This safety dQM captures the number of patients who experience harm in the form of a pressure injury during their inpatient hospitalization. The incidence of pressure injuries in hospitalized patients has been estimated at 5.4 per 10,000 patient-days, and the rate of hospital-acquired pressure injuries (HAPIs) has been estimated at 8.4% (Li et al., 2020). Over 50% of reported pressure injuries in hospitals were stage 2 or higher (Li et al., 2020). HAPIs are serious events and one of the most common patient harms. Pressure injuries commonly cause local infection, osteomyelitis, anemia, and sepsis in addition to causing significant depression, pain, and discomfort to patients (Shui et al., 2021). Pressure injury is considered a serious reportable event by the National Quality Forum (NQF) (NQF, 2011).

Studies have shown that age, severity of illness, comorbidity indexes, and Braden scores are predictors of HAPIs (Rondinelli et al., 2018). However, even after risk adjustment for patient risk factors, significant variation in rates of HAPI exist between hospitals (Rondinelli et al., 2018). It is widely accepted that the risk of developing a pressure injury can be reduced through best practices. Hospital controlled factors that have been found to be significantly associated with an increase in pressure ulcer risk include infrequent repositioning (p=0.005) and number of days to bed change (OR, 2.89 [95% CI, 1.26-6.63]) (Tayyib et al., 2016; Bly et al., 2016). Nurse staffing, measured as hours per patient day (HPPD), skill mix, and expertise are also significant predictors of HAPI development; patients who require more nursing activity have actually been found to have a lower risk for HAPIs (Tschannen & Anderson, 2020). Systematically measuring patients who develop new pressure injuries while in the hospital setting will provide hospitals with a reliable and timely measurement to more reliably assess harm reduction efforts and modify their improvement efforts in near real-time. This dQM fills a gap in measurement and provides incentives for hospitals' quality improvement. The intent of this measure is to incentivize greater achievements in reducing harms and enhance hospital performance on patient safety outcomes.

Stage 2 pressure injuries, characterized by partial-thickness skin loss, carry a less serious burden in terms of patient harm than stage 3, stage 4, unstageable, and deep tissue pressure injuries (DTPI). Partial-thickness wounds heal primarily as a result of epidermal regeneration and often heal without untoward consequences, loss of skin function, or scar tissue formation. Based on the healing capabilities inherent in these partial-thickness wounds, it is the expert opinion of the National Pressure Ulcer Advisory Panel (NPUAP) that the presentation of stage 2 pressure injuries does not carry the same potential longstanding negative consequences to patients as do full thickness pressure injuries. Stage 2 pressure injuries constitute a very real patient harm that should be monitored and addressed; however, the relative level of harm is less than with stage 3, stage 4, unstageable pressure injuries and potentially DTPI (NPUAP, 2019).

The accurate and timely identification of DTPI is important for several reasons. Early discovery of DTPI allows prompt identification of possible causes, initiation of treatment, and potential development of preventive strategies. In addition, 24 to 72 hours can lapse between the precipitating pressure event and the onset of purple or maroon skin. This delayed manifestation becomes particularly important when the precipitating event occurred before the patient's admission, yet the DTPI appears beyond the 24-hour window for present-on-admission status (Tescher et al., 2018).

The Clinical Guidelines Committee for the American College of Physicians (ACP) presents the available evidence on the comparative effectiveness of various risk assessment instruments and benefits and harms of strategies to prevent pressure ulcers (Qaseem et al., 2015).

Recommendation 1: ACP recommends that clinicians should perform a risk assessment to identify patients who are at risk of developing pressure ulcers.

Recommendation 2: ACP recommends that clinicians should choose advanced static mattresses or advanced static overlays in patients who are at an increased risk of developing pressure ulcers.

Recommendation 3: ACP recommends against using alternating-air mattresses or alternating-air overlays in patients who are at an increased risk of developing pressure ulcers.

The European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance's Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline (The International Guideline) provides guidance for categorizing pressure injuries and recommendations for structured skin and risk assessment (European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance, 2019).

Guidelines focused on risk factors and risk assessment: 1.1: Consider individuals with limited mobility, limited activity and a high potential for friction and shear to be at risk of pressure injuries. 1.2: Consider individuals with a category/stage I pressure injury to be at risk of developing a category/stage II or greater pressure injury. 1.7: Consider the impact of diabetes mellitus on the risk of pressure injuries. 1.8: Consider the impact of perfusion and circulation deficits on the risk of pressure injuries. 1.12: Consider the impact of increased body temperature on the risk of pressure injuries. 1.17: Consider the impact of time spent immobilized before surgery, the duration of surgery and the American Society of Anesthesiologists (ASA) Physical Status Classification on surgery-related pressure injury risk.

Guidelines focused on skin and tissue assessment: 2.2: Inspect the skin of individuals at risk of pressure injuries to identify presence of erythema. 2.3: Differentiate blanchable from non-blanchable erythema using either finger pressure or the transparent disk method and evaluate the extent of erythema.

Guidelines focused on preventative skin care: 3.1: Implement a skin care regimen that includes: - Keeping skin clean and appropriately hydrated - Cleansing the skin promptly after episodes of incontinence - Avoiding use of alkaline soaps and cleansers - Protecting the skin from moisture with a barrier product 3.3: Use high absorbency incontinence products to protect the skin in individuals with or at risk of pressure injuries who have urinary incontinence. 3.4: Consider using textiles with low friction coefficients for individuals with or at risk of pressure injuries. 3.5: Use a soft silicone multi-layered foam dressing to protect the skin for individuals at risk of pressure injuries.

Guidelines focused on nutrition screening: 4.1: Conduct nutritional screening for individuals at risk of a pressure injury. 4.2: Conduct a comprehensive nutrition assessment for adults at risk of a pressure injury who are screened to be at risk of malnutrition and for all adults with a pressure injury. 4.3: Develop and implement an individualized nutrition care plan for individuals with or at risk of a pressure injury who are malnourished or who are at risk of malnutrition. 4.4: Optimize energy intake for individuals at risk of pressure injuries who are malnourished or at risk of malnutrition. 4.6: Provide 30 to 35 kcalories/kg body weight/day for adults with a pressure injury who are malnourished or at risk of malnutrition. 4.7: Provide 1.25 to 1.5 g protein/kg body weight/day for adults with a pressure injury who are malnourished or at risk of malnutrition. 4.9: Offer high calorie, high protein nutritional supplements in addition to the usual diet for adults with a pressure injury who are malnourished or at risk of malnutrition, if nutritional requirements cannot be achieved by normal dietary intake. 4.12: Discuss the benefits and harms of enteral or parenteral feeding to support pressure injury treatment in light of preferences and goals of care for individuals with pressure injuries who cannot meet their nutritional requirements through oral intake despite nutritional interventions.

Guidelines focused on repositioning and early mobilization: 5.1: Reposition all individuals with or at risk of pressure injuries on an individualized schedule, unless contraindicated. 5.2: Determine repositioning frequency with consideration to the individual's level of activity and ability to independently reposition.

Guidelines focused on heel pressure injury: 6.1: Assess the vascular/perfusion status of the lower limbs, heels and feet when performing a skin and tissue assessment, and as part of a risk assessment. 6.2: For individuals at risk of heel pressure injuries and/or with category/stage I or II pressure injuries, elevate the heels using a specifically designed heel suspension device or a pillow/ foam cushion. Offload the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon and the popliteal vein. 6.4: Use a prophylactic dressing as an adjunct to heel offloading and other strategies to prevent heel pressure injuries.

Guidelines focused on support surfaces: 7.4: Use a high specification reactive single layer foam mattress or overlay in preference to a foam mattress without high specification qualities for individuals at risk of developing pressure injuries. 7.7: Assess the relative benefits of using an alternating pressure air mattress or overlay for individuals at risk of pressure injuries. 7.8: Use a pressure redistribution support surface on the operating table for all individuals with or at risk of pressure injuries who are undergoing surgery. 7.12: Use a pressure redistribution cushion for preventing pressure injuries in people at high risk who are seated in a chair/wheelchair for prolonged periods, particularly if the individual is unable to perform pressure relieving maneuvers. 7.13: Assess the relative benefits of using an alternating pressure air cushion for supporting pressure injury healing in individuals who are seated in a chair/wheelchair for prolonged periods, particularly if the individual is unable to perform pressure relieving maneuvers.

Guidelines focused on device related pressure injury: 8.1: To reduce the risk of medical device related pressure injuries, review and select medical devices with consideration to: - The device's ability to minimize tissue damage - Correct sizing/shape of the device for the individual - Ability to correctly apply the device according to manufacturer's instructions - Ability to correctly secure the device 8.5: Use a prophylactic dressing beneath a medical device to reduce the risk of medical device related pressure injuries.

Guidelines focused on implementing best practices: 20.2: At the organizational level, assess the knowledge health professionals have about pressure injuries to facilitate implementation of an education program and a quality improvement program. 20.4: At an organizational level, assess and maximize the availability and quality of equipment and standards for its use as part of a quality improvement plan to reduce the incidence of pressure injuries. 20.5: At an organizational level, develop and implement a structured, tailored and multi-faceted quality improvement program to reduce the incidence of pressure injuries. 20.6: At an organizational level, engage all key stakeholders in oversight and implementation of the quality improvement program to reduce the incidence of pressure injuries. 20.7: At an organizational level, include evidence-based policies, procedures and protocols and standardized documentation systems to reduce the incidence of pressure injuries. 20.8: At an organizational level, provide clinical decision support tools as part of a quality improvement plan to reduce the incidence of pressure injuries. 20.9: Provide clinical leadership in pressure injury prevention and treatment as part of a quality improvement plan to reduce pressure injuries. 20.10: At a professional level, provide education in pressure injury prevention and treatment as part of a quality improvement plan to reduce the incidence of pressure injuries. 20.11: At an organizational level, regularly monitor, analyze and evaluate performance against quality indicators for pressure injury prevention and treatment. 20.12: At an organizational level, use feedback and reminder systems to promote the quality improvement program and its outcomes to stakeholders.

Guidelines focused on health professional education: 21.1: At the organizational level, assess the knowledge health professionals have about pressure injuries to facilitate implementation of an education program and a quality improvement program. 21.2: At an organizational level, develop and implement a multi-faceted education program for pressure injury prevention and treatment.

This dQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.

This FHIR-based measure has been derived from the QDM-based measure: CMS826v3. Please refer to the HL7 QI-Core Implementation Guide (https://hl7.org/fhir/us/qicore/STU6/) for more information on QI-Core and mapping recommendations from QDM to QI-Core STU 6 (https://hl7.org/fhir/us/qicore/STU6/qdm-to-qicore.html).

Inpatient hospitalizations that end during the measurement period for patients aged 18 and older

Equals Initial Population

Inpatient hospitalizations for patients with a DTPI or stage 2, 3, 4 or unstageable pressure injury diagnosis present on admission as indicated by a present on admission indicator of Y or W Inpatient hospitalizations for patients with a DTPI found on exam within 72 hours after the start of the encounter Inpatient hospitalizations for patients with a stage 2, 3, 4, or unstageable pressure injury found on exam within 24 hours after the start of the encounter

Inpatient hospitalizations for patients with a new deep tissue pressure injury (DTPI) or stage 2, 3, 4, or unstageable pressure injury, as evidenced by any of the following: A DTPI or stage 2, 3, 4, or unstageable pressure injury diagnosis not present on admission as indicated by a present on admission indicator of N or U A DTPI found on exam greater than 72 hours after the start of the encounter A stage 2, 3, 4 or unstageable pressure injury found on exam greater than 24 hours after the start of the encounter Only one harm (new qualifying pressure injury) is counted per hospitalization