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 Q2020_3 and Q2021_2
| Unit Name | Campus | Q2020_3 | Q2020_4 | Q2021_1 | Q2021_2 | Total |
|---|---|---|---|---|---|---|
| 02N - REHABILITATION | UH | 0.00 | 0.00 | 0.45 | 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 | 0.00 | 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 | 0.50 | 0.49 | 0.24 |
| 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 | 0.82 | 0.00 | 0.00 | 0.00 | 0.19 |
| 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 | 0.64 | 0.00 | 0.00 | 0.16 |
| 09E - NEUROSCIENCES INTERMED | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 09F - NEUROSCIENCES ICU | UH | 0.82 | 0.00 | 0.00 | 0.00 | 0.21 |
| 09G - NEUROSCIENCES M/S | UH | 0.00 | 0.63 | 0.62 | 0.00 | 0.31 |
| 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 | 1.90 | 0.47 |
| 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 | 0.00 | 0.00 | 0.00 | 0.00 |
| 3W - 3 WEST MEDICAL CC | CC | 0.00 | 0.48 | 0.00 | 0.00 | 0.14 |
| 4E - 4 EAST PMR CC | CC | 0.00 | 0.00 | 0.00 | 1.02 | 0.23 |
| 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 | 0.45 | 0.42 | 0.00 | 0.21 |
| 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 Q2020_3 and Q2021_2
| Unit Name | Campus | Q2020_3 | Q2020_4 | Q2021_1 | Q2021_2 | Total |
|---|---|---|---|---|---|---|
| 02N - REHABILITATION | 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 | 0.00 | 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 | 2.18 | 0.00 | 0.00 | 0.97 | 0.78 |
| 06I - MEDICAL ICU | UH | 0.00 | 1.06 | 1.03 | 0.00 | 0.56 |
| 06K - MED/SURG | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 07A - ORTHOPEDICS | UH | 1.98 | 0.00 | 0.00 | 0.00 | 0.56 |
| 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 | 1.18 | 0.00 | 0.00 | 0.00 | 0.30 |
| 08G - CARDIOVASCULAR MED/SURG | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 09E - NEUROSCIENCES INTERMED | UH | 0.00 | 1.50 | 0.00 | 0.00 | 0.40 |
| 09F - NEUROSCIENCES ICU | UH | 0.00 | 2.53 | 1.16 | 0.00 | 0.98 |
| 09G - NEUROSCIENCES M/S | UH | 0.00 | 0.00 | 1.92 | 0.00 | 0.60 |
| 10E - ONCOLOGY | UH | 0.74 | 1.44 | 0.00 | 1.39 | 0.89 |
| 10G - MEDICINE | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 10H - BONE MARROW TRP UNIT | UH | 0.00 | 2.39 | 2.15 | 0.00 | 1.19 |
| 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 | 7.35 | 0.00 | 2.56 |
| 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 | 0.00 | 0.00 | 0.00 |
| 4N - 4 NORTH MED/SURG CC | CC | 2.89 | 6.02 | 0.00 | 0.00 | 2.59 |
| 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 | 0.00 | 0.00 |
| IC - ICU CC | CC | 2.17 | 0.00 | 0.00 | 0.00 | 0.51 |
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 Q2020_3 and Q2021_2
| Unit Name | Campus | Q2020_3 | Q2020_4 | Q2021_1 | Q2021_2 | Total |
|---|---|---|---|---|---|---|
| 02N - REHABILITATION | UH | 0.00 | 6.71 | 0.00 | 0.00 | 2.30 |
| 05A - GEN/ENT/GYN SURGERY | UH | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 |
| 05B - GENSURG/TRAN/URO/PLA | UH | 0.00 | 5.24 | 0.00 | 0.00 | 1.45 |
| 06A - MED/PULM/ID/CRITCARE | UH | 3.33 | 3.68 | 3.02 | 0.00 | 2.65 |
| 06B - GENERAL MED/SURG | UH | 0.00 | 2.60 | 0.00 | 0.00 | 0.86 |
| 06E - BURN ICU | UH | 11.05 | 4.33 | 14.49 | 10.36 | 9.85 |
| 06H - MEDICAL ICU | UH | 1.18 | 1.08 | 4.43 | 2.29 | 2.25 |
| 06I - MEDICAL ICU | UH | 0.00 | 1.13 | 1.09 | 0.00 | 0.60 |
| 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 | 1.42 | 0.00 | 3.11 | 1.10 |
| 08F - CARDIOPULMONARY ICU | UH | 2.89 | 3.83 | 1.35 | 0.00 | 2.08 |
| 08G - CARDIOVASCULAR MED/SURG | UH | 0.00 | 0.00 | 5.09 | 0.00 | 1.81 |
| 09E - NEUROSCIENCES INTERMED | UH | 6.64 | 3.41 | 1.61 | 4.71 | 4.03 |
| 09F - NEUROSCIENCES ICU | UH | 3.23 | 1.42 | 1.35 | 5.63 | 2.70 |
| 09G - NEUROSCIENCES M/S | UH | 7.19 | 0.00 | 3.61 | 6.37 | 4.04 |
| 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 | 16.39 | 12.66 | 9.22 |
| 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 | 9.01 | 0.00 | 2.17 |
| 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 | 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 |
| 6thFloor - 6 MED/SURG/ORTHO CC | CC | 0.00 | 0.00 | 0.00 | 7.75 | 1.80 |
| IC - ICU CC | CC | 2.04 | 1.55 | 0.00 | 0.00 | 0.95 |