Transcript HEN Readmission Affinity Call

Intermountain-led
CMS Hospital Engagement Network
Preventing Pressure Ulcers
March 25, 2014
Affinity Call
Marlyn Conti –Patient Safety Coordinator, Intermountain
Monica Spencer—NP/ Manager Wound Care, Baylor Scott & White Health
Gina Honermann-Garinger—Baylor Scott & White Health Center for
Clinical Innovation
Outline for Discussion
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Review of 2013 data through Q4
‘High performers’ – what are they doing?
PfP recommended metrics
“Just-one-thing” – updated document
2014 plans for improvement:
– Reach out to low performers to provide assistance.
– Baylor has called a task force together to review the
HAPU policy/procedure and document performance
– Intermountain PrU Bundle
Overall Progress Through 2013
Intermountain HEN 2012-13
submitting Hospitals
AHRQ PSI 3 Pressure Ulcers
National high performing
benchmark (0.25)
Intermountain HEN 2012-13
submitting Hospitals
AHRQ PSI 3 Pressure Ulcers
Intermountain HEN 2012-13
submitting Hospitals
HAPU (Prevalence)
Intermountain HEN 2012-13
submitting Hospitals
HAPU (Prevalence)
HEN Pressure Ulcer Measures
• Metric specification resource manual
http://www.henlearner.org/wpcontent/uploads/2012/03/HEN_measure_Feb5.pdf
• Submission schedule:
– May 20, 2014: for data through March 2014
HEN Pressure Ulcer Measures
PSI 3
SOURCE/DEFINITION
NUMERATOR
DENOMINATOR
Outcome
AHRQ PSI #3
All inpatient medical and surgical discharges age 18 years
and older defined by specific DRGs or MS-DRGs.
Decubitus ulcer Adult
Patients with Stage III,
Stage IV or
unstageable pressure
ulcers
Inpatient discharges among cases meeting the
inclusion and exclusion rules for the
denominator with ICD-9-CM code of pressure
ulcer in any secondary diagnosis field and ICD9-CM code of pressure ulcer stage III or IV (or
unstageable) in any secondary diagnosis field.
ICD-9-CM Pressure ulcer diagnosis codes:
7070 – PRESSURE ULCER
70700 - PRESSURE ULCER, SITE NOS
70701 - PRESSURE ULCER, ELBOW
70702 - PRESSURE ULCER, UPR BACK
70703 - PRESSURE ULCER, LOW BACK
70704 - PRESSURE ULCER, HIP
70705 - PRESSURE ULCER, BUTTOCK
70706 - PRESSURE ULCER, ANKLE
70707 - PRESSURE ULCER, HEEL
70709 - PRESSURE ULCER, SITE NEC
ICD-9-CM Pressure ulcer stage diagnosis codes:
70723 - PRESSURE ULCER, STAGE III
70724 - PRESSURE ULCER, STAGE IV
70725 – PRESSURE ULCER, UNTAGEBL
EXCLUDE CASES:
• with length of stay of less than 5 days
• with principal diagnosis of pressure ulcer or a secondary
diagnosis of pressure ulcer present on admission* and a
secondary diagnosis of pressure ulcer stage III or IV
present on admission
• MDC 9 (Skin, Subcutaneous Tissue, and Breast)
• MDC 14 (pregnancy, childbirth, and puerperium)
• with any diagnosis of hemiplegia, paraplegia, or
quadriplegia
• with any diagnosis of spina bifida or anoxic brain damage
• with a procedure code for debridement or pedicle graft
before or on the same day as the major operating room
procedure (surgical cases only)
• transfer from a hospital (different facility)
• transfer from a Skilled Nursing Facility (SNF) or
Intermediate Care Facility (ICF)
• transfer from another health care facility
• with missing gender (SEX=missing), age (AGE=missing),
quarter (DQTR=missing), year (YEAR=missing) or principal
diagnosis (DX1=missing)
* Only for cases that otherwise qualify for the numerator
HEN Pressure Ulcer Measures
HAPU Prevalence
SOURCE/DEFINITION
Outcome
NDNQI Prevalence
HAPU Prevalence
Patients with
hospital acquired
pressure ulcers
NUMERATOR
The total number of patients with a
hospital-acquired pressure ulcer.
DENOMINATOR
Number of patients surveyed during the prevalence
survey day.
INCLUDE:
INCLUDE:
Stage 1,2,3,4, unstageable and deep tissue Inpatients, short stay patients, observation patients,
injuries.
and same day surgery patients who receive care on
an inpatient unit for all or part of a day.
EXCLUDE:
Critical care, step-down, medical, surgical, medicalPressure ulcers present on arrival.
surgical combined, critical access and rehabilitation
inpatient units.
Patients of any age on an eligible reporting unit
HEN Pressure Ulcer Measures
HAPU Prevalence—Stage III & greater
SOURCE/DEFINITION
Outcome
HAPU ≥ St3
Prevalence
NDNQI St3
Prevalence
NUMERATOR
Count of hospital acquired pressure ulcers
stage 3 or greater.
Patients with
INCLUDE:
hospital acquired
Stage 3, 4 injuries.
pressure ulcer stage
3 or greater
EXCLUDED:
Pressure ulcers present on arrival.
DENOMINATOR
Number of patients surveyed during the prevalence
survey day.
INCLUDE:
Inpatients, short stay patients, observation patients,
and same day surgery patients who receive care on
an inpatient unit for all or part of a day.
Critical care, step-down, medical, surgical, medicalsurgical combined, critical access and rehabilitation
inpatient units.
Patients of any age on an eligible reporting unit
Should we change this to be in-line with the national metric and
include stage II and greater?
High Performing Hospital Highlight…
% Improvement
• Baylor University Medical Center - actions
Hospital Name
SUTTER COAST HOSPITAL
BAYLOR MEDICAL CENTER AT WAXAHACHIE
THE HEART HOSPITAL BAYLOR PLANO
DENVER HEALTH MEDICAL CENTER
BAYLOR MEDICAL CENTER AT CARROLLTON
CALIFORNIA PACIFIC MEDICAL CTR
BAYLOR ALL SAINTS MEDICAL CENTER AT FW
BAYLOR MEDICAL CENTER AT IRVING
BAYLOR REGIONAL MEDICAL CENTER AT GRAPEVINE
BAYLOR MEDICAL CENTER AT GARLAND
BAYLOR UNIVERSITY MEDICAL CENTER
SUTTER ROSEVILLE MEDICAL CENTER
ALTA VIEW HOSPITAL
AMERICAN FORK HOSPITAL
High Performing Hospital Highlight…
Rates
Hospital Acquired Pressure Ulcers (Prevalence)
Top 10 HOSPITALS
ALTA VIEW HOSPITAL
OREM COMMUNITY HOSPITAL
PARK CITY MEDICAL CENTER
THE ORTHOPEDIC SPECIALTY HOSPITAL
BEAR RIVER VALLEY HOSPITAL
SANPETE VALLEY HOSPITAL - CAH
BAYLOR MEDICAL CENTER AT WAXAHACHIE
ST PATRICK HOSPITAL
HILLCREST BAPTIST MEDICAL CENTER
DELTA COMMUNITY MEDICAL CENTER
Just One Thing Matrix
Recommendations
Getting Started
Working Harder
Ahead of the Curve
Appoint a leadership
supported team or work
group to drive
improvement & education
SWAT (or champion) teams
that includes unit nurse
Adopt decision algorithms
for nursing staff to select
appropriate surfaces,
physical therapy and
dietary referrals
Establish monthly
prevalence studies or
collect incidence data from
electronic medical records,
then feed that data back to
the SWAT teams
(moderate-high evidence)
(moderate-high evidence)
(moderate-high evidence)
Intermountain Pressure Ulcer Bundle
Getting Started
Getting Started
Access Available Tool Kits
• Preventing Pressure Ulcers
in Hospitals: A Toolkit for
Improving Quality of Care
http://www.ahrq.gov/resea
rch/ltc/pressureulcertoolkit/
• National Pressure Ulcer
Advisory Panel
http://www.npuap.org/
• http://www.Henlearner.org
• AHRQ PSNet
http://www.psnet.ahrq.g
ov/
• AHRQ Web M&M
http://www.webmm.ahrq
.gov/
• AHRQ Health Care
Innovations Exchange
http://www.innovations.a
hrq.gov/
2014 plans for improvement
• Reach out to low performers to provide assistance.
• Baylor has called a task force together to review the
HAPU policy/procedure and document performance
• Intermountain PrU Bundle
• Collect and share best practices across our network
hospitals & system in a single document