Nursing Quality Measures

Staffing Plans

Upstate Medical University - Current Budgeted

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 Plan

Unit Name Unit Type
02N - REHABILITATION SPECIAL UNIT
04B - PSYCHIATRY SPECIAL UNIT
05A - GEN/ENT/GYN SURGERY MED/SURG
05B - GENSURG/TRAN/URO/PLA MED/SURG
06A - MED/PULM/ID/CRITCARE MED/SURG
06B - GENERAL MED/SURG MED/SURG
06E - BURN ICU ICU
06H - MED ICU ICU
06I - SURG ICU ICU
06K - MED/SURG MED/SURG
07A - ORTHOPEDICS MED/SURG
07U - SECURED UNIT SPECIAL UNIT
08E - CORONARY CARE UNIT ICU
08F - CARDIOPULMONARY ICU ICU
08G - CARDIOVASCULAR MED/SURG MED/SURG
09E - NEUROSCIENCES INTERMED MED/SURG
09F - NEUROSCIENCES ICU ICU
09G - NEUROSCIENCES M/S MED/SURG
10E - ONCOLOGY MED/SURG
10G - MEDICINE MED/SURG
10H - BONE MARROW TRP UNIT MED/SURG
11E - PEDIATRIC SURGERY PEDIATRICS
11G - PEDS HEM/ONC PEDIATRICS
12E - PEDIATRICS/ADOLESCENT PEDIATRICS
12F - PEDIATRIC ICU PEDIATRICS
ED - EMERGENCY DEPARTMENT EMERGENCY

Staffing Data

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 Name Unit Type
02N - REHABILITATION SPECIAL UNIT
04B - PSYCHIATRY SPECIAL UNIT
05A - GEN/ENT/GYN SURGERY MED/SURG
05B - GENSURG/TRAN/URO/PLA MED/SURG
06A - MED/PULM/ID/CRITCARE MED/SURG
06B - GENERAL MED/SURG MED/SURG
06E - BURN ICU ICU
06H - MED ICU ICU
06I - SURG ICU ICU
06K - MED/SURG MED/SURG
07A - ORTHOPEDICS MED/SURG
07U - SECURED UNIT SPECIAL UNIT
08E - CORONARY CARE UNIT ICU
08F - CARDIOPULMONARY ICU ICU
08G - CARDIOVASCULAR MED/SURG MED/SURG
09E - NEUROSCIENCES INTERMED MED/SURG
09F - NEUROSCIENCES ICU ICU
09G - NEUROSCIENCES M/S MED/SURG
10E - ONCOLOGY MED/SURG
10G - MEDICINE MED/SURG
10H - BONE MARROW TRP UNIT MED/SURG
11E - PEDIATRIC SURGERY PEDIATRICS
11G - PEDS HEM/ONC PEDIATRICS
12E - PEDIATRICS/ADOLESCENT PEDIATRICS
12F - PEDIATRIC ICU PEDIATRICS
ED - EMERGENCY DEPARTMENT EMERGENCY

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 Q2011_3 and Q2012_2



Unit Name Q2011_3 Q2011_4 Q2012_1 Q2012_2 Total
02N - REHABILITATION 1.14 1.56 0.40 0.82 0.99
04B - PSYCHIATRY 0.52 0.53 0.00 1.11 0.54
05A - GEN/ENT/GYN SURGERY 0.00 0.53 0.00 0.00 0.13
05B - GENSURG/TRAN/URO/PLA 0.00 0.00 0.51 0.00 0.13
06A - MED/PULM/ID/CRITCARE 0.65 1.05 1.54 0.99 1.08
06B - GENERAL MED/SURG 0.00 0.00 0.00 0.00 0.00
06E - BURN ICU 0.00 0.00 0.00 0.00 0.00
06H - MED ICU 0.00 0.00 0.00 0.00 0.00
06I - SURG ICU 0.00 0.00 0.00 0.00 0.00
06K - MED/SURG 0.92 0.96 0.00 0.00 0.45
06L - ORTHOPEDICS 0.00 8.93 0.00 0.00 0.37
07A - ORTHOPEDICS 0.00 0.00 0.00 0.00 0.00
07U - SECURED UNIT 2.87 3.29 0.00 0.00 1.25
08E - CORONARY CARE UNIT 0.00 1.03 0.00 0.94 0.49
08F - CARDIOPULMONARY ICU 0.00 0.00 0.00 0.83 0.22
08G - CARDIOVASCULAR MED/SURG 1.34 1.40 0.65 1.95 1.33
09E - NEUROSCIENCES INTERMED 0.00 0.00 0.75 0.00 0.19
09F - NEUROSCIENCES ICU 0.00 1.08 0.00 1.10 0.54
09G - NEUROSCIENCES M/S 0.65 1.35 0.00 1.37 0.84
10E - ONCOLOGY 1.27 1.73 0.83 0.42 1.06
10G - MEDICINE 3.51 0.00 0.00 0.00 0.89
10H - BONE MARROW TRP UNIT 2.20 0.00 2.14 0.00 1.07
11E - PEDIATRIC SURGERY 0.00 1.74 1.39 1.77 1.26
11G - PEDS HEM/ONC 0.00 0.00 0.00 1.68 0.38
12E - PEDIATRICS/ADOLESCENT 0.00 0.00 0.00 0.00 0.00
12F - PEDIATRIC ICU 0.00 0.00 0.00 0.00 0.00

Pressure Ulcer Stage


What this means:
The total number of patients that have nosocomial (hospital-acquired) stage II or greater pressure ulcers on the day of the prevalence study. A pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure in combination with shear and/or friction. A less-specific, general term for pressure ulcers is bed sores.

Nosocomial pressure ulcer stage 2 or above rate = # of patients with a facility acquired pressure ulcer stage 2 or above / # of patients assessed * 1000

Data for the period between Q2011_2 and Q2012_1



Unit Name Q2011_2 Q2011_3 Q2011_4 Q2012_1 Total
02N - REHABILITATION 0.00% 0.00% 0.00% 0.00% 0.00%
04B - PSYCHIATRY 0.00% 0.00% 0.00% 0.00% 0.00%
05A - GEN/ENT/GYN SURGERY 0.00% 0.00% 0.00% 0.00% 0.00%
05B - GENSURG/TRAN/URO/PLA 0.00% 0.00% 0.00% 0.00% 0.00%
06A - MED/PULM/ID/CRITCARE 0.00% 0.00% 0.00% 0.00% 0.00%
06B - GENERAL MED/SURG 0.00% 0.00% 0.00% 0.00% 0.00%
06E - BURN ICU 0.00% 0.00% 0.00% 0.00% 0.00%
06H - MED ICU 0.00% 13.33% 0.00% 0.00% 4.55%
06I - SURG ICU 0.00% 6.67% 0.00% 0.00% 1.89%
06K - MED/SURG 0.00% 0.00% 0.00% 0.00% 0.00%
06L - ORTHOPEDICS 0.00% 0.00% 0.00% 0.00% 0.00%
07A - ORTHOPEDICS 0.00% 0.00% 0.00% 0.00% 0.00%
07U - SECURED UNIT 0.00% 0.00% 0.00% 0.00% 0.00%
08E - CORONARY CARE UNIT 0.00% 0.00% 0.00% 0.00% 0.00%
08F - CARDIOPULMONARY ICU 0.00% 0.00% 0.00% 0.00% 0.00%
08G - CARDIOVASCULAR MED/SURG 0.00% 0.00% 0.00% 2.78% 0.87%
09E - NEUROSCIENCES INTERMED 0.00% 0.00% 0.00% 0.00% 0.00%
09F - NEUROSCIENCES ICU 0.00% 0.00% 0.00% 0.00% 0.00%
09G - NEUROSCIENCES M/S 0.00% 0.00% 0.00% 0.00% 0.00%
10E - ONCOLOGY 0.00% 0.00% 0.00% 4.17% 1.43%
10G - MEDICINE 0.00% 7.69% 0.00% 0.00% 2.22%
10H - BONE MARROW TRP UNIT 0.00% 0.00% 0.00% 0.00% 0.00%
11E - PEDIATRIC SURGERY 0.00% 0.00% 0.00% 0.00% 0.00%
11G - PEDS HEM/ONC 0.00% 0.00% 0.00% 0.00% 0.00%
12E - PEDIATRICS/ADOLESCENT 0.00% 0.00% 0.00% 0.00% 0.00%
12F - PEDIATRIC ICU 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) is 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 Q2011_3 and Q2012_2



Unit Name Q2011_3 Q2011_4 Q2012_1 Q2012_2 Total
06E - BURN ICU 0.00 9.09 0.00 0.00 1.75
06F - CP ICU 0.00 0.00 0.00 0.00 0.00
06H - MED ICU 1.02 2.96 0.00 1.05 1.11
06I - SURG ICU 0.00 0.00 0.00 0.00 0.00
08E - CORONARY CARE UNIT 0.00 0.00 2.99 0.00 0.73
08F - CARDIOPULMONARY ICU 0.00 0.00 1.60 0.00 0.43
09E - NEUROSCIENCES INTERMED 0.00 0.00 0.00 0.00 0.00
09F - NEUROSCIENCES ICU 0.00 1.73 0.00 0.00 0.45
12F - PEDIATRIC ICU 11.11 3.15 0.00 0.00 3.36