Hospital-Acquired Pressure Injury (HAPI) Prevention—Is Repositioning Enough?

HAPIs occur most commonly in patients who are immobile or elderly. In the U.S., it is estimated that 2.5 million pressure injuries occur in acute care facilities each year. The cost of managing a single, full-thickness pressure injury is as much as $70,000. Expenditures in the U.S. for pressure injury treatment have been estimated at $11 billion per year.¹

Repositioning is one strategy to prevent the development of HAPIs. This helps the skin stay healthy and promotes blood perfusion to the skin. Are your patients repositioned, and repositioned properly, to prevent pressure injuries? Is this something that is verified during leadership rounding?

Repositioning Guidance

The following method off-loads heels effectively to prevent pressure injuries. Place a pillow vertically under each lower leg between the knees and ankles without pressure to the popliteal space or Achilles tendon. Place a pillow horizontally on top of the vertical pillows. Heels should be off-loaded from the bed surface.²

A proper side-lying position when the patient is positioned with pillows or a wedge at a 30-degree position is as follows: Place a pillow under the head and a pillow to support the back. Position the upper leg over or in front of the lower leg, with a pillow between knees and ankles. Extend the knee to help prevent the patient from rolling back onto his or her sacrum and off-load the sacrum. Keep the head of bed as flat as possible. Make sure heels are off-loaded with pillows.³

Additional strategies and resources can be found below and HSAG HQIC HAPI tools webpage.

Data show that HAPI rates have worsened since the baseline period of 2019 (lower rates are better).

Visit the HSAG HQIC Quality Improvement and Innovation Portal (QIIP) to view your HAPI data by selecting the Measure Category of Other Harms and Measure of HAPI Stage 3 or Greater (PSI-3) or Hospital Acquired Pressure Ulcer (HAPU) Rate—All Stages.

PSI = Patient Safety Indicator

* Rates are per 1,000 admissions.

Source: Medicare Fee-for-Service Claims Data. For additional details on measure specifications, please reference the HSAG HQIC Compendium of Measures. The baseline time period is 01/01/2019–12/31/2019 and current time period is 11/01/2022–10/31/2023

Pan Pacific Pressure Injury Alliance Classification System

Stage I pressure injuries may be difficult to detect in individuals with darkly pigmented skin tone versus light skin tone individuals. Older adult skin has thinner layers, skin moisture is reduced, and skin pH is higher, which can affect susceptibility for pressure injury.⁴ Find detailed images and descriptions at the links below, or visit the Pan Pacific Injury Alliance website at www.pppia.org.

Postoperative Sepsis: PSI-13

PSI-13 is a complication of surgery. Some risk factors include male gender, pre-existing heart failure, diabetes, and chronic kidney disease.⁵ Additionally, patients undergoing elective colorectal surgery had increased risk of postoperative sepsis if they were older than 65, had an American Society of Anesthesiology (ASA) score greater than 2, and had comorbidities, such as diabetes and cardiovascular disease.⁶

The PSI-13 numerator is discharges with secondary diagnosis code(s) for sepsis, and the denominator is elective surgical discharges for operating room procedure for patients ages 18 and older. Exclusions include sepsis present on admission (POA), principal diagnosis of infection, secondary diagnosis of sepsis POA, and major diagnosis category 14 (pregnancy, childbirth, puerperium).

HSAG HQIC has seen worsening PSI-13 rates. Consider using HSAG HQIC's Postoperative Sepsis After Elective Surgery Prevention Checklist.

One Size Does Not Fit All for Critical Care Orientation

The American Association of Critical-Care Nurses (AACN) has a new tool to support new intensive care unit and progressive care unit nurses. Nurses can be enrolled and have an individualized assessment of their current knowledge based upon their practice area. This tailored orientation can address any learning needs identified during the assessment.

For additional resources, visit the HSAG HQIC tools and resources for staff onboarding, training, and retention.

Ensuring Medication for Opioid Use Disorder (MOUD) Treatment Through the Care Continuum

This webinar series—a collaboration of all Quality Improvement Organizations—provides strategies, interventions, and targeted solutions to ensure Medicare beneficiaries have access to MOUD treatment and facilitate the continuity of care.

Next: March 8, 2024 | 12 noon ET (9 a.m. PT).

Care Coordination Quickinar Series: Readmission Incentive and Penalty Programs

Discover ways to manage avoidable hospital readmissions by registering for these short, 30-minute webinars (quickinars)—offered monthly January through May 2024. Find details and recordings for past presentations on the webpage.

1st Tuesdays. Next: April 2, 2024 | 2–2:30 p.m. ET (11 a.m. PT)

Find on-demand quickinar recordings, slides, and podcasts from past HSAG HQIC learning series.

Quality and Safety Quickinar Series

References

1 WoundSource. (2022). Turning and position for pressure injury prevention. https://www.woundsource.com/blog/turning-and-positioning-pressure-injury-prevention

2 National Pressure Injury Advisory Panel. Offloading heels effectively in adults to prevent pressure injuries. https://npiap.com/store/viewproduct.aspx?id=16489419

3 Kapp, S. (2019). An observational study of the maintenance of the 30 side-lying lateral tilt position among aged care residents at risk of developing pressure injuries when using the standard care pillow and a purpose-designed positioning device. International Wound Journal. https://onlinelibrary.wiley.com/doi/full/10.1111/iwj.13142

4 PPPIA. Pressure Injury Classification System. https://pppia.org/

5 Plaeke, P., et al. (2020). Clinical- and surgery – specific risk factors for post-operative sepsis: a systematic review and meta-analysis of over 30 million patients. Springer Link. https://link.springer.com/article/10.1007/s00595-019-01827-4

6 Mulita, F., et al. (2022). Postoperative sepsis after colorectal surgery: a prospective single-center observational study and review of the literature. Gastroenterology Review. https://www.termedia.pl/Postoperative-sepsis-after-colorectal-surgery-r-na-prospective-single-center-observational-study-r-nand-review-of-the-literature,41,44049,0,1.html

This material was prepared by Health Services Advisory Group (HSAG), a Hospital Quality Improvement Contractor (HQIC) under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. Publication No XS-HQIC-XT-03052024-01