Table 9 'Decubitus Ulcer'

PSI 38: Decubitus Ulcer
Review of OECD PSI/AHRQ/CIHI PSI (3;33)
Dimension Description
Description of Specific
Aspects of Patient Safety
Decubitus ulcers or bedsores are a common complication of inadequate
care for immobilised patients. The occurrence of a decubitus ulcer in a
hospitalised patient has a serious negative impact on the individual’s
health and often leads to a much prolonged hospital stay. Decubitus
ulcers can be prevented with good quality nursing care. Thus, the
indicator has great clinical plausibility as a patient safety measure.
Aim of the PSI This PSI is intended to flag cases of in-hospital decubitus ulcers.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) This indicator was originally proposed by Iezzoni et al. as part of the
Complications Screening Program (CSP 6, “cellulitis or decubitus
ulcer”). Needleman and Buerhaus identified decubitus ulcer as an
“outcome potentially sensitive to nursing” The American Nurses
Association, its State associations, and the California Nursing
Outcomes Coalition have identified the total prevalence of inpatients
with Stage I, II, III, or IV pressure ulcers as a “nursing-sensitive
quality indicator for acute care settings” (3).
Extent of Clinically
Testing
The OECD Health Care Quality Indicators (HCQI) Project was
initiated to implement quality measures for international
benchmarking of medical care at the health system level. Five priority
areas including patient safety were selected. International expert
panels were formed to identify clinically important, scientifically
sound, and feasible measures based on a structured consensus process.
The consensus process was successfully completed in all five priority
areas leading to a recommendation of 86 indicators of which 21
covered patient safety (34).
The project team developing the AHRQ PSI conducted extensive
empirical analyses on this PSI. The team concluded that this PSI
generally performs well on several different dimensions, including
reliability, bias, relatedness of indicators, and persistence over time.
(3).
While the indicator was found to be well operationalised, the biggest
threat to construct validity is the inability to precisely distinguish
between pre-existing and hospital-acquired decubitus ulcers on the
basis of administrative data (33)
The AHRQ PSI software was applied to Veteran Affairs (VA)
administrative data to identify potential instances of compromised
patient safety; determine occurrence rates of PSI events in the VA;
and examine the construct validity of the PSIs. The study population
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25
was 97% male, with a mean age of 65 years, 54% were age 65 and
older. Mean length of stay was 7.1.days. All together 11411 PSI
events were identified, 46% of PSI events occurred in surgical
hospitalisation and 54% in medical hospitalisation. The observed PSI
rate per 1000 discharges was 15.41 the highest of all for decubitus
ulcer. This PSI was not significantly associated with any other PSI
studied. Statistically differences were found for hospitalisations with
this PSI events and those without PSI events for longer lengths of
stay, higher mortality and higher costs (4).
The performance of the AHRQ PSIs was analysed to: 1) provide a
descriptive analysis of the incidence of PSI events from 2001 to 2004
in the VA; 2) examine trends in national PSI rates at the hospital
discharge level over time; and 3) assess whether hospital
characteristics (e.g., teaching status, number of beds, and degree of
quality improvement implementation) and baseline safety-related
hospital performance predict future hospital safety-related
performance. Risk-adjusted rates of the PSI for iatrogenic
pneumothorax and failure to rescue demonstrated a consistent rate over
time. After accounting for patient and hospital characteristics,
hospitals' baseline risk-adjusted PSI rates were the most important
predictors of the 2004 risk-adjusted rates for eight PSIs among these
decubitus ulcer. It was concluded, that the PSIs are useful tools for
tracking and monitoring patient safety events. Future research should
investigate whether trends reflect better or worse care or increased
attention to documenting patient safety events (5).
Administrative data from community hospitals in 16 US states with
reliable race/ethnicity measures using the AHRQ PSIs was analysed to
determine whether racial and ethnic differences in patient safety
events disappear when income (a proxy for socioeconomic status) is
taken into account. No differences in the occurrence of this PSI event
were found according to race. It was concluded that: ”The AHRQ
PSIs are a broad screen for potential safety events that point to needed
improvement in the quality of care for specific populations” (7).
AHRQ is determining the feasibility and practicality in a project
concerning validation of selected AHRQ Quality Indicators (8).
The results suggest that this PSI may be useful as a measure of patient
safety (3-5;7;8;33;34).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Institution-wide PSI.
Data definitions Cases of decubitus ulcer per 1000 discharges with a length of stay
greater than 4 days.
Numerator Description Discharges with ICD-9-CM code of decubitus ulcer in any secondary
diagnosis field.
Denominator Description All medical and surgical discharges 18 years and older defined by
specific DRGs.
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Exclude cases:
− with length of stay of less than 5 days
− with ICD-9-CM code of decubitus ulcer in the principal diagnosis
field
− MDC 9 (Skin, Subcutaneous Tissue, and Breast)
− MDC 14 (pregnancy, childbirth, and puerperium)
− with any diagnosis of hemiplegia, paraplegia, or quadriplegia
− with an ICD-9-CM diagnosis code of spina bifida or anoxic brain
damage
− with an ICD-9-CM procedure code for debridement or pedicle graft
before or on the same day as the major operating room procedure
(surgical cases only)
− admitted from a long-term care facility (Admission Source=3)
− transferred from an acute care facility (Admission Source=2)
Data Source Administrative data.
Identifying the
institutional context
The impact of decubitus makes this PSI important for both financial
and quality improvement policies.
Care Setting The PSI applies for high quality nursing care.
Professionals Responsible
for Health Care
Nurses.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
Allowance for Patient
Factors
Risk adjustment for : Age, sex, DRG, comorbidity categories
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison No specific standards given.
Scoring AHRQ has PSI software for scoring.