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patientregistry.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module2/module2_managingchange_slides.pptx
November 20, 2014 - Relationships
Unit-Based Team
Staff on the unit who provide daily care to patients, including skin and pressure … ulcer assessment and care planning
Wound Care Team
Interdisciplinary group
of experts who provide … patient/family
Implementation Team
Interdisciplinary team charged with designing and implementing pressure … ulcer change project
13
Assess Current Pressure Injury Processes
Understand current
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patientregistry.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module4/module4_pu-implementation.docx
August 31, 2017 - Ulcer Prevention Program – AHRQ Pressure Injury Prevention Program Training Webinar
Materials Checklist … Ulcer Knowledge Test and staff training needs.
· Alert the information technology (IT) representative … Ulcer Prevention Program. … Ulcer Knowledge Test is administered to staff to help determine their educational needs. … Instructor’s Note: Tool 2H: Pressure Ulcer Baseline Assessment, which is a shorter knowledge test, is
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patientregistry.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b3a_combo_chartsforpresentations.xlsx
January 01, 2006 - Remove the
"Pressure Ulcers" part of the title and revise it to reflect your PSI or IQI of interest … Remove the
"Pressure Ulcers" part of the title and revise it to reflect your PSI or IQI of interest … Remove the
"Pressure Ulcers" part of the title and revise it to reflect your PSI or IQI of interest … Remove the
"Pressure Ulcers" part of the title and revise it to reflect your PSI or IQI of interest … Remove the
"Pressure Ulcers" part of the title and revise it to reflect your PSI or IQI of interest
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patientregistry.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/b4_combo_documentationcoding.pdf
March 15, 2016 - ulcers). … PDI 02 Pressure Ulcer Rate (stage
III, IV, Unstageable)
Diagnosis and site of pressure ulcer must … PSI 03 Pressure Ulcer Encourage providers to document pressure ulcers as part of the admission H&P to … Provider must document the site of pressure ulcer; the stage of
the ulcer can be documented and coded … PSI 03 Pressure Ulcer X “Unspecified stage” and “unstageable”
are not interchangeable terms; the code
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patientregistry.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 … Neonatal Blood Stream Infection Rate
Pediatric PDI 01 Accidental Puncture or Laceration Rate
PDI 02 Pressure … Ulcer Rate
PDI 05 Iatrogenic Pneumothorax Rate
PDI 06 RACHS-1 Pediatric Heart Surgery Mortality
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patientregistry.ahrq.gov/patient-safety/settings/hospital/resource/about.html
December 01, 2017 - Hospitals Training Program to support the training of hospital staff on how to implement AHRQ’s Preventing Pressure … Ulcers in Hospitals Toolkit . … Preventing Pressure Ulcers in Hospitals
Each year, more than 2.5 million people in the United States … develop pressure ulcers. … The aim of this toolkit is to assist hospital staff in implementing effective pressure ulcer prevention
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patientregistry.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/2014FinalHACreport4Web-13Dec2016.pdf
December 01, 2016 - ulcers, and about 16 percent from catheter-
associated urinary tract infections (CAUTIs) (Exhibit 4) … Most of the deaths averted
occurred as a result of reductions in the rates of pressure ulcers and adverse … Ulcers
MPSMS
(2014)
Hospital-Acquired
Pressure Ulcers
1,010,000 30.9
Surgical Site
Infections … Ulcers were modified in 2012 from earlier higher projections. … ulcer, rather than on the incremental cost due to the HAC.
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patientregistry.ahrq.gov/patient-safety/settings/hospital/index.html
March 01, 2024 - Ulcers in Hospitals
Re-Engineered Discharge Toolkit
QI Toolkit
Venous Thromboembolism … Preventing Pressure Ulcers in Hospitals is a toolkit that assists hospital staff in implementing effective … pressure ulcer prevention practices through an interdisciplinary approach to care. … Hospitals Training Program supports the training of hospital staff on how to implement AHRQ's Preventing Pressure … Ulcers in Hospitals Toolkit.
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patientregistry.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module3/module3_pu-bestpractices_slides.pptx
November 20, 2014 - documentation forms
Lacking ways to empower staff to report abnormal skin findings:
Consider using Tool 3C: Pressure … Ulcer Identification Pocket Pad.
11
ID Pocket Pad
Tool 3C
12
Practice Insight
Or note location … 27
Practice Insight
EHR Care Plans Triggered Based on Risk Assessment
Braden Scale for Predicting Pressure … Sore Risk
SENSORY PERCEPTION 1.
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patientregistry.ahrq.gov/hai/pfp/2015-interim.html
December 01, 2016 - About 42 percent of this reduction is from adverse drug events, about 23 percent from pressure ulcers … Ulcers
MPSMS (2015)
Hospital-Acquired Pressure Ulcers
1,190,000
36.3
Surgical Site Infections … Ulcers were modified in 2012 from earlier higher projections. … ulcer, rather than on the incremental cost due to the HAC. … [7] The AHRQ-developed pressure ulcer toolkit and falls toolkit are online.
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patientregistry.ahrq.gov/npsd/data/dashboard/index.html
October 01, 2023 - Pressure Ulcer 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.
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patientregistry.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/module5_pressureinjury-msmt_slides.pptx
July 02, 2008 - Care plan addressing every deficit on pressure ulcer risk factor assessment has been developed and is … 46
Next Steps
Over the next several weeks, we will meet weekly to refine your Action Plan for the Pressure … Ulcer Prevention Program.
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patientregistry.ahrq.gov/hai/pfp/2014-final.html
January 01, 2018 - ulcers, and about 16 percent from catheter-associated urinary tract infections (CAUTIs) ( Exhibit 4 … Most of the deaths averted occurred as a result of reductions in the rates of pressure ulcers and adverse … Ulcers
MPSMS (2014)
Hospital-Acquired Pressure Ulcers
1,010,000
30.9
Surgical Site Infections … Ulcers were modified in 2012 from earlier higher projections. … ulcer, rather than on the incremental cost due to the HAC.
1 AHRQ Partnership for Patients Web page
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patientregistry.ahrq.gov/hai/pfp/methods.html
December 01, 2017 - Adverse Events
PSI
OB Trauma in Vaginal Delivery With (PSI 18) and Without Instrument (PSI 19)
Pressure … Ulcers
MPSMS
Hospital-Acquired Pressure Ulcers
Surgical Site Infections
NHSN
SSIs combined … Tract Infections
18.80
25.58
0.73
Falls
In-Hospital Patient Falls
12.25
14.56
0.84
Pressure … Ulcers
Hospital-Acquired Pressure Ulcers
53.03
62.45
0.85
VAP
Ventilator-Associated Pneumonia … Ulcer
MPSMS
Hospital-Acquired Pressure Ulcers
1,317,211
32,750,000
40.220
Surgical Site
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patientregistry.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/Updated-hacreportFInal2017data.pdf
July 01, 2020 - 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%
Surgical Site Infections 2.5 2.5 2.5 2.7 8% … Ulcer MPSMS Hospital-Acquired Pressure Ulcers/Pressure Injuries
Surgical Site
Infection
NHSN SSIs … Ulcer
MPSMS Hospital-
Acquired
Pressure
647,096 21.75 699,790 23.52 676,834 22.75 682,984 22.96
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patientregistry.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/natlhacratereport-rebaselining2014-2016_0.pdf
January 01, 2016 - ulcers and falls. … ulcers increased from 2014 to 2016. … Ulcer MPSMS Hospital-Acquired Pressure Ulcers
Surgical Site
Infection
NHSN SSIs for 17 procedures … Ulcer
MPSMS Hospital-Acquired Pressure Ulcers 643,230 21.62
Surgical
Site
Infection
NHSN SSIs … Ulcer
MPSMS Hospital-Acquired
Pressure Ulcers
0643,23 21.62 708,301 23.81 704,906 23.69
Surgical
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patientregistry.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module1/module1_pu-whychange.docx
July 12, 2017 - Ulcers in Hospitals Toolkit training. … Preventing in-facility pressure ulcers. … Ulcers in Hospitals Toolkit. … Preventing in-facility pressure ulcers. … Preventing in-facility pressure ulcers.
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patientregistry.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 … 03 Neonatal Blood Stream Infection Rate
• PDI 01 Accidental Puncture or Laceration Rate
• PDI 02 Pressure … Ulcer Rate
• PDI 03 Retained Surgical Item or Unretrieved Device Fragment Count
• PDI 05 Iatrogenic
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patientregistry.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hacreport-2019.pdf
January 01, 2019 - 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 … Ulcer MPSMS Hospital-Acquired Pressure Ulcers/Pressure Injuries
Surgical Site
Infection
NHSN SSIs … Ulcer
MPSMS Hospital-
Acquired
Pressure
647,096 21.75 699,790 23.52 676,834 22.75 682,984 22.96
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patientregistry.ahrq.gov/prevention/guidelines/archive.html
July 01, 2018 - Pressure Ulcer Prevention Clinical Guide / Quick Reference Guide
Consumer Version: English / Spanish … Pressure Ulcer Treatment Clinical Guide / Quick Reference Guide
Consumer Version: English / Spanish