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Lutheran Hospital

The Quality Performance Report shows how Lutheran Hospital has been doing at providing the right care for certain common conditions and preventing certain types of infections.

Why Heart Failure Care Measures are Important

Heart failure is a weakening of the heart's pumping power. With heart failure, your body doesn't get enough oxygen and nutrients to meet its needs. Your heart tries to pump more blood, but the muscle walls become weaker over time. These measures show some of the standards of care provided for most adults with heart failure.

Symptoms of heart failure may include:

  • shortness of breath from fluid in the lungs
  • swelling (such as in legs, ankles or abdomen)
  • dizziness
  • fatigue
  • weakness
  • cold or clammy skin
  • a rapid or irregular heartbeat

Heart failure can be a result of heart condition due to:

  • hardening of the arteries, also known as coronary artery disease a heart attack
  • cardiomyopathy (heart muscle damage from infection or alcohol or drug abuse)
  • an overworked heart (caused over time by conditions like high blood pressure, kidney disease, diabetes, or a defect from birth)

For more information about heart health go to:

View other publicly reported data about heart failure care in hospitals:

How is Lutheran Hospital performing on Heart Failure Care?

This score tells you the percent of heart failure patients who got all the recommended care appropriate for them from the list below:

  1. left ventricular systolic (LVS) function was evaluated before hospital arrival, during hospitalization, or scheduled for after discharge
  2. angiotensin-converting enzyme (ACE) inhibitor medication or an angiotensin receptor-blocker (ARB) medication was prescribed at discharge from the hospital (applies only to patients with left ventricular systolic dysfunction, also called LVSD)
  3. received written instructions or educational material about heart failure before discharge from the hospital

This information is important because one way to tell if a hospital is doing a good job is to look at the percent of heart failure patients who got all the recommended care on the list (as appropriate for each individual).

Higher numbers are better.

Lutheran Hospital (July 2013 - December 2013) 100%
U.S. Hospitals (July 2013 - September 2013)   95%

Updated: June 2014

Heart Failure Patient Mortality (Death)

This score tells you about the percent (rate) of heart failure patients that died within 30 days of going into the hospital.

This information is important because one way to tell if a hospital is doing a good job is to see if the death (mortality) rate for heart failure patients treated at that hospital is better than, the same as or worse than the U.S. national average. The death rates take into account how sick patients were before they were admitted to the hospital.

Lower numbers are better.

How is Lutheran Hospital doing with heart failure patient deaths?
July 2009 – June 2012
Lutheran Hospital 11.9%
U.S. national average 11.7%

The heart failure death rate shown for Lutheran Hospital is higher (worse) than the national average, but that difference is not significant. This means that Lutheran Hospital’s rate is basically the same as the national average.

Only regular Medicare patients are included. People in Medicare Advantage (managed care plans) and people who do not have Medicare are not included.

Updated: May 2013

Heart Failure Patient Hospital Readmission

This score tells you about the percent (rate) of hospitalized heart failure patients who go back into a hospital again within 30 days after going home. Patients may have been readmitted back to the same hospital or to a different hospital. They may have been readmitted for heart failure-related care or for a different reason.

This information is important because one way to tell if a hospital is doing a good job is to see if the readmission rate for heart failure patients is better than, the same as or worse than the U.S. national average. The readmission rates take into account how sick patients were before they were admitted to the hospital.

Lower numbers are better.

How is Lutheran Hospital doing with heart failure patient hospital readmission?
July 2009 – June 2012
Lutheran Hospital 23.1%
U.S. national average 23.0%

Lutheran Hospital‘s readmission rate is higher (worse) than the national average, but that difference is not significant. This means that Lutheran Hospital’s rate is basically the same as the national average.

Only regular Medicare patients are included. People in Medicare Advantage (managed care plans) and people who do not have Medicare are not included.

Updated: July 2013

What is Pneumonia?

Pneumonia is an infection of the lungs. It is caused by bacteria or a virus. The lungs fill with mucus. This lowers the oxygen level in your blood. Symptoms of pneumonia can include the following:

  • difficulty breathing
  • "wet" cough – mucus may look green or bloody
  • chest pain
  • fever and chills
  • fatigue

You should also be aware that flu shots reduce the risk of influenza, a serious and sometimes deadly lung infection that can spread quickly in a community. Hospitals should check to make sure that pneumonia patients get a flu shot during flu season to protect them from another lung infection and to help prevent the spread of influenza in the community.

For more information about lung health go to:

View other publicly reported data about pneumonia care in hospitals:

How is Lutheran Hospital Performing on Pneumonia Care?

This score tells you the percent of pneumonia patients who got all the recommended care appropriate for them from the list below:

  1. had a blood culture (test to check type of bacteria) in the emergency department before receiving any antibiotic in the hospital
  2. were given the right antibiotic

This information is important because one way to tell if a hospital is doing a good job is to look at the percent of pneumonia patients who got all the recommended care on the list (as appropriate for each individual).

Higher numbers are better.

Lutheran Hospital (July 2013 - December 2013) 91%
U.S. Hospitals (July 2013 - September 2013)  96%

Updated: June 2014

Pneumonia Patient Mortality (Death)

This score tells you about the percent (rate) of pneumonia patients that died within 30 days of going into the hospital.

Lower numbers are better.

This information is important because one way to tell if a hospital is doing a good job is to see if the death (mortality) rate for pneumonia patients treated at that hospital is better than, the same as or worse than the U.S. national average. The death rates take into account how sick patients were before they were admitted to the hospital.

How is Lutheran Hospital doing with pneumonia patient deaths?
July 2009 – June 2012
Lutheran Hospital 10.3%
U.S. national average 11.9%

The pneumonia death rate shown for Lutheran Hospital is lower (better) than the national average, but that difference is not significant. This means that Lutheran Hospital's rate is basically the same as the national average.

Only regular Medicare patients are included. People in Medicare Advantage (managed care plans) and people who do not have Medicare are not included.

Updated: May 2013

Pneumonia Patient Hospital Readmission

This score tells you about the percent (rate) of hospitalized pneumonia patients who go back into a hospital again within 30 days after going home. Patients may have been readmitted back to the same hospital or to a different hospital. They may have been readmitted for pneumonia-related care or for a different reason.

This information is important because one way to tell if a hospital is doing a good job is to see if the readmission rate for pneumonia patients is better than, the same as or worse than the U.S. national average. The readmission rates take into account how sick patients were before they were admitted to the hospital.

Lower numbers are better.

How is Lutheran Hospital doing with pneumonia patient hospital readmission?
July 2009 – June 2012
Lutheran Hospital 17.4%
U.S. national average 17.6%

Lutheran Hospital‘s readmission rate is lower (better) than the national average, but the difference is not significant. This means that Lutheran Hospital's rate is basically the same as the national average.

Only regular Medicare patients are included. People in Medicare Advantage (managed care plans) and people who do not have Medicare are not included.

Updated: July 2013

Why Surgical Care Measures are Important

Hospitals can improve surgical care and reduce the risk of wound infection after surgery by making sure they provide care that’s known to get the best results for most patients.

There are also steps that you, as a patient, can take to make sure the surgery is as safe as possible. For example, your doctor or nurse can tell you how to wash with an antibiotic soap the day before surgery. You can also give your doctor or nurse a list of all your medications, including vitamins, herbal medicines and over-the-counter medications. You should also tell your doctor or nurse about any allergies and bad reactions to anesthesia. Sometimes patients get an infection after surgery, even if the hospital took steps to prevent it. Here are signs to look out for:

  • the surgical wound is red, hot, and swollen
  • you have a fever of over 100 degrees after you go home
  • a smelly or yellow/green fluid is coming out of the wound
  • your pain is increasing even though you are taking pain medication

Call your doctor or local hospital immediately if you have any of these signs.

View other publicly reported data about surgical care in hospitals:

How is Lutheran Hospital Performing on Surgical Care?

This score tells you the percent of surgical care patients who got all the recommended care appropriate for them from the list below:

  1. an antibiotic (medicine that prevents and treats infections) was given at the right time (within one hour before surgery)
  2. the right kind of antibiotic was given
  3. antibiotics were stopped at the right time (within 24 hours after surgery ended - or 48 hours after open heart surgery or other cardiac surgery)
  4. cardiac surgery patients’ blood sugar (blood glucose) was kept at a normal level in the days right after surgery
  5. urinary catheter (a small tube placed in the bladder to drain urine) was removed on the first or second day after surgery
  6. steps were taken to keep patients warm in the operating room and/or body temperature was near normal by the end of surgery
  7. patients on beta-blocker medicine before going into the hospital continued to get that medicine during the time before and after surgery
  8. the right treatment to prevent blood clots was provided at the right time (within 24 hours before or after surgery)

This information is important because one way to tell if a hospital is doing a good job is to look at the percent of surgery patients who got all the recommended care on the list (as appropriate for each individual).

Higher numbers are better.

Lutheran Hospital (October 2013 - December 2013) 90%
U.S. Hospitals (July 2013 - September 2013) 95%

Updated: June 2014

These scores tell you about how often patients had certain serious, but potentially preventable complications (listed below) related to medical or surgical inpatient hospital care.

Where does the score come from? The information comes from documenting certain events in patient medical records. These events are then “coded” by the hospital for billing Medicare. Coded information is sometimes called “administrative” data.

This information is important because one way to tell if a hospital is doing a good job is to look at how often patients experienced certain complications that might have been preventable.

Lower numbers are better.

How is Lutheran Hospital doing with preventing certain serious complications?
July 2010 – June 2012

Rate per 1,000 Hospitalized Patients
Serious Complication U.S. National Average Lutheran Hospital
Death among surgical patients with serious treatable complications 110.25 97.23*
Collapsed lung due to medical treatment 0.32 0.25*
Blood clot in the lung or large vein after surgery 4.14 4.14*
Wound that splits open after surgery 0.92 0.81*
Accidental cut or tear during surgery or other procedure 1.83 1.07*

Includes only people with “regular” Medicare. People in Medicare Advantage (managed care plans) and people who do not have Medicare are not included.

* The difference between Lutheran Hospital and the national average is not significant. This means that Lutheran Hospital’s rate is basically the same as the national average.

What is Lutheran Hospital doing to improve?

Lutheran Hospital has many initiatives underway to keep patients safe. Standard “best” practices are the key to success. Examples:

  • To prevent collapsed lungs due to medical treatment, Lutheran Hospital implemented a standard procedure for placing and checking central lines (small tubes inserted and passed into a large vein or the heart).
  • To prevent blood clots in the lung or large vein after surgery, Lutheran Hospital implemented a standard approach that includes checking each hospitalized patient’s risk for blood clots and providing medications or other treatment as indicated.

Preventing Patient Falls

Nationally, falls are a leading cause of hospital patient injury. A fall is more likely to occur in an environment that is unfamiliar such as a hospital room. Other risks for falling in the hospital include: medications that cause dizziness and tests or treatments that make you feel weak or unsteady. Some falls cause moderate to severe injuries.

How is Lutheran Hospital Doing at Preventing Falls with Injuries?

This score tells you how many patients fell during their hospital stay and had a moderate or serious injury such as a cut that needed stitches, a head injury or a hip fracture.

This information is important because one way to tell if a hospital is doing a good job is to look at how many patients are moderately or seriously injured due to falls.

Lower numbers are better.

Lutheran Hospital (January 2013 – December 2013) 6
Target 0
What we are doing to prevent falls

All hospitals aim for zero patient injuries. Our fall prevention efforts include: identifying patients who are at risk for falls, checking on them frequently, assisting them to the bathroom and providing non-skid footwear. Caregivers make sure patients have all necessary items, including a call light, within easy reach.

Updated: March 2014

Keep in mind that you should not choose a hospital based solely on reported data.
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