Jennifer M. Hogan RN, MSN, CCDS & Kathy Jabour RN, BSN, LNC, CCDS Patient safety Indicator (PSI-90) #3 Pressure Ulcers/INJURies and Documentation Improvement February 2019 Jennifer M. Hogan RN, MSN, CCDS & Kathy Jabour RN, BSN, LNC, CCDS

Objectives Audience will have an understanding of PSI-90 # 3 related to documentation improvement. Audience will be able to distinguish pressure ulcers from non-pressure ulcer and corresponding elements for accurate and complete Provider documentation. Audience will identify CDI and Coding opportunities when conflictual data appears in a record and reference an Algorithm to prevent discrepancies regarding ulcer type, POA status, site and stage for Pressure Ulcers.

purpose FY 2019 Initiative, part of the 4 “Ps”. PSI-90# 3 is part of the CMS HAC Reduction Program and Value-Based Purchasing. 4th highest Domain 1 HACRP weight, assist in penalty reduction via Risk-Adjustment. PSI-90 #3 rates have increased in prevalence, CDI collaboration can assist concurrently to reduce discrepancies regarding site, type, stages of pressure ulcers, and POA status found in documentation amongst providers, consulting physicians and nurses. Purpose is to improve documentation for accurate coding of ulcers. https://www.qualityindicators.ahrq.gov/News/PSI90_Factsheet_FAQ_v1.pdf

AHRQ Quality Indicators hyperlink AHRQ Quality Indicators

PSI-90 #3 Pressure Ulcer Rate DESCRIPTION: “Stage III or IV pressure ulcers or unstageable (secondary diagnosis) per 1,000 discharges among surgical and medical patients ages 18 years and older. Excludes stays less than 3 days; cases with a principal diagnosis of pressure ulcer; cases with a secondary diagnosis of Stage III or IV pressure ulcer or unstageable that is present on admission; obstetric cases; and transfers from another facility.” “Numerator: Discharges, among cases meeting the inclusion and exclusion rules for the denominator, with any secondary diagnosis for pressure ulcer stage III or IV or unstageable. Prior to October 1, 2008, pressure ulcer stage codes are not available, and discharges with a pressure ulcer code prior to this date are included regardless of stage.” “Denominator: Surgical or medical discharges, for patients ages 18 years and older. Surgical and medical discharges are defined by specific MS-DRG codes.”

PSI-90 #3 –Pressure Ulcer AHRQ V2018 Specs 2018 Denominator Exclusion Changes: Removed exclusions for: hemiplegia/quadriplegia, spina bifida, anoxic brain damage and graft procedure, and transfers-in. Added exclusions for: severe burns (>or = 20% TBSA), exfoliative disorders (example : erythroderma/exfoliative dermatitis tx: corticosteroids) (> or = 20% TBSA). Revised exclusion of secondary diagnosis of stage III, IV, or unstageable ulcer POA to clarify that if more than one exits all must be POA. *AHRQ Rationale: “Before POA reporting was required, these conditions and procedures potentially associated with pressure ulcers were assumed to indicate that the pressure injury was POA. Therefore, exclusions for these conditions and procedures served as a means for removing events that might not be attributable to hospitals. However, now that POA status IS required, these exclusions are redundant and lead to undercounting of hospital-acquired pressure ulcers.”

Risk Adjustment: TOP Comorbid Category Groups Immune conditions Weight loss Pulmonary circulation Peripheral vascular conditions Renal failure (PARA- removed see previous slide) Paid programs are available for diagnosis breakdown within each Category. Optimized chart review includes capturing of all diagnoses across every PSI in every Category.

Algorithm CDI ulcer related education has historically included and continues to include face- to-face provider education and awareness, queries, new Resident and Intern formal education, and updated pocket guides. CDI algorithm was developed through research of relevant Coding Clinics, with AHA definitions. It was approved by our Physician Advisor, Dr. Jill O’Brien. The algorithm was e-mailed as a Critical Documentation Notification to providers. CDI has collaborated with Nursing, providing face-to-face education and laminated versions of the algorithm for awareness regarding PSI-90 #3 documentation.

Algorithm

Stages of Pressure Ulcers (Use only for Pressure Ulcers) STAGE 1: - Non-blanching erythema of intact skin. STAGE 2: -Partial thickness skin loss with exposed dermis. STAGE 3: - Full thickness skin loss with adipose tissue visible. STAGE 4: - Full thickness skin and tissue loss. Muscle, fascia, tendon, ligament, cartilage, bone may be visible. DEEP TISSUE INJURY: - Intact or non-intact skin with localized area of persistent non- blanchable deep red, maroon purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister UNSTAGEABLE: - Full thickness skin and tissue loss in which the extent of tissue damage cannot be confirmed since base of ulcer is obscured by slough or eschar. Once slough/eschar removed, a Stage 3 or 4 will be revealed. The staging system was defined by Shea in 1975 and provides a name to the amount of anatomical tissue loss. The original definitions were confusing to many clinicians and lead to inaccurate staging of ulcers associated or due to perineal dermatitis and those due to deep tissue injury. https://www.npuap.org/wp-content/uploads/2012/01/NPUAP-Pressure-Ulcer-Stages-Categories.pdf

Also, Unstageable DTI on next slide

Deep Tissue Injury A pressure-related injury to subcutaneous tissue under intact skin. Underlying is deeper level of pressure ulceration (Stage 3 or 4). Appearance: Deep bruise; black and blue to maroon in color, often on a bony prominence. Location: usually on bony prominences or traumatized area

Venous stasis ulcers Population: Vasculopaths Also known as: PVD ulcers, Venous insufficiency ulcers, stasis dermatitis, varicose ulcers. Appearance: Classic margins have uneven edges Location: found on the medial to lateral aspect of lower legs Occurrence: “They are the major occurrence of chronic wounds, occurring 70-90% of leg ulcer cases.” Source: Snyder RJ (2005) “Treatment of non-healing ulcers with allografts” 23 (4) 388-95.

Arterial Ulcers Population: Atherosclerotic patients. Ulcers are caused from poor circulation from ischemia due to chronic PAD. Location: Mostly located on distal digits and lateral ankle Appearance: Classic margins are even and round

Diabetic ulcers Population: Around 15% of Diabetics Location: usually at the bottom of foot Appearance: Round, yellowish Leading cause for lower leg amputations in the U.S. Source: medScape, Updated March12, 2018, Vincent Lopez Rowe M.D.

CDI & Coding opportunities Collaborate with Nursing and Providers to ensure all ulcers are documented accurately. Query the Provider. Algorithm may be used as a reference tool for Ulcer Type, Location, POA status (or unable to determine), and if Pressure Ulcer, the Stage. Pressure ulcer stage may be taken from Nursing and Wound Care RN notes. If the queried Provider doesn’t know if the Pressure Ulcer was obtained this admission; always offer the choice , “unable to determine” (W). Remember HAC 4: Stage 3, 4, DTI and Unstageable Pressure Ulcers POA (N) Risk Adjust: “holistic approach”, or Software assisted approach: popular Diagnoses often coorelate across Mortality and LOS Models: Malnutrition, Renal, Fluid electrolytes, chronic pulmonary conditions, malignancies, and others. Search for, “injury”, “ulcer”, “decub”, “breakdown” Look for Wound Care RN and HAPI Team Champions documentation in Plan of Care Note, Flowsheet, “L/D/A”, (now HAPI Team rather than HAPU Team).

Sample pressure ulcer query H&P: “84-year-old wheel-chair bed-bound patient admitted with Sepsis and Pneumonia. Admitted on 12/1/18” ED Nursing documentation of 12/1/18: “Stage 3 pressure ulcer left buttock.” Nursing documentation on 12/1/2018 : “Stage 3 pressure ulcer left buttock, Allevyn dressing changes every 5 days” Based on the above clinical information and if clinically significant please specify the following: Type of ulcer (e.g. Pressure, Diabetic, Arterial, Venous Stasis) Location and laterality of ulcer Present on admission status of ulcer Or, Clinically unable to determine *National Pressure Ulcer Advisory Panel definitions: Stage I: Intact skin with non-blanchable redness of a localized area Stage II: Partial thickness skin loss involving dermis with a shallow open ulcer or an open serum-filled blister Stage III: Full thickness skin loss involving damage or necrosis of subcutaneous tissue Stage IV: Full thickness skin loss with exposed bone, tendon or muscle Unstageable: Full thickness tissue loss in which the base of the of ulcer is covered by slough and/or eschar in the wound bed Deep tissue Injury (DTI): Purple or maroon localized area of intact skin due to damage of underlying soft tissue from pressure and/or shear

This editing helps the skin documentation stay accurate. Wound Nurse Update: Deep Tissue Injury If a patient has a deep tissue injury (DTI) and it evolves or progresses into a different type of pressure ulcer, please edit the Flowsheet to reflect the progression. For example, the DTI on someone’s buttock is now a stage 2 pressure ulcer, change the label of the wound on the Flowsheet from a DTI to a Stage 2. To edit the Flowsheet:  Click on Pressure Ulcer Properties  Click Edit button  Make the necessary changes  Click Accept This editing helps the skin documentation stay accurate.

Future considerations PSI-3 Pressure Ulcer AHRQ V2018 Specs Education Collaboration

Discussion and QUESTIONS