part 1: characteristics of participated facilities fig 1. · pcca quality benchmark: data from 2015...

PCCA Quality Benchmark: Data from 2015 Q2 to 2018 Q4

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PART 1: CHARACTERISTICS OF PARTICIPATED FACILITIES Fig 1.


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Fig.2


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Fig.3


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Fig. 4


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Fig. 5-1 Q5. What was your census on the last day of this quarter?


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Fig. 5-2

Average Daily Census =Patient days/90


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Fig. 5-2-1

Average daily census=Number of patient days/90. Overall mean=60.6, Median=52.6


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Fig. 5-3 Q6. From your census reported in question 5, how many represent children under 21?


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Fig. 5-4


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Fig. 6 Q7. What was your total number of patient days in your facility during this quarter?

Overall: Mean=5,457, Median=4,733


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Fig.7 Q8. What were your total admissions this quarter?


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Fig. 7-1


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Fig. 7-2


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Fig. 7-3

Percent of New Patient =(Total admission/Total census)×100


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PART 2: STAFFING

Fig. 8 Q9 What was the total number of Registered Nurse (RN) hours (including supervisor on duty) for this quarter?

Mean= 11,251 hours, median= 8,241 hours


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Fig.8-1

RN hours per patient day= RN hours/Number of patient days. Mean=3.2 hours, Median=2.1 hours


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Fig. 9 Q10. What was the total number of Licensed Practical Nurse (LPN) hours for this quarter?

Mean=7,491 hours, Median=5,106 hours


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Fig. 9-1

LPN hours per patient day= LPN hours/Number of patient days. Mean=2.0, Median= 1.3


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Fig. 10

Licensed nursing hours per patient day= (RN hours + LPN hours)/Patient days. Mean= 5.2, Median= 3.5


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Fig. 11 Q11. What was the total number of Non-Licensed nursing staff hours for this quarter?

Mean=21,343; Median=15,896


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Fig. 11-1

Non-Licensed nursing staff hours per patient day= Non-Licensed nursing staff hours /Patient days. Mean= 4.6, Median= 3.9


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Fig. 11-2

Total nursing hours per patient day= (RN hours + LPN hours+ Non-Licensed nursing staff hours)/Patient days. Mean= 9.8, Median= 7.6


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Fig. 11-3.


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Fig. 11-5 (2015)


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Fig. 11-5 (2016)


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Fig.11-5 (2017)


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Fig.11-5 (2018)


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PART 3: INFECTION CONTROL Fig.12. Q13. How many patients this quarter had an indwelling catheter in place?


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Fig. 13 Q14. What was the total number of indwelling catheter days?


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Fig. 14 Q15. How many urinary tract infections (UTI) were diagnosed this quarter in patients who had an indwelling catheter in place at the time?

Number of UTIs per 1000 indwelling catheter days= (Number of patients this quarter had an indwelling catheter in place/ Total number of indwelling catheter days)×1000. Overall mean=96, median=11.


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Fig. 15. Q16. How many UTIs were diagnosed this quarter in patients who did not have an indwelling catheter in place at the time?

Note: Number of UTIs per 1000 patient days without an indwelling catheter in place= (Number of UTIs were diagnosed this quarter in patients who did not have an indwelling catheter in place at the time / Patient days)×1000. Overall mean=1, median=0.


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Fig.16. Q17. How many patients this quarter had a central line in place?

Note: Overall mean=2.7, median=1.0.


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Fig. 17 Q18. What was the total number of central line days?

Note: The overall mean=174.5, median=86.0


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Fig. 18 Q19. What was the number of laboratory confirmed blood stream infections where a central line was in place this quarter?

Note: Number of laboratory confirmed blood stream infections where a central line was in place per 1000 central line days=(Number of laboratory confirmed blood stream infections where a central line was in place this quarter/ Total number of central line days)×1000. The overall mean=1.8, median=0.0.


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Fig. 19 Q 20. What was the total number of laboratory confirmed blood stream infections this quarter?

Note: Number of laboratory confirmed blood stream infections per 1000 patient days=(Total number of laboratory confirmed blood stream infections this quarter / Patient days)×1000. The overall mean=0.06, median=0.0.


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PART 4: HOSPITAL TRANSFER Fig. 20 Q 22. During this quarter, how many patients were emergently transferred out and admitted to an acute care hospital within 30 days of admission to your facility?

Note: The overall mean=1.46, median=0.00.


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Fig. 21-1 Q23. From the number of patients reported in question 22, how many of those patients resided prior to admission in the following: Family Home



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Fig. 21-2 Q23. From the number of patients reported in question 22, how many of those patients resided prior to admission in the following: Group Home


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Fig. 21-3 Q23. From the number of patients reported in question 22, how many of those patients resided prior to admission in the following: Acute Hospital

Note: The overall mean=1.04, median=0.00. Fig. 21-4 Q23. From the number of patients reported in question 22, how many of those patients resided prior to


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admission in the following: Long Term Care Facility

Note: The overall mean=0.28, median=0.00. Fig. 21-5 Q23. From the number of patients reported in question 22, how many of those patients resided prior to


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admission in the following: Residential Facility



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Fig. 21-6 Q23. From the number of patients reported in question 22, how many of those patients resided prior to admission in the following: Other Facility



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Fig. 22. Q24 From the number of patients reported in question 22, how many were transferred for the following reasons:


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Fig. 22-1 Q24 From the number of patients reported in question 22, how many were transferred for the following reasons?


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Fig. 22-2 Q24 From the number of patients reported in question 22, how many were transferred for the following reasons?


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Fig. 22-3. Q24 From the number of patients reported in question 22, how many were transferred for the following reasons?


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Fig 22- 4. Q24 From the number of patients reported in question 22, how many were transferred for the following reasons?


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Fig. 23. Q 25. During this quarter, how many patients were emergently transferred out and admitted to an acute care hospital more than 30 days after admission to your facility?

Mean: 9.05, Median= 6.00.


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PART 5: ACCIDENTAL DISLODGEMENT OF INVASIVE DEVICE Fig. 24. Q26. How many patients this quarter had a trach in place?

Note: Dash lines show mean. Overall: Mean= 24.65, Median=23.5.


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Fig 25. Q27. What was the total number of trach days?


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Fig.26

Average Number of Trach Days per Patient with a Trach=Total Trach Days/Number of Patients with a Trach.


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Fig. 27 Q28. How many accidental/unplanned trach decannulations occurred this quarter in your patients with trachs?

Number of accidential/unplanned trach decanulation per 1000 trach days= (Accidental/unplanned trach decannulations occurred this quarter in your patients with trachs/ Total number of trach days)×1000 Question: 2018 Q1: Facility 10 is 448.3, Is it accurate? Excluded from this chart.


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Fig. 28 Q29. How many patients this quarter had a GT/GJ tube in place?

Note: Dash lines show mean.


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Fig. 29 Q30. What was the total number of GT/GJ Tube days?

Note: Dash lines show mean. Overall: Mean=4395, Media=4136.


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Fig. 30 Q31. How many accidental/unplanned dislodgements of GT/GJ Tubes were reported where the balloon was inflated?

Accidental dislogement of GT/GJ tube per 1000 GT/GJ days= (Accidental/unplanned dislodgements of GT/GJ tubes were

reported where the balloon was inflated/ Total number of GT/GJ tube days)×1000


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PART 6: PRESSURE ULCER Q31. How many pressure ulcers (≥stage II) were identified in patients present in your facility this quarter?


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Fig. 31-1

PU identified per 1000 patient days=(Number pressure ulcers (≥stage II) were identified in patients present in your facility this quarte/Patient days)×1000. Mean=0.8, Median=0.1.


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Fig. 32 Q33. How many pressure ulcers (≥stage II) were present in patients at the time of admission to your facility?


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Fig. 33


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Fig. 34 Q34. How many pressure ulcers (≥stage II) were developed while the patient was present in your facility?

Note: Mean=1.63, Median=0.00.


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Fig. 35 Q35. How many pressure ulcers (≥stage II) were developed as a result of the use of medical/clinical devices while the patient was present in your facility?



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Fig. 36


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PART 7: MEDICATION SAFETY Fig. 37 Q36. What is the total number of medication events that actually reached a patient this quarter?

Number of medication events that actually reached a patient per 1000 patient days=(Number of medication events that actually reached a patient/Patient days)×1000. Overall: Mean=2.69, Median= 1.82.


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PART 8: RESPIRATORY PROGRAMS Fig. 38 Q37. How many patients who were receiving oxygen were eligible for weaning this quarter?

Mean= 4.01, Median= 0.00


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Fig. 39 Q38. How many patients were weaned from oxygen during this quarter?



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Fig. 40

Percent of patients successfully weaned from oxygen=(Number of patients were weaned from oxygen during this quarter/Number of patients who were receiving oxygen were eligible for weaning this quarter)×100


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Fig. 41 Q39. How many patients who had a trach in place were eligible for trach weaning this quarter?



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Fig. 42 Q40. How many patients were successfully decanulated during this quarter?

Note: Mean=35%, Median=0.00.

% of Patients were successfully decanulated=(number of patients were successfully decanulated/number of patients with a trach inplace were eligible for trach weaning)×100


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Fig. 43 Q41. Does your facility have a ventilator program?


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PART 9: VENTILATOR WEANING Fig. 44 Q42. How many patients required ventilator support during the quarter?

Note: Dash lines show mean.


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Fig. 45 Q43. Of the number of patients who were on a ventilator (question 42), how many were eligible for weaning to 12 hours or less per day (partial wean) during this quarter?

Note: Mean=2.22, Median=1.00


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Fig. 46 Q44. How many patients were successfully weaned to 12 hours per day or less (partial wean) during this quarter?

Note: Mean=74%, median=100%

% of patients were successfully weaned to 12 hours per day or less= (Patients were successfully weaned to 12 hours per day or less/Patients were eligible for weaning to 12 hours or less per day)×100


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Fig. 47 Q45. Of the number of patients who were on a ventilator (question 42), how many were eligible to be fully weaned from ventilator support?


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Fig. 48 Q46. How many patients were fully weaned from ventilator support during this quarter?

Note: Mean=82%, Median=100%.

% of Patients were fully weaned from ventilator support= (Patients were fully weaned from ventilator support/Patients were eligible to be fully weaned from ventilator support)×100


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Fig. 50


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PART 10. FRACTURES Fig. 51

Note: Mean=0.1, Median=0.0. 38 new fractures were reported from 2017 Q4 to 2018 Q4.

Fracture rates per 1000 patient days = (Number of fractures/ Patient days) ×1000

part 1: characteristics of participated facilities fig 1. · pcca quality benchmark: data from 2015...

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