• AHRQ quality indicators. Pediatric quality indicators: technical specifications [version 3.2]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2008 Feb 29. various p.



• McDonald K, Romano P, Davies S, Haberland C, Geppert J, Ku A, Choudhry K. Measures of pediatric health care quality based on hospital administrative data: the pediatric quality indicators. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2006 Sep. 130 p. [82 references]

Does not apply to this measure

This measure is used to assess the number of patients with decubitus ulcer per 1,000 eligible admissions with a length of stay of 5 or more days.

This indicator is intended to flag cases of in-hospital decubitus ulcers (pressure sores). Common practice asserts that decubiti can be prevented by frequent movement, close monitoring of at risk patients, and specialized beds or bedding.

Decubitus ulcer

All medical and surgical discharges under age 18 defined by specific Diagnosis Related Groups (DRGs)

Exclude cases:

• neonates
• with length of stay of less than 5 days
• with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code of decubitus in the principal diagnosis field
• in Major Diagnostic Category (MDC) 9 (Skin, Subcutaneous Tissue, and Breast) or MDC 14 (pregnancy, childbirth and the puerperium)
• with an ICD-9-CM procedure code for debridement or pedicle graft before or on the same day as the major operating room procedure (surgical cases only)
• with an ICD-9-CM procedure code for debridement or pedicle graft as the only major operating room procedure (surgical cases only)
• admitted from a long-term care (SID ASOURCE=3) or acute care facility (SID ASOURCE=2)

Note: Refer to the original measure documentation for specific DRGs and ICD-9-CM codes.

Discharges among cases meeting the inclusion and exclusion rules for the denominator with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code of decubitus ulcer in any secondary diagnosis field

Note: Refer to the original measure documentation for specific ICD-9-CM codes.

• A formal consensus procedure involving experts in relevant clinical, methodological, and organizational sciences
• One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Variation in quality for the performance measured

Current routine use

Internal quality improvement
Quality of care research

Hospitals

Advanced Practice Nurses
Allied Health Personnel
Nurses
Physicians

Single Health Care Delivery Organizations

Age less than 18 years

Either male or female

Stratify by high risk (hemi-, para-, and quadriplegia, spina bifida and anoxic brain damage [diagnosis codes 348.1, 768.5]), mechanical ventilation greater than 96 hours.

Studies have attempted to modify existing adult risk assessment tools to the pediatric population to help medical personnel assess the risk for decubitus ulcers in their patients. Other groups have analyzed rates of this indicator using the publicly available indicator definition applied to a pediatric population; this definition differs slightly from the definition proposed for this measure. This indicator was applied to pediatric hospital populations (e.g., 7.67 per 1,000 discharges at 0 to 17 years, 4.95 at 18 to 44 years, 9.84 at 45 to 64 years, and 25.17 at 65 or more years). Other groups have analyzed rates of this indicator using the publicly available indicator definition applied to a pediatric population; this definition differs slightly from the definition proposed for this measure. Miller and colleagues analyzed Healthcare Cost and Utilization Project (HCUP) data from 2000 and found a significant incidence of decubitus ulcers in pediatric patients 0 to 18 years of age (2.4 per 1,000). Sedman et al. found observed rates varying from 4.1 per 1,000 in 1999 to 4.3 per 1,000 in 2001 in the National Association of Children's Hospitals and Related Institutions (NACHRI) database (i.e., a slight upward trend over time). Additionally, Miller & Zhan found that this complication resulted in increased mean length of stay (by 18 days) and $85,344 in increased charges in affected patients, with 3.5 times higher odds of in-hospital mortality (after adjusting for age, gender, expected payer, up to 30 comorbidities, and multiple hospital characteristics, including ownership, teaching status, nursing expertise, urban location, bed size, pediatric volume, coding intensity, intensive care unit (ICU) bed percentage, and surgical discharge percentage).

While children, on the whole, are more active and less chronically ill than their adult counterparts, decubitus ulcers are of great concern to those caring for critically ill infants and children. These skin injuries represent a significant iatrogenic problem in pediatric health care.

See the "Incidence/Prevalence" field.

• McDonald K, Romano P, Davies S, Haberland C, Geppert J, Ku A, Choudhry K. Measures of pediatric health care quality based on hospital administrative data: the pediatric quality indicators. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2006 Sep. 130 p. [82 references]

See the "Incidence/Prevalence" field.

See the "Incidence/Prevalence" field.

See the "Incidence/Prevalence" field.

Getting Better

Effectiveness
Safety

Users of care only

All medical and surgical discharges under age 18 defined by specific Diagnosis Related Groups (DRGs) (see the "Denominator Inclusions/Exclusions" field)

Patients associated with provider

Inclusions
All medical and surgical discharges under age 18 defined by specific Diagnosis Related Groups (DRGs)

Exclusions
Exclude cases:

• neonates
• with length of stay of less than 5 days
• with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code of decubitus in the principal diagnosis field
• in Major Diagnostic Category (MDC) 9 (Skin, Subcutaneous Tissue, and Breast) or MDC 14 (pregnancy, childbirth and puerperium)
• with an ICD-9-CM procedure code for debridement or pedicle graft before or on the same day as the major operating room procedure (surgical cases only)
• with an ICD-9-CM procedure code for debridement or pedicle graft as the only major operating room procedure (surgical cases only)
• admitted from a long-term care (SID ASOURCE=3) or acute care facility (SID ASOURCE=2)

Note: Refer to the original measure documentation for specific DRGs and ICD-9-CM codes.

All cases in the denominator are equally eligible to appear in the numerator

Clinical Condition
Institutionalization
Therapeutic Intervention

Time window is a single point in time

Inclusions
Discharges among cases meeting the inclusion and exclusion rules for the denominator with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code of decubitus ulcer in any secondary diagnosis field

Note: Refer to the original measure documentation for specific ICD-9-CM codes.

Exclusions
Unspecified

The measure results are somewhat or substantially under the control of the health care professionals, organizations and/or policymakers to whom the measure applies.

Institutionalization

Administrative data

Not Individual Case

Adverse Outcome

Unspecified

Rate

Better quality is associated with a lower score

Analysis by high-risk subgroup (stratification on vulnerable populations)
Analysis by subgroup (stratification on patient factors, geographic factors, etc.)
Case-mix adjustment
Risk adjustment method widely or commercially available

Internal time comparison

The development of the Agency for Healthcare Research and Quality (AHRQ) Pediatric Quality Indicators utilizes a four pronged approach: identification of candidate indicators, literature review, empirical analyses, and panel review. Candidate indicators were identified through both published literature and a brief survey of national organizations. Literature review provided descriptions and evaluations of some candidate indicators and the underlying relationship to quality of care. Empirical analyses were conducted to explore alternative definitions; to assess nationwide rates and hospital variation; and to develop appropriate methods to account for variation in risk. Clinical panel review helped to refine indicator definitions and risk groupings, and to establish face validity in light of the limited evidence from the literature for most pediatric indicators. Information from these sources was used to specify indicator definitions and make recommendations to AHRQ regarding the best indicators for inclusion in the pediatric indicator set.

A structured review of each indicator was undertaken to evaluate face validity (from a clinical perspective). This process mirrored that undertaken during the initial development of the Patient Safety Indicators. Specifically, the panel approach established consensual validity, which "extends face validity from one expert to a panel of experts who examine and rate the appropriateness of each item...." The methodology for the structured review was adapted from the RAND/UCLA Appropriateness Method and consisted of an initial independent assessment of each indicator by clinician panelists using an initial questionnaire, a conference call among all panelists, followed by a final independent assessment by clinician panelists using the same questionnaire. The panel process served to refine definitions of some indicators, add new measures, and dismiss indicators with major concerns from further consideration.

Empirical analyses were conducted to provide the clinical panels and peer review participants with additional information about the indicators. These analyses were also used by the development team to test the alternative specifications and the relative contribution of indicator components in the numerator and denominator. These analyses were not intended to inform issues of precision, bias and construct validity, which will be addressed separately. The data source used in the empirical analyses was the 2003 Kids' Inpatient Sample (KID).

Refer to the original measure documentation for additional details.

• Fitch K, Bernstein SJ, Aguilar MD, et al. The RAND/UCLA appropriateness method user's manual. Santa Monica (CA): RAND; 2001. 109 p.



• Green L, Lewis F. Measurement and evaluation in health education and health promotion. Mountain View (CA): Mayfield Publishing Company; 1998.



• McDonald K, Romano P, Davies S, Haberland C, Geppert J, Ku A, Choudhry K. Measures of pediatric health care quality based on hospital administrative data: the pediatric quality indicators. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2006 Sep. 130 p. [82 references]

Decubitus ulcer (PDI 2).

Agency for Healthcare Research and Quality

Agency for Healthcare Research and Quality (AHRQ)

The Agency for Healthcare Research and Quality (AHRQ) Quality Indicators are in the public domain and the specifications come from multiple sources, including the published and unpublished literature, users, researchers, and other organizations. AHRQ as an agency is responsible for the content of the indicators.

None

National Quality Forum

This measure was adapted from the AHRQ Patient Safety Quality Indicators.

Decubitus Ulcer (PSI 3) (Agency for Healthcare Research and Quality [AHRQ])

2006 Feb

2008 Feb

This is the current release of the measure.

• AHRQ quality indicators. Pediatric quality indicators: technical specifications [version 3.2]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2008 Feb 29. various p.



• McDonald K, Romano P, Davies S, Haberland C, Geppert J, Ku A, Choudhry K. Measures of pediatric health care quality based on hospital administrative data: the pediatric quality indicators. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2006 Sep. 130 p. [82 references]

This NQMC summary was completed by ECRI Institute on December 28, 2007. The information was verified by the measure developer on March 31, 2008.

No copyright restrictions apply.