-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-assessment.pdf
June 02, 2025 - The On-Time Pressure Ulcer Assessment incorporates elements from the Bates-Jensen Wound Assessment … In partial thickness wounds it can occur throughout the wound bed as well as from the wound
edges. … In full thickness wounds it occurs from the edges only. … to <50% wound covered
5= <25% wound covered
Pain
Pressure Ulcer Site Pain
Select … Stage 1
Stage 2
Stage 3
Stage 4
Unstageable
Suspected Deep Tissue Injury
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report-nov-rev.pdf
January 01, 2022 - injuries or complications of pressure injuries present on admission (POA)
was significantly higher … injuries or complications of pressure injuries
present on admission (13.4% vs. 4.7%) and catheter-associated … When the individual AE rates were analyzed by sex, the AE rate for advancing
pressure injuries or complications … of pressure injuries POA was significantly higher for males than
females (7.2% vs. 4.9%). … Pressure Injury/Ulcer
(PI)
Advancing PI or Secondary Comorbidity in PI Present
on Admission
New
-
www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report-oct-rev.pdf
January 01, 2022 - injuries or complications of pressure injuries present on admission (POA)
was significantly higher … injuries or complications of pressure injuries
present on admission (13.4% vs. 4.7%) and catheter-associated … When the individual AE rates were analyzed by sex, the AE rate for advancing
pressure injuries or complications … of pressure injuries POA was significantly higher for males than
females (7.2% vs. 4.9%). … Pressure Injury/Ulcer
(PI)
Advancing PI or Secondary Comorbidity in PI Present
on Admission
New
-
www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK2_T1-Medical_Care_Referral_Form_Word_doc_for_html_only.doc
June 02, 2025 - including recent fever pattern and change in recent/current health status:
CURRENT VITAL SIGNS
Blood pressure … Suspected minor injury
Yes No ?
Suspected serious injury
Yes No ? … New or increasing pus draining from wound
Y
N
?
New breakdown
Y
N
? … New or expanding redness around wound
Y
N
?
Pain / tenderness
Y
N
?
Warmth
Y
N
?
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/ltvv-mvpguide.pdf
January 01, 2017 - (so-called ZEEP)6-15 and limiting plateau pressures to < 30 cm/H2O (as
compared with 10–12 mL/kg and … to be beneficial in patients at risk for
ARDS, such as those with sepsis, pneumonia, or traumatic injuries … tidal volumes in the 6–8 mL/kg PBW range
along with the avoidance of ZEEP6-13,24 and limiting plateau pressures … admitted to the ICU already have risk factors for ARDS, such as pneumonia,
sepsis, noncardiogenic shock, trauma … Tidal volume
and plateau pressure use for acute lung injury from
2000 to present: A systematic literature
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/056-nursing-protocol-bathing-cloths.docx
October 01, 2024 - CHG is also safe for superficial wounds, including stage 1 and stage 2 pressure injuries.
7.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/057-nursing-protocol-bathing-liquid.docx
October 01, 2024 - CHG is also safe for superficial wounds, including stage 1 and stage 2 pressure injuries.
12.
-
www.ahrq.gov/sites/default/files/publications/files/interimhacrate2013_0.pdf
October 27, 2014 - MPSMS
(2013)
In-Hospital Patient
Falls
240,000 7.2
Obstetric
Adverse
Events
PSI (2012) OB Trauma … Fall and injury prevention (Chapter 10). In: Hughes RG, ed. … Preventing falls and eliminating injury at Ascension Health. … The road to zero preventable birth injuries. … Eliminating birth trauma at Ascencion Health.
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursinghome-resourcelist.pdf
April 01, 2023 - Falls Management Program
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries … Provider Fax Report and Orders
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries … professionals/onthejob/falls.asp
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries … /fallspx/index.html
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspx … /fallspx/fallspxmanapb10pcp.html
http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb1txt.html
December 01, 2017 - Monthly falls analysis by:
location and time of fall
shift and day of week
type of injury … Monthly falls analysis by # of falls, fallers, patients ≥2 falls, and falls with serious injury?
… of falls
high-risk medications, sleep hygiene measures for management of anxiety
low blood pressure … care plan include general behavior management strategies and specific interventions to reduce risk of injury … results of fall (BP, BS, mental status, VS, tests ordered, ER or hospital visit)
description of injury
-
www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK2_T1-Medical_Care_Referral_Form.pdf
May 01, 2014 - Positive culture
If yes, positive for:_______________________________
CURRENT VITAL SIGNS
Blood pressure … New or increasing pus draining from wound
Y N ? New breakdown
Y N ? … New or expanding redness around wound
Y N ? Pain / tenderness
Y N ? Warmth
Y N ? … Suspected minor injury Yes No ?
Suspected serious injury Yes No ?
-
www.ahrq.gov/hai/tools/mvp/modules/technical/early-mobility-icu-slides.html
February 01, 2017 - Systolic blood pressure <90 mmHg (4).
Oxygen saturation <80% (3). … Systolic blood pressure >200 mmHg (1).
No extubations. … (i.e., 6 per 1,000 PT treatment):
80% of events were transient physiological (heart rate, blood pressure … Subjects: 2,176 trauma and burn ICU patients,
Pre (n=1044) and post (n=1132) EM program. … Slide 23: 5-Year Sustainability of Time to PT Postacute Lung Injury Diagnosis 8
Post-QI → earlier
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-195-fullreport.pdf
December 17, 2019 - , seizure associated with trauma, loss of consciousness associated
with trauma, repeated vomiting, documented … These risks include dental trauma;
airway edema (swelling of the windpipe); vocal cord spasm or injury … Was there documentation of increased intracranial pressure? … The sensitivity of claims for identification of indicators of
increased intracranial pressure was 8.1 … in a
non-trauma center.
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-indications.pptx
April 01, 2022 - Knight is a 25-year-old man who was admitted with acute urinary retention, due to spinal injury. … when no or little urine is seen in bladder
Consider urology consultation for prostatitis and urethral trauma … Closed pressure ulcers: stage I, deep tissue injury No No, unless has chronic ISC needs Yes, if the patient … require an indwelling urinary catheter if the wound can be kept clean by other methods
Use alternatives … J Wound Ostomy Continence Nurs. 2020;47(6):601-18. PMID: 33201147.
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab16.html
December 01, 2012 - 9,257
6,892
Composite: ACSC Overall
17,570
24,934
20,620
17,662
23,518
18,337
Pressure … 10,435
7,884
Composite: ACSC Overall
19,406
27,524
22,656
19,821
25,958
20,278
Pressure … 5,382
4,110
Composite: ACSC Overall
12,450
16,541
14,919
11,150
15,491
12,897
Pressure … 3,777
3,248
Composite: ACSC Overall
5,094
6,963
6,484
4,695
6,310
5,297
Pressure … 8,215
6,780
Composite: ACSC Overall
17,579
23,121
20,378
17,055
21,295
18,297
Pressure
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.pdf
June 02, 2025 - purchasing
• Sentinel
event
• Publicly
reported
• Public
perception
• Marketing
• Competitive
pressure … Rate on scale of 10 (agree/high) to 0 (disagree/low)
PSI 14 Postoperative
Wound … Dehiscence
PSI 15 Accidental
Puncture or Laceration
PSI 17 Birth Trauma-
Injury to Neonate
PSI … 18 Obstetric Trauma-
Vaginal Delivery With
Instrument
PSI 19 Obstetric Trauma-
Vaginal Delivery … 09 Postoperative
Respiratory Failure Rate
PDI 10 Postoperative
Sepsis Rate
PDI 11 Postoperative
Wound
-
www.ahrq.gov/hai/cauti-tools/archived-webinars/ed-catheter-insertions-slides.html
December 01, 2017 - Few days later, he develops fever and his blood pressure drops. … Keeps patients from having to get up to urinate, protecting them from injury. … Trauma)
Admitting service (e.g. … Is the patient incontinent with open sacral or perineal wounds? … Protocolized care for trauma
Incontinence without open sacral or perineal wounds
Pre-operative
-
www.ahrq.gov/es/patient-safety/settings/hospital/resource/pressureulcer/tool/put5.html
October 01, 2014 - Remember, pressure ulcers are areas of soft tissue damage caused by pressure or pressure and shear. … If unsure whether it is a pressure ulcer, get help from the wound care nurse or another experienced clinician … Typically, this comprehensive evaluation is performed by an "outside" expert such as a wound nurse or … Therefore, consider performing a comprehensive skin assessment every 3 months with a wound care nurse … Pressure ulcers may take several days to develop after a severe pressure injury.
-
www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/put5.html
October 01, 2014 - Remember, pressure ulcers are areas of soft tissue damage caused by pressure or pressure and shear. … If unsure whether it is a pressure ulcer, get help from the wound care nurse or another experienced clinician … Typically, this comprehensive evaluation is performed by an "outside" expert such as a wound nurse or … Therefore, consider performing a comprehensive skin assessment every 3 months with a wound care nurse … Pressure ulcers may take several days to develop after a severe pressure injury.
-
www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/prevent/clinical-faqs.html
March 01, 2017 - Assistance in healing of open pressure ulcers, skin grafts, and stage III or IV perineal and sacral wounds … After having contact with body fluids or excretions, mucous membranes, nonintact skin and wound dressings … or trauma. … Bowel perforation and intra-abdominal injuries are possible during the insertion. … Management of the neurogenic bladder for adults with spinal cord injuries.