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Hospital Harm - Pressure Injury

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Compare Versions of: "Hospital Harm - Pressure Injury"

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Table Options
Measure Information 2025 Reporting Period
Title Hospital Harm - Pressure Injury
CMS eCQM ID CMS826v2
Short Name

HH-PI

CBE ID* 3498e
Measure Steward Centers for Medicare & Medicaid Services (CMS)
Description

The measure assesses the number of inpatient hospitalizations for patients aged 18 and older who suffer the harm of developing a new stage 2, stage 3, stage 4, deep tissue, or unstageable pressure injury

Measure Scoring Proportion measure
Measure Type Outcome
Stratification

None

Risk Adjustment

None

Rationale

This safety eCQM captures the number of patients who experience harm in the form of a pressure injury, during their inpatient hospitalization. The incidence of pressure injuries in hospitalized patients has been estimated at 5.4 per 10,000 patient-days and the rate of hospital-acquired...

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Clinical Recommendation Statement

The Clinical Guidelines Committee for the American College of Physicians (ACP) presents the available evidence on the comparative effectiveness of various risk assessment instruments and benefits and harms of strategies to prevent pressure ulcers (Qaseem et al., 2015).

Recommendation 1:...

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Improvement Notation

A lower measure score indicates higher quality

Definition

Inpatient hospitalizations: Includes time in the emergency department and observation when the transition between these encounters (if they exist) and the inpatient encounter are within an hour or less of each other.

The measure defines a new stage 2, stage 3, stage 4, or unstageable...

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Guidance
Initial Population

Inpatient hospitalizations for patients aged 18 and older

Denominator

Equals Initial Population

Denominator Exclusions

Inpatient hospitalizations for patients with a DTPI or stage 2, 3, 4 or unstageable pressure injury diagnosis present on admission, i.e., the diagnosis of pressure injury has a Present on Admission indicator = Y yes (Diagnosis was present at time of inpatient admission) or W (clinically...

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Numerator

Inpatient hospitalizations for patients with a new deep tissue pressure injury (DTPI) or stage 2, 3, 4, or unstageable pressure injury, as evidenced by any of the following:

A diagnosis of DTPI with the DTPI not present on admission, i.e., the diagnosis of DTPI has a Present on Admission...

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Numerator Exclusions

Not Applicable

Denominator Exceptions

None

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Last Updated: May 06, 2025