Hospital Harm - Pressure Injury

Inpatient hospitalizations for patients aged 18 and older

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 pressure injuries has been estimated at 8.4% (Li et al., 2020). Over 50% of reported pressure injuries in hospitals were stage 2 or higher (Li et al., 2020). Hospital-acquired pressure injuries are serious events and one of the most common patient harms. Pressure injuries commonly cause 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). Pressure injury is considered a serious reportable event by the National Quality Forum (NQF) (Centers for Medicare and Medicaid Services, 2015).

Studies have shown that age, severity of illness, comorbidity indexes, and Braden scores are predictors of hospital-acquired pressure injuries (HAPI) (Rondinelli et al., 2018). However, even after risk adjustment for patient risk factors, significant variation in rates of HAPI exist between hospitals (Rondinelli et al., 2018). It is widely accepted that the risk of developing a pressure injury can be reduced through best practices. Hospital controlled factors that have been found to be significantly associated with an increase in pressure ulcer risk include infrequent repositioning (p=0.005) and number of days to bed change (OR, 2.89 [95% CI, 1.26-6.63]) (Tayyib, Coyer, and Lewis, 2016; Bly et al., 2016). High nursing workload has additionally been found to reduce risk of pressure ulcers (OR, 0.916 [95% CI, 0.855-0.980]; p=0.011) (Cremasco et al., 2013). Systematically measuring patients who develop new pressure injuries while in the hospital setting will provide hospitals with a reliable and timely measurement, to more reliably assess harm reduction efforts and modify their improvement efforts in near real-time. This eCQM will fill a gap in measurement and provide incentives for hospitals’ quality improvement. Although several pressure injury measures are currently in use, there are no electronic health record (EHR)-based measures intended for use in acute care hospitals. In addition, the intent of this measure is to incentivize greater achievements in reducing harms and enhance hospital performance on patient safety outcomes.

Stage 2 pressure injuries carry a less serious burden in terms of patient harm than stage 3, stage 4, unstageable, and deep tissue pressure injuries (DTPI). Partial thickness wounds heal primarily as a result of epidermal regeneration and often heal without untoward consequences, loss of skin function or scar tissue formation. Based on the healing capabilities inherent in these partial thickness wounds, it is the expert opinion of the NPUAP that the presentation of a stage 2 pressure injuries does not carry the same potential longstanding negative consequences to patients as do full thickness pressure injuries. Stage 2 pressure injuries constitute a very real patient harm that should be monitored and addressed; however, the relative level of harm is less than with stage 3, stage 4, unstageable pressure injuries and potentially DTPI (National Pressure Ulcer Advisory Panel, 2019).

The accurate and timely identification of DTPI is important for several reasons. Early discovery of DTPI allows prompt identification of possible causes, initiation of treatment, and potential development of preventive strategies. In addition, 24 to 72 hours can lapse between the precipitating pressure event and the onset of purple or maroon skin. This delayed manifestation becomes particularly important when the precipitating event occurred before the patient’s admission, yet the DTPI appears beyond the 24-hour window for present-on-admission status (Wound Management and Prevention, 2018).