Hospital Inpatient Quality Reporting

Inpatients age 65 years and older and 5-64 years of age who have a high risk condition who are screened for Pneumococcal Vaccine status and vaccinated prior to discharge if indicated.

Surgical patients with prophylactic antibiotics initiated within one hour prior to surgical incision. Patients who received vancomycin or a fluoroquinolone for prophylactic antibiotics should have the antibiotics initiated within two hours prior to surgical incision. Due to the longer infusion time required for vancomycin or a fluoroquinolone, it is acceptable to start these antibiotics within two hours prior to incision time.

Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure).

Surgical patients whose prophylactic antibiotics were discontinued within 24 hours after Anesthesia End Time. The Society of Thoracic Surgeons (STS) Practice Guideline for Antibiotic Prophylaxis in Cardiac Surgery (2006) indicates that there is no reason to extend antibiotics beyond 48 hours for cardiac surgery and very explicitly states that antibiotics should not be extended beyond 48 hours even with tubes and drains in place for cardiac surgery.

This measure captures the proportion of ischemic or hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given on the day of or the day after hospital admission.

This is a hospital level performance score reported as the percent of infants with Unexpected Newborn Complications among full term newborns with no preexisting conditions, typically calculated per year.

This measure assesses the number of patients diagnosed with confirmed VTE who received an overlap of Parenteral (intravenous [IV] or subcutaneous [subcu]) anticoagulation and warfarin therapy. For patients who received less than five days of overlap therapy, they should be discharged on both medications or have a Reason for Discontinuation of Parenteral Therapy.