Nursing Quality Measures
Nurse Staffing Actual
What this means:
Number of Nursing Staff - Number of RN's, LPN's and HCT providing direct nursing care.
Percent of Nursing Staff - Number of RN's, LPN's and HCT providing direct nursing care / Total number of RN's, LPN's and HCT's providing direct nursing care.
Nursing hours per patient day (NHPPD) - Number of hours of direct care a patient can expect to receive from an RN, LPN, HCT, in a 24-hour period.
RN Hours Per Patient Day (RNHPPD) - Number of hours of direct care a patient can expect to receive from and RN in a 24-hour period.
Nurse : Patient Ratio - Number of patients cared for by one nurse; calculated as 24 / RN Hours Per Patient Day.
Click on a unit below to see its Staffing Actual
Patient Falls with Injury
What this means:
All documented patient falls with an injury level of moderate or greater.
Moderate - resulted in suturing, application of steri-strips/skin glue, or splinting.
Falls with injury rate = # of falls w/ injury of moderate or greater severity / Patient Days * 1000
Data for the period between Q2021_1 and Q2021_4
| Unit Name | Campus | Q2021_1 | Q2021_2 | Q2021_3 | Q2021_4 | Total |
|---|---|---|---|---|---|---|
| 02N - REHABILITATION | UH | 0.45 | 0.00 | 0.44 | 0.00 | 0.23 |
| 04B - PSYCHIATRY | UH | 0.00 | 0.00 | 0.60 | 0.00 | 0.14 |
| 05A - GEN/ENT/GYN SURGERY | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 05B - GENSURG/TRAN/URO/PLA | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 06A - MED/PULM/ID/CRITCARE | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 06B - GENERAL MED/SURG | UH | 0.50 | 0.49 | 0.00 | 0.00 | 0.25 |
| 06E - BURN ICU | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 06H - MEDICAL ICU | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 06I - MEDICAL ICU | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 06K - MED/SURG | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 07A - ORTHOPEDICS | UH | 0.00 | 0.00 | 0.00 | 0.47 | 0.11 |
| 07U - SECURED UNIT | UH | 0.00 | 0.00 | 0.00 | 0.00 | |
| 08E - SURGICAL ICU | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 08F - CARDIOPULMONARY ICU | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 08G - CARDIOVASCULAR MED/SURG | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 09E - NEUROSCIENCES INTERMED | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 09F - NEUROSCIENCES ICU | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 09G - NEUROSCIENCES M/S | UH | 0.62 | 0.00 | 1.19 | 0.00 | 0.45 |
| 10E - ONCOLOGY | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 10G - MEDICINE | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 10H - BONE MARROW TRP UNIT | UH | 0.00 | 1.90 | 0.00 | 0.00 | 0.47 |
| 11E - PEDIATRIC SURGERY | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 11G - PEDS HEM/ONC | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 12E - PEDIATRICS GENERAL | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 12F - PEDIATRIC ICU | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 2 - 2 POSTPARTUM GYN CC | CC | 0.00 | ||||
| 2L - LABOR AND DELIVERY CC | CC | 0.00 | 0.00 | 0.00 | ||
| 3W - 3 WEST MEDICAL CC | CC | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 4E - 4 EAST PMR CC | CC | 0.00 | 1.02 | 1.71 | 0.74 | |
| 4N - 4 NORTH MED/SURG CC | CC | 0.00 | 0.00 | 0.91 | 0.00 | 0.24 |
| 4W - 4 WEST MED/SURG CC | CC | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 5W - 5 WEST PSYCHIATRY CC | CC | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 6thFloor - 6 MED/SURG/ORTHO CC | CC | 0.42 | 0.00 | 0.00 | 0.00 | 0.09 |
| EU - EPILEPSY MONITORING UNIT CC | CC | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| IC - ICU CC | CC | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
Central Line Infections
What this means:
The rate of CLABSI for ICU Locations. Central line associated blood stream infection (CLABSI) as defined as a bloodstream infection thought to have been caused by the presence of a central line.
Central line associated blood stream infections (CLABSI) in ICU patients = # of CLABSI's / # of central line days * 1000
Data for the period between Q2021_1 and Q2021_4
| Unit Name | Campus | Q2021_1 | Q2021_2 | Q2021_3 | Q2021_4 | Total |
|---|---|---|---|---|---|---|
| 02N - REHABILITATION | UH | 0.00 | 0.00 | 1.79 | 0.00 | 0.49 |
| 05A - GEN/ENT/GYN SURGERY | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 05B - GENSURG/TRAN/URO/PLA | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 06A - MED/PULM/ID/CRITCARE | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 06B - GENERAL MED/SURG | UH | 0.00 | 0.00 | 1.42 | 0.00 | 0.41 |
| 06E - BURN ICU | UH | 0.00 | 0.00 | 0.00 | 7.43 | 1.92 |
| 06H - MEDICAL ICU | UH | 0.00 | 0.97 | 0.00 | 0.88 | 0.48 |
| 06I - MEDICAL ICU | UH | 1.03 | 0.00 | 0.00 | 1.16 | 0.55 |
| 06K - MED/SURG | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 07A - ORTHOPEDICS | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 07U - SECURED UNIT | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 08E - SURGICAL ICU | UH | 0.00 | 0.00 | 1.55 | 0.00 | 0.39 |
| 08F - CARDIOPULMONARY ICU | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 08G - CARDIOVASCULAR MED/SURG | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 09E - NEUROSCIENCES INTERMED | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 09F - NEUROSCIENCES ICU | UH | 1.16 | 0.00 | 0.00 | 0.00 | 0.36 |
| 09G - NEUROSCIENCES M/S | UH | 1.92 | 0.00 | 0.00 | 2.42 | 1.06 |
| 10E - ONCOLOGY | UH | 0.00 | 1.39 | 0.61 | 0.66 | 0.66 |
| 10G - MEDICINE | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 10H - BONE MARROW TRP UNIT | UH | 2.15 | 0.00 | 2.04 | 8.32 | 3.23 |
| 11E - PEDIATRIC SURGERY | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 11G - PEDS HEM/ONC | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 12E - PEDIATRICS GENERAL | UH | 7.35 | 0.00 | 0.00 | 0.00 | 3.10 |
| 12F - PEDIATRIC ICU | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 3W - 3 WEST MEDICAL CC | CC | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 4E - 4 EAST PMR CC | CC | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 4N - 4 NORTH MED/SURG CC | CC | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 4W - 4 WEST MED/SURG CC | CC | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 5W - 5 WEST PSYCHIATRY CC | CC | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 6thFloor - 6 MED/SURG/ORTHO CC | CC | 0.00 | 0.00 | 0.00 | 1.73 | 0.62 |
| IC - ICU CC | CC | 0.00 | 0.00 | 0.00 | 1.46 | 0.48 |
Catheter associated UTI
What this means:
The rate of Catheter associated UTIs for ICU Locations. Catheter associated urinary tract infection (CAUTI) as defined as a urinary tract infection thought to have been caused by an indwelling urinary catheter.
Catheter associated urinary tract infections (CAUTI) in ICU patients = # of CAUTI's / # of foley catheter days * 1000
Data for the period between Q2021_1 and Q2021_4
| Unit Name | Campus | Q2021_1 | Q2021_2 | Q2021_3 | Q2021_4 | Total |
|---|---|---|---|---|---|---|
| 02N - REHABILITATION | UH | 0.00 | 0.00 | 11.90 | 14.18 | 7.14 |
| 05A - GEN/ENT/GYN SURGERY | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 05B - GENSURG/TRAN/URO/PLA | UH | 0.00 | 0.00 | 2.86 | 0.00 | 0.76 |
| 06A - MED/PULM/ID/CRITCARE | UH | 3.02 | 0.00 | 0.00 | 5.21 | 2.07 |
| 06B - GENERAL MED/SURG | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 06E - BURN ICU | UH | 14.49 | 10.36 | 0.00 | 0.00 | 6.68 |
| 06H - MEDICAL ICU | UH | 4.43 | 2.29 | 2.53 | 3.88 | 3.29 |
| 06I - MEDICAL ICU | UH | 1.09 | 0.00 | 1.23 | 4.08 | 1.51 |
| 06K - MED/SURG | UH | 0.00 | 0.00 | 0.00 | 3.65 | 0.89 |
| 07A - ORTHOPEDICS | UH | 0.00 | 0.00 | 4.87 | 0.00 | 1.37 |
| 07U - SECURED UNIT | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 08E - SURGICAL ICU | UH | 0.00 | 3.11 | 1.46 | 3.17 | 1.88 |
| 08F - CARDIOPULMONARY ICU | UH | 1.35 | 0.00 | 1.37 | 0.00 | 0.75 |
| 08G - CARDIOVASCULAR MED/SURG | UH | 5.09 | 0.00 | 0.00 | 0.00 | 1.87 |
| 09E - NEUROSCIENCES INTERMED | UH | 1.61 | 4.71 | 0.00 | 8.62 | 3.47 |
| 09F - NEUROSCIENCES ICU | UH | 1.35 | 5.63 | 1.97 | 4.63 | 3.16 |
| 09G - NEUROSCIENCES M/S | UH | 3.61 | 6.37 | 5.10 | 0.00 | 3.78 |
| 10E - ONCOLOGY | UH | 0.00 | 0.00 | 0.00 | 4.42 | 0.82 |
| 10G - MEDICINE | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 10H - BONE MARROW TRP UNIT | UH | 16.39 | 12.66 | 12.66 | 0.00 | 11.90 |
| 11E - PEDIATRIC SURGERY | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 11G - PEDS HEM/ONC | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 12E - PEDIATRICS GENERAL | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 12F - PEDIATRIC ICU | UH | 9.01 | 0.00 | 0.00 | 0.00 | 2.41 |
| 3W - 3 WEST MEDICAL CC | CC | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 4E - 4 EAST PMR CC | CC | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 4N - 4 NORTH MED/SURG CC | CC | 0.00 | 0.00 | 2.93 | 0.00 | 0.75 |
| 4W - 4 WEST MED/SURG CC | CC | 0.00 | 0.00 | 10.10 | 0.00 | 1.64 |
| 6thFloor - 6 MED/SURG/ORTHO CC | CC | 0.00 | 7.75 | 5.52 | 2.31 | 3.56 |
| IC - ICU CC | CC | 0.00 | 0.00 | 2.06 | 1.85 | 1.00 |