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 Q2023_3 and Q2024_2
| Unit Name | Campus | Q2023_3 | Q2023_4 | Q2024_1 | Q2024_2 | Total |
|---|---|---|---|---|---|---|
| 02N - REHABILITATION | UH | 0.00 | 1.29 | 0.00 | 0.00 | 0.33 |
| 04B - PSYCHIATRY | UH | 0.00 | 0.00 | 0.53 | 0.52 | 0.27 |
| 05A - GEN/ENT/GYN SURGERY | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 05B - GENSURG/TRAN/URO/PLA | UH | 0.00 | 0.94 | 0.00 | 0.00 | 0.23 |
| 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 | 0.00 | 0.00 |
| 06I - MEDICAL ICU | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 06K - MED/SURG | UH | 0.00 | 0.70 | 0.00 | 0.00 | 0.18 |
| 07A - ORTHOPEDICS | UH | 0.00 | 0.00 | 0.81 | 0.00 | 0.21 |
| 07U - SECURED UNIT | UH | 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 | 0.00 | 1.15 | 0.00 | 0.00 | 0.29 |
| 10E - ONCOLOGY | UH | 0.00 | 0.41 | 0.00 | 0.41 | 0.21 |
| 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 | 0.00 | 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 | ||||
| 3W - 3 WEST MEDICAL CC | CC | 0.00 | 0.00 | 0.44 | 0.42 | 0.22 |
| 4E - 4 EAST PMR CC | CC | 0.00 | ||||
| 4N - 4 NORTH MED/SURG CC | CC | 0.46 | 0.00 | 0.00 | 0.00 | 0.12 |
| 4W - 4 WEST MED/SURG CC | CC | 0.60 | 0.00 | 0.00 | 0.00 | 0.15 |
| 5W - 5 WEST PSYCHIATRY CC | CC | 0.00 | 0.00 | 0.00 | 1.05 | 0.25 |
| 6thFloor - 6 MED/SURG/ORTHO CC | CC | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 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 | 1.04 | 0.26 |
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 Q2023_3 and Q2024_2
| Unit Name | Campus | Q2023_3 | Q2023_4 | Q2024_1 | Q2024_2 | Total |
|---|---|---|---|---|---|---|
| 02N - REHABILITATION | UH | 0.00 | 0.00 | 3.39 | 0.00 | 0.85 |
| 05A - GEN/ENT/GYN SURGERY | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 05B - GENSURG/TRAN/URO/PLA | UH | 1.71 | 0.00 | 0.00 | 2.43 | 0.98 |
| 06A - MED/PULM/ID/CRITCARE | UH | 0.00 | 1.56 | 0.00 | 1.88 | 0.86 |
| 06B - GENERAL MED/SURG | UH | 2.23 | 0.00 | 0.00 | 0.00 | 0.48 |
| 06E - BURN ICU | UH | 0.00 | 0.00 | 0.00 | 4.74 | 1.12 |
| 06H - MEDICAL ICU | UH | 1.03 | 0.00 | 0.00 | 2.29 | 0.77 |
| 06I - MEDICAL ICU | UH | 0.00 | 0.00 | 0.00 | 1.18 | 0.28 |
| 06K - MED/SURG | UH | 0.00 | 1.57 | 1.58 | 0.00 | 0.86 |
| 07A - ORTHOPEDICS | UH | 0.00 | 0.00 | 0.00 | 1.72 | 0.48 |
| 07U - SECURED UNIT | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 08E - SURGICAL ICU | UH | 1.47 | 1.78 | 0.00 | 1.69 | 1.21 |
| 08F - CARDIOPULMONARY ICU | UH | 1.36 | 1.31 | 1.24 | 0.00 | 1.00 |
| 08G - CARDIOVASCULAR MED/SURG | UH | 0.00 | 0.00 | 0.00 | 2.01 | 0.50 |
| 09E - NEUROSCIENCES INTERMED | UH | 1.41 | 1.59 | 0.00 | 1.71 | 1.18 |
| 09F - NEUROSCIENCES ICU | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 09G - NEUROSCIENCES M/S | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 10E - ONCOLOGY | UH | 0.00 | 0.64 | 1.25 | 0.67 | 0.64 |
| 10G - MEDICINE | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 10H - BONE MARROW TRP UNIT | UH | 4.02 | 2.16 | 2.20 | 0.00 | 2.10 |
| 11E - PEDIATRIC SURGERY | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 11G - PEDS HEM/ONC | UH | 0.00 | 2.78 | 1.49 | 0.00 | 1.26 |
| 12E - PEDIATRICS GENERAL | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 12F - PEDIATRIC ICU | UH | 8.23 | 0.00 | 3.88 | 3.86 | 4.24 |
| 3W - 3 WEST MEDICAL CC | CC | 0.00 | 0.00 | 2.93 | 0.00 | 0.79 |
| 4E - 4 EAST PMR CC | CC | 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 | 4.88 | 0.00 | 0.00 | 0.00 | 1.23 |
| 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 | ||||
| IC - ICU CC | CC | 0.00 | 0.00 | 2.15 | 0.00 | 0.55 |
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 Q2023_3 and Q2024_2
| Unit Name | Campus | Q2023_3 | Q2023_4 | Q2024_1 | Q2024_2 | Total |
|---|---|---|---|---|---|---|
| 02N - REHABILITATION | UH | 0.00 | 7.75 | 0.00 | 0.00 | 2.15 |
| 05A - GEN/ENT/GYN SURGERY | UH | 2.94 | 6.02 | 3.66 | 0.00 | 3.27 |
| 05B - GENSURG/TRAN/URO/PLA | UH | 3.22 | 5.52 | 0.00 | 0.00 | 2.34 |
| 06A - MED/PULM/ID/CRITCARE | UH | 0.00 | 3.34 | 0.00 | 0.00 | 0.82 |
| 06B - GENERAL MED/SURG | UH | 3.47 | 0.00 | 0.00 | 0.00 | 0.97 |
| 06E - BURN ICU | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 06H - MEDICAL ICU | UH | 1.31 | 1.32 | 3.59 | 1.64 | 2.02 |
| 06I - MEDICAL ICU | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 06K - MED/SURG | UH | 3.56 | 10.64 | 0.00 | 3.89 | 4.37 |
| 07A - ORTHOPEDICS | UH | 0.00 | 1.86 | 1.71 | 2.38 | 1.53 |
| 07U - SECURED UNIT | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 08E - SURGICAL ICU | UH | 3.14 | 0.00 | 0.00 | 1.50 | 1.21 |
| 08F - CARDIOPULMONARY ICU | UH | 2.29 | 0.00 | 0.00 | 0.00 | 0.50 |
| 08G - CARDIOVASCULAR MED/SURG | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 09E - NEUROSCIENCES INTERMED | UH | 1.76 | 0.00 | 5.70 | 0.00 | 1.93 |
| 09F - NEUROSCIENCES ICU | UH | 3.63 | 2.22 | 1.76 | 0.00 | 1.84 |
| 09G - NEUROSCIENCES M/S | UH | 8.70 | 5.24 | 5.32 | 0.00 | 4.62 |
| 10E - ONCOLOGY | UH | 2.61 | 3.70 | 0.00 | 6.54 | 2.63 |
| 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 | 0.00 | 0.00 | 0.00 |
| 12F - PEDIATRIC ICU | UH | 13.42 | 0.00 | 0.00 | 0.00 | 3.70 |
| 3W - 3 WEST MEDICAL CC | CC | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 4E - 4 EAST PMR CC | CC | 0.00 | ||||
| 4N - 4 NORTH MED/SURG CC | CC | 0.00 | 0.00 | 0.00 | 4.05 | 0.89 |
| 4W - 4 WEST MED/SURG CC | CC | 4.55 | 4.31 | 0.00 | 0.00 | 2.44 |
| 6thFloor - 6 MED/SURG/ORTHO CC | CC | 0.00 | ||||
| IC - ICU CC | CC | 0.00 | 0.00 | 2.11 | 1.93 | 0.97 |