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www.qualitymeasures.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab15.html
February 01, 2023 - Effectiveness Reviews
Facilities
Home and Community Resources
Findings Report
Injuries … Conditions
8,997
6,894
8,597
6,888
Composite: ACSC Overall
22,706
18,412
21,951
18,376
Pressure … Conditions
4,856
4,215
4,625
4,246
Composite: ACSC Overall
14,792
13,022
14,282
13,066
Pressure … Conditions
3,483
3,293
3,410
3,308
Composite: ACSC Overall
5,671
5,408
5,482
5,469
Pressure … Conditions
3,483
3,293
3,410
3,308
Composite: ACSC Overall
5,671
5,408
5,482
5,469
Pressure
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www.qualitymeasures.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.qualitymeasures.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.qualitymeasures.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.qualitymeasures.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.qualitymeasures.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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www.qualitymeasures.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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www.qualitymeasures.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
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www.qualitymeasures.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.qualitymeasures.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.qualitymeasures.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
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www.qualitymeasures.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
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www.qualitymeasures.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.
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www.qualitymeasures.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.qualitymeasures.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
-
www.qualitymeasures.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.qualitymeasures.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.qualitymeasures.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab16.html
December 01, 2012 - Effectiveness Reviews
Facilities
Home and Community Resources
Findings Report
Injuries … 7,115
9,257
6,892
Composite: ACSC Overall
17,570
24,934
20,620
17,662
23,518
18,337
Pressure … 10,435
7,884
Composite: ACSC Overall
19,406
27,524
22,656
19,821
25,958
20,278
Pressure … 3,002
3,777
3,248
Composite: ACSC Overall
5,094
6,963
6,484
4,695
6,310
5,297
Pressure … 13,343
9,904
Composite: ACSC Overall
24,097
33,576
25,800
27,762
32,363
25,065
Pressure
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www.qualitymeasures.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 .
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www.qualitymeasures.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