Clinical Coders' Perspectives on Pressure Injury Coding in Acute Care Services in Victoria, Australia

Abstract

Pressure injuries (PIs) substantively impact quality of care during hospital stays, although only when they are severe or acquired as a result of the hospital stay are they reported as quality indicators. Globally, researchers have repeatedly highlighted the need to invest more in quality improvement, risk assessment, prevention, early detection, and care for PI to avoid the higher costs associated with treatment of PI. Coders' perspectives on quality assurance of the clinical coded PI data have never been investigated. This study aimed to explore challenges that hospital coders face in accurately coding and reporting PI data and subsequently, explore reasons why data sources may vary in their reporting of PI data. This article is based upon data collected as part of a multi-phase collaborative project to build capacity for optimizing PI prevention across Monash Partners health services. We have conducted 16 semi-structured phone interviews with clinical coders recruited from four participating health services located in Melbourne, Australia. One of the main findings was that hospital coders often lacked vital information in clinicians' records needed to code PI and report quality indicators accurately and highlighted the need for quality improvement processes for PI clinical documentation. Nursing documentation improvement is a vital component of the complex capacity building programs on PI prevention in acute care services and is relied on by coders. Coders reported the benefit of inter-professional collaborative workshops, where nurses and coders shared their perspectives. Collaborative workshops had the potential to improve coders' knowledge of PI classification and clinicians' understanding of what information should be included when documenting PI in the medical notes. Our findings identified three methods of quality assurance were important to coders to ensure accuracy of PI reporting: (1) training prior to initiation of coding activity and (2) continued education, and (3) audit and feedback communication about how to handle specific complex cases and complex documentation. From a behavioral perspective, most of the coders reported confidence in their own abilities and were open to changes in coding standards. Transitioning from paper-based to electronic records highlighted the need to improve training of both clinicians and coders.

Acute care nurses' experience in providing evidence‐based care for patients with laparotomy wounds: A scoping review

“…In studies from South Africa, Nigeria, Australia and Denmark, researchers linked nurses' suboptimal documentation with wound knowledge deficiencies, poor time management, resource accessibility and unsafe workloads, which mirrored the TDF barriers identified in our review 19,25,35,60,68–71 . In Australia, documentation for wound care did not improve in electronic record programmes compared to paper formats 64 . These examples show that the wound management practice may not be evidence‐based as nurses inconsistently reported fundamental wound care data in documentation.…”

“…The TDF successfully recognised behavioural influences associated with the barriers and enablers to EBC for patients with laparotomy wounds reported by acute care nurses. As a theoretical approach, the TDF has been applied widely to understand and explore various determinants of behaviours in other studies 12,62–64 . To the authors' knowledge, this is the first review to apply the TDF to explore the experiences of acute care nurses experiences of barriers and enablers relating to EBC of patients with laparotomy wounds.…”

“…As a theoretical approach, the TDF has been applied widely to understand and explore various determinants of behaviours in other studies. 12 , 62 , 63 , 64 To the authors' knowledge, this is the first review to apply the TDF to explore the experiences of acute care nurses experiences of barriers and enablers relating to EBC of patients with laparotomy wounds.…”

“… 19 , 25 , 35 , 60 , 68 , 69 , 70 , 71 In Australia, documentation for wound care did not improve in electronic record programmes compared to paper formats. 64 These examples show that the wound management practice may not be evidence‐based as nurses inconsistently reported fundamental wound care data in documentation.…”

Risk Factors for Postoperative Complications and In-Hospital Mortality Following Surgery for Cervical Spinal Cord Injury

“…The main strength of this study lies in the reliability of the dataset, which was rigorously extracted using multiple ICD codes and validated using multiple sources [46]. Evidence suggests significant inaccuracies inherent in hospital coding data [47][48][49][50] and underreporting of adult variants of SCI without radiological abnormality (SCIWORA) [51,52]. The data collection methodology employed in this study used multiple validation points between coding, EMR documentation, and medical imaging in an attempt to reduce information bias.…”