Electronic Quality Measures: Pressure Injuries

Download Infographic here: eCQM Infographic

Electronic Clinical Quality Measure – eCQM  

What is it?

The Centers for Medicare and Medicaid (CMS) report that the incidence of pressure injuries in hospitalized patients has been estimated at 5.4 per 10,000 patient days and the rates of hospital-acquired pressure injuries has been estimated at 8.4%. The Inpatient Prospective Payment System (IPPS) is how Medicare pays eligible facilities for inpatient stays. Instead of billing for every service, these facilities receive a fixed payment based on the patient’s diagnosis and treatment. This system rewards these facilities for being efficient while ensuring quality care. Complying with these regulations is critical for a facility as it leads to financial incentives and helps a facility avoid penalties while improving the quality of care provided to patients. There are currently 15 quality measures that will be phased in over the next several years. See the list below:  

The focus of education by NPIAP is the quality measure Hospital Harm: Pressure Injury HH-PI. This quality measure has been mandated by CMS to be reported in 2028. The CMS calendar year begins its calendar year in the last quarter of the previous year (October to December of 2027). CMS will quarterly abstract pressure injury data directly from the hospital electronic medical record system. The system will abstract data from patient records, who are 18 years old and older, that have developed a pressure injury during their health care encounter (hospitalization) during that quarter. The severity of a pressure injury is not the focus but rather the actual occurrence of a new pressure injury.

NPIAP recognizes that there are new areas of concern for which we can provide support and education:  

• Stage 2 is now reportable, the correct diagnosis of this pressure injury will require increased facility education.
• The Emergency Room has not been a historically a focused department for pressure injury prevention. This department will require increased education for pressure injury documentation and resources for pressure injury prevention when patients remain in the department for greater lengths of time awaiting an inpatient bed.
• The Observation Department has not been a historically a focused department for pressure injury prevention. This department will require increased education for pressure injury documentation and resources for pressure injury prevention when patients remain in the department for   
  greater lengths of time awaiting an inpatient bed.
• The Perioperative Area does have pressure injury prevention within their own guidelines. This area may require renewed structure review and resources for implementation of a pressure injury prevention program in a three of the Perioperative Areas.   

Performance Rate = Facility Payment %

What is counted (aka Inclusions)?

Patients 18 years and older

• Only one new occurrence of harm is counted per patient.
• Stage 2 through Stage 4, Deep Tissue Pressure Injury, and Unstageable   
  pressure injuries that were not present at the start of the encounter qualify as an occurrence against the facility.

• A Stage 2 through Stage 4 and Unstageable that becomes present greater than 24 hours or more from the start of the encounter. 
• A Deep Tissue Pressure Injury that becomes present greater than 72 hours or more from the start of the encounter.   

• The encounter begins when a provider completes the assessment of a patient in the Emergency Room, Observation Area, or the Pre-Op Area, NOT when the admitting order is written.
• Time spent in the Emergency Room Department or the Observation Department followed by admission as an inpatient within a one hour transition.  
• The EMR cannot be changed if a pressure injury is misdiagnosed. A chart addendum may be entered and attached to the patient record stating the correction. Records with attached addendums will be reviewed separately if the correction is entered within the measure time period.  
• Patients with a diagnosis of Skin Failure or who are terminally ill who are receiving comfort measures or who are discharged to hospice care. 

What is not counted (aka Exclusions)?  

• Stage 2 through 4 and Unstageable pressure injuries documented as present on admission  
• Stage 2 through 4 and Unstageable pressure injuries that evolve to be present within 24 hours or less from the start of the encounter.  
• Deep Tissue Pressure Injuries documented as present on admission.  
• Deep Tissue Pressure Injuries that evolve to be present within 72 hours or less from the start of the encounter.  
• Patients with the admitting diagnosis of COVID-19.

The Performance Rate for a facility is determined by dividing the numerator by the denominator multiplied by 100 to give a percentage value using the calculation below:

Numerator: Patients 18 years and older that develop a new pressure injury during hospitalization that were not present on admission or found within the 24 hour or 72 hour defined time frames.  

Denominator: Initial population(Inpatient hospitalizations for patients 18 years and older during the measurement period) minus PIs present on admission, and/or minus Stg 2 – Stg 4 and Unstageable Pressure Injuries that present within 24 hours or less, and/or minus Deep Tissue Pressure Injuries that present within 72 hours or less of the start of the encounter, and minus those patients with a diagnosis of COVID.

This number is the Performance Rate value, a lower number is better.

Example:  

400 ÷ 14,000 – (250 + 150 + 50) = 400 ÷ 13550 = 2.95%

Resources:

eCQI Resource Center: https://ecqi.healthit.gov/

eCQM 101: https://ecqi.healthit.gov/sites/default/files/eCQM-101-Introduction-122023.pdf