conjunction with current national reporting initiatives and that
sufficient resources be allocated to implement a meaningful reporting system. Should the state
continue to pursue mandatory public reporting of health care acquired infections, the
subcommittee has the following recommendations:

   1. All institutions that deliver health care treating either inpatients or outpatients including
      ambulatory surgical centers, free standing surgical centers, long term care facilities, and
      rehabilitation centers are included except Critical Access Hospitals or hospitals with an
      average daily census of less than 25. The quality indicators recommended are less
      commonly encountered in those settings. At a later date, applicable quality indicators
      may be recommended.
   2. All health care institutions with a daily census of greater than 25 in the State of
      Tennessee join the CDC’s NNIS/NHSN surveillance system when it becomes open to all
      health care types in an effort to unify the reporting systems and benchmark against
      national standards. The NNIS/NHSN system is offered by the federal government at no
      cost to the end user. Many states seeking legislation on mandatory reporting of health
      care acquired infections have also recommended the NNIS/NHSN system.

Outcome Measures
        The subcommittee recommends monitoring central line associated blood stream
infections. Health care facilities should be required to attend training provided by the CDC via
the internet before collecting or entering data on this outcome measure. Hospitals should be
required to join the National Healthcare Safety Network (NHSN) and to use the NHSN software
to collect and report data to the Tennessee Department of Health. The reports for blood stream
infections should be limited to intensive care units. Health care facilities should report the
central line associated blood stream infections grouped by intensive care units in order to use
CDC NNIS/NHSN comparative data benchmarks. Health care facilities will use CDC
NNIS/NHSN definitions and methods for identifying these infections. The subcommittee
recommends excluding data from Burn Units and Level I Trauma Units.



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        The subcommittee further recommends reporting all surgical site infections associated
with coronary artery bypass surgery to the Tennessee Department of Health, but not for public
reporting. The subcommittee recognizes the gravity of such infections and agreed to track and
trend these infections reporting feed back to the facilities providing this data. Several members
of the subcommittee felt that these infection rates not be reported publicly, as there will be major
incentives to “game the system”, and it will be difficult to validate infection rates. Furthermore,
many infections may occur after hospital discharge and there is yet no clear consensus on how to
best conduct post-discharge surveillance. Hospitals that perform coronary artery bypass graft
surgery should use CDC/NNIS/NHSN definitions and methodology and use the NHSN software
to collect and report data to the Tennessee Department of Health but not to the public at this
time.

        After discussing current mandatory reporting requirements including the “Unusual Event
Reporting,” the subcommittee concluded that there is much confusion across the state regarding
Unusual Event Reporting related to surgical site infections. The subcommittee recommends
clarifying the “Interpretive Guidelines for Reporting Unusual Events” with regard to Class I and
Class II surgical site infections. Surgical site infections are coded as 808 under procedure related
events. The subcommittee concludes that Class I and Class II surgical site infections should not
be reported to the Tennessee Department of Health unless the patient dies as a direct result of the
surgical site infection or the patient suffers serious or life threatening injury as a result of the
surgical site infection not related to underlying medical conditions or the natural course of the
patient’s illness. It is the consensus of the subcommittee that the “Interpretive Guidelines for
Reporting Unusual Events” be changed to reflect the language of the JCAHO Sentinel Event
Policy which can be reviewed at the following web site:
(http://www.jcaho.org/accredited+organizations/sentinel+event/se_pp.htm#1).

According to the JCAHO, a sentinel event is an unexpected occurrence involving death or
serious physical or psychological injury, or the risk thereof. Serious injury specifically includes
loss of limb or function. The phrase, "or the risk thereof" includes any process variation for
which a recurrence would carry a significant chance of a serious adverse outcome. Such events
are called "sentinel" because they signal the need for immediate investigation and response. The
JCAHO definition has national acceptance and would not add additional burden to what
hospitals currently report.

Process Measures
       The subcommittee recommends reporting the required CMS measures for SCIP involving
pre-operative and post-operative antibiotic timing for selected CMS procedures: hip and knee
replacements, colorectal surgery, vascular procedures, and hysterectomy as outlined in SCIP.
Data collection should be performed using CMS definitions, methodology and software. The
SCIP measure mandates that preoperative antibiotics for infection prevention are given within
one hour of the surgical incision in order for tissue to have adequate levels of antibiotics. Post-
operative antibiotics should not extend beyond 24 hours after surgery. The subcommittee
recommends monitoring the timing for antibiotics given pre-operatively for coronary artery
bypass grafts and not post-operatively. Cardiovascular surgeons across the nation have not
reached consensus on the timing for post-operative antibiotics following coronary artery bypass



                                                                                                  9
grafting; thus when this measure is added to the SCIP protocol, the subcommittee recommends
adding it to the mandatory public reporting schemata.

        It is essential to use well defined sterile technique when inserting central venous
catheters. The CDC has guidelines on preventing intravascular catheter associated infections.
The subcommittee agrees that monitoring central line insertion techniques is very important in an
overall infection prevention program. The subcommittee recommends monitoring central line
insertion according to CDC guidelines and placing the requirement for this monitoring in the
“Rules of Tennessee Department of Health Board for Licensing Health Care Facilities Division
of Health Care Facilities” section of Chapter 1200-8-1. The subcommittee strongly urges using a
standardized check list with a minimum number of events observed. Institutions can collect
more data than is on the check list, but not less data. The subcommittee recommends that it
should be reconvened to establish a model standardized check list and standardized methods for
monitoring.

         Hand hygiene is essential for the prevention of health care associated infections.
However, the subcommittee does not recommend reporting hand hygiene monitoring at this time
because of difficulty in standardizing and validating this measurement. Monitoring hand hygiene
compliance is labor intensive and consensus has not been reached concerning the exact methods
to facilitate these observations. Tracking usage of soaps and alcohol based hand sanitizers offers
a surrogate marker but does not track actual hand hygiene practices. In order to emphasize the
importance of hand hygiene as a patient safety goal, the subcommittee recommends adding the
monitoring of hand hygiene to the “Rules of Tennessee Department of Health Board for
Licensing Health Care Facilities Division of Health Care Facilities” requiring evidence of
monitoring and annual education for health care workers with direct patient contact.

        Preventing influenza infection in a health care setting is a patient safety goal. Influenza
infection causes an average of 36,000 excess deaths and 226,000 hospitalizations in the United
States yearly. Because of their contact with patients, health care workers are at particular risk for
acquiring influenza and transmitting the disease to their patients. During influenza season,
transmission of influenza among the medical staff causes absenteeism and significant disruption
in health care delivery. The subcommittee therefore recommends mandatory influenza
vaccination of all direct patient care givers or if the direct patient care provider declines the
influenza vaccine, a signed statement indicating that choice be provided at the end of December
each year. This is the consensus of the Healthcare Infection Control Practices Advisory
Committee (HICPAC,) the Society for Healthcare Epidemiology of America (SHEA,) and the
Advisory Committee on Immunization Practices (ACIP). The subcommittee recommends
placing this requirement in the “Rules” section of the Tennessee Department of Health Board for
Licensing Health Care Facilities. The subcommittee does not recommend this as a public
reporting measure.

Implementation
       The subcommittee further recommends that these measures be phased in over time to
ensure data quality. The subcommittee is willing to reconvene to provide recommendations on
the implementation of these measures, including training, timing and validation methodologies.




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Summary

        After thorough review of available data, this subcommittee recommends the outcome
measures and process measures as described. The Tennessee Improving Patient Safety
committee and the Tennessee Department of Health should continue to promote awareness and
strengthen the adoption of infection control guidelines as well as participating in the national
reporting efforts currently underway. Acknowledging the desire of consumers for access to
information on health care acquired infections, the collaboration between the infection control
community, hospital association, consumers, the Department of Health and legislators should
continue in order to insure that useful and meaningful information is provided for the consumer
that does not overburden the health care industry.

Respectfully submitted,

Vicki Brinsko RN, CIC – co-chair
Infection Control Coordinator
Vanderbilt University Medical Center
Nashville, TN

Bryan Simmons MD – co-chair
Medical Director Infection Control
Methodist Hospital
Memphis, TN

Stephanie Brooks RN, CIC – Infection Control – St Mary’s Medical Center, Knoxville, TN
Bill Cecil- Blue Cross Blue Shield of TN, Chattanooga, TN
Chris Clarke – Tennessee Hospital Association, Nashville, TN
Judy Eads – Assistant Commissioner of Health - State Department of Health, Nashville, TN
Katy Gammon – Director of Health Care Facilities – State Department of Health, Nashville, TN
Victor Giovanetti –CHE, CEO- Southern Hills Medical Center, Nashville, TN
Cathy Green – Director of Licensure – State Department of Health, Nashville, TN
Lisa Heaton - CEO, CNO – Johnson County Health Center, Mountain City, TN
Wanda Hooper, RN, CIC – Board of Nursing, Nashville, TN
Marion Kainer, MD, MPH – Medical Epidemiologist – State Department of Health, Nashville, TN
Gaye Mayernick RN, CIC – Infection Control – Skyline Medical Center, Nashville, TN
Jennifer Plattenburg, RN, CIC – APIC President Chapter #85 Middle TN - Winchester, TN
Stuart Polly, MD - Regional Medical Center at Memphis – Memphis TN
Camilla Richard, RN, CIC- Infection Control - Baptist Memorial Healthcare System, Memphis
William Schaffner, MD – Hospital Epidemiologist – Vanderbilt Hospital, Nashville, TN
Nanette Todd – CNO- Marshall Medical Center, Lewisburg, TN
Coretha Weaver RN, CIC- Infection Control - Erlanger Health System, Chattanooga TN




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                  The Department of Health’s Summary of Recommendations

Administrative Recommendations

The Department accepts the report compiled by the subcommittee. Below is a summary of
administrative and legislative recommendations that the Department supports.

1.     Require hospitals to join National Healthcare Safety Network (NHSN) and to use the
       National Healthcare Safety Network (NHSN) software to collect and report data to the
       Tennessee Department of Health.

2.     The Department will establish a task force to work on the clarification of the
       Interpretitive Guidelines for Reporting Unusual Events with regard to Class I and Class II
       surgical site infections.

3.     The subcommittee should meet at least biannually to evaluate the reporting of health care
       acquired infections and make recommendations to the Tennessee Department of Health
       and Tennessee Improving Patient Safety Coalition for any improvement in the patient
       safety efforts.

4.     Since the recommended process indicators only relate to procedures performed in
       hospitals and the Centers for Medicare and Medicaid Services’ (CMS) web page allows
       for hospital reporting only, the recommended process quality indicators should be applied
       to hospitals not other facility types. When CMS includes other facility types, on their
       compare site, then Ambulatory Surgical Centers and others may be added at that time.

5.     In the attached summary chart, quality measures number four (4) through number seven
       (7) should be applied to all facility types that provide direct patient care.

Additional recommendations are listed in the summary table with required legislative changes or
rule changes.




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                                  Summary of Recommendations for Public Reporting of Hospital Acquired Infections

     QUALITY                      METHOD OF                                                                                                     REQUIRED
                                                              TRAINING               VERIFICATIONS                EXCLUSIONS
     MEASURES                     REPORTING                                                                                                     CHANGES
Process                       Report to Centers for    None                         By CMS. Statistical        None                        Modify law to require
                              Medicare and Medicaid                                 Outliers are required to                               reporting to CMS.
1. Prophylactic antibiotic    Services (CMS) to be                                  monitor surgeon specific
   received within 1 hour     displayed on CMS web                                  data for 3 months and
   prior to the surgical      site.                                                 report to the state.
   procedures: CABG,
   Hip, Knee
   Replacement,
   Hysterectomy,
   Colorectal and
   Vascular Surgery
Process                       Report to Centers for    None                         By CMS. Statistical        CABG’s                      Modify law to require
                              Medicare and Medicaid                                 Outliers are required to                               reporting to CMS.
2. Prophylactic antibiotic    Services (CMS) to be                                  monitor surgeon specific
   discontinued within 24     displayed on CMS web                                  data for 3 months and
   hours after surgery end    site.                                                 report to the state.
   time
   (for above procedures)
Outcome                       Report to State Health   Require hospitals to join    During survey visits.      None                        Modify current law to add
                              Department               National Healthcare Safety                                                          SSI after CABG to list of
3. Surgical Site Infections                            Network (NHSN) for                                                                  reportable events and
   after CABG                                          training and use NHSH                                                               require training for those
                                                       software to collect and                                                             health care workers
                                                       report data.                                                                        collecting and entering
                                                                                                                                           data.

Outcome                       Report to State Health   Require hospitals to join    During survey visits.      Burn Units Level I Trauma   Modify current law to add
                              Department               National Healthcare Safety                              Units                       central line infection rates
4. Central Line Infection                              Network (NHSN) for                                                                  to list of reportable events
   Rate                                                training and use NHSH                                                               and require training for
                                                       software to collect and                                                             those health care workers
                                                       report data.                                                                        collecting and entering
                                                                                                                                           data.


                                                                                                                                                             13
                                 Summary of Recommendations for Public Reporting of Hospital Acquired Infections

     QUALITY                     METHOD OF                                                                              REQUIRED
                                                               TRAINING    VERIFICATIONS            EXCLUSIONS
     MEASURES                    REPORTING                                                                              CHANGES

Process                      Reported in survey         None              Federal/State Survey    None             Revise rules for licensed
                             findings if deficiencies                     Visits                                   health care agencies
5. Hand Hygiene              found.                                       Observation/Interview

Process                      Reported in survey         None              Federal/State Survey    None             Revise rules
                             findings if deficiencies                     Visits
6. Sterile technique when    found.                                       Observation/Interview
   Inserting Central
   Venous Catheters

Process                      Reported in survey         None              Federal/State Survey    None             Revise rules
                             findings if deficiencies                     Visits
7. Influenza Vaccination     found.                                       Observation/Interview
   for all direct patient
   care personnel - either
   vaccination or signed
   declination statement


JE/G4045361/BHLR




                                                                                                                                    14
Chapter No. 323]                      PUBLIC ACTS, 2005                                     1


                                      CHAPTER NO. 323

                                     SENATE BILL NO. 441

                                       By Fowler, Cohen

                           Substituted for: House Bill No. 1342

                                     By Shepard, Overbey

AN ACT to amend Tennessee Code Annotated, Title 68, relative to certain disclosures by
     hospitals.

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF TENNESSEE:

       SECTION 1. The department of health is directed to report to the house health and
human resources committee and the senate general welfare, health and human resources
committee on or before December 31, 2005, concerning hospital-acquired infections after
consultation with the Tennessee Improving Patient Safety coalition and program and receiving
any recommends from such coalition. The report shall address issues involving hospital-
acquired infections raised by Senate Bill 441/House Bill 1342.

       SECTION 2. This act shall take effect upon becoming a law, the public welfare requiring
it.


PASSED: May 24, 2005




APPROVED this       7th     day of      June       2005
                                                                    Filed for intro on 02/03/2005



                                        SENATE BILL 441
                                           By Fowler



                                      AN ACT to amend Tennessee Code Annotated, Title 68,
                                            relative to certain disclosures by hospitals.

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF TENNESSEE:

       SECTION 1. This act shall be known and may be cited as the Hospital Infections

Disclosure Act.

       SECTION 2. For purposes of this act:

              (1) "Department" means the department of health.

              (2) “Hospital" means a hospital as defined under § 68-11-201.

              (3) "Hospital-acquired infection" means a localized or systemic condition that

       results from adverse reaction to the presence of an infectious agent or its toxins and that

       was not present or incubating at the time of admission to the hospital.

       SECTION 3.

              (a) Individual hospitals shall collect data on hospital-acquired infection rates for

       the specific clinical procedures determined by the department by regulation, including

       the following categories:

                      (1) Surgical site infections;

                      (2) Ventilator-associated pneumonia;

                      (3) Central line-related bloodstream infections;

                      (4) Urinary tract infections; and

                      (5) Other categories as provided under subsection (d).

              (b)

                      (1) Hospitals shall submit annual reports on their hospital-acquired

              infection rates to the department. Reports shall be submitted, in a format set



                                              SB0441
                                             00347657
                                                -1-
forth in regulations adopted by the department, to the department by February 1

each year for the previous year. Annual reports shall be made available to the

public at each hospital and through the department. The first annual report shall

be due in 2007.

       (2) If the hospital is a division or subsidiary of another entity that owns or

operates other hospitals or related organizations, the annual report shall be for

the specific division or subsidiary and not for the other entity.

(c)

       (1) The commissioner of health shall appoint an advisory committee,

including representatives from public and private hospitals (including from

hospital infection control departments), direct care nursing staff, physicians,

epidemiologists with expertise in hospital-acquired infections, academic

researchers, consumer organizations, health insurers, health maintenance

organizations, organized labor, and purchasers of health insurance, such as

employers. The advisory committee shall have a majority of members

representing interests other than hospitals employers. The advisory committee

shall have a majority of members representing interests other than hospitals.

       (2) The advisory committee shall assist the department in the

development of all aspects of the department's methodology for collecting,

analyzing, and disclosing the information collected under this act, including

collection methods, formatting, and methods and means for release and

dissemination.

       (3) In developing the methodology for collecting and analyzing the

infection rate data, the department and advisory committee shall consider

existing methodologies and systems for data collection, such as the Centers for


                             - 2 -                                          00347657
       Disease Control's National Nosocomial Infection Surveillance Program, or its

       successor, however the department's discretion to adopt a methodology shall not

       be limited or restricted to any existing methodology or system. The data

       collection and analysis methodology shall be disclosed to the public prior to any

       public disclosure of hospital-acquired infection rates.

               (4) The department and the advisory committee shall evaluate on a

       regular basis the quality and accuracy of hospital information reported under this

       act and the data collection, analysis, and dissemination methodologies.

       (d) The department may, after consultation with the advisory committee, require

hospitals to collect data on hospital-acquired infection rates in categories additional to

those set forth in subdivision (a).

SECTION 4.

       (a) The department shall annually submit to the general assembly a report

summarizing the hospital annual reports and shall publish the annual report on its

website. The first annual report shall be submitted and published in 2007.

       (b) All reports issued by the department shall be risk-adjusted.

       (c) The annual report shall compare the risk-adjusted hospital-acquired infection

rates collected under section 3, for each individual hospital in the state. The department,

in consultation with the advisory committee, shall make this comparison as easy to

comprehend as possible. The report shall also include an executive summary, written in

plain language, that shall include, but not be limited to, a discussion of findings,

conclusions, and trends concerning the overall state of hospital-acquired infections in the

state, including a comparison to prior years. The report may include policy

recommendations, as appropriate.




                                      - 3 -                                        00347657
                (d) The department shall publicize the report and its availability as widely as

        practical to interested parties, including, but not limited to hospitals, providers, media

        organizations, health insurers, health maintenance organizations, purchasers of health

        insurance, organized labor, consumer or patient advocacy groups, and individual

        consumers. The annual report shall be made available to any person on the

        department’s web page.

                (e) No hospital report or department disclosure may contain information

        identifying a patient, employee, or licensed health care professional in connection with a

        specific infection incident.

        SECTION 5. It is the expressed intent of the general assembly that a patient's right of

confidentiality shall not be violated in any manner. Patient social security numbers and any

other information that could be used to identify an individual patient shall not be released

notwithstanding any other provision of law.

        SECTION 6. A determination that a hospital has violated the provisions of this act may

result in any of the following:

                (1) Termination of licensure or other sanctions relating to licensure under title 68,

        chapter 11, part 2.

                (2) A civil penalty of up to five hundred dollars ($500) per day per violation for

        each day the hospital is in violation of the act.

        SECTION 7. The department shall be responsible for ensuring compliance with this act

as a condition of licensure under title 68, chapter 11, part 2, and shall enforce such compliance

according to the provisions of title 68, chapter 11, part 2.

        SECTION 8. The commissioner of health is authorized to promulgate rules and

regulations to effectuate the purposes of this act. All such rules and regulations shall be

promulgated in accordance with the provisions of title 4, chapter 5.


                                             - 4 -                                          00347657
SECTION 9. This act shall take effect July 1, 2005, the public welfare requiring it.




                                   - 5 -                                         00347657
SENATE GENERAL WELFARE COMMITTEE AMENDMENT 1
                                                                                      FILED
                                 Amendment No. 1 to SB0441                            Date _____________
                                                                                      Time _____________
                                             Ford                                     Clerk ____________
                                     Signature of Sponsor
                                                                                      Comm. Amdt. ______
       AMEND Senate Bill No. 441*                          House Bill No. 1342        __________________

by deleting all language after the enacting clause and by substituting instead the following:

               SECTION 1. The department of health is directed to report to the house health

       and human resources committee and the senate general welfare, health and human

       resources committee on or before December 31, 2005 concerning hospital-acquired

       infections after consultation with the Tennessee Improving Patient Safety coalition and

       program and receiving any recommends from such coalition. The report shall address

       issues involving hospital-acquired infections raised by Senate Bill 441/House Bill 1342.

       SECTION 2. This act shall take effect upon becoming a law, the public welfare requiring

it.




                                              SA0364
                                             00778657
                                                -1-
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         Search         About          Data Details        Resources

   Search Criteria > Select Hospitals > Select Conditions > Select Measures > Quality Measur

> Quality Measure Tables



Quality Measure Tables

                                 Start a New Search


  Heart Attack Care Quality Measures - Higher Percentages Are Better
  (some of the recommended care given to patients if appropriate*)

  Quality Measure
                                         PERCENTAGE FOR VANDERBILT UNIVERSITY
  Click on a measure name to compare
                                                      HOSPITAL
  all hospitals in a graph

  Percent of Heart Attack
  Patients Given ACE Inhibitor or
  ARB for Left Ventricular                            79% of 14 patients1,2
  Systolic Dysfunction (LVSD) if
  appropriate*

  Percent of Heart Attack
  Patients Given Aspirin at                            99% of 81 patients2
  Arrival if appropriate*

  Percent of Heart Attack
  Patients Given Aspirin at                           97% of 212 patients2
  Discharge if appropriate*
   Percent of Heart Attack
   Patients Given Beta Blocker at                                          94% of 81 patients2
   Arrival if appropriate*

   Percent of Heart Attack
   Patients Given Beta Blocker at                                         94% of 208 patients2
   Discharge if appropriate*

   Percent of Heart Attack
   Patients Given PCI Within 120                                          67% of 18 patients1,2
   Minutes Of Arrival if appropriate*

   Percent of Heart Attack
   Patients Given Smoking
                                                                          90% of 125 patients2
   Cessation Advice/Counseling if
   appropriate*

   Percent of Heart Attack
   Patients Given Thrombolytic
                                                                           0% of 1 patients1,2,3
   Medication Within 30 Minutes
   Of Arrival if appropriate*

* The percentage includes only patients whose history and condition indicate the treatment is appropriate. Talk to your
health care provider if you have questions about your treatment.
1: The number of cases is too small (n<25) for purposes of reliably predicting hospital's performance.
2: Measure reflects the hospital's indication that its submission was based on a sample of its relevant discharges.
3: Rate reflects fewer than the maximum possible quarters of data for the measure.


Note: Use the information in Hospital Compare with the other information you gather about
hospitals as you decide where to get hospital services. You may want to contact your health care
provider, your State Survey Agency or your state Quality Improvement Organization (QIO) for
more information. If you have a complaint about the quality of the medical care you or a loved one
received at a hospital, first contact the hospital’s patient advocate. Or, contact your state QIO. If
you have other complaints about a health care facility, contact your State Survey Agency. Their
phone numbers can be found at medicare.gov/Helpful Contacts. Additional information
about hospitals may be found on the state websites.

 Quality Measure Graphs


Provides quality measure information for all the hospitals that you have selected in bar graph
format (for ease in comparison), including National and State averages for each measure.



   Heart Failure Care Quality Measures - Higher Percentages Are Better
   (some of the recommended care given to patients if appropriate*)

   Quality Measure
                                                        PERCENTAGE FOR VANDERBILT UNIVERSITY
   Click on a measure name to compare
                                                                     HOSPITAL
   all hospitals in a graph

   Percent of Heart Failure
   Patients Given ACE Inhibitor or                                         82% of 51 patients2
   ARB for Left Ventricular
   Systolic Dysfunction (LVSD) if
   appropriate*

   Percent of Heart Failure
   Patients Given Assessment of
                                                                          96% of 557 patients2
   Left Ventricular Function (LVF)
   if appropriate*

   Percent of Heart Failure
   Patients Given Discharge                                               76% of 492 patients2
   Instructions if appropriate*

   Percent of Heart Failure
   Patients Given Smoking
                                                                          82% of 115 patients2
   Cessation Advice/Counseling if
   appropriate*

* The percentage includes only patients whose history and condition indicate the treatment is appropriate. Talk to your
health care provider if you have questions about your treatment.
2: Measure reflects the hospital's indication that its submission was based on a sample of its relevant discharges.


Note: Use the information in Hospital Compare with the other information you gather about
hospitals as you decide where to get hospital services. You may want to contact your health care
provider, your State Survey Agency or your state Quality Improvement Organization (QIO) for
more information. If you have a complaint about the quality of the medical care you or a loved one
received at a hospital, first contact the hospital’s patient advocate. Or, contact your state QIO. If
you have other complaints about a health care facility, contact your State Survey Agency. Their
phone numbers can be found at medicare.gov/Helpful Contacts. Additional information
about hospitals may be found on the state websites.

 Quality Measure Graphs


Provides quality measure information for all the hospitals that you have selected in bar graph
format (for ease in comparison), including National and State averages for each measure.



   Pneumonia Care Quality Measures - Higher Percentages Are Better
   (some of the recommended care given to patients if appropriate*)

   Quality Measure
                                                        PERCENTAGE FOR VANDERBILT UNIVERSITY
   Click on a measure name to compare
                                                                     HOSPITAL
   all hospitals in a graph

   Percent of Pneumonia Patients
   Assessed and Given
                                                                          43% of 121 patients2
   Pneumococcal Vaccination if
   appropriate*

   Percent of Pneumonia Patients
   Given Initial Antibiotic(s)
                                                                          38% of 279 patients2
   within 4 Hours After Arrival if
   appropriate*
   Percent of Pneumonia Patients
   Given Oxygenation                                                      100% of 389 patients2
   Assessment if appropriate*

   Percent of Pneumonia Patients
   Given Smoking Cessation                                                 20% of 91 patients2
   Advice/Counseling if appropriate*

   Percent of Pneumonia Patients
   Given the Most Appropriate                                             61% of 127 patients2
   Initial Antibiotic(s) if appropriate*

   Percent of Pneumonia Patients
   Having a Blood Culture
   Performed Prior to First                                               84% of 244 patients2
   Antibiotic Received in Hospital
   if appropriate*

* The percentage includes only patients whose history and condition indicate the treatment is appropriate. Talk to your
health care provider if you have questions about your treatment.
2: Measure reflects the hospital's indication that its submission was based on a sample of its relevant discharges.


Note: Use the information in Hospital Compare with the other information you gather about
hospitals as you decide where to get hospital services. You may want to contact your health care
provider, your State Survey Agency or your state Quality Improvement Organization (QIO) for
more information. If you have a complaint about the quality of the medical care you or a loved one
received at a hospital, first contact the hospital’s patient advocate. Or, contact your state QIO. If
you have other complaints about a health care facility, contact your State Survey Agency. Their
phone numbers can be found at medicare.gov/Helpful Contacts. Additional information
about hospitals may be found on the state websites.

 Quality Measure Graphs


Provides quality measure information for all the hospitals that you have selected in bar graph
format (for ease in comparison), including National and State averages for each measure.



   Surgical Infection Prevention Quality Measures - Higher Percentages Are Better
   (some of the recommended care given to patients if appropriate*)

   Quality Measure
                                                        PERCENTAGE FOR VANDERBILT UNIVERSITY
   Click on a measure name to compare
                                                                     HOSPITAL
   all hospitals in a graph

   Percent of Surgery Patients
   Who Received Preventative
                                                                          51% of 306 patients2,3
   Antibiotic(s) One Hour Before
   Incision if appropriate*

   Percent of Surgery Patients
   Whose Preventative                                                     80% of 240 patients2,3
   Antibiotic(s) are Stopped
   Within 24 hours After Surgery
   if appropriate*

* The percentage includes only patients whose history and condition indicate the treatment is appropriate. Talk to your
health care provider if you have questions about your treatment.
2: Measure reflects the hospital's indication that its submission was based on a sample of its relevant discharges.
3: Rate reflects fewer than the maximum possible quarters of data for the measure.


Note: Use the information in Hospital Compare with the other information you gather about
hospitals as you decide where to get hospital services. You may want to contact your health care
provider, your State Survey Agency or your state Quality Improvement Organization (QIO) for
more information. If you have a complaint about the quality of the medical care you or a loved one
received at a hospital, first contact the hospital’s patient advocate. Or, contact your state QIO. If
you have other complaints about a health care facility, contact your State Survey Agency. Their
phone numbers can be found at medicare.gov/Helpful Contacts. Additional information
about hospitals may be found on the state websites.

 Quality Measure Graphs


Provides quality measure information for all the hospitals that you have selected in bar graph
format (for ease in comparison), including National and State averages for each measure.




                                                        Start a New Search

Data Last Updated: December 1, 2005
Page Last Updated: September 1, 2005


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         Search         About         Data Details          Resources

   Search Criteria > Select Hospitals > Select Conditions > Select Measures > Quality Measur



Quality Measure Graphs

                                  Start a New Search

Heart Attack Graphs

Heart Failure Graphs

Pneumonia Graphs

Surgical Infection Prevention Graphs




Graph 1 of 20
   Percent of Heart Attack Patients Given ACE Inhibitor or ARB for Left
   Ventricular Systolic Dysfunction (LVSD)
  The rates displayed in this graph are from data reported for discharges January 2005
  through March 2005.

                                                                                              Top
                                                                                            Hospitals
                                                                                             100%
AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                        80%
THE UNITED STATES
AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                       79%
THE STATE OF TENNESSEE
                                          The number of cases is too small (n<25) for purposes of reliably
VANDERBILT UNIVERSITY
                                          predicting hospital performance. Click here for more information
HOSPITAL                                  on this hospital.



                                  Top Hospitals represents the top 10% of hospitals nationwide. Top hospitals achieved
                                  a 100% rate or better.
  Why is this Important?

  ACE (angiotensin converting enzyme) inhibitors and ARBs (angiotensin receptor blockers) are
  medicines used to treat patients with heart failure and are particularly beneficial in those patients
  with heart failure and decreased function of the left side of the heart. Early treatment with ACE
  inhibitors and ARBs in patients who have heart failure symptoms or decreased heart function
  after a heart attack can also reduce their risk of death from future heart attacks. ACE inhibitors
  and ARBs work by limiting the effects of a hormone that narrows blood vessels, and may thus
  lower blood pressure and reduce the work the heart has to perform. Since the ways in which
  these two kinds of drugs work are different, your doctor will decide which drug is most appropriate
  for you. If you have a heart attack and/or heart failure, you should get a prescription for ACE
  inhibitors or ARBs if you have decreased heart function before you leave the hospital.

  For more information about Heart Attack Care, click here.

  Note: Use the information in Hospital Compare with the other information you gather about
  hospitals as you decide where to get hospital services. You may want to contact your health care
  provider, your State Survey Agency or your state Quality Improvement Organization (QIO) for
  more information. If you have a complaint about the quality of the medical care you or a loved one
  received at a hospital, first contact the hospital’s patient advocate. Or, contact your state QIO. If
  you have other complaints about a health care facility, contact your State Survey Agency. Their
  phone numbers can be found at medicare.gov/Helpful Contacts. Additional information
  about hospitals may be found on the state websites.


   Quality Measure Tables
                              Click here to see quality information in a
                              table. This may be easier to use to                          More Graphs Below
                              compare hospitals side-by-side.

  Graph 2 of 20
     Percent of Heart Attack Patients Given Aspirin at Arrival
     The rates displayed in this graph are from data reported for discharges April 2004 through
     March 2005.

                                                                                                                 Top
                                                                                                               Hospitals
                                                                                                                100%


AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                                 91%
THE UNITED STATES
AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                             85%
THE STATE OF TENNESSEE
VANDERBILT UNIVERSITY
                                                                                                              99%
HOSPITAL


                                   Top Hospitals represents the top 10% of hospitals nationwide. Top hospitals achieved
                                   a 100% rate or better.
  Why is this Important?

  The heart is a muscle that gets oxygen through blood vessels. Sometimes blood clots can block
  these blood vessels, and the heart can’t get enough oxygen. This can cause a heart attack.
  Chewing an aspirin as soon as symptoms of a heart attack begin may help reduce the severity of
  the attack. This chart shows the percent of heart attack patients who were given (or took) aspirin
  within 24 hours of arrival at the hospital.

  Higher percentages are better.

  For more information about Heart Attack Care, click here.

  Note: Use the information in Hospital Compare with the other information you gather about
  hospitals as you decide where to get hospital services. You may want to contact your health care
  provider, your State Survey Agency or your state Quality Improvement Organization (QIO) for
  more information. If you have a complaint about the quality of the medical care you or a loved one
  received at a hospital, first contact the hospital’s patient advocate. Or, contact your state QIO. If
  you have other complaints about a health care facility, contact your State Survey Agency. Their
  phone numbers can be found at medicare.gov/Helpful Contacts. Additional information
  about hospitals may be found on the state websites.


   Quality Measure Tables
                              Click here to see quality information in a
                              table. This may be easier to use to                           More Graphs Below
                              compare hospitals side-by-side.

  Graph 3 of 20
     Percent of Heart Attack Patients Given Aspirin at Discharge
     The rates displayed in this graph are from data reported for discharges April 2004 through
     March 2005.

                                                                                                                  Top
                                                                                                                Hospitals
                                                                                                                 100%


AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                               87%
THE UNITED STATES
AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                         80%
THE STATE OF TENNESSEE
VANDERBILT UNIVERSITY
                                                                                                             97%
HOSPITAL
                                   Top Hospitals represents the top 10% of hospitals nationwide. Top hospitals achieved
                                   a 100% rate or better.
  Why is this Important?

  Blood clots can block blood vessels. Aspirin can help prevent blood clots from forming or help
  dissolve blood clots that have formed. Following a heart attack, continued use of aspirin may help
  reduce the risk of another heart attack. Aspirin can have side effects like stomach inflammation,
  bleeding, or allergic reactions. Talk to your health care provider before using aspirin on a regular
  basis to make sure it’s safe for you.

  Higher percentages are better.

  For more information about Heart Attack Care, click here.

  Note: Use the information in Hospital Compare with the other information you gather about
  hospitals as you decide where to get hospital services. You may want to contact your health care
  provider, your State Survey Agency or your state Quality Improvement Organization (QIO) for
  more information. If you have a complaint about the quality of the medical care you or a loved one
  received at a hospital, first contact the hospital’s patient advocate. Or, contact your state QIO. If
  you have other complaints about a health care facility, contact your State Survey Agency. Their
  phone numbers can be found at medicare.gov/Helpful Contacts. Additional information
  about hospitals may be found on the state websites.


   Quality Measure Tables
                              Click here to see quality information in a
                              table. This may be easier to use to                           More Graphs Below
                              compare hospitals side-by-side.

  Graph 4 of 20
     Percent of Heart Attack Patients Given Beta Blocker at Arrival
     The rates displayed in this graph are from data reported for discharges April 2004 through
     March 2005.

                                                                                                                  Top
                                                                                                                Hospitals
                                                                                                                 100%


AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                            84%
THE UNITED STATES
AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                     76%
THE STATE OF TENNESSEE
VANDERBILT UNIVERSITY
                                                                                                          94%
HOSPITAL


                                   Top Hospitals represents the top 10% of hospitals nationwide. Top hospitals achieved
                                   a 100% rate or better.
  Why is this Important?

  Beta blockers are a type of medicine that is used to lower blood pressure, treat chest pain
  (angina) and heart failure, and to help prevent a heart attack. Beta blockers relieve the stress on
  the heart by slowing the heart rate and reducing the force with which the heart muscle contracts
  (to pump blood). Most heart attack patients should be given a beta blocker within 24 hours of
  arriving at the hospital.

  Higher percentages are better.

  For more information about Heart Attack Care, click here.

  Note: Use the information in Hospital Compare with the other information you gather about
  hospitals as you decide where to get hospital services. You may want to contact your health care
  provider, your State Survey Agency or your state Quality Improvement Organization (QIO) for
  more information. If you have a complaint about the quality of the medical care you or a loved one
  received at a hospital, first contact the hospital’s patient advocate. Or, contact your state QIO. If
  you have other complaints about a health care facility, contact your State Survey Agency. Their
  phone numbers can be found at medicare.gov/Helpful Contacts. Additional information
  about hospitals may be found on the state websites.


   Quality Measure Tables
                              Click here to see quality information in a
                              table. This may be easier to use to                           More Graphs Below
                              compare hospitals side-by-side.

  Graph 5 of 20
     Percent of Heart Attack Patients Given Beta Blocker at Discharge
     The rates displayed in this graph are from data reported for discharges April 2004 through
     March 2005.

                                                                                                                  Top
                                                                                                                Hospitals
                                                                                                                 100%


AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                              86%
THE UNITED STATES
AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                       78%
THE STATE OF TENNESSEE
VANDERBILT UNIVERSITY
                                                                                                          94%
HOSPITAL


                                   Top Hospitals represents the top 10% of hospitals nationwide. Top hospitals achieved
                                   a 100% rate or better.
  Why is this Important?

  Beta blockers are a type of medicine that is used to lower blood pressure, treat chest pain
  (angina) and heart failure, and to help prevent a heart attack. Beta blockers relieve the stress on
  your heart by slowing the heart rate and reducing the force with which your heart muscles
  contract to pump blood. They also help keep blood vessels from constricting in your heart, brain,
  and body. If you have a heart attack, you should get a prescription for a beta blocker before you
  leave the hospital.

  Higher percentages are better.

  For more information about Heart Attack Care, click here.
  Note: Use the information in Hospital Compare with the other information you gather about
  hospitals as you decide where to get hospital services. You may want to contact your health care
  provider, your State Survey Agency or your state Quality Improvement Organization (QIO) for
  more information. If you have a complaint about the quality of the medical care you or a loved one
  received at a hospital, first contact the hospital’s patient advocate. Or, contact your state QIO. If
  you have other complaints about a health care facility, contact your State Survey Agency. Their
  phone numbers can be found at medicare.gov/Helpful Contacts. Additional information
  about hospitals may be found on the state websites.


   Quality Measure Tables
                              Click here to see quality information in a
                              table. This may be easier to use to                           More Graphs Below
                              compare hospitals side-by-side.

  Graph 6 of 20
     Percent of Heart Attack Patients Given PCI Within 120 Minutes Of Arrival
     The rates displayed in this graph are from data reported for discharges July 2004 through
     March 2005.

                                                                                                         Top
                                                                                                       Hospitals
                                                                                                         88%


AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                         61%
THE UNITED STATES
AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                          62%
THE STATE OF TENNESSEE
                                           The number of cases is too small (n<25) for purposes of reliably
VANDERBILT UNIVERSITY
                                           predicting hospital performance. Click here for more information
HOSPITAL                                   on this hospital.



                                   Top Hospitals represents the top 10% of hospitals nationwide. Top hospitals achieved
                                   a 88% rate or better.
  Why is this Important?

  The heart is a muscle that gets oxygen through blood vessels. Sometimes blood clots can block
  these blood vessels, and the heart can’t get enough oxygen. This can cause a heart attack.
  Percutaneous Coronary Interventions (PCI) are procedures that are among the most effective
  ways to open blocked blood vessels and help prevent further heart muscle damage. A PCI is
  performed by a doctor to open the blockage and increase blood flow in blocked blood vessels.
  Improving blood flow to your heart as quickly as possible lessens the damage to your heart
  muscle. It also can increase your chances of surviving a heart attack. There are three procedures
  commonly described by the term PCI. These procedures all involve a catheter (a flexible tube)
  that is inserted, often through your leg, and guided through the blood vessels to the blockage.
  The three procedures are:

      •   Angioplasty - a balloon is inflated to open the blood vessel.
      •   Stenting - a small wire tube called a stent is placed in the blood vessel to hold it open.
      •   Atherectomy - a blade or laser cuts through and removes the blockage.

  Higher percentages are better.
  For more information about Heart Attack Care, click here.

  Note: Use the information in Hospital Compare with the other information you gather about
  hospitals as you decide where to get hospital services. You may want to contact your health care
  provider, your State Survey Agency or your state Quality Improvement Organization (QIO) for
  more information. If you have a complaint about the quality of the medical care you or a loved one
  received at a hospital, first contact the hospital’s patient advocate. Or, contact your state QIO. If
  you have other complaints about a health care facility, contact your State Survey Agency. Their
  phone numbers can be found at medicare.gov/Helpful Contacts. Additional information
  about hospitals may be found on the state websites.


   Quality Measure Tables
                              Click here to see quality information in a
                              table. This may be easier to use to                           More Graphs Below
                              compare hospitals side-by-side.

  Graph 7 of 20
     Percent of Heart Attack Patients Given Smoking Cessation
     Advice/Counseling
     The rates displayed in this graph are from data reported for discharges April 2004 through
     March 2005.

                                                                                                                  Top
                                                                                                                Hospitals
                                                                                                                 100%


AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                    75%
THE UNITED STATES
AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                         80%
THE STATE OF TENNESSEE
VANDERBILT UNIVERSITY
                                                                                                       90%
HOSPITAL


                                   Top Hospitals represents the top 10% of hospitals nationwide. Top hospitals achieved
                                   a 100% rate or better.
  Why is this Important?

  Smoking increases your risk for developing blood clots and heart disease that can result in a
  heart attack, heart failure or stroke. Smoking causes your arteries to thicken and your blood
  vessels to narrow. Fat and plaque stick to the walls of your arteries, which makes it harder for
  blood to flow. Reduced blood flow to your heart may result in chest pain, high blood pressure, and
  an increased heart rate. Smoking is also linked to lung disease and cancer, and can cause
  premature death. It is important that you get information to help you quit smoking before you
  leave the hospital. Quitting may help prevent another heart attack.

  Higher percentages are better.

  For more information about Heart Attack Care, click here.

  Note: Use the information in Hospital Compare with the other information you gather about
  hospitals as you decide where to get hospital services. You may want to contact your health care
  provider, your State Survey Agency or your state Quality Improvement Organization (QIO) for
  more information. If you have a complaint about the quality of the medical care you or a loved one
  received at a hospital, first contact the hospital’s patient advocate. Or, contact your state QIO. If
  you have other complaints about a health care facility, contact your State Survey Agency. Their
  phone numbers can be found at medicare.gov/Helpful Contacts. Additional information
  about hospitals may be found on the state websites.


   Quality Measure Tables
                              Click here to see quality information in a
                              table. This may be easier to use to                           More Graphs Below
                              compare hospitals side-by-side.

  Graph 8 of 20
     Percent of Heart Attack Patients Given Thrombolytic Medication Within 30
     Minutes Of Arrival
     The rates displayed in this graph are from data reported for discharges April 2004 through
     March 2005.

                                                                                                   Top
                                                                                                 Hospitals
                                                                                                   80%


AVERAGE FOR ALL
REPORTING HOSPITALS IN                                31%
THE UNITED STATES
AVERAGE FOR ALL
REPORTING HOSPITALS IN                                    36%
THE STATE OF TENNESSEE
                                           The number of cases is too small (n<25) for purposes of reliably
VANDERBILT UNIVERSITY
                                           predicting hospital performance. Click here for more information
HOSPITAL                                   on this hospital.



                                   Top Hospitals represents the top 10% of hospitals nationwide. Top hospitals achieved
                                   a 80% rate or better.
  Why is this Important?

  The heart is a muscle that gets oxygen through blood vessels. Sometimes blood clots can block
  these blood vessels and the heart can’t get enough oxygen. This can cause a heart attack.
  Thrombolytics are medicines that can help dissolve blood clots in blood vessels and improve
  blood flow to your heart. You should get them within 30 minutes of arrival at the hospital.

  Higher percentages are better.

  For more information about Heart Attack Care, click here.

  Note: Use the information in Hospital Compare with the other information you gather about
  hospitals as you decide where to get hospital services. You may want to contact your health care
  provider, your State Survey Agency or your state Quality Improvement Organization (QIO) for
  more information. If you have a complaint about the quality of the medical care you or a loved one
  received at a hospital, first contact the hospital’s patient advocate. Or, contact your state QIO. If
  you have other complaints about a health care facility, contact your State Survey Agency. Their
  phone numbers can be found at medicare.gov/Helpful Contacts. Additional information
  about hospitals may be found on the state websites.
   Quality Measure Tables
                              Click here to see quality information in a
                              table. This may be easier to use to                          More Graphs Below
                              compare hospitals side-by-side.

  Graph 9 of 20
     Percent of Heart Failure Patients Given ACE Inhibitor or ARB for Left
     Ventricular Systolic Dysfunction (LVSD)
     The rates displayed in this graph are from data reported for discharges January 2005
     through March 2005.

                                                                                                                 Top
                                                                                                               Hospitals
                                                                                                                100%


AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                       79%
THE UNITED STATES
AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                    76%
THE STATE OF TENNESSEE
VANDERBILT UNIVERSITY
                                                                                               82%
HOSPITAL


                                  Top Hospitals represents the top 10% of hospitals nationwide. Top hospitals achieved
                                  a 100% rate or better.
  Why is this Important?

  ACE (angiotensin converting enzyme) inhibitors and ARBs (angiotensin receptor blockers) are
  medicines used to treat patients with heart failure and are particularly beneficial in those patients
  with heart failure and decreased function of the left side of the heart. Early treatment with ACE
  inhibitors and ARBs in patients who have heart failure symptoms or decreased heart function
  after a heart attack can also reduce their risk of death from future heart attacks. ACE inhibitors
  and ARBs work by limiting the effects of a hormone that narrows blood vessels, and may thus
  lower blood pressure and reduce the work the heart has to perform. Since the ways in which
  these two kinds of drugs work are different, your doctor will decide which drug is most appropriate
  for you. If you have a heart attack and/or heart failure, you should get a prescription for ACE
  inhibitors or ARBs if you have decreased heart function before you leave the hospital.

  For more information about Heart Failure Care, click here.

  Note: Use the information in Hospital Compare with the other information you gather about
  hospitals as you decide where to get hospital services. You may want to contact your health care
  provider, your State Survey Agency or your state Quality Improvement Organization (QIO) for
  more information. If you have a complaint about the quality of the medical care you or a loved one
  received at a hospital, first contact the hospital’s patient advocate. Or, contact your state QIO. If
  you have other complaints about a health care facility, contact your State Survey Agency. Their
  phone numbers can be found at medicare.gov/Helpful Contacts. Additional information
  about hospitals may be found on the state websites.


   Quality Measure Tables
                              Click here to see quality information in a
                              table. This may be easier to use to                          More Graphs Below
                              compare hospitals side-by-side.
  Graph 10 of 20
     Percent of Heart Failure Patients Given Assessment of Left Ventricular
     Function (LVF)
     The rates displayed in this graph are from data reported for discharges April 2004 through
     March 2005.

                                                                                                                  Top
                                                                                                                Hospitals
                                                                                                                  97%


AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                        79%
THE UNITED STATES
AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                    74%
THE STATE OF TENNESSEE
VANDERBILT UNIVERSITY
                                                                                                            96%
HOSPITAL


                                   Top Hospitals represents the top 10% of hospitals nationwide. Top hospitals achieved
                                   a 97% rate or better.
  Why is this Important?

  The proper treatment for heart failure depends on what area of your heart is affected. An
  important test is to check how your heart is pumping, called “the left ventricular function
  assessment.” It can tell your health care provider whether the left side of your heart is pumping
  properly. Other ways to check on how your heart is pumping include:

      •   your medical history
      •   a physical examination
      •   listening to your heart sounds
      •   other tests as ordered by a physician (like an ECG (electrocardiogram), chest x-ray,
          blood work, and an echocardiogram)

  Higher percentages are better.

  For more information about Heart Failure Care, click here.

  Note: Use the information in Hospital Compare with the other information you gather about
  hospitals as you decide where to get hospital services. You may want to contact your health care
  provider, your State Survey Agency or your state Quality Improvement Organization (QIO) for
  more information. If you have a complaint about the quality of the medical care you or a loved one
  received at a hospital, first contact the hospital’s patient advocate. Or, contact your state QIO. If
  you have other complaints about a health care facility, contact your State Survey Agency. Their
  phone numbers can be found at medicare.gov/Helpful Contacts. Additional information
  about hospitals may be found on the state websites.


   Quality Measure Tables
                              Click here to see quality information in a
                              table. This may be easier to use to                           More Graphs Below
                              compare hospitals side-by-side.

  Graph 11 of 20
     Percent of Heart Failure Patients Given Discharge Instructions
     The rates displayed in this graph are from data reported for discharges April 2004 through
     March 2005.

                                                                                                       Top
                                                                                                     Hospitals
                                                                                                       86%


AVERAGE FOR ALL
REPORTING HOSPITALS IN                                              48%
THE UNITED STATES
AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                50%
THE STATE OF TENNESSEE
VANDERBILT UNIVERSITY
                                                                                           76%
HOSPITAL


                                   Top Hospitals represents the top 10% of hospitals nationwide. Top hospitals achieved
                                   a 86% rate or better.
  Why is this Important?

  Heart failure is a chronic condition. It results in symptoms such as shortness of breath, dizziness,
  and fatigue. Before you leave the hospital, the staff at the hospital should provide you with
  information to help you manage the symptoms after you get home. The information should
  include your

      •   activity level (what you can and can’t do)
      •   diet (what you should, and shouldn’t eat or drink)
      •   medications
      •   follow-up appointment
      •   watching your daily weight
      •   what to do if your symptoms get worse

  Higher percentages are better.

  For more information about Heart Failure Care, click here.

  Note: Use the information in Hospital Compare with the other information you gather about
  hospitals as you decide where to get hospital services. You may want to contact your health care
  provider, your State Survey Agency or your state Quality Improvement Organization (QIO) for
  more information. If you have a complaint about the quality of the medical care you or a loved one
  received at a hospital, first contact the hospital’s patient advocate. Or, contact your state QIO. If
  you have other complaints about a health care facility, contact your State Survey Agency. Their
  phone numbers can be found at medicare.gov/Helpful Contacts. Additional information
  about hospitals may be found on the state websites.


   Quality Measure Tables
                              Click here to see quality information in a
                              table. This may be easier to use to                           More Graphs Below
                              compare hospitals side-by-side.

  Graph 12 of 20
     Percent of Heart Failure Patients Given Smoking Cessation
     Advice/Counseling
     The rates displayed in this graph are from data reported for discharges April 2004 through
     March 2005.

                                                                                                                  Top
                                                                                                                Hospitals
                                                                                                                 100%


AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                               68%
THE UNITED STATES
AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                     75%
THE STATE OF TENNESSEE
VANDERBILT UNIVERSITY
                                                                                                 82%
HOSPITAL


                                   Top Hospitals represents the top 10% of hospitals nationwide. Top hospitals achieved
                                   a 100% rate or better.
  Why is this Important?

  Smoking increases your risk for developing blood clots and heart disease, which can result in a
  heart attack, heart failure or stroke. Smoking causes your blood vessels to thicken. Fat and
  plaque then stick to the wall of your blood vessels, which makes it harder for blood to flow.
  Reduced blood flow to your heart may result in chest pain, high blood pressure, and an increased
  heart rate. Smoking is linked to lung disease and cancer, and can cause premature death. It is
  important for your health that you get information to help you quit smoking before you leave the
  hospital.

  Higher percentages are better.

  For more information about Heart Failure Care, click here.

  Note: Use the information in Hospital Compare with the other information you gather about
  hospitals as you decide where to get hospital services. You may want to contact your health care
  provider, your State Survey Agency or your state Quality Improvement Organization (QIO) for
  more information. If you have a complaint about the quality of the medical care you or a loved one
  received at a hospital, first contact the hospital’s patient advocate. Or, contact your state QIO. If
  you have other complaints about a health care facility, contact your State Survey Agency. Their
  phone numbers can be found at medicare.gov/Helpful Contacts. Additional information
  about hospitals may be found on the state websites.


   Quality Measure Tables
                              Click here to see quality information in a
                              table. This may be easier to use to                           More Graphs Below
                              compare hospitals side-by-side.

  Graph 13 of 20
     Percent of Pneumonia Patients Assessed and Given Pneumococcal
     Vaccination
     The rates displayed in this graph are from data reported for discharges April 2004 through
     March 2005.


                                                                                                       Top
                                                                                                   Hospitals
                                                                                                     83%


AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                 51%
THE UNITED STATES
AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                      57%
THE STATE OF TENNESSEE
VANDERBILT UNIVERSITY
                                                                43%
HOSPITAL


                                   Top Hospitals represents the top 10% of hospitals nationwide. Top hospitals achieved
                                   a 83% rate or better.
  Why is this Important?

  The pneumococcal vaccine may help you prevent, or lower the risk of complications of
  pneumonia caused by bacteria. It may also help you prevent future infections. Patients with
  pneumonia should be asked if they have been vaccinated recently for pneumonia and, if not,
  should be given the vaccine.

  Higher percentages are better.

  For more information about Pneumonia Care, click here.

  Note: Use the information in Hospital Compare with the other information you gather about
  hospitals as you decide where to get hospital services. You may want to contact your health care
  provider, your State Survey Agency or your state Quality Improvement Organization (QIO) for
  more information. If you have a complaint about the quality of the medical care you or a loved one
  received at a hospital, first contact the hospital’s patient advocate. Or, contact your state QIO. If
  you have other complaints about a health care facility, contact your State Survey Agency. Their
  phone numbers can be found at medicare.gov/Helpful Contacts. Additional information
  about hospitals may be found on the state websites.


   Quality Measure Tables
                              Click here to see quality information in a
                              table. This may be easier to use to                           More Graphs Below
                              compare hospitals side-by-side.

  Graph 14 of 20
     Percent of Pneumonia Patients Given Initial Antibiotic(s) within 4 Hours
     After Arrival
     The rates displayed in this graph are from data reported for discharges April 2004 through
     March 2005.

                                                                                                          Top
                                                                                                        Hospitals
                                                                                                          90%


AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                    75%
THE UNITED STATES
AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                     76%
THE STATE OF TENNESSEE
VANDERBILT UNIVERSITY
                                                            38%
HOSPITAL


                                   Top Hospitals represents the top 10% of hospitals nationwide. Top hospitals achieved
                                   a 90% rate or better.
  Why is this Important?

  Antibiotics are used to treat adults with pneumonia caused by bacteria. Early treatment with
  antibiotics can cure bacterial pneumonia and reduce the possibility of complications. This
  information shows the percent of patients who were given their first dose of antibiotics within 4
  hours of arrival at the hospital. Patients who get pneumonia during their stay at the hospital are
  not counted in this measure.

  Higher percentages are better.

  For more information about Pneumonia Care, click here.

  Note: Use the information in Hospital Compare with the other information you gather about
  hospitals as you decide where to get hospital services. You may want to contact your health care
  provider, your State Survey Agency or your state Quality Improvement Organization (QIO) for
  more information. If you have a complaint about the quality of the medical care you or a loved one
  received at a hospital, first contact the hospital’s patient advocate. Or, contact your state QIO. If
  you have other complaints about a health care facility, contact your State Survey Agency. Their
  phone numbers can be found at medicare.gov/Helpful Contacts. Additional information
  about hospitals may be found on the state websites.


   Quality Measure Tables
                              Click here to see quality information in a
                              table. This may be easier to use to                           More Graphs Below
                              compare hospitals side-by-side.

  Graph 15 of 20
     Percent of Pneumonia Patients Given Oxygenation Assessment
     The rates displayed in this graph are from data reported for discharges April 2004 through
     March 2005.

                                                                                                                  Top
                                                                                                                Hospitals
                                                                                                                 100%


AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                                        98%
THE UNITED STATES
AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                                        99%
THE STATE OF TENNESSEE
VANDERBILT UNIVERSITY
                                                                                                              100%
HOSPITAL
                                  Top Hospitals represents the top 10% of hospitals nationwide. Top hospitals achieved
                                  a 100% rate or better.
 Why is this Important?

 Pneumonia can lower the oxygen in your blood because the air spaces in your lungs fill with
 mucus. The oxygen you breathe does not get into your bloodstream. It is important that the
 amount of oxygen in your blood be measured within 24 hours of arriving at the hospital to see if
 you need oxygen therapy. The assessment may include an ABG (arterial blood gas) or pulse
 oximetry (electrodes attached to a part of your body like a finger, earlobe, or skin fold).

 Higher percentages are better.

 For more information about Pneumonia Care, click here.

 Note: Use the information in Hospital Compare with the other information you gather about
 hospitals as you decide where to get hospital services. You may want to contact your health care
 provider, your State Survey Agency or your state Quality Improvement Organization (QIO) for
 more information. If you have a complaint about the quality of the medical care you or a loved one
 received at a hospital, first contact the hospital’s patient advocate. Or, contact your state QIO. If
 you have other complaints about a health care facility, contact your State Survey Agency. Their
 phone numbers can be found at medicare.gov/Helpful Contacts. Additional information
 about hospitals may be found on the state websites.



   Quality Measure Tables
                              Click here to see quality information in a
                              table. This may be easier to use to                          More Graphs Below
                              compare hospitals side-by-side.

  Graph 16 of 20
     Percent of Pneumonia Patients Given Smoking Cessation
     Advice/Counseling
     The rates displayed in this graph are from data reported for discharges April 2004 through
     March 2005.

                                                                                                                 Top
                                                                                                               Hospitals
                                                                                                                 96%


AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                            66%
THE UNITED STATES
AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                     76%
THE STATE OF TENNESSEE
VANDERBILT UNIVERSITY
                                            20%
HOSPITAL


                                  Top Hospitals represents the top 10% of hospitals nationwide. Top hospitals achieved
                                  a 96% rate or better.
  Why is this Important?

  Smoking damages your lungs and can make it hard to breath. Smoking increases your chances
  of getting pneumonia or other chronic lung diseases like emphysema and bronchitis. Smoking is
  also linked to lung cancer, heart disease, and stroke, and can cause premature death. It is
  important for you to get information to help you quit smoking before you leave the hospital.
  Quitting may reduce your chance of getting pneumonia again.

  Higher percentages are better.

  For more information about Pneumonia Care, click here.

  Note: Use the information in Hospital Compare with the other information you gather about
  hospitals as you decide where to get hospital services. You may want to contact your health
  care provider, your State Survey Agency or your state Quality Improvement Organization (QIO)
  for more information. If you have a complaint about the quality of the medical care you or a loved
  one received at a hospital, first contact the hospital’s patient advocate. Or, contact your state
  QIO. If you have other complaints about a health care facility, contact your State Survey Agency.
  Their phone numbers can be found at medicare.gov/Helpful Contacts. Additional
  information about hospitals may be found on the state websites.


   Quality Measure Tables
                               Click here to see quality information in a
                               table. This may be easier to use to                          More Graphs Below
                               compare hospitals side-by-side.

  Graph 17 of 20
     Percent of Pneumonia Patients Given the Most Appropriate Initial
     Antibiotic(s)
     The rates displayed in this graph are from data reported for discharges July 2004 through
     March 2005.

                                                                                                          Top
                                                                                                        Hospitals
                                                                                                          89%


AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                     76%
THE UNITED STATES
AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                    75%
THE STATE OF TENNESSEE
VANDERBILT UNIVERSITY
                                                                               61%
HOSPITAL


                                   Top Hospitals represents the top 10% of hospitals nationwide. Top hospitals achieved
                                   a 89% rate or better.
  Why is this Important?

  Pneumonia is a lung infection that is usually caused by bacteria or a virus. If pneumonia is
  caused by bacteria, hospitals will treat the infection with antibiotics. Different bacteria are treated
  with different antibiotics. To learn about how hospitals use a blood test to choose the most
  effective treatment for pneumonia patients, click here.

  Higher percentages are better.
  For more information about Pneumonia Care, click here.

  Note: Use the information in Hospital Compare with the other information you gather about
  hospitals as you decide where to get hospital services. You may want to contact your health
  care provider, your State Survey Agency or your state Quality Improvement Organization (QIO)
  for more information. If you have a complaint about the quality of the medical care you or a loved
  one received at a hospital, first contact the hospital’s patient advocate. Or, contact your state
  QIO. If you have other complaints about a health care facility, contact your State Survey Agency.
  Their phone numbers can be found at medicare.gov/Helpful Contacts. Additional
  information about hospitals may be found on the state websites.


   Quality Measure Tables
                               Click here to see quality information in a
                               table. This may be easier to use to                          More Graphs Below
                               compare hospitals side-by-side.

  Graph 18 of 20
     Percent of Pneumonia Patients Having a Blood Culture Performed Prior to
     First Antibiotic Received in Hospital
     The rates displayed in this graph are from data reported for discharges April 2004 through
     March 2005.

                                                                                                             Top
                                                                                                           Hospitals
                                                                                                             93%


AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                          82%
THE UNITED STATES
AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                        79%
THE STATE OF TENNESSEE
VANDERBILT UNIVERSITY
                                                                                                  84%
HOSPITAL


                                   Top Hospitals represents the top 10% of hospitals nationwide. Top hospitals achieved
                                   a 93% rate or better.
  Why is this Important?

  Different types of bacteria can cause pneumonia. A blood culture is a test that lets the health
  care provider know which bacteria may have caused your pneumonia, and which antibiotic
  should be prescribed. It is best to do the blood culture within 24 hours of arrival at the hospital
  and before antibiotics are started. It is also important to start antibiotics as soon as possible. A
  blood culture lets your health care provider know how to best treat you and if any precautions
  are necessary to prevent the spread of your illness.

  Higher percentages are better.

  For more information about Pneumonia Care, click here.

  Note: Use the information in Hospital Compare with the other information you gather about
  hospitals as you decide where to get hospital services. You may want to contact your health
  care provider, your State Survey Agency or your state Quality Improvement Organization (QIO)
  for more information. If you have a complaint about the quality of the medical care you or a loved
  one received at a hospital, first contact the hospital’s patient advocate. Or, contact your state
  QIO. If you have other complaints about a health care facility, contact your State Survey Agency.
  Their phone numbers can be found at medicare.gov/Helpful Contacts. Additional
  information about hospitals may be found on the state websites.


   Quality Measure Tables
                              Click here to see quality information in a
                              table. This may be easier to use to                           More Graphs Below
                              compare hospitals side-by-side.

  Graph 19 of 20
     Percent of Surgery Patients Who Received Preventative Antibiotic(s) One
     Hour Before Incision
     The rates displayed in this graph are from data reported for discharges July 2004 through
     March 2005.

                                                                                                             Top
                                                                                                           Hospitals
                                                                                                             93%


AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                                70%
THE UNITED STATES
AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                              67%
THE STATE OF TENNESSEE
VANDERBILT UNIVERSITY
                                                                       51%
HOSPITAL


                                   Top Hospitals represents the top 10% of hospitals nationwide. Top hospitals achieved
                                   a 93% rate or better.
  Why is this Important?

  Antibiotics are medicines to prevent and treat infections. Research shows that surgery patients
  who get antibiotics within the hour before their operation are less likely to get wound infections.
  Getting an antibiotic earlier, or after surgery begins, is not as effective. This shows how often
  hospitals make sure surgery patients get antibiotics at the right time.

  Higher percentages are better.

  For more information about Surgical Infection Prevention Care, click here.

  Note: Use the information in Hospital Compare with the other information you gather about
  hospitals as you decide where to get hospital services. You may want to contact your health
  care provider, your State Survey Agency or your state Quality Improvement Organization (QIO)
  for more information. If you have a complaint about the quality of the medical care you or a loved
  one received at a hospital, first contact the hospital’s patient advocate. Or, contact your state
  QIO. If you have other complaints about a health care facility, contact your State Survey Agency.
  Their phone numbers can be found at medicare.gov/Helpful Contacts. Additional
  information about hospitals may be found on the state websites.
   Quality Measure Tables
                              Click here to see quality information in a
                              table. This may be easier to use to                           More Graphs Below
                              compare hospitals side-by-side.

  Graph 20 of 20
     Percent of Surgery Patients Whose Preventative Antibiotic(s) are Stopped
     Within 24 hours After Surgery
     The rates displayed in this graph are from data reported for discharges July 2004 through
     March 2005.

                                                                                                                  Top
                                                                                                                Hospitals
                                                                                                                  98%


AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                             66%
THE UNITED STATES
AVERAGE FOR ALL
REPORTING HOSPITALS IN                                                             66%
THE STATE OF TENNESSEE
VANDERBILT UNIVERSITY
                                                                                               80%
HOSPITAL


                                   Top Hospitals represents the top 10% of hospitals nationwide. Top hospitals achieved
                                   a 98% rate or better.
  Why is this Important?

  Antibiotics are medicines to prevent and treat infections. While the likelihood of infection after
  surgery can be reduced by giving patients preventative antibiotics, taking these antibiotics for
  more than 24 hours after routine surgery is usually not necessary and can increase the risk of
  side effects such as stomach aches, serious types of diarrhea, and antibiotic resistance (when
  antibiotics are used too much, they will not work anymore.) There are exceptions – for example,
  where the surgical site has been contaminated (making the surgery not routine).Talk to your
  doctor if you have questions about how long you should take antibiotics after surgery.

  Higher percentages are better.

  For more information about Surgical Infection Prevention Care, click here.

  Note: Use the information in Hospital Compare with the other information you gather about
  hospitals as you decide where to get hospital services. You may want to contact your health
  care provider, your State Survey Agency or your state Quality Improvement Organization (QIO)
  for more information. If you have a complaint about the quality of the medical care you or a loved
  one received at a hospital, first contact the hospital’s patient advocate. Or, contact your state
  QIO. If you have other complaints about a health care facility, contact your State Survey Agency.
  Their phone numbers can be found at medicare.gov/Helpful Contacts. Additional
  information about hospitals may be found on the state websites.


   Quality Measure Tables
                              Click here to see quality information in a
                              table. This may be easier to use to
                              compare hospitals side-by-side.
                                                    Start a New Search

Data Last Updated: December 1, 2005
Page Last Updated: December 15, 2005



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                                       HOSPITAL INFECTIONS STUDY COMMITTEE
                                                  MEMBERSHIP LIST

 ORGANIZATION REPRESENTED                           MEMBERS                     TELEPHONE                         ADDRESS
                                                                                   & FAX
Baptist Memorial Health Care System    Camilla Brandon                       P 901-226-2059   6019 Walnut Grove Road
                                       Director – Infection Control          F 901-226-5854   Memphis, TN 38120
                                       Camilla.Brandon@bmhcc.org
Blue Cross Blue Shield of TN           Bill Cecil                            P 423-755-3372   801 Pine Street
                                       bill_cecil@bcbst.com                                   Chattanooga, TN 37402

Erlanger Health System                 Coretha Weaver                        P 423-778-2048   975 East Third Street
                                       Infection Control Coordinator         F 423-427-6364   Chattanooga, TN 37403
                                       coretha.weaver@erlanger.org
Johnson County Health Center           Lisa Heaton CEO, CNO                  P 423-727-1111   1901 South Shady Street
                                       heatonla@msha.com                                      Mountain City, TN 37683-2271
Baptist Hospital                       Nanette Todd                          P 615-284-6347   2000 Church Street
                                       QCCS Supervisor                                        Nashville, TN 37236
                                       Nanette.Todd@baptisthospital.com
Methodist Health Care                  Bryan Simmons, MD                     P 901-516-8231   188 South Belleview, Suite 408
                                       Medical Director, Infection Control                    Memphis, TN 38104
                                       Methodist Hospital
                                       simmonsb@methodisthealth.org
Skyline Medical Center                 Gaye Mayernick                        P 615-769-2000   3441 Dickerson Pike
                                       Infection Control Director            F                Nashville, TN 37207
                                       Glenda.mayernick@HCAhealthcare.
                                       com
Southern Hills Medical Center          Victor E. Giovanetti, CHE             P 615-781-4150   391 Wallace Road
                                       CEO                                   F 615-781-4113   Nashville, TN 37211
                                       Victor.Giovanetti@HCAHealthcare.com
Southern Tennessee Medical Center      Jennifer Plattenburg, RN              P 931-967-8200   185 Hospital Road
                                       Dir. of Quality and Risk Managmt.     F                Winchester, TN 37398
                                       President of APIC, Chapter 85
                                       Jennifer.plattenburg@lpnt.net
St. Mary’s Medical Center              Stephanie Brooks, RN                  P 865-545-7592   900 East Oak Hill Avenue
                                       Infection Control Director            F                Knoxville, TN 37917
                                       sbrooks@stmaryshealth.com
St. Thomas Hospital                    Wanda Hooper                          P 615-222-3806   4487 Post Place
                                       Board of Nursing Representative       F 615-222-6616   Nashville, TN 37205-1605
                                       whooper@stthomas.org
Tennessee Hospital Association         Chris Clarke - cclarke@tha.com        P 615-401-7434   500 Interstate Blvd. South
                                       cclarke@tha.com                       F 615-242-4803   Nashville, TN 37210-4634
Vanderbilt University Medical Center   Vicki Brinsko, RN                     P 615-936-0724   21st Avenue South and Garland Avenue
                                       Director of Infection Control         F                Nashville, TN
                                       vic.brinsko@vanderbilt.edu
Vanderbilt University Medical Center   William Schaffner, MD                 P 615-322-2037   A-1124 Medical Center North
                                       William.schaffner@Vanderbilt.Edu      F                Campus Zip 2637
                                                                                              Nashville, TN
Regional Medical Center at Memphis     Stuart M. Polly, MD                   P 901-545-7676   877 Jefferson Avenue, AG62
                                       spolly@the-med.org                    F 901-545-7966   Memphis TN 38103

Department of Health                   Judy Eads                             P 615-741-8404   425 5th Ave North, 1st Floor, Cordell Hull Bldg.
                                       Assistant Commissioner of Health      F 615-741-5542   Nashville, TN 37247
                                       judy.eads@state.tn.us
Department of Health                   Katy Gammon                           P 615-741-7532   425 5th Ave North, 1st Floor, Cordell Hull Bldg.
                                       Director of Health Care Facilities    F 615-741-7051   Nashville, TN 37247
                                       katy.gammon@state.tn.us
Department of Health                   Cathy Green, Director of Licensure    P 615-532-6595   425 5th Ave North, 1st Floor, Cordell Hull Bldg.
                                       cathy.c.green@state.tn.us             F 615-741-7051   Nashville, TN 37247
Department of Health                   Marion A. Kainer, MD                  P 615-741-7247   425 5th Avenue N, 4th Floor, Cordell Hull Bldg.
                                       Medical Epidemiologist/Infectious     F 615-741-3857   Nashville, TN 37247-4911
                                       Diseases Physician
                                       marion.kainer@state.tn.us




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Description: Hospital Acquired Infections Spreadsheet document sample