-
www.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.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/contentcalls/small_hospitals-slides/Small-and-Rural-Critical-Access-Hospitals-July-19-2011-508.ppt
January 01, 2011 - Ulcers
on the Unit
Develop a team -- Include staff nurses
Gather baseline data
Have first team meeting … ; educate on science of safety, data, goals
Research the evidence-based practices that eliminate pressure … ulcers
The CUSP/Improvement Intervention
Alt text
CUSP
1. … Provide feedback, investigate each case
Eliminate Stage 3, 4 Pressure Ulcers
1. … Standardized pressure ulcer risk assessment
3.
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab11.html
February 01, 2023 - Overall
Yes
14,177
28,212
18,788
9,372
No
19,380
19,211
19,521
20,716
Pressure … Ulcer
Yes
2,730
11,421
3,150
1,840
No
3,506
3,461
3,696
3,731
Injurious … Composite: ACSC Overall
50,783
40,549
9,972
20,001
18,997
10,923
20,108
19,218
Pressure … Ulcer
12,696
8,204
883
4,475
3,415
1,644
3,729
3,459
Injurious Falls
469
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19e.html
March 01, 2023 - 6,924
7,208
Composite: ACSC Overall
20,218
17,976
20,084
17,046
19,215
17,075
Pressure … Ulcer
3,124
2,492
3,084
2,232
2,819
2,301
Injurious Falls
297
218
268
212 … 6,471
8,020
7,037
6,881
Composite: ACSC Overall
17,757
20,393
19,476
16,171
Pressure … Ulcer
2,658
2,731
2,846
2,191
Injurious Falls
239
247
236
260
Notes
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19d.html
March 01, 2023 - 3,685
2,830
Composite: ACSC Overall
6,401
5,144
6,083
4,903
6,049
4,408
Pressure … Ulcer
1,887
1,225
1,703
1,115
1,573
1,084
Injurious Falls
88
67
77
69
79 … 3,503
3,242
3,720
2,668
Composite: ACSC Overall
5,768
5,111
6,087
4,163
Pressure … Ulcer
1,543
1,223
1,589
999
Injurious Falls
77
67
77
63
Notes:
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19g.html
March 01, 2023 - 12,136
Composite: ACSC Overall
32,463
23,973
25,306
28,599
25,757
29,466
Pressure … Ulcer
4,845
3,916
4,034
4,473
4,279
3,822
Injurious Falls
694
450
520
525 … 12,380
10,227
12,540
Composite: ACSC Overall
24,470
31,390
25,983
29,126
Pressure … Ulcer
4,169
4,242
4,328
3,449
Injurious Falls
498
580
497
653
Notes
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19c.html
March 01, 2023 - 4,435
3,912
Composite: ACSC Overall
14,847
12,685
13,750
12,591
14,039
10,413
Pressure … Ulcer
3,144
1,922
2,311
2,203
2,306
2,125
Injurious Falls
114
46
72
55
58 … 4,284
4,429
4,470
3,725
Composite: ACSC Overall
13,151
13,631
14,134
9,746
Pressure … Ulcer
2,071
2,713
2,345
1,945
Injurious Falls
68
59
59
92
Notes:
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19b.html
March 01, 2023 - 8,456
8,118
Composite: ACSC Overall
25,741
19,330
21,845
20,450
21,888
19,402
Pressure … Ulcer
4,659
3,573
4,127
3,570
4,133
3,186
Injurious Falls
476
335
399
346 … 8,162
8,798
8,469
8,012
Composite: ACSC Overall
20,856
22,154
22,042
18,402
Pressure … Ulcer
4,014
3,688
4,171
2,882
Injurious Falls
384
365
381
366
Notes
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19.html
March 01, 2023 - 7,387
7,164
Composite: ACSC Overall
23,095
17,584
19,743
18,467
19,802
17,363
Pressure … Ulcer
4,291
3,139
3,655
3,225
3,647
2,945
Injurious Falls
388
259
314
272 … 7,138
7,741
7,427
6,977
Composite: ACSC Overall
18,821
20,092
19,980
16,312
Pressure … Ulcer
3,501
3,452
3,695
2,655
Injurious Falls
301
291
297
299
Notes
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/tab19f.html
March 01, 2023 - 5,990
6,632
Composite: ACSC Overall
23,094
19,763
20,681
21,282
21,204
19,420
Pressure … Ulcer
6,082
4,303
4,919
4,872
4,765
5,535
Injurious Falls
173
119
141
130 … 5,861
6,673
6,037
6,455
Composite: ACSC Overall
20,343
22,153
21,427
18,076
Pressure … Ulcer
4,499
5,846
4,870
5,072
Injurious Falls
140
131
131
168
Notes
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hac-cost-report2017.pdf
November 01, 2017 - Pressure Ulcers A new pressure ulcer developed during a stay, or Stage 1 or 2 pressure ulcer(s)
present … Ulcers
( (“Pressure Ulcer” [MeSH] OR “Pressure Ulcer” [tiab] OR “Bedsore” [tiab] OR “Bed Sores” [tiab … ] OR “Decubitus
Ulcer” [tiab] OR “Pressure Sore” [MeSH] OR “Pressure Sore” [tiab] OR “Suspected Deep … Tissue Injury” [tiab] OR
“Pressure Ulcer” [MeSH] OR “Pressure Ulcer” [tiab] OR “osteomyelitis” [MeSH … Ulcer
All hospitalized patients
who are at risk to have
pressure ulcer
0.018c 2.42–5.06 3.26
-
www.ahrq.gov/sites/default/files/publications2/files/hac-cost-report2017.pdf
November 01, 2017 - Pressure Ulcers A new pressure ulcer developed during a stay, or Stage 1 or 2 pressure ulcer(s)
present … Ulcers
( (“Pressure Ulcer” [MeSH] OR “Pressure Ulcer” [tiab] OR “Bedsore” [tiab] OR “Bed Sores” [tiab … ] OR “Decubitus
Ulcer” [tiab] OR “Pressure Sore” [MeSH] OR “Pressure Sore” [tiab] OR “Suspected Deep … Tissue Injury” [tiab] OR
“Pressure Ulcer” [MeSH] OR “Pressure Ulcer” [tiab] OR “osteomyelitis” [MeSH … Ulcer
All hospitalized patients
who are at risk to have
pressure ulcer
0.018c 2.42–5.06 3.26
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/faqs/faq-wound-cleaning.docx
March 01, 2022 - CHG in clinical trials with the explicit instructions to clean superficial wounds and stage 1 and 2 decubitus … ulcers. … CHG can be applied to any superficial wound, including stage 1 and 2 decubitus ulcers, friable skin/rashes
-
www.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 … Ulcers
Hospital-Acquired Pressure Ulcers
53.03
62.45
0.85
VAP
Ventilator-Associated … Vaginal Delivery With (PSI 18) and Without Instrument (PSI 19)
82,300
32,750,000
2.513
Pressure … Ulcer
MPSMS
Hospital-Acquired Pressure Ulcers
1,317,211
32,750,000
40.220
Surgical Site
-
www.ahrq.gov/sites/default/files/wysiwyg/npsd/Data_Submission_Dashboard_Data_2024.xlsx
January 01, 2024 - 10.5%
Surgery or Anesthesia CFER-H V1.1 25,264 9.4%
Surgery or Anesthesia CFER-H V1.2 132,724 5.2%
Pressure … Ulcer CFER-H V1.1 16,374 6.1%
Pressure Ulcer CFER-H V1.2 124,964 4.9%
Device or Medical/Surgical Supply
-
www.ahrq.gov/hai/cusp/toolkit/content-calls/small-hospitals/slides.html
October 01, 2014 - Walking Through the Process
Eliminate Hospital-Acquired Stage 3/4 Pressure Ulcers on the Unit … meeting; educate on science of safety, data, goals
Research the evidence-based practices that eliminate pressure … ulcers
Return to Contents
Slide 13. … unit
Implement teamwork tools
Provide feedback, investigate each case
Eliminate Stage 3, 4 Pressure … Ulcers
Comprehensive skin assessment
Standardized pressure ulcer risk assessment
Care planning
-
www.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
-
www.ahrq.gov/topics/injuries-and-wounds.html
Topic: Injuries and Wounds
AHRQ wound research centers on pressure ulcers.
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/findings/find4.html
December 01, 2012 - All but two of the indicators (Pressure Ulcer and Injurious Falls) build on existing AHRQ Prevention … Pressure Ulcer.
Injurious Falls.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/pfphac.pdf
September 01, 2014 - Obstetric 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 for 17 procedures … Ulcers
Hospital-Acquired Pressure
Ulcers
53.03 62.45 0.85
VAP Ventilator-Associated
Pneumonia … Discharges
(HCUP)
2010 PFP
Measured
HACs per
1,000
Discharges
Pressure Ulcer MPSMS Hospital-Acquired … Pressure Ulcers 1,317,211 32,750,000 40.220
Surgical Site
Infection
NHSN SSIs for 17 procedures in