Pressure Injury: All-Cause Harm Event for Hospitals
Thank you for registering for and/or attending the HQIC Pressure Injury webinar! Hospital leaders from across the country attended the event. The small, rural, and critical access voice was amplified through sharing of barriers and best practices alike. Furthermore, subject matter experts shared their perspectives and their favorite resources. Now, it is time to act! 

Why now?
Hospitals across the country have seen an increase in device-associated pressure injuries because of the COVID-19 pandemic. Increased use of common medical devices such as catheters, electrodes, and nasogastric tubes have amplified the risk of pressure injuries for patients in all care settings. Additionally, the use of prone positioning to promote ventilation in COVID-19 ICU patients has shown to apply pressure to delicate areas of skin such as the eye sockets, lower costal margins, and the shins. One study estimates the cost of each device related injury could be around $5,000 (Gefen & Ousey, 2020).

Review the Data
Telligen HQIC Program Pressure Ulcer Rate: Baseline Data
Log in to CDS and view your individual hospital’s PU rate.

Consider Common Barriers
Review common barriers identified during the webinar and brainstorm ways to mitigate challenges to implementation in your organization.
  • Lack of an in house wound team and/or training of wound specialists
  • Limited staffing resources in the small/rural environment
  • Lack of all-staff accountability (pressure injury prevention is only a nursing responsibility)
  • Limited incentive for becoming a wound champion
  •  Lack of automated clinical decision support built into EHRs
  • Low compliance with implementing interventions based on Braden assessment
  • Lack of data collection related to pressure injuries

Perform a Root-Cause Analysis
Fill in the Five Whys template to identify the cause of your facility’s specified pressure injury problem.

Identify Promising Practices
Choose a pressure injury prevention intervention to try at your facility. (not an exhaustive list)
Patient and Family Engagement & Health Equity Promising Practices

Craft Your AIM Statement
Identify your organization’s goals related to pressure injury prevention. Fill in the blanks with your AIM.

By October 30th, 2021, the pressure injury team on med-surg unit 5 E will implement and monitor compliance of comprehensive skin assessments performed on admission and daily to decrease the overall rate of pressure injuries stage 2 or greater to 1.0 or less to benefit patients at risk for skin breakdown. 

Next Steps
Not sure how to identify your organization’s root cause? Need help getting started on implementing your selected intervention? Seeking feedback on your AIM statement? Reach out to your Telligen or hospital association quality improvement facilitator for assistance. 
Was the content of this resource helpful to you?
Do you have a promising practice to share with the program? Reply directly to this email to share your own!

This material was prepared by Telligen, the Hospital Quality Improvement Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. This material is for informational purposes only and does not constitute medical advice; it is not intended to be a substitute for professional medical advice, diagnosis or treatment. HQIC-TO1-05/20/21-0048