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_3 and Q2022_2
| Unit Name | Campus | Q2021_3 | Q2021_4 | Q2022_1 | Q2022_2 | Total |
|---|---|---|---|---|---|---|
| 02N - REHABILITATION | UH | 0.44 | 0.00 | 0.00 | 0.00 | 0.11 |
| 04B - PSYCHIATRY | UH | 0.60 | 0.00 | 0.00 | 0.00 | 0.17 |
| 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 | 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 | 0.00 | 0.00 | 0.71 | 0.18 |
| 07A - ORTHOPEDICS | UH | 0.00 | 0.47 | 0.00 | 0.47 | 0.23 |
| 07U - SECURED UNIT | UH | 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 | 1.19 | 0.00 | 0.00 | 0.59 | 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 | 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 | 1.10 | 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 | 1.71 | 1.71 | |||
| 4N - 4 NORTH MED/SURG CC | CC | 0.91 | 0.00 | 0.00 | 0.00 | 0.25 |
| 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 | 0.69 | 0.14 |
| 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 | 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_3 and Q2022_2
| Unit Name | Campus | Q2021_3 | Q2021_4 | Q2022_1 | Q2022_2 | Total |
|---|---|---|---|---|---|---|
| 02N - REHABILITATION | UH | 1.79 | 0.00 | 0.00 | 0.00 | 0.60 |
| 05A - GEN/ENT/GYN SURGERY | UH | 0.00 | 0.00 | 2.00 | 0.00 | 0.50 |
| 05B - GENSURG/TRAN/URO/PLA | UH | 0.00 | 0.00 | 0.00 | 1.63 | 0.45 |
| 06A - MED/PULM/ID/CRITCARE | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 06B - GENERAL MED/SURG | UH | 1.42 | 0.00 | 2.00 | 0.00 | 0.82 |
| 06E - BURN ICU | UH | 0.00 | 7.43 | 0.00 | 0.00 | 1.83 |
| 06H - MEDICAL ICU | UH | 0.00 | 0.88 | 0.00 | 0.00 | 0.25 |
| 06I - MEDICAL ICU | UH | 0.00 | 1.16 | 0.00 | 0.00 | 0.29 |
| 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 | 1.55 | 0.00 | 0.00 | 0.00 | 0.42 |
| 08F - CARDIOPULMONARY ICU | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 08G - CARDIOVASCULAR MED/SURG | UH | 0.00 | 0.00 | 2.39 | 0.00 | 0.52 |
| 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 | 2.42 | 0.00 | 0.00 | 0.54 |
| 10E - ONCOLOGY | UH | 0.61 | 0.66 | 0.66 | 2.12 | 0.98 |
| 10G - MEDICINE | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 10H - BONE MARROW TRP UNIT | UH | 2.04 | 8.32 | 2.14 | 0.00 | 3.15 |
| 11E - PEDIATRIC SURGERY | UH | 0.00 | 0.00 | 0.00 | 3.31 | 1.26 |
| 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 | 5.21 | 0.00 | 0.00 | 0.00 | 1.07 |
| 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 | |
| 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 | 1.73 | 0.00 | 0.00 | 0.62 |
| IC - ICU CC | CC | 0.00 | 1.46 | 0.00 | 0.00 | 0.47 |
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_3 and Q2022_2
| Unit Name | Campus | Q2021_3 | Q2021_4 | Q2022_1 | Q2022_2 | Total |
|---|---|---|---|---|---|---|
| 02N - REHABILITATION | UH | 11.90 | 14.18 | 0.00 | 11.76 | 8.85 |
| 05A - GEN/ENT/GYN SURGERY | UH | 0.00 | 0.00 | 3.85 | 0.00 | 0.86 |
| 05B - GENSURG/TRAN/URO/PLA | UH | 2.86 | 0.00 | 3.44 | 0.00 | 1.68 |
| 06A - MED/PULM/ID/CRITCARE | UH | 0.00 | 5.21 | 0.00 | 0.00 | 1.13 |
| 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 | 6.90 | 1.36 |
| 06H - MEDICAL ICU | UH | 2.53 | 3.88 | 0.00 | 1.63 | 2.11 |
| 06I - MEDICAL ICU | UH | 1.23 | 4.08 | 1.36 | 0.00 | 1.75 |
| 06K - MED/SURG | UH | 0.00 | 3.65 | 0.00 | 0.00 | 1.06 |
| 07A - ORTHOPEDICS | UH | 4.87 | 0.00 | 0.00 | 2.60 | 2.13 |
| 07U - SECURED UNIT | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 08E - SURGICAL ICU | UH | 1.46 | 3.17 | 0.00 | 0.00 | 1.24 |
| 08F - CARDIOPULMONARY ICU | UH | 1.37 | 0.00 | 4.40 | 0.00 | 1.35 |
| 08G - CARDIOVASCULAR MED/SURG | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 09E - NEUROSCIENCES INTERMED | UH | 0.00 | 8.62 | 0.00 | 0.00 | 2.28 |
| 09F - NEUROSCIENCES ICU | UH | 1.97 | 4.63 | 2.03 | 2.02 | 2.59 |
| 09G - NEUROSCIENCES M/S | UH | 5.10 | 0.00 | 0.00 | 0.00 | 1.21 |
| 10E - ONCOLOGY | UH | 0.00 | 4.42 | 0.00 | 0.00 | 0.88 |
| 10G - MEDICINE | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 10H - BONE MARROW TRP UNIT | UH | 12.66 | 0.00 | 0.00 | 0.00 | 4.83 |
| 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 | 7.25 | 2.01 |
| 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 | |
| 4N - 4 NORTH MED/SURG CC | CC | 2.93 | 0.00 | 0.00 | 0.00 | 0.76 |
| 4W - 4 WEST MED/SURG CC | CC | 10.10 | 0.00 | 0.00 | 0.00 | 1.51 |
| 6thFloor - 6 MED/SURG/ORTHO CC | CC | 5.52 | 2.31 | 3.60 | 0.00 | 2.86 |
| IC - ICU CC | CC | 2.06 | 1.85 | 0.00 | 0.00 | 1.00 |