Intermountain-led CMS Hospital Engagement Network

Preventing Pressure UlcersMarch 25, 2014

Affinity Call

Marlyn Conti –Patient Safety Coordinator, IntermountainMonica Spencer—NP/ Manager Wound Care, Baylor Scott & White HealthGina Honermann-Garinger—Baylor Scott & White Health Center for Clinical Innovation

Outline for Discussion

• Review of 2013 data through Q4• ‘High performers’ – what are they doing?• PfP recommended metrics• “Just-one-thing” – updated document• 2014 plans for improvement:– Reach out to low performers to provide assistance.– Baylor has called a task force together to review the

HAPU policy/procedure and document performance– Intermountain PrU Bundle

Overall Progress Through 2013

Intermountain HEN 2012-13 submitting Hospitals

AHRQ PSI 3 Pressure Ulcers

National high performing benchmark (0.25)

Intermountain HEN 2012-13 submitting Hospitals

AHRQ PSI 3 Pressure Ulcers

Intermountain HEN 2012-13 submitting HospitalsHAPU (Prevalence)

Intermountain HEN 2012-13 submitting HospitalsHAPU (Prevalence)

HEN Pressure Ulcer Measures

• Metric specification resource manual http://www.henlearner.org/wp-content/uploads/2012/03/HEN_measure_Feb5.pdf

• Submission schedule: – May 20, 2014: for data through March 2014

HEN Pressure Ulcer MeasuresPSI 3

SOURCE/DEFINITION NUMERATOR DENOMINATOR

Outcome Decubitus ulcer - Adult

AHRQ PSI #3 Patients with Stage III, Stage IV or unstageable pressure ulcers

Inpatient discharges among cases meeting the inclusion and exclusion rules for the denominator with ICD-9-CM code of pressure ulcer in any secondary diagnosis field and ICD-9-CM code of pressure ulcer stage III or IV (or unstageable) in any secondary diagnosis field.

ICD-9-CM Pressure ulcer diagnosis codes:7070 – PRESSURE ULCER70700 - PRESSURE ULCER, SITE NOS70701 - PRESSURE ULCER, ELBOW70702 - PRESSURE ULCER, UPR BACK70703 - PRESSURE ULCER, LOW BACK70704 - PRESSURE ULCER, HIP 70705 - PRESSURE ULCER, BUTTOCK70706 - PRESSURE ULCER, ANKLE 70707 - PRESSURE ULCER, HEEL70709 - PRESSURE ULCER, SITE NEC ICD-9-CM Pressure ulcer stage diagnosis codes:70723 - PRESSURE ULCER, STAGE III 70724 - PRESSURE ULCER, STAGE IV 70725 – PRESSURE ULCER, UNTAGEBL

All inpatient medical and surgical discharges age 18 years and older defined by specific DRGs or MS-DRGs.

EXCLUDE CASES:• with length of stay of less than 5 days• with principal diagnosis of pressure ulcer or a secondary

diagnosis of pressure ulcer present on admission* and a secondary diagnosis of pressure ulcer stage III or IV present on admission

• MDC 9 (Skin, Subcutaneous Tissue, and Breast)• MDC 14 (pregnancy, childbirth, and puerperium)• with any diagnosis of hemiplegia, paraplegia, or

quadriplegia• with any diagnosis of spina bifida or anoxic brain damage• with a procedure code for debridement or pedicle graft

before or on the same day as the major operating room procedure (surgical cases only)

• transfer from a hospital (different facility)• transfer from a Skilled Nursing Facility (SNF) or

Intermediate Care Facility (ICF)• transfer from another health care facility• with missing gender (SEX=missing), age (AGE=missing),

quarter (DQTR=missing), year (YEAR=missing) or principal diagnosis (DX1=missing)

* Only for cases that otherwise qualify for the numerator

HEN Pressure Ulcer MeasuresHAPU Prevalence

SOURCE/DEFINITION NUMERATOR DENOMINATOROutcome HAPU Prevalence

NDNQI Prevalence Patients with hospital acquired pressure ulcers

The total number of patients with a hospital-acquired pressure ulcer.

INCLUDE:Stage 1,2,3,4, unstageable and deep tissue

injuries. EXCLUDE:Pressure ulcers present on arrival.

Number of patients surveyed during the prevalence survey day.

INCLUDE: Inpatients, short stay patients, observation patients,

and same day surgery patients who receive care on an inpatient unit for all or part of a day.

Critical care, step-down, medical, surgical, medical-surgical combined, critical access and rehabilitation inpatient units.

Patients of any age on an eligible reporting unit

HEN Pressure Ulcer MeasuresHAPU Prevalence—Stage III & greater

SOURCE/DEFINITION NUMERATOR DENOMINATOROutcome HAPU ≥ St3 Prevalence

NDNQI St3 Prevalence Patients with hospital acquired pressure ulcer stage 3 or greater

Count of hospital acquired pressure ulcers stage 3 or greater.

INCLUDE: Stage 3, 4 injuries. EXCLUDED: Pressure ulcers present on arrival.

Number of patients surveyed during the prevalence survey day.

INCLUDE: Inpatients, short stay patients, observation patients,

and same day surgery patients who receive care on an inpatient unit for all or part of a day.

Critical care, step-down, medical, surgical, medical-surgical combined, critical access and rehabilitation inpatient units.

Patients of any age on an eligible reporting unit

Should we change this to be in-line with the national metric and include stage II and greater?

High Performing Hospital Highlight… % Improvement

• Baylor University Medical Center - actionsHospital NameSUTTER COAST HOSPITALBAYLOR MEDICAL CENTER AT WAXAHACHIETHE HEART HOSPITAL BAYLOR PLANODENVER HEALTH MEDICAL CENTERBAYLOR MEDICAL CENTER AT CARROLLTONCALIFORNIA PACIFIC MEDICAL CTRBAYLOR ALL SAINTS MEDICAL CENTER AT FWBAYLOR MEDICAL CENTER AT IRVINGBAYLOR REGIONAL MEDICAL CENTER AT GRAPEVINEBAYLOR MEDICAL CENTER AT GARLANDBAYLOR UNIVERSITY MEDICAL CENTERSUTTER ROSEVILLE MEDICAL CENTERALTA VIEW HOSPITALAMERICAN FORK HOSPITAL

High Performing Hospital Highlight… Rates

Hospital Acquired Pressure Ulcers (Prevalence)Top 10 HOSPITALS

ALTA VIEW HOSPITALOREM COMMUNITY HOSPITALPARK CITY MEDICAL CENTERTHE ORTHOPEDIC SPECIALTY HOSPITALBEAR RIVER VALLEY HOSPITALSANPETE VALLEY HOSPITAL - CAHBAYLOR MEDICAL CENTER AT WAXAHACHIEST PATRICK HOSPITALHILLCREST BAPTIST MEDICAL CENTERDELTA COMMUNITY MEDICAL CENTER

Just One Thing MatrixRecommendations

Getting Started Working Harder Ahead of the Curve

Appoint a leadership supported team or work group to drive improvement & education SWAT (or champion) teams that includes unit nurse

(moderate-high evidence)

Adopt decision algorithms for nursing staff to select appropriate surfaces, physical therapy and dietary referrals

(moderate-high evidence)

Establish monthly prevalence studies or collect incidence data from electronic medical records, then feed that data back to the SWAT teams

(moderate-high evidence)

Intermountain Pressure Ulcer Bundle

Getting StartedAccess Available Tool Kits

• Preventing Pressure Ulcers in

Hospitals: A Toolkit for Improving Quality of Care http://www.ahrq.gov/research/ltc/pressureulcertoolkit/

• National Pressure Ulcer Advisory Panel http://www.npuap.org/

• http://www.Henlearner.org

• AHRQ PSNet http://www.psnet.ahrq.gov/

• AHRQ Web M&M http://www.webmm.ahrq.gov/

• AHRQ Health Care Innovations Exchange http://www.innovations.ahrq.gov/

Getting Started

2014 plans for improvement

• Reach out to low performers to provide assistance.• Baylor has called a task force together to review the

HAPU policy/procedure and document performance• Intermountain PrU Bundle• Collect and share best practices across our network

hospitals & system in a single document