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    Our Quality and Safety Programs

    California Pacific is committed to being on the leading edge of quality and safety innovation. As part of that commitment, we seek out other like-minded institutions and participate in every national collaborative that measures and compares quality and safety data we can find. In addition, we have developed new quality and safety initiatives that we are seeking others with which to compare. Some examples are:


    Our Primary Stroke Program
    The Primary Stroke Program at California Pacific strives to deliver the highest quality, most advanced, and effective stroke care to our patients. We possess necessary personnel, infrastructure, expertise, and programs to diagnose and treat stroke patients rapidly, using specialized medical and surgical care, advanced diagnostic testing, and interventional therapies as outlined by the Brain Attack Coalition recommendations for Comprehensive Stroke Centers.

    Our stroke program is a valuable resource for other health care providers in the San Francisco Bay area. This includes providing expertise about managing complex and unusual cases, offering help for triage of patients, performing advanced diagnostic tests and treatments, including patients treated initially at other facilities, and being an educational resource for other hospitals and health care professionals.

    Get With the Guidelines / Joint Commission Certification
    In an effort to provide the highest standards of stroke care, we participate in the American Stroke Association (ASA) Get With the Guidelines continuous quality improvement program. This program enables us to input, analyze, and nationally benchmark our data in real time. In addition, it enables us to submit all necessary data to the Joint Commission to maintain the status of certified Primary Stroke Center and to obtain the ASA recognition.

    In 2009, California Pacific received the American Stroke Association's Get With The Guidelines®-Stroke Gold Performance Achievement Award by reaching the goal of treating stroke patients with 85% or higher compliance to core standard levels of care.

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    National Surgery Quality Improvement Program

    The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) is a risk-adjusted surgical quality improvement program. California Pacific began participating in NSQIP in January 2006. This program allows us to compare our outcomes with other national centers.

    Currently, there are 227 hospitals across the United States and Canada that are participating, with over 700,000 cases with completed 30-day postoperative follow-up in the database.

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    VTE Prophylaxis

    Venous thromboembolism (VTE) is a blood clot condition that includes deep vein thrombosis (DVT) and pulmonary embolism (PE). VTE is the most common preventable cause of hospital death. Despite the fact that several clinical interventions are known to be effective in preventing and treating VTE, only one-third of all patients at risk for VTE who are appropriate candidates for prophylactic treatment actually receive such treatment.

    CPMC has launched a medical center-wide protocol for the prophylactic treatment (prevention) of DVT/PE that includes the use of mechanical compression devices for early ambulation after surgery.

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    Aspiration Pneumonia Prevention

    What is Aspiration Pneumonia?
    Aspiration pneumonia occurs from the inhalation of mouth or stomach contents into the larynx and lower respiratory track of the lung. Although not every aspiration event leads to pneumonia, some patients are at high risk for developing pneumonia after aspirating. Our prevention program focuses on checking all patients for aspiration risk.

    Why is Aspiration Pneumonia Prevention Important?
    Answer: It saves lives

    Hospital Acquired Pneumonia (HAP) is the second most common hospital acquired infection in adults in the United States and is associated with high mortality and morbidity. Recent surveys estimate HAP accounts for 15% to 18% of all hospital-acquired infections can increase a patient's hospital stay by an average of 7-9 days per patient, and costs in excess of $40,000 per case.

    The Leapfrog Group, an initiative driven by organizations that purchase health care, reports to the public on individual hospital's quality and safety performances. Prevention of Aspiration Pneumonia is one the 27 patient safety practices included in the Leapfrog Group report.

    CPMC Quality Plan on Aspiration Pneumonia Prevention
    An ongoing Aspiration Pneumonia Prevention Workgroup was established in August 2006 to formulate a plan based on recommendations outlined in the 2003 Centers for Disease Control and Prevention (CDC) Guidelines for Prevention of Healthcare-Associated Pneumonia; the 2005 American Thoracic Society Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia; and other evidence based practices.

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    Preventing Hospital-Acquired Complications

    California Pacific has ongoing programs to prevent complications acquired in the hospital.

    • Ventilator-Associated Pneumonia Prevention
      Ventilator-Associated Pneumonia (VAP) is a lung infection that can develop in patients who are put on ventilators. California Pacific has not had a case of VAP in over two years. We utilize a "ventilator bundle" which is a combination of best practices used to reduce the occurrence of pneumonia in ventilated patients.

    • Central Line Bloodstream Infection Prevention
      A central intravenous catheter is a device inserted directly into a major blood vessel to allow quick delivery of medications. Patients in ICUs may have a central line placed if they need intravenous nutrition, medications, or monitoring. Our rate of central line-associated bloodstream infections in our adult ICUs is 0.63 per one thousand central line days. This puts us just above the 25th percentile compared to other hospitals nationwide, which means that 75% of hospitals have an infection rate higher than us. In order to reduce the number of infections, we use a central line insertion checklist, and staff are trained in dressing changes and care of the line.

    • Surviving Sepsis Campaign
      California Pacific began a program in 2005 to detect the early symptoms of sepsis, which is a serious condition caused by the body's response to an infection. This program involves nurses screening all hospitalized patients every shift for the early signs of sepsis. If a patient tests positive, a nurse notifies a doctor so that immediate steps can be taken. Early detection of severe sepsis/septic shock and Early Goal-Directed Therapy (EGDT) within the first 6 hours are critical and can lower the death rate.

    • Elimination of Catheter-Acquired UTI's
      In order to reduce the number of catheter-associated urinary tract infections, we use nationally recognized criteria to make sure that the catheter is discontinued as soon as possible.

    • Pressure Ulcer Prevention
      California Pacific has implemented a multi-disciplinary program led by the Nursing department to prevent pressure ulcers (bed sores). This involves steps such as helping patients move regularly, protecting their skin and eating nutritious foods.

    • Surgical Care Improvement
      California Pacific fully participates in the Surgical Care Improvement Project (SCIP). This project covers an assortment of process measures developed by the Centers for Medicare and Medicaid Services in order to prevent common complications after surgical procedures. There is a total of nine measures: six are aimed at prevention of surgical site infection, while the other measures focus on the prevention of development of blood clots and the prevention of perioperative heart attack by assuring continuance of the patient’s beta blocker medications. All members of the surgical team are involved with efforts to continuously improve our performance on these elements.

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    Preventing Delirium

    Delirium is a mental disorder where there is a sudden decline in attention and cognition. It is common in elderly patients, is often unrecognizable, and can lead to serious complications.

    Thirty-five percent of the U.S. population over the age of 65 is hospitalized each year. Assuming a delirium rate of 20%, approximately 7% of all persons over the age of 65 will develop delirium each year. This will complicate hospital stay for over 2 million patients per year, at an estimated cost of over $8 billion. Post-hospital costs, such as institutionalization, rehabilitation and home care can exceed $100 billion in one year.

    California Pacific has implemented a program to help improve the rate of recognition of this condition and lower its occurrence.

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