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Hospital Harm – Pressure Injury

CMS Measure ID
CMS826v0
Version
0
NQF Number
Not Applicable
Measure Description

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.

Initial Population

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.

Denominator Statement
Denominator Exclusions

None

Numerator Statement

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.

Numerator Exclusions

Not Applicable

Denominator Exceptions

None

Measure Scoring
Measure Type
Improvement Notation

A lower proportion indicates better quality.

Guidance

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.

Meaningful Measure
Notes

Pre-rulemaking

Specifications

Attachment Size
CMS826v0.html 47.42 KB
CMS826v0.zip 29.54 KB
Last Updated: Oct 10, 2019