Pressure Ulcer Quality Improvement Monitoring Report

On-Time Pressure Ulcer Healing Project

This report compiles pressure ulcer statistics from data captured by nursing staff on weekly ulcer assessment documentation. This report is an example to clinicians of how health information technology can be leveraged to collect, store, and compile data for reporting. Information that displays in this report is usually compiled manually by nursing staff or quality improvement (QI) teams. Clinicians will use this report for internal reporting and to monitor and analyze facility pressure ulcer development patterns and rates to formulate improvement strategies. Clinicians will run this report at the end of each month.

The monthly report provides the following information at the nursing unit and facility level. This report displays data for one full month; if a user generates the report prior to the last day of the current month, display data from the first day of the current month to the current date. The intent of this report is to display statistics for one calendar month.

Using the example report layout below, end users may access this report to answer the following questions (please note this is a representative sample and is not an exhaustive list of questions that may be answered):

  • How many pressure ulcers were being treated on nursing Unit A during October 2007? Unit B? Unit C? Unit D?
  • Of the total number of pressure ulcers on Unit A in October 2007, how many were Stage I? Stage II? Stage III? Stage IV? Unstageable?
  • How many ulcers were healed on Unit A in October 2007?
  • Of the total number of ulcers on Unit A in October, how many were discovered on new admissions to the nursing unit? Of the total number of ulcers that were discovered on new admissions, how many were Stage I? Stage II? Stage III? Stage IV? Unstageable?
  • Of the total number of ulcers that were on nursing Unit A during October 2007, how many were developed in-house? Of the in-house-developed ulcers, how many were Stage I? Stage II? Stage III? Stage IV? Unstageable?
  • On nursing Unit A, how many ulcers have been treated for longer than 30 days, by ulcer stage?
  • What are the total numbers of pressure ulcers on nursing Unit B? Unit C?
  • What are the total numbers of ulcers for the entire facility for October 2007?
  • For the facility, how many ulcers in October 2007 are Stage I? Stage II? Stage III? Stage IV? Unstageable?
  • What ulcer stage was treated most often in October 2007?
  • What ulcer stage is most often identified upon admission?
  • At which stage are ulcers most often found when identified on in-house residents?
  • At the facility level, how many ulcers have been treated for longer than 30 days?
  • Which nursing unit has the most ulcers of 30 day or longer duration?
  • How many new ulcers were identified during October 2007? Of these new ulcers, how many were identified upon admission? How many were acquired in-house?
  • Of all ulcers being treated in the facility in October 2007, were clinicians treating more ulcers identified upon admission or ulcers identified in-house?

Sample Report October 2007 for Facility X

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Sample Report October 2007 for Facility X

Beginning of dialog window. Escape will cancel and close the window.
Nsg Unit# Pressure Ulcers During Report Month# Ulcers on Admission# Ulcers Acquired In-House# Ulcers >30 days
Stage  Stage  Stage  Stage  
IIIIIIIVUTotal
by
Unit
#
Healed
Ulcers
IIIIIIIVUTotal
by
Unit
#
Healed
Ulcers
IIIIIIIVUTotal
by
Unit
#
Healed
Ulcers
IIIIIIIVUTotal
by
Unit
#
Healed
Ulcers
A770101537501013302000200028004
B6300090610007002000202010003
C4100051200002121000312000002
D4010051201003120000210010001
Total
Current
Ulcers
     34      25      9      10 
Totals
by
Stage
2111110 5176110 345000 240420  
% by
Stage
62%32%3%3%0%  68%24%4%4%0%  44%56%0%0%0%  40%0%40%20%0%  
       Total
New/Total
Discontinued
      Total
New
Ulcers:
Admission
      Total
New
Ulcers:
In-
House
       
# New
Ulcers
410005 210003 200002        
# Dis-
continued
Ulcers
112408                      
%
Total
Ulcers
            74%     26%       29% 

Below are a few rules to determine ulcer state. Please refer to (1) Wound Assessment Specification, (2) Wound Assessment Form Requirements, for additional information and other business rules. The following fields, referenced below, can be found on page 4 of the Wound Assessment Form included with other wound module specification documents:

  • Followup ulcer status
  • Current visualized ulcer stage
  • Resident disposition

Ulcer Stage:
1. When counting ulcers, an ulcer is either in progress OR healed OR discontinued; ulcers are counted once in the QI Monitoring Report
An ulcer in progress will have:

  • Followup Status = improving or same/no change or worsening except initial or first assessments where Followup Status will be blank.
  • Current Visualized Stage = Stage I or II or III or IV or Unstageable.
Exception: *Ulcers that develop (new) and heal or discontinue during the report month:
  • If an ulcer developed during the report month (Ulcer ID Date = report month) and also healed, count as ulcer in progress and healed.
  • If an ulcer developed during the report month (Ulcer ID Date = report month) and also discontinued, count as ulcer in progress and ulcer discontinued.
  • Use the most recent current visualized ulcer stage for in progress count by ulcer stage.
  1. An ulcer that is healed will have:
    • Followup Status = healed.
    • Current Visualized Stage = blank (no data entry).
  1. An ulcer that is discontinued will have:
    • Disposition = discharged or expired and/OR
    • Discharge date or is otherwise considered an inactive resident in the system.

The report provides the following information by nursing unit (ulcer count from first day of month to report date)

  • Unit total number of pressure ulcers by ulcer stage
    1. Include all Pressure Ulcer assessments for the report month for each nursing unit.
    2. Each ulcer has a unique ulcer ID: pressure ulcer ID consisting of resident ID, ulcer onset date, and ulcer location = unique pressure ulcer ID.
    3. For each unique ulcer, sort by assessment date.
    4. On the last assessment date of the month for each unique ulcer: If Followup Ulcer Status is healed and Current Visualized Ulcer Stage is blank, treat ulcer as healed. Healed ulcers do not contribute to the total number of ulcers.
      Note: If Followup Ulcer Status is healed and Current Visualized Ulcer Stage is NOT blank, make current visualized stage blank and treat ulcer as healed.
    5. On the last assessment date of the month for each unique ulcer:If Ulcer Status is not healed, use Current Visualized Ulcer Stage as ulcer stage.
    6. For each ulcer stage, count the number of unique pressure ulcer IDs during report month.
    7. Sum the number of unique ulcers with an ulcer stage for the Total by Unit.
    8. Count the number of unique healed ulcers for the # of Healed Ulcers.
  • Unit total number of pressure ulcers identified upon admission by ulcer stage
    1. Using #6 above, count the number of unique pressure ulcer IDs during month where Ulcer Occurrence was Admission.
    2. Sum the number of unique ulcers with an ulcer stage with an occurrence of Admission for the Total by Unit.
    3. Using #8 above, count the number of unique pressure ulcer IDs during month where ulcer occurrence was Admission for the # of Healed Ulcers.
  • Unit total of in-house-acquired pressure ulcers by ulcer stage
    1. Using #6 above, count the number of unique pressure ulcer IDs during month where ulcer occurrence was In-House Acquired.
    2. Sum the number of unique ulcers with an ulcer stage with an occurrence of In-House Acquired for the Total by Unit.
    3. Using #8 above, count the number of unique pressure ulcer IDs during month where ulcer occurrence was Acquired for the # of Healed Ulcers.
  • Unit total of ulcers treated >30 days by stage
    1. Using #6 above, create an Ulcer Treatment Days variable by subtracting the Ulcer Onset Date from the last day of the month.
    2. For each ulcer stage, count the number of unique pressure ulcer IDs where Ulcer Treatment Days is >30 days.
    3. Sum the number of unique ulcers with an ulcer treatment time >30 days for the Total by Unit.
  • Facility total number of ulcers and percentages by ulcer stage
    1. Sum the unit total of unique ulcers by ulcer stage for the Totals by Stage. Do not include healed or discontinued ulcers.
    2. Sum the unit total of unique ulcers for Total Current Ulcers. Do not include healed or discontinued ulcers.
    3. Divide #1 by #2 to calculate the % by Stage for the facility.
  • Facility total number of pressure ulcers identified upon admission and percentages by ulcer stage
    1. Sum the unit total of unique ulcers with an occurrence of Admission by ulcer stage for the Totals by Stage. Do not include healed or discontinued ulcers.
    2. Sum the unit total of unique ulcers with occurrence of Admission for Total Current Ulcers. Do not include healed or discontinued ulcers.
    3. Divide #1 by #2 to calculate the % by Stage for the facility.
  • Facility total number of in-house acquired pressure ulcers and percentages by ulcer stage
    1. Sum the unit total of unique ulcers with an occurrence of In-House Acquired by ulcer stage for the Totals by Stage. Do not include healed or discontinued ulcers.
    2. Sum the unit total of unique ulcers with an occurrence of In-House Acquired for Total Current Ulcers.
    3. Divide #1 by #2 to calculate the % by Stage for the facility.
  • Facility total number of pressure ulcers with treatment time >30 days and percentages by ulcer stage
    1. Sum the unit total of unique ulcers with treatment days >30 days by ulcer stage for the Totals by Stage.
    2. Sum the unit total of unique ulcers with treatment days >30 days for Total Current Ulcers.
    3. Divide #1 by #2 to calculate the % by Stage for the facility.
  • Facility total number of new pressure ulcers developed by ulcer stage since previous monthly report
    1. Identify all pressure ulcers with Onset Date during the current month.
    2. Use unique pressure ulcer ID consisting of Resident ID, Onset Date, and Location.
    3. On the last assessment date of the month for each unique ulcer: If Followup Ulcer Status is healed and Current Visualized Ulcer Stage is blank, treat ulcer as healed. Healed ulcers do not contribute to the total number of # ulcers.
      Note: If followup ulcer status is healed and current visualized ulcer stage is NOT blank, make current visualized stage blank and treat ulcer as healed.
    4. On the last assessment date of the month for each unique ulcer: If Ulcer Status is not healed, use Current Visualized Ulcer Stage as ulcer stage.
    5. For each unique ulcer, sort by assessment date.
    6. For each ulcer stage, count the number of unique pressure ulcer IDs during month.
    7. Sum the number of unique ulcers with an ulcer stage for the Total by Unit.

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Current as of July 2009
Internet Citation: Pressure Ulcer Quality Improvement Monitoring Report: On-Time Pressure Ulcer Healing Project. July 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressure-ulcers/pressureulcerhealing/qimonitor.html