Module 5: How To Measure Pressure Injury Rates and Prevention Practices

Slide Presentation

Slide 1: How To Measure Pressure Injury Rates and Prevention Practices

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ADD Hospital Name Here

Module 5

Slide 2: Basic Quality Improvement  Principle

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If you can’t measure it, you can’t improve it.

Image: Puzzle pieces are labeled “assess readiness,” “manage change,” “implement practices,” “best practices,” “measure,” “sustain,” and “tools.” The piece labeled “measure” is highlighted in blue.

Slide 3: Quality Improvement Principle

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  • Pressure injury rates and prevention practices must be counted and tracked as one component of a quality improvement program.

Image: Photograph shows a medical provider writing and using laptop.

Slide 4: Module 5 Goals

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  • The Implementation Team will agree on and develop a plan for:
    • Measuring pressure injury rates.
    • Measuring pressure injury prevention practices.
    • Communicating trends in pressure injury rates to key stakeholders.

Slide 5: Definition of Pressure Injury

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  • National and international (NPUAP-EPUAP) pressure injury definition:
    Localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical or other device. The injury occurs as a result of intense and/or prolonged pressure, or pressure in combination with shear.
  • National Database of Nursing Quality Indicators (NDNQI) uses the same definition.

Slide 6: Pressure Injury Definition

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  • Do you use the NPUAP definition to measure and monitor pressure injuries?
    • If not, what other definition would be appropriate for this hospital?
  • Definition should be incorporated into:
    • Policies and procedures.
    • Root cause analyses/huddles.
    • Staff education (definition and stages).

Slide 7: Pressure Injury Staging

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  • There are four stages of pressure injuries.
  • The stages range from mild reddening of the skin to severe tissue damage that can become infected, extending into muscle and bone.

Slide 8: Stage 1

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  • Intact skin with nonblanchable redness of a localized area, usually over a bony prominence.

Image: Cross-section of Stage 1 pressure injury.

Source: National Pressure Ulcer Advisory Panel.

Slide 9: Stage 2

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  • Shallow open injury with a red-pink wound bed.
  • No slough.

Image: Cross-section of Stage 2 pressure injury.

Source: National Pressure Ulcer Advisory Panel.

Slide 10: Stage 3

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  • Full-thickness tissue loss.
  • Visible subcutaneous fat.
  • No exposed bone, tendon, or muscle.

Image: Cross-section of Stage 3 pressure injury.

Source: National Pressure Ulcer Advisory Panel.

Slide 11: Stage 4

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  • Full-thickness tissue loss.
  • Exposed bone, tendon, or muscle.

Image: Cross-section of Stage 4 pressure injury.

Source: National Pressure Ulcer Advisory Panel.

Slide 12: Unstageable

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  • Full-thickness skin and tissue loss in which the extent of tissue damage within the injury cannot be confirmed because it is obscured by slough or eschar.
  • If slough or eschar is removed, a Stage 3 or 4 pressure injury will be revealed.

Image: Cross-section of unstageable pressure injury.

Source: National Pressure Ulcer Advisory Panel.

Slide 13: Deep Tissue Injury

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  • Persistent nonblanchable deep red, maroon, or purple discoloration.

Image: Cross-section of suspected deep tissue injury.

Source: National Pressure Ulcer Advisory Panel.

Slide 14: What Should Be Monitored?

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  • It is recommended that you regularly monitor:
    • An outcome measure, preferably pressure injury incidence or prevalence rates.
    • At least one or two care processes, such as skin assessment and pressure injury risk assessment.
    • Key aspects of the infrastructure to support best care practices, such as clear lines of responsibility for overseeing the accuracy of skin assessments.

Slide 15: Measuring Pressure Injury Rates

Measuring Pressure Injury Rates

Slide 16: Measure Only Pressure Injuries

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  • Many types of skin lesions may develop in hospitalized patients.
  • Pressure injuries are areas of soft tissue damage caused by pressure or pressure and shear.
  • Do not count skin lesions not related to pressure, such as skin breaks or maceration from friction/moisture.
  • If not sure, ask the Wound Care Team or Nurse.

Slide 17: Measures

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  • Measures used in monitoring pressure injury rates:
    • Incidence.
    • Prevalence.

Slide 18: Incidence Rate

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  • Describes the number or percentage of patients developing a new pressure injury while in the hospital or on a particular unit.
  • Provides the most direct evidence of the quality of your care.
  • Should be the focus of your quality improvement efforts.

Slide 19: Prevalence Rate

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  • Prevalence rate describes the number or percentage of patients who have a pressure injury while in the hospital or unit.
    • Point prevalence reflects a single point in time.
    • Period prevalence reflects a prolonged period of time, such as an entire hospital stay.
    • Point and period prevalence include injuries present on admission and new injuries that develop in your facility or unit.

Slide 20: Calculation Requirements

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  • Conduct a comprehensive skin assessment on every patient.
  • Document the results of the assessment, noting:
    • Presence of an injury.
    • Number of injuries.
    • Location of injuries.
    • Stage of the deepest injury.

Slide 21: Common Methodology

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  • Monitor pressure injury rates:
    1. Choose a date.
    2. Have an outside expert perform a skin exam on each patient.
    3. Document the presence of each pressure injury:
      • Stage of injury.
      • New injury or present on admission.
    4. This process helps you determine incidence and prevalence rates.

Slide 22: Incidence Calculation

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Monthly Unit Numbers Example
# of patients who develop a new pressure injury after admission 21 patients with a new pressure injury
# of patients who develop a new >Stage 2 injury after admission 5 patients with a new >Stage 2 pressure injury
# of patients admitted during the month in question 227 patients admitted
# of patients with a new pressure injury divided by # of patients admitted 21/227 = .093
5/227 = .022
Times 100 .093 X 100 = 9.3% with an acquired pressure injury
.022 X 100 = 2.2% with an acquired Stage 2 or greater pressure injury

Slide 23: Prevalence Calculation

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Monthly Unit Numbers Example
# of patients with any pressure injury (count only patients, not the # of injuries) 17 patients with any pressure injury
# of patients with a >Stage 2 pressure injury 5 patients with >Stage 2 pressure injury
# of patients admitted during the month in question 183 patients
# of patients with a pressure injury divided by # of patients admitted during the month in question 17/183 = .093
5/183 = .027
Times 100 .093 X 100 = 9.3% with a pressure injury
.027 X 100 = 2.7% with a Stage 2 or greater pressure injury

Slide 24: Who Will Calculate Rates?

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  • When you complete your Action Plan, you will:
    • Identify sources of data to complete.
    • Select a person or team responsible for doing the calculations and tracking.
    • Count the number and stage of pressure injuries in a month.

Image: Photograph shows two providers reviewing documents.

Slide 25: Stage 3 and 4 Injuries

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  • All pressure injuries are important to address.
  • Yet Stage 3 and 4 injuries are very serious.
  • Study what led to the occurrence.
    • Usually when a deep pressure injury develops, it reflects a system failure.
  • Conduct a root cause analysis.

Image: An icon of a magnifying glass in front of open book refers to Page 81.

Slide 26: Use of Data

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  • Examine the rates for trends over time:
    • Graph the data to visually examine.
    • Are the rates getting better or worse?
    • Can you relate changes in rates to changes in practice?
    • Rates are probably quite different by patient unit.
    • Focus on trends over time. There will be fluctuations. Don’t overreact.

Slide 27: Displaying Data/Storytelling

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  • Run charts.
  • Annotation: Show your interventions.

Slide 28: Annotated Run Chart Example

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Intervention: Unit education, biweekly audits
Pilot Unit: ICU

Image: A line graph shows the number of pressure injuries, annotated with interventions.

Slide 29: Annotated Run Chart Example

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Intervention: Annual education fair for all hospital staff and Shadowing Program in pilot units
Pilot Units: Med-Surg Unit and Critical Care Unit

Image: A line graph shows the number of Stage 2 or greater hospital-acquired pressure injuries per 1,000 patient days, annotated with interventions.

Slide 30: Annotated Run Chart Example

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Images: Four line graphs chart the Percentage of Patients With Skin Assessment Within 24 Hours of Admission, before and after intervention, and Percentage of Patients with hospital-acquired pressure injuries (HAPIs) per 1,000 patient days, before and after intervention. A line between the before and after parts of the graph show when skin assessment training and monitoring compliance were initiated in pilot unit.

Slide 31: Painting the Picture With Data

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  • Data can tell you:
    • Is your program improving?
    • Are your patients safer?

Slide 32: Use of Data

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  • Find ways to disseminate the information to key stakeholders and unit staff.
    • Post monthly rates where all staff can see how the unit is doing.
    • Send reports to leadership.

Image: Photograph shows medical providers looking at papers.

Slide 33: Practice Insight

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Visibility board shows:

  • Immediate feedback each week.
  • Best practice plans for improvement.
  • Unit goal.
  • Trended data.

Images: Icon of binoculars. Photograph of a visibility board.

Slide 34: Measuring Key Processes of Care

Measuring Key Processes of Care

Slide 35: Measuring Prevention Practices

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  • Measuring pressure injury rates tells you how your facility is performing.
  • Measuring pressure injury prevention practices may tell you how to improve care.
    • If the pressure injury rate is high, what specific areas should you focus on?
    • Are key practices to reduce pressure injuries being used consistently?

Slide 36: Which Prevention Practices Should Be Measured?

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  • Initially, look at three practices:
    1. Performance of comprehensive skin assessment within 24 hours of admission.
    2. Performance of standardized risk assessment within 24 hours of admission.
    3. Performance of care planning that addresses each risk factor identified during risk factor assessment.

Image: Photograph shows medical providers standing at a patient’s bedside.

Slide 37: Performance Review of Comprehensive Skin Assessment

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  • Ensure that a skin assessment was performed within 24 hours of admission.
  • Use Tool 5C: Assessing Comprehensive Skin Assessment.

Images: A screenshot shows a sample comprehensive skin assessment. An icon of a magnifying glass in front of open book identifies this as Tool 5C.

Slide 38: Risk Factor Assessment Within 24 Hours

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  • Use the Braden Pressure Injury Scale (or the one this hospital agreed on).
  • Ensure the known risk factors for pressure injuries are assessed.
  • Tool 5D provides a sample protocol for assessing performance.                                  

Slide 39: Risk Assessment Measurement Example

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Images: A screenshot shows a sample standardized risk assessment. An icon of a magnifying glass in front of open book identifies this as Tool 5D.

If available, use data from your EHR to support calculation of this measure.

Slide 40: Assessment of Care Planning

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  • All the risk factors identified in the pressure injury risk factor assessment need to be addressed in the patient’s care plan.
  • Act on the care plan:
    • Use critical thinking.
    • Tailor your approach to each patient, based on the patient’s risk factors.
  • Ensure that the care plan addresses all areas of risk.

Slide 41: Care Plan Measurement Example

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Images: A screenshot shows a sample care planning assessment. An icon of a magnifying glass in front of open book identifies this as Tool 5E.

Slide 42: Pressure Injury Prevention Practices

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  • Good performance on these key processes is critical to preventing pressure injuries.
  • There is always an opportunity for improvement if you aren’t doing as well as you’d like.
  • Examine what the problem is, and plan how to overcome this barrier.

Slide 43: Action Plan for Measuring Progress

Action plan for measuring progress

Slide 44: Measurement Action Plan

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Action Plan Tool To Measure Pressure Injury Rates and Prevention Practices

Measure Pressure Injury Rates
Key indicator Who is responsible? Completion date for plan
Incidence and/or prevalence pressure injury rates are calculated.    
Pressure injury rates are monitored at least quarterly, and preferably monthly.    
Information on rates is disseminated to key stakeholders and staff.    
Root cause analysis is conducted for each >Stage 2 pressure injury.    
Measure Pressure Injury Prevention Practices
Key indicator Who is responsible? Completion date for plan
Comprehensive skin assessment is performed accurately within 24 hours of admission.    
Pressure injury risk factor assessment is performed accurately within 24 hours of admission.    
Care plan addressing every deficit on pressure ulcer risk factor assessment has been developed and is being implemented.    

 

Slide 45: Action Plan

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  • Your Measurement Action Plan becomes Key Intervention 5.

Images: A sample Action Plan is shown with Key Intervention 5 circled in red. An icon of a magnifying glass in front of open book sits above the text "Refer to your Action Plan Template."

Slide 46: Summary of Accomplishments

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  • Discussed:
    • Measuring pressure injury rates.
    • Measuring pressure injury prevention practices.
    • Communicating the trends in pressure injury rates to key stakeholders.
  • Developed a Measurement Action Plan.
  • Developed an overall Pressure Injury Prevention Program Action Plan.

Slide 47: Next Steps

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  • Over the next several weeks, we will meet weekly to refine your Action Plan for the Pressure Ulcer Prevention Program.
  • Thank you for being part of this Team to make this hospital safer for patients.
Page last reviewed October 2017
Page originally created September 2017
Internet Citation: Module 5: How To Measure Pressure Injury Rates and Prevention Practices. Content last reviewed October 2017. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/professionals/systems/hospital/pressureinjurypxtraining/workshop/module5/mod5-slides.html
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