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