Transcript Pressure Ulcer Prevention Data Collection - K

Pressure Ulcer
K-HEN Data Collection
& Submission
Dolores Hagan, RN BSN
K-HEN Education and Data Manager
August 2012
Objectives
• Review reporting requirements
• Review K-HEN recommended measures
• Review the specifications for monitoring
data (Inclusion and exclusion criteria)
• Discuss requirements for baseline data
• Define data entry and submission timeline
• Identify measures that may be pulled
from other systems where data is
currently being entered
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Reporting Requirements
• For each topic area chosen, hospitals are
required to submit data for at least
– One process measure AND
– One outcome measure
• Hospitals are strongly encouraged to
report on the K-HEN recommended
measures
• Additional outcome and/or process
measures may be selected and reported as
desired
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K-HEN Recommended Measures
• Purpose—standardize reporting on the same
measures across the state for robust
benchmarking capability
• Measures selected based on polling data from
the KHA Quality Conference in March 2012
• Have continued to evolve with your feedback
(Keep it coming! )
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HRET HEN Encyclopedia of Measures
• Lists all measures available in the CDS
• Defines the numerator and denominator for
each measure
• Provides a link to the source of the measure
• http://www.khen.com/Portals/16/Documents/HRET_HEN_
Encyclopedia_of_MeasuresV3.pdf
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Pressure Ulcer Prevention: Outcome Measure
• Preferred measures: Depends on your
patient population)
– # 61 Adult patients with Stage III, Stage IV or
unstageable pressure ulcers (AHRQ PSI 3)
– #62 Pediatric patient with a decubitus ulcer
(AHRQ PDI 2)
– #63 Number of occurrences of hospital acquired
pressure ulcer at Stage III or IV
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#61 Pressure Ulcer Outcome Criteria
• Numerator--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 ICD-9-CM code of
pressure ulcer stage III or IV (or unstageable). ICD9-CM Pressure ulcer diagnosis codes
Codes are listed in the
– Encyclopedia of Measures
– http://www.qualityindicators.ahrq.gov/Downloads/Soft
ware/SAS/V43/TechnicalSpecifications/PSI%2003%20Pr
essure%20Ulcer%20Rate.pdf
Source: AHRQ Patient Safety Indicators
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#61 Pressure Ulcer Outcome Criteria
• Denominator—All medical and surgical discharges
age 18 years and older defined by specific DRGs or
MS-DRGS (See Patient Safety Indicator Appendices)
Exclusions
– LOS < 5 days
– Principal or secondary diagnosis of pressure ulcer present
on admission
– MDC 9 (skin, subq tissue and breast)
– MDC 14 (pregnancy, childbirth and puerperium)
– Any diagnosis of hemi, para or quadraplegia
– ICD-9 procedure code for debridement or pedicle graft
before or on the same day as the major OR procedure
Source: AHRQ Patient Safety Indicators
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Exclusions Continued
– Transfer from a hospital (different facility)
– Transfer from a Skilled Nursing Facility or
Intermediate care facility
– Transfer from another health care facility
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# 63 Pressure Ulcer Outcome Criteria
• Numerator—Number of occurrences with Pressure
ulcer stages III or IV (ICD-9 Codes: 707.23(MCC) or
707.24(MCC)) as a secondary diagnosis with a POA
code of ‘N’ or ‘U’
• Denominator—Number of acute inpatient FFS
discharges
Exlcusions:
– Swing bed patients
Pressure Ulcer Process Measure
• Preferred Measure: #57 Patients with skin
assessment documented within 24 hours of
admission
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#57 Pressure Ulcer Process Criteria
• Numerator—Inpatients with timely,
complete skin assessment
– Skin temp, color, moisture, turgor, integrity
• Denominator—All inpatients admitted to
hospital or unit under surveillance
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Source AHRQ Pressure Ulcer Toolkit
Baseline Data
• Only submitted one time
• For all topic areas except Readmissions:
– Baseline data is from 2011 prior to January 1, 2012
– May be the entire calendar year of 2011 or any other
period within the year (a month, a quarter, etc)
– Enter your specific period beginning and ending
dates
• Readmission Baseline Data
– Preferably CY 2011
– May use Jan – Jun 2012 if 2011 data is not available
• If no baseline data is available, do not enter anything for
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baseline—begin with monitoring data
Pressure Ulcer Data Entry
Complete baseline
data entry by
August 31!
• Data should be entered on a monthly basis as
much as possible
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Pressure Ulcer
2012 Monthly Data Entry Schedule
Monitoring Month
Data Entry Available
Data Entry Complete
January
Immediately
As soon as possible*
February
Immediately
As soon as possible*
March
Immediately
As soon as possible*
April
Immediately
As soon as possible*
May
Immediately
As soon as possible*
June
Immediately
As soon as possible*
July
August 1, 2012
August 31, 2012
August
September 1, 2012
September 30, 2012
September
October 1, 2012
October 31, 2012
October
November 1, 2012
November 30, 2012
November
December 1, 2012
December 31, 2012
December
January 1, 2013
January 31, 2013
*If data is available
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Comprehensive Data System (CDS)
• Link to HRET training webinar for CDS
located on K-HEN website under Data Page
• https://www.hretcds.org/Login.aspx
• Data coordinator receives initial login and
creates hospital’s users
– At least two data administrators
– As many data entry users as needed
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Measure Selection
• Review the K-HEN Recommended
Measures and the HRET Encyclopedia of
Measures
• Determine which measures you will report
Remember you MUST report on at least one
process and one outcome measure
per topic area selected
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Measure Enrollment
• Enroll in the measures that you are
reporting
• Select Admin  Measure Enrollment
– Select the topic area
– Select/deselect and save the measures that
you will be reporting on
– This will narrow your choices for data entry to
only those selected
– You may reselect those measures at a later
time if desired
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Data Collection & Entry
• Review the numerator and denominator
criteria for the measures selected
• Collect and compile the data
• Sign on to the CDS
– Select Data Entry tab
– Select the topic from the drop  Select Next
– Find the appropriate measure  Select Enter
Data
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Baseline Data Entry
• Defaults to the Baseline tab
• Enter the Measurement start and end dates  Select
‘Add’
• Under ‘Data Entry’ column, Select ‘Go’
• Was data collected for this measurement period? 
Select Yes or No
– If No, enter reason (e.g. data not available)
– If Yes, enter the numerator and denominator
– Select Save or Submit
• Save holds data in ‘temporary’ area and is not available for
reporting within the CDS
• Data may be edited by the hospital until it is submitted
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Monitoring Data Entry
• Select the Monitoring tab
• Under the Data Entry column, Select ‘Go’ for
the appropriate month
• Was data collected for this measurement
period?  Select Yes or No
• If No, enter reason (e.g. data not available)
• If Yes, enter the numerator and denominator
• Select Save or Submit
– ‘Save’ holds data in ‘temporary’ area and is available for
reporting within the CDS
– Data may be edited by the hospital until it is submitted
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Data Tidbits
• Each month should have data entered or a
reason it was not collected
• Additional training will be provided after data
has been entered and reporting is available
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Monthly Progress Report
•
•
•
•
Due to K-HEN by the 10th of each month
Use template provided
One report per topic area
Report template and sample complete
report located on K-HEN website (www.khen.com) under Tools and Resources
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Project Title: ______________________________
Hospital Name: ____________________________
Date: _____________
State: _____________
Self Assessment Score, 1-5 (see AHA/HRET Assessment Scale document) = <enter score here>
Aim Statement
Aim?: (Including your How
Good and By When
statement)
Why is this project
important?:
Changes being Tested,
Implemented or Spread
(For each listed change,
indicate whether it is being
tested (T), Implemented (I)
or Spread (S))
Run Charts
Lessons Learned
(Make fonts large, title, labels, dates
and notes very simple on graphs
prior
to shrinking graphs. Should be able
to
fit 6-8 readable graphs here.
If no data are available for a particular
measures either create “empty” run
list
the name of the measure(s) to be
collected.)
(Enter summary here)
Recommendations and
Next Steps
• Enter summary here (what
do you need from Executive
Project Champion, Sponsor
at this time to move
project?)
• Recommendations
• Next steps for testing
Team Members
(Name of Project
Champion, Senior Leader
Sponsor & all other names
& roles)
© 2012 Institute for Healthcare Improvement
Sample Completed Report
Project Title: Reduction in Stage II pressure ulcers
Hospital Name: Tulare Regional Medical Center
Date: June 28, 2012
State: California
Self Assessment Score, 1-5 (see AHA/HRET Assessment Scale document) = 3
Aim Statement
Run Charts
Reduce the occurrence of hospital
acquired Stage II pressure ulcers
in the ICU/PICU unit 50% by
December 31, 2013.
Lessons Learned
• Still awaiting Stryker Isoflex
mattresses
Stage 2 Hospital Acquired Pressure
Ulcers in ICU/PICU at TRMC during
2012.
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6.09
Why is this project
important?: Pressure Ulcers
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cause pain and decrease the
patient’s quality of life. State fines
can be costly to health care
organizations.
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PICU Stage 2
Pressure Ulcer
4
ICU Stage 2
Pressure Ulcer
3
ICU Rate/1000 inpatient days
2
PICU Rate/1000 inpatient days
Changes being
Tested, Implemented
or Spread
• 6 ICU beds equipped with Stryker
IsoFlex mattresses (I).
•8 PICU beds are made with a
waffle mattress in place (I).
•Charge Nurses ensure turning
schedule is maintained for all
patients (T).
•Multi-disciplinary wound team
meets monthly (I).
1
1
0
0
lst Qtr.
0
2nd Qtr.
Recommendations
and Next Steps
•Purchase of 8 new Stryker Iso
Flex mattresses for PICU area.
•Continue staff education skin care
interventions & prevention
measures.
•Initiate pressure ulcer MD printed
order sets.
Team Members
Josh Warren, RN BSN, WCC Lead
Wound Team
Barbara Haling, RN MSN ICU
Director
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© 2012 Institute for Healthcare Improvement
Project Assessment Scale
• http://www.khen.com/Portals/16/Documents/HRETHEN
ProjectAssessmentScale.pdf
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Homework
• Set up CDS users for your site
• Collect and enter baseline data by Aug 31
• Enter monitoring data for Jan - Jun 2012 as
available
• Enter monitoring data for Jul 2012 by Aug
31
• Complete July progress report by Aug 31
and email to [email protected]
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Questions
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