The year 2008 was an important one for hospitals regarding pressure ulcers (PrUs). The Centers for Medicare and Medicaid Services (CMS) provided new financial incentive for hospitals to prevent PrUs when the present-on-admission (POA) indicators became effective on October 1, 2008.1 CMS will no longer reimburse acute care facilities for the development of a hospital-acquired Stage III or IV PrU at a higher diagnosis-related group (DRG) rate when hospital-acquired PrUs are billed as a secondary diagnosis. Thus, the challenge of documenting existing PrUs on admission, as well as preventing the development of a PrU during hospitalization, has become essential.
In 2007, CMS gave hospitals 1 year to prepare for this billing change when PrUs became 1 of the 8 original conditions that would no longer be paid the higher rate if it was not documented POA. For American hospitals, the focus became 2-fold: documenting PrUs that a patient had on admission and preventing a PrU from occurring during a patient's hospitalization. Perhaps to understand why PrUs are a POA condition requires reviewing some of the issues faced by CMS-the federal agency charged by law to administer the Medicare program. This article seeks to clarify some of the misunderstandings of this CMS initiative, as well as to report on some of the common elements from successful institutions that have addressed PrU incidence concerns.
CMS AND MEDICARE
As one of the largest purchasers of healthcare in the United States, CMS is interested in providing quality care for its healthcare beneficiaries. Medicare as a healthcare system was signed into law by former President Lyndon B. Johnson on July 30, 1965.2 Within this system, CMS is the government body charged with oversight of the program.
With the graying of the American population, the US healthcare system is faced with many issues, one of which is how to afford coverage for the more than 75 million older and disabled Americans who rely on Medicare and Medicaid services. Without a change in the system, Medicare funds could be depleted by 2017. Figure 1 shows CMS data concerning the increase by trillions of dollars in healthcare spending since 1960, as well as where the money is spent.3 It is noteworthy that one of the largest proportions of spending at $570.3 billion is for hospital care.3 Under the prospective payment system (PPS), CMS reimburses hospitals by predetermined rates for each patient discharge. To get the most for its dollar expenditure is a challenge. To that end, CMS has embarked on a program of value-based purchasing (VBP).3 Among the VBP program goals are reducing adverse events, improving patient safety, and avoiding unnecessary costs in the delivery of care. In this transformation of Medicare to an active purchaser of more efficient healthcare, CMS has looked at its PPSs with an eye on resource consumption and quantity of care. CMS is less supportive of the redundancy of tests and procedures that increases hospital payments and more on providing quality of services. The VBP initiatives include hospital-acquired conditions (HACs) and POAs. Detailed information on the CMS VBP initiatives can be found on the CMS Web site at http://www.cms.hhs.gov/HospitalAcqCond/07_EducationalResources.asp.3
HACs AND POAs
Under the 2005 Deficit Reduction Act Section 5001(c) signed into law by President George W. Bush on February 8, 2006, the Secretary of Health or designee (most likely the CMS Administrator) had to identify a minimum of 2 conditions that were "high cost or high volume or both, resulted in the assignment to case DRG that has a higher payment when present as a secondary diagnosis and could reasonably have been prevented through the application of evidence-based guidelines."3 The original list of 8 conditions released on August 1, 2007, that included PrUs had financial implications that took effect October 1, 2008. This list was expanded to 10 categories on July 31, 2008. The payment implications for the HAC categories went into effect on October 1, 2008. Three new HACs will be added for October 1, 2009. They include: surgical site infection following specific procedures (bariatric surgery and orthopedic procedures), extreme blood glucose derangement, and deep vein thrombosis/pulmonary embolism after total knee and hip replacement surgeries (http://www.cms.hhs.gov/HospitalAcqCond/06_Hospital-Acquired_Conditions.asp#TopOfPage). On July 31, 2009, CMS released its final rule about the Inpatient Prospective Payment System (IPPS), which said that there would be "no changes for FY 2010 in the list of HACs or to the present on admission (POA) reporting."4 Thus, the POA is about reimbursement determinations for particular hospital conditions that CMS has decided it will no longer pay more money for (the higher DRG) if the condition occurred during the patient's hospitalization.
A TALE OF TWO NUMBERS
Although national organizations including the National Pressure Ulcer Advisory Panel5 and the Wound, Ostomy and Continence Nurses Society6 have brought attention to the problem of PrUs in the United States, PrUs have been increasing in hospitalized adults.
A recent report by the Healthcare Cost and Utilization Project7released in December 2008 found that, over the past 13 years, PrUs have increased by almost 80%. PrUs were noted in 503,300 hospital stays in 2006, compared with 280,000 hospital stays in 1993.7 Although the total number of hospitalizations during this period increased by only 15%, PrU-related hospital stays were greatly increased. For those patients with a primary diagnosis of PrUs, hospital stays increased by 27.2% and by 86.4% for those with a secondary diagnosis of PrUs.7
In a national survey of 87,004 acute care patients8 (Hill-Rom data), 6589 or 36.8% had hospital-acquired PrUs. Most were Stage I or II (4985); 13.3% (876) were Stage III, IV, or unable to stage; and the least number was deep tissue injury (642). Device-related PrUs accounted for 9.1% of the identified ulcers with ears being the most frequent location (20%).8
Having a PrU increased both length of stay (LOS) and in-hospital mortality.7 Although LOS for those hospitalized with a primary diagnosis of PrUs was just a little longer (14.1 days) compared with those with a secondary diagnosis of PrUs (12.7 days), both were well above the 5-day LOS for those with no PrU diagnosis.7 In-hospital mortality was 11.6% for stays with PrUs as a secondary diagnosis compared with 4.2% of stays primarily for PrUs and 2.6% for stays for all other conditions.7 Principal reasons for hospitalizations where PrUs were also present in adult patients were septicemia, pneumonia, and urinary tract infections.7
PrUs are not just a high-volume condition. In 2006, the cost for adult hospital stays with a diagnosis of PrUs totaled $11.0 billion.7 CMS data from FY 2007 as posted on its Web site reported 257,412 cases and cost approximately $43,180 per hospital stay.1
Given the prevalence of PrUs, along with the publication of several clinical guidelines9-12 that provide prevention guidance, PrUs met the CMS selection criteria for POA conditions.
PRESENT ON ADMISSION
As defined on the CMS Web site, POA is "present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as POA."1 Although this information was published in the literature as having to be documented by the second day of hospitalization,13 there has been further clarification about the time frame for documenting POA. According to current CDC information, the originally published time frame of 48 hours is not correct, and in fact, there was no specific time frame for documentation (Figure 2).
One of the common misunderstandings surrounding the new CMS policy on PrUs is the incorrect idea that hospitals will not get paid for PrUs. To clarify, the POA indicator implies that for hospital patients admitted with a Stage III or IV PrU that is documented in the medical record by a CMS-defined provider, the hospital will get the higher DRG rate. However, for patients whose PrUs are not documented on admission or who develop a PrU during their hospitalization (secondary diagnosis), the hospital will get a DRG payment, but not at the higher DRG rate. They will be paid as if the PrU did not exist.
DOCUMENTING PRESSURE ULCERS ON ADMISSION
A Change in Accountability
With the implementation of the CMS POA indicator, there is a new accountability for PrU documentation for clinicians, such as physicians, who, in the past, may not have thought that PrU documentation was their responsibility.
One must understand that POA is a billing compliance issue for CMS providers, which CMS defines as "MD or any qualified healthcare practitioner legally accountable for establishing patient's diagnosis."1 Consequently, what is written and by whom has financial implications. Because billing for DRG occurs at the time of discharge, coders are directed to look for the existence of a Stage III or IV PrU at the time of admission by the CMS-defined "provider."
New Coding and Financial Implications
Providers must now include both the location and the stage of an existing PrU to comply with the new reimbursement. Because providers are held accountable for both the status of the PrU (preexisting, healing, healed) and Stage (I, II, III, and IV; suspected deep tissue injury; and unstageable), accuracy of PrU documentation takes on new urgency Figure 3. New coding numbers for PrU staging have been approved for use by the Centers for Disease Control and Prevention (CDC) Figure 4.1 Omission of documentation of an existing Stage III or IV PrU by a CMS-defined provider may result in a loss of thousands of dollars per case. An example of the financial implication of failure to document an existing PrU with a resulting loss of more than $2000 is posted on the CMS Web site Figure 5.1
The CMS Web site includes educational postings that ask coders to work with clinicians to address the inconsistencies in documentation. Furthermore, CDC guidance to coders directs them to query the physician or other providers if such inconsistencies in documentation for POA occur.1 Thus, POA has given rise to more collaborative dialogue between providers and coders.
PrU coding is also linked to staging and coders have been given guidance regarding how to code based on the PrU stage Figures 4 and 6. Therefore, one of the important tasks has been to make sure that providers, particularly physicians, have accurate knowledge of PrU staging and are more aware of the necessity of documenting PrUs on admission for the financial health of their affiliated hospitals. Also, providers must be able to accurately differentiate PrUs from other skin injuries, such as moisture-related skin damage, skin tears, or other chronic wounds. For example, determining the etiology of sacral skin injuries to decide whether the etiology is either a PrU or a moisture-associated skin injury can be challenging. Several recent articles,14-16 however, may be helpful to clinicians in making those clinical determinations.
PREVENTION IS IMPERATIVE
Preventing PrUs is the key to reducing the incidence of hospital-acquired PrUs. In addition to documentation of existing PrUs on admission, the CMS POA indicator also includes preventing PrUs while the patient is hospitalized. Preventing and treating PrUs in hospitals are not new. Florence Nightingale, in her classic book Notes on Nursing,17 spoke about the important difference nursing can make in preventing PrUs in our patients. Yet, the truth is, PrUs are a complex and multifactorial problem that requires a holistic view of the hospital system to reduce PrU incidence data. Rather than reinventing the wheel, lessons from state,18-20 health systems,21 and individual hospitals22-28 can provide guidance and option possibilities for others to consider as they implement aggressive programs to prevent PrUs from occurring in their hospitalized patients.
Exemplars of Success in PrU Reduction
With the emphasis on quality and reduction of PrUs, several success stories exist that were instrumental in providing guidance for other initiatives. This includes the New Jersey Hospital Association (NJHA) collaborative,18,19 Ascension Health,21 and some other specific individual hospitals.22-28 Details about these programs can be found elsewhere in the literature.18,19,21-28
The authors believe that the commonalities of these prevention programs can be easily summarized by "A, B, C, D, E." They include the following:
* Administrative support backed by support at the patient care level is vital
○ Support from both the highest levels of administration as well as at the unit level is required
○ Institutions where administration at the highest level demonstrates to staff that preventing PrUs is a priority have better outcomes. This support is actualized in many facets including providing adequate resources and listening to staff in how best to implement best practices within their hospital. Staff at the patient point of care must be engaged in PrU prevention. Shared governance models appear to work well in achieving PrU reduction rates.
* Bundling care practices and having an identifiable theme
○ Putting care practices together into bundles of interventions increases the chances that staff will do the necessary interventions and not forget important care steps.18,19,21,29-31
○ Building prompts in care practices such as playing a "theme song" to remind staff to turn and reposition patients.25
○ Review of care practices to identify patients with particular diagnoses would universally get specific products. For example, one hospital used heel protective devices on all patients with end-stage renal disease or on ventilators.27
* Creating a culture of change, commitment, and communication
○ Need for system-wide change including a culture change. One hospital improved communication across departments by building an automatic trigger within its electronic system that sent a message to central to send the preventive product to the patient unit.27
○ Commitment to PrU improvement in many levels of the institution. While all within the institution are included in the work and their opinions are valued, there is a cohesive purpose and all strategies converge to a singular institutional direction to prevent PrUs.
○ Communication enhancements including interdisciplinary are paramount. One hospital uses a "present on admission" sticker to communicate to the physicians to document that the patient has a PrU on admission that needs documentation by them in their note.28
○ Creating interdisciplinary teams that make rounds on all patients at risk for PrUs or have early stage ulcers (Stage I and Stage II).
○ Empowering the unlicensed staff to be proactive in identifying and reporting early skin changes.
○ Promoting a culture of "nonblaming" of PrUs detected.18,19
○ The process is data driven. The hospital collects PrU incidence data and makes it available to staff so they understand the link between their prevention protocol efforts and how they are doing regarding PrU occurrence.
* Documentation ofPrU prevention practices must be visible°
○ Rewarding staff for efforts needs to be an ongoing part of the process. Be sure not to reward staff only at the endpoint or when the desired reduction in PrUs has occurred. Consider rewards during the process to keep staff motivated and encouraged to do the work of prevention. Avoid rewarding only units with the lowest PrU incidence rate. Rewards for units showing improvement in their PrU incidence rate may benefit from the recognition of their efforts.
○ Use posters and progress charts so staff is aware of how PrU rates are changing.
○ Using an easy, identifiable theme for the care practice bundles helps to facilitate the delivery of care. Some examples are Surface selection, Keep turning, Incontinence management, and Nutrition (SKIN©);21 save our skin (SOS);25 Pressure Ulcer Prevention Protocol Interventions (PUPPI);24 and Nutrition and fluid status, Observation of Skin, Up and walking or turn and position, Lift (do not drag) skin, Clean skin and continence care, Elevate heels, Risk assessment, and Support surfaces for pressure redistribution (No Ulcers).18,19 Many institutions find that having a "kick-off" event to announce their theme and PrU prevention initiative is helpful to engage staff.
○ Major components of PrU prevention protocols include pressure redistribution by use of support mattresses/cushions or beds and turning and repositioning. Avoiding lag time for getting support surfaces used for persons identified at risk is important. One study found that among 792 patients 65 years or older who were identified at risk for a PrU, only just more than half (51%) had a preventive device in place.32
○ Identification of persons at risk for PrUs using a validated tool and other risk factors.
○ Linking skin assessment with PrU risk assessment.
○ Providing appropriate skin care, based on hospital-wide protocols. Review skin care products so there is a complete range of products to protect the skin and maintain appropriate moisture balance, as well as to prevent or treat incontinence and other moisture associated skin injuries. Make sure products are easily available to staff on all shifts.
○ Replacing existing mattresses with pressure redistributing mattresses or beds in units with high risk patients such as critical care.
○ Automation of systems using the electronic medical records as prompts. There continues to be gaps in documentation in the medical record between assessment findings and care implemented. One study found that only 67.5% of patients who actually had a PrU when their skin was examined had it documented in the medical record.32 Technology within electronic medical records can be helpful in reducing PrU incidence. For example, one hospital introduced automatic triggers based on the Braden Scale assessment to help nurses identify prevention care interventions. It also updated its electronic documentation to include skin and heel assessment.26
○ Using stickers on charts and Kardex to alert clinicians to document PrUs on admission or those at risk. For example, one hospital had a "Stop skin sign alert" stamped on the Kardex to identify patients at risk.26 Other visual prompts, such as color-coded arm bands, can help to identify patients at risk for PrU development.33
* Education is essential
○ Education of all levels of staff both initially and on a regular ongoing basis.
The need for instruction for all levels of staff was an important component of reducing facility-acquired PrUs. This included education for new staff, as well as annual education for existing staff. With the implementation of the CMS POA indicator, education on PrU staging for physicians and physician assistants became imperative. One hospital found having "Save our skin champions" on each patient care unit to be helpful in reducing PrU incidence.25 Besides professional staff, educating and empowering nursing assistants also were important. Patients and family also should have information on prevention. Brochures34 on admission were used successfully at the NJHA initiative. Teaching prevention and providing updates on any skin condition are a part of the bundle of best practice.
Some facilities choose to develop their own educational materials, such as videos, whereas others use existing resources, such as free materials available on the Internet. For example, the National Database of Nursing Quality Indicators has available on its Web site learning sessions on PrUs and other skin problems.35 The Institute for Health Care Improvement, as part of its 5 Million Lives campaign, has on its Web site several tools, including a getting-started kit with a how-to guide for preventing PrUs, PowerPoint slides, and an annotated bibliography.36 Information and educational materials on the Braden Scale are available on the official "Prevention Plus" Web site.37 Other resources about the Braden Scale are also available from the John A. Hartford Institute for Geriatric Nursing, including a 2-page summary of the key points of the Braden Scale that is part of the "Try this" series, and a video teaching nurses how to do PrU risk assessment using a hospital patient.38
New areas within the hospital are beginning to focus on PrU prevention. For example, in the operating room, surgical staff are being urged to use recommendations to identify patients at risk for PrUs, as well as including interventions to reduce pressure.20,39
CMS has sought comment on HAC/POA regarding expansion of the IPPS HAC payment provision to other settings. Clinicians should be alert to calls for public comments on proposed changes, as well as participation in listening sessions that provide an opportunity to hear the latest information directly from CMS. Moreover, listening to these calls can give clinicians a wonderful opportunity to provide valuable feedback on issues and concerns. Announcements about these opportunities are listed in the Federal Register, which is published weekly.
Preventing PrUs is not a new concern; yet, since 2008, it has new financial consequences. By educating providers about the importance of documenting PrUs that are POA and using the lessons learned from several initiatives that have decreased the incidence of PrUs, hospitals can help position themselves for financial health, as well as improved patient outcomes.
3. Overview section and specific educational resource materials from the December 18, 2008 HAC and POA listening session audiofile, transcript, and PowerPoint presentation. http://www.cms.hhs.gov/HospitalAcqCond
. Last accessed August 28, 2009.
5. National Pressure Ulcer Advisory Panel (NPUAP). http://www.npuap.org
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6. Wound, Ostomy and Continence Nurses Society (WOCN). http://www.wocn.org
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8. VanGilder C, Amlung S, Harrison P, Meyer S. A Unit Specific Analysis in US Acute Care Facilities of the International Pressure Ulcer Prevalence™ Survey: 2007-2009. Ostomy Wound Manage. (2009, in review).
9. Panel on the Prediction and Prevention of Pressure Ulcers in Adults. Pressure ulcers in adults: prediction and prevention. Clinical Practice Guideline 3. Publication 92-0047. Rockville, MD: Agency for Health Care Policy and Research; 1992.
10. Bergstrom N, Bennett MA, Carlson CE, et al. Treatment of pressure ulcers. Clinical Practice Guideline 15. AHCPR Publication 95-0652. Rockville, MD: Agency for Health Care Policy and Research; 1994.
11. Wound, Ostomy and Continence Nurses Society. Guideline for Prevention and Management of Pressure Ulcers. Glenview, IL: Wound, Ostomy and Continence Nurses Society; 2003.
12. Whitney J, Phillips L, Aslam R, et al. Guidelines for the treatment of pressure ulcers. Wound Repair Regen 2006;14:663-79.
13. Krapfl LA, Mackey D. Medicare changes to the hospital inpatient prospective payment systems: commentary on the implications for the hospital-based wound care clinician. J Wound Ostomy Continence 2008;35:61-2.
14. DeFloor T, Schoonhoven L, Fletcher J, et al. Statement of the European Pressure Ulcer Advisory Panel-Pressure Ulcer Classification. J Wound Ostomy Continence Nurs 2005;32:302-6.
15. Gray M, Bliss DZ, Doughty DB. Incontinence-associated dermatitis-a consensus. J Wound Ostomy Continence Nurs 2007;34:45-54.
16. Zulkowski K. Perineal dermatitis versus pressure ulcer: distinguishing characteristics. Adv Skin and Wound Care 2008;21:382-8.
17. Nightingale F. Notes on Nursing: What it is and what it is not. Philadephia, PA: JB Lippincott, 1859.
18. Holmes A, Edelstein T. Envisioning a world without pressure ulcers. Ext Care Product News 2007;122:24-9.
19. Ayello EA, Lyder CH. A new era of pressure ulcer accountability in acute care. Adv Skin Wound Care 2008; 21:134-40.
20. Minnesota Hospital Association. Safe skin. http://www.MHA.org
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21. Gibbons W, Shanks HT, Kleinhelter P, Jones P. Eliminating facility-acquired pressure ulcers at Ascension Health. Jt Comm J Qual Patient Saf 2006;32:488-96.
22. Stewart S, Box-Parksepp JS. Preventing hospital acquired pressure ulcers: a point of prevalence study. Ostomy Wound Manage 2004;50(3):46-51.
23. Hiser B, Rochette J, Philbin S, Lowerhouse N, Terburgh C, Pietsch C. Implementing a pressure ulcer prevention program and enhancing the role of the CWOCN: impact on outcomes. Ostomy Wound Manage 2006;52(2):48-59.
24. Catania K, Huang CH, James P, Madison M, Moran M, Ohr M. Wound wise: PUPPI: the pressure ulcer prevention protocol interventions. Am J Nurs 2007;107(4):44-52.
25. Griffin B, Cooper H, Horack C, Klyber M, Schimmekpfenning D. Best practice protocols: reducing harm from pressure ulcers. Nurs Manage 2007;29-31, 69.
26. Chicano SG, Drolshagen C. Reducing hospital-acquired pressure ulcers. J Wound Ostomy Continence Nurs 2009;36:45-50.
27. McInerney JA. Reducing hospital-acquired pressure ulcer prevalence through a focused prevention program. Adv Skin Wound Care 2008;21:75-8.
28. Walsh NS, Blanck AW, Barrett KL. Pressure ulcer management in the acute care setting. A response to regulatory mandates. J Wound Continence Nurs 2009;36(4):385-8.
29. Resar R, Pronovost P, Haraden C, et al. Using bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia. Jt Comm J Qual Patient Saf 2005; 31:243-8.
30. Resar RK. Making noncatastropic health care processes reliable: learning to walk before running in creating high-reliability organizations. Health Serv Res 2006;41(4 Pt 2):1677-89.
32. Rich SE, Shardell M, Margolis, D, Baumgarten M. Pressure ulcer preventive device use among elderly patients early in the hospital stay. Nursing Research 2009;58(2):95-103.
33. Armstrong DG, Ayello EA, Capitulo KL, et al. New opportunities to improve pressure ulcer prevention and treatment: Implications of the CMS Inpatient Hospital Care Present on Admission (POA) Indicators/ Hospital-Acquired Conditions (HAC) Policy. A consensus paper from the International Expert Wound Advisory Panel. May 14, 2008. http:// www.medline.com
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34. NJHA Patient Education Booklet-Help us protect your skin. WCET J 2009;29(2):41-2.
36. IHI Protecting 5 Million Lives from Harm. Getting started kit: prevent pressure ulcers: how-to-guide. http://www.ihi.org
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38. The John A Hartford Institute for Geriatric Nursing. Resources and Assessment Tools. Try this series. (See: Try this series 5 on pressure ulcer risk).http://www.ConsultGeriRN.org/resources
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39. Association of Operating Room Nurses. (AORN) recommended practices for position the patient in the perioperative practice setting. http://www.aorn,org
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