1 CalNOC Data Definitions and Calculations: Prevalence Studies Reports Pressure Ulcer Prevalence Measures 1. % of Pt. with any Ulcers The number of patients with Stage I-IV, and unable to stage pressure ulcers + DTI (regardless of when discovered) as a study INCLUDES DTI. 2. % of Pt. with Category II+ Ulcers The number of patients with Stage II-IV, and unable to stage pressure ulcers + DTI (regardless of when discovered) as a study INCLUDES DTI. 3. % of Pt. with Hospital Acq. Press. Ulcers All Categories The number of patients with Stage I-IV, patients in the prevalence study. See calculation rules below. INCLUDES DTI. 4. % of Pt. with Hospital Acq. Press. Ulcers All Categories (Hosp Coding/NDNQI) The number of patients with Stage I-IV patients in the prevalence study. Uses hospital coding of HAPU (calculation rules below). Patients with community acquired ulcers who later develop HAPU will be included in this measure. (Used for NDNQI data for NDNQI members.) INCLUDES DTI. 5. % of Pt. with Hospital Acq. Press. Ulcers Categories I and II (partial thickness) The number of patients with Stage I-II hospital acquired pressure ulcers as a study. See calculation rules below. Uses existing data to provide partial thickness category defined by NPUAP. 6. % of Pt. with Hospital Acq. Press. Ulcers Category II+ The number of patients with Stage II-IV patients in the prevalence study. See calculation rules below hospital acquired=discovered AFTER day 1 of hospitalization (first 24 hours). INCLUDES DTI.
2 7. % of Pt. with Hospital Acq. Press. Ulcers Category II+ (Hosp Coding/NDNQI) The number of patients with Stage II-IV patients in the prevalence study. Uses hospital coding of HAPU (calculation rules below). Patients with community acquired ulcers who later develop HAPU will be included in this measure. (Used for NDNQI data for NDNQI members.) INCLUDES DTI. The number of patients with Stage III-IV 8. % of Pt. with Hospital Acq. Press. Ulcers Category III+ w. unstageable and unable to stage hospital acquired, pressure ulcers as a percent of all matches CDPH definition patients in the prevalence study (calculation rules below). 9. % of Pt. with Hospital Acq. Press. Ulcers Category III+ w. unstage/dti (full thickness) 10. % of Pt. with Hospital Acq. Press. Ulcers Category III+ w. unstage/dti (Hosp Coding/NDNQI) The number of patients with Stage III-IV and unable to stage hospital acquired patients in the prevalence study (calculation rules below). INCLUDES DTI. The number of patients with Stage III-IV and unable to stage hospital acquired patients in the prevalence study. Uses hospital coding of HAPU III+IV, unstaageable and DTI (calculation rules below). Patients with community acquired ulcers who later develop HAPU will be included in this measure. (Used for NDNQI data for NDNQI members.) 11. % of Pt. with Suspected Deep Tissue Injury The number of patients with DTI as a study. 12. % of Pt. with Hospital Acq. Suspected Deep Tissue Injury The number of patients with hospital acquired DTI as a percent of all patients in the prevalence study. (Hospital acquired=discovered AFTER day 1 of hospitalization (first 24 hours).
3 13. % of Pt. with Hospital Acq. Device Related Ulcers The number of patients with hospital acquired device related ulcers as a study (Hospital acquired=discovered New Q4 2013 AFTER day 1 of hospitalization (first 24 hours). 14. % of Pt. with Unit Acq. Press. Ulcers All Categories The number of patients with Stage I-IV, unable to stage, and DTI acquired ON THIS UNIT as a percent of all patients on this unit in the prevalence study. Patients New Q4 2013 with community acquired ulcers who later develop HAPU ON THIS UNIT will be included in this measure. 15. % of Pt. with Unit Acq. Press. Ulcers Category II+ The number of patients with Stage II-IV, unable to stage, and DTI acquired ON THIS UNIT as a percent of all patients on this unit in the prevalence study. Patients New Q4 2013 with community acquired ulcers who later develop HAPU ON THIS UNIT will be included in this measure. 16. % of Pt. with Unit Acq. Press. Ulcers Category III+ w. unstage/dti The number of patients with Stage III-IV, unable to stage, and DTI acquired ON THIS UNIT as a percent of all patients on this unit in the prevalence study. Patients New Q4 2013 with community acquired ulcers who later develop HAPU ON THIS UNIT will be included in this measure. Pressure Ulcer Prevention Measures 13. % of Pt. with Ulcer Risk Assess Documented w/in 24 hours of admission Calculated from the question: Admission pressure ulcer risk assessment documented within 24 hours of admission? Total patients with yes answers are divided by the sum of patients with yes and no answers and multiplied by 100 to calculate percent. Not applicable to patients not at risk or admitted within 24 hours of survey.
4 14. % of Pt. with Ulcer Skin Assess Documented w/in 24 hours of admission Calculated from the question: Admission pressure ulcer skin assessment documented within 24 hours of admission? Total patients with yes answers is divided by the sum of patients with yes and no answers and multiplied by 100 to calculate percent. Not applicable to patients not at risk or admitted within 24 hours of survey. 15. % of Pt. with Ulcer Risk Assess Documented w/in LAST 24 Hours Calculated from the question: How long ago was last pressure ulcer risk assessment performed? Total patients with 0-24 hours is divided by the sum of all applicable patients and multiplied by 100 to calculate percent. Applicable to all patients except those admitted within 24 hours of survey. 16. % of Assessed Pt. Identified "At Risk" for Ulcers At Admission Calculated from the question: If patient was assessed, was patient identified at risk at admission? Total patients with yes answers is divided by the sum of patients with yes and no answers and multiplied by 100 to calculate percent. Patients with missing data, no admission assessment, or NA omitted from calculation. 17. % of Assessed Pt. Currently Identified "At Risk" for Ulcers (time of survey) Calculated from the question: Is patient currently identified at risk at time of survey? Total patients with yes answers is divided by the sum of patients with 100 to calculate percent. Patients with missing data, not assessed or NA omitted from calculation. 18. % of Currently "At Risk" Pts. With Risk Reassess. Day Before Survey at risk (at time of survey), did patient receive risk reassessment on day before survey? Total patients with yes answers is divided by the sum of patients with 100 to calculate percent. Patients with missing data, not at risk, or NA omitted from calculation.
5 19. % of Currently "At Risk" Pts. With Skin Reassess. Day Before Survey at risk (at time of survey), did patient receive skin reassessment on day before survey? Total patients with yes answers is divided by the sum of patients with 100 to calculate percent. Patients with missing data, not at risk, or NA omitted from calculation. 20. % At Risk Pts. with Prevention Protocol Implemented at Time of Survey at risk had prevention protocol been implemented at time of survey? Total patients with yes answers are divided by the sum of patients with yes and no answers and multiplied by 100 to calculate percent. Patients coded as not at risk or NA are omitted from calculation. 21. % At Risk Pts. with Pressure Redistribution Surface in Use within Past 24 Hrs at risk was pressure redistribution surface in use within past 24 hours? Total patients with yes answers are divided by the sum of patients with yes and no answers and multiplied by 100 to calculate percent. Other patients are omitted from calculation. at risk was routine positioning implemented as prescribed within past 24 22. % At Risk Pts. with Routine Positioning Implemented as Prescribed w/in Past hours? Total patients with yes answers 24 Hrs are divided by the sum of patients with 100 to calculate percent. Other patients are omitted from calculation. 23. % At Risk Pts. Receiving Nutritional Support w/in Past 24 Hrs at risk was nutritional support implemented within past 24 hours? Total patients with yes answers are divided by the sum of patients with yes and no answers and multiplied by 100 to calculate percent. Other patients are omitted from calculation.
6 24. % At Risk Pts. Receiving Moisture Management Interventions w/in Past 24 Hrs at risk was moisture management implemented within past 24 hours? Total patients with yes answers are divided by the sum of patients with yes and no answers and multiplied by 100 to calculate percent. Other patients are omitted from calculation. Restraints and Sitter Measures 25. % of Pt. with any Restraints Total patients with yes answers are divided by the sum of patients with yes and no answers and multiplied by 100 to calculate percent. 26. % of Pt. in Restraint (Limb +/or Vest only) Total patients with limb and/or vest restraints are divided by the sum of patients with yes and no answers to any restraints and multiplied by 100 to calculate percent. Total patients with yes answers are 27. % of Pt. with Sitter divided by the sum of patients with yes and no answers and multiplied by 100 to calculate percent. Patient Descriptors 28. Patient Age Calculated for all patients included in the prevalence study. Allows comparisons with other hospitals on patient age. 29. % Medical Patients Percent of patients with primary reason for hospitalization coded as medical. Provides a measure of relative percentage of medical and surgical patients. Allows comparisons with other hospitals on percentage of medical Vs. surgical patients 30. % Male (Patient Gender) Percent of patients who were male. Provides a measure of relative percentage of male and female patients. Allows comparisons with other hospitals on patient gender.
7 Hospital Acquired Pressure Ulcer Coding: Total number of observed pressure ulcers (include all) ulcers): None Total Stage I ulcers: 1 2 3 4 5 6 7 8+ Total Stage II ulcers: 1 2 3 4 5 6 7 8+ Total Stage III ulcers: 1 2 3 4 5 6 7 8+ Total Stage IV ulcers: 1 2 3 4 5 6 7 8+ Total ulcers unable to stage: 1 2 3 4 5 6 7 8+ Total suspected deep tissue injury (DTI): 1 2 3 4 5 6 7 8+ Important: Day of first staff discovery/documentation of pressure ulcer MUST be entered if any pressure ulcers are documented in the patient s record. CalNOC will use this Measure to calculate your hospital acquired (nosocomial) pressure ulcers. Incomplete data may result in more hospital acquired ulcers being counted for your hospital. Calculation Rules: Hospital Acquired Pressure Ulcer All patients with ulcers not meeting the community acquired criteria below are designated as having hospital-acquired pressure ulcers. Community Acquired Pressure Ulcer: Ulcer discovered/documented on first day of hospitalization), or Prevalence study was done on day 1 of patient s hospital stay and ulcer was already present. All patients with ulcers not meeting the community acquired criteria should be designated as having hospital-acquired pressure ulcers (nosocomial). Hospital Acquired Pressure Ulcers (Hospital Coding/NDNQI Hospital coding entered in the prevalence study section below is used for all Measures with the label: Hosp Coding/NDNQI. For CalNOC hospitals that are also NDNQI members, data from this section is being transferred to NDNQI for calculation of hospital acquired pressure ulcers. Hospitals will use the Calculation Rules detailed above to complete this section. Patients who have community acquired ulcers and later also develop HAPU should be coded here. These patients are not captured in the CALNOC calculations above, but will be included in the Hosp Coding/NDNQI Measures. This percent of patients with hospital acquired ulcers may be higher than the CALNOC calculations because hospitals will be able to identify patients who came in with community acquired ulcers and who ALSO developed a hospital acquired ulcers. Patients with community acquired ulcers who later develop HAPU will be included in these measures. Unit acquired pressure ulcers follow the same rules for ulcers developed on the unit of the study. Total number of nosocomial (hospital acquired) ulcers: None 1 2 3 4 5 6 7 8+ No. of nosocomial Stage I ulcers: None 1 2 3 4 5 6 7 8+ No. of nosocomial Stage II ulcers: None 1 2 3 4 5 6 7 8+ No. of nosocomial Stage III ulcers: None 1 2 3 4 5 6 7 8+ No. of nosocomial Stage IV ulcers: None 1 2 3 4 5 6 7 8+ No. of nosocomial unable to stage: None 1 2 3 4 5 6 7 8+ No. of nosocomial suspected DTI: None 1 2 3 4 5 6 7 8+