Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency
As discussed with the short stay Quality Measure for Pressure Ulcers/Injury, we have seen that it is all about understanding different ulcer types and staging, which directly impacts Documentation and MDS Accuracy.
1) Root Cause Analysis
The first step in drilling down to the root cause of this Quality Measure is to understand how the measure is calculated. This Long Stay Quality Measure is calculated and used both in the Five Star reporting system and the Public Reporting Nursing Home Compare website. The measure specifically focuses on High Risk Residents who have Stage 2 up to Stage 4 Pressure Ulcers (Injuries).
2) Understanding the Defined Criterion
This particular measure looks at several different areas to calculate the measure. Target assessments must meet both of the following criteria:
• Stage 2 – 4 present as indicated in M0300
• High Risk which includes any of the following:
• Impaired bed mobility or transfer (either or both)
• Bed Mobility self-performance = 3,4,7 or 8
• Transfer self-performance = 3,4,7 or 8
• Comatose coded in B0100
• Malnutrition risk coded in I5600
• Exclusion-If the target MDS is the Admission Assessment (A0310A=01) or the MDS is a PPS 5 Day or Readmission/Return Assessment (A0310B=01; 06)
• Exclusion-The MDS response to M0300 is dashed (‘-‘)
First and foremost, it is critical that the MDS Coordinator verify the accuracy of the ADL Self Performance Data for accuracy.
Secondly, understanding etiology of the ulcer will affect coding. With the elderly population and their vast amount of co-morbidities, determining if an ulcer is pressure or something else can sometimes be a challenge. Harmony (HHI) provides the following definitions and guidelines to assist staff in making the all-important decision.
Fact Gathering: Look at all of the facts. Review all diagnosis, fully assess the wound, and identify all factors that may impede wound healing, including psychosocial and environmental. A wound will not heal until the cause is determined and removed. Remember, the center of the wound tells the story of the wound.
Per NPUAP guidelines, pressure ulcer (injury)is defined as localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or a combination of pressure, shear and/or friction. Typically, round or oval in shape.
• Location – typically over bony prominences, but can be anywhere that there is external pressure.
• Distribution – isolated and individual.
• Shape – rounded, crater like. Can resemble the shape of what caused the pressure.
• Depth – partial or full thickness.
• Wound Bed – varies depending on thickness of the ulcer.
• Margins – smooth, regular edge, demarcated.
• Surrounding Tissue – varies. Often non-blanchable.
Developed by the NPUAP. Based upon the deepest tissue injury present. Cannot be accurately staged until the deepest viable tissue layer is visible.
• Unstageable – full thickness loss in which entire the base of the ulcer is covered with slough and/or eschar.
• Stage 1 – intact skin with non-blanchable redness.
• Stage 2 – Partial thickness loss of dermis. Presents as shallow opening with red or pink wound bed. Can present as a blister. There will never be slough or eschar in a stage 2 pressure ulcer. An easy way to identify the stage II is to remember the three “P”s – pink, partial and painful.
• Stage 3 – full thickness tissue loss. Subcutaneous fat may be visible. Bone, tendon or muscle is NOT visible. Slough may be present, but does not cover entire wound base. May include undermining and tunneling. Depth varies by anatomical location.
• Stage 4 – full thickness tissue loss. Bone, muscle, fascia, ligament or tendon will be visible. May contain slough, but not over the entire wound bed. Often includes undermining and tunneling.
• Deep Tissue Injury – purple or maroon localized area of discoloration, may be blood filled blister due to damage to underlying soft tissue. Caused by pressure and/or shear. Surrounding tissue may be mushy, boggy or painful. Evolution to other stages can be rapid, even with appropriate treatment. Fingers will sink, not rebound upon palpation.
All wounds, no matter the type, are classified based upon the level of tissue damage. Wounds are placed into one of two categories, dependent upon this level of destruction, partial or full thickness.
Partial Thickness – Tissue destruction through the epidermis and parts of the dermis Pink and painful. Never yellow. Epidermis repair typically takes 24 hours. Dermis repair is a longer process. Generally, it takes 7 days for new blood vessels to sprout and 9 days for collagen fibers to be visible and for re-epithelialization (regeneration of epidermis) to occur. Note: this is not granulation. Granulation can only occur once the subcutaneous tissue is involved.
Full Thickness – Tissue destruction through the epidermis, the dermis, into the subcutaneous tissue and possibly bone, tendon and muscle. There are four overlapping phases in the healing process.
• Hemostasis: 1st Initiates the wound healing process. The main function is coagulation.
• Defensive/Inflammatory: 2nd Main function is to remove debris. Characterized by edema, erythema, heat and pain.
• Proliferative: 3rd Granulation and contraction occurs. Appears red and bumpy, often with red ridges.
• Maturation: 4th Tensile strength is increased and remodeling of tissue occurs. Note – Risk for wound reopening is very high. Do not stop treatment or aggressive preventative measures.
Other Ulcer Types: While properly identifying the pressure ulcer is important, it is equally important to be able to accurately identify other ulcer types in order to provide the best treatment and interventions.
Arterial – caused by lower extremity arterial disease and conditions such as atherosclerosis. There is low blood flow, so the lower extremities appear pale. Typically found on the tips of the toes, around the lateral malleolus and at pressure points from footwear. Present as round with even wound margins. Punched out appearance. Wound bed is pale, non-granulating with slough, eschar or epithelial tissue. Generally minimal to no exudates.
Venous – caused by peripheral vascular disease and chronic venous insufficiency. Legs appear woody and hard with firm edema. Ulcers typically located on medial lower leg and ankle. Seldom on the foot or above the knee. Present with an irregular shape, superficial initially. Wound base is red, ruddy and granular. Exudate is moderate to heavy.
Diabetic - caused by peripheral neuropathy associated with diabetes. Typically located on the plantar aspect of the foot, over metatarsal heads, under the heel and areas of the foot exposed to repeated trauma. Shape is well defined, round or oblong and deep. Surrounding tissue is usually callused.
Stay tuned and we will continue to define and refine Quality Measures in our weekly blog posts. Harmony Healthcare International (HHI) is available to provide onsite analysis and associated medical record reviews to help you improve your Quality Measure Scores. Please contact Harmony Healthcare International by clicking here or calling our office at 1.800.530.4413.
References: NPUAP Guidelines – 2014 revised; April 2016 update
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