Using clinical data to predict high-cost performance coding issues associated with pressure ulcers: a multilevel cohort model.

The number of hospital patients who develop pressure sores has risen by 63 % over the last 10 years, and nearly 60,000 deaths occur annually from hospital-acquired pressure ulcers. It has been estimated that it costs between 1.5 and 5.0 billion dollars a year to manage pressure ulcers in the United States [1]. In the United States in October of 2008, the Centers for Medicare and Medicaid Services announced that it will stop reimbursing hospitals for treating reasonably preventable conditions—pressure ulcers are among these conditions. That announcement has put hospitals into a state of anxiety, and with good reason, up until now, the majority of hospitals focus on the treatment of pressure ulcers, rather than preventing them. Section 5001(c) of the DRA required the Secretary to identify, by October 1, 2007, at least two conditions for which hospitals under the IPPS (Inpatient Prospective Payment System) would not receive additional payment beginning on October 1, 2008, if the condition was not present on admission. The conditions (a) must be of high cost or high volume or both, (b) must result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and (c) could reasonably have been prevented through the application of evidence-based guidelines. For discharges occurring on or after October 1, 2008, hospitals would not receive additional payment for cases in which one of the selected HACs was not present on admission. That is, the case would be paid as though the secondary diagnosis was not present. Pressure ulcers are one of the hospital-acquired complications that CMS deems to be preventable, and as a result, prevention is on the forefront of all hospital policies. Pressure ulcers can affect any patient that has limited mobility due to illness or disease. There are some patient populations that are at greater risk than others. Individuals with spinal cord injuries have a high incidence of pressure ulcer development. It has been estimated that 25 % of individuals will develop a pressure ulcer in a year, with 85 % having at least one pressure ulcer in his/her lifetime [1]. Individuals aging with spinal cord injuries will have increased risk as age-related changes affect the strength and elasticity of the skin. Niazi et al. found that the recurrence rate for patients with spinal cord injuries who develop pressure ulcers was 35 % [1]. The treatment of pressure ulcers is approximately 25 % of the cost of caring for individuals with spinal cord injury. The cost of prevention is approximately 10 % the cost of treatment [1, 2]. Another population at greater risk for pressure ulcer development is the elderly especially those in long-term care facilities. Twenty-five to thirty-five percent of elderly patients in these facilities develop pressure ulcers during their length of stay. Prevention is the key to improving these patients’ quality of life and reduces the burden that pressure ulcers place on our healthcare systems.

The incidence and prevalence rates of pressure ulcers in the paediatric population: A meta-review of systematic reviews.

Prevalence, incidence, length of stay and cost of healthcare-acquired pressure ulcers in pediatric populations: A systematic review and meta-analysis

Hospital-acquired pressure ulcers are a common problem. Although a number of risk factors have been identified, relationships among risk profile characteristics and pressure ulcer outcomes have not been described in hospitalized patients. To describe patients' characteristics and risk factors associated with pressure ulcer outcome. A retrospective chart review was used to collect data on 87 patients in whom hospital-acquired pressure ulcers developed from May 2007 to November 2008. All pressure ulcers were staged by a certified wound nurse. Relationships among risk profile characteristics and pressure ulcer outcomes were determined via bivariate analysis and multivariate logistic regression. High severity of illness was present in patients with hospital-acquired pressure ulcers; 89% were intensive care patients. Vasopressor infusion, spinal cord injury, and age 40 or greater conferred risk for nonhealing pressure ulcers. Among pressure ulcer stages, suspected deep tissue injury ulcers were less likely to heal. Identification of characteristics and risk factors associated with development of nonhealing hospital-acquired pressure ulcers will allow nurses to recognize patients at risk for nonhealing and to take aggressive preventative measures.

Prospective observational cohort study. To describe time to occur and time until closure of hospital-acquired pressure ulcers (HAPUs) in patients with spinal cord injury (SCI). Specialised SCI acute care and rehabilitation clinic in Switzerland. Daily registration of the presence and severity of HAPUs in a consecutive sample of SCI patients during their entire in-patient stay. Out of 185 observed SCI patients, 55 patients (29.7%) developed at least one HAPU. Within the first 30 days after admission, 50% of all HAPUs occurred. Less severe HAPUs occurred earlier than severe HAPUs. The occurrence of HAPUs was significantly associated with reason of admission (P<0.01), and was highest in first rehabilitation (51.4%) and orthopaedic surgery patients (41.4%). The incidences of first HAPU in these groups were 1.04 and 2.31 per patient-year, respectively. Patients in first rehabilitation or readmitted because of pressure ulcer (PU) showed an initial lower risk for HAPUs in the Kaplan-Meier curve compared with patients readmitted for other reasons. Cox regression analysis revealed an association between longer time since SCI and time until occurrence (P=0.01). Closure of the HAPUs during hospitalisation was observed in 37 patients (67.3%) after 38.9 days on average. No significant associations were found between patient characteristics and time until closure. The dynamics of HAPUs varied according to admission reason and time since lesion. However, ongoing awareness to prevent HAPUs is needed in all patients with SCI.

&lt;p&gt;Although great strides have been made to tackle hospital-acquired pressure ulcers (HAPUs), there is a need for greater recognition of device-related pressure ulcers (DRPUs), including their causes, management and prevention. This consensus statement, an updated second edition, aims to continue raising awareness of these largely preventable injuries and, crucially, to stimulate action. DRPUs are relatively common and account for a growing proportion of HAPUs. Updated information on the incidence of DRPUs is described in chapter 1. Although it is recognised that DRPUs increase the financial burden of healthcare, there is little formal analysis of their economic impact. This needs to be addressed; robust evidence on the burden of DRPUs and the value that can be released by adopting prevention strategies is needed to help drive action. Our understanding of the pathophysiology of DRPUs has improved significantly over the past few years; this is described in chapter 2. One crucial difference between PUs and DRPUs is that body-weight forces are less significant in DRPUs, with the force being exerted from a device that is typically strapped or taped onto the body. Devices and their securement may generate high stress concentrations in tissues, leading to cell and tissue-damage pathways associated with sustained deformation. As more evidence is published on DRPUs, recurring themes are emerging, as outlined in chapter 3: The most vulnerable patients are bearing the brunt of DRPUs; paediatric and neonatal patients, and all those needing critical care are particularly susceptible. During the COVID-19 pandemic, a new high-risk population (people with severe COVID-19 infection) emerged. They are at increased risk of DRPUs because of their need for prolonged ventilatory support, especially when 'proning' Devices associated with DRPUs are often used to perform essential, life-saving functions. They include continuous positive airway pressure (CPAP) masks or endotracheal tubes. Minimising their use is clearly not an option, so practice innovation is needed Although the most common locations for DRPUs are the face, ears, lower legs and heels, any location where a device comes into close contact with the skin can be at risk. In the same vein, any device, whether needed for a medical purpose or not, has the capacity to cause injury if its use is not properly managed. Vigilance is needed for all patients. What can be done? The importance of routine risk assessment is covered in chapter 4. Although use of a validated risk assessment tool is the vital first step, this will not be enough on its own. Several steps can be taken to ensure the safe use of devices. These are described in chapter 5 and include device repositioning, cushioning with prophylactic dressings and moisture control (only where possible and clinically appropriate). Of key importance is the development of an institutional protocol and champions to ensure all necessary steps are adopted. For any of these changes to be put into practice, awareness of DRPUs needs to increase. A number of proposals are outlined in chapter 6. A change of focus among health professionals and policy makers, along with more investment in education and training, are needed. All patients being managed with a medical device must be considered as at high risk. The pandemic introduced the world to the problem of DRPUs in health professionals caused by the extended wear of personal protective equipment. Health professionals also have a right to expect institutional protocols and provision of devices that protect them from DRPUs. Cutting-edge ideas and technologies that may be available in the future are described in chapter 7. When designing new products, manufacturers of medical devices have a duty of care to investigate the risks of DRPUs associated with their products and mitigate them, wherever possible. Our developing understanding of how the design, structure and materials used in medical devices contribute to DRPUs will help us develop new solutions for tomorrow. The first step is for everyone involved to ask themselves, 'what can I do to help?' There is work to be done-your journey to reduce DRPUs starts here!.&lt;/p&gt;

Hospital-acquired pressure ulcers (HAPUs) are a problem that has been under increased scrutiny in recent years. To help reduce the incidence of HAPUs and to improve their management, a burn unit-centered wound care team was established. The team decided to pursue two goals: to identify opportunities for improvement that may help prevent HAPUs and to evaluate all available support surfaces to identify those that might best help with pressure redistribution. To identify opportunities for improvement, the team studied each new case of HAPUs throughout our hospital with a forensic chart review for a 3-year period. To identify the best support surfaces to help reduce the incidence of pressure ulcers, we evaluated all support surfaces available at our institution by pressure mapping in healthy volunteers. From 3 years of collecting and reporting data for quality improvement, we identified 23 patients with HAPUs and obtained more than 800 data sets from pressure mapping in healthy volunteers. Most (23/24; 96%) patients with HAPUs identified in this series had undergone a surgical procedure. The results of the quality improvement studies are presented. We conclude that prevention planning of HAPUs needs to be improved in patients undergoing surgery, in particular. No single support surface can prevent pressure ulcers, but use of overlays may help reduce peak pressures over bony prominences.

IntroductionA hospital-acquired pressure ulcer (HAPU) is a localized lesion or injury to the underlying tissue (wound) while the patient is on admission. It occurs when standardized nursing care is not correctly followed in the presence of friction and shear, leading to skin or underlying tissue breakdown. Unfortunately, inadequate knowledge of nurses to assess and provide standardized care for pressure ulcers or manage HAPUs results in patient harm. We aim to share lessons from a reported HAPU incident and address the knowledge gap in patient safety risk assessment, identification, and wound management at Nyaho Medical Centre (Accra, Ghana).MethodsA review of HAPU incidents was conducted using quality improvement tools such as cause-and-effect analyses to identify contributing factors and root causes. Subsequently, plan-do-study-act (PDSA) cycles were used to test interventions to improve pressure ulcer assessments and wound management. A run chart was used to analyze and evaluate the interventions over 12 weeks (Aug–Oct 2021).ResultsDevelopment of policies and a standard operating procedure for pressure ulcers and wounds improved accuracy in identifying pressure ulcer risks and management of wounds. Eighty-three patients were assessed with the pressure ulcer assessment tool. Complete (100%) adherence to the pressure ulcer and wound policy and standard operating procedure (SOP) was achieved, and the number of HAPUs decreased from five to one during the study period.ConclusionThis study demonstrated that the combined use of quality methods and tools can be suitable for improving processes and outcomes for patients at risk for HAPUs.

Objective To analyze the continuous monitoring results of pressure ulcer, so as to provide scientific basis for the prevention and treatment of pressure ulcer. Methods Based on the results of continuous monitoring of pressure sores in hospitalized patients in People's Hospital of Longyou between 2009 and 2016, the prevalence rate, incidence rate and distribution characteristics of pressure sores were obtained by retrospective statistical analysis. Results There were 112 206 cases monitoring during eight years. Pressure ulcer prevalence rate was 0.54%. The incidence rates of primary diagnostic pressure ulcers and hospital acquired pressure ulcers were 0.47% and 0.07%, respectively. ICU had the highest prevalence rate accounting for 4.25%. In all pressure ulcer patients, male to female ratio was 2.124∶1, and the average age was (70.57±19.89) years old with 62.71% of people over 70 years old. There were 606 pressure sore cases with a total occurrence of 917 pressure ulcers and 1.513 bedsores per patient. The most common site was the end of the sacral pressure sores which accounted for 53.00%, followed by the ministry of the iliac crest of 12.98%, and the ankle of 10.47%. Pressure ulcer in phase Ⅱ was most common stage, accounting for 46.78%, followed by phase Ⅲ of 20.28%, and phase Ⅰ of 13.09%. Conclusions The results show lower existing and incidence rates in our hospital than those reported in present domestic literatures. Aged male patients are of high incidence pressure ulcers. The sacral pressure ulcers and the phase Ⅱ ulcers are most common. Continuous monitoring and prudent management can effectively reduce the incidence of pressure ulcers. Key words: Incidence; Pressure ulcer; Monitoring

The cost of treating a hospital-acquired pressure ulcer (HAPU) places a significant burden on healthcare facilities. Associated expenses potentially include increased supplies, equipment, specialty beds, staffing, nutritional support, laboratory testing, and hospital length of stay. The quarterly HAPU data revealed an increased prevalence in our 25-bed intermediate care unit at Central DuPage Hospital at Winfield, Illinois. There were 6 occurrences of HAPU during fiscal year 2005 to fiscal year 2006, and 5 occurred during fiscal year 2006 to 2007. Based on these data, our unit quality council investigated contributory factors and reviewed current tools and standards of practice related to pressure ulcer prevention. Strategic plans were developed to reduce the incidence of HAPU. Follow-up monitoring revealed no HAPU occurrence from October 2006 through September 2007. Pressure ulcer prevention strategies proved effective in reducing incidence during a 1-year period and have been approved as standards of practice for the unit.

The purpose of this study was to describe the evolution of unstageable pressure ulcers (PUs) over time to determine if their healing trajectory is consistent with full- or partial-thickness wounds. Retrospective review of electronic medical record and a clinical PU database. Patients with hospital-acquired, unstageable PUs were evaluated. Subjects were cared for at a level 1 trauma/burn center and safety net hospital in the Pacific Northwest between November 2007 and March 2011. Electronic medical records and a clinical PU database for 194 unstageable PUs were examined. The PU database is managed by certified wound care nurses; it includes data on all verified hospital-acquired PUs since 2007. The unit of analysis for this study was the individual PU site. Of the initial 194 unstageable PUs identified, 120 were excluded due to lack of data needed to address research questions. Out of the 74 unstageable PUs that remained in the study, approximately one-third (33.8%) were found to follow a healing trajectory consistent with partial-thickness wounds. Findings indicate that while approximately two-thirds of unstageable PUs demonstrate healing trajectories consistent with full-thickness wounds, slightly more than a third follow a trajectory consistent with partial-thickness wounds. Additional research is needed to clarify the healing trajectories of unstageable PUs and to determine whether the current definition for unstageable PUs is adequate.

Pressure ulcers remain a perennial challenge in the management of patients with spinal cord injury in developing countries due to lack of preventive facilities and trained personnel. This study assessed the prevalence and factors associated with healing outcomes of hospital-acquired pressure ulcers among patients with spinal cord injury in a Nigerian tertiary hospital. A retrospective case chart review of patients with spinal cord injury between January, 1997 and December, 2006 was carried out. Data were gleaned on gender, age, marital status, presence and number pressure ulcers per patient, worst hit body site by pressure ulcer, cause of spinal cord injury, spinal cord injury level, American spinal injury association impairment score (AIS), diabetes status, stage of worst hit body site and outcomes of healing. Data was analyzed using both descriptive and inferential statistics at α 0.05. The prevalence of pressure ulcers in the study was 51.58%. The sacrum and coccyx (56.20%) were the worst hit body sites by pressure ulcers. Gender (p = 0.00), aetiology of spinal cord injury (p = 0.01) and stage of worst hit body site by PU (p = 0.00) were associated with healing outcomes. The prevalence of pressure ulceration was high with a high majority of the ulcers not healing. Key words: Pressure ulcers, retrospective, spinal cord injury.

The purpose of this study was to estimate the incidence of hospital-acquired pressure ulcers among elderly patients hospitalized for hip fracture surgery and to identify extrinsic factors that are associated with increased risk. We conducted a secondary analysis of data abstracted from medical records at 20 hospitals in Pennsylvania, Texas, New Jersey, and Virginia. Participants were patients aged 60 years and older admitted with hip fracture to the study hospitals between 1983 and 1993. The incidence of hospital-acquired pressure ulcers was 8.8% (95% confidence interval 8.2%-9.4%). After adjusting for confounding variables, longer wait before surgery, intensive care unit stay, longer surgical procedure, and general anesthesia were significantly associated with higher pressure ulcer risk. Extrinsic factors may be important markers for high pressure ulcer risk in hospitalized hip fracture patients. Although it is not possible to eliminate factors such as requiring an intensive care unit stay or having a long surgical procedure, it may be possible to develop interventions that minimize pressure ulcer risk in patients who experience these factors.

Implementing a Novel Guideline to Prevent Hospital-Acquired Pressure Ulcers in a Trauma Population: A Patient-Safety Approach

Objective To compare the prevalence of anxiety/depression and overweight/obesity (Aim 1) and the multimorbidity of these conditions (Aim 2) in a sample of adults with and without spinal cord injury (SCI). Aim 3 was to examine whether overweight/obese individuals with SCI differ on the prevalence of anxiety/depressive disorders compared to non-overweight/obese individuals with SCI. Design Retrospective cohort study. Participants Individuals ≥16 years old who had patient encounters between January 1, 2011, and February 28, 2018. In total, 761 598 individuals were included, of which 3136 had SCI. Main Outcome Measures Individuals were identified as diagnosed with SCI, anxiety and/or depressive disorders, and overweight/obesity using the International Classification of Diseases. Results Age-adjusted odds ratios (ORs) were calculated using logistic regression. In contrast to non-SCI individuals, those with SCI had increased odds of anxiety disorders (OR: 3.58, 95% CI [3.29–3.90]), depressive disorders (OR: 4.33, 95% CI [3.95–4.74]), and overweight/obesity (OR: 3.08, 95% CI [2.80–3.38]). Pertaining to multimorbidity, individuals with SCI had increased odds of having overweight/obesity alongside anxiety disorders (OR: 4.30, 95% CI [3.71–4.98]) and overweight/obesity alongside depressive disorders (OR: 4.69, 95% CI [4.01–5.47]) compared to those without SCI. Individuals with SCI who were diagnosed as overweight/obese had increased odds of having anxiety disorders (OR: 2.54, 95% CI [2.06–3.13]), and depressive disorders (OR: 2.70, 95% CI [2.18–3.36]), relative to non-overweight/obese individuals with SCI. Conclusions This work is among the first to find evidence that individuals with SCI are at heightened odds of overweight/obesity alongside anxiety and/or depressive disorders. This early work holds clinical implications for treating these interrelated comorbidities in SCI.