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.
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: Equals Initial Population
Denominator Exclusions: None
Numerator: 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
Supplemental Data Elements: For every patient evaluated by this measure, also identify payer, race, ethnicity, and gender.
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).
Clinical Workflow
NOTE: IMPAQ is seeking input from the community regarding workflow related to the clinical practice, documentation and reporting of Pressure Injury hospital harms.
Please share your role: e.g., clinician, EHR vendor, specialty society, quality/safety positions (CNO, Director of Quality and Safety)
- Documentation: How are PIs documented at your orgs, please share any policies/procedures for documentation, standards of practice, training modules (See Test Results)
- Clinical Implications: From a clinical perspective, do you have any input regarding Stage 2 y/n, worsening y/o
- Administrative perspective: From a regulatory reporting (P4P, etc.) perspective, what challenges do you envision regarding reporting of this quality measure/hospital harm.
Based on your feedback, we may add follow-up questions.
For clinical documentation, please share your documentation process for pressure injuries.
For quality professionals, what challenges do you envision regarding reporting of this quality measure/hospital harm.
Test Results
Screen shots encouraged; please upload via Test Results button.
- Documentation: How are PIs documented at your orgs (screen shots welcome, if able), please share any policies/procedures for documentation, standards of practice, training modules
- Clinical Implications: From a clinical perspective, do you have any input regarding Stage 2 yes /no, worsening yes / no
- Administrative perspective: From a regulatory reporting (P4P, etc.) perspective, what challenges do you envision regarding reporting of this quality measure/hospital harm.
Based on your feedback, we may add follow-up questions.
Comments
I have been the Director of Wound care in this level one trauma- safety net hospital for over 10 years. I have studied both hospital and community acquired pressure injuries and have found that pressure ulcers start as a Deep Tissue Injury that evolves into a full thickness pressure ulcer/injury.
The national Pressure Ulcer Advisory Panel Guidelines have removed friction from the etiology and have the main components as pressure and shear/ over time. Stage 1 and 2 pressure ulcers injuries are due from pressure and friction and to not evolve into deep tissue injuries. We actually see many patients who have low blood pressure transported on a gurney for hours and arrive with DTIs which can be found within 24-48 hours of admission.
1. I believe stage 2 pressure injuries should not be monitored/ involved - as different etiology and often confused with incontinence associated dermatitis etc
2. I believe if nurses have performed all preventative interventions for pressure ulcers -these should be termed "Unavoidable"
3. When patients are actively dying we need to be able to document "Skin Changes at Lifes End" and not be penalized for patients who do not choose Hospice and develop end of life skin breakdown while in our care.
Hello Holly,
Thank you for your feedback. We have brought this to the clinical leads attention and will consider your insightful feedback as we continue the specification development and testing.
Sincerely,
Katie Magoulick, IMPAQ International