Reviews of Delivery at Mount Carmel East Hospital

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Preventing and Responding to Patient Damage

Mensurate name	Leapfrog'southward Standard	Infirmary's Progress
Effective Leadership to Prevent Errors	Hospitals should accept meaningful steps to heighten awareness about patient safety, hold leadership accountable for reducing unsafe practices, provide resource to implement a patient safety program, and develop systems and structures to back up action to improve patient rubber. more	CONSIDERABLE Achievement
	Bear witness more on this infirmary'due south functioning Prove less This hospital scored 110.77 out of 120.00 possible points.
Staff Work Together to Preclude Errors	Hospitals should assess their culture of safety and concord leadership accountable for implementing policies, procedures, and staff education to improve the culture of safety. more	Achieved THE STANDARD
	Bear witness more on this hospital'southward performance Show less This hospital scored 120.00 out of 120.00 possible points.
Support for Nursing Workforce	Hospitals should assess their nursing staff levels and cadre competencies, included nurses in leadership, and develop and implement plans to accost any areas of improvement. more	ACHIEVED THE STANDARD
	Bear witness more than on this hospital's performance Bear witness less This infirmary scored 100.00 out of 100.00 possible points.
Handwashing	Hospitals should regularly monitor manus hygiene practices for everyone interacting with patients, and give feedback to ensure compliance. Hospitals should foster a culture of proficient manus hygiene, offering training and instruction, and provide equipment, such every bit paper towels, soap dispensers, and hand sanitizer. more	Accomplished THE STANDARD
	Testify more on this hospital'south performance Show less Hand Hygiene Domain Performance Hospital regularly monitors hand hygiene practices Met the monthly requirements for monitoring using direct observation only. Feedback provided to ensure compliance with hand hygiene Met Advisable preparation and pedagogy provided Did Not Meet Access to paper towels, soap dispensers, and hand sanitizer maintained Met Culture of expert mitt hygiene emphasized Met
Responding to Never Events	Hospitals should take a never events policy that includes all nine (9) actions that should occur following a "never event," which includes apologizing to the patient and not charging for costs associated with the never issue. more than	Achieved THE STANDARD

Medication Safety

Measure proper noun	Leapfrog's Standard	Hospital'southward Progress
Safe Medication Assistants	Hospitals should have nurses and other clinicians use BCMA in all medical/surgical units, intensive care units, and labor and delivery units to scan the patient and medication prior to administration at least 95% of the time. The BCMA organization includes decision support to preclude errors and the infirmary has processes to forestall workarounds. more	CONSIDERABLE Achievement
	Show more than on this infirmary's performance Bear witness less Implementation Performance The extent of BCMA implementation throughout the hospital with a focus on medical and/or surgical units (adult and pediatric), labor and delivery units, and intensive care units (developed, pediatric, and neonatal) 100% Compliance with both patient and medication scans at the bedside prior to administering medications 91% The types of conclusion support that the BCMA system offers 5 out of 5 Structures to monitor and reduce workarounds 8 out of eight
Rubber Medication Ordering	Hospitals should enter at least 85% of inpatient medication orders through the CPOE system. more	Achieved THE STANDARD
	Show more on this hospital's functioning Testify less This hospital'south percentage of inpatient medication orders entered electronically: 85% or greater
Medication Reconciliation	Hospitals should have a charge per unit of unintentional medication discrepancies per medication that is lower than or equal to the 50th percentile (where lower operation is ameliorate) nationally. more	Achieved THE STANDARD
	Prove more on this infirmary's functioning Testify less This hospital's charge per unit of unintentional discrepancies per medication is: 0.026
Medication Documentation for Elective Outpatient Surgery Patients	Hospitals should certificate 90% or more than of habitation medications, visit medications, and allergies/agin reaction(s) in the patients' clinical record. more	LIMITED Accomplishment

Healthcare Associated Infections

Measure proper noun	Leapfrog'due south Standard	Hospital's Progress
Infection in the Blood	Hospitals should have fewer than expected key-line associated blood stream infections. Leapfrog uses a standardized infection ratio (SIR) calculated past the CDC's National Healthcare Safe Network (NHSN) to compare the number of infections that really happened at this hospital to the number of infections expected for this hospital, given diverse factors. A number lower than one means fewer infections than expected; a number more than one ways more infections than expected. more	CONSIDERABLE Accomplishment
	Show more on this hospital's performance Evidence less This hospital's standardized infection ratio (SIR) is: 0.757 Note: The standardized infection ratio (SIR) includes some data collected during the COVID-19 pandemic.
Infection in the Urinary Tract	Hospitals should take fewer than expected catheter-associated urinary tract infections. Leapfrog uses a standardized infection ratio (SIR) calculated past the CDC's National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given diverse factors. A number lower than one means fewer infections than expected; a number more than than 1 ways more infections than expected. more	CONSIDERABLE ACHIEVEMENT
	Prove more on this hospital'due south performance Show less This hospital'southward standardized infection ratio (SIR) is: 0.709 Note: The standardized infection ratio (SIR) includes some data collected during the COVID-19 pandemic.
C. difficile Infection	Hospitals should have fewer than expected colon infections from C. diff bacteria. Leapfrog uses a standardized infection ratio (SIR) calculated past the CDC'southward National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this infirmary to the number of infections expected for this infirmary, given various factors. A number lower than one ways fewer infections than expected; a number more than than 1 means more than infections than expected. more	Accomplished THE STANDARD
	Evidence more on this infirmary'south operation Testify less This hospital's standardized infection ratio (SIR) is: 0.302 Annotation: The standardized infection ratio (SIR) includes some data collected during the COVID-nineteen pandemic.
MRSA Infection	Hospitals should have fewer than expected antibiotic resistant bacterial infections. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC'south National Healthcare Condom Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one ways more infections than expected. more	SOME ACHIEVEMENT
	Testify more on this hospital's performance Show less This hospital's standardized infection ratio (SIR) is: 1.187 Notation: The standardized infection ratio (SIR) includes some information nerveless during the COVID-19 pandemic.
Surgical Site Infection Later on Colon Surgery	Hospitals should have fewer than expected surgical site infections afterward major colon surgery. Leapfrog uses a standardized infection ratio (SIR) calculated by the CDC's National Healthcare Safety Network (NHSN) to compare the number of infections that actually happened at this hospital to the number of infections expected for this hospital, given various factors. A number lower than one means fewer infections than expected; a number more than one means more than infections than expected. more	SOME Achievement
	Show more than on this hospital's performance Show less This hospital's standardized infection ratio (SIR) is: 1.181 Annotation: The standardized infection ratio (SIR) includes some information collected during the COVID-19 pandemic.

Motherhood Care

Measure proper noun	Leapfrog's Standard	Infirmary's Progress
Cesarean Sections	This is divers every bit first-time mothers giving nascence to a single babe, at full-term, in the head-down position deliver their babies through a C-section. Hospitals should have a rate of C-sections of 23.6% or less. more	ACHIEVED THE STANDARD
	Show more than on this hospital's performance Show less This hospital's rate of Cesarean sections is19.9%
Early Elective Deliveries	This is defined as mothers being scheduled for cesarean sections or medication inductions prior to 39 weeks gestation without a medical reason. Hospitals should take a charge per unit of early on elective deliveries of 5% or less. more	ACHIEVED THE STANDARD
	Bear witness more on this hospital's performance Show less This hospital's rate of early elective deliveries is0.6%
Episiotomies	This is defined as mothers having an incision fabricated in the perineum (the birth canal) during childbirth. Hospitals should have a charge per unit of episiotomies of v% or less. more	Accomplished THE STANDARD
	Evidence more on this hospital'southward performance Evidence less This hospital's charge per unit of episiotomies isii.0%
Screening Newborns for Jaundice Before Discharge	Hospitals should screen at least xc% of babies for jaundice. more	Achieved THE STANDARD
	Bear witness more than on this hospital'due south performance Testify less This hospital's rate of screening newborns for jaundice before discharge is100.0%
Preventing Blood Clots in Women Undergoing Cesarean Section	At least 90% of women undergoing a cesarean section receive treatment to prevent blood clots. more	Accomplished THE STANDARD
	Show more than on this hospital's performance Show less This hospital'south charge per unit of preventing blood clots in women undergoing cesarean section100.0%
High-Risk Deliveries	Hospitals should deliver at least 50 very-low nascency weight babies per year OR the hospital must maintain a lower-than-average morbidity/mortality rate for very-low birth weight babies. more	CONSIDERABLE ACHIEVEMENT
	Show more than on this hospital'south operation Prove less Number of Deliveries Performed Outcome 28

More Data

Number of Live Births

The hospital had1,952 alive births (i.east., liveborn infants) at this hospital location for the reporting time menses.

Pediatric Intendance

Mensurate proper noun	Leapfrog's Standard	Infirmary'southward Progress
Experience of Children and Their Parents	Hospitals should perform better than most hospitals in five (5) areas: Advice with Parent – Communication nigh your kid's medicines Communication with Parent – Keeping you informed about your kid's care Advice with Kid – How well nurses communicate with your child Advice with Kid – How well doctors communicate with your child Attention to Condom and Comfort – Preventing mistakes and helping y'all study concerns. more	DOES NOT APPLY
	Show more on this hospital'southward performance Evidence less This hospital does not admit pediatric patients or had also few pediatric admissions to administer the patient experience survey.
Radiations Dose for Abdomen/Pelvis Scans	Hospitals should employ a CT radiation dose for routine CT scans of the abdomen and pelvis that falls within national benchmarks. more	DOES Not APPLY
Radiations Dose for Head Scans	Hospitals should accept an average radiations dose for routine CT scans of the head that falls within national benchmarks. more	DOES Non Employ

Critical Intendance

Measure name	Leapfrog's Standard	Hospital'due south Progress
Specially Trained Doctors Care for Critical Care Patients	Hospitals should accept intensivists nowadays on-site at least eight hours a twenty-four hour period, seven days per week or has intensivists present via 24/7 telemedicine with some on-site intensivist presence. When not in the ICU, the intensivist immediately responds to calls and has another physician or trained clinician who can immediately accomplish the patient. more	Achieved THE STANDARD
	Show more on this hospital's performance Show less This hospital achieved the standard using on-site intensivist coverage.

Complex Developed and Pediatric Surgery

Measure name	Leapfrog's Standard	Hospital's Progress
Carotid Artery Surgery	Hospitals should perform at least 20 procedures annually, and as office of their process for privileging surgeons, ensure that each surgeon performs at least 10 procedures annually. more	CONSIDERABLE ACHIEVEMENT
	Show more on this hospital's functioning Show less This hospital performed 127 carotid avenue surgeries compared to Leapfrog's standard of xx procedures annually. Every bit office of their procedure for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog's minimum surgeon book standard of at to the lowest degree 10 procedures annually for carotid artery surgery. Additionally, this infirmary does not accept protocols in place to ensure that carotid artery surgeries are only performed on patients that come across defined criteria.
Mitral Valve Repair and Replacement	Hospitals should perform at to the lowest degree 40 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at to the lowest degree 20 procedures annually. In addition, hospitals should participate in a national clinical registry and achieve the same or better outcomes when compared to others who also perform this procedure. more than	SOME Achievement
	Bear witness more on this hospital's functioning Show less This hospital performed 6 mitral valve repairs and replacements compared to Leapfrog's standard of xl procedures annually. Equally office of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog's minimum surgeon volume standard of at to the lowest degree 20 procedures annually for mitral valve repair and replacement. This hospital does participate in the Social club of Thorasic's Surgeons Adult Cardiac Surgery Database. This hospital'due south outcome (absence of mortality and major morbidity) for mitral valve repairs and replacements is: As Expected. Additionally, this infirmary does non have protocols in place to ensure that mitral valve repairs and replacements are only performed on patients that run into divers criteria.
Open up Aortic Procedures	Hospitals should perform at to the lowest degree 10 procedures annually, and equally part of their process for privileging surgeons, ensure that each surgeon performs at least vii procedures annually. more	CONSIDERABLE Achievement
	Show more on this hospital's performance Show less This hospital performed fifteen open up aortic procedures compared to Leapfrog's standard of ten procedures annually. As part of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog's minimum surgeon volume standard of at least 7 procedures annually for open up aortic procedures. Additionally, this infirmary does non take protocols in identify to ensure that open up aortic procedures are only performed on patients that meet divers criteria.
Bariatric Surgery for Weight Loss	Hospitals should perform at least 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 20 procedures annually. more than	DOES NOT APPLY
Esophageal Resection for Cancer	Hospitals should perform at least 20 procedures annually, and equally office of their procedure for privileging surgeons, ensure that each surgeon performs at to the lowest degree 7 procedures annually. more	Limited ACHIEVEMENT
	Show more on this infirmary's performance Show less This hospital performed 3 esophageal resections for cancer compared to Leapfrog's standard of 20 procedures annually. As role of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog'southward minimum surgeon volume standard of at least vii procedures annually for esophageal resection for cancer. Additionally, this hospital does indicate having a multidisciplinary tumor board that prospectively reviews cancer cases to ensure that esophageal resections for cancer are but performed on patients that meet defined criteria.
Lung Resection for Cancer	Hospitals should perform at least 40 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 15 procedures annually. more	LIMITED ACHIEVEMENT
	Show more on this hospital'southward performance Show less This infirmary performed eighteen lung resections for cancer compared to Leapfrog'southward standard of 40 procedures annually. Every bit part of their procedure for privileging surgeons, this hospital does non ensure that each surgeon meets or exceeds Leapfrog's minimum surgeon book standard of at least 15 procedures annually for lung resection for cancer. Additionally, this hospital does bespeak having a multidisciplinary tumor lath that prospectively reviews cancer cases to ensure that lung resections for cancer are only performed on patients that see defined criteria.
Pancreatic Resection for Cancer	The hospital performs at least 20 procedures annually, and as part of their process for privileging surgeons, ensures that each surgeon performs at least 10 procedures annually. more	CONSIDERABLE Accomplishment
	Show more on this hospital's functioning Testify less This hospital performed xxx pancreatic resections for cancer compared to Leapfrog's standard of 20 procedures annually. As part of their process for privileging surgeons, this infirmary does not ensure that each surgeon meets or exceeds Leapfrog's minimum surgeon volume standard of at least 10 procedures annually for pancreatic resection for cancer. Additionally, this hospital does indicate having a multidisciplinary tumor board that prospectively reviews cancer cases to ensure that pancreatic resections for cancer are just performed on patients that come across defined criteria.
Rectal Cancer Surgery	Hospitals should perform at to the lowest degree xvi procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at to the lowest degree 6 procedures annually. more	CONSIDERABLE Achievement
	Evidence more on this hospital's functioning Show less This hospital performed 24 rectal cancer surgeries compared to Leapfrog'due south standard of xvi procedures annually. As part of their process for privileging surgeons, this infirmary does not ensure that each surgeon meets or exceeds Leapfrog'due south minimum surgeon book standard of at least 6 procedures annually for rectal cancer surgery. Additionally, this hospital does indicate having national accreditation from the American College of Surgeons or a multidisciplinary tumor board that prospectively reviews cancer cases to ensure that rectal cancer surgery is just performed on patients that see defined criteria.
Total Hip Replacement Surgery	Hospitals should perform at to the lowest degree 50 procedures annually, and as part of their process for privileging surgeons, ensure that each surgeon performs at least 25 procedures annually. more	CONSIDERABLE Accomplishment
	Prove more than on this infirmary'south performance Testify less This hospital performed 272 total hip replacement surgeries compared to Leapfrog's standard of 50 procedures annually. As part of their process for privileging surgeons, this infirmary does not ensure that each surgeon meets or exceeds Leapfrog'southward minimum surgeon book standard of at least 25 procedures annually for total hip replacement surgeries. Additionally, this infirmary does not have protocols in place to ensure that total hip replacement surgery is only performed on patients that meet defined criteria.
Total Knee Replacement Surgery	Hospitals should perform at least l procedures annually, and as part of their procedure for privileging surgeons, ensure that each surgeon performs at least 25 procedures annually. more	CONSIDERABLE Accomplishment
	Evidence more on this infirmary'due south functioning Show less This infirmary performed 344 total knee replacement surgeries compared to Leapfrog's standard of fifty procedures annually. As role of their process for privileging surgeons, this hospital does not ensure that each surgeon meets or exceeds Leapfrog's minimum surgeon volume standard of at to the lowest degree 25 procedures annually for total knee replacement surgeries. Additionally, this hospital does not have protocols in place to ensure that full knee replacement surgery is only performed on patients that run into defined criteria.
Built Heart Surgery for Infants (Norwood Process)	Hospitals should perform at to the lowest degree 8 procedures annually, and as function of their process for privileging surgeons, ensure that each surgeon performs at least five procedures annually. more	DOES Non Utilize

Constituent Outpatient Surgery - Developed

Dermatology (Peel)

Procedure		Number of Procedures Performed Annually
Complex Pare Repairs		iv

Gastroenterology (Stomach and Digestive)

Process		Number of Procedures Performed Annually
Upper GI Endoscopies		316
Other Upper GI Procedures		0
Small Intestine and Stomal Endoscopies		8
Lower GI Endoscopies		236

General Surgery

Procedure		Number of Procedures Performed Annually
Cholecystectomies and Common Duct Explorations		54
Hemorrhoid Procedures		0
Inguinal and Femoral Hernia Repairs		17
Laparoscopies		4
Lumpectomies and Quadrantectomies of Breast		9
Mastectomies		iii
Other Hernia Repairs		36

Neurosurgery

Procedure		Number of Procedures Performed Annually
Spinal Fusion Procedures		21

Obstetrics and Gynecology

Procedure		Number of Procedures Performed Annually
Cervix Procedures		12
Hysteroscopies		62
Uterus and Adnexa Laparoscopies		12

Orthopedic (Bones and Joints)

Procedure		Number of Procedures Performed Annually
Finger, Mitt, Wrist, Forearm, and Elbow Procedures		38
General Orthopedic Procedures		13
Hip Procedures		fourteen
Knee Procedures		60
Shoulder Procedures		17
Spine Procedures		17
Toe, Foot, Talocrural joint, and Leg Procedures		28

Otolaryngology (Ear, Olfactory organ, Rima oris, and Pharynx)

Procedure		Number of Procedures Performed Annually
Ear Procedures		8
Oral cavity Procedures		6
Nasal and Sinus Procedures		66

Plastic and Reconstructive Surgery

Procedure		Number of Procedures Performed Annually
Breast Repairs or Reconstructions		20
Skin Grafts and Repairs		0

Urology (Urinary Tract, Male Reproductive)

Process		Number of Procedures Performed Annually
Circumcisions		0
Cystourethroscopies		135
Male person Genital Procedures		iii
Urethra Procedures		one
Vaginal Repair Procedures		15

Care for Elective Outpatient Surgery Patients

Measure proper name	Leapfrog'southward Standard	Hospital'due south Progress
Elective Outpatient Surgery Recovery Staffing - Adult	Hospitals should ensure that a specially certified clinician and at to the lowest degree one medico or nurse anesthetist are present and immediately available while an adult patient is present until discharge. more	ACHIEVED THE STANDARD
Constituent Outpatient Surgery Recovery Staffing - Pediatric	Hospitals should ensure that a especially certified clinician and at least one physician or nurse anesthetist are present and immediately available while a pediatric patient is present until discharge. more	SOME ACHIEVEMENT
Prophylactic Surgery Checklist - Elective Outpatient Surgery	Hospitals should go through all the elements of a complete safe surgery checklist on all patients every time a procedure is performed. more	ACHIEVED THE STANDARD
Feel of Patients Undergoing Elective Outpatient Surgery	Hospitals should perform better than most on four (four) areas including: (a) facilities and staff (b) communication about the procedure, (c) patients' overall rating of the facility, and (d) patients willingness to recommend the facility. more	LIMITED ACHIEVEMENT
	Show more on this hospital's performance Show less Performance on the following 4 domains of the Outpatient and Ambulatory Surgery (OAS) CAHPS Survey make up a hospital's score on Leapfrog'southward "Experience of Patients Undergoing Elective Outpatient Surgery" measure out. "Elevation Box Score" represents the percentage of respondents who gave the virtually favorable response. OAS CAHPS Survey Domain Top Box Score Facilities and staff 95% Communication well-nigh the procedure 87% Patients' overall rating of the facility 80% Patients willingness to recommend the facility 76%

More Information

Patient Consent for Elective Outpatient Surgery	The hospital provides written surgical consent forms the day of their procedure.
Patient Consent to Anesthesia for Elective Outpatient Surgery	The infirmary provides written anesthesia consent forms the day of their procedure.
Patient Selection	The infirmarydoes non have a screening protocol to make up one's mind whether a patient'south procedure tin safely be performed on an outpatient basis, and the protocol includes the following components: History of difficult intubation Difficult airway/aspiration risk Torso Mass Index (BMI) American Lodge of Anesthesiologists (ASA) Physical Status Nomenclature Recent Medical History (within 30 days of scheduled process) Cognitive Assessment Sleep Apnea Assessment Availability of transportation following discharge Availability of a caregiver following discharge

Mount Carmel Due east Hospital

6001 E. Wide Street
Columbus, Ohio 43213

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Source: https://ratings.leapfroggroup.org/facility/details/36-0035/mount-carmel-east-hospital-columbus-oh

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