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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange_slides.pptx
June 16, 2017 - Preventing Pressure Injuries in Hospitals
Preventing Pressure Injuries in Hospitals
ADD Name of Hospital … The incidence of pressure injuries increased by 80% from 1995 to 2008. … Most pressure injuries are preventable. … significant reductions in pressure injury rates. … How do you measure pressure injury rates and pressure injury prevention practices?
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/module5_pu_measurement.docx
January 01, 2016 - pressure injuries. … pressure injuries. … If you are not sure a skin lesion is a pressure injury, ask the Wound Care Team or Wound Care Nurse. … ,
· Number of injuries,
· Location of injuries, and
· Stage of the deepest injury. … Can you relate changes in pressure injury rates, including the rates of types of pressure injuries, to
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/module5_pressureinjury-msmt_slides.pptx
July 02, 2008 - Injury rates
15
Measure Only Pressure Injuries
Many types of skin lesions may develop in hospitalized … Pressure injuries are areas of soft tissue damage caused by pressure or pressure and shear. … If not sure, ask the Wound Care Team or Nurse.
16
Measures
Measures used in monitoring pressure injury … # of injuries) 17 patients with any pressure injury
# of patients with a >Stage 2 pressure injury 5 … Count the number and stage of pressure injuries in a month.
24
Stage 3 and 4 Injuries
All pressure
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www.cahps.ahrq.gov/patient-safety/settings/hospital/resource/pressure-injury/index.html
October 01, 2017 - injuries. … Risk Factors for Pressure Injuries: Going Beyond Validated Instruments —AHRQ Pressure Injury Prevention … Device-Related Pressure Injury —AHRQ Pressure Injury Prevention Program Implementation Sharing Webinar … Putting the Nutrition Guidelines into Practice for Pressure Injury Prevention —AHRQ Pressure Injury Prevention … Wound Classification —AHRQ Pressure Injury Prevention Program Training Webinar.
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4a_combo_psi03-pressureulcer-bestpractices.pdf
January 01, 2012 - o Wound edges. … -
terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-
injury/
Staff … Washington, DC: National Pressure Ulcer
5 Tool D.4a
http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury … /
http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury … /
http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4p_combo_pdi02-pressureulcer-bestpractices.pdf
January 01, 2012 - hospital mattress.7,8-11
o Consider the use of foam overlay to reduce occipital pressures in children … /national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-
terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure … /
http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury … /
http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury … Medical device related pressure ulcers in
hospitalised patients. Int Wound J 2010;7:358-65.
7.
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module3/putoolkit_module3_tools.docx
August 31, 2017 - Pressure Ulcer Prevention Toolkit
Pressure Ulcer Prevention Toolkit
Module 3 Tools
3A: Pressure Ulcer … If a skin disruption is found, the type of skin injury will need to be identified. … Since there are many different etiologies of skin wounds and ulcers, differential diagnosis of the skin … For example is it a skin tear, a pressure ulcer, or moisture-associated skin damage or injury? … A wound/ostomy nurse consult revealed he has a slightly pink coccyx area (base of spinal column).
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-203-section-2-tech-specs.pdf
December 14, 2011 - ulcers and deep tissue injury in critically ill and injured children. … Wound assessment and decision making options. … These patients may be admitted with existing wounds and they may develop impaired skin
integrity due … Describes the different types of injuries that critically ill children, including infants, experience … Wound Ostomy and Continence Nurses Society.
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/putoolkit_module5_tools.docx
August 02, 2017 - Pressure Ulcer Prevention Toolkit
Pressure Ulcer Prevention Toolkit
Module 5 Tools
Action Plan Tool … to Measure Pressure Ulcer Rates and Pressure Ulcer Prevention Practices
Tool 5C: Assessing Comprehensive … Assessment
Tool 5D: Assessing Standardized Risk Assessment
Tool 5E: Assessing Care Planning
AHRQ Pressure … stakeholders and staff
Root cause analysis is conducted for each fall with at least moderate level of injury … admission nursing assessment, subsequent nursing progress notes, or any notes specifically documenting pressure
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
November 01, 2021 - • Patient safety concerns such as falls,
pressure injuries, and adverse medication
events were reported … Pressure Injury
Among the pressure injury events (n = 10; 3.3%), several records identified the development … of pressure
injuries due to the interaction between patient pronation and poor patient mobility. … Four records identified
the development of multiple pressure injuries to the lips, tongue, ears, and … The remaining pressure injuries were identified across multiple other contact points such as
the coccyx
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www.cahps.ahrq.gov/patient-safety/about/challenge-competition.html
February 01, 2024 - Toolkit for Improving Quality of Care to decrease Patient Safety Indicator 03 (PSI-03) (reportable pressure … injuries) by 92% and save an estimated $350,000 in avoidable costs. … Implementation focused on MU Health Care’s 390-bed University Hospital, the only level I trauma center … injury rates and PSI-03 among Vizient peers to the top decile over the course of 2 years. … Injuries by 92%."
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www.cahps.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.cahps.ahrq.gov/patient-safety/settings/hospital/resource/about.html
December 01, 2017 - Process
Millions of patients visit hospital emergency departments (EDs) each year for a variety of injuries … Pressure Injury Prevention in Hospitals Training Program
AHRQ developed the Pressure Injury Prevention … injury prevention program. … Preventing Pressure Ulcers in Hospitals
Each year, more than 2.5 million people in the United States … develop pressure ulcers.
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www.cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module3/module3_tools.docx
January 01, 2012 - · Identify all visible injuries and initiate first aid; for example, cover wounds.
· Assist patient … hydration).
· Clean and dress any wounds … · Identify all visible injuries and initiate first aid; for example, cover wounds. … · Clean and dress any wounds.
· Arrange medical review. … Describe injuries; check all that apply
Injury
Yes
No
Site of Injury
Abrasion/bruise/laceration
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www.cahps.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.cahps.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.cahps.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.cahps.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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www.cahps.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.cahps.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 ?