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61. AHRQ National Scorecard on Hospital-Acquired Conditions: Updated Baseline Rates and Preliminary Results 2014-2017 (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hacreport-2019.pdf
    January 01, 2019 - 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 21.7 23.5 22.7 23.0 6% 17.4 Surgical Site Infections 2.5 2.5 2.5 … Pressure Ulcers/Pressure Injuries Surgical Site Infection NHSN SSIs for 17 procedures w/CDC SCIP … Ulcers/Pressure Injuries Surgical Site Infection NHSN SSIs for 17 procedures w/CDC SCIP+5

62. Initial Risk Assessment for Immobility-Related Pressuer Ulcer Within 24 Hours of Pediatric Intensive Care Unit (PICU) Admission (pdf file)
    ce.effectivehealthcare.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.

63. Introduction to the Quality Indicators Best Practices Tool (pdf file)
    ce.effectivehealthcare.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

64. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/ltvv-factsheet.docx
    January 01, 2017 - Emerging evidence links protective tidal ventilation to decreased incidence of acute lung injury (ALI … Use at least 5 cm H2O positive end expiratory pressure (PEEP). Why wait? … not yet have ARDS and particularly those with risk factors to prevent progressive development of lung injury … Ventilator-associated lung injury in patients without acute lung injury at the onset of mechanical ventilation … What tidal volumes should be used in patients without acute lung injury?

65. Indwelling Urinary Catheter Indications Facilitator Notes (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/urinary-catheter-indications-notes.docx
    April 01, 2022 - Knight is a 25-year-old man who was admitted with acute urinary retention due to a spinal cord injury … the last row on this table), urology consultation should be considered for prostatitis and urethral trauma … Of note, catheters are appropriate in the case of urinary incontinence with open wounds if the urine … cannot be kept from contaminating the wounds using other strategies. … . · Not all open sacral/hip wounds require an indwelling catheter if the wound can be kept clean by other

66. Chapter 3. Data Collection and Analysis Using TRIPS | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man3.html
    December 01, 2017 - Include alarms attached to a wheelchair and consider all types of pressure or position change alarms … Item 14 asks if the resident's blood pressure was taken after the fall. … If so, the nurse should check the injury site and which side of the resident's body sustained the injury … across from the injury site and specify the type of injury. … https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man3.html

67. Tool 3F: Orthostatic Vital Sign Measurement | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/orthostatic-vital-sign.html
    January 01, 2013 - Injury Preventing Pressure Ulcers in Hospitals Re-Engineered Discharge Toolkit QI … Have possible spinal injuries. Have lower extremity or pelvic fractures. … Blood pressure cuff of correct size for the patient. … Check sitting blood pressure and pulse. … Support the forearm at heart level when taking the blood pressures to prevent inaccurate measurement.

68. Weight Summary (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/functional-specifications.docx
    February 10, 2014 - The vendor determines the methodology to assign unique IDs to resident wounds. … : · 1, 2, 3, 4, U (Unstageable) or Suspected Deep Tissue Injury (sDTI) Most Recent Assess Ulcer Stage … Display as 1, 2, 3, 4, U (Unstageable) or Suspected Deep Tissue Injury (sDTI) Ulcer Origin Wound Assessment … : Stage 1, 2, 3, 4, U (Unstageable) or Suspected Deep Tissue Injury (sDTI) Ulcer Origin Wound Assessment … Display as 1, 2, 3, 4, U (Unstageable) or Suspected Deep Tissue Injury (sDTI).

69. Agency for Healthcare Research and Quality
    ce.effectivehealthcare.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

70. PMCoE PICU Expert Work Group and Leadership Team Roster (pdf file)
    ce.effectivehealthcare.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

71. Section 6-B, Expert Workgroup Roster and Materials (pdf file)
    ce.effectivehealthcare.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

72. Section 6-B, PMCoE PICU Expert Workgroup and Leadership Team Roster (pdf file)
    ce.effectivehealthcare.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

73. Puh-Assessment (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-assessment.docx
    April 08, 2016 - AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Healing On-Time Pressure Ulcer Assessment … The On-Time Pressure Ulcer Assessment incorporates elements from the Bates-Jensen Wound Assessment Tool … 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. … Stage 3 Stage 4 Unstageable Suspected Deep Tissue Injury

74. AHRQ’s Safety Program for Nursing Homes: On-Time Prevention | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/index.html
    November 01, 2017 - Effectiveness Reviews Facilities Home and Community Resources Findings Report Injuries … Adverse Events Pressure Ulcer Prevention . Pressure Ulcer Healing .

75. Module 5: How To Measure Fall Rates and Fall Prevention Practices—Slide Presentation | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.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

76. PowerPoint Presentation
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/prevhosp/prevhosp-reports-slides.pptx
    November 30, 2013 - Major injury Minor injury Non-Fall-Related Injury Major injury Minor injury Musculoskeletal Joint pain … & Skin Cellulitis Edema Infected wound or decubitus Jaundice Rash Treatment Unavailable at Transferring … & Skin Injury: Fall Related Injury : Non-Fall Related Musculoskeletal Abnormal Labs or Anemia Fever/ … or Skin Fall-Related Injury Non-Fall-Related Injury Abnormal Lab Results Fever / Possible Infection … Disease Asthma Circulatory Problems Hypertension or Renal Failure Gastroenteritis Angina Pectoris Falls /Trauma

77. Puh-Assessment (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-assessment.pdf
    December 15, 2016 - 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

78. Pressure Ulcer Dashboard | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/npsd/data/dashboard/pressure-ulcer.html
    October 01, 2023 - of Patient Safety Databases (NPSD) Data Reporting Tools NPSD Dashboards Pressure … SHARE: Go to NPSD Dashboards Pressure … This dashboard details the documentation of increased risk for pressure ulcer following a risk assessment … ; and the timing of the first risk assessment for reported pressure ulcers or sDTIs. … https://www.ahrq.gov/npsd/data/dashboard/pressure-ulcer.html   Back to

79. Appendix B11: Fall Interventions Plan | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb6.html
    February 01, 2023 - Patient Safety Patient Safety Resources by Setting Long Term Care Resources Injuries … Orthostatic Hypotension Risk Factor: Unsafe Behavior Selected Interventions __ Low blood pressure … __ Behavior management strategies __ Increase assistance and surveillance    __ Position or pressure … _ Increase activities involvement    __ Other ___________________________ __ Reduce risk of injury … https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb6.html

80. Early Mobility in the Intensive Care Unit: Slide Presentation | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.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. … sessions (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