Post-Operative Blood Clot (DVT) / Lung Artery Clot (PE) Patient Safety Measure

Quality and patient safety is a primary focus at St. Mary-Corwin Medical Center. To support that focus, St. Mary-Corwin has implemented aggressive quality patient safety programs around post-surgical blood clot/lung artery clot as part of the Centura Health network, and has consistently led the Centura Health network in CMS (Centers for Medicare and Medicaid Services) perfect care scores (PCS).

PCS measures whether a patient received all the evidence based care he or she was eligible to receive and is therefore a measure of how often the hospital provided perfect care. Since early 2008, St. Mary-Corwin has led the entire Centura Health network with an average 92% perfect care score. The Centura Health system goal is 90% while the national average on quality and patient safety during this same period was just 81%.

In response to the data published in the CHA Report Card for 2008, St. Mary-Corwin conducted a review of the 47 cases identified with Post Surgical Blood Clot (DVT)/ Lung Artery Clot (PE) complications. Of the 47 cases, 63% (30 out of 47 cases) reflected a diagnosis of DVT/PE being present on admission to the hospital. This finding indicates that the blood clot did not develop as a result of being a patient at St. Mary-Corwin and does not reflect the level of preventative care received by the patient.

The patient care protocol for the prevention of blood clots includes two performance measures: ordering prophylactic medication before and after surgery.

St. Mary-Corwin’s evidence based performance in providing medications to prevent blood clots before and after surgery exceeded the national benchmark of 80% in 2008. St. Mary-Corwin’s compliance range was 92-97% during that time frame.

The remaining 17 cases did not have a diagnosis of blood clot upon admission to SMC. These 17 cases were compared to patients in these two groups and are unrelated to the surgical patient care. Therefore, the actual number of cases with complications developing after admission to the hospital is 17. When adjusted to overall patient cases, St. Mary-Corwin rating increases to Better Than Average for developing blood clots.