Treatment Area

Activity Results

Annual Volume Results

Open Heart Surgery

13 (actual volume)

200 (coalition threshold)

Percutaneous Coronary Intervention

2 (actual volume)

400 (coalition threshold)

Abdominal Aortic Aneurysm Repair

n/a

Carotid Endarterectomy Surgery

n/a

Esophagectomy

1 (actual volume)

7 (coalition threshold)

Low Birthweight Infants

39 (actual volume)

70 (coalition threshold)

Infants with Congenital Anomalies

39 (actual volume)

70 (coalition threshold)

Intensive Care Unit Physician Staffing (IPS)

n/a

Open Heart Surgery

Open heart procedures are included in our Pediatric Surgical Care Infection Prevention (SCIP)initiative. There is a Cardiology/Cardiovascular Multi-disciplinary Committee to determine need for open-heart surgery.

Low Birthweight Infants and Infants with Congenital Anomalies

Children's Hospital of Michigan NICU is part of the NICHD, which is a neonatal research center (17 academic institutions throughout the USA). The network is similar to the Vermont Oxford Network which mainatains a continuous registry of morbidity and mortality and follows all infants < 1,000 grams birthweight to 18 months of age. The network has annual publications of benchmarking data pertaining to neonatal care since 1987.

Intensive Care Unit Physician Staffing (IPS)

Use of telemedicine is used as an adjunct service, in addition to 8 hr/7 day a week coverage.

General Comments on Patient Safety Activities

Patient safety activities includes, but is not limited to the following: • Surgical Infection Prevention Initiative • Ventilator-associated Pneumonia Prevention Initiative • Blood Stream Infection Prevention Initiative • Time Out Protocols • Safe Medication Practices (i.e.ISMP, JCAHO) • Surgical Site Marking • Critical Test Notification • Immunization ‘No Missed Opportunities’ • Injury Prevention Program (includes falls reduction plan) • Adverse Clinical Event Monitoring (includes near misses) • Medication/Infusion Event Monitoring (includes near misses) • Hand Hygiene Program • Respiratory Etiquette • Patient/Parent Hand Hygiene Empowerment • HCW annual Tuberculin Skin Testing (TST) • TB Control Plan • HCW annual Flu vaccines, and other vaccines • Pandemic Flu plan • Syndromic Surveillance • Communicable Disease Surveillance • Isolation Plan • Isolation Compliance Monitoring • RSV Prevention • RO system monitoring (Dialysis Unit) • Air Monitoring of Isolation and Protective Care rooms • Infection Control Risk Assessment for Construction and Renovation • Water damage Remediation • Product Recall Notification system • Toy Cleaning • Biohazardous Waste Plan • Soiled Linen Management • Latex Allergy Protection • Legionella Preventive Maintenance • Disinfection/Sterilization of medical devices