Treatment Area

Activity Results

Annual Volume Results

Open Heart Surgery

338 (actual volume)

200 (coalition threshold)

Percutaneous Coronary Intervention

1048 (actual volume)

400 (coalition threshold)

Abdominal Aortic Aneurysm Repair

78 (actual volume)

20 (coalition threshold)

Carotid Endarterectomy Surgery

94 (actual volume)

50 (coalition threshold)

Esophagectomy

0 (actual volume)

7 (coalition threshold)

Low Birthweight Infants

n/a

Infants with Congenital Anomalies

n/a

Intensive Care Unit Physician Staffing (IPS)

n/a

Open Heart Surgery

IRMC formed a cardiovascular surgery peer review QI committee, which began meeting in July 2005. All CV surgeons review all mortalities and significant compliations using the peer review format. This group also reviews compliance to national standards and benchmarks.

Percutaneous Coronary Intervention

IRMC participates in BCM², a statewide consortium of PTCA/stents procedures, in lieu of ACC-NCDR. BCM² is sponsored by BCBSM. IRMC uses BCM² database as our quality and outcomes benchmarks.

Abdominal Aortic Aneurysm Repair

MHA releases severity-adjusted statewide norms for all APR-DRGs, which allows member hospitals to compare internal data to statewide data.

Carotid Endarterectomy Surgery

MHA releases severity-adjusted statewide norms for all APR-DRGs, which allows member hospitals to compare internal data to statewide data.

Esophagectomy

MHA releases severity-adjusted statewide norms for all APR-DRGs, which allows member hospitals to compare internal data to statewide data.

Intensive Care Unit Physician Staffing (IPS)

IRMC participates in the Keystone ICU initiative, which includes the use of the ICU toolkit.

General Comments on Patient Safety Activities

Core Measures (AMI, HF, PNE, SIP) Patient Safety Committee Falls Committee Restraint Review Pharmacy/Nursing Medication Safety Committee Corporate Patient Safety Committee and Dashboard Keystone ICU project Cardiac Center of Excellence program Stoke Team