We have a very low volume of cases. Most case are referred to the larger affiliates within St. John Health System. We have access to risk-adjusted data in Care Science through Ascension Health. We are currently revising our surgical pre-operative assessment to address cardiac risk factors to allow us to identify patients that are at increased risk and require pre-op and perioperative beta blockade as recommended by NQF.

Most of our AAA cases are emergent in nature. We do review all cases and report to Department of Surgery. We conduct 100% review of all mortalities at St John Oakland through our local Morbidity and Mortality Committee. The Morbidity & Mortality Committee supports the pre-operative and peri-operative beta blockade for patients identified at increased cardiac risk. The Surgery and Anesthesia Departments have developed an assessment tool and policy.

All carotid endarterectomy cases are reviewed for mortality and morbidity ( post-procedure stroke). As of FY06 review (cases from July 1, 2005-June 30, 2006) there were 0 mortalities identified. Cases are also reviewed to determine if Interqual criteria was met for the procedure. We also review for complications. Pre-operative assessment tools have been updated to identify patients at increased cardiac risk to allow for administration of pre and peri-operative beta blockade to those identified at risk.

Involved in Keystone ICU project through MHA since onset. Projects include prevention of central line BSI (rates have been at 0 the past 6 consecutive quarters); prevention of ventilator-associated pneumonia utilizing VENT BUNDLE ( our rates have been below NNIS rate). Tight glycemic control. Sepsis identification and management. Data is collected and reported as required. Daily goal sheets are utilized. Multidisciplinary rounds are conducted daily in the ICU by the intensivist.