Stagnant or Worsening Pressure Ulcers Report

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This report lists residents with pressure ulcers that have been treated for more than 20 days and for whom one of the following is true: (1) ulcer surface area is unimproved for two consecutive wound assessments or (2) ulcer has worsened since last assessment, as recorded by nursing on weekly wound assessment. Clinicians can use this report to help manage ulcers that remain unhealed 20 days after ulcer identification. Nurses report that a list of stagnant ulcers is not readily available because of the need to calculate manually how long wounds have been treated; therefore, organizing and tracking stagnant ulcers is not performed routinely.

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This report provides resident-specific ulcer information and associated clinical information that may be relevant in determining the cause of unimproved ulcers. Clinical information is captured by two sources: (1) certified nursing assistant (CNA) daily documentation, such as average meal intake, weight loss, and urinary incontinence episodes; and (2) nurse documentation of wound assessment, including acute change in resident health status, as documented on wound assessments. The report is intended to provide the clinician with insights into potential reasons for delays in ulcer healing and the total number of treatments implemented for each ulcer. It also indicates whether a treatment has not changed in 14 days so that alternative strategies can be initiated, if needed.

Assumptions:

1. Report can be sorted by nursing station or facility.
2. Report is sorted by resident, e.g., keep resident ulcers together.
3. Residents who are discharged are excluded from report.
4. Ulcers that are healed are excluded from report.
5. Most recent ulcer assessment data are displayed.

Sample Table: Stagnant or Worsening Pressure Ulcers

Ulcers > 20 days and ulcer surface area unimproved for 2 consecutive report weeks and/or ulcer status worsened for most recent report week

#	Room/ Bed	Resi- dent Name (Last, First)	Resi- dent ID	Ulcer Onset Date	Admit/ Acquired	Ulcer Site	Initial Stage	Highest Visual- ized Stage	Current Stage	Ulcer Length (cm)	Ulcer Width (cm)	Ulcer SA Unimproved 2 Wks	Ulcer Status Worse	Ulcer Days	Avg Meal Intake	Wt Loss ≥5% Within 30 Days	Acute Change in Health Status	# Tx Chg	BWAT Score
1	111/2	Brown, Betty	002229	4/1/07	AD	LHL	II	III	II	1.2	2.4		X	75	34%	X		6	35
2	234/2	Greene, James	003299	4/2/07 (R)	AQ	RB	II	IV	IV	1.3	1.6	X		74	57%	X		5*	51
3	314	Black, Richard	002229	3/5/07	AD	CX	III	III	II	2.1	1.6	X	X	100	63%		X	5*	45
4	322/2	White, Mary	000221	5/1/07	AD	LB	III	IV	II	0.6	1.2	X		44	40%			5	50
5	322/2	White, Mary	000221	5/10/07	AQ	LHL	II	II	II	0.8	1.4	X		34	33%			7	30

Column Definitions (all information captured on wound assessment form except where indicated)

Term	Definition
Room/Bed	Resident room and bed location
Resident Name	Last Name, First
Resident ID	Resident unique identifier
Ulcer Onset Date	Date ulcer first identified
Admit/Acquired	Ulcer found on admission (AD) or acquired (AQ)
Ulcer Site	Pressure ulcer location code; displays one code per resident per line
Initial Stage	Stage of ulcer when it was first identified: I, II, III, IV, Unstageable (U), or Deep tissue injury (DTI)
Highest Visualized Stage	Highest visualized ulcer stage; system stores current visualized ulcer stage each report week; display highest stored stage during course of ulcer. The facility acknowledges the National Pressure Ulcer Advisory Panel (NPUAP) and Wound, Ostomy and Continence Nurses (WOCN) recommendations not to downstage pressure ulcers; however, to comply with Medicare and Medicaid documentation requirements, pressure ulcers will be staged as visualized at the time of each report or assessment period. If resident is discharged, enter stage of ulcer at time of discharge.
Current Stage	Current ulcer stage; capture most recently reported ulcer stage from "current visualized ulcer stage" on wound assessment tool (Form 2)
Ulcer Length	Ulcer length (in cm) as recorded on wound assessment form, "ulcer length" field.
Ulcer Width	Ulcer width (in cm) as recorded on wound assessment form, "ulcer width" field.
Ulcer Surface Area (SA) Unimproved 2 Wks	Bates-Jensen Wound Assessment Tool (BWAT) for ulcer size parameters used to calculate the ulcer size by multiplying ulcer length x ulcer width; assign a value to results as follows: 1 = <4 sq cm 2 = 4-16 sq cm 3 = 16.1-36 sq cm 4 = 36.1-80 sq cm 5 = >80 sq cm X if ulcer surface area category has not decreased in past 2 weeks, e.g., if ulcer size = 2 for 2 consecutive weeks OR ulcer size increases to a 3 or greater value for 2 consecutive weeks
Ulcer Status Worse	X if ulcer status (outcome) = worsened (WO) for most recent report week; capture from wound assessment form field "followup ulcer status" = "worsening"
Ulcer Days	Duration of pressure ulcer in days as calculated from onset date to report date
Avg Meal Intake	Average meal intake (includes breakfast, lunch, and dinner) for the current week that matches this report. If the report is generated midweek, display average meal intake for the previous week. If meal intake is documented in ranges, the middle of the range should be the value used in the average calculation. For example, if a range is 51-75%, the percent value used would be 63%. If an option of Refused Meal or NPO (nothing by mouth) is selected, the value used in the average calculation should be 0. If missing meal intake value, i.e., CNA/dietitian tech did not document, no value should contribute to the average calculation.
Wt. Loss ≥5% Within 30 Days	X if resident had weight loss of ≥5% in the last 30 days Static Week Calculation: (from Nutrition Report specifications) Identify the resident's lowest weight for each static week starting at the current week and the dates of the lowest weekly weights. All weights referred to below are the lowest weekly weights. Keep all weights that occur in the last 35 days. Calculate the percentage of weight loss for all weights during that time period. For example, if four weights were taken for a resident (180 on 1/1/08, 170 on 1/7/08, 181 on 1/14/08, and 171on 1/24/08 where 1/21/08 is the current week), you would start with the weight farthest in time from the current weight (1/1/08) and calculate the percentage of weight loss with the three most recent weights. If a weight loss of ≥5% is identified and the time between the weight loss date and the date this report is generated is ≤30 days, display an X.
Acute Change in Health Status	X if resident has the risk factor "acute change in health status" checked on Resident Risk Factors section of wound assessment for report week (row #22)
# Treatment Changes	Treatment sum or # times the ulcer treatment orders have changed during course of ulcer care; treatment orders include "treatment" and "adjunctive therapy" categories of the wound assessment form. If one or more Treatment items selected, assign Treatment count as 1. If no Treatment items selected, assign Treatment count as 0. If "no change since last report date" selected, assign Treatment count as 0. If one or more Adjunctive Therapies items selected, assign Adjunctive Therapies count as 1. If no Adjunctive Therapies items selected, assign Adjunctive Therapies count as 0. If "no change since last report date" selected, assign Adjunctive Therapies count as 0. If Treatments count + Adjunctive Therapies count >0, # Treatment Changes for report week = 1; add 1 to previous Treatment Sum and display as # Treatment Changes.
No Treatment Change for 2 weeks	Display asterisk next to value in "# Treatment Changes" if there have not been treatment and adjunctive therapy changes for 2 or more report weeks; Treatment Sum = 0 for 2 consecutive report weeks or 14 days.
BWAT Score	See calculation below; range = 13-65.

Bates-Jensen Wound Assessment Tool (BWAT) Score

There are 13 value categories used to determine the BWAT score. For each category, assign a score using the value associated with the selected response. The sum of the 13 value category scores = BWAT score. If any of the 13 categories are missing a response, assign BWAT score to blank; all sections must have a response before BWAT score can be assigned.

1. Ulcer Size (length x width). Assign value 1-5:

   1 = <4 sq cm
   2 = 4-16 sq cm
   3= 16.1-36 sq cm
   4 = 36.1-80 sq cm
   5 = >80 sq cm

2. Ulcer Depth. Ulcer depth is not included on the wound assessment document. Use Current Visualized Ulcer Stage to assign depth score:

   If Stage I, Depth = 1
   If Stage II, Depth = 2
   If Stage III, Depth = 3
   If Stage IV, Depth = 4
   If Healed, Depth = 0
   If Unstageable, Depth = 4

3. Wound Edges
4. Undermining
5. Necrotic Tissue Type
6. Necrotic Tissue Amount
7. Drainage/Exudate Type
8. Drainage/Exudate Amount
9. Peri Wound Area
10. Peri Wound Edema
11. Peri Wound Induration
12. Granulation
13. Epithelialization

Note: If any value category has more than five response options, assign a score of 5 to each additional response beyond 5. For example, Drainage/Exudate Type category has 6 options, so option 5 and option 6 are each assigned a score of 5; one response per category for maximum score 65.

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Current as of July 2009

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Internet Citation:

On-Time Pressure Ulcer Healing Project: Stagnant or Worsening Pressure Ulcers Report. July 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/pressureulcerhealing/stagnworse.htm

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