1
Supplemental Digital Content 1
Nightingale Metrics Database
The Nightingale Metrics database was developed by Martha Curley, RN, PhD and Patricia Hickey, RN,
PhD as a quality monitoring program that identifies, implements, and monitors best nursing practices
across the Cardiovascular and Critical Care program at Children’s Hospital Boston (5). The Nightingale
data was collected every 3 months from March 2004 to May 2008, then every 4 months after August
2008. A random day was selected for data collection, which could occur at any date/time within the month
of data collection. Data on all ICU patients were obtained at the time of data collection. To ensure data
reliability, a staff nurse who was trained in the data collection process and a research assistant were
responsible for data entry and report generation. In addition, the nurse scientist conducts regular data
checks for any inconsistencies and errors. Data extracted from the Nightingale database include the
Continuity of Care Index (CCI) values and the proportion of nurses with low (Level I nurse) and high
expertise (Level II/III nurse) (5).
Virtual Pediatric Intensive Care Unit Performance System Database
The Virtual Pediatric Intensive Care Unit Performance System is an integrated line of services formed by
the National Association of Children’s Hospitals and Related Institutions, Children’s Hospital Los Angeles,
and Children’s Hospital of Wisconsin, primarily for standardizing data sharing and benchmarking among
ICUs with the aim of improving the quality of care for critically ill children. A M/S ICU physician leader, a
nurse leader, and a quality improvement technician from the Program for Patient Safety and Quality were
closely involved in the management of this database. All data were collected and entered by the nurse
leader, who underwent intensive definitions and technical training. To ensure validity and reliability of data
collection, extensive quality control checks were performed quarterly by the Virtual Pediatric ICU
Performance System staff at the National Outcomes Center in Wisconsin. ICU data collection began in
2004. All patients admitted to the ICU who meet the inclusion criteria were included in data collection.
Clinical data were collected from these patients from ICU admission through ICU discharge. The following
2
data from March 2004 to December 2010 were extracted: ICU admission diagnosis, risk of mortality
scores (Pediatric Index of Mortality 2 (PIM2) and Pediatric Risk of Mortality 3 (PRISM3)), patient
disposition (e.g. discharge alive or death during stay in ICU), demographic information (race, gender, and
date of birth), ICU admission and discharge dates, and ICU interventions and procedures. The PIM2
scores were available from March 2004 to December 2010, whereas the PRISM3 scores were available
from August 2005 to December 2010.
Medical-Surgical Intensive Care Unit-Acquired Infection Database
The ICU infection control practices and surveillance data, also known as the M/S ICU-Acquired Infection
database, consisted of prospectively collected data of all patients who developed an infection during their
stay in the ICU and up to 48 hours after discharge from the ICU. However, a patient who developed an
infection < 48 hours after transfer/admission into the ICU is not considered as ICU-acquired infection.
Three types of infection data were closely monitored and collected: catheter-associated bloodstream
infection, ventilator-associated pneumonia, and catheter-associated urinary tract Infection. The
surveillance definitions of the 3 main types of infections were defined by the Centers for Disease Control
and the Prevention/National Healthcare Safety Network (45). All data were collected by a M/S ICU-based
infection control coordinator who worked closely with the infection control department, infection control
attending physician, and epidemiologist in the surveillance and prevention of infection in the ICU. To
ensure accuracy of data, external data checks were conducted by staff from the Program for Patient
Safety and Quality. Data from August 2006 to December 2010 were extracted from the infection
database.
Safety Event Reporting System Database
The Safety Event Reporting System database consists of adverse events that occurred during a patient’s
hospitalization. This project began in 2005, when senior hospital administrators at Boston Children’s
Hospital initiated a hospital-wide computer-based management system known as the Safety Event
3
Reporting System program, to improve patient care quality and safety through the tracking and monitoring
of data. All hospital staff were encouraged to report errors such as a near miss, a procedure-related
problem, or a patient event. Table 1 presents the definition and examples of adverse events categories in
the Safety Event Reporting System database. Adverse events closely related to nursing care are
asterisked. An adverse event is considered as nurse-sensitive if it resulted from direct nursing care. A
nurse-sensitive adverse event was identified based on criteria indicated on the Beacon Award by the
American Association of Critical-Care Nurses, as well as through qualitative descriptions on the Safety
Event Reporting System database. A Safety Event Reporting System manager, typically a nurse in a
leadership position was appointed to monitor any adverse events that occur within each unit. Every
Safety Event Reporting System manager received training in the definition, documentation, and
management of adverse events. In any adverse event report, the Program for Patient Safety and Quality
staff and Safety Event Reporting System managers reviewed the data relevant to their areas of
responsibility, ensuring that there is proper follow-up to the event, and ultimately signing off on the event.
Both the Program for Patient Safety and Quality staff and the Safety Event Reporting System managers
and ICU staff worked closely in the adjudication and validity of the data, coordinating efforts for the
resolution of any issues raised, and generating corrective action plans.