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effectivehealthcare.ahrq.gov/get-involved/nominated-topics/diagnosis-and-management-pressure-ulcer-the-questions-we-would-like-answered-by-this-evidence-review-are-the-following-1-how-can-we-identify-patients-at-risk-for-pressure-ulcers-in-the-hospital-or-long-term-care-setting-and-
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psnet.ahrq.gov/issue/avoidable-sepsis-infections-send-thousands-seniors-gruesome-deaths
March 27, 2019 - nursing homes such as poor staffing and communication with families that contribute to unmanaged pressure … ulcers and sepsis that result in hospital admissions and death. … A WebM&M commentary discussed a case involving a patient who had a pressure ulcer and sepsis in long-term
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/resources/PS-tools-2024.pdf
January 01, 2024 - Web: ahrq.gov/goinghomeguide/
Pressure Ulcers
Preventing Pressure Ulcers: A Toolkit for Improving … Quality of Care in Hospitals assists hospital staff
in implementing effective pressure ulcer prevention … Ulcers in
Hospitals Toolkit. … Web: ahrq.gov/pressureinjuryprevtraining
Safety Program for Nursing
Homes: On-Time Pressure
Ulcer … ulcers.
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hcup-us.ahrq.gov/datainnovations/clinicaldata/ExampleofUsingPOA-CMSHACsusingall-payerdata.jsp
August 01, 2011 - ulcers (66 percent). … ulcer and 18 percent had manifestations of poor glycemic control CMS HACs. … Stage 3 and 4 pressure ulcers: private insurance: 0.32; Medicaid: 1.25. … Stage 3 and 4 pressure ulcers: 45-64 year olds: 1.44; 65-84 year olds: 2.18; 85 years and older: 2.57 … Ulcers are:
707.23, pressure ulcer, stage III
707.24, pressure ulcer, stage IV
The ICD-9-
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psnet.ahrq.gov/node/45533/psn-pdf
November 02, 2016 - improvement project in the United Kingdom to
address four patient safety issues: venous thromboembolism, pressure … ulcers, catheter–associated urinary
tract infections, and falls. … preventability-hospital-acquired-venous-thromboembolism
https://psnet.ahrq.gov/issue/organisational-strategies-implement-hospital-pressure-ulcer-prevention-programmes-findings
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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
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psnet.ahrq.gov/node/45202/psn-pdf
October 08, 2016 - psnet.ahrq.gov/issue/towards-international-consensus-patient-harm-perspectives-pressure-injury-
policy
Pressure … ulcers are never events that continue to occur, despite potential repercussions on reimbursement. … towards-international-consensus-patient-harm-perspectives-pressure-injury-policy
https://psnet.ahrq.gov/issue/preventing-facility-pressure-ulcers-patient-safety-strategy-systematic-review
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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.
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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
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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
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hcup-us.ahrq.gov/reports/statbriefs/sb96.pdf
September 01, 2010 - ■ Among the nine selected potentially
preventable hospitalizations, stays for
pressure ulcers had … Data are also presented on
injurious falls and pressure ulcers, two conditions that are highly relevant … Stays principally for pressure ulcers were relatively rare among other Medicare beneficiaries (49 stays … ulcers (32 percent of all dual eligible pressure ulcer stays), asthma (30
percent of all dual eligible … Data are also presented on pressure ulcers and injurious falls, two conditions that are not from the
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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
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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
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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
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digital.ahrq.gov/health-it-tools-and-resources/ahrq-funded-project-resources-archives/lessons-learned-successes-and
January 01, 2023 - This review pertains to a project that standardized pressure ulcer data elements and electronic documentation
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/a2_pdi_boardpresentation.pptx
October 01, 2015 - Ulcer Rate
PDI 03 Retained Surgical Item or Unretrieved Device Fragment Count
PDI 05 Iatrogenic Pneumothorax … ulcer)
Denominator = population at risk (e.g., hospitalized patients)
Observed rate = numerator/denominator … ulcer in any secondary diagnosis field among cases meeting the inclusion and exclusion rules for the … Several exclusions (e.g., length of stay <5 days, principal diagnosis of pressure ulcer). … An Example: Pressure Ulcer (PDI 02)
Tool A.2 Slide ‹#›
Pediatric Toolkit for Using the AHRQ Quality
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psnet.ahrq.gov/issue/assessment-nursing-home-reporting-major-injury-falls-quality-measurement-nursing-home-compare
August 24, 2022 - Download Citation
Related Resources From the Same Author(s)
Accuracy of pressure … ulcer events in US nursing home ratings. … September 14, 2022
Accuracy of pressure ulcer events in US nursing home ratings.
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digital.ahrq.gov/population/individuals-end-life-care-needs
January 01, 2023 - Project Name
Health Information Technology in the Nursing Home
Stage 2 pressure … ulcer healing in nursing homes. … Stage 2 pressure ulcer healing in nursing homes. J Am Geriatr Soc 2008 Jul;56(7):1252-8.
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psnet.ahrq.gov/node/44845/psn-pdf
July 01, 2016 - room hospital accommodation associated with
differences in healthcare-associated infection, falls,
pressure … ulcers or medication errors? … room hospital accommodation associated with differences in
healthcare-associated infection, falls, pressure … ulcers or medication errors? … Falls,
pressure ulcers, and Clostridium difficile infections increased in the older patients' ward after
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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.