Note: The following measure(s) will be retired from CheckPoint in December 2014:
  • AMI-2 – Aspirin on Discharge
  • PN-3b – Blood Culture before First Abx
  • HF-1 – Discharge Instructions
  • HF-3 – ACEI/ARB for LVSD
  • SCIP-Inf-10 – Periop Temp. Management
St. Croix Regional Medical Center
Demographic Information

235 State Street
St. Croix Falls, WI  54024
715-483-3261
http://www.scrmc.org
Services: Adult Intensive Care, Cardiovascular, Emergency, Gynecology, Hospice/Palliative Care, Long Term Acute Care, Neurology, Obstetrics, Oncology, Orthopedics, Pediatrics, Psychiatry, Pulmonary, Rehabilitation/Physical Medicine, Trauma, Urology/Nephrology
Discharges/Yr: 1952
Population: Rural
Staffed Beds: 25
KEY
- No Cases Met Criteria. The hospital had no cases that met the measure criteria during the applicable time period.
+ Low Volume. The hospital collects data, but their volume of data was too small to report with statistical confidence.
IP In Progress. The hospital is collecting data, but does not have four quarters of data necessary for public reporting.
DNR Did not report. The hospital has not authorized CheckPoint to report this measure or the hospital has not provided data for this measure.
NA Not Applicable. The hospital does not provide this service.
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 Oct 25 2014 12:31 AM

Medical Services

Measurement data are from 1/1/2013—12/31/2013
Heart Attack Hosp.
Score
State
Benchmark
State
Average
National
Average
Aspirin at discharge (%) DNR 100 100 99
PCI <90 min DNR 100 96 96
Heart Failure Hosp.
Score
State
Benchmark
State
Average
National
Average
LVF assessment (%) 100 100 99 99
ACEI for LVSD (%) + 100 97 97
Discharge Instructions (%) 97 100 96 94
Pneumonia Hosp.
Score
State
Benchmark
State
Average
National
Average
Approp Anbtc + 100 96 95
Blood Culture Collected 97 100 99 98

Error Prevention

Measurement data are from 1/1/2014—6/30/2014
National Safety Goals Hosp.
Score
State
Benchmark
State
Average
 
Site marking (%) DNR 100 99  
Procedure verification (%) DNR 100 99  
Medication reconciliation (%) DNR 100 92  

Surgical Services

Measurement data are from 1/1/2013—12/31/2013
Colon Surgery Hosp.
Score
State
Benchmark
National
Average
Start Antibiotics (%) + 100
Appropriate Antibiotics (%) + 100
Stop Antibiotics (%) + 100
Hip Surgery Hosp.
Score
State
Benchmark
National
Average
Start Antibiotics (%) 92 100
Appropriate Antibiotics (%) 100 100
Stop Antibiotics (%) 100 100
Hysterectomy Hosp.
Score
State
Benchmark
National
Average
Start Antibiotics (%) + 100
Appropriate Antibiotics (%) + 100
Stop Antibiotics (%) + 100
Knee Surgery Hosp.
Score
State
Benchmark
National
Average
Start Antibiotics (%) 100 100
Appropriate Antibiotics (%) 100 100
Stop Antibiotics (%) 99 100
Other Cardiac Hosp.
Score
State
Benchmark
National
Average
Start Antibiotics (%) 100
Appropriate Antibiotics (%) 100
Stop Antibiotics (%) 100
Blood Sugar Controlled (%) 100
Vascular Surgery Hosp.
Score
State
Benchmark
National
Average
Start Antibiotics (%) 100
Appropriate Antibiotics (%) 100
Stop Antibiotics (%) 100
CABG Hosp.
Score
State
Benchmark
National
Average
Start Antibiotics (%) 100
Appropriate Antibiotics (%) 100
Stop Antibiotics (%) 100
Blood Sugar Controlled (%) 100
Index Hosp.
Score
State
Benchmark
State
Average
Surgical Infection Prevention index (%) 92 99 96
Surgical Care – All Procedures Hosp.
Score
State
Benchmark
National
Average
Start Antibiotics (%) 97 100 99
Appropriate Antibiotics (%) 97 100 99
Stop Antibiotics (%) 99 100 98
Clot Prevention Given (%) 100 98
Cath Removal (%) + 100 97
Temp Management (%) 100 100 100
Beta Blocker Received (%) 100 98

 Deaths data (2012)
Deaths due to IllnessExperienceNat'l Avg(%)State Avg(%)
Acute stroke mortality rate+9.136.91
Gastrointestinal (GI) hemorrhage mortality rateAs Expected2.411.40
Hip fracture mortality rate+2.780.61
Deaths During a ProcedureExperienceNat'l Avg(%)State Avg(%)
Hip replacement mortality rateBetter0.090.00
High Risk Procedure - Volumes Volume
AAA Volume
CABG Volume
CEA Volume
PTCA Volume
Incidental Appendectomy (%) +

     
 Birth Measures Data (7/1/2013 - 6/30/2014)
MeasureRateState Average
Pre-Birth Steroids 91
Forceps Delivery01
Vacuum Delivery66
Breast Feeding8379
Infant Composite12
Early Elective Delivery180

     
 Patient Experience of Care Survey Data (10/1/2012 - 9/30/2013)
Measure Rate National Average State Average State Benchmark
Patients ranked hospital high 71 71 74 83
Definitely recommend hospital 73 71 74 84
Doctors always communicated well 78 82 83 89
Nurses always communicated well 79 79 82 87
Patients always received requested help 73 68 72 83
Staff always explained medications 66 64 68 76
Pain always well controlled 69 71 72 78
Always quiet at night 62 61 63 72
Room always clean 79 73 79 88
Staff provided discharge instructions 90 85 89 92

 
   
 Stroke Data (Measure Data are from 1/1/2013 – 12/31/2013)
 IP

     
 CMS 30-Day Mortality Data (7/1/2009 - 6/30/2012)
Measure Rate National Average State Average
Pneumonia 11.7 11.9 12.0
Heart Failure 11.7 11.7 12.4
Heart Attack DNR 15.2 15.4

     
 CMS 30-Day Readmission Data (7/1/2009 - 6/30/2012)
Measure Rate National Average State Average
Pneumonia 17.3 17.6 17.1
Heart Failure 24.0 23.0 22.0
Heart Attack DNR 18.3 17.7

     
 CLABSI - Central Line Associated Blood Stream Infection Data (ICU Patients) (4/1/2013 - 3/31/2014)
Measure Ratio National Comparison State Comparison
CLABSI DNR 1.000 0.423

     
 CAUTI – Catheter Associated Urinary Tract Infections (4/1/2013 - 3/31/2014)
Measure Ratio National Comparison State Comparison
CAUTI DNR 1.000 0.832

     
 Surgical Site Infections (SSI) - Colon Surgery(4/1/2013 - 3/31/2014)
Measure Ratio National Comparison State Comparison
SSI – Colon Surgery DNR 1.000 0.946

     
 Surgical Site Infections (SSI) – Abdominal Hysterectomy (4/1/2013 - 3/31/2014)
Measure Ratio National Comparison State Comparison
SSI – Abdominal Hysterectomy DNR 1.000 1.046


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