Reports Detail

Home WHA.org News Contact Us Hospital Login Related Links

Columbia St. Mary's Hospital Milwaukee
Demographic Information
2323 N. Lake Drive Milwaukee, WI 53211 414-291-1000 http://www.columbia-stmarys.org	Services:	Adult Intensive Care, Alcohol/Chemical Dependency, Cardiovascular, Emergency, Gynecology, Neonatal Intensive Care, Neurology, Obstetrics, Oncology, Orthopedics, Pediatrics, Pulmonary, Rehabilitation/Physical Medicine, Trauma, Urology/Nephrology
	Discharges/Yr:	12052
	Population:	Urban
	Staffed Beds:	481

KEY
— No data collected at this time or no cases met criteria. [MORE INFO]
+ Data collected, but not enough cases to be representative of care provided in this reporting period. As CheckPoint adds data, more hospitals will report this measure. [MORE INFO]
n/a Not applicable.
n/r Hospital opted not to report data for this measure.

Click here for definitions of Better, As Expected and Worse, with regard to Deaths.

State Benchmark - The 90th percentile of Wisconsin hospitals reporting each measure.
State Average - The average of Wisconsin hospitals reporting each measure.
National Average - The average of hospitals in the U.S. accredited by The Joint Commission

Report generated 24 May 2013 3:40 PM

Medical Services Measurement data are from 7/1/2011—6/30/2012
Heart Attack	Hosp. Score	State Benchmark	State Average	National Average
Aspirin at discharge (%)	99	100	99	99
PCI <90 min	83	100	94	94
Throm Med <30 min	—	—	—	—

Heart Failure	Hosp. Score	State Benchmark	State Average	National Average
LVF assessment (%)	100	100	98	99
ACEI for LVSD (%)	98	100	95	97
Discharge Instructions (%)	97	100	92	94

Pneumonia	Hosp. Score	State Benchmark	State Average	National Average
Approp Anbtc	96	100	96	96
Blood Culture Collected	98	100	98	98
Error Prevention Measurement data are from 7/1/2012—12/31/2012

National Safety Goals	Hosp. Score	State Benchmark	State Average
Site marking (%)	96	100	98
Procedure verification (%)	95	100	98
Med Rec at Discharge (%)	96	100	87

Surgical Services Measurement data are from 7/1/2011—6/30/2012
Colon Surgery	Hosp. Score	State Benchmark	National Average
Start Antibiotics (%)	96	100	97
Appropriate Antibiotics (%)	98	100	94
Stop Antibiotics (%)	89	100	94
Hip Surgery	Hosp. Score	State Benchmark	National Average
Start Antibiotics (%)	98	100	98
Appropriate Antibiotics (%)	100	100	100
Stop Antibiotics (%)	100	100	98
Hysterectomy	Hosp. Score	State Benchmark	National Average
Start Antibiotics (%)	96	100	98
Appropriate Antibiotics (%)	91	100	97
Stop Antibiotics (%)	100	100	97
Knee Surgery	Hosp. Score	State Benchmark	National Average
Start Antibiotics (%)	100	100	99
Appropriate Antibiotics (%)	98	100	100
Stop Antibiotics (%)	98	100	98
Other Cardiac	Hosp. Score	State Benchmark	National Average
Start Antibiotics (%)	+	100	99
Appropriate Antibiotics (%)	+	100	100
Stop Antibiotics (%)	+	100	98
Blood Sugar Controlled (%)	+	100	—
Vascular Surgery	Hosp. Score	State Benchmark	National Average
Start Antibiotics (%)	+	99	97
Appropriate Antibiotics (%)	+	100	99
Stop Antibiotics (%)	+	100	95
CABG	Hosp. Score	State Benchmark	National Average
Start Antibiotics (%)	96	100	99
Appropriate Antibiotics (%)	100	100	100
Stop Antibiotics (%)	100	100	98
Blood Sugar Controlled (%)	93	100	—
Index	Hosp. Score	State Benchmark	State Average
Surgical Infection Prevention index (%)	87	97	92
Surgical Care – All Procedures	Hosp. Score	State Benchmark	National Average
Start Antibiotics (%)	97	100	98
Appropriate Antibiotics (%)	97	100	99
Stop Antibiotics (%)	96	100	97
Clot Prevention Ordered (%)	96	100	98
Clot Prevention Given (%)	94	100	98
Cath Removal (%)	96	100	95
Temp Management (%)	100	100	100
Beta Blocker Received (%)	95	100	97

Deaths data (2011)

Deaths due to Illness	Experience	Nat'l Avg(%)	State Avg(%)
Acute stroke mortality rate	As Expected	9.24	8.85
Gastrointestinal (GI) hemorrhage mortality rate	As Expected	2.08	1.51
Hip fracture mortality rate	Worse	2.58	2.19

Deaths During a Procedure	Experience	Nat'l Avg(%)	State Avg(%)
AAA repair mortality rate	+	4.45	3.32
CABG mortality rate	As Expected	2.24	1.45
CEA mortality rate	+	0.33	0.34
Craniotomy mortality rate	As Expected	5.77	4.05
Esophageal resection mortality rate	+	5.49	2.31
Hip replacement mortality rate	As Expected	0.07	0.06
Pancreatic resection mortality rate	+	4.58	1.56
PTCA mortality rate	As Expected	1.20	1.03

	High Risk Procedure - Volumes	Volume
	AAA Volume	16
	CABG Volume	74
	CEA Volume	27
	Esophageal Resection Volume	5
	PTCA Volume	115
	Pancreatic Resection Volume	+
	Incidental Appendectomy (%)	1.21

Birth Measures Data (1/1/2012 - 12/31/2012)
Please note, the C-Section w/Labor and C-Section w/out Labor measures will be discontinued from CheckPoint as of second quarter, 2013.
Measure	Rate	State Average
Pre-Birth Steroids	90	84
Forceps Delivery	1	1
Vacuum Delivery	3	6
C-Section w/Labor	91	88
C-Section w/out Labor	6	10
Breast Feeding	83	77
Infant Composite	3	2

Patient Experience of Care Survey Data (7/1/2011 - 6/30/2012)
Measure	Rate	National Average	State Average	State Benchmark
Patients ranked hospital high	72	70	74	84
Definitely recommend hospital	75	71	74	84
Doctors always communicated well	82	81	83	88
Nurses always communicated well	76	78	81	87
Patients always received requested help	58	67	72	82
Staff always explained medications	65	63	68	74
Pain always well controlled	71	71	72	78
Always quiet at night	66	60	63	72
Room always clean	64	73	79	87
Staff provided discharge instructions	84	84	88	91

Stroke Data (Measure Data are from 7/1/2011 – 6/30/2012)
Measure	Rate	National Average	State Average	State Benchmark
STK-2: AntiThrom on Dischg	100	98	96	100
STK-3: Anticoag for AFib/AFlut	+	93	93	100
STK-5: Early AntiThrom	100	97	89	100
STK-6: Dischg on Statin Med	97	91	88	100
STK-8: Stroke Education	97	88	85	100
STK-10: Assess for Rehab	99	97	96	100

CMS 30-Day Mortality Data (7/1/2008 - 6/30/2011)
Measure	Rate	National Average	State Average
Pneumonia	12.4	12.0	12.2
Heart Failure	13.2	11.6	12.0
Heart Attack	14.3	15.5	15.7

CMS 30-Day Readmission Data (7/1/2008 - 6/30/2011)
Measure	Rate	National Average	State Average
Pneumonia	19.5	18.5	17.9
Heart Failure	24.1	24.7	23.6
Heart Attack	20.6	19.7	18.9

CLABSI - Central Line Associated Blood Stream Infection Data (ICU Patients) (1/1/2011 - 12/31/2011)
Measure	Ratio	National Comparison	State Comparison
CLABSI	0.374	1.000	0.606