Electronic Quality Measures: Pressure Injuries

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, the estimated prevalence rate is 12.8%, 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:  

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What is the Quality Measure Hospital Harm: Pressure Injury HH-PI?

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:  

Staging Recognition:

• Stage 2, 3,4, Unstageable, and Deep Tissue Pressure Injury is included in the data collection of HH-PI ; the correct diagnosis of this pressure injury will require increased facility education.

Including but not limited to all admitted Patients from the below areas:

• The Emergency Department
• The Observation Area
• The Perioperative/Procedural Area

What is counted as an Inclusion?

• 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 PI that is identified greater than 24 hours or more from the start of the encounter. 
• A Deep Tissue Pressure Injury that is identified greater than 72 hours or more from the start of the encounter.   
• The encounter begins when a provider/care partner completes the assessment (not specific to the skin assessment) of a patient in the Emergency Department, Observation Area, or the Perioperative/Procedural Area, NOT when the admitting order is written.
• Time spent in the Emergency Room Department, Observation Area, Perioperative/Procedural Area followed by admission as an inpatient with a one hour transition.  
• Patients with a diagnosis of Skin Failure, diagnosis of Terminal Illness,  or receiving comfort measures or are discharged to Hospice Care. 
• A diagnosis of COVID-19 is yet to be determined as an inclusion.

What is counted as an Exclusion?  

• 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.  
• A diagnosis of COVID-19 is yet to be determined as an exclusion.

How is Performance Rate Calculated?

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 the encounter/episode of care that was not present on admission or found within the 24 hour or 72 hour defined time frames. This number is divided by the Denominator.  

Denominator: Initial population (Patients 18 years and older that were admitted and discharged during the measurement period) minus the combined amount of PIs present on admission, Stg 2 – Stg 4 and Unstageable Pressure Injuries that presented within 24 hours or less, and Deep Tissue Pressure Injuries that presented within 72 hours or less of the start of the encounter/episode of care.

This number multiplied by 100 yields the Performance Rate value, a lower number is better.

Example:  

Numerator Inclusions

A) DPTI not POA or not found on exam within 72 hours of encounter start

PLUS

B) Stage 2, 3, 4, or Unstageable PIs not POA or not found on exam within 24 hours   of encounter start

Denominator Exclusions

C) Number of inpatient hospitalizations (age 18 and older) during collection quarter

Minus

D) DPTI documented as  POA or found on exam within 72 hours

Download eCQM Infographic (PDF)

Resources:

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

CMS EH Measures - https://ecqi.healthit.gov/eligible-hospital/critical-access-hospital-eCQMs

Get Started with eCQMs - https://ecqi.healthit.gov/ecqms?qt-tabs_ecqm=education

Teach Me Clinical Quality Language (CQL) Video Series - https://ecqi.healthit.gov/cql?qt-tabs_cql=2

Hospitalization with Observation - https://www.youtube.com/watch?v=3yqwOU2XcZM&ab_channel=CMSHHSgov

What is a Value Set -https://register.gotowebinar.com/recording/4766956164118938369