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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/prp/prp-wound-care.pdf
September 17, 2020 - formation include diabetes, pressure
injuries, and venous or arterial diseases. … formation include diabetes, pressure
injuries, and venous or arterial diseases. … Haesler E, ed Prevention and Treatment of
Pressure Ulcers/Injuries. … EPUAP/NPIAP/PPPIA: European Pressure
Ulcer Advisory Panel, National Pressure
Injury Advisory Panel … and Pan Pacific
Pressure Injury Alliance; 2019.
32
Abbreviations and Acronyms
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ce.effectivehealthcare.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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ce.effectivehealthcare.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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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.html
October 01, 2014 - Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … If a skin disruption is found, the type of skin injury will need to be identified. … For example is it a skin tear, a pressure ulcer, or moisture-associated skin damage or injury? … Wound care team *
Wound Care Physician
Directs patient care, orders tests and treatments, … medical staff, wound team, and unit staff for pressure ulcer practice
Certified Wound Care
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/slides.html
December 01, 2017 - Use Low Blood Pressure Precautions
Slide 1. … Physical Restraints
Physical restraints increase the likelihood of serious injury resulting from … Consequences of Falls
Serious injury such as hip fracture
Increased risk of death associated … Use Low Blood Pressure Precautions
For residents with low blood pressure:
Sit on edge of bed … https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/slides.html
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/implementation-guide/appendix-c.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 … This webinar tells how to measure fall and fall-related injury rates and prevention practices. … how to implement post-fall huddles, use data from post-fall huddles to reduce falls and fall-related injuries … This webinar describes core evaluation measures of fall and fall injury program components.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/saworksheet.pdf
December 15, 2016 - the On-Time electronic
reports into current workflow to help inform pressure ulcer wound interventions … Ulcer Healing Tool
BWAT – Bates-Jenson Wound Assessment
Tool
None of the above
Other … Injury Alliance’s Prevention and Treatment of Pressure Ulcers
Guidelines
Wound, Ostomy, and Continence … Pressure ulcer debridement?
Selection of dressings based on wound
characteristics? … Wound cleansing?
Assessing the resident for pain?
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevehosp-trans-intakenotes.pdf
June 29, 2017 - disorders/neurological/psychological, gastrointestinal/genitourinary,
endocrine/nutritional/metabolic, wound … infection
Endocrine/Nutritional/Metabolic
Dehydration
Malnutrition
Uncontrolled diabetes
Wound … & Skin
Cellulitis
Edema
Infected wound or decubitus
Jaundice
Rash
Fall-Related Injury … Major injury
Minor injury
Non-Fall-Related Injury
Major injury
Minor injury
Musculoskeletal … Medication reaction
Mental status change
Mental disorder/psychosis
Neoplasm
Pneumonia
Pressure
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ce.effectivehealthcare.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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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu3a.html
October 01, 2014 - Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … After surgery or injury, the favorite may not be possible. … Pressure ulcer prevention and treatment following spinal cord injury: a clinical practice guideline for … National Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Panel (EPUAP). … Wound, Ostomy and Continence Nurses Society.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/Updated-hacreportFInal2017data.pdf
July 01, 2020 - due to procedures,
as well as pressure ulcers/pressure injuries and falls. … ulcers/pressure injuries
increased from 2014 to 2015 and then decreased somewhat from 2015 to 2016 … Ulcers/Pressure
Injuries
Obstetric Adverse Events
Falls
Clostridioides difficile
Infections
Central … Ulcers/
Pressure Injuries
21.7 23.5 22.7 23.0 6%
Surgical Site Infections 2.5 2.5 2.5 2.7 8% … Pressure Ulcers/Pressure Injuries
Surgical Site
Infection
NHSN SSIs for 17 procedures w/CDC SCIP
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ce.effectivehealthcare.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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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK2_T1-Medical_Care_Referral_Form_Word_doc_for_html_only.doc
June 17, 2014 - 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
?
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/put5.html
October 01, 2014 - Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … 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.
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ce.effectivehealthcare.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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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/measure-fall-rates.html
January 01, 2013 - Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … Also, staff may feel pressure to underreport borderline cases because of concern that their unit will … The NDNQI definitions for injury follow:
None—patient had no injuries (no signs or symptoms) resulting … " Minor—resulted in application of a dressing, ice, cleaning of a wound, limb elevation, topical medication … The actual rates of falls with trauma occurring within the hospital may be found on the Medicare data
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/webinars/webinar5_falls_measuringratespractices.pdf
January 01, 2013 - • Level of injury for each fall. … rates such as—
– Falls related to toileting needs
– Falls related to risk factors (medicines, blood
pressure … —
• Collects data after a patient falls
• Seeks to find out if the patient
has immediate risk of injuries … Injury Rates
Data Needed for Fall and Fall-Related Injury Rates
How Often To Calculate Fall and Fall-Related … Injury Rates
How To Calculate Fall and Fall-Related Injury Rates
Improving Data for Fall and Fall-Related
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pukey.html
October 01, 2014 - Patient Safety Resources by Setting
Hospital
Hospital Resources
Preventing Pressure … Injury
Preventing Pressure Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI … What are the best practices in pressure ulcer prevention that we want to use?
4. … How do we measure our pressure ulcer rates and practices?
6. … Tools 4A-4B
Assessing Current Staff Education and Training
Tool 4C
Defining the Role of the Wound
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ce.effectivehealthcare.ahrq.gov/patient-safety/resources/learning-lab/enhancing-long-desc.html
April 01, 2021 - Identify areas of skin at risk for developing pressure ulcers (recently renamed by expert organizations … as pressure injury) from exposure to intense or prolonged pressure, moisture, friction, and shear and … The M-Safety Lab created a patient safety display—a digital bedside display of catheter and wound information … display improved provider's awareness of indwelling urinary catheters, central venous catheters, and pressure … injuries (formerly called "pressure ulcers").
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/menu.html
December 01, 2017 - Effectiveness Reviews
Facilities
Home and Community Resources
Findings Report
Injuries … Wound rounds
4. Weekly wound review meetings
5. Skin rounds
6. … Weekly wound review meetings
4. Internal nutritional review
5. … Wound rounds
2. Weekly nutrition-at-risk meetings
3. … Weekly wound review meetings
5. Restorative care review
6.