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 Q2019_2 and Q2020_1
| Unit Name | Campus | Q2019_2 | Q2019_3 | Q2019_4 | Q2020_1 | Total |
|---|---|---|---|---|---|---|
| 02N - REHABILITATION | UH | 0.44 | 0.00 | 0.00 | 0.00 | 0.11 |
| 04B - PSYCHIATRY | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 05A - GEN/ENT/GYN SURGERY | UH | 0.00 | 0.48 | 0.00 | 0.00 | 0.12 |
| 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 | 0.00 | 0.00 | 0.00 |
| 06E - BURN ICU | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 06H - MEDICAL ICU | UH | 0.00 | 0.00 | 0.00 | 0.79 | 0.19 |
| 06I - MEDICAL ICU | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 06K - MED/SURG | UH | 0.71 | 0.00 | 0.00 | 0.00 | 0.18 |
| 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 | 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 | 0.88 | 0.00 | 0.00 | 0.00 | 0.22 |
| 09G - NEUROSCIENCES M/S | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 10E - ONCOLOGY | UH | 0.00 | 0.00 | 0.42 | 0.00 | 0.11 |
| 10G - MEDICINE | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 10H - BONE MARROW TRP UNIT | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 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 | 0.56 | 0.00 | 0.15 |
| 12F - PEDIATRIC ICU | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 2E - 2 EAST OB/GYN CC | CC | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 2L - LABOR AND DELIVERY CC | CC | 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 | 1.06 | 0.00 | 0.00 | 0.28 |
| 4N - 4 NORTH MED/SURG CC | CC | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 5W - 5 WEST PSYCHIATRY CC | CC | 0.00 | 0.48 | 0.00 | 0.00 | 0.12 |
| 6 - 6 MED/SURG/ORTHO CC | CC | 0.00 | 0.00 | 0.45 | 0.00 | 0.12 |
| EU - EPILEPSY MONITORING UNIT CC | CC | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| IC - ICU CC | CC | 1.87 | 0.00 | 0.00 | 0.00 | 0.42 |
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 Q2019_2 and Q2020_1
| Unit Name | Campus | Q2019_2 | Q2019_3 | Q2019_4 | Q2020_1 | Total |
|---|---|---|---|---|---|---|
| 02N - REHABILITATION | UH | 0.00 | 0.00 | 0.00 | ||
| 05A - GEN/ENT/GYN SURGERY | UH | 0.00 | 0.00 | 0.00 | ||
| 05B - GENSURG/TRAN/URO/PLA | UH | 3.55 | 0.00 | 2.24 | ||
| 06A - MED/PULM/ID/CRITCARE | UH | 0.00 | 0.00 | 0.00 | ||
| 06B - GENERAL MED/SURG | UH | 0.00 | 0.00 | 0.00 | ||
| 06E - BURN ICU | UH | 0.00 | 12.74 | 5.10 | ||
| 06H - MEDICAL ICU | UH | 1.33 | 0.00 | 0.74 | ||
| 06I - MEDICAL ICU | UH | 0.00 | 0.00 | 0.00 | ||
| 06K - MED/SURG | UH | 0.00 | 5.97 | 2.38 | ||
| 07A - ORTHOPEDICS | UH | 0.00 | 0.00 | 0.00 | ||
| 07U - SECURED UNIT | UH | 0.00 | 0.00 | 0.00 | ||
| 08E - SURGICAL ICU | UH | 0.00 | 0.00 | 0.00 | ||
| 08F - CARDIOPULMONARY ICU | UH | 0.00 | 0.00 | 0.00 | ||
| 08G - CARDIOVASCULAR MED/SURG | UH | 0.00 | 0.00 | 0.00 | ||
| 09E - NEUROSCIENCES INTERMED | UH | 0.00 | 0.00 | 0.00 | ||
| 09F - NEUROSCIENCES ICU | UH | 0.00 | 0.00 | 0.00 | ||
| 09G - NEUROSCIENCES M/S | UH | 3.45 | 0.00 | 2.00 | ||
| 10E - ONCOLOGY | UH | 0.66 | 0.00 | 0.43 | ||
| 10G - MEDICINE | UH | 0.00 | 3.44 | 1.39 | ||
| 10H - BONE MARROW TRP UNIT | UH | 2.45 | 0.00 | 1.50 | ||
| 11E - PEDIATRIC SURGERY | UH | 0.00 | 7.63 | 3.64 | ||
| 11G - PEDS HEM/ONC | UH | 2.12 | 0.00 | 1.32 | ||
| 12E - PEDIATRICS GENERAL | UH | 0.00 | 0.00 | 0.00 | ||
| 12F - PEDIATRIC ICU | UH | 0.00 | 3.83 | 1.80 | ||
| 3W - 3 WEST MEDICAL CC | CC | 0.00 | 0.00 | 0.00 | ||
| 4E - 4 EAST PMR CC | CC | 0.00 | 0.00 | 0.00 | ||
| 4N - 4 NORTH MED/SURG CC | CC | 0.00 | 0.00 | 0.00 | ||
| 5W - 5 WEST PSYCHIATRY CC | CC | 0.00 | 0.00 | 0.00 | ||
| 6 - 6 MED/SURG/ORTHO CC | CC | 3.79 | 4.22 | 0.00 | 0.00 | 2.08 |
| IC - ICU CC | CC | 0.00 | 0.00 | 0.00 |
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 Q2019_2 and Q2020_1
| Unit Name | Campus | Q2019_2 | Q2019_3 | Q2019_4 | Q2020_1 | Total |
|---|---|---|---|---|---|---|
| 02N - REHABILITATION | UH | 11.36 | 15.75 | 0.00 | 0.00 | 8.57 |
| 05A - GEN/ENT/GYN SURGERY | UH | 0.00 | 0.00 | 3.92 | 0.00 | 1.04 |
| 05B - GENSURG/TRAN/URO/PLA | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 06A - MED/PULM/ID/CRITCARE | UH | 0.00 | 3.66 | 0.00 | 0.00 | 1.10 |
| 06B - GENERAL MED/SURG | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 06E - BURN ICU | UH | 6.37 | 0.00 | 10.70 | 10.99 | 6.85 |
| 06H - MEDICAL ICU | UH | 1.44 | 0.00 | 4.82 | 3.82 | 2.48 |
| 06I - MEDICAL ICU | UH | 1.49 | 1.35 | 0.00 | 0.00 | 0.74 |
| 06K - MED/SURG | UH | 3.12 | 3.89 | 0.00 | 0.00 | 2.02 |
| 07A - ORTHOPEDICS | UH | 0.00 | 3.30 | 0.00 | 0.00 | 0.76 |
| 07U - SECURED UNIT | UH | 0.00 | 15.15 | 0.00 | 0.00 | 4.90 |
| 08E - SURGICAL ICU | UH | 0.00 | 4.79 | 1.49 | 2.50 | 2.19 |
| 08F - CARDIOPULMONARY ICU | UH | 2.94 | 1.63 | 0.00 | 2.43 | 1.67 |
| 08G - CARDIOVASCULAR MED/SURG | UH | 0.00 | 0.00 | 0.00 | 6.80 | 1.26 |
| 09E - NEUROSCIENCES INTERMED | UH | 0.00 | 0.00 | 8.93 | 0.00 | 2.98 |
| 09F - NEUROSCIENCES ICU | UH | 1.65 | 5.53 | 4.79 | 0.00 | 3.52 |
| 09G - NEUROSCIENCES M/S | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 10E - ONCOLOGY | UH | 0.00 | 0.00 | 3.38 | 0.00 | 1.14 |
| 10G - MEDICINE | UH | 6.13 | 0.00 | 7.63 | 0.00 | 3.82 |
| 10H - BONE MARROW TRP UNIT | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 11E - PEDIATRIC SURGERY | UH | 0.00 | 0.00 | 0.00 | 20.00 | 4.24 |
| 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 | 4.93 | 0.00 | 0.00 | 1.60 |
| 3W - 3 WEST MEDICAL CC | CC | 0.00 | 0.00 | 0.00 | 6.33 | 1.05 |
| 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 | 2.91 | 0.00 | 0.00 | 0.78 |
| 6 - 6 MED/SURG/ORTHO CC | CC | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| IC - ICU CC | CC | 0.00 | 6.58 | 0.00 | 0.00 | 2.23 |