ICU Acquired Ulcer Rate

Number of ICU acquired pressure ulcers per 1000 ICU patient days

Indicators
Indicator:	ICU Acquired Ulcer Rate
Created/Raw:	Created
Program:	Critical Care
Start Date:
End Date:
Reports:	Critical Care Program Quality Indicator Report, WRHA ICU Hospital-Acquired Conditions
Data Dependencies(Reports/Indicators/Data Elements):	Admit DtTm • Dispo DtTm field • LOS • Decubitus (pressure) ulcer, stage not indicated • Decubitus (pressure) ulcer, Stage I (surface reddening), of sacral area • Decubitus (pressure) ulcer, Stage I (surface reddening), of heel • Decubitus (pressure) ulcer, Stage I (surface reddening), of other area • Decubitus (pressure) ulcer, Stage II (to fascia, just under skin), of sacral area • Decubitus (pressure) ulcer, Stage II (to fascia, just under skin), of heel • Decubitus (pressure) ulcer, Stage II (to fascia, just under skin), of other area • Decubitus (pressure) ulcer, Stage III (deep, to but not including muscle), of sacral area • Decubitus (pressure) ulcer, Stage III (deep, to but not including muscle), of heel • Decubitus (pressure) ulcer, Stage III (deep, to but not including muscle), of other area • Decubitus (pressure) ulcer, Stage IV (involves bone), of sacral area • Decubitus (pressure) ulcer, Stage IV (involves bone), of heel • Decubitus (pressure) ulcer, Stage IV (involves bone), of other area • Pressure-induced deep tissue damage, of sacral area • Pressure-induced deep tissue damage, of heel • Pressure-induced deep tissue damage, of other area • Decubitus (pressure) ulcer, stage not indicated, of sacral area • Decubitus (pressure) ulcer, stage not indicated, of heel • Decubitus (pressure) ulcer, stage not indicated, of other area • Decubitus (pressure) ulcer, Stage I (surface reddening) • Decubitus (pressure) ulcer, Stage II (to fascia, just under skin) • Decubitus (pressure) ulcer, Stage III (deep, to but not including muscle) • Decubitus (pressure) ulcer, Stage IV (involves muscle, tendon, or bone)

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• Helper template:

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none

• Default form: none, this is populated by Template:Report and Template:Reporting Indicators and their respective forms.

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Used in aggregate form as "per location" and/or "per timeframe", e.g. by month/quarter/year x Ward/Unit x Hospital

QI domain

• Safe

Significance

Significance: Pressure ulcers development is a hospital acquired complication that is associated with poor patient outcomes and has multiple strategies to prevent its occurrence.

Sampling Plan / Procedure

100 % of all patients will be monitored for acquired Pressure Decubitus Ulcer.

Diagnosis Codes

Before 2019

• Decubitus Ulcer only - codes from 94500 to 94505

Starting Jan2019

• L89.0 Decubitus
• L89.1 Decubitus
• L89.2 Decubitus
• L89.3 Decubitus
• L89.9 Decubitus (pressure) ulcer, stage not indicated

Inclusion Criteria

All

Exclusion Criteria

None

Frequency

• Recorded once per patient regardless of the stage(s) of the decubitus ulcer.
• On quarterly basis based on discharge dates, tabulate the number of cases on acquired and total number of patient days or Total ICU_LOS in LOS Per Service

Is it correct to include any stage (or even unknown stage) in recording the count of decubitus ulcer? --JMojica 10:32, 2023 November 23 (CST)

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Definition and Derivation

Number of ICU acquired pressure ulcers per 1000 ICU patient days

Numerator

Number of new ICU pressure ulcers acquired cases

Denominator

Total ICU_LOS in LOS Per Service

Data Sources

• Starting 2019, Pressure Ulcer is part of the ICD10 collection with codes L89.0 to L89.9 under the Acquired Diagnosis / Complication.

• Before 2019, Ulcers - Decubitus only has old diagnosis code 945 and saved in table L_Dxs

SAS Program

• The SAS program to get the Decubitus Ulcer is X:\Julie\SAS_CFE\CFE_macros\Pre_ICD10_AcqDx.sas
• The SAS program to get the LOS is X:\Julie\SAS_CFE\CFE_macros\datetimes.sas

Report Users

Critical Care Directors, Critical Care Unit Managers and WRHA Outcome Improvement Team Committee