Pressure Ulcer Management
Background Patients in intensive care units are likely to have limited mobility owing to hemodynamic instability and activity orders for bed rest. Bed rest is indicated because of the severity of the disease process, which often involves intubation, sedation, paralysis, surgical procedures, poor nutrition, low flow states, and poor cir- culation. These patients are predisposed to the develop- ment and/or the progression of pressure ulcers not only because of their underlying diseases, but also because of limited mobility and deconditioned states of health. Objective To assess whether treating high-risk patients with a prophylactic sacral dressing decreases the inci- dence of unit-acquired sacral pressure ulcers. Methods An evidence-based tool for identifying patients at high risk for pressure ulcers was used in 3 intensive care units at an urban tertiary care hospital and academic medical center. Those patients deemed at high risk had a prophylactic sacral dressing applied. Incidence rates were collected and compared for the 7 months preced- ing use of the dressings and for 7 months during the trial period when the dressing was used. Results After the sacral dressing began being used, the number of unit-acquired sacral pressure ulcers decreased by 3.4 to 7.6 per 1000 patient days depending on the unit. Conclusions A prophylactic sacral dressing may help prevent unit-acquired sacral pressure ulcers. Implemen- tation of an involved care team with heightened aware- ness and increased education along with a prophylactic sacral dressing in patients deemed high risk for skin breakdown are all essential for success. (American Jour- nal of Critical Care. 2016;25:228-234)
PROPHYLACTIC SACRAL DRESSING FOR PRESSURE ULCER PREVENTION IN HIGH-RISK PATIENTS By Jaime Byrne, RN, MSN, CCRN, Patricia Nichols, RN, MSN, CCRN, Marzena Sroczynski, RN, BSN, CWOCN, Laurie Stelmaski, RN, BSN, CWON, Molly Stetzer, RN, BSN, CWOCN, Cynthia Line, PhD, and Kristen Carlin, MPH
228 AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2016, Volume 25, No. 3 www.ajcconline.org
P atients in intensive care units (ICUs) are predisposed to pressure ulcers because of
limited mobility and the severity of their disease processes. Pressure ulcers result
from pressure or a combination of pressure and shear, usually over bony promi-
nences, and cause localized injury to the skin and underlying tissues.1 The prevalence
of pressure ulcers in acute care settings is estimated at 12% to 19.7%, of which 20%
occur on the sacrum or coccyx.2 In ICUs, pressure ulcers rates can occur in 14% to 42% of
patients.3 For patients, pressure ulcers can be painful, embarrassing, isolating, and, in some
cases, life-threatening.4
The standard of care to prevent pressure ulcers
includes routine repositioning to offload pressure
points, moisture management, use of support sur-
faces, and assessment of nutritional requirements by
registered dietitians. Despite these practices designed
to mitigate risk, pressure ulcers continue to develop in many high-risk ICU patients. In practice, pressure ulcers are indicators of quality of care.5 The Joint Commission considers prevention of health care associated pressure ulcers a National Patient Safety Goal.6 The Institute for Healthcare Improvement included pressure ulcer prevention in its 5 Million Lives Campaign.7 More recently, the federal govern- ment identified pressure ulcers as one of the hospi- tal-acquired conditions included in the Agency for Healthcare Research and Quality composite mea- sure PSI-90.8 Hospital-acquired conditions are included in 2 pay-for-performance programs under the Patient Protection and Affordable Care Act that have great implications for hospital finances: pen- alties for hospital-acquired conditions and val- ue-based purchasing incentives.9
Treatment of pressure ulcers is expensive, with estimates of the cost at a mean of $1200 to $1600 per day.10 The Centers for Medicare and Medicaid Services no longer reimburses facilities for pressure ulcer care when the ulcers are acquired in the hospi- tal.11 Starting in 2015, hospitals that rank among
the worst 25% for hospital-acquired conditions,
including pressure ulcers, will see their reimburse-
ment rates decline.12 Reducing the incidence of
pressure ulcers would not only reduce the negative
physical and psychological impact on patients and
improve patients outcomes, it might also reduce costs and increase reim- bursement for hospitals. Yet, despite the widespread recognition of the need to prevent pressure ulcers in critical care patients, chal- lenges remain in the ability to prevent them. Recent studies indicate that silicone dressings may hold promise for prevention of pressure ulcers. ICU patients who received a soft silicone multilayered foam dressing on the sacrum showed significantly fewer pressure ulcers.13-15
This study sought to evaluate the effects of a prophylactic silicone adhesive hydrocellular sacral foam dressing on incidence of sacral pressure ulcers among high-risk ICU patients. The product for the trial was chosen because the facility already used Allevyn (Smith & Nephew) dressings of various sizes and shapes for care of skin tears with good results and the nurses were already familiar with this type of product. The particular dressing used in this trial
is specifically designed for use on the difficult-to-fit coccyx area.
Methods Setting
This study was conducted in an urban tertiary care academic medical center that is also a level I
trauma center with 951 licensed acute care beds. Three ICUs at the institution participated in the
study: the surgical coronary care unit (SCCU), a 9-bed surgical cardiac ICU; the medical coronary
care unit (MCCU), a 9-bed medical cardiac ICU; and a 25-bed medical ICU (MICU). The SCCU
generally provides care for patients after coronary
artery bypass surgery, valve replacement or repair,
About the Authors Jaime Byrne is an intensive care clinical nurse specialist, Marzena Sroczynski is a certified wound ostomy conti- nence nurse specialist, and Laurie Stelmaski is a certified wound ostomy nurse at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania. Patricia Nichols is director of nursing education at Aria Health, Philadelphia, Pennsylvania. Molly Stetzer is a certified wound ostomy continence nurse specialist, Childrens Hospital of Phila- delphia, Philadelphia, Pennsylvania. Cynthia Line is a proj- ect manager and Kristen Carlin is a biostatistician, Office of Nursing Research, Thomas Jefferson University Hospital.
Corresponding author: Jaime Byrne, RN, MSN, CCRN, Thomas Jefferson University Hospital, 111 South 11th Street, Philadelphia, PA 19107 (e-mail: [email protected]).
www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2016, Volume 25, No. 3 229
In practice, pressure ulcers are often perceived as quality of care indicators.
230 AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2016, Volume 25, No. 3 www.ajcconline.org
implantation of a ventricular assist device, heart
transplant, or extracorporeal membrane oxygenation
cannulation. The MCCU provides care for patients
who had a recent ST-segment elevation myocardial
infarction, cardiogenic shock, or heart failure with
decompensation and for patients who require opti-
mization before cardiothoracic surgery. The MICU
generally provides care for patients with liver failure,
respiratory failure requiring intubation and mechani-
cal ventilation, pulmonary hypertension, septic shock,
multisystem organ failure, and acute respiratory dis-
tress syndrome. The hospitals standard mattress in
all 3 of these ICUs was the AtmosAir 9000 (KCI).
Sample The study was approved by the institutional
review board and granted a waiver of consent. All adults, aged 18 years and older, and admitted to any of these ICUs were screened for inclusion in the trial on the basis of their risk factors for skin breakdown. Patients assessed as having any 1 of the following criteria were included in the study: surgery longer than 4 hours or cumulative surgeries longer than 6 hours; cardiac arrest during this admission; vasopressor use for more than 48 hours; shock; sepsis; or multiorgan dysfunction syndrome.
If patients did not meet the afore- mentioned singular criteria, they were evaluated for the following: age more than 65 years old; bed rest; traction; diabetes; liver fail- ure; hemodynamic instability; body mass index (calculated as weight in kilograms divided by height in meters squared) less than 18.5 (underweight) or greater than 40 (morbid obesity); malnutri- tion (prealbumin < 20 mg/dL, albumin < 2.5 g/dL, nothing by mouth > 3 days); spinal cord injury (quadriplegia/
paraplegia); sedation/paralysis for more than 48
hours; history of pressure ulcers; mechanical venti- lation for more than 48 hours; nitric oxide ventila- tion; drive lines (left or right ventricular assist
device balloon pump, extracorporeal membrane
oxygenation); history of vascular disease; expected length of stay greater than 5 days; intermittent hemodialysis/continuous venovenous hemodialysis;
Braden score 12 or less; or orthopedic injuries. Any
patient who screened positive for 5 or more of these conditions was included in the study.
Patients with any of the following conditions were excluded from the study: urinary or fecal incon-
tinence not managed with a urinary catheter or fecal
management system, weeping edema or anasarca, diaphoresis in sacral area, or preexisting sacral
pressure ulcer. Patients who were excluded from
the study could still receive the study dressing if a
wound ostomy and continence nurse (WOCN) rec-
ommended it, but those patients were not included
in the evaluation.
Design A prospective, nonrandomized, quasi-experimental
observational study was conducted to compare ICU-
acquired sacral pressure ulcers in patients assessed
at high risk for development of pressure ulcers before
and after implementing prophylactic use of silicone
adhesive hydrocellular sacral foam dressings. Base-
line data on the daily incidence of pressure ulcers
on the sacrum, buttocks, and coccyx were collected
for the 7 months before implementation of the
dressings, from October 2011 to April 2012. During this 7-month period, a screening tool to determine which patients were at high risk for pressure ulcer development on the sacrum, buttocks, and coccyx was developed after an extensive literature review. This tool was validated by the 3 WOCNs employed by the facility. In preparation for intervention data collection, in February 2012, each participating ICU conducted an informal evaluation of the screening criteria for risk of pressure ulcers and the applica- tion of the sacral dressing as prophylaxis. Registered nurses were asked to assess patients using the screen- ing criteria and apply the dressing as pressure ulcer prophylaxis in patients who met screening criteria. The nurses were also asked to evaluate the dressing for ease of application, removal, wear time, patient comfort, ease of repositioning, and patient safety. Overall, the nurses rated the aspects of the sacral dressing positively. During this study preparation, fewer than 10% of patients had clear fluid-filled blisters related to moisture develop under the sacral dressing. Following the review of these patients by the WOCN, the screening criteria and follow-up
assessment criteria were clarified to minimize the risk for blistering under the dressing during the interven- tion phase. Before the intervention phase, staff in
all 3 units and the cardiothoracic operating room,
where patients had dressings applied before their procedure, received education regarding the dressing criteria tool, dressing application (Table 1), the data
collection tool (Figure 1), and dressing removal.
The intervention phase of this study occurred from May through November 2012. During the trial period, each adult patient who was admitted to any
of the 3 ICUs was assessed by a registered nurse upon
arrival to the unit and screened for study eligibility. Patients who met inclusion criteria received a
prophylactic sacral dressing. The dressing used in this study was the Allevyn Gentle Border Sacrum
Dressing manufactured by Smith & Nephew. Data
Nurses evaluated the dressing for
ease of application, removal, wear time,
patient comfort, ease of repositioning,
and patient safety.
www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2016, Volume 25, No. 3 231
on ICU-acquired pressure ulcers were collected
daily by clinical nurse specialists and registered
nurses for each unit.
Once the sacral dressing was applied to a patient,
an assessment was performed by the primary nurse
every shift (minimum every 12 hours) and docu-
mented on the data collection tool and in the
electronic medical record. Skin assessments were
completed per the hospitals standard of nursing
care and included peeling back the sacral dressing
to perform a full skin inspection underneath. Also
documented on the data collection tool were assess-
ments of the skin condition under the dressing,
whether the dressing was reapplied or changed, and
the end date of the patients participation either
because the dressing was removed or because the
patient was transferred out of a participating ICU. Each patient had a data collection tool for each shift. Completed data collection tools were col- lected weekly by each units clinical nurse specialist.
To ensure appropriate assessment and clinical care for patients with the sacral dressing, a mark was placed next to the patients name on the units patient assignment board in the nurses break room. The sacral dressing was changed every 3 days while the patient remained in the study. Any patients who had exclusion criteria develop after application of the sacral dressing during this study had the dress- ing removed. The removal date was noted on the data collection tool as the end date of the patients participation. If, during the study, any skin changes occurred under the dressing, the dressing was removed unless continued use was recommended by a WOCN. Each event that required dressing removal was inves- tigated by a WOCN, and if any further treatment was recommended, it was implemented promptly. In addition, because the study included patients at very high risk for skin breakdown, any skin break- down or redness was noted and a WOCN evaluated
further use of sacral dressing treatment.
Statistical Analysis Data were entered into an Excel (Microsoft
Corp) spreadsheet and imported into IBM SPSS
Statistics 19 (IBM SPSS) for analysis. Descriptive
statistics were used to characterize the dressing use. Pressure ulcer rates were calculated by using the industrys standardized rate per 1000 patient days.
Differences in pressure ulcer rates were obtained
by calculating incidence rate ratios and confidence intervals. P values were calculated by using a 2 test.
Results Data from all 3 units (SCCU, MCCU, and MICU)
were combined for analysis. Of the 584 patients assessed for inclusion, 243 (41.6%) had a sacral
dressing applied but completed data were received on only 200 of those patients (Figure 2). Among the 243 who had a sacral dressing applied, surgery longer than 4 hours or cumulative surgeries longer than 6 hours (32.5%, n = 79) and sepsis (23.5%, n = 57) were the
most common singular inclusion criteria (Figure 3). Table 2 lists the characteristics for the 132 patients
who met inclusion criteria for 5
or more factors and had a sacral dressing applied. The mean dura- tion for a patient to have a dress-
ing in place was 3.26 days (SD,
3.17, n = 200), with a range of 0 to 24 days. In all, 71.5% (n = 143) of patients had a dressing applied for 3 or fewer days.
Depending on the unit, implementation of the
sacral dressing reduced unit-acquired sacral pressure ulcers anywhere from 3.4 to 7.6 per 1000 patient days.
The SCCU had the most dramatic reduction at 7.6 per 1000 patient days, the MCCU had a reduction
of 3.4/1000 patient-days, and the MICU reduced
rates by 3.6 per 1000 patient days (Table 3).
Table 1 Quick tips and daily expectations for use of dressings
Quick tips
Key reminders Refer to criteria checklist to iden-
tify proper patient Place preventatively on clean dry
intact skin Apply dressing before applying
any emollients (skin prep, pro- tectants, wipes)
Check under dressing every 12 hours and document skin
Peel right or left top corner quarter way to view skin
Place dressing back and trace over with warm hand
If dressing slightly soiled, clean from inside out
Change every 3 days Remove if patient transfers out of
unit If dressing stays on < 24 hours because of multiple incontinence episodes, discontinue use Dressing Application Remove center backing of dressing and start with center in gluteal fold Point/tail of dressing covers coccyx Start in center and work up and out Dont stretch wings when removing remaining backing Once dressing is in place, hold warm hand on dressing for 30 seconds Apply as directed and mark dress- ing with date and time of appli- cation Peel back every shift for skin assessment, reseal existing dressing after assessing Document any new findings, report changes to clinical nurse specialist, wound ostomy conti- nence nurse, or both Remove and discard dressing every 3 days Reapply as long as patient meets the inclusion criteria If dressing exterior is soiled but remains intact, it does not need to be changed; wipe clean and change on third day If dressing does not stay intact more than 24 hours because of incontinence, discontinue dressing and use barrier cream or alternative management Daily expectations Use of the sacral dressing reduced pressure ulcers by 3.4 to 7.6 per 1000 patient days. Carina Highlight 232 AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2016, Volume 25, No. 3 www.ajcconline.org Figure 1 Data collection tool. Abbreviations: DTI, deep tissue injury; PU, pressure ulcer; WOCN, wound ostomy continence nurse. ALLEVYN Sacral Gentle Border for Pressure ReductionData Collection ***Consult Wound Care on Each Patient*** Room #:_______________ ICU admission date: ____/______/____ Evaluation period: Date dressing originally applied: ____/______/____ End date (either date dressing permanently removed or when patient transferred out of the ICU): ____/_____/____ Did the patient die? Please circle. Yes / No ***PLEASE COMPLETE ON EVERY PATIENT MEETING CRITERIA FOR ALLEVYN SACRAL DRESSING*** ADD additional sheets as needed. Once completed, place in allotted bin in the unit for collection. Date Time Skin condition Dressing AM Intact Nonblanchable erythema or color different from skin tone/stage I PU Partial thickness/stage II PU Full thickness/stage III or IV PU/unstageable PU Evidence of DTI Exclusion criteria met Other (describe): Reapplied Changed Permanently removed WOCN consulted PM Intact Nonblanchable erythema or color different from skin tone/stage I PU Partial thickness/stage II PU Full thickness/stage III or IV PU/unstageable PU Evidence of DTI Exclusion criteria met Other (describe): Reapplied Changed Permanently removed WOCN consulted AM Intact Nonblanchable erythema or color different from skin tone/stage I PU Partial thickness/stage II PU Full thickness/stage III or IV PU/unstageable PU Evidence of DTI Exclusion criteria met Other (describe): Reapplied Changed Permanently removed WOCN consulted PM Intact Nonblanchable erythema or color different from skin tone/stage I PU Partial thickness/stage II PU Full thickness/stage III or IV PU/unstageable PU Evidence of DTI Exclusion criteria met Other (describe): Reapplied Changed Permanently removed WOCN consulted Figure 2 Flow chart shows how studys sample size was deter- mined. Total number of patients assessed for inclusion in the study Number of patients who had a sacral dressing applied Number of patients who had a sacral dressing applied and had complete data 584 243 200 Five patients experienced unanticipated skin issues during the trial. Two patients had a deep tissue injury (DTI) develop, 1 had a stage I pressure ulcer develop, and 1 had a blister develop on the sacrum. In all of these cases, the dressing was imme- diately removed upon discovery of the skin changes, a WOCN was consulted, and further treatment was implemented, if recommended by the WOCN. The fifth case was a DTI located on the patients left buttock that resulted from pressure caused by the patient lying on a partially dislodged sacral dress- ing. Upon discovery of the altered dressing integ- rity, this patient was treated appropriately with a wound care consultation and the application of a mild topical vasodilator, and the DTI resolved. www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2016, Volume 25, No. 3 233 Discussion Minimizing pressure ulcers is an important issue for the management of critically ill patients. The intention of the study was to see if the use of a new product on the market would improve out- comes in our patients at high risk for pressure ulcers. Study findings revealed that during the 7-month trial, use of the dressing led to decreases in the incidence of pressure ulcers on the sacral, coccyx, and buttock area in all 3 ICUs. These findings suggested that the dressing could decrease cost for institutions and improve patient care, contributing to the body of knowledge about interventions to minimize the risk of pressure ulcers. Our results were similar to those of Santamaria et al,13 Chaiken,15 and Walsh et al.14 Education and reminders to the bedside staff on exactly how to apply and use the dressing are imper- ative to the prevention of pressure ulcers in patients. Limitations and Strengths Because of the nature of the prospective study design, demographic information was not collected. This lack of demographic data prevented a direct comparison between the pretrial population and the population during the trial. Other risk factors for pressure ulcers, not related to the prophylactic dressing, may have differed between these 2 popula- tions, thus biasing the results of this trial. Addition- ally, the study sample was nonrandomized; it was a convenience sample that looked only at feasibility. Interrater reliability could not be assessed because repositioning of patients was not monitored. Docu- mentation was incomplete in 43 of the patients who had the dressing applied, making it impossible to track the reason for application and wear time in those patients. Multiple initiatives were taking place during this time frame that also focused on preven- tion of pressure ulcers. A multidisciplinary hospital- acquired pressure ulcer committee was developed in September 2011 that evaluated wound care practices, policies, and products and implemented changes, all with the common goal of decreasing the incidence of pressure ulcers. Dermal defense champions were chosen in February 2012, and their focus was to receive monthly education on pressure ulcer preven- tion and then relay that information at the unit level to staff nurses. The units had increased education and awareness during this period, which caused more active participation. The decrease in pressure ulcer incidence during the intervention phase improved patients outcomes. Conclusion The results of this study indicated that a pro- phylactic sacral dressing may prevent ICU-acquired sacral pressure ulcers. Future studies could evaluate the effects of prophylactic dressings in conjunction with a critical care bundle for prevention of pres- sure ulcers that addresses nutritional status and frequent repositioning. Conducting a randomized controlled trial would be beneficial for further Figure 3 Frequencies of conditions that led to automatic inclusion in the study among patients who had the dressing applied. Abbreviations: MODS, multiorgan dysfunction syndrome. P e rc e n ta g e o f p a ti e n ts Condition 35 30 25 20 15 10 5 0 Cardiac arrest MODSShockSepsisSurgery Vasopressor Factor Table 2 Nonautomatic inclusion factors of 243 patients who had Allevyn dressing applied: 5 or more factors required for inclusion Bed rest Expected stay > 5 days
Age > 65 years
Hemodynamic instability
Diabetes
Mechanical ventilation
Sedation
Braden score > 12
History of vascular disease
Malnutrition
Body mass index
Liver failure
Intermittent hemodialysis
Drive lines
History of pressure ulcers
Orthopedic injuries
Spinal cord
Nitric oxide ventilation
Traction
159 (65.4)
104 (42.8)
101 (41.6)
97 (39.9)
51 (21.0)
50 (20.6)
48 (19.8)
44 (18.1)
34 (14.0)
24 (9.9)
22 (9.1)
18 (7.4)
16 (6.6)
15 (6.2)
7 (2.9)
4 (1.6)
3 (1.2)
1 (0.4)
0 (0.0)
No. (%) of patients
234 AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2016, Volume 25, No. 3 www.ajcconline.org
Unit
Table 3 Improvements seen in each unit in the study during the Allevyn trial period
Surgical coronary care
Medical coronary care
Medical intensive care
.08
.31
.27
0.16-1.09
0.16-1.78
0.14-1.73
0.41
0.54
0.49
7.62
3.44
3.58
5.38
3.96
3.40
13.00
7.40
6.98
P95% ClIncidence rate ratio Rate difference
(per 1000 patient days)
Pressure ulcer incidence (per 1000 patient days)
During trialBefore trial
analysis of the effects of the dressing itself. It would
be useful to study the cost-effectiveness of such
interventions. Also, it would be useful to study
prophylactic dressings on other body areas prone
to pressure damage, such as around devices or
specialty equipment.
FINANCIAL DISCLOSURES Some of the Allevyn dressings were donated by the man- ufacturer, Smith & Nephew (120 dressings comprising approximately 50% of 1 months supply). However, this donation covered only a portion of necessary supplies. Additional supplies were provided by Thomas Jefferson University Hospital. Smith & Nephew played no role in the design of the research study or the collection of data and was not considered a contributing partner or coauthor.
eLetters Now that youve read the article, create or contribute to an online discussion on this topic. Visit www.ajcconline.org and click Submit a response in either the full-text or PDF view of the article.
SEE ALSO For more about preventing pressure ulcers, visit the Critical Care Nurse Web site, www.ccnnonline.org, and read the article by Cooper, et al, Against All Odds: Preventing Pressure Ulcers in High-Risk Cardiac Surgery Patients (October 2015).
REFERENCES 1. European Pressure Ulcer Advisory Panel and National
Pressure Ulcer Advisory Panel. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guidelines. Washing- ton, DC: National Pressure Ulcer Advisory Panel; 2009.
2. Jenkins ML, ONeal E. Pressure ulcer prevalence and inci- dence in acute care. Adv Skin Wound Care. 2010;23:556-559.
3. Cox J. Pressure ulcer development and vasopressor agents in adult critical care patients: a literature review. Ostomy Wound Manage. 2013;59(4):50-54, 56-60.
4. Langemo DK, Melland H, Hanson D, Olson B, Hunter S. The lived experience of having a pressure ulcer: a qualita- tive analysis. Adv Skin Wound Care. 2000;13:225-235.
5. Gallant C, Morin D, St-Germain D, Dallaire D. Prevention and treatment of pressure ulcers in a university hospital center: a correlational study examining nurses knowledge and best practice. Int J Nurs Pract. 2010;16:183-187.
6. The Joint Commission. 2011 Joint Commission national patient safety goals. http://www.lovell.fhcc.va.gov/about /2011Nation- alPatientSafety.pdf. 2011. Accessed February 22, 2016.
7. Institute for Healthcare Improvement. 5 Million lives cam- paign. http://www.ihi.org/offerings/Initiatives/PastStrategi- cInitiatives/5MillionLivesCampaign/Pages/default.aspx. 2008. Accessed February 22, 2016.
8. Agency for Healthcare Research and Quality: US Department of Health and Human Services. Quality indicator user guide: patient safety indicators (psi) composite measures version 4.3. http://www.qualityindicators.ahrq.gov/Downloads/Mod- ules/PSI/V43/Composite_User_Technical _Specification_ PSI_4.3.pdf. Accessed February 22, 2016.
9. American Hospital Association. Quality reporting and pay-for-performance. April 15, 2014. http://www.aha.org /content/14/ip-qualreport.pdf. Accessed February 22, 2016.
10. Russo CA, Steiner C, Spector W. Hospitalizations related to pressure ulcers among adults 18 years and older, 2006. Sta- tistical brief #64, AHRQ Healthcare Cost and Utilization Proj- ect. www.hcup-us.ahrq.gov/reports/statbriefs/sb64.pdf. December 2008. Accessed February 22, 2016.
11. Centers for Medicare & Medicaid Services. Hospital-acquired conditions. http://www.cms.gov/Medicare/Medicare-Fee-for- Service-Payment/HospitalAcqCond/Hospital-Acquired _Con- ditions.html. Accessed February 22, 2016.
12. Medicare website. Linking quality to payment. http://www
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