ICU Acquired Ulcer Rate

Number of ICU acquired pressure ulcers per 1000 ICU patient days

Indicators
Indicator:	ICU Acquired Ulcer Rate
Created/Raw:	not stated
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)

• Cargo

• Helper template:

• Cargo

• Categories

none

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

• SMW:

• Categories

• Default form:

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 in the data sources below.

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

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 July 1, 2025:

• Starting 2019 to June 2025:

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

Decubitus (pressure) ulcer, Stage I (surface reddening) (L89.0) Decubitus (pressure) ulcer, Stage II (to fascia, just under skin) (L89.1) Decubitus (pressure) ulcer, Stage III (deep, to but not including muscle) (L89.2) Decubitus (pressure) ulcer, Stage IV (involves muscle, tendon, or bone) (L89.3) Decubitus (pressure) ulcer, stage not indicated (L89.9)

• Before 2019, Ulcers:

Coded in Old Diagnostic Coding Schema before Conversion from our old diagnosis schema to ICD10/CCI as Ulcers - Decubitus only with old diagnosis codes 945 and saved in L Dxs table

SAS Program

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

Report Users

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