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How To Prevent Hospital Acquired Pressure Ulcers

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Which Hospitals Do The Hac Reduction Program Apply To

Medical Device-Related Pressure Injury: AHRQ Preventing Pressure Ulcers in Hospitals Toolkit

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 .

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

Goal 1 Objective : Expand Safe High

Strengthening the nations 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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Bundle Up To Prevent Pressure Ulcers

Pressure ulcers arent always simple wounds that eventually heal with the right treatment. They can have devastating effects on the quality of life for both patients and their families. Whats worse, they cause thousands of deaths eachyear, particularly among the elderly. In many more cases, they probably contribute to death even if they arent listed as the cause.

An estimated 2.5 million patients in the United States develop pressure ulcers, and we spend about $11 billion for their treatment. With Medicare no longer reimbursing healthcare facilities to treat certain types of hospital-acquired pressure ulcers, your nursing care may come under suspicion if your patient develops one.

This article explains how to make pressure ulcer prevention a part of your everyday nursing practice. By using the bundle approach and practicingthe Golden Rule, you can develop a prevention program on your unit or in your facility.

Strength And Limitation Of Study

Pressure Ulcer Prevention Campaign

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.

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Reduce Friction And Shear

Friction is the rubbing of skin on an external surface, usually bed sheets. Friction to the most commonly affected areas can be reduced with protective devices. Heel and elbow cradles are typically made of egg-crate material and Velcro on.

Skin protecting dressings, such as films and thin hydrocolloid bandages can protect the skin from repeated friction but wont help reduce pressure.

The most important thing you can do to prevent injury from the friction is to make sure you dont create any yourself when youre repositioning your loved one. Use a draw sheet to help you lift your loved one off the bed when you lift and reposition.

Shear is created when the deeper fatty tissues and blood vessels are damaged by a combination of friction and gravity. The best way to avoid this type of injury is to avoid a semi-Fowler and upright position in bed. A semi-fowler position is where the head is raised less than 30 degrees and upright positions more than 30 degrees.

Now, you obviously cant avoid these positions all of the time. Many patients need to be semi-Fowler to help ease shortness of breath or prevent gastric reflux and all patients need to be in an upright position to eat safely.

To minimize the risk of shear injury in a semi-Fowler or upright position, take precautions to prevent your loved one from sliding down in bed. You can do this by raising the foot of the bed and propping the knees up with pillows.

Objective 12 Table Of Related Performance Measures

Reduce all-cause hospital readmission rate for Medicare-Medicaid Enrollees

Pending Pending

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 patients 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


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The Repose Foot/heel Protector

Repose foot protectors are designed specifically to minimise the risk of pressure damage to heels. They come in the form of splints made of Platilon, a polyurethane material with unique stretch, thermal and vapour-permeable properties. They are most effective when the patient is recumbent, semirecumbent or upright while on bed-rest, as the heels are supported above a void and therefore close to zero pressure, while the malleoli are protected by air-filled compartments.

The foot protectors are inflated using a hand-help pump. A valve ensures they are inflated to the correct pressure with no chance of over-inflation. This provides a pressure-reducing splint where the weight of the lower leg is redistributed over a wider area.

Check In For Part Two: Improving Pressure Management

Wound Classification: AHRQ Preventing Pressure Ulcers in Hospitals toolkit

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.

Improve Your Support Surfaces Right Now

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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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 .

The Implications Of Pressure Injuries

Its no secret that pressure injuries can become incredibly serious, from deep tissue damage all the way to sepsis, resulting in death. Developing pressure sores can lead to skin damage and infection, causing injuries that are, in many cases, preventable. They also place a significant legal strain on hospitals. According to the Agency for Healthcare Research and Quality, there are more than 17,000 lawsuits filed related to pressure ulcers a year, and the pressure ulcers themselves cost between $9.1 billion and $11.6 billion a year in fees.

With unnecessary patient suffering and legal issues both at stake, its important to create a culture of urgency within hospitals to reduce pressure sore cases among patients. By becoming quickly aware of the issues and monitoring skin from the beginning, this is much easier to do.

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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 Preventions 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
  • Methicillin-resistant Staphylococcus aureus bacteremia
  • Clostridium difficile Infection

The Financial Impacts For Providers

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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

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Are Pressure Ulcers Preventable

Many clinicians believe all pressure ulcers are preventable, while admitting that some may be harder than others to prevent and require more aggressiveintervention. But the truth is some pressure ulcers may not be preventable. Why? Think back to basic anatomy and the organ systems: The skin is the largest organ of the body. If your patient is in multisystem organ failure with his kidneys, liver, and heart all failing, his skin is likely to fail, too.

Whether or not you view pressure ulcers as preventable, make sure to accurately document the patients condition and all interventions taken to prevent them.

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Data Collection And Analysis

After the sample was defined and the study quality evaluated, data from the included studies were abstracted into an Excel-based literature review matrix for analysis and synthesis. The data abstraction was completed by two reviewers and verified by a third. The quality of evidence was evaluated with the American Association of Critical-Care Nurses Levels of Evidence . Studies assessed within the first four evidence levels were included in the review, while level M studies were excluded. Studies assessed as the highest level of evidence, or level A, include a meta-analysis of multiple controlled studies or meta-synthesis of qualitative studies with results that consistently support a specific action, intervention, or treatment. The next level, or level B, describes well-designed controlled studies, both randomized and non-randomized, with results that consistently support a specific action, intervention, or treatment. Then, level C studies are qualitative, descriptive, correlational, integrative reviews, systematic reviews, or randomized controlled studies with inconsistent results. Next, level D studies include peer-reviewed professional organizational standards, with clinical studies to support recommendations. Finally, level M are manufacturer recommendations. This leveling facilitated study comparison to identify the strongest evidence for clinical practice .

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Pressure Injury Prevention In Hospitals Training Program

AHRQ developed the Pressure Injury Prevention in Hospitals Training Program to support the training of hospital staff on how to implement AHRQs Preventing Pressure Ulcers in Hospitals Toolkit. The content of the Training Program and supporting materials help hospitals become familiar with each of the components of the Toolkit and learn how to overcome the challenges associated with developing, implementing, and sustaining a pressure injury prevention program.

This content was developed from an AHRQ project that ran from 2014 to 2017. It is based on AHRQs Pressure Ulcer Prevention Toolkit and the experiences of 11 hospitals that participated in a 2-year pilot project of the Training Program. Hospitals participating in this pilot implementation of the Training Program and Toolkit reduced their hospital acquired Stage 2+ pressure injury rates and sustained these reductions for a year .

The Training Program consists of a five-module, in-person training curriculum and a series of companion Webinars on specific topics related to pressure injury prevention. An Implementation Guide provides additional suggestions for how to use the Training Program and the Toolkit.

Staff Education With Audit Feedback

Stop the pressure

From a systematic review of interventions, Sullivan & Schoelles reported successful quality improvement programs with care bundles reporting reduced HAPU risk almost always included staff education and frequently included staff feedback from audits . In addition, Swafford et al. assessed the effectiveness of a year-long HAPU prevention program in an adult ICU, including the Braden scale, revised skin-care protocol, fluidized repositioners, silicone adhesive dressings, and face-to-face staff education.There was a 69% reduction in HAPUs at the end of the program . The authors reported staff education with performance feedback positively contributed to the program outcomes. Similarly, Armour-Burton et al. reported a multidisciplinary healthy skin project eliminated HAPUs in a surgical progressive care unit . The key intervention strategies were staff education, unit based WOC nurse, risk assessment with the normal care . Finally, Kelleher et al. attributed the elimination of HAPU to enhanced education and feedback provided by a WOC nurse. Overall, quality improvement programs with multidisciplinary participation, structured education, and adherence to evidence-based protocols resulted in significant HAPU reductions .

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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.

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How Pressure Ulcers Develop

Pressure ulcers can develop when a large amount of pressure is applied to an area of skin over a short period of time. They can also occur when less pressure is applied over a longer period of time.

The extra pressure disrupts the flow of blood through the skin. Without a blood supply, the affected skin becomes starved of oxygen and nutrients, and begins to break down, leading to an ulcer forming.

Pressure ulcers tend to affect people with health conditions that make it difficult to move, especially those confined to lying in a bed or sitting for prolonged periods of time.

Conditions that affect the flow of blood through the body, such as type 2 diabetes, can also make a person more vulnerable to pressure ulcers.

Learn more about the causes of pressure ulcers.

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New Sizes Now Available

The Repose Foot Protector is now available in a range of sizes to support a variety of patient needs.

New sizes include the Repose Foot Protector Small and Repose Foot Protector Extra Small products.

To learn more about Repose Foot Protector please contact us using the button below.

  • Low Air technology distributes weight evenly and doesnt lose its shape
  • Designed to relieve pressure on soft tissue areas and provide comfort
  • Lightweight for easier transport
  • Repose can be cleaned and reused
  • Can be used with other dynamic or static support surfaces
  • Reduces impact of pressure, friction and shear

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