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121. Section 6-B, Expert Workgroup Roster and Materials (pdf file)
     www.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

122. Low Tidal Volume Ventilation Guide for Reducing Ventilator-Associated Events in Mechanically Ventilated Patients (pdf file)
     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

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

124. AHRQ National Scorecard on Hospital-Acquired Conditions: Updated Baseline Rates and Preliminary Results 2014-2017 (pdf file)
     www.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

125. Declines in Hospital-Acquired Conditions Save 8,000 Lives and $2.9 Billion in Costs | Agency for Healthcare Research and Quality
     www.ahrq.gov/news/newsroom/press-releases/declines-in-hacs.html
     June 01, 2018 - National efforts to reduce hospital-acquired conditions, such as adverse drug events and injuries from … events, catheter-associated urinary tract infections, central-line associated bloodstream infections, pressure … injuries, and surgical site infections, among others. … Opportunities for further improvement exist for reducing some harms, such as pressure injuries (pressure

126. Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/studies/index.html?page=152
     January 01, 2024 - Uncontrolled hypertension is driven by clinical uncertainty around blood pressure data. … Keywords: Antibiotics, Injuries and Wounds, Medication Nelson HD , Cantor A , Wagner J … did not significantly reduce risk of any fall but did significantly reduce chance of a fall-related injury … These older adults are at increased risk for injury and their recovery is multi-faceted. … Keywords: Elderly, Patient-Centered Healthcare, Injuries and Wounds, Care Coordination, Nursing Homes

127. Introduction to the Quality Indicators Best Practices Tool (pdf file)
     www.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

128. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
     www.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?

129. Indwelling Urinary Catheter Indications Facilitator Notes (doc file)
     www.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

130. Monahrq 41 Measure List (xls file)
     www.ahrq.gov/downloads/monahrq/xls/MONAHRQ_41_Measure_List.xlsx
     February 20, 2014 - ) Dying in the hospital while getting care for a condition that rarely results in death Y 1.0 PSI3 Pressure … cut or tear Y 1.0 PSI16 Transfusion Reaction Volume Blood transfusion reaction Y 2.0 PSI17 Birth Trauma … - Injury to Neonate Newborns with a birth injury or infection N 1.0 PSI18 Obstetric Trauma Rate - Vaginal … Obstetric Trauma Rate - Vaginal Delivery Without Instrument Obstetric injury after vaginal delivery … Kept on the Beta Blockers During the Period Before and After Their Surgery Medicine to lower blood pressure

131. Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/studies/index.html?page=4
     January 01, 2024 - military sexual trauma (MST). … Trauma center trauma-sensitive yoga versus cognitive processing therapy for women veterans with PTSD … severe, and 1.6% were critical injuries. … The most common area of injury was extremities (36.9%), followed by chest (27.4%), head and neck (25.6% … Keywords: Healthcare Cost and Utilization Project (HCUP), Injuries and Wounds, Emergency Department

132. Weight Summary (doc file)
     www.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).

133. Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/studies/index.html?page=360
     January 01, 2024 - from falls and abusive head trauma. … Hospital variation in cervical spine imaging of young children with traumatic brain injury. … Keywords: Brain Injury, Children/Adolescents, Imaging, Hospitals, Practice Patterns Lau BD , … Keywords: Elderly, Injuries and Wounds, Long-Term Care, Nursing Homes, Racial and Ethnic Minorities … Marginal hospital cost of surgery-related hospital-acquired pressure ulcers.

134. Monahrq 40 Measure List (xls file)
     www.ahrq.gov/downloads/monahrq/xls/MONAHRQ_40_Measure_List.xls
     April 23, 2013 - Dying in the hospital while getting care for a condition that rarely results in death Y 0347 1.0 PSI3 Pressure … tear Y 0345 1.0 PSI16 Transfusion Reaction Count Blood transfusion reaction Y 0349 2.0 PSI17 Birth Trauma … - Injury to Neonate Newborns with a birth injury or infection N -- 1.0 PSI18 Obstetric Trauma Rate … - Vaginal Delivery With Instrument Obstetric injury after a vaginal delivery with medical instruments … N -- 1.0 PSI19 Obstetric Trauma Rate - Vaginal Delivery Without Instrument Obstetric injury after vaginal

135. 5. How do we measure our pressure ulcer rates and practices? | Agency for Healthcare Research and Quality
     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.

136. 5. How do we measure our pressure ulcer rates and practices? | Agency for Healthcare Research and Quality
     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.

137. Puh-Assessment (doc file)
     www.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

138. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 (pdf file)
     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

139. Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022: Preliminary Report (pdf file)
     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

140. PCOR Findings Nominated for Consideration | Agency for Healthcare Research and Quality
     www.ahrq.gov/pcor/ahrq-dissemination-and-implementation-initiative/pcor-findings-nominated-for-consideration.html
     March 01, 2021 - Screening (EPICS) Evidence-Based Research and The Need for New Standards of Care in Anesthesia: Cuff Pressure … Monitoring and Proper ETT Sizing To Prevent Injury and Catastrophic Complications Families as Partners … for Stimulant Use Disorder Improving Cardiac Rehabilitation Utilization Just Check It: Home Blood Pressure … Adolescents Aged 12 to 18 Years Secondary Prevention of Fractures in Older Adults Self-Measured Blood Pressure … Using Clinical Data to Predict High-Cost Performance Coding Issues Associated with Hospital-Acquired Pressure