clinical and safety performance metrics (october 2021)
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CLINICAL AND SAFETY PERFORMANCE METRICS Executive Dashboard
NIH Clinical Center October 2021
Infection Control Metrics • Hand Hygiene • Central-Line Associated Bloodstream Infections
• Whole-House • Intensive Care Unit
• Catheter Associated Urinary Tract Infections • Intensive Care Unit • Surgical Oncology
• Surgical Site Infections
Hand Hygiene Compliance
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0% 2020-Q2 2020-Q3 2020-Q4 2021-Q1 2021-Q2
Whole-House
Central-Line Associated Bloodstream Infection (CLABSI) Rate In
fect
ions
per
1,0
00 c
athe
ter d
ays 1.20
1.40
1.00
0.80
0.60
0.40
0.20
0.00 2020-Q2 2020-Q3 2020-Q4 2021-Q1 2021-Q2
ICU Central-Line Associated Bloodstream Infection (CLABSI) Rate
Infe
ctio
ns p
er 1
,000
cat
hete
r day
s
3.00
2.50
2.00
1.50
1.00
0.50
0.00
ICU CLABSI Rate NHSN ICU Benchmark
2020-Q2 2020-Q3 2020-Q4 2021-Q1 2021-Q2
2013 CDC National Healthcare Safety Network (NHSN) Benchmark: Critical Care Units, Medical/Surgical -major teaching mean 1.1
ICU Catheter-Associated Urinary Tract Infections (CAUTI) Rate
Infe
ctio
ns p
er 1
,000
fole
y da
ys
5.00
4.50
4.00
3.50
3.00
2.50
2.00
1.50
1.00
0.50
0.00
ICU CAUTI Rate NHSN ICU Benchmark
2020-Q2 2020-Q3 2020-Q4 2021-Q1 2021-Q2
2013 CDC National Healthcare Safety Network (NHSN) Benchmark: Critical Care Units, Medical/Surgical -major teaching mean 2.7
Surgical Oncology Catheter-Associated Urinary Tract Infections (CAUTI) Rate
Surgical Oncology CAUTI Rate NHSN Medical/Surgical Benchmark 5.00
1.50
2.00
2.50
3.00
3.50
4.00
4.50
Infe
ctio
ns p
er 1
,000
fole
y da
ys
1.00
0.50
0.00 2020-Q2 2020-Q3 2020-Q4 2021-Q1 2021-Q2
2013 CDC National Healthcare Safety Network (NHSN) Benchmark: Inpatient Wards, Medical/Surgical mean 1.3
Surgical Site Infections
Infe
ctio
ns p
er 1
00 p
roce
dure
s
4.50
SSI Rate 2018 - 2019 Clinical Center Average
4.00
3.50
3.00
2.50
2.00
1.50
1.00
0.50
0.00 2020-Q2 2020-Q3 2020-Q4 2021-Q1 2021-Q2
Nursing Quality Metrics • Falls • Pressure Injury • Medication Administration Barcoding
Inpatient Falls Rate
Quarterly Rate Inpatient Falls with Injury NDNQI Benchmark
3.00
2.50
2.00
0.00 Q2 CY 2020 Q3 CY 2020 Q4 CY 2020 Q1 CY 2021 Q2 CY 2021
0.50
1.00
1.50
Falls
per
1,0
00 p
atie
nt d
ays
Pressure Injury Prevalence
Quarterly Rate National Mean (NDNQI) Stage 3 + 4 Pressure Injury Prevalence 7
6
2
% o
f sur
veye
d pa
tient
s with
pre
ssur
e in
jury
5
4
3
1
0 Q2 CY 2020 Q3 CY 2020 Q4 CY 2020 Q1 CY 2021
NDNQI Benchmark for Total Pressure Injury Rate only
Medication Administration Barcode Use
% B
arco
de U
se
100% Clinical Center Rate Goal
99%
98%
97%
96%
95%
94%
93%
92%
91%
90% Q2 CY 2020 Q3 CY 2020 Q4 CY 2020 Q1 CY 2021
Emergency Response • Code Blue and Rapid Response
• Types of P atients • Type of E vent • Patient Disposition
Code Blue Response: Types of “Patients”
250
200
150
100
50
0
Inpt 6 20 23 14 32 95 Outpt 1 6 12 15 14 48 Employee 4 10 10 11 12 47 Visitor 2 1 2 2 1 8 Incorrect Calls 0 0 0 0 0 0
Num
ber
Q2 CY 2020 Q3 CY 2020 Q4 CY 2020 Q1 CY 2021 Q2 CY 2021 Total
Code Blue Response: Type of Event
250
200
150
100
50
0
Brain Code 0 0 2 4 1 7 Arrest 0 6 3 2 11 22 Acute Emergency 9 21 24 13 18 85 Stable Event 4 9 18 24 28 83
Num
ber
Q2 CY 2020 Q3 CY 2020 Q4 CY 2020 Q1 CY 2021 Q2 CY 2021 TOTAL
Code Blue Response: Patient Disposition
Q2 CY 2020
Q3 CY 2020
Q4 CY 2020
Q1 CY 2021
Q2 CY 2021 TOTAL
Transfer to ICU 4 15 13 7 16 55 Transfer to OSH 4 9 14 15 11 53 Remained on Unit 4 10 11 13 17 55 Expired 0 1 1 2 4 8 Released 1 0 0 1 0 2 Other 0 1 8 5 10 24
0
50
100
150
200
250
Num
ber
Rapid Response Team: Patient Disposition
Q2 CY 2020
Q3 CY 2020
Q4 CY 2020
Q1 CY 2021
Q2 CY 2021 Total
ICU 2 5 4 11 2 24 Unit/Other 0 6 1 1 9 17 Remained on Unit 3 5 17 12 14 51
0
10
20
30
40
50
60
70
80
90
100
Num
ber
Blood and Blood Product Use • Crossmatch to Transfusion (C:T) Ratio • Transfusion Reaction by Class • Unacceptable Blood Bank Specimens
Crossmatch to Transfusion (C/T) Ratio
C/T Ratio CC C/T Ratio Goal 2.50
Cros
smat
ch to
Tra
nsfu
sed
Uni
ts R
atio
2.00
1.50
1.00
0.50
0.00 Q2 CY 2020 Q3 CY 2020 Q4 CY 2020 Q1 CY 2021 Q2 CY 2021
The NIH CC goal is to have a C:T ratio of 2.0 or less. Monitoring this metric ensures that blood is not held unused in reserve when it could be available for another patient
Transfusion Reactions by Class
Perc
ent o
f Tra
nsfu
sion
s
Anaphylactic
0.45%
0.40%
0.35%
0.30%
0.25%
0.20%
0.15%
0.10%
0.05%
0.00%
Other Febrile, Nonhemolytic Hemolytic, Septic, Anaphylactoid, and TRALI
Q2 CY 2020 Q3 CY 2020 Q4 CY 2020 Q1 CY 2021 Q2 CY 2021
Unacceptable Blood Bank Specimens
Perc
ent U
nacc
epta
ble
Spec
imen
s
% Specimens with Collection Problems CC Threshold 3.5%
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0% Q2 CY 2020 Q3 CY 2020 Q4 CY 2020 Q1 CY 2021 Q2 CY 2021
Clinical Documentation • Medical Record Completeness
• Delinquent Records • “Agent for” Countersignature Adherence • Unacceptable Abbreviation Use
• Accuracy of Coding
Delinquent Records (>30 days post discharge)
% re
cord
s del
inqu
ent a
fter
30
days
% Records Delinquent Joint Commission Benchmark
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0% Q2 CY 2020 Q3 CY 2020 Q4 CY 2020 Q1 CY 2021 Q2 CY 2021
"Agent for" Orders Countersignature Compliance
% v
erba
l ord
ers s
igne
d in
72
hour
s
100%
% of Compliance CC Goal
95%
90%
85%
80%
75%
70%
65%
60%
55%
50% Q2 CY 2020 Q3 CY 2020 Q4 CY 2020 Q1 CY 2021 Q2 CY 2021
"Do Not Use" Abbreviation Adherence
Compliance with Abbreviation Use CC Goal
100%
95%
90%
85%
80%
75% Q2 CY 2020 Q3 CY 2020 Q4 CY 2020 Q1 CY 2021 Q2 CY 2021
% a
ppro
pria
te u
se o
f abb
revi
atio
ns
Accuracy of Record Coding
% a
ccur
acy
of c
odin
g
Accuracy of Coding CC Goal
100%
80%
70%
60%
50%
40%
30%
20%
10%
0% Q2 CY 2020 Q3 CY 2020 Q4 CY 2020 Q1 CY 2021 Q2 CY 2021
90%
Employee Safety • Occupational Injury and I llness
Recordable Occupational Injuries and Illnesses Among CC Employees in CY 2021
TRC: Total Recordable Cases; ORC: Other Recordable Cases; DAFW: Days Away From Work; DJTR: Days Job Transfer, Restriction; DART: Days Away, Restricted or Transferred (DAFW + DJTR)