AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention
3. Specifications for Each Pressure Ulcer Prevention Report (continued)
3.4. Trigger Summary Report: Resident Level
3.4.1. Report Description
There are two Trigger Summary Reports. Each report uses the same risk variables; the Resident Level report displays resident-specific data for a specified nursing unit and the Unit Level report displays risk for the entire census of a single nursing unit.
Each report displays residents who have at least one trigger activated during the report week presented in descending order of total number of pressure ulcer triggers for the report week. The report displays the prior week trigger totals and the current total, and provides a weekly snapshot of a resident’s risk for pressure ulcer development. These triggers are derived primarily from electronic CNA documentation.
3.4.2. Dependencies and Clinical Assumptions
188.8.131.52. Resident weights are recorded in the EMR.
184.108.40.206. Electronic daily documentation by CNA staff is required for the following:
- Meal Intake.
220.127.116.11. Weekly wound assessments are recorded in the EMR.
18.104.22.168. Physician order entry or nurse documentation is required for the following:
- Foley Catheter.
3.4.3. Report Example
|Name||Room||Wt Loss ≥5% in Prior 30 Days (Any)||Wt Loss ≥7.5% in Prior 90 Days (Point-to-Point)||Wt Loss ≥10% in Prior 180 Days (Point-to-Point)||2 Meals ≤50% in 1 Day||Weekly Meal Intake Average <50%||Daily Urinary Incont||>3 Days Bowel Incont||Foley Catheter||Current Pressure Ulcer||# of Triggers Last Week||# of Triggers This Week|
3.4.4. Valid Input, Calculations, and Displays
22.214.171.124. Completeness of main categories for each resident must be >75% in order to calculate the triggers.
126.96.36.199. There are nine criteria for pressure ulcer risk. Only residents having at least one of the nine criteria during the report week will display on this report.
188.8.131.52. Sort the residents in descending order of the number of triggers for the current report week and then alphabetically by resident last name.
184.108.40.206. Display a dash (-) in cells when there is insufficient documentation to compute values.
220.127.116.11. For calculations in sample report, assume 35 residents on the nursing unit (denominator = 35) and 10 residents meet criteria for risk and display on the report.
18.104.22.168. Use the same rules, calculations, and displays for weights as described for the Weight Summary Report in 3.3.4 for the following cells:
- Wt Loss ≥5% in Prior 30 Days (Any).
- Wt Loss ≥7.5% in Prior 90 days (Point-to-Point).
- Wt Loss ≥10% in Prior 180 Days (Point-to-Point).
|Report Column||Data Source||Valid Input & Display|
|Wt Loss ≥5% Prior 30 Days (Any)||Vital Signs or Weight documentation||Use same calculations as used in Weight Summary Report.
The calculations below will identify ANY weight loss within the last 30 days.
Static Week Calculation:
|Wt Loss ≥7.5% in Prior 90 days (Point-to-Point)||Vital Signs or Weight documentation||Note: Use same calculations as used in Weight Summary Report.
Displays weight loss ≥7.5% in 90 days.
Static Week Calculation:
|Wt Loss ≥10% in prior 180 Days (Point-to-Point)||Vital Signs or Weight documentation||Note: Use same calculations as used in Weight Summary Report.
Displays resident weight loss ≥10% in the last 180 days.
Static Week Calculation:
|2 Meals ≤50% in 1 Day||CNA documentation of meal intake||Display X if meal intake is ≤50% for two meals in one day. Do not display X if:
|Weekly Meal Intake Average <50%||CNA documentation of meal intake||If meal intake completeness is <75% for the current week, then display a dash, -, for the resident.
Use calculation from the Nutrition Report.
|Daily Urine Incontinence||CNA documentation of resident bladder habits||If resident has ≥1 episodes of urinary incontinence each day for the current week, then display an X.|
|>3 Days Bowel Incontinence||CNA documentation of resident bowel habits||If resident has ≥1 episode of bowel incontinence for >3 days during the current week, then display an X.|
|Foley Catheter||Physician Orders or nurse documentation||
|Current Pressure Ulcer||Nurse Wound Assessment||If the resident has at least one pressure ulcer for the current week, then display an X.|
|# of Triggers Last Week||Prior Week Total from Trigger Summary Report: Resident Level||Carry forward the total number of triggers (columns listed above) that the resident had for the previous week and display count in the column.
Note: If unable to store previous count, then recalculate using same rules.
|# of Triggers This Week||For each resident on the report, count the number of X’s and display count.|
|Total||For each column on the report (i.e., Wt Loss ≥5% in Prior 30 Days (Any), Wt Loss ≥10% in Prior 180 Days, 2 Meals ≤50% in 1 Day, Weekly Meal Intake Average <50%, Daily Urine Incontinence, >3 Days Bowel Incontinence, Foley Catheter, and Current Pressure Ulcer), count the number of X’s and display count.|
Page originally created September 2014