The rate of hospital-acquired pressure injuries has continued to rise while other hospital-acquired conditions (HACs) have fallen, prompting some providers to question whether federal regulators are taking the right approach to reduce incidence rates, Maria Castellucci reports for Modern Healthcare.

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The rise of pressure injuries

In the 2000s, CMS determined that pressure injuries, such as sores or ulcers, are "reasonably preventable," and in 2008 stopped paying for care related to treating pressure injuries that develop during a hospital stay, Castellucci reports. As a result, hospitals that report such injuries are responsible for the full cost of treating them, which can cost anywhere from $500 to more than $70,000 per injury.

In addition, CMS in October 2014 launched the HAC Reduction Program, which uses a composite score to evaluate hospitals based on their rates of several avoidable complications, including bed sores, blood clots, central line infections, falls, and infection from methicillin-resistant Staphylococcus aureus (MRSA) or Clostridium difficile (C. diff).

Yet, while rates for many HACs have declined, data from the Agency for Healthcare Research and Quality shows that the national rate of pressure injuries rose by 6% from 2014 to 2017, rising from 21.7 injuries per 1,000 discharges in 2014 to 23 per 1,000 discharges in 2017.

"Pressure ulcers are the only [HAC] pointing up in the wrong direction, so while we have managed to stabilize or reduce these other conditions, pressure ulcers are still harming patients," William Padula, assistant professor of health economics at the University of Southern California, said.

Experts say hospitals lack incentive

Some experts argue that not all pressure injuries can be avoided by following prevention guidelines, which makes some providers "question the fairness of the regulation as it stands," Castellucci reports.

Basically, "[w]e get dinged for things that we can't prevent," according to Sue Creehan, the former program manager of the inpatient wound-care team at the Virginia Commonwealth University Health System, "and it's discouraging from a nurse's point of view." Creehan added, "If we had an incentive that we wouldn't be financially penalized for unavoidable pressure injuries, across the country everyone would do better. Everyone's game would step up."

However, according to Castellucci, research to date hasn't shown whether or not all pressure injuries can be avoided, and CMS is unlikely to change its policy until there's conclusive data proving they are not always preventable.

In addition, others note that CMS' use of a composite score to measure HACs may cause some hospitals to de-prioritize pressure injuries. For instance, CMS' HAC Reduction Program relies on a composite measure, called PSI-90, that includes 10 measures, including pressure injuries. To determine which hospitals will be penalized under the program, CMS evenly weighs the score a hospital gets on PSI-90 and the scores for five infection measures. Hospitals that score greater than the 75th percentile compared with their peers receive a 1% penalty on their Medicare payments.

William Padula, assistant professor of health economics at the University of Southern California who has studied pressure injuries, said the composite score "led to hospitals prioritizing the things they could do well at low financial investment" since pressure injuries are just one of many factors that get assessed

Padula said CMS instead should consider weighing pressure injuries individually to better capture hospitals' attention. Creehan agreed, noting that the composite also can make it hard for hospitals that want to lower their pressure injury rates to track progress.

How hospitals prevent pressure injuries

However, the CMS regulation did alert hospitals to the increasing prevalence of pressure injuries, Creehan said.

Before the penalties, "taking care of patients with pressure injuries was taking care of them after the injury had already occurred. It was after that move by … CMS that hospitals got serious about developing pressure injury prevention programs," according to Creehan.

According to Castellucci, hospitals have adopted several approaches to preventing pressure injuries, but there are a few commonalities. For instance, hospitals aiming to prevent pressure injuries must perform regular comprehensive skin assessments to determine patients' risk of developing pressure injuries. If a patient is considered at risk, providers will apply prevention measures like rotating the patient in his or her bed or changing his or her meals to enhance nutrition, Castellucci reports.

University of Chicago Medical Center since 2014 has focused on training nurses to identify pressure injuries, providing pressure injury-prevention training during both nurse orientation and annually after that.  The hospital also assigns two nurses in each unit to stay on top of pressure injuries. Through these interventions, University of Chicago has reduced its pressure injury rate by 94% since 2014.

Other hospitals, like Johns Hopkins, have invested in special pressure-reducing mattresses.

Creehan said that having executive buy-in is key to effective prevent of pressure injuries. "A group of nurses aren't able to really orchestrate [organization-wide] culture change," she said. "You need the help of senior leadership to set the expectations, monitor the data and allocate resources."

Could prevention efforts spur new policy change?

And while much of these prevention efforts came in response to CMS' policy change, they could actually end up spurring policy change themselves, since an effective prevention program may help demonstrate that some pressure injuries cannot be avoided , according to Susan Solmos manager of nursing clinical service at University of Chicago Hospital. "High-performing organizations that are able to demonstrate that practices were implemented and a pressure injury still occurred, that would be unavoidable," she said (Castellucci, Modern Healthcare, 11/2).