Comparing physical assessment with administrative data for detecting pressure ulcers in a large Canadian academic health sciences centre

Abstract

ObjectiveThis study aimed to compare classification of pressure ulcers from administrative data with a gold standard assessment, specifically; pressure ulcers confirmed by an independent physical assessment performed by trained nurse surveyors.SettingA retrospective analysis of pooled cross-sectional samples of inpatients assessed across 3 consecutive prevalence surveys in a large academic health sciences centre between 2012 and 2013.ParticipantsThere were 2001 patients for whom physical and chart assessments were completed, and for whom a discharge abstract was also available at the time of analysis. The cohort's mean age was 65 years and 55% were women.ResultsBased on the physical assessment findings, 14.6% of patients (n=292) had at least 1 pressure ulcer, with a total of 345 pressure ulcers documented among these patients: (stage I=162; stage II=120; stage III=22; stage IV=22 and unstageable=19). Based on coded information, 78 (3.9%) of patients had a pressure ulcer. Of patients with a pressure ulcer determined by the physical assessment, only 21% also had a pressure ulcer captured in the administrative data. Furthermore, only 6% of the patients with a hospital-acquired pressure ulcer, stage II or greater determined by the physical assessment were coded in the Discharge Abstract Database (DAD).ConclusionsThe results of this study demonstrate that coding in the DAD may under-report and fail to accurately reflect the true burden of pressure ulcers in hospitalised patients. This may occur because the presence of pressure ulcers is currently documented in the health record by nurses and not by physicians, yet the administrative data recorded in the DAD only includes physician documented pressure ulcers. We recommend enhancements to the coding methods to monitor and report on pressure ulcers.

Validation of two case definitions to identify pressure ulcers using hospital administrative data

“…Compared with other studies of pressure ulcer prevalence, using the same set of ICD-10 codes (definition 1), our finding of 0.4% for unadjusted prevalence is lower than another Canadian study that reported 3.5% cross-sectional prevalence, which can produce an overestimation. 4 As well, our prevalence of 0.4% is substantially low relative to previous studies described above. 3 5 This can be attributed to several factors: the assumption that ET nurse consults likely included mostly the more severe (stage III, IV and unstageable) pressure ulcers while other studies included pressure ulcers of all severities, there were differences in the population(s) studied and there were different methods and data sources used.…”

“… 10 The medical chart has been considered the ‘reference standard’ as a source of research and quality improvement data due to the clinical information it contains. Thus, retrospective reviews of medical records have been undertaken to identify prevalence and incidence of pressure ulcers as well as patient characteristics and associated risk factors among various patient populations, 4 11–24 evaluate preventive and management strategies 25–29 and evaluate the Braden scale in assessing risk for pressure ulcer development. 30 Chart reviews and prospective studies involving physical assessment are costly and time-consuming; thus, other data sources are needed for surveillance.…”

Pressure injury identification, measurement, coding, and reporting: Key challenges and opportunities

“…Some routine practices, such as documenting PIs by 2 professional groups in 2 different systems, have demonstrated discrepancies in PI reporting as a study conducted in major Canadian hospitals has shown . Findings from this study indicate that only 21% of patients with PIs identified by the physical assessment were recorded in the administrative data.…”

“…Despite these developments in assessment, measurement, and coding, measurement subjectivity related to visual inspection remains an issue in clinical practice. Individual papers published in the field report various issues that affect the accuracy of PI measures at different PI assessment, coding, and reporting stages, from admission to discharge or transfer . In this article, we summarise the main challenges of PI identification, coding, and reporting that influence the quality of PI measures.…”

“…Moreover, only 6% of the patients with hospital‐acquired pressure injuries (HAPI) stage II or greater identified by the physical assessment were recorded in the discharge abstract database. The researchers concluded that underreporting in the discharge abstract database may occur as a result of the hospital's reporting practices, including nurse‐led PI documenting in patients’ health records yet physician‐led documenting in the discharge abstract database …”