EP22EO Unit or clinic-level nurse-sensitive clinical indicator data outperform the mean or median or the national database used.
Core measure: nurse sensitive clinical indicators from the Core Measure Sets must be benchmarked and presented at the organizational level.
1. Central Line-Associated Blood Stream Infection
Exhibit EP22EOa: Central Line-Associated Blood Stream Infection per 1000 Central Line Days, Intensive Care Unit (ICU), Critical Care
*Legend: NHSN=National Health Safety Network, which publishes pooled mean in its annual data report; latest report released as of 1/12/15 was for 2012.
Analysis: Above graph shows that ICU has outperformed the benchmark in 8/8 quarters.
Exhibit EP22EOb: Central Line-Associated Blood Stream Infection per 1000 Central Line Days, Progressive Care Unit (PCU), Critical Care
*Legend: NHSN=National Health Safety Network, which publishes pooled mean in its annual data report; latest report released as of 1/12/15 was for 2012.
Analysis: Above graph depicts that ICU has outperformed the benchmark in 8/8 quarters.
Exhibit EP22EOc: Central Line-Associated Blood Stream Infection per 1000 Central Line Days, 3 South, MS4, MS5, MS3, Medical-Surgical
*Legend: ND=No Data; NHSN=National Health Safety Network, which publishes pooled mean in its annual data report; latest report released as of 1/12/15 was for 2012.
Analysis: Above graph demonstrates that 3 South, MS4 and MS5 have outperformed the benchmark in 8/8 quarters. MS3 has recently been reopened as a full-time unit in May 2104 and did not have enough central line days to report for April-June and July-September 2014.
Exhibit EP22EOd: Central Line-Associated Blood Stream Infection per 1000 Central Line Days, Perinatal Services
*Legend: NHSN=National Health Safety Network, which publishes pooled mean in its annual data report; latest report released as of 1/12/15 was for 2012.
Analysis: Above graph portrays that Perinatal Services have outperformed the benchmark in 8/8 quarters.
Table of Outperformance for Central-Line Associated Blood Stream Infection
Unit |
Outperformance |
ICU |
8/8 quarters |
PCU |
8/8 quarters |
3 South |
8/8 quarters |
MS4 |
8/8 quarters |
MS5 |
8/8 quarters |
MS3 |
Newly opened unit– not enough central line days |
Perinatal Services |
8/8 quarters |
100% of reporting units have outperformed the benchmark. |
|
2. Catheter-Associated Urinary Tract Infection
Exhibit EP22EOe: Catheter-Associated Urinary Tract Infection per 1000 Catheter Days, ICU, Critical Care
*Legend: NHSN=National Health Safety Network, which publishes pooled mean in its annual data report; latest report released as of 1/12/15 was for 2012.
Analysis: Above graph shows that ICU has outperformed the benchmark in 6/8 quarters.
Exhibit EP22EOf: Catheter-Associated Urinary Tract Infection per 1000 Catheter Days, PCU, Critical Care
*Legend: NHSN=National Health Safety Network, which publishes pooled mean in its annual data report; latest report released as of 1/12/15 was for 2012.
Analysis: Above graph depicts that PCU has outperformed the benchmark in 8/8 quarters.
Exhibit EP22EOg: Catheter-Associated Urinary Tract Infection per 1000 Catheter Days, 3 South, MS4, MS5, MS3, Medical-Surgical
*Legend: ND=No Data; NHSN=National Health Safety Network, which publishes pooled mean in its annual data report; latest report released as of 1/12/15 was for 2012.
Analysis: Above graph demonstrates that 3 South, MS4 and MS5 have outperformed the benchmark in 8/8 quarters. MS3 has recently been reopened as a full-time unit in May 2014 and did not have enough catheter days to report for April-June and July-September 2014.
Exhibit EP22EOh: Catheter-Associated Urinary Tract Infection per 1000 Catheter Days, Perinatal Services
*Legend: NHSN=National Health Safety Network, which publishes pooled mean in its annual data report; latest report released as of 1/12/15 was for 2012.
Analysis: Above graph portrays that Perinatal Services have outperformed the benchmark in 8/8 quarters.
Table of Outperformance for Catheter-Associated Urinary Tract Infection
Unit |
Outperformance |
ICU |
6/8 quarters |
PCU |
8/8 quarters |
3 South |
8/8 quarters |
MS4 |
8/8 quarters |
MS5 |
8/8 quarters |
MS3 |
Newly opened unit – did not have enough catheter days |
Perinatal Services |
8/8 quarters |
100% of reporting units have outperformed the benchmark. |
|
3. Hospital-Acquired Pressure Ulcer Stages 2 and Above
Exhibit EP22EOi: Hospital-Acquired Pressure Ulcer Stages 2 and Above, ICU, Critical Care
*Legend: NDNQI=National Database for Nursing Quality Indicators
Analysis: Above graph depicts that ICU has outperformed the benchmark in 6/8 quarters.
Exhibit EP22EOj: Hospital-Acquired Pressure Ulcer Stages 2 and Above, PCU, Critical Care
*Legend: NDNQI=National Database for Nursing Quality Indicators; ND=No Data
Analysis: Above graph demonstrates that PCU has outperformed the benchmark in 4/7 quarters (The unit was closed when prevalence study was done for April-June 2014.).
Exhibit EP22EOk: Hospital-Acquired Pressure Ulcer Stages 2 and Above, 3 South, MS4, MS5, MS3, Medical-Surgical
*Legend: NDNQI=National Database for Nursing Quality Indicators; ND=No Data
Analysis: Above graph demonstrates that 3 South and MS4 have outperformed the benchmark in 8/8 quarters. MS5 has also outperformed the benchmark in 5/8 quarters. MS3 has recently been reopened as a full-time unit in May 2104 and was closed when prevalence study was conducted for April-June and July-September 2014.
Table of Outperformance for Hospital-Acquired Pressure Ulcers Stages 2 and Above
Unit |
Outperformance |
ICU |
6/8 quarters |
PCU |
4/7 quarters |
3 South |
8/8 quarters |
MS4 |
8/8 quarters |
MS5 |
5/8 quarters |
MS3 |
Newly opened unit– closed when prevalence study was conducted for April-June and July-September 2014 |
100% of reporting units have outperformed the benchmark. |
|
3. Falls with Injury
Exhibit EP22EOl: Injury Falls per 1000 Patient Days, ICU, Critical Care
*Legend: NDNQI=National Database for Nursing Quality Indicators
Analysis: Above graph shows that ICU has outperformed the benchmark in 5/8 quarters.
Exhibit EP22EOm: Injury Falls per 1000 Patient Days, PCU, Critical Care
*Legend: NDNQI=National Database for Nursing Quality Indicators
Analysis: Above graph depicts that PCU has outperformed the benchmark in 8/8 quarters.
Exhibit EP22EOn: Injury Falls per 1000 Patient Days, 3 South, MS4, MS5, MS3, Medical-Surgical
*Legend: NDNQI=National Database for Nursing Quality Indicators; ND=No Data
Analysis: Above graph demonstrates that 3 South and MS4 have outperformed the benchmark in 4/8 quarters, which is not the majority of the quarters. MS5 has outperformed the benchmark in 3/8 quarters, which is not the majority of the quarters. MS3 was previously utilized as an overflow unit and did not meet vendor criteria for reporting until it has been recently reopened as a full-time unit in May 2014. It has outperformed the benchmark in 3/3 quarters.
Table of Outperformance for Falls with Injury
Unit |
Outperformance |
ICU |
5/8 quarters |
PCU |
8/8 quarters |
3 South |
4/8 quarters |
MS4 |
4/8 quarters |
MS5 |
3/8 quarters |
MS3 |
3/3 quarters |
50% of reporting units have outperformed the benchmark. |
|
Acute Care Organization with Ambulatory Outpatient Services
5. Core Measure Set Nurse-Sensitive Clinical Indicator
Exhibit EP22EOo: Aspirin on Arrival, Homestead Hospital
*Legend: CMS=Center for Medicare and Medicaid Services
Analysis: Above graph portrays that Homestead Hospital has outperformed the benchmark 8/8 quarters.
6. Primary Ambulatory/Outpatient Services Nurse-Sensitive Clinical Indicator
Exhibit EP22EOp: Outpatients Having Surgery Who Got the Right Kind of Antibiotic (Surgical Care Set), Ambulatory Surgery, Surgical Services
*Legend: CMS=Center for Medicare and Medicaid Services; ND=No Data
Analysis: Above graph demonstrates that the Ambulatory Surgery department has outperformed the benchmark in 7/8 quarters.
Summary
Table of Hospital-Wide Outperformance
Nurse-Sensitive Indicator |
Number of Reporting Units Outperforming |
CLABSI |
6/6 (100%) |
CAUTI |
6/6 (100%) |
HAPU Stages 2 & Above |
5/5 (100%) |
Falls with Injury |
3/6 (50%) |
Aspirin within 24-Hours of Arrival |
1/1 (100%) |
Outpatients Surgical Patients Receiving the Correct Antibiotic |
1/1 (100%) |