Hospital Harm – Pressure Injury

This measure assesses the proportion of inpatient encounters of patients 18 years of age or older at admission, who suffer the harm of developing a new stage 2, stage 3, stage 4 pressure injury, deep tissue pressure injury, or unstageable pressure injury. The measure defines a new pressure injury as not present on arrival to the hospital or not documented within the first 24 hours after hospital arrival. Only one harm (new qualifying pressure injury) is counted per encounter.

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CPT(R) contained in the Measure specifications is copyright 2004-2016 American Medical Association. LOINC(R) copyright 2004-2016 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2016 International Health Terminology Standards Development Organisation. ICD-10 copyright 2016 World Health Organization. All Rights Reserved.

This measure and specifications are subject to further revisions. 

This performance measure is not a clinical guideline, does not establish a standard of medical care, and has not been tested for all potential applications.

THE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].

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Pressure injury is a serious event and one of the most common patient harms. Pressure injuries commonly lead to local infection, osteomyelitis, anemia, and sepsis (Brem, et al., 2010), in addition to causing significant depression, pain, and discomfort to patients (Gunningberg et al., 2011). The rate of pressure injuries varies across hospitals, suggesting opportunity for further improvement. 

A pressure injury (stage 3 or stage 4) is considered a serious reportable event by the National Quality Forum (NQF) (Centers for Medicare and Medicaid Services, 2015). CMS established non-payment for pressure injury (National Quality Forum, 2016), and the rate of pressure injuries is considered an indicator of the quality of nursing care a hospital provides (National Quality Forum, 2005). It is widely accepted that the risk of developing a pressure injury can be reduced through best practices such as frequent repositioning, proper skin care, and specialized cushions or beds (Berlowitz, et al., 2012). While several pressure injury measures are currently in use, there are no electronic health record (EHR)-based measures intended for use in acute care hospitals. This measure identifies pressure injuries using direct extraction of structured data from the EHR to provide hospitals with reliable and timely measurement of their pressure injury rates (Gunningberg, et al., 2011).

The National Pressure Ulcer Advisory Panel (National Perssure Ulcer Advisory Panel, et al., 2014) provides guidance for categorizing pressure injuries.

The National Pressure Ulcer Advisory Panel (National Pressure Ulcer Advisory Panel, et al., 2014) also provides recommendations for structured skin and risk assessment:

Conduct a structured risk assessment as soon as possible (but within a maximum of eight hours after admission) to identify individuals at risk of developing pressure ulcers. 

Repeat the risk assessment as often as required by the individual’s acuity.

The Joint Commission (The Joint Commission, 2016) and NPUAP (National Pressure Ulcer Advisory Panel, 2016) also identify guidelines for pressure injury prevention: 

Protecting and monitoring the condition of the patient’s skin is important for preventing pressure injury and identifying Stage 1 injuries early so they can be treated before they worsen. 
- 	Inspect the skin upon admission and at least daily for signs of pressure injuries. 
- 	Assess pressure points, temperature and the skin beneath medical devices.
- 	Clean the skin promptly after episodes of incontinence, use skin cleansers that are pH balanced for the skin, and use skin moisturizers. 
- 	Avoid positioning the patient on an area of pressure injury.

Immobility can be a big factor in causing pressure injuries. Immobility can be due to several factors, such as age, general poor health condition, sedation, paralysis and coma. 
- 	Turn and reposition at-risk patients, if not contraindicated. 
- 	Plan a scheduled frequency of turning and repositioning the patient.
- 	Consider using pressure-relieving devices when placing patients on any support surface. 

Consider the patient’s body size, level of immobility, exposure to shear, skin moisture, and perfusion when choosing a support surface.

A lower proportion indicates better quality.

Berlowitz, D. VanDeusen Lukas, C.; Parker, V.; Niederhauser, A.;, & Silver, J. L., C.; Ayello, E.; Zulkowski, K. (2012). Preventing Pressure Ulcers in Hospitals - A Toolkit for Improving Quality of Care.

Brem H, M. J., Nierman D, et al. (2010). High Cost of Stage IV Pressure Ulcers. doi:10.1016/j.amjsurg.2009.12.021. American Journal of Surgery, 200(4), 473-477. 

Centers for Medicare & Medicaid Services. (2015). Hospital-Acquired Conditions. Retrieved January 13, 2017, from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html

Gunningberg, L., Donaldson, N., Aydin, C., Idvall, E. ( 2011). Exploring variation in pressure ulcer prevalence in Sweden and the USA: Benchmarking in action. 18. 10.1111/j.1365-2753.2011.01702.x. Journal of evaluation in clinical practice., 904-910.

The Joint Commission. (2016). Preventing Pressure Injuries Quick Safety.

National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, & Pan Pacific Pressure Injury Alliance. (2009). Prevention and Treatment of Pressure Ulcers: Quick Reference Guide.

National Pressure Ulcer Advisory Panel. (2016). Pressure Injury Prevention Points.

National Quality Forum. (2005). National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial Performance Measure Set. Retrieved January 13, 2017, from http://www.qualityforum.org/Publications/2004/10/National_Voluntary_Consensus_Standards_for_Nursing-Sensitive_Care__An_Initial_Performance_Measure_Set.aspx.

National Quality Forum. (2016). List of SREs. Retrieved January 13, 2017, from http://www.qualityforum.org/Topics/SREs/List_of_SREs.aspx#sre4

This measure defines a pressure injury (harm) as a stage 2, stage 3, stage 4, deep tissue pressure injury, or unstageable pressure injury, which was not documented within the first 24 hours after hospital arrival.

This measure does not count pre-existing pressure injuries documented within the first 24 hours after hospital arrival, even if they advance to a qualifying status after these first 24 hours. However, if a patient with a documented pre-existing pressure injury develops another pressure injury after 24 hours of their hospitalization, this new pressure injury is considered a harm. Patients with pre-existing pressure injuries are not excluded from the measure.

Only one harm (new qualifying pressure injury) is counted per encounter.

To calculate the hospital-level measure result, divide the total numerator events by the total number of eligible encounters (denominator).

For each encounter, qualifying encounters (denominator) include all patients 18 years of age or older at the start of the encounter. 

To create the numerator, include any qualifying encounters which include a new (not documented within first 24 hours after hospital arrival) stage 2, stage 3, stage 4, deep tissue pressure injury, or unstageable pressure injury.

Only one harm (new qualifying pressure injury) is counted per encounter.

TBD

All patient encounters where the patient is 18 years of age or older at the start of the encounter. 

Measure includes inpatient admissions who were initially seen in the emergency department or in observation status and then were admitted to the hospital.

Equals Initial Population

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All encounters which include a new (not documented within first 24 hours after hospital arrival) stage 2, stage 3, stage 4, deep tissue pressure injury, or unstageable pressure injury.

Only one harm (new qualifying pressure injury) is counted per encounter.

Not Applicable

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For every patient evaluated by this measure, also identify payer, race, ethnicity, and gender.