We all have a role to play in preventing hospital acquired pressure injuries, or “HAPI.” These injuries harm patients, prolong the hospital stay, and are costly. With teamwork and attention to proven strategies, nearly all HAPIs can be prevented. 

How does a HAPI impact our patients? In addition to an extended length of stay, HAPI’s can lead to sepsis and may require surgical intervention. 

HAPI definition and stage descriptions: Pressure injuries are damage to the skin and/or underlying soft tissue related to positional pressure on a bony prominence or external pressure from a medical device. Medical device related pressure injuries often take on the shape of the device. Pressure injuries can occur due to a high amount of pressure over a short period of time or a low amount of pressure over a long period of time. They can range from an area of redness on intact skin to deep cavernous wounds with exposed bone and are often painful. 

How are HAPIs monitored at UI Hospitals & Clinics? Our performance is monitored through two primary methods. Our PSI-03 CMS reportable event is captured exclusively through physician documentation. The staging and determination of present on admission (POA) status are both required documentation per coding guidelines. Effective Feb. 15, 2022, providers are now able to use the dot phrase .PRESSUREINJLIP in their note to incorporate wound nursing documentation. Providers then have an attestation statement to complete.  

This change will help to standardize and accurately reflect the correct stage of HAPI. Additionally, the wound and ostomy nursing team completes Riskonnect events to monitor HAPI performance. 

Fiscal year 2022 HAPI reduction initiative 

Beginning in July 2021, Greg Schmidt, MD, professor of internal medicine, associate chief quality officer, and Nick Poch, DNP, RN, MBA, VA-BC, interim director of Centralized Function, Interim associate chief quality officer, have been co-chairing the organizational HAPI reduction initiative for UI Hospitals & Clinics. During the past nine months, much work has focused on improving documentation tools in Epic, reporting tools for frontline staff and leaders to proactively identify high-risk HAPI patients, and identification of HAPI reduction tools such as the HoverTech Q2 Roller designed to provide consistent and adequate sacral pressure relief. Additionally, effective March 1, 2022, all VoalteOne nursing phones have the Rover application capable of uploading images directly into the patient’s medical record. 

Stages of pressure ulcers  

• Stage 1 Non-blanchable erythema of intact skin: Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. 
• Stage 2 Partial thickness skin loss with exposed dermis: The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible.  
• Stage 3 (PSI-03 reportable event to CMS): Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, or bone are not exposed. 
• Stage 4 (PSI-03 reportable event to CMS): Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occur. 
• Unstageable (PSI-03 reportable event to CMS): Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. 
• Deep tissue injury: Persistent non-blanchable deep red, maroon, or purple discoloration; 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. Pain and temperature change often precedes skin color changes. Discoloration may appear differently in darkly pigmented skin. 

You can see further information on the staging system for pressure injuries in this guide with definitions and illustrations. Stage 3, 4 and unstageable pressure injuries determined by physician documentation coding are reported to CMS for the PSI-03 Quality Performance Metric. 

Plans for future improvements  

• Organization-wide use of four eyes skin assessment on admission and transfer 
• Education on device-related pressure injuries 
• Education and monitoring of consistent and effective turning  

Key Points 

• Everyone on the health care team has a role in pressure injury prevention 
• When documenting in a note, use .PRESSUREINJLIP 
• Consult wound ostomy care nurses (Inpatient Consult Wound Ostomy Nurse – Adult) when you are concerned about any skin breakdown  
• Complete and document a full body skin assessment with a colleague (four eyes skin assessment) upon admission and transfer 
• Use the Rover application on the VoalteOne phones to capture and upload images when any skin injury is identified 
• Refer to this guide for further information on the NPIAP staging system for pressure injuries 

Blog contributors:
– Julia Langin, MSN, RN, CMSRN, CWON, Nursing Practice Leader, Adult Wound and Ostomy/Quality, Nursing Centralized Functions
– Nick Poch, DNP, RN, MBA, VA-BC, Interim Director of Centralized Function, Interim Associate Chief Quality Officer, Department of Nursing
– Greg Schmidt, MD, Professor of Internal Medicine, Associate Chief Quality Officer