Injuries from patient falls in hospitals are a leading cause of death among people 65 and older. Of those patients who fall, up to half may suffer moderate to severe injuries that increase the risk of premature death. The potential for falls increases with hospital stays of 19 days or longer, dependency for ambulation and lack of regular exercise. Hip fractures are the most feared complication from falls with up to 20% of people sustaining hip fracture becoming nonambulatory and many are unable to recover their ability to carry out activities of daily living.

Participating hospitals will reduce their 2007 falls with injury rate per 1,000 patient days by more than 50%, with an ultimate goal of zero falls with injury. Individual improvement goals will be determined by each facility and may vary.

Data will be obtained from Cal NOC for all facilities that have executed their CalNOC addendum.

Baseline: 

2007 — 0.10 falls with injury per 1,000 patient days for BEACON hospitals that participated in CalNOC.

Severe sepsis kills approximately 30% of those who develop it and another 20% die within six months as a result of lingering damage. A prompt diagnosis and thorough treatment are necessary to saving lives.

Participating hospitals will reduce their baseline for hospital defined sepsis mortality by a minimum of 30%. . Individual improvement goals will be determined by each facility and may vary.

Hospitals will submit data on a quarterly basis for initiatives. When possible, hospitals will provide historical data to establish a baseline for improvement. Improvement will be determined by a trend line. The slope of the line from the baseline until the end of the data collection period will be used to determine if the improvement goal was successfully obtained.

Each hospital will provide their definition of sepsis and severe sepsis for their facility’s improvement data.

Baseline:
Rolling 12 months Q307–Q208 prior data or Q109 data if not previously supplied.

In the United States, every year an estimated 1.1 million people are diagnosed with an AMI. Speed of treatment is essential in the initial care of AMI patients.

Participating hospitals will reduce their AMI mortality rate without transfers by a minimum of 15%. . Individual improvement goals will be determined by each facility and may vary.

Hospitals will submit data on a quarterly basis for initiatives. When possible, hospitals will provide historical data from 2008 or data from published sources, when available, may be used to establish a baseline for improvement. Improvement will be determined by a trend line. The slope of the line from the baseline until the end of the data collection period will be used to determine if the improvement goal was successfully obtained.

Baseline:
AHRQ Baseline for 2006 25th percentile 6%

Urinary catheters are a major contributor to hospital acquired urinary tract infections. Shortening the duration of catheter use can reduce the risk of costly infections.

Participating hospitals will reduce their baseline for hospital acquired catheter associated urinary tract infection rate by a minimum of 30%. . Individual improvement goals will be determined by each facility and may vary.

Hospitals will submit data on a quarterly basis for initiatives. When possible, hospitals will provide historical data from 2008. Improvement will be determined by a trend line. The slope of the line from the baseline until the end of the data collection period will be used to determine if the improvement goal was successfully obtained.

Data will be supplied by Hospital Infection Preventionist using NHSN definitions

Baseline:
US Centers for Disease Control and Prevention (CDC) rate of 20% >4 days
NHSN 2006 data rate 4.4 and 3.4 in Combined ICU non-teaching and teaching respectively, 3.7 combined M/S unit

In the US, nearly half a million people each year suffer symptoms from Clostridium difficile (C. dif) infections. This represents an increase of over six times previous estimates. The bacteria can cause extreme diarrhea, dehydration, inflammation of the color and even death. In a hospital, C. dif can contaminate virtually every surface. Many healthy patients who go into the hospital for elective surgery have contracted C. dif and died. Studies confirm that the more bacteria found on surfaces touched by doctors and nurses, the higher the risk these bacteria will cause infection in patients.

Solutions include promoting proper cleaning of surfaces with bleach, hospitals laundering scrubs for their staff, encouraging doctors to change their lab coats more often and requiring caregivers to wear two layers of gloves.

Participating hospitals will reduce their baseline rate of patients with a discharge diagnosis of C. dificile by a minimum of 30%. . Individual improvement goals will be determined by each facility and may vary.

Hospitals will submit data on a quarterly basis for initiatives. When possible, hospitals will provide historical data from 2008. Improvement will be determined by a trend line. The slope of the line from the baseline until the end of the data collection period will be used to determine if the improvement goal was successfully obtained.

Data will be supplied by hospital using selected ICD-9 codes obtained from the hospitals information system.

Baseline:
US Centers for Disease Control and Prevention (CDC) diagnosis for 2003 61/100,000 population.
Canada C-difficile rate for 2008 0.39 per 1,000 patient days

Pressure ulcers cause considerable harm to patients, slowing recovery, causing pain and can lead to the development of serious infections. Reducing the occurrence of pressure ulcers stops suffering from this potentially dangerous condition and saves hospitals millions of dollars that would otherwise be spent on treating this injury. Successful reduction of pressure ulcers involves identifying at risk patients and implementing prevention strategies for those patients. Most pressure ulcers can be prevented.

Participating hospitals will reduce their 2007 HAPU rate by a minimum of 50% (all units combined). . Individual improvement goals will be determined by each facility and may vary.

Data will be obtained from CHART for hospitals participating in CHART.

Baseline:
2007 mean for hospitals that participate in CHART 4.5%, median 3%, 25th percentile 2%

Adverse events during labor and delivery are rare relative to the number of births but when they occur, affect not only the baby but can inflict psychological and financial consequences on family, care providers and the community.

Participating hospitals will reduce their baseline birth trauma rate per 1,000 live births by a minimum of 30%. . Individual improvement goals will be determined by each facility and may vary.

Hospitals will submit data on a quarterly basis for initiatives. When possible, hospitals will provide historical data from 2008.. Improvement will be determined by a trend line. The slope of the line from the baseline until the end of the data collection period will be used to determine if the improvement goal was successfully obtained.

Data will be supplied by Hospital Information System.

Baseline: AHRQ National Observed rate 2004–2006 1.8/1,000 live births

A stroke is the rapidly developing loss of brain functions due to a disturbance in the blood vessels supplying blood to the brain. This can be due to ischemia (lack of blood supply) caused by thrombosis or embolism or due to a hemorrhage. As a result, the affected area of the brain is unable to function, leading to inability to move one or more limbs on one side of the body, inability to understand or formulate speech or inability to see one side of the visual field. In the past, stroke was referred to as cerebrovascular accident or CVA, but the term "stroke" is now preferred.

Participating hospitals will reduce their baseline stroke mortality rate by a minimum of 15% in patients 18 years and older. Individual improvement goals will be determined by each facility and may vary.

Hospitals will submit data on a quarterly basis for initiatives. When possible, hospitals will provide historical data from 2008. Improvement will be determined by a trend line. The slope of the line from the baseline until the end of the data collection period will be used to determine if the improvement goal was successfully obtained.

Data will be supplied by hospital using selected ICD-9 codes obtained from the hospitals information system.

Baseline:
Rolling 12 months Q307–Q208, Mean 9%, median 8.3%, 25th percentile 6%
AHRQ Baseline for 2006 25th percentile 8.33%