Carotid Artery Stenting Complication Rates

Carotid Artery Stenting Complication Rates Aggregate Rate = 0.0% 10 The target set by The Joint Commission for complications after carotid artery stenting is an aggregate rate of < 6%. Complications include stroke and/or death within 30 days post-procedure. Erlanger Southeast Regional Stroke Center out-performs this standard with a complication rate of 0.0% for carotid artery stenting procedures. The graph below demonstrates the number of carotid artery stenting procedures completed each month along with the number 9 of complications.

Number of CasesNumber of 4

0 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14

Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 COMPLICATION 0 0 0 0 0 0 0 0 0 0 0 0 TOTAL CASES 0 3 7 3 1 4 1 1 1 1 2 5 Carotid Endarterectomy Complication Rates Aggregate Rate = 20 The target set by The Joint Commission for complication rates after0.76% symptomatic carotid endarterectomy is an aggregate rate of < 6%. Complications include myocardial infarction within 24 hours post-procedure or stroke and/or death within 30 days post-procedure. Erlanger Southeast Regional Stroke Center out- performs this standard with a complication rate of 0.76% for symptomatic carotid endarterectomy procedures. The graph below demonstrates the number 18 of carotid endarterectomy procedures completed each month along with the number of complications.

Number of CasesNumber of 8

0 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14

Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 COMPLICATION 0 0 0 1 0 0 0 0 0 0 0 0 TOTAL CASES 6 8 9 11 8 7 13 11 14 13 3 10 Diagnostic Cerebral Angiography Complication Rates Aggregate Rate = 0.43% 70 The target set by The Joint Commission for the complication rate after diagnostic cerebral angiography is below 1%. Complications include stroke and/or death within 24 hours post-procedure. Erlanger Southeast Regional Stroke Center out-performs this standard with a complication rate of 0.43%. The graph below demonstrates the number of diagnostic cerebral angiograms completed each month along with the number of complications.

30 Number of CasesNumber of

0 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14

Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 COMPLICATION 0 2 0 0 0 0 0 0 0 0 0 0 TOTAL CASES 42 39 43 36 53 25 36 46 39 52 26 41 Best Demonstrated Practices Stroke Comprehensive Stroke (CSTK) Center Metrics Data Through December 2014

Current Month: December 2014 FYTD: July 2014 - December 2014 Current Current FY15 FY vs Qualified Observed Observed *** National EHS Actual vs. National Actual Discharge Incidence Incidence Average Previous Average Valid IP Discharged Patients Only Events s Rate Rate (Dec 14 ) FY ***Trend CSTK-01 National Institutes of Health Stroke Scale Score on 0 0 #DIV/0! 75.0% 14.6% -6.0% Arrival (NIHSS) CSTK-02 Modified Rankin Score (mRS) at 90 Days 2 25 8.0% 9.4% 6.97% -2.9% CSTK-03 Severity Measurement on Arrival 1 2 50.0% 43.2% 15.17% 18.9% CSTK-04 Median Time to Treatment with a Procoagulant 0 128.3 Reversal Agent Minutes CSTK-04a Median Time to INR Reversal 0 4562 306.2 Minutes

STK) Center Metrics Center STK) CSTK-05 Hemorrhagic Complication for Patients Treated with Intra-Venous (IV) Thrombolytic (t-PA) Therapy Without Catheter- 0 7 0.0% 0.0% 0.3% -8.7% Based Reperfusion CSTK-05a Hemorrhagic Complication for Patients Treated with Intra-Arterial (IA) Thrombolytic Therapy or Mechanical Endovascular Reperfusion Procedure With or Without Intra- 0 10 0.0% 0.0% 1.68% -6.5% Venous (IV) Thrombolytic (t-PA) Therapy CSTK-06 Nimodipine Treatment Initiated 0 0 #DIV/0! 40.0% 23.9% 25.7%

Comprehensive Stroke (C Comprehensive CSTK-07 Median Time to Recanalization Therapy 72.0 106 137 2 0 #DIV/0! Minutes Minutes Minutes Minutes CSTK-8 Thrombolysis in Cerebral Infarction (TICI) Post- 10 11 90.9% 87.8% 39.5% 2.1% Treatment Reperfusion Grade

P:\Current Scorecards\Stroke.xls, Scorecard, 2/16/2015 Best Demonstrated Practices Stroke Get With The Guidelines

Includes Inpatient,Outpatient and non Core Measure Patients Data Through December 2014 Current Month: December 2014 FYTD: Jul 14 - Dec 14 Overall Stroke Measure Compliance Rate: EHS % of EHS % of Actual Current Month = 98.4% Patients Eligible Eligible Current Current FY15 = 98.3% Patients NOT Patients Patients *** FY vs. FY14 = 98.0% Receiving Receiving Receiving Receiving National EHS ***Trend FY13 = 92.1% the Req'd the Req'd Patients the Req'd the Req'd Average Previous (Jul 12 - Process Measures Treatment Treatment Excluded Treatment Treatment (Dec 14 ) FY Dec 14) 1) DVT Prophylaxis by End of Hospital Day 2 35 0 0 100.0% 98.1% 98% +3%

2) Discharged on Antithrombotics 24 1 10 96.0% 99.3% 98% -1%

3) Atrial Fibrillation Discharged on Anticoagulation Therapy 2 0 33 100.0% 96.2% 95% -2%

4) Thrombolytic Therapy Administered within 3 hours 10 0 25 100.0% 97.7% 86% +1%

4a) Thrombolytic Therapy Administered within 4.5 hours 12 1 22 92.3% 98.3% 73% -1%

5) Antithrombotic Therapy By End of Hospital Day 2 6 0 29 100.0% 100.0% 97% +0%

6) Discharged on Cholesterol Reducing Medication 19 0 16 100.0% 98.3% 94% +1%

7) Screen for Dysphagia before anything given by mouth 31 0 4 100.0% 96.3% 84% 0%

Get With The Guidelines Key Measures The Guidelines With Get 8) Stroke Education During Hospital Stay 16 1 18 94.1% 96.5% 93% -1%

9) Smoking Cessation Counseling for Smokers 8 0 27 100.0% 100.0% 96% +0%

10) Assessed for Rehabilitation 27 0 8 100.0% 100.0% 97% +0%

NIH Stroke Scale Performed 31 1 3 96.9% 96.4% 84% +3%

Pt Receiving CT Scan within 25 minutes of arrival 17 3 15 85.0% 77.8% 62% -10% Other Arrival to CT Scan (Median Minutes) 8.0 18 +0% Number of Rapid Response Team Calls for Suspected Stroke 1

P:\Current Scorecards\Stroke.xls, Scorecard, 2/16/2015 Best Demonstrated Practices Stroke Data Through December 2014

Current Month: December 2014 FYTD: Jul 2014 - Dec 2014

Current FY15 Qualified Observed Observed Current FY Actual Discharge Incidence Incidence vs. EHS Monthly Trend Valid IP Discharged Patients Only Events s Rate Rate Previous FY (Jul 12 - Dec 14) DVT Acquired During Hospital Stay 0 169 0.0% 0.59% -0.17%

PE Acquired During Hospital Stay 0 169 0.0% 0.00% -0.10% Aspiration Pneumonia Aquired During Hospital Stay 6 169 3.6% 4.30% 0.48% Per Billing/Coding Aspiration Pneumonia Aquired During Hospital Stay Other Per Staff Review Stroke Patients Readmitted within 30 Days of Discharge 11 153 7.2% 8.11% 0.68% (Unadjusted) Stroke Patient Mortality within 30 Days of Discharge 16 169 9.5% 7.43% -0.11% (Unadjusted)

P:\Current Scorecards\Stroke.xls, Scorecard, 2/16/2015