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www.cpsi.ahrq.gov/patient-safety/settings/hospital/resource/index.html
August 01, 2022 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … Patients with Limited English Proficiency
NICU Toolkit
Preventing Falls in Hospitals
Preventing Pressure
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www.cpsi.ahrq.gov/hai/pfp/hacrate2013-appendix.html
October 01, 2015 - (2013)
OB Trauma in Vaginal Delivery With (PSI18) and Without Instrument (PSI19)
77,000
2.4
Pressure … Ulcers
MPSMS (2013)
Hospital-Acquired Pressure Ulcers
1,060,000
32.5
Surgical Site Infections … $144,680,000
1' 100
Obstetric Adverse Events
82,000
77,000
5,000
6%
$15,000,000
7
Pressure … 12.5%
25,000
$7,234
Obstetric Adverse Events
380,000
30%
50%
15%
57,000
$3,000
Pressure … been wrongly based on the full cost of a hospital stay that included a fall or a hospital-acquired pressure
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www.cpsi.ahrq.gov/patient-safety/settings/hospital/resource/qitool/webinar080116/index.html
December 01, 2017 - Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … The number of hospitalizations involving pressure ulcers increased by about 80% between 1993 and 2006 … patients may have pressure ulcers at any one time. … Include in the medical record complete documentation of any pressure ulcer found. … Pressure Ulcer Risk Assessment at Admission and Daily: Evaluate all patients for pressure ulcers and
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/a2_combo_boardpresentation.pdf
October 01, 2015 - • Several exclusions (e.g., length of stay <5 days,
principal diagnosis of pressure ulcer). … • Several exclusions (e.g., length of stay <5 days,
principal diagnosis of pressure ulcer). … An Example: Pressure Ulcer (PDI 02)
http://www.qualityindicators.ahrq.gov/Downloads/Modules/PDI/V45/ … A PSI Example: Pressure Ulcer (PSI 03)�
What are the Inpatient Quality Indicators (IQIs)? … An Example: Pressure Ulcer (PDI 02)�
How can the AHRQ QIs be used in quality assessment?
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/evidencenow/cooperatives/evidencenow-executive-summary-midwest.pdf
November 01, 2017 - patients adopt the
ABCS of cardiovascular disease prevention: Aspirin in high-risk individuals, Blood pressure … ethnically and socioeconomically) faces many cardiac health challenges:
31.2 percent have high blood pressure … prescription and cholesterol management;
education and patient self-management tools to improve
blood pressure … • Crash Course: Diving Deep into MIPS [2017]
• Implementing a Practice-Led Self-Measured Blood
Pressure … Monitoring Program [2017]
• Improving Health Outcomes: Blood Pressure
Measurement [2017]
• Improving
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/intervention-tracking-notes-sw.pdf
July 19, 2018 - follow up; PDSA on data
accuracy of aspirin therapy; established a standardized clinic-wide blood pressure … on this
topic
Started work
on this topic
and achieved
aim/goal
Aspirin therapy
Blood Pressure … management:
Started work on this topic but stopped before reaching aimgoalBlood Pressure management … :
Started and continue to work on this topicBlood Pressure management:
Started work on this topic … and achieved aimgoalBlood Pressure management:
Did not formally work on thisCholesterol management
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www.cpsi.ahrq.gov/sites/default/files/publications/files/interimhacrate2014_2.pdf
November 19, 2015 - About 40 percent of this reduction is from adverse drug events,
about 28 percent from pressure ulcers … Most of the deaths averted
occurred as a result of reductions in the rates of pressure ulcers and adverse … Urinary Tract Infections
Central Line-Associated Bloodstream Infections Falls
Obstetric Adverse Events Pressure … 2013) OB Trauma in
Vaginal Delivery W ith
(PSI 18) and Without
Instrument (PSI 19)
77,000 2.4
Pressure … Ulcers
MPSMS
(2014)
Hospital-Acquired
Pressure Ulcers
1,010,000 30.9
7 2010 baseline data
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b3a_combo_chartsforpresentations.xlsx
January 01, 2006 - Death in low-mortality DRGs 0 0 0.000717 0.265 -100 0 0.2705660377 PSI 02 Statistically Lower 0
PSI 03 Pressure … 0.00057 -47.8771929825 -100 88.5614035088 PDI 01 No Statistically Significant Difference 0
PDI 02 Pressure … Remove the
"Pressure Ulcers" part of the title and revise it to reflect your PSI or IQI of interest … Remove the
"Pressure Ulcers" part of the title and revise it to reflect your PSI or IQI of interest … Remove the
"Pressure Ulcers" part of the title and revise it to reflect your PSI or IQI of interest
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/topicrefinement/hmv-protocol.pdf
February 02, 2018 - addition, some patients with chronic respiratory failure may benefit from continuous positive
airway pressure … Areas of device variability include: mode of ventilation (such as pressure
targeted ventilation versus … targeted ventilation using a mask interface, the FDA
has approved HMVs which can provide pressure targeted … ventilation supplied by a Home Mechanical Ventilator (HMV), Bilevel
Positive Airway Pressure device … (BPAP), and Continuous Positive Airway Pressure device
(CPAP) in the home through a noninvasive interface
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hacreport-2019.pdf
January 01, 2019 - ulcers/pressure injuries and falls. … For
example, measured adverse drug events continued to drop from 2014 to 2017, while measured
pressure … ulcers/pressure injuries increased from 2014 to 2015 and then decreased somewhat from
2015 to 2016 … Ulcers/
Pressure Injuries
21.7 23.5 22.7 23.0 6% 17.4
Surgical Site
Infections
2.5 2.5 2.5 … Ulcer MPSMS Hospital-Acquired Pressure Ulcers/Pressure Injuries
Surgical Site
Infection
NHSN SSIs
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www.cpsi.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/slides.html
December 01, 2017 - Use Low Blood Pressure Precautions
Slide 1. … Paralysis, tremors
Loss of joint mobility, contractures
Lower extremity weakness
Drop in blood pressure … Provide safe shoes and slippers
Promote safety during transfer and bathroom use
Use low blood pressure … - Provide safe shoes and slippers - Promote safety during transfer and bathroom use - Use low blood pressure … Use Low Blood Pressure Precautions
For residents with low blood pressure:
Sit on edge of bed
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/evidencenow/about/evidencenow-factsheet.pdf
April 01, 2021 - This included the “ABCS” of heart
health: Aspirin use by high-risk individuals, Blood pressure
control … Such pressures
worsen a fundamental problem: it takes many years for
new evidence to make its way into … aspirin for eligible patients
n A 6.3% increase in cholesterol management
n A 2.8% increase in blood pressure … control – an important finding,
given decreasing national rates of blood pressure control.
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/nicu_toolkit/nicupacket-apb-nephro.pdf
December 13, 2013 - ■ Blood pressure: Not higher in infants with nephrocalcinosis, but overall higher in preterm
infants … ■ Should have:
– Blood pressure checked at every visit.
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www.cpsi.ahrq.gov/evidencenow/projects/heart-health/about/stories/achievements.html
March 01, 2021 - Health Center Holly Clinic (Holy, CO)
Helping primary care practices use evidence to improve blood pressure … selected Million Hearts® Hypertension Control Champions have worked with their patients to achieve blood pressure
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.xlsx
July 01, 2016 - Value-based purchasing
• Sentinel event
• Publicly reported
• Public perception
• Marketing
• Competitive pressure … Patient Safety PSI 03 Pressure Ulcer
PSI 06 Iatrogenic Pneumothorax
PSI 07 Central Venous Catheter-Related … Neonatal Blood Stream Infection Rate
Pediatric PDI 01 Accidental Puncture or Laceration Rate
PDI 02 Pressure
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014FinalHACreport4Web-13Dec2016.pdf
December 01, 2016 - About 40 percent of the overall reduction is from adverse
drug events, about 28 percent from pressure … Tract
Infections
Central Line-Associated Bloodstream
Infections
Falls
Obstetric Adverse Events
Pressure … Most of the deaths averted
occurred as a result of reductions in the rates of pressure ulcers and adverse … 2014) OB Trauma in
Vaginal Delivery With
(PSI 18) and Without
Instrument (PSI 19)
74,000 2.3
Pressure … Ulcers
MPSMS
(2014)
Hospital-Acquired
Pressure Ulcers
1,010,000 30.9
Surgical Site
Infections
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www.cpsi.ahrq.gov/patient-safety/settings/hospital/match/table-6.html
August 01, 2012 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … ordered for patient instead of extended-release
E
Error that could have caused temporary harm
Blood pressure
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.pdf
June 29, 2016 - purchasing
• Sentinel
event
• Publicly
reported
• Public
perception
• Marketing
• Competitive
pressure … PSI 03 Pressure
Ulcer
1.2 1.3 7 $109,870 $ 769,087 N 6 7 7 Y Y Y Y Y
PSI 06 Iatrogenic … purchasing
• Sentinel
event
• Publicly
reported
• Public
perception
• Marketing
• Competitive
pressure … purchasing
• Sentinel
event
• Publicly
reported
• Public
perception
• Marketing
• Competitive
pressure … Y N
PDI 01 Accidental
Puncture
0.3 0.6 1 $41,204 $ 41,204 N 9 9 9 Y Y Y Y Y
PDI 02 Pressure
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www.cpsi.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/medicaidmgmt/exh7-4.html
October 01, 2014 - Blood Pressure (AQA and HEDIS Measure)
Percentage of members with diabetes with most recent blood pressure … √
√
12 mos
Seeing a change in clinical outcomes, such as blood pressure, might take a year …
√
12 mos
Blood Pressure
Percentage of members with congestive heart failure (CHF) … with most recent blood pressure <140/80 mm Hg
Claims. … √
√
12 mos
Seeing a change in clinical outcomes, such as blood pressure, might take a year
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www.cpsi.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/clabsitools/clabsitoolsap5.doc
December 11, 2012 - lumen (to avoid air embolism and ensure intravascular placement)
Transduce central venous pressure … or estimate central venous pressure by fluid column (to avoid arterial placement)
After the