Preventing Pressure Ulcers In Hospitals
Each year, more than 2.5 million people in the United States develop pressure ulcers. These skin lesions bring pain, associated risk for serious infection, and increased health care utilization. The aim of this toolkit is to assist hospital staff in implementing effective pressure ulcer prevention practices through an interdisciplinary approach to care.
Prepared by: Dan Berlowitz, M.D., M.P.H. Bedford VA Hospital and Boston University School of Public Health Carol VanDeusen Lukas, Ed.D. VA Boston Healthcare System and Boston University School of Public Health Victoria Parker, Ed.M. D.B.A. Andrea Niederhauser, M.P.H. Jason Silver, M.P.H. and Caroline Logan, M.P.H. Boston University School of Public Health Elizabeth Ayello, Ph.D., RN, APRN, BC, CWOCN, FAPWCA, FAAN, Excelsior College School of Nursing, Albany, New York and Karen Zulkowski, D.N.S., RN, CWS, Montana State University-Bozeman.
The Financial Case For Prioritizing Prevention
In the United States, PIs are scored by stage, and nearly half of all PIs can be categorized as late-stage , according to the Ostomy/Wound Management study. Late-stage PIs take months or longer to heal and require additional resources to treat infectious complications. Some consequences that lead to additional cost include readmissions, increased lengths of stay and clinical resources like antibiotics, diagnostic tests, procedures and use of wound care disposables. In 2007, CMS estimated that each late-stage PI added $43,180 in costs to a hospital stay, while other estimates exceed $100,000.c
Hospitals also face financial burdens due to CMS regulations around HAPIs. They may receive no payment for incremental treatment costs of HAPIs, which CMS and many commercial health plans consider preventable. Hospitals with higher readmission rates and hospital acquired conditions , commonly seen in HAPI patients, are penalized by various CMS Quality Care Programs. Nearly 80% of hospitals receive some form of penalty.d
Reviewinternational Comparison Of Pressure Ulcer Measures In Long
Pressure ulcer rates from point prevalence surveys are often used in long-term care.
Four measurement systems spanning 28 countries have been compared.
Currently the comparability of the four measurement systems is limited.
It could be improved by introducing some changes to the study protocols.
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What Measures Are Included In The Hac Reduction Program
The following measures are included in the HAC Reduction Program, grouped here by category:
Patient Safety and Adverse Events Composite
We calculate the CMS PSI 90 using Medicare Fee-for-service claims. The CMS PSI 90 measure includes:
- PSI 03 Pressure Ulcer Rate
- PSI 06 Iatrogenic Pneumothorax Rate
- PSI 08 In Hospital Fall with Hip Fracture Rate
- PSI 09 Perioperative Hemorrhage or Hematoma Rate
- PSI 10 Postoperative Acute Kidney Injury Requiring Dialysis Rate
- PSI 11 Postoperative Respiratory Failure Rate
- PSI 12 Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate
- PSI 13 Postoperative Sepsis Rate
- PSI 14 Postoperative Wound Dehiscence Rate
- PSI 15 Abdominopelvic Accidental Puncture/Laceration Rate
Centers for Disease Control and Prevention’s National Healthcare Safety Network healthcare-associated infection measures
We calculate the following HAI measures using data on infections taken from charts, reports, and other sources and reported to the National Healthcare Safety Network:
- Central Line-Associated Bloodstream Infection
- Catheter-Associated Urinary Tract Infection
- Surgical Site Infection
- Methicillin-resistant Staphylococcus aureus bacteremia
- Clostridium difficile Infection
Pressure Ulcer Prevalence Varied By Age Sex And Length Of Time Since Admission To The Nursing Home But Not By Race
Residents aged 64 years and under were more likely than older residents to have pressure ulcers . Pressure ulcers were more common in males than in females . Residents in nursing homes for 1 year or less were more likely to have pressure ulcers than those with a longer length of stay . There was no significant difference between white and nonwhite populations with respect to having pressure ulcers.
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Enhancing Healthcare Team Outcomes
When pressure injuries develop, systems should be able to identify issues leading to their occurrence and implement methods for resolving these issues. There is increasing evidence that multidisciplinary interventions aimed to prevent pressure injuries in both long-term care facilities and acute care settings can have success in decreasing the prevalence or incidence rates of pressure injuries. This can include clinical staff becoming more involved at the patient care level, bundling of care practices, and incorporating them into routine care, making documentation of pressure injury prevention practices more visible, and educating all staff on a regular basis. In terms of implementing these interventions, the more often new care practices are merged with usual care practices, the more likely staff will be to perform them on a consistent basis with better outcomes overall.
How Do Payments Change Under The Hac Reduction Program
We reduce the payments of subsection hospitals with a Total HAC Score greater than the 75th percentile of all Total HAC Scores by 1 percent.
We first adjust payments for the Hospital Value-Based Purchasing Program, Hospital Readmissions Reduction Program, disproportionate share hospital payments, and indirect medical education payments based on the base-operating diagnosis-related group amount. Then, we apply the HAC Reduction Program payment reduction based on the overall Medicare payment amount.
For example, if a hospital is subject to a 2-percent payment reduction for both the Hospital Readmissions Reduction Program and Hospital Value-Based Purchasing Programs, does not have disproportionate share hospital adjustments, does not have indirect medical education adjustments, and is subject to the HAC Reduction Program payment adjustment, then the final Medicare payment for a discharge with a $10,000 base-operating diagnosis-related group payment would be as follows:
Base-operating diagnosis-related group amount: $10,000
Hospital Readmissions Reduction Program payment adjustment = $10,000 * -0.02 = -$200
Hospital Value-Based Purchasing Program payment adjustment = $10,000 * -0.02 = -$200
Disproportionate share hospital and indirect medical education payment adjustment = $0
Overall Medicare payment amount = $10,000 – $200 – $200 = $9,600
HAC Reduction Program payment adjustment = $9,600 * -0.01 = -$96
Final Medicare payment = $9,600 – $96 = $9,504
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Cdc Checklist For Core Elements Of Hospital Antibiotic Stewardship Programs
The checklist is a companion to Core Elements of Hospital Antibiotic Stewardship Programs. This checklist should be used to systematically assess key elements and actions to ensure optimal antibiotic prescribing and limit overuse and misuse of antibiotics in hospitals. CDC recommends that all hospitals implement an Antibiotic Stewardship Program.
Base Case Model Inputs
For the example base case analysis, the indicated values were set for each variable.
Pressure injury incidence rate 3.6% PI reduction from high-risk beds 99% Stage 1 incidence % of Total PI 16.0% Stage 2 incidence % of Total PI 38.0% Late-stage incidence % of Total PI 46% Unstageable incidence % of Total PI 7.0% Stage 1 PI treatment cost per case $2,000 Stage 2 PI treatment cost per case $8,000 Late-stage PI treatment cost per case $18,000
The potential budgetary impact due to reduction of HAPI incidence rates at a medium-sized hospital archetype of 344 beds was evaluated using this model. For this analysis, occupancy rate was fixed at 65% and the average initial PI incidence was set at 3.6%.e
In the base case scenario, this medium-sized hospital would experience 644 HAPIs and 146 readmissions within 30 days due to HAPIs each year, with estimated costs totaling $10.4 million annually. Leaving all other variables constant, a 50% reduction in the HAPI rate would result in a potential savings of over $5 million. That level of reduction is equivalent to preventing less than one HAPI per day on average. Therefore, even a small reduction in daily HAPI incidence can substantially impact a hospitals costs, improve patient outcomes and reduce LOS for these patients, creating additional capacity for additional inpatient cases and revenue.
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Selection Criteria For Subjects
This study included only the first patient admission during the study period, assuming that prior hospitalization might contribute to pressure ulcer development. In addition, patients were selected if they stayed longer than four days and had both health history and physical assessment records, including admission route activities of daily living prior to admission endocrine history as well as genitourinary, cardiovascular, musculoskeletal, neurological, and gastrointestinal histories/ assessments. Since this study used the Braden scale as a reference standard of predictive modeling results, patients also needed to have Braden scores documented on admission in order to be eligible for the study. Among the patients who met the selection criteria, patients with pressure ulcers were excluded if it was unclear whether or not the pressure ulcers developed during their stay. As a result, 84 subjects with hospital-acquired pressure ulcers and 2,263 non-HPU subjects were available for the analysis .
Which Hospitals Do The Hac Reduction Program Apply To
As set forth under Section 1886 of the Social Security Act, the HAC Reduction Program applies to all subsection hospitals .
Some hospitals and hospital units, such as the following, are exempt from the HAC Reduction Program:
- Critical access hospitals
- Prospective Payment System-exempt cancer hospitals
- Veterans Affairs medical centers and hospitals
- Short-term acute care hospitals located in U.S. territories
- Religious nonmedical health care institutions
Note: For a full description of subsection hospitals, refer to the Social Security Act on the Social Security Administrations website at .
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The Financial Impacts For Providers
CMS and Providers Are Often at Odds Over Prevention
The debate surrounding HAPIs centers on preventability. Many providers believe that a significant percentage of HAPIs are a direct result of the patients condition, not the quality of their care. Certain experts feel that in penalizing providers for HAPIs they cant prevent, theyre actually being discouraged from improving HAPIs rates as a whole. The CMS disagrees with these arguments. It has classified HAPIs amongst the HACs that it considers ineligible for reimbursement since 2008 and has offered no indication of a change in policy.2
Check In For Part Two: Improving Pressure Management
In the second part of this series, well look into better alternatives to basic open-cell foams, which materials offer the best HPAI prevention in perioperative settings, and how to trouble-shoot common problems like replacing one piece of a multi-section table pad.
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Burlington Medicals selection of table pads and covering fabrics, as well as custom repairs all come at a lower costwith faster turnaround.
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Deterrence And Patient Education
Deterrence of pressure injuries includes identification of patients at risk, improvement of overall health, reducing external forces, and promoting education about pressure injuries. American College of Physicians clinical practice guidelines from 2015 advise performing a risk assessment to recognize patients at risk of pressure injury formation. Several scales have been created to predict the risk of pressure injuries in order to identify patients for whom prevention measures or early treatment should be considered. The most commonly used tools for this are the Braden and Norton scales. Reducing external forces includes minimizing extrinsic risk factors, such as friction, shear, pressure, and moisture, which is important for the deterrence of pressure injury formation. Evidence has demonstrated that the education of both providers and patients can lead to a decrease in the incidence of pressure injuries as well as an increase in the ability to manage them.
Goal 1 Objective : Expand Safe High
Strengthening the nation’s health care system is not achievable without improving health care quality and safety for all Americans. The immediate consequences of poor quality and safety include health care-associated infections, adverse drug events, and antibiotic resistance.
Health care safety is a national priority. HHS investments in prevention have yielded both human and economic benefits. From 2010 to 2014, efforts to reduce hospital-acquired conditions and infections resulted in a decrease of 17 percent nationally, which translates to 87,000 lives saved, $19.8 billion in unnecessary health costs averted, and 2.1 million instances of harm avoided.2
In the previous administration, the Office of the Secretary led this objective. The following divisions are responsible for implementing programs under this strategic objective: ACL, AHRQ, CDC, CMS, HRSA, OCR, ONC, and SAMHSA. HHS has determined that performance toward this objective is progressing. The narrative below provides a brief summary of progress made and achievements or challenges, as well as plans to improve or maintain performance.
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Strength And Limitation Of Study
The main strength of the study is the size of the sample obtained during the 4 consecutive years of the study period, we believe this gives it the necessary validity, and will be useful in future comparisons. A limitation of this study the was retrospective data collection, although hospital protocols normalize nursing activity on prevention, communication and follow-up of PUs, there may be undocumented or incomplete or even underestimated information in the HAPU.
Ucla Researchers Have Found That Pressure Ulcers First Form On The Inside Of The Body At A Cellular Level Says Researcher And Ceo Martin Burns
Pressure ulcers are a major health issue for providers and kill more patients a year than any single cancer except lung cancer, according to one expert who, with other researchers, is releasing the results of new findings in the field next month.
Pressure ulcers, also called pressure injuries and in the vernacular, bedsores, are also costly to treat.
Nationally, the U.S. spends about $26.8 billion a year on treatment costs for pressure ulcers, according to Martin Burns, CEO of BBI, Bruin Biometrics.
Pressure ulcers cause the number one patient harm in a care facility, Burns said. The Agency for Healthcare Research and Quality data shows other hospital acquired conditions – such as adverse drug events and surgical site infections – have gone down, but the number of pressure ulcers continues to climb.
This is because pressure ulcers are generally found only after a wound appears, and this can be too late to stop an infection from getting into the body.
But what Burns and researchers from the University of California, Berkeley have discovered is that pressure ulcers form from the inside of the body, out, not the other way around. Damage occurs at the cellular level, he said.
Both the Centers for Medicare and Medicaid Services and the National Health Service in the United Kingdom are interested in the findings, according to Burns, who said he has recently spoken with representatives from both agencies.
WHY THIS MATTERS
THE LARGER TREND
THE PROBLEM FOR HOSPITALS
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Why Investing In Hospital
Hospital-acquired pressure injuries affect 2.5 million patients per year in the United States. With the cost of treating a single instance as high as $70,000, and because many payers, including Medicare and Medicaid, are not covering them, the business case for prevention is apparent.a HAPIs also are the second most common hospital lawsuit claim after wrongful death, claiming 60,000 patients each year, according to a study published by Ostomy/Wound Management.b Although the health-related complications associated with PIs are high, there have been no comprehensive assessments of PI costs, including both direct and indirect costs, on an individual hospital basis.
Data Source And Methods
The 2004 National Nursing Home Survey data were used for these analyses. NNHS is a continuous cross-sectional survey of a nationally representative sample of U.S. nursing homes. It is designed to provide descriptive information on nursing homes, their services, their staff members, and the residents they currently serve.
The sample design for the 2004 NNHS was a stratified, multistage probability design. The first stage was the selection of facilities and the second stage was the selection of residents. The primary sampling strata of facilities was defined by sampling bed size category and metropolitan area status. For the 2004 NNHS, 1,500 nursing homes were selected using systematic sampling with probability proportional to their bed sizes. The second stage sampling of current residents was carried out by the interviewers at the time of their visits to the facilities. The sampling frame for current residents was the total number of residents on the register of the facility as of midnight the day before the survey. A sample of up to 12 current residents per facility was selected, resulting in a total of 14,017 residents. The 2004 NNHS was administered using a computer-assisted personal interviewing system. Data were collected on facility characteristics and characteristics of the sampled residents.
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Objective 12 Table Of Related Performance Measures
Reduce all-cause hospital readmission rate for Medicare-Medicaid Enrollees
A “hospital readmission” occurs when a patient who has recently been discharged from a hospital is once again readmitted to a hospital. A thirty-day period for readmission data has been standard across the quality measure industry for several years. Discharge from a hospital is a critical transition point in a patient’s care incomplete handoffs at discharge can lead to adverse events for patients and avoidable readmissions. Hospital readmissions may indicate poor care, missed opportunities to better coordinate care, and result in unnecessary costs.
While many studies have pointed to opportunities for improving hospital readmission rates, the rate of readmissions for individuals who are dually eligible for both Medicare and Medicaid is often higher than for Medicare beneficiaries overall. In 2019, an estimated 12.3 million beneficiaries were dually eligible for Medicare and Medicaid.
CMS will continue to implement programs and innovations aimed at incentivizing a reduction in Medicare fee-for-service hospital readmissions:
An array of CMS Innovation Center models with financial incentives to reduce utilization and readmissions, including Bundled Payments Care Improvement initiative, the Next Generation ACO model, and Primary Care First.
Improve hospital patient safety by reducing preventable patient harms 3, 4
When Do We Adjust Payments Under The Hac Reduction Program
We adjust payments when we pay hospital claims. The payment reduction is for all Medicare fee-for-service discharges in the corresponding fiscal year. We let hospitals know whether their payment will be reduced in a HAC Reduction Program Hospital-Specific Report, which is delivered to hospitals from the Hospital Quality Reporting system Managed File Transfer inbox.
More information is available in the QualityNet HAC Reduction Program Scoring Methodology section.
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