Hospital Harm - Pressure Injury

The proportion 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

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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.

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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).

American College of Physicians (ACP) guideline - ACP (Risk Assessment and Prevention of Pressure Ulcers: A Clinical Practice Guideline from the American College of Physicians. ACP: 2015) presents the available evidence on the comparative effectiveness of various risk assessment instruments and benefits and harms of strategies to prevent pressure ulcers. Https://www.acpjournals.org/doi/pdf/10.7326/M14-1567

Recommendation 1: ACP recommends that clinicians should perform a risk assessment to identify patients who are at risk of developing pressure ulcers. 

Recommendation 2: ACP recommends that clinicians should choose advanced static mattresses or advanced static overlays in patients who are at an increased risk of developing pressure ulcers.

Recommendation 3: ACP recommends against using alternating-air mattresses or alternating-air overlays in patients who are at an increased risk of developing pressure ulcers.

The European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance (Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. EPUAP/NPIAP/PPPIA:2019) provide guidance for categorizing pressure injuries and recommendations for structured skin and risk assessment.

Guidelines focused on risk factors and risk assessment: 
1.1: Consider individuals with limited mobility, limited activity and a high potential for friction and shear to be at risk of pressure injuries. 
1.2: Consider individuals with a category/stage I pressure injury to be at risk of developing a category/stage II or greater pressure injury. 
1.7: Consider the impact of diabetes mellitus on the risk of pressure injuries. 
1.8: Consider the impact of perfusion and circulation deficits on the risk of pressure injuries. 
1.12: Consider the impact of increased body temperature on the risk of pressure injuries. 
1.17: Consider the impact of time spent immobilized before surgery, the duration of surgery and the American Society of Anesthesiologists (ASA) Physical Status Classification on surgery-related pressure injury risk. 

Guidelines focused on skin and tissue assessment: 
2.2: Inspect the skin of individuals at risk of pressure injuries to identify presence of erythema. 
2.3: Differentiate blanchable from non-blanchable erythema using either finger pressure or the transparent disk method and evaluate the extent of erythema. 

Guidelines focused on preventative skin care: 
3.1: Implement a skin care regimen that includes: 
 - Keeping skin clean and appropriately hydrated 
 - Cleansing the skin promptly after episodes of incontinence 
 - Avoiding use of alkaline soaps and cleansers 
 - Protecting the skin from moisture with a barrier product 
3.3: Use high absorbency incontinence products to protect the skin in individuals with or at risk of pressure injuries who have urinary incontinence. 
3.4: Consider using textiles with low friction coefficients for individuals with or at risk of pressure injuries.  
3.5: Use a soft silicone multi-layered foam dressing to protect the skin for individuals at risk of pressure injuries. 

Guidelines focused on nutrition screening:  
4.1: Conduct nutritional screening for individuals at risk of a pressure injury. 
4.2: Conduct a comprehensive nutrition assessment for adults at risk of a pressure injury who are screened to be at risk of malnutrition and for all adults with a pressure injury.  
4.3: Develop and implement an individualized nutrition care plan for individuals with or at risk of a pressure injury who are malnourished or who are at risk of malnutrition.  
4.4: Optimize energy intake for individuals at risk of pressure injuries who are malnourished or at risk of malnutrition.  
4.6: Provide 30 to 35 kcalories/kg body weight/day for adults with a pressure injury who are malnourished or at risk of malnutrition.  
4.7: Provide 1.25 to 1.5 g protein/kg body weight/day for adults with a pressure injury who are malnourished or at risk of malnutrition.  
4.9: Offer high calorie, high protein nutritional supplements in addition to the usual diet for adults with a pressure injury who are malnourished or at risk of malnutrition, if nutritional requirements cannot be achieved by normal dietary intake.  
4.12: Discuss the benefits and harms of enteral or parenteral feeding to support pressure injury treatment in light of preferences and goals of care for individuals with pressure injuries who cannot meet their nutritional requirements through oral intake despite nutritional interventions. 

Guidelines focused on repositioning and early mobilization: 
5.1: Reposition all individuals with or at risk of pressure injuries on an individualized schedule, unless contraindicated. 
5.2: Determine repositioning frequency with consideration to the individual’s level of activity and ability to independently reposition. 

Guidelines focused on heel pressure injury: 
6.1: Assess the vascular/perfusion status of the lower limbs, heels and feet when performing a skin and tissue assessment, and as part of a risk assessment. 
6.2: For individuals at risk of heel pressure injuries and/or with category/stage I or II pressure injuries, elevate the heels using a specifically designed heel suspension device or a pillow/ foam cushion. Offload the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon and the popliteal vein. 
6.4: Use a prophylactic dressing as an adjunct to heel offloading and other strategies to prevent heel pressure injuries.
 
Guidelines focused on support surfaces: 
7.4: Use a high specification reactive single layer foam mattress or overlay in preference to a foam mattress without high specification qualities for individuals at risk of developing pressure injuries. 
7.7: Assess the relative benefits of using an alternating pressure air mattress or overlay for individuals at risk of pressure injuries. 
7.8: Use a pressure redistribution support surface on the operating table for all individuals with or at risk of pressure injuries who are undergoing surgery. 
7.12: Use a pressure redistribution cushion for preventing pressure injuries in people at high risk who are seated in a chair/wheelchair for prolonged periods, particularly if the individual is unable to perform pressure relieving maneuvers. 
7.13: Assess the relative benefits of using an alternating pressure air cushion for supporting pressure injury healing in individuals who are seated in a chair/wheelchair for prolonged periods, particularly if the individual is unable to perform pressure relieving maneuvers. 
 
Guidelines focused on device related pressure injury: 
8.1: To reduce the risk of medical device related pressure injuries, review and select medical devices with consideration to: 
 - The device's ability to minimize tissue damage
 - Correct sizing/shape of the device for the individual 
 - Ability to correctly apply the device according to manufacturer's instructions 
 - Ability to correctly secure the device 
8.5: Use a prophylactic dressing beneath a medical device to reduce the risk of medical device related pressure injuries.  
 
Guidelines focused on implementing best practices: 
20.2: At the organizational level, assess the knowledge health professionals have about pressure injuries to facilitate implementation of an education program and a quality improvement program.  
20.4: At an organizational level, assess and maximize the availability and quality of equipment and standards for its use as part of a quality improvement plan to reduce the incidence of pressure injuries.  
20.5: At an organizational level, develop and implement a structured, tailored and multi-faceted quality improvement program to reduce the incidence of pressure injuries.  
20.6: At an organizational level, engage all key stakeholders in oversight and implementation of the quality improvement program to reduce the incidence of pressure injuries.  
20.7: At an organizational level, include evidence-based policies, procedures and protocols and standardized documentation systems to reduce the incidence of pressure injuries.  
20.8: At an organizational level, provide clinical decision support tools as part of a quality improvement plan to reduce the incidence of pressure injuries.  
20.9: Provide clinical leadership in pressure injury prevention and treatment as part of a quality improvement plan to reduce pressure injuries.  
20.10: At a professional level, provide education in pressure injury prevention and treatment as part of a quality improvement plan to reduce the incidence of pressure injuries.  
20.11: At an organizational level, regularly monitor, analyze and evaluate performance against quality indicators for pressure injury prevention and treatment. 
20.12: At an organizational level, use feedback and reminder systems to promote the quality improvement program and its outcomes to stakeholders. 

Guidelines focused on health professional education: 
21.1: At the organizational level, assess the knowledge health professionals have about pressure injuries to facilitate implementation of an education program and a quality improvement program.  
21.2: At an organizational level, develop and implement a multi-faceted education program for pressure injury prevention and treatment.

A lower proportion indicates better quality

Reference Type: CITATION

Reference Text: 'American College of Physicians (ACP). (2015). Risk assessment and prevention of pressure ulcers: a clinical practice guideline.'

Reference Type: CITATION

Reference Text: 'Bly, D., Schallom, M., Sona, C., & Klinkenberg, D. (2016). A model of pressure, oxygenation, and perfusion risk factors for pressure ulcers in the intensive care unit. American Journal of Critical Care, 25(2), 156–154'

Reference Type: CITATION

Reference Text: 'Brem, H., Maggi, J., Nierman, D., Rolnitzky, L., Bell, D., Rennert, R., Golinko, M., Yan, A., Lyder, C., Vladeck, B. High cost of stage IV pressure ulcers. Am J Surg. 2010 Oct;200(4):473-7. doi: 10.1016/j.amjsurg.2009.12.021. PMID: 20887840; PMCID: PMC2950802.'

Reference Type: CITATION

Reference Text: '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'

Reference Type: CITATION

Reference Text: 'Cremasco, M. F., Wenzel, F., Zanei, S. S. V., & Whitaker, I. Y. (2013). Pressure ulcers in the intensive care unit: the relationship between nursing workload, illness severity and pressure ulcer risk. Journal of Clinical Nursing, 22(15–16), 2183–2191. https://doi.org/10.1111/j.1365-2702.2012.04216.x'

Reference Type: CITATION

Reference Text: 'European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. (2019). Prevention and treatment of pressure ulcers/injuries: clinical practice guideline. The International Guideline: Haesler (Ed.). EPUAP/NPIAP/PPPIA.'

Reference Type: CITATION

Reference Text: 'Gunningberg, L., Donaldson, N., Aydin, C., Idvall, E. (2011). Exploring variation in pressure ulcer prevalence in Sweden and the USA: Benchmarking in action. 18. Journal of evaluation in clinical practice., 904-910'

Reference Type: CITATION

Reference Text: 'Li, Z., Lin, F., Thalib, L., & Chaboyer, W. (2020). Global prevalence and incidence of pressure injuries in hospitalised adult patients: A systematic review and meta-analysis. International Journal of Nursing Studies, Vol. 105. https://doi.org/10.1016/j.ijnurstu.103546'

Reference Type: CITATION

Reference Text: 'National Pressure Ulcer Advisory Panel (NPUAP), Submission of Open Comment August 23, 2019, retrieved May 12, 2020 from: https://cdn.ymaws.com/npiap.com/resource/resmgr/npuap_nqf_response_final_8.2.pdf'

Reference Type: CITATION

Reference Text: 'Rondinelli, J., Zuniga, S., Kipnis, P., Kawar, L. N., Liu, V., & Escobar, G. J. (2018). Hospital-acquired pressure injury: Risk-adjusted comparisons in an integrated healthcare delivery system. Nurs Res, 67(1), 16–25'

Reference Type: CITATION

Reference Text: 'Tayyib, N., Coyer, F., & Lewis, P. (2016). Saudi Arabian adult intensive care unit pressure ulcer incidence and risk factors: A prospective cohort study. International Wound Journal, 13(5), 912–919. https://doi.org/10.1111/iwj.12406'

Reference Type: CITATION

Reference Text: 'Wound Management & Prevention. (2018, November). Index: Ostomy wound management. 64(11):30-41. ISSN 1943-2720'

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 pressure injury as found on exam greater than 24 hours after hospital arrival and was not present on admission.

In addition to clinical electronic health record data, this measure uses Present on Admission (POA) indicators (e.g., POA = U) as found in billing/claims system within the measure criteria.

The measure defines a new deep tissue pressure injury (DTPI) as found on exam greater than 72 hours after hospital arrival and was not present on admission, i.e., POA indicator = N (Diagnosis was not present at time of inpatient admission) or U (Documentation insufficient to determine if the condition was present at the time of inpatient admission).

This measure excludes encounters for patients with a DTPI or stage 2, stage 3, stage 4, and unstageable pressure injuries that are present on admission, i.e., POA indicator = Y (Diagnosis was present at the time of inpatient admission) or W (clinically undetermined).

The POA Indicator is intended to differentiate conditions present at the time of admission from those conditions that develop during the inpatient admission. 
 - A POA Indicator of Y = yes (Diagnosis was present at time of inpatient admission).
 - A POA Indicator of N = no (Diagnosis was not present at time of inpatient admission.)
 - A POA Indicator of W = clinically undetermined
 - A POA Indicator of U = documentation insufficient to determine if the condition was present at the time of inpatient admission

Per CMS and the Agency for Healthcare Research and Quality (AHRQ) convention, POA indicators of Y and W are accepted indicators of a diagnosis present on admission. POA indicators of N and U are accepted indicators of a diagnosis that is not present on admission.

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

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

This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.

This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

TBD

Inpatient hospitalizations for patients aged 18 and older

Equals Initial Population

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 undetermined)

Inpatient hospitalizations for patients with a DTPI found on exam within 72 hours after the start of the encounter

Inpatient hospitalizations for patients with a stage 2, 3, 4, or unstageable pressure injury found on exam within 24 hours after the start of the encounter

Inpatient hospitalizations for patients with diagnosis of a COVID-19 infection during the encounter

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 indicator = N no (Diagnosis was not present at time of inpatient admission) or U (documentation insufficient to determine if the condition was present at the time of inpatient admission)

A diagnosis of stage 2, 3, 4 or unstageable pressure injury with the pressure injury diagnosis not present on admission, i.e., the diagnosis of pressure injury has a Present on Admission indicator = N no (Diagnosis was not present at time of inpatient admission) or U (documentation insufficient to determine if the condition was present at the time of inpatient admission)

A DTPI found on exam greater than 72 hours after the start of the encounter

A stage 2, 3, 4 or unstageable pressure injury found on exam greater than 24 hours after the start of the encounter

Not Applicable

None

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