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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

Unit NameUnit TypeCampus
02N - REHABILITATIONSPECIAL UNITUH
04B - PSYCHIATRYSPECIAL UNITUH
05A - GEN/ENT/GYN SURGERYMED/SURGUH
05B - GENSURG/TRAN/URO/PLAMED/SURGUH
06A - MED/PULM/ID/CRITCAREMED/SURGUH
06B - GENERAL MED/SURGMED/SURGUH
06E - BURN ICUICUUH
06H - MEDICAL ICUICUUH
06I - MEDICAL ICUICUUH
06K - MED/SURGMED/SURGUH
07A - ORTHOPEDICSMED/SURGUH
07U - SECURED UNITSPECIAL UNITUH
08E - SURGICAL ICUICUUH
08F - CARDIOPULMONARY ICUICUUH
08G - CARDIOVASCULAR MED/SURGMED/SURGUH
09E - NEUROSCIENCES INTERMEDMED/SURGUH
09F - NEUROSCIENCES ICUICUUH
09G - NEUROSCIENCES M/SMED/SURGUH
10E - ONCOLOGYMED/SURGUH
10G - MEDICINE MED/SURGUH
10H - BONE MARROW TRP UNITMED/SURGUH
11E - PEDIATRIC SURGERYPEDIATRICSUH
11G - PEDS HEM/ONCPEDIATRICSUH
12E - PEDIATRICS GENERALPEDIATRICSUH
12F - PEDIATRIC ICUPEDIATRICSUH
ERMADULT - EMERGENCY DEPARTMENTEMERGENCYUH
ERMPED - PEDIATRIC EMERGENCY DEPARTMENTEMERGENCYUH
3W - 3 WEST MEDICAL CCMED/SURGCC
4E - 4 EAST PMR CCSPECIAL UNITCC
4N - 4 NORTH MED/SURG CCMED/SURGCC
4W - 4 WEST MED/SURG CCMED/SURGCC
5E - 5 EAST TRANSITIONAL CARE CCSPECIAL UNITCC
5W - 5 WEST PSYCHIATRY CCSPECIAL UNITCC
6thFloor - 6 MED/SURG/ORTHO CCMED/SURGCC
ED - EMERGENCY DEPARTMENT CCEMERGENCYCC
EU - EPILEPSY MONITORING UNIT CCMED/SURGCC
IC - ICU CCICUCC

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 NameCampusQ2021_1Q2021_2Q2021_3Q2021_4Total
02N - REHABILITATIONUH0.450.000.440.000.23
04B - PSYCHIATRYUH0.000.000.600.000.14
05A - GEN/ENT/GYN SURGERYUH0.000.000.000.000.00
05B - GENSURG/TRAN/URO/PLAUH0.000.000.000.000.00
06A - MED/PULM/ID/CRITCAREUH0.000.000.000.000.00
06B - GENERAL MED/SURGUH0.500.490.000.000.25
06E - BURN ICUUH0.000.000.000.000.00
06H - MEDICAL ICUUH0.000.000.000.000.00
06I - MEDICAL ICUUH0.000.000.000.000.00
06K - MED/SURGUH0.000.000.000.000.00
07A - ORTHOPEDICSUH0.000.000.000.470.11
07U - SECURED UNITUH0.000.000.000.00
08E - SURGICAL ICUUH0.000.000.000.000.00
08F - CARDIOPULMONARY ICUUH0.000.000.000.000.00
08G - CARDIOVASCULAR MED/SURGUH0.000.000.000.000.00
09E - NEUROSCIENCES INTERMEDUH0.000.000.000.000.00
09F - NEUROSCIENCES ICUUH0.000.000.000.000.00
09G - NEUROSCIENCES M/SUH0.620.001.190.000.45
10E - ONCOLOGYUH0.000.000.000.000.00
10G - MEDICINE UH0.000.000.000.000.00
10H - BONE MARROW TRP UNITUH0.001.900.000.000.47
11E - PEDIATRIC SURGERYUH0.000.000.000.000.00
11G - PEDS HEM/ONCUH0.000.000.000.000.00
12E - PEDIATRICS GENERALUH0.000.000.000.000.00
12F - PEDIATRIC ICUUH0.000.000.000.000.00
2 - 2 POSTPARTUM GYN CCCC0.00
2L - LABOR AND DELIVERY CCCC0.000.000.00
3W - 3 WEST MEDICAL CCCC0.000.000.000.000.00
4E - 4 EAST PMR CCCC0.001.021.710.74
4N - 4 NORTH MED/SURG CCCC0.000.000.910.000.24
4W - 4 WEST MED/SURG CCCC0.000.000.000.000.00
5W - 5 WEST PSYCHIATRY CCCC0.000.000.000.000.00
6thFloor - 6 MED/SURG/ORTHO CCCC0.420.000.000.000.09
EU - EPILEPSY MONITORING UNIT CCCC0.000.000.000.000.00
IC - ICU CCCC0.000.000.000.000.00

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 NameCampusQ2021_1Q2021_2Q2021_3Q2021_4Total
02N - REHABILITATIONUH0.000.001.790.000.49
05A - GEN/ENT/GYN SURGERYUH0.000.000.000.000.00
05B - GENSURG/TRAN/URO/PLAUH0.000.000.000.000.00
06A - MED/PULM/ID/CRITCAREUH0.000.000.000.000.00
06B - GENERAL MED/SURGUH0.000.001.420.000.41
06E - BURN ICUUH0.000.000.007.431.92
06H - MEDICAL ICUUH0.000.970.000.880.48
06I - MEDICAL ICUUH1.030.000.001.160.55
06K - MED/SURGUH0.000.000.000.000.00
07A - ORTHOPEDICSUH0.000.000.000.000.00
07U - SECURED UNITUH0.000.000.000.000.00
08E - SURGICAL ICUUH0.000.001.550.000.39
08F - CARDIOPULMONARY ICUUH0.000.000.000.000.00
08G - CARDIOVASCULAR MED/SURGUH0.000.000.000.000.00
09E - NEUROSCIENCES INTERMEDUH0.000.000.000.000.00
09F - NEUROSCIENCES ICUUH1.160.000.000.000.36
09G - NEUROSCIENCES M/SUH1.920.000.002.421.06
10E - ONCOLOGYUH0.001.390.610.660.66
10G - MEDICINE UH0.000.000.000.000.00
10H - BONE MARROW TRP UNITUH2.150.002.048.323.23
11E - PEDIATRIC SURGERYUH0.000.000.000.000.00
11G - PEDS HEM/ONCUH0.000.000.000.000.00
12E - PEDIATRICS GENERALUH7.350.000.000.003.10
12F - PEDIATRIC ICUUH0.000.000.000.000.00
3W - 3 WEST MEDICAL CCCC0.000.000.000.000.00
4E - 4 EAST PMR CCCC0.000.000.000.000.00
4N - 4 NORTH MED/SURG CCCC0.000.000.000.000.00
4W - 4 WEST MED/SURG CCCC0.000.000.000.000.00
5W - 5 WEST PSYCHIATRY CCCC0.000.000.000.000.00
6thFloor - 6 MED/SURG/ORTHO CCCC0.000.000.001.730.62
IC - ICU CCCC0.000.000.001.460.48

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 NameCampusQ2021_1Q2021_2Q2021_3Q2021_4Total
02N - REHABILITATIONUH0.000.0011.9014.187.14
05A - GEN/ENT/GYN SURGERYUH0.000.000.000.000.00
05B - GENSURG/TRAN/URO/PLAUH0.000.002.860.000.76
06A - MED/PULM/ID/CRITCAREUH3.020.000.005.212.07
06B - GENERAL MED/SURGUH0.000.000.000.000.00
06E - BURN ICUUH14.4910.360.000.006.68
06H - MEDICAL ICUUH4.432.292.533.883.29
06I - MEDICAL ICUUH1.090.001.234.081.51
06K - MED/SURGUH0.000.000.003.650.89
07A - ORTHOPEDICSUH0.000.004.870.001.37
07U - SECURED UNITUH0.000.000.000.000.00
08E - SURGICAL ICUUH0.003.111.463.171.88
08F - CARDIOPULMONARY ICUUH1.350.001.370.000.75
08G - CARDIOVASCULAR MED/SURGUH5.090.000.000.001.87
09E - NEUROSCIENCES INTERMEDUH1.614.710.008.623.47
09F - NEUROSCIENCES ICUUH1.355.631.974.633.16
09G - NEUROSCIENCES M/SUH3.616.375.100.003.78
10E - ONCOLOGYUH0.000.000.004.420.82
10G - MEDICINE UH0.000.000.000.000.00
10H - BONE MARROW TRP UNITUH16.3912.6612.660.0011.90
11E - PEDIATRIC SURGERYUH0.000.000.000.000.00
11G - PEDS HEM/ONCUH0.000.000.000.000.00
12E - PEDIATRICS GENERALUH0.000.000.000.000.00
12F - PEDIATRIC ICUUH9.010.000.000.002.41
3W - 3 WEST MEDICAL CCCC0.000.000.000.000.00
4E - 4 EAST PMR CCCC0.000.000.000.000.00
4N - 4 NORTH MED/SURG CCCC0.000.002.930.000.75
4W - 4 WEST MED/SURG CCCC0.000.0010.100.001.64
6thFloor - 6 MED/SURG/ORTHO CCCC0.007.755.522.313.56
IC - ICU CCCC0.000.002.061.851.00
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