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www.healthcare411.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/index.html
May 01, 2016 - Effectiveness Reviews
Facilities
Home and Community Resources
Findings Report
Injuries … Pressure ulcers remain a serious problem in nursing homes despite regulatory and market approaches to … Pressure ulcers cause pain, disfigurement, and increased infection risk and are associated with longer … Median annual nursing home pressure ulcer prevalence was 7.5 percent in 2009, with associated costs of … Materials
Self-Assessment Worksheet for Pressure Ulcer Prevention .
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/data/infographics/hac-rates-2019-updated.pdf
January 01, 2019 - Conditions
National efforts to reduce hospital-acquired conditions such
as adverse drug events and injuries … CLABSI+
-6%
Clostridioides
difficile
Infections
-37%
Falls
-5%
Obstetric
Adverse
Events
-3%
Pressure
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www.healthcare411.ahrq.gov/talkingquality/translate/labels/describe.html
January 01, 2023 - Massachusetts General Hospital (MGH) URL: https://www.massgeneral.org/quality-and-safety/patient-safety/pressure-injury-prevalence … (To view complete information, go to https://www.massgeneral.org/quality-and-safety/patient-safety/pressure-injury-prevalence … Overall, the rate of patients who have pressure ulcers at MGH is low. … that nurses have the necessary knowledge for skin assessment and intervention they attend a Phase I Wound … Bed surface is a key factor in preventing pressure ulcers.
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www.healthcare411.ahrq.gov/patient-safety/settings/hospital/fall-prevention/webinars/index.html
September 01, 2017 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … Assessment Tools in Care Planning (25 min) ( PDF of the Slides , 2.16 MB)
Measuring Fall and Fall-Related Injury … Network Webinars
Creating Control Charts To Interpret Fall Data (62 min)
Critical Thinking for Fall Injury … Prevention Care Planning (61 min)
Post-Fall Huddles: Reducing Preventable Falls and Fall-Related Injuries
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www.healthcare411.ahrq.gov/patient-safety/settings/hospital/fall-prevention/index.html
September 01, 2018 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … Module 3 Tools ( MS Word , 268 KB)
Post-Fall Huddles: Reducing Preventable Falls and Fall-Related Injuries … Network Webinars
Related AHRQ Resources
Preventing Falls in Hospitals Toolkit
Pressure … Injury Prevention in Hospitals Training Program
Page last reviewed September
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.xlsx
July 01, 2016 - Patient Safety PSI 03 Pressure Ulcer
PSI 06 Iatrogenic Pneumothorax
PSI 07 Central Venous Catheter-Related … Perioperative Pulmonary Embolism or Deep Vein Thrombosis
PSI 13 Postoperative Sepsis
PSI 14 Postoperative Wound … Dehiscence
PSI 15 Accidental Puncture or Laceration
Obstetric 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
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-203-fullreport.pdf
April 10, 2017 - Ulcer Advisory Panel (EPUAP) — “A pressure ulcer is localized injury to the skin and/or
underlying … ulcers are a serious iatrogenic injury. … They may have
preexisting wounds or altered skin integrity due to a variety of factors related to their … Are pressure ulcers preventable? A survey of experts. Adv
Skin Wound Care 2001; 14(5):244-8. … Unavoidable Pressure Injury. J Wound Ostomy
Continence Nurs 2014; 41(4): 313-34.
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www.healthcare411.ahrq.gov/research/findings/studies/index.html?page=1
January 01, 2024 - and Wounds
(207)
Inpatient Care
(220)
Intensive Care Unit (ICU)
(264)
Kidney Disease and … Outcome measures included hypertension, systolic blood pressure >130 mmHG, and hyperglycemia. … center (NTC) and were diagnosed with a traumatic injury with an injury severity score of greater than … , major chest injury, and presentation at a teaching hospital. … , Injuries and Wounds
Cron DC , Braun HJ , Ascher NL Sex-based disparities in access to
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www.healthcare411.ahrq.gov/hai/pfp/hacrate2013-refs.html
October 01, 2015 - Injury From Falls
Barrett JA, Bradshaw M, Hutchinson K, et al. … Fall and injury prevention (Chapter 10). In: Hughes RG, ed. … Preventing falls and eliminating injury at Ascension Health. … Eliminating birth trauma at Ascencion Health. Jt Comm J Qual Patient Saf 2007;33:15-24. … Pressure Ulcers
Agency for Healthcare Research and Quality.
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4_combo_bestpracticescover.pdf
June 05, 2016 - Best practices forms exist for the following 14 PSIs:
• PSI 03 Pressure Ulcer Rate
• PSI 05 Retained … Pulmonary Embolism or Deep Vein Thrombosis Rate
• PSI 13 Postoperative Sepsis Rate
• PSI 14 Postoperative Wound … 03 Neonatal Blood Stream Infection Rate
• PDI 01 Accidental Puncture or Laceration Rate
• PDI 02 Pressure … Postoperative Respiratory Failure Rate
• PDI 10 Postoperative Sepsis Rate
• PDI 11 Postoperative Wound … • PSI 17 Birth Trauma Rate―Injury to Neonate: The existing literature on birth trauma
and injury
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www.healthcare411.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 ?
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-200-section-6-b-expert-workgroup.pdf
September 18, 2014 - providers dedicated to skin care and HAPU prevention, e.g., an
institution-wide skin-care council led by wound … stakeholders including CCM, ENT, General Surgery, Plastic
Surgery, Dermatology, Transplant Surgery, Trauma … • Staging of Pressure ulcers would need to be done by a wound care expert vs. the PICU staff nurse … • Evaluation of potential pressure injury is labor intensive and subjective; data cannot be obtained … • Given the severity of illness/injury in PICU patients, 48 or 72 hours seems more reasonable to
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-199-section-6-b-pmcoe-picu-expert-workgroup.pdf
September 18, 2014 - providers dedicated to skin care and HAPU prevention, e.g., an
institution-wide skin-care council led by wound … stakeholders including CCM, ENT, General Surgery, Plastic
Surgery, Dermatology, Transplant Surgery, Trauma … • Staging of Pressure ulcers would need to be done by a wound care expert vs. the PICU staff nurse … • Evaluation of potential pressure injury is labor intensive and subjective; data cannot be obtained … • Given the severity of illness/injury in PICU patients, 48 or 72 hours seems more reasonable to
-
www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-203-section-6-b-workgroup.pdf
September 18, 2014 - providers dedicated to skin care and HAPU prevention, e.g., an
institution-wide skin-care council led by wound … stakeholders including CCM, ENT, General Surgery, Plastic
Surgery, Dermatology, Transplant Surgery, Trauma … • Staging of Pressure ulcers would need to be done by a wound care expert vs. the PICU staff nurse … • Evaluation of potential pressure injury is labor intensive and subjective; data cannot be obtained … • Given the severity of illness/injury in PICU patients, 48 or 72 hours seems more reasonable to
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www.healthcare411.ahrq.gov/patient-safety/settings/hospital/index.html
March 01, 2024 - Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … pressure ulcer prevention practices through an interdisciplinary approach to care. … Pressure Injury Prevention in Hospitals Training Program supports the training of hospital staff on … how to implement AHRQ's Preventing Pressure Ulcers in Hospitals Toolkit. … injury prevention.
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www.healthcare411.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.
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www.healthcare411.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-5/slides.html
September 01, 2017 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … None or no injury: The patient is free of injuries (no signs or symptoms) resulting from a fall … Death: The patient died as a result of injuries sustained from the fall (not from physiologic events … Slide 13: NDNQI Definitions of Fall Injury
None: No injury
Minor: Resulted in bruise, abrasion
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www.healthcare411.ahrq.gov/hai/hac/tools.html
March 01, 2024 - Hospitals
Central line-associated blood stream infections (CLABSI): Tools for Reducing CLABSI
Injuries … Non-ICU Patients With Devices
Obstetrical adverse events: Toolkit for Improving Perinatal Safety
Pressure … ulcers: Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care
Surgical
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www.healthcare411.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-5/guide.html
September 01, 2017 - Resources
CANDOR
Family-Centered Rounds Toolkit
MATCH Toolkit
NICU Toolkit
Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … injuries (no signs or symptoms) resulting from the fall. … treating with ice, cleaning the wound, limb elevation, topical medication, or a bruise or abrasion. … Interventions to prevent falls and fall injuries are tracked.
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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b4_combo_documentationcoding.pdf
March 15, 2016 - PDI 02 Pressure Ulcer Rate (stage
III, IV, Unstageable)
Diagnosis and site of pressure ulcer must … PSI 18,
PSI 19
OB Trauma – Vaginal Delivery
With Instrument
OB Trauma – Vaginal Delivery
Without … X
PDI 11 Postoperative Wound
Dehiscence Rate
X Depth of the wound dehiscence:
external/superficial … X
PSI 14 Postoperative Wound
Dehiscence
X Depth of the wound dehiscence:
external/superficial vs … PSI 18
PSI 19
OB Trauma – Vaginal
Delivery With Instrument
OB Trauma – Vaginal
Delivery Without