CQI Project Assignment

Leadership and Management

Project Name: Skin Integrity & Changes in Skin Integrity in Coolsville Inpatient Rehabilitation Facility

Oversight Committee: Mel Canna, John Barker, & Kelsey Didericksen

Start date: 11/9/21

Situation/Problem Statement:

The development and prevention of pressure ulcers is a major concern that continuously

impacts healthcare facilities, specifically inpatient rehabilitation facilities (IRF). Pressure ulcers are

injuries that occur to the skin and underlying tissue as a consequence of pressure on the skin over

extended periods of time (National Health Services, 2020). Various factors play into the development of

pressure ulcers, including the patient’s condition, pressure, temperature, time, and hygiene.

Immobilization and bed rest are often correlated with an increased risk of development of pressure

sores (Lindgren et al., 2004). Complications from pressure ulcers can be life threatening and lead to

development of cellulitis, bone and joint infections, cancer, and sepsis (The Mayo Clinic, n.d.). Not only

can pressure ulcers be problematic for the patient, but they also increase the cost of healthcare in the

United States by 26.8 billion dollars each year (Padula & Delarmente, 2019).

A study was conducted on an IRF on 2902 pairs of pressure ulcer patients and pressure-ulcer

free patients. It was found that the pressure ulcer group had a longer length of stay, and were less likely

to be discharged to the community after their IRF stay, than the patients without pressure ulcers (Wang

et al., 2014). In another study by DiVita, et al. (2018), with use of the International Pressure Ulcer

Survey, it was found that the overall prevalence of pressure injuries was 11.2% in long-term care

facilities, IRF, and acute care hospitals after surveying 932 facilities. The survey specifically discovered

that the prevalence of pressure injuries in IRFs was higher at 13.3% with an incidence rate of 3.7%.

Pressure injuries were more prevalent with individuals with spinal cord injuries and amputations.

Overall, after implementation of the pressure ulcer quality indicator, it was discovered that pressure
injuries made it so that patients were less likely to gain functional independence, made less functional

gain during their time in the IRF, were less likely to be discharged to community settings, and had poorer

rehabilitation outcomes.

At Coolsville IRF, there has been a steady increase over the last five years in the number of

pressure ulcers reported. This quality improvement initiative will aim to reduce the incidence rate of

pressure ulcers in the IRF. An external driver of this is to improve our rehabilitation services and

therefore maintain funding. The internal drivers include addressing the quality of care concerns within

our organization, upholding our company values of safety and quality, and continuing to follow our

vision of striving to improve our quality of care.

Key Metrics:

● Meaningful measures

○ Patient-focused Episode of Care: Measures in this area emphasize care delivered

through a longitudinal, episode-based approach that places the patient at the center of

focus. These measures can help guide improvements in the effectiveness and efficiency

of care.

○ Preventive Care: Preventive care services include routine healthcare activities such as

screenings, check-ups, and counseling that are focused on helping individuals avoid or

enable early detection of disease, reduce the impact of health conditions, and promote

wellness.

○ Preventable Healthcare Harm: This area focuses on unintended adverse events caused

or influenced by the delivery of health care that could be prevented by avoiding errors

and following accepted standards of care. Examples include pressure ulcers, falls, acute

kidney injury among others.

● Appropriate measures
○ The Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI): Is an

assessment instrument that providers use in an inpatient rehabilitation facility to collect

patient assessment data for quality measure calculation and the determination of

payment in accordance with the IRF Quality Reporting Program. They collect data to

measure quality of care and are used to improve hospital discharge planning, medicare

patient outcomes, and provide research. Users of the IRF-PAI must complete training as

implementation of the assessment is required by the Centers for Medicare & Medicaid

Services (CMS) as part of the Inpatient Rehabilitation Facility Prospective Payment

System (IRF-PPS) (Centers for Medicare & Medicaid Services, 2021). The assessment can

be downloaded free of charge from CMS.gov. (Centers for Medicare & Medicaid

Services, n.d.).

○ Percent of Residents or Patients with Pressure Ulcers that are New or Worsened (Short

Stay): This measure reports the percentage of stay-level records with Stage 2, 3, or 4

pressure ulcers that are new or worsened since admission. Data is gathered from the

IRF-PAI. The measure is calculated by reviewing a patient's IRF-PAI pressure ulcer

discharge assessment data for reports of Stage 2-4 pressure ulcers that were not

present or were at a lesser stage at the time of admission (Centers for Medicare &

Medicaid Services, 2021).

○ Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury: This outcome measure

reports the percentage of patients with stage 2-4 pressure ulcers or pressure ulcers that

are unstaged that are new or worsened since patient admission to the facility. Data is

gathered from the IRF-PAI. It is used in IRFs, long-term care, skilled nursing facilities, and

post-acute settings (Centers for Medicare & Medicaid Services, 2021).

Project Team Members: This project will be led by the clinical team leader and will include monthly

meetings with the occupational therapy (OT) team lead, physical therapy (PT) team lead, and nursing

team lead.

Clinical team lead: Coordinates the overall effort of the quality improvement project. Acquires outcome

measures and instructs team members on its use.

Nursing team lead: Completes research on pressure ulcer prevention and treatment best practices and

presents to the rest of the team. Coordinates with clinical team lead.

Nursing staff: Conducts daily skin checks on patients and reports updates to the team during daily

meetings. Nursing staff will be primary reports on outcome measures.

OT and PT team lead: Coordinates between rehab team (OT and PT practitioners) and the clinical team

lead. Attends monthly meetings to follow up with plans with the nursing team lead and the clinical team

lead.

Rehabilitation team (OTs, PTs, Speech Language Pathologist): Implements best practices as taught by the

nursing team lead. Reports incidence of pressure ulcer to nursing staff.

Project Timeline: January 2022-January 2023

January 2022: The clinical team leader will present the situation and plan of action at the team meeting.

They will also acquire the outcome measures for the organization and instruct all clinical team members

to collect daily data on skin integrity and initial skin integrity. Rehab team members will be educated and

trained on reporting procedures to report incidence of worsening skin integrity to nursing staff.

The nursing team lead will do research on best practices around skin integrity and pressure ulcers.

She/he will present relevant findings at the end of the month to the entire clinical team including

nursing, OT, PT, SLP, and CNAs. Nursing staff will enter data for outcome measures.
February 2022-January 2023 (ongoing):

● Nursing staff will give pressure ulcer updates to identify patients with current pressure ulcers at

each morning meeting with all staff members.

● Daily skin checks conducted by nursing staff

● Implementation of best practices for pressure ulcer prevention and treatment by nursing and

rehab team

● Rehab team reports any incidence of pressure ulcer to nursing staff

Quarterly Meetings (March, June, September, December): Nursing will meet with a clinical team lead

each quarter throughout the year to report incidence and prevalence of pressure ulcers on the floor to

determine if there has been any decrease or increase and identify improvements that can be made.

Plans will later be relayed to each discipline to implement during the new quarter.

December 2022: Clinical team lead will review results of IRF-PAI, Percent of Residents or Patients with

Pressure Ulcers that are New or Worsened, and Changes in Skin Integrity Post-Acute Care: Pressure

Ulcer/Injury and modify a continuing plan if needed.

References

American Occupational Therapy Association. (2018, August 6). CMS releases FY 2019 inpatient
rehabilitation facility final rule. https://www.aota.org/Advocacy-Policy/Federal-Reg-
Affairs/News/2018/CMS-FY-2019-Inpatient-Rehabilitation-Facility-Final-Rule.aspx

Centers for Medicare & Medicaid Services. (2021). Changes in skin integrity post-acute care: Pressure
ulcer/injury. https://cmit.cms.gov/CMIT_public/ReportMeasure?measureId=5740
Centers for Medicare & Medicaid Services (2021). Inpatient rehabilitation facility patient assessment
instrument (IRF-PAI) and IRF-PAI manual. https://www.cms.gov/Medicare/Quality-Initiatives-
Patient-Assessment-Instruments/IRF-Quality-Reporting/IRF-PAI-and-IRF-PAI-
Manual#:~:text=The%20IRF%2DPAI%20is%20the,Quality%20Reporting%20Program%20(QRP).

Centers for Medicare & Medicaid Services. (2021). Percent of residents or patients with pressure ulcers
that are new or worsened (short stay). https://cmit.cms.gov/CMIT_public/ReportMeasure?
measureId=178

Centers for Medicare & Medicaid Services. (2019). Meaningful measure area definitions.

Centers for Medicare & Medicaid Services (n.d.). IRF-PAI. https://www.cms.gov/Medicare/Medicare-

Fee-for-Service-Payment/InpatientRehabFacPPS/IRFPAI

Centers for Medicare & Medicaid Services. (n.d.). The inpatient rehabilitation facility - patient
assessment instrument (IRF-PAI) training manual. https://www.cms.gov/medicare/medicare-
fee-for-service-payment/inpatientrehabfacpps/downloads/irfpai-manual-2012.pdf

DiVita, M. A., Granger, C. V., Goldstein, R., Niewczyk, P. M., & Freudenheim, J. L. (2018). Mandated
Quality of Care Metrics for Medicare Patients: Examining New or Worsened Pressure Ulcers and
Rehabilitation Outcomes in United States Inpatient Rehabilitation Facilities. Archives of Physical
Medicine & Rehabilitation, 99(8), 1514–1524.e1. https://doi-
org.ezproxy.lib.utah.edu/10.1016/j.apmr.2018.03.007

John Hopkins Medicine (n.d.). Bedsores. https://www.hopkinsmedicine.org/health/conditions-and-

diseases/bedsores

Lindgren, M., Unosson, M., Fredrikson, M., & Ek, A.-C. (2004). Immobility - a major risk factor for
development of pressure ulcers among adult hospitalized patients: a prospective study.
Scandinavian Journal of Caring Sciences, 18(1), 57–64. https://doi.org/10.1046/j.0283-
9318.2003.00250.x

Mayo Clinic. (n.d.). Bedsores (pressure ulcers). https://www.mayoclinic.org/diseases-conditions/bed-

sores/symptoms-causes/syc-20355893
National Health Service. (2020). Overview pressure ulcers (pressure sores).
https://www.nhs.uk/conditions/pressure-sores/

Padula, W. V., & Delarmente, B. A. (2019). The national cost of hospital-acquired pressure injuries in the
United States. International wound journal, 16(3), 634–640. https://doi.org/10.1111/iwj.13071

Wang, H., Niewczyk, P., DiVita, M., Camicia, M., Appelman, J., Mix, J., & Sandel, M. E. (2014). Impact of
Pressure Ulcers on Outcomes in Inpatient Rehabilitation Facilities. In American Journal of
Physical Medicine & Rehabilitation (Vol. 93, Issue 3, pp. 207–216). Ovid Technologies (Wolters
Kluwer Health). https://doi.org/10.1097/phm.0b013e3182a92b9c