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 Q2022_1 and Q2022_4
| Unit Name | Campus | Q2022_1 | Q2022_2 | Q2022_3 | Q2022_4 | Total |
|---|---|---|---|---|---|---|
| 02N - REHABILITATION | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 04B - PSYCHIATRY | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 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 | 0.52 | 0.45 | 0.26 |
| 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 | 0.53 | 0.00 | 0.14 |
| 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 | 0.71 | 0.00 | 0.00 | 0.18 |
| 07A - ORTHOPEDICS | UH | 0.00 | 0.47 | 0.00 | 0.00 | 0.12 |
| 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 | 1.13 | 0.30 |
| 09F - NEUROSCIENCES ICU | UH | 0.00 | 0.00 | 0.93 | 0.00 | 0.23 |
| 09G - NEUROSCIENCES M/S | UH | 0.00 | 0.59 | 0.00 | 0.00 | 0.15 |
| 10E - ONCOLOGY | UH | 0.00 | 0.00 | 0.41 | 0.00 | 0.10 |
| 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 | 1.10 | 0.00 | 0.00 | 0.00 | 0.27 |
| 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 | 0.00 | 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 | 0.00 | 0.00 |
| 4W - 4 WEST MED/SURG CC | CC | 0.00 | 0.00 | 0.58 | 0.00 | 0.15 |
| 5W - 5 WEST PSYCHIATRY CC | CC | 0.00 | 0.69 | 0.64 | 0.00 | 0.31 |
| 6thFloor - 6 MED/SURG/ORTHO CC | CC | 0.00 | 0.00 | 0.41 | 0.00 | 0.11 |
| 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 Q2022_1 and Q2022_4
| Unit Name | Campus | Q2022_1 | Q2022_2 | Q2022_3 | Q2022_4 | Total |
|---|---|---|---|---|---|---|
| 02N - REHABILITATION | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 05A - GEN/ENT/GYN SURGERY | UH | 2.00 | 0.00 | 0.00 | 0.00 | 0.47 |
| 05B - GENSURG/TRAN/URO/PLA | UH | 0.00 | 1.63 | 0.00 | 0.00 | 0.42 |
| 06A - MED/PULM/ID/CRITCARE | UH | 0.00 | 0.00 | 0.00 | 2.74 | 0.81 |
| 06B - GENERAL MED/SURG | UH | 2.00 | 0.00 | 0.00 | 0.00 | 0.44 |
| 06E - BURN ICU | UH | 0.00 | 0.00 | 0.00 | 3.45 | 0.88 |
| 06H - MEDICAL ICU | UH | 0.00 | 0.00 | 1.23 | 0.00 | 0.28 |
| 06I - MEDICAL ICU | UH | 0.00 | 0.00 | 1.15 | 0.00 | 0.28 |
| 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 | 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 | 2.39 | 0.00 | 0.00 | 0.00 | 0.55 |
| 09E - NEUROSCIENCES INTERMED | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 09F - NEUROSCIENCES ICU | UH | 0.00 | 0.00 | 1.37 | 0.00 | 0.36 |
| 09G - NEUROSCIENCES M/S | UH | 0.00 | 0.00 | 0.00 | 1.94 | 0.53 |
| 10E - ONCOLOGY | UH | 0.66 | 2.12 | 0.00 | 1.20 | 0.99 |
| 10G - MEDICINE | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 10H - BONE MARROW TRP UNIT | UH | 2.14 | 0.00 | 1.97 | 7.09 | 2.68 |
| 11E - PEDIATRIC SURGERY | UH | 0.00 | 3.31 | 0.00 | 0.00 | 1.28 |
| 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 |
| 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 | |||
| 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 | 2.03 | 0.67 |
| IC - ICU CC | CC | 0.00 | 0.00 | 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 Q2022_1 and Q2022_4
| Unit Name | Campus | Q2022_1 | Q2022_2 | Q2022_3 | Q2022_4 | Total |
|---|---|---|---|---|---|---|
| 02N - REHABILITATION | UH | 0.00 | 11.76 | 0.00 | 0.00 | 2.22 |
| 05A - GEN/ENT/GYN SURGERY | UH | 3.85 | 0.00 | 0.00 | 0.00 | 0.88 |
| 05B - GENSURG/TRAN/URO/PLA | UH | 3.44 | 0.00 | 0.00 | 2.51 | 1.59 |
| 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 | 6.90 | 0.00 | 7.75 | 4.17 |
| 06H - MEDICAL ICU | UH | 0.00 | 1.63 | 0.00 | 0.00 | 0.39 |
| 06I - MEDICAL ICU | UH | 1.36 | 0.00 | 0.00 | 2.60 | 1.08 |
| 06K - MED/SURG | UH | 0.00 | 0.00 | 0.00 | 4.93 | 1.17 |
| 07A - ORTHOPEDICS | UH | 0.00 | 2.60 | 0.00 | 0.00 | 0.72 |
| 07U - SECURED UNIT | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 08E - SURGICAL ICU | UH | 0.00 | 0.00 | 4.20 | 2.66 | 1.95 |
| 08F - CARDIOPULMONARY ICU | UH | 4.40 | 0.00 | 2.35 | 0.00 | 1.57 |
| 08G - CARDIOVASCULAR MED/SURG | UH | 0.00 | 0.00 | 7.52 | 0.00 | 2.47 |
| 09E - NEUROSCIENCES INTERMED | UH | 0.00 | 0.00 | 4.50 | 0.00 | 1.20 |
| 09F - NEUROSCIENCES ICU | UH | 2.03 | 2.02 | 0.00 | 0.00 | 0.99 |
| 09G - NEUROSCIENCES M/S | UH | 0.00 | 0.00 | 4.39 | 0.00 | 1.14 |
| 10E - ONCOLOGY | UH | 0.00 | 0.00 | 0.00 | 3.04 | 0.75 |
| 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 | 7.25 | 0.00 | 0.00 | 2.14 |
| 3W - 3 WEST MEDICAL CC | CC | 0.00 | 0.00 | 5.41 | 0.00 | 1.21 |
| 4E - 4 EAST PMR CC | CC | 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 | 4.81 | 4.15 | 2.41 |
| 6thFloor - 6 MED/SURG/ORTHO CC | CC | 3.60 | 0.00 | 0.00 | 0.00 | 0.81 |
| IC - ICU CC | CC | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |