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NSIs: Analyzing key trends before, during, and after COVID-19

Coauthored by Angela Pascale, Research Analyst, Press Ganey; and Nora Warshawsky, Nurse Scientist, Press Ganey.

Nursing-sensitive quality indicators (NSIs) are important ways to gauge the quality of nursing care. NSIs measure adverse clinical events like hospital-acquired infections, pressure injuries, and falls. To prevent these and similar adverse events, nurses perform continuous surveillance, routine assessments, regular communication with the healthcare team, and evidence-based interventions. When nursing care quality is high, patients experience better outcomes and fewer adverse events. NSIs also provide essential insight into how significant stressors affect nursing practice and the healthcare system.

COVID-19, for example, was a major stressor to our healthcare systems. Nurses were overwhelmed with disruptions to routine nursing care, tensions were running high, and, in general, a culture of uncertainty permeated organizations. By investigating NSIs before, during, and after the pandemic, we gain insight into how both the nursing practice and the healthcare system were affected by the environmental pressures of COVID-19.

Nursing Sensitive Quality Indicators provide key insight into nursing practice and healthcare system policies throughout the pandemic and recovery periods

Press Ganey’s National Database of Nursing Sensitive Quality Indicators (NDNQI) is the largest database of NSIs. To better understand the prevalence and trends of NSIs throughout the pandemic period, we analyzed our NDNQI data from 2019 to 2022 for:

  • Falls
  • Ventilator-associated events (VAE)
  • Central line-associated bloodstream infection (CLABSI)
  • Hospital-acquired pressure injuries (HAPI)
  • Catheter-associated urinary tract infections (CAUTI)

We calculated annual rates per 1,000 patient days (apart from HAPIs, which were calculated as the percent of surveyed patients with pressure injuries) in both medical-surgical and critical care units for each NSI by averaging the four quarters of complete data in each year (2019–2022). We then compared each NSI annual average in 2020, 2021, and 2022 to the pre-COVID levels in 2019.

In critical care and medical-surgical units combined, we found the following trends.

  • Fall rates were significantly lower (n = 2.20) in 2019 compared to 2020, 2021, and 2022.
  • CLABSI were significantly lower (n = 0.68) in 2019 compared to 2020, 2021, and 2022.
  • HAPI had a significantly lower average HAPI rates (n = 2.41) in 2019 compared to 2020, 2021, and 2022.
  • CAUTI had no significant differences in average CAUTI rates from 2019 to 2022 for either medical-surgical or critical care units.
  • In critical care units only, VAE rates were significantly lower in 2019 (n = 6.58) compared to 2020, 2021, and 2022.

Except for CAUTI, NSIs got significantly worse during 2020 and 2021

We found that four out of five nursing-sensitive indicators worsened significantly during 2020 and 2021. The good news is that these indicators are improving—though they have not yet returned to pre-pandemic levels. The increases in NSI trends are likely due to a combination of factors: higher patient acuity, disruption in nurses’ work, and changes to healthcare system policies in response to COVID-19.

Graph of NSI trends in med-surg and critical care units.

At Press Ganey, we partner with healthcare organizations to help them keep the finger on the pulse of safety data—and more—and rebound from any setbacks. To discuss your unique challenges 1:1, reach out to a member of our nursing team here. We’re ready to dive in with you.  

About the author

As Chief Nursing Officer, Jeff leads Press Ganey’s focus on improving patient and caregiver experience and developing nursing leadership at healthcare organizations nationwide. He also plays an integral role in the company’s workforce initiatives, including Press Ganey’s Workforce Well-Being Collaborative, which focuses on supporting caregivers as they deal with the ongoing challenges of the pandemic. Prior to joining Press Ganey, Jeff served in various chief nursing officer roles at both community-based organizations and major academic medical centers throughout the US. In addition, he was the inaugural Vice President of the Magnet Recognition and Pathway to Excellence programs at the American Nurses Credentialing Center.

Profile Photo of Dr. Jeff Doucette, DNP, RN, NEA-BC, FACHE, FAAN