Healthy Life-Years Lost and Excess Bed-Days Due to 6 Patient Safety Incidents: Empirical Evidence From English Hospitals

Pressure ulcers in German hospitals: Analysis of reimbursement and length of stay

Objective

Hospital-acquired pressure ulcers are an important indicator of the quality of care. Most pressure ulcers are avoidable with a robust protocol for prevention, but prevention activities often have a low priority for senior management because the true costs to the hospital are not visible. Our aim was to raise awareness of the value of pressure ulcer prevention by estimating the excess length of inpatient stay associated with hospital-acquired pressure ulcers, and by assessing whether additional costs are covered by increased reimbursement.

Methods

National activity data for hospitals in Germany are available through the InEK Data Browser. Data were extracted covering discharges from German hospitals between January 1 and December 31, 2021. Cases were selected according to the presence of a pressure ulcer diagnosis using ICD-10-GM codes L89.0-L89.3. Information was extracted for the ten most common German Diagnosis-Related Group (G-DRG) codes in patients with a secondary pressure ulcer diagnosis on mean length of stay and average reimbursement. Ulcer-associated excess length of stay was estimated by comparing cases within the same G-DRG with and without a pressure ulcer diagnosis.

Results

Mean length of stay was higher in patients with a pressure ulcer than in patients with no ulcer by between 1.9 (all ages) and 2.4 days (patients aged ≥65) per case. In patients aged ≥65 years, 22.1% of cases with a pressure ulcer had a length of stay above the norm for the DRG. In the German system length of stay above the norm is not normally reimbursed. Excess length of stay between 1.9 and 2.4 days leads to a potential cost to a hospital of between 1,633€ and 2,074€ per case.

Conclusion

Hospital-acquired pressure ulcers represent an important source of cost for a hospital which highlights the potential value of effective prevention.

Assessing the excess costs of the in-hospital adverse events covered by the AHRQ's Patient Safety Indicators in Switzerland

There currently exists no comprehensive and up-to date overview on the financial impact of the different adverse events covered by the Patient Safety Indicators (PSIs) from the Agency for Healthcare Research and Quality. We conducted a retrospective case-control study using propensity score matching on a national administrative data set of 1 million inpatients in Switzerland to compare excess costs associated with 16 different adverse events both individually and on a nationally aggregated level. After matching 8,986 cases with adverse events across the investigated PSIs to 26,931 controls, we used regression analyses to determine the excess costs associated with the adverse events and to control for other cost-related influences. The average excess costs associated with the PSI-related adverse events ranged from CHF 1,211 (PSI 18, obstetric trauma with instrument) to CHF 137,967 (PSI 10, postoperative acute kidney injuries) with an average of CHF 27,409 across all PSIs. In addition, adverse events were associated with 7.8-day longer stays, 2.5 times more early readmissions (within 18 days), and 4.1 times higher mortality rates on average. At a national level, the PSIs were associated with CHF 347 million higher inpatient costs in 2019, which corresponds to about 2.2% of the annual inpatient costs in Switzerland. By comparing the excess costs of different PSIs on a nationally aggregated level, we offer a financial perspective on the implications of in-hospital adverse events and provide recommendations for policymakers regarding specific investments in patient safety to reduce costs and suffering.

Socio-economic and environmental factors associated with community-acquired pressure injuries: A mixed method study

AIMS

To: (1) report on the prevalence of community-acquired pressure injuries (CAPIs) in patients admitted into the acute care setting; (2) examine the socio-economic and home environment associated with CAPIs; and (3) understand the challenges of caring for patients with CAPIs at home.

METHODS

This mixed-method study recruited patients admitted with CAPIs in the acute care hospital between March 2021 to June 2022. The hospital's pressure injury (PI) database was used to screen patients admitted with CAPIs. A purposive sample of CAPI patients and their caregivers participated in this study. A cross-sectional survey study was first performed to examine the prevalence of CAPIs and the socio-economic and home environment factors. Semi-structured interviews were conducted to understand the caregivers' challenges in caring for patients with CAPIs at home.

RESULTS

The CAPI prevalence was reported at 1.1 % during the study period (1039 had CAPIs out of 97 912 patients admitted to the hospital). A total of 70 caregivers and patients consented to participate in the study. The mean age of patients was 84.2 (SD = 10.4) years old; 68.6 % (n = 48) were females. Majority presented with a deep tissue injury (DTI) (37.1 %; n = 26) or unstageable PI (31.4 %; n = 22). More than half of the patients had alternating air mattresses at home (54.3 %; n = 38), and only 10 % (n = 7) had positioning wedges and used a sliding sheet for turning. The mean age of the caregivers was 43.4 years old (SD = 13.1), and 84.3 % (n = 59) were female. Continuous data were summarised using means and standard deviations, and categorical data were summarised using frequencies and percentages. Logistic regression found no significant socio-demographic and clinical predictors of patients having PI stages 2, 3, and 4 compared to patients with DTI and unstageable PI. Challenges to caring for PI at home included high financial burden, physical limitations, and personal challenges in CAPIs management.

CONCLUSION

CAPIs are prevalent among older patients admitted to the acute care setting. Understanding the influence of socio-economic factors is crucial for developing comprehensive strategies to mitigate the occurrence and impact of PIs. Ongoing support and education to the caregivers in the community is essential to address the reported challenges in PI care.

Perceived barriers and facilitators to preventing hospital-acquired pressure injury in paediatrics: A qualitative analysis

AIM

This qualitative study aimed to identify nurses' and allied health professionals' perceptions and experiences of providing hospital-acquired pressure injury (HAPI) prevention in a paediatric tertiary hospital in Australia, as well as understand the perceived barriers and facilitators to preventing HAPI.

DESIGN

A qualitative, exploratory study of hospital professionals was undertaken using semi-structured interviews between February 2022 and January 2023.

METHODS

Two frameworks, the Capability, Opportunity and Motivation Model of Behaviour (COM-B) and the Theoretical Domains Framework (TDF), were used to give both theoretical and pragmatic guidance. Participants included 19 nursing and allied health professionals and data analysis was informed by the framework approach.

RESULTS

Analysis revealed nine core themes regarding professionals' beliefs about the barriers and facilitators to HAPI prevention practices across seven TDF domains. Themes included HAPI prevention skills and education, family-centred care, automated feedback and prompts, allocation and access to equipment, everybody's responsibility, prioritizing patients and clinical demands, organizational expectations and support, integrating theory and reality in practice and emotional influence.

CONCLUSION

These findings provide valuable insights into the barriers and facilitators that impact paediatric HAPI prevention and can help identify and implement strategies to enhance evidence-based prevention care and prevent HAPI in paediatric settings.

IMPACT

Overcoming barriers through evidence-based interventions is essential to reduce HAPI cases, improve patient outcomes, and cut healthcare costs. The findings have practical implications, informing policy and practice for improved preventive measures, education, and staffing in paediatric care, ultimately benefiting patient well-being and reducing HAPIs.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution. The focus of the study is on healthcare professionals and their perspectives and experiences in preventing HAPIs in paediatric patients. Therefore, the involvement of patients or the public was not deemed necessary for achieving the specific research objectives.

The impact of patient safety incidents during hip and knee replacements on patients' health related quality of life: a before and after study using longitudinal data linked to patient-reported outcome measures

BACKGROUND

The burden of patient safety incidents (PSIs) is often characterized by their impact on mortality, morbidity, and treatment costs. Few studies have attempted to estimate the impact of PSIs on patients' health-related quality of life (HRQoL) and the studies that have made such estimates primarily focus on a narrow set of incidents. The aim of this paper is to estimate the impact of PSIs on HRQoL of patients undergoing elective hip and knee surgery in England.

PATIENTS AND METHODS

A unique linked longitudinal data set consisting of patient-reported outcome measures for patients with hip and knee replacements linked to Hospital Episode Statistics (HES) collected between 2013/14 and 2016/17 was examined. Patients with any of nine US Agency for Healthcare Research and Quality (AHRQ) PSI indicators were identified. HRQoL was measured using the general EuroQol five dimensions questionnaire (EQ-5D) before and after surgery. Exploiting the longitudinal structure of the data, exact matching was combined with difference in differences to estimate the impact of experiencing a PSI on HRQoL and its individual dimensions, comparing HRQoL improvements after surgery in similar patients with and without a PSI in a retrospective cohort study. This design compares the change in HRQoL before and after surgery in patients who experience a PSI to those who do not.

RESULTS

The sample comprised 190 697 and 204 649 observations for patients undergoing hip replacement and knee replacement respectively. For six out of nine PSIs, patients who experienced a PSI reported improvements in HRQoL that were 14-23% lower than those who did not experience a PSI during surgery. Those who experienced a PSI were also more likely to report worse health states after surgery than those without a PSI on all five dimensions of HRQoL.

CONCLUSION

PSIs are associated with a substantial negative impact on patients' HRQoL.

Medical error analysis in dermatology according to the reports of the North Rhine Medical Association from 2004 to 2018

BACKGROUND

Assessment of complaints addressed to the Expert Committee for Medical Malpractice Claims of the North Rhine Medical Association helps to identify quality assurance problems in dermatology.

METHODS

333 dermatological reports (years 2004-2018) were allocated to three five-year intervals in order to show changes of total number of reports and with regard to indications, types of care, defined diagnosis categories, and therapeutic interventions. Statistical analysis was mainly descriptive (SPSS 27). Representative cases are explained in more detail.

RESULTS

The number of dermatological reports fell from 119 in the first to 92 reports in the last five-year interval, along with a decline in treatment error rates (43 % and 29 %) despite an increasing number of procedures across disciplines. 104 reports dealt with (supposed) diagnostic errors, 156 with physical or pharmacological therapies, and 73 reports with surgery. The latter had a low treatment error rate (29 %).

CONCLUSIONS

In comparison to the number of dermatological treatments in Germany, patient allegations are raised only rarely indicating greater patient satisfaction and/or a lower risk potential in dermatology. Incorrect dosages or device settings, diagnostic errors, and deficits in obtaining informed consent are relevant sources of error as underlined by the presented case reports.

Assessing The Dangers Of A Hospital Stay For Patients With Developmental Disability In England, 2017-19

People with developmental disability have higher health care needs and lower life expectancy compared with the general population. Poor quality of care resulting from interpersonal and systemic discrimination may further entrench existing inequalities. We examined the prevalence of five avoidable in-hospital patient safety incidents (adverse drug reactions, hospital-acquired infections, pressure ulcers, postoperative pulmonary embolism or deep vein thrombosis, and postoperative sepsis) for four developmental disability groups (people with intellectual disability, chromosomal abnormalities, pervasive developmental disorders, and congenital malformation syndrome) in the English National Health Service during the period April 2017-March 2019. We found that the likelihood of experiencing harm in disability groups was up to 2.7-fold higher than in patients without developmental disability. Patient safety incidents led to an excess length-of-stay in hospital of 3.6-15.4 days and an increased mortality risk of 1.4-15.0 percent. We show persisting quality differences in patients with developmental disability, requiring an explicit national policy focus on the needs of such patients to reduce inequalities, reach parity of care, and lower the burden on health system resources.

Pressure injuries in Australian public hospitals: A cost of illness study

BACKGROUND

Pressure injuries are a leading hospital adverse event, yet they are mostly preventable. Understanding their financial costs will help to appreciate the burden they place on the health system and assist in better planning and management of health expenditures to prevent pressure injuries.

OBJECTIVE

To estimate the cost of pressure injuries in Australian public hospitals in 2020 demonstrating its economic burden in a well-resourced health system.

METHODS

A cost of illness study with a 12-month time horizon was conducted. Resource use for the treatment of pressure injuries and productivity loss due to pressure injuries were derived using a bottom-up approach. Parameters of the cost estimates were obtained from secondary sources and literature syntheses. A simulation with 10,000 draws was used to generate statistical properties of the cost estimates.

RESULTS

Based on a prevalence of 12.9%, the total cost of pressure injuries in Australian public hospitals was $9.11 billion [95% confidence intervals: 9.02, 9.21]. The two largest shares of costs were accounted for by the opportunity cost of excess length of stay of $3.60 billion [3.52, 3.68] and treatment costs of $3.59 billion [3.57, 3.60]. Productivity loss associated with pressure injuries amounts to $493 million [482, 504]. Hospital-acquired pressure injuries account for a total of $5.50 billion [5.44, 5.56], whereas pressure injuries present on admissions costed $3.71 billion [3.70, 3.72]. In terms of severity, Stage 2 pressure injuries contributed the most to total treatment costs, total excessive length of stay, and total loss of healthy life years. Australian society is willing to pay $1.43 billion [1.40, 1.45] to save 6,701 [6,595; 6,807] healthy life years lost by pressure injury.

CONCLUSIONS

Reducing preventable pressure injuries and stopping the progression of Stage 1 pressure injuries will likely result in an immense cost-saving for Australia and will likely have similar benefits for other countries with comparable profiles.

TWEETABLE ABSTRACT

Australian public hospital study provides comprehensive analysis of the cost of pressure injury, including estimates of direct and indirect medical costs, and indirect non-medical costs - such as productivity and quality of life.

Global, Regional, and National Levels and Trends in the Burden of Pressure Ulcer from 1990 to 2019: A Systematic Analysis for the Global Burden of Disease 2019

Pressure ulcer (PU) is a type of chronic ulcer, placing a high burden not only on patients' families but also on national healthcare systems globally. To determine the level, trends, and burden of PU worldwide and to provide an essential foundation for building targeted public policies on PUs at the national, regional, and global levels, data on PU were obtained from the Global Burden of Disease (GBD) 2019 Study. The incidence, disability-adjusted life years (DALYs), and deaths of PUs in 204 countries and regions from 1990 to 2019 were calculated and stratified by sex, age, geographical location, and sociodemographic index (SDI). The estimated annual percentage change (EAPC) of incidence, DALYs, and deaths was calculated to evaluate the temporal trends. A total of 3,170,796 new cases (95% uncertainty interval (UI), 3,499,729-2,875,433 cases) of PU were identified globally in 2019, more than 55% of which were among male individuals, and most of the new cases were concentrated in those 75-90 years of age. The burden of PU measured in DALYs was 481 423 (95% UI, 583 429-374 334) in 2019, 73% and 27% of which could be attributed to years of life lost (YLLs) and years lived with disability (YLDs), respectively. The burden increased gradually from 1990 to 2019 (from 267 846 [360 562-211 024] to 481 423 [95% UI, 583 429-374 334]). A total of 24 389 deaths were attributed to PU (95% UI, 31 260.82-17 299). The EAPC of incidence, DALYs, and deaths were negative in most regions, the age-standardized rate (ASR) of incidence, DALYs, and deaths were considered to be decreasing in most of the regions, and the EAPCs were negatively correlated with the SDI levels, universal health coverage (UHC), and gross domestic product (GDP), which shows that the ASRs of PU decreased as the economy developed and countries' healthcare system performances improved.

Comparing the dangers of a stay in English and German hospitals for high-need patients

OBJECTIVE

To estimate the risk of an avoidable adverse event for high-need patients in England and Germany and the causal impact that has on outcomes.

DATA SOURCES

We use administrative, secondary data for all hospital inpatients in 2018. Patient records for the English National Health Service are provided by the Hospital Episode Statistics database and for the German health care system accessed through the Research Data Center of the Federal Statistical Office.

STUDY DESIGN

We calculated rates of three hospital-acquired adverse events and their causal impact on mortality and length of stay through propensity score matching and estimation of average treatment effects.

DATA COLLECTION/EXTRACTION METHODS

Patients were identified based on diagnoses codes and translated Patient Safety Indicators developed by the Agency for Healthcare Research and Quality.

PRINCIPAL FINDINGS

For the average hospital stay, the risk of an adverse event was 5.37% in the English National Health Service and 3.26% in the German health care system. High-need patients are more likely to experience an adverse event, driven by hospital-acquired infections (2.06%-4.45%), adverse drug reactions (2.37%-2.49%), and pressure ulcers (2.25%-0.45%). Adverse event risk is particularly high for patients with advancing illnesses (10.50%-27.11%) and the frail elderly (17.75%-28.19%). Compared to the counterfactual, high-need patients with an adverse event are more likely to die during their hospital stay and experience a longer length of stay.

CONCLUSIONS

High-need patients are particularly vulnerable with an adverse event risking further deterioration of health status and adding resource use. Our results indicate the need to assess the costs and benefits of a hospital stay, particularly when care could be provided in settings considered less hazardous.

Cost-DALY comparison of hip replacement care in 12 Belgian hospitals

BACKGROUND

In view of the expected increase in expenditure on hip replacement treatment in Belgium, the complication rate and potential waste reduction, as estimated by the Organisation for Economic Cooperation and Development, we are not yet in a position to assess the efficiency of hip replacement treatment in Belgian hospitals. This objective study uses a cost-disability-adjusted life years (DALYs) ratio to propose a comparison of hip replacement surgery among 12 Belgian hospitals.

METHODS

Our study seeks to innovate by proposing an interhospital comparison that simultaneously integrates the weighting of quality indicators and the costs of managing a patient. To this end, we associated a DALY impact with each patient safety indicator, readmission and mortality outcome. We then compared hospitals using both costs and DALYs adjusted to their case mix index. The adjusted values (costs and DALYs) were obtained by relating the observed value to the predicted value obtained from the linear regression model.

RESULTS

We registered a total of 246.5 DALYs for the 12 hospital institutions, the average cost (SD) of a stay being €8013 (€4304). Our model allowed us to identify hospitals with observed values higher than those predicted. Out of the 12 hospitals evaluated, 4 need to reduce costs and DALYs impacts, 6 have to improve one of the two factors and 2 appear to have good results. The costs for the worst performing hospitals can rise to over €150 000.

CONCLUSION

Evaluating the rates of patient safety indicators, associated with cost, is a prerequisite for quality and cost improvement efforts on the part of managers and practitioners. However, it appears essential to evaluate the entire care chain using a comparable unit of measurement. The hospital's case mix index must also be considered in benchmarking to avoid drawing the wrong conclusions. In addition, other indicators, such as the patient's perception of the actual results, should be added to our study.

Repositioning for pressure injury prevention in adults: An abridged Cochrane systematic review and meta-analysis

BACKGROUND

A pressure injury is an area of localised damage to the skin and underlying tissues. Patient repositioning is an important prevention strategy, as those with limited mobility are at increased risk of developing pressure injury.

OBJECTIVES

To assess the clinical and cost-effectiveness of repositioning schedules on the prevention of pressure injury in adults.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

The Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials; MEDLINE (Ovid); Embase (Ovid) and Cumulative Index of Nursing and Allied Health Literature Plus (EBSCO) were searched in February 2019. No restrictions were applied to language or date of publication.

REVIEW METHODS

Studies were eligible if they were randomised controlled trials including cluster trials, published or unpublished, and undertaken in any healthcare setting that assessed the clinical and/or cost effectiveness of repositioning schedules for prevention of pressure injury in adults. Methodological quality of the studies was independently assessed by three authors. Heterogeneity between studies was assessed using the I² statistic, and the pooled risk ratios along with their 95% confidence intervals were estimated using either fixed and random effects models, as indicated. Grading of Recommendations Assessment, Development and Evaluation was used to appraise the certainty of evidence.

RESULTS

Eight eligible trials involving 3,941 participants published between 2004 and 2018 were identified. Trials compared either different repositioning frequencies or positioning regimens. Three trials (1074 participants) compared 2-hourly with 4-hourly repositioning (risk ratio 1.06, 95% confidence interval 0.80 to 1.41; I² = 45%). Two other trials (252 participants) compared a 30-degree tilt with a 90-degree tilt (risk ratio0.62, 95% confidence interval 0.10 to 3.97; I² =69%). Only two trials included economic analyses, both amongst nursing home residents. One study estimated the costs of repositioning to be Canadian dollars $11.05 and Canadian dollars $16.74 less per resident per day for the 3-hourly or 4-hourly regimens, respectively, when compared to 2-hourly regimen. The second study reported 3-hourly repositioning using a 30-degree tilt to cost €46.50 (95% confidence interval €1.25 to €74.60) less per patient in nursing time compared with 6-hourly repositioning with a 90-degree lateral rotation.

CONCLUSION

It remains unclear which repositioning frequencies or positions are most effective in preventing pressure injury in adults. There is limited evidence to support the cost effectiveness of repositioning frequencies and positions. Registration: Cochrane protocol published in 2012.

Trends in Decubitus Ulcer Disease Burden in European Union 15+ Countries, from 1990 to 2017

Supplemental Digital Content is available in the text.

Background:

Decubitus ulcers (DU) are a common pathology with significant morbidity and financial implications for health services globally. This study aimed to compare the burden of DU across European Union (EU) 15+ countries between 1990 and 2017.

Methods:

Age-standardized incidence, mortality, and disability-adjusted life-years (DALYs) rates per 100,000 were extracted from the Global Burden of Disease Study online data repository for EU15+ countries (a group of 19 countries with comparable health expenditure, including the United States, Canada, the United Kingdom, and Australia). A joinpoint regression analysis was used to describe trends.

Results:

The incidence of DU increased between 1990 and 2017 in 15 of 19 EU15+ countries for both men and women. Mortality from DU decreased over the time period analyzed in the majority of EU15+ countries: only in Denmark, Finland, and Germany were increasing mortality rates observed. Decreasing DALY rates were generally observed, with the largest decreases observed in Ireland for men and women. Denmark and Germany were the only countries to demonstrate unfavorable trends in mortality, incidence, and DALYs between 1990 and 2017 for men and women. The United States, the Netherlands, and France were the only EU15+ countries in which improving disease burden was identified between 1990 and 2017 for all parameters assessed.

Conclusions:

Incidence of DU is increasing in EU15+ countries, whereas mortality rates and DALYs are improving. The trends in disease burden in Denmark and Germany have followed contrasting and unfavorable trends. Investigation into these trends is called for.

The prevalence of pressure ulcers in Europe, what does the European data tell us: a systematic review

OBJECTIVE

The main aim of this systematic review was to establish the prevalence of pressure ulcers (PU) within published studies from Europe.

METHOD

Using systematic review methodology, quantitative design studies which explored prevalence data and/or the epidemiology of PUs in Europe were considered. The primary outcome was PU prevalence. The search, conducted in April 2019, using Cochrane, Medline, Embase, CINAHL, PubMed, Scopus and Web of Science databases, returned 3065 records, of which 79 met the inclusion criteria. Data were extracted using a pre-designed extraction tool, and validity analysis was undertaken using the Evidence-Based Librarianship (EBL) Critical Appraisal Checklist.

RESULTS

We included 79 articles in this review. Across the studies, the median prevalence was 10.8% (standard deviation: 7%; range: 4.6-27.2%). The highest PU prevalence reported was from the Netherlands (27.2%; n=17,494 participants), and the lowest was reported from Finland (4.6%; n=629 participants). Almost 32.4% (n=151,195) of the PUs were category I and the most common site for PUs was the sacrum.

CONCLUSION

The prevalence data is consistently high. These data indicate the continued need for further resource allocation into PU prevention and management.

Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis

OBJECTIVE

To systematically quantify the prevalence, severity, and nature of preventable patient harm across a range of medical settings globally.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline, PubMed, PsycINFO, Cinahl and Embase, WHOLIS, Google Scholar, and SIGLE from January 2000 to January 2019. The reference lists of eligible studies and other relevant systematic reviews were also searched.

REVIEW METHODS

Observational studies reporting preventable patient harm in medical care. The core outcomes were the prevalence, severity, and types of preventable patient harm reported as percentages and their 95% confidence intervals. Data extraction and critical appraisal were undertaken by two reviewers working independently. Random effects meta-analysis was employed followed by univariable and multivariable meta regression. Heterogeneity was quantified by using the I2 statistic, and publication bias was evaluated.

RESULTS

Of the 7313 records identified, 70 studies involving 337 025 patients were included in the meta-analysis. The pooled prevalence for preventable patient harm was 6% (95% confidence interval 5% to 7%). A pooled proportion of 12% (9% to 15%) of preventable patient harm was severe or led to death. Incidents related to drugs (25%, 95% confidence interval 16% to 34%) and other treatments (24%, 21% to 30%) accounted for the largest proportion of preventable patient harm. Compared with general hospitals (where most evidence originated), preventable patient harm was more prevalent in advanced specialties (intensive care or surgery; regression coefficient b=0.07, 95% confidence interval 0.04 to 0.10).

CONCLUSIONS

Around one in 20 patients are exposed to preventable harm in medical care. Although a focus on preventable patient harm has been encouraged by the international patient safety policy agenda, there are limited quality improvement practices specifically targeting incidents of preventable patient harm rather than overall patient harm (preventable and non-preventable). Developing and implementing evidence-based mitigation strategies specifically targeting preventable patient harm could lead to major service quality improvements in medical care which could also be more cost effective.

Pressure induced skin and soft tissue injury in the emergency department

The incidence of pressure ulcers or injuries is a global healthcare issue and in the top six most common adverse events in healthcare. Pressure injuries also are symptomatic of wider system failure and poor care. Recognition of these injuries and prevention strategies must start in the emergency department. This article will detail best practice in relation to both assessment of these injuries and their prevention in the emergency department.

Tracking pressure injuries as adverse events: National use of the Global Trigger Tool over a 4-year period

AIM

To examine the frequency, preventability, and consequences of hospital acquired pressure injuries in acute care hospitals over a 4-year period.

METHOD

A retrospective record review was performed using the Swedish version of the Global Trigger Tool (GTT). A total of 64 917 hospital admissions were reviewed. Data were collected between 2013 and 2016 from all 63 Swedish acute care hospitals.

RESULTS

The prevalence of pressure injuries (category 2-4) was 1%. Older patients, "satellite patients", and patients with acute admissions had more pressure injuries. Most pressure injuries (91%) were determined to be preventable. The mean extended length of hospital stay was 15.8 days for patients who developed pressure injuries during hospitalization.

CONCLUSION

The GTT provides a useful and complementary national perspective on hospital acquired pressure injuries across hospitals, informing health care providers on safety priorities to reduce patient harm. Clinical leaders can use information on the preventability and the consequences of pressure injuries, as well as evidence-based arguments for improving the health care organization.

Utility of a sensor-based technology to assist in the prevention of pressure ulcers: A clinical comparison

Detection of subcutaneous tissue damage before it is visible can trigger early intervention and decrease hospital-acquired pressure ulcer (HAPU) rates. The objective of this two-phase study was to evaluate the clinical utility of the Sub-Epidermal Moisture (SEM) Scanner (Bruin Biometrics (BBI), LLC), a hand-held device that assesses increases in interstitial fluid or subepidermal moisture, indicating early tissue damage. Phase 1: Patients were provided standard-of-care risk assessment and interventions and were scanned with the SEM Scanner, but the resulting SEM scores were not used to determine interventions. This gave a baseline pressure ulcer incidence rate. Phase 2: This phase is the same as Phase 1 except the resulting SEM scores were used in conjunction with risk assessment scores to determine appropriate interventions and care planning. In Phase 1, 12 of the 89 subjects or 13.5% developed visible pressure ulcers-4 Stage I's, 6 Stage II's, 1 Stage III, and 1 deep tissue injury. In Phase 2, 2 of the 195 subjects or 1.0% developed visible pressure ulcers-1 Stage I and 1 Stage II. Patients in Phase 2 were more incontinent, less mobile, and had longer lengths of stay than those in Phase 1. Use of the Scanner resulted in a 93% decrease in HAPU. No deep injuries developed in Phase 2.

Cost-Utility Analysis of Venous Thromboembolism Prophylaxis Strategies for People Undergoing Elective Total Hip and Total Knee Replacement Surgeries in the English National Health Service

Background: Major orthopedic surgery, such as elective total hip replacement (eTHR) and elective total knee replacement (eTKR), are associated with a higher risk of venous thromboembolism (VTE) than other surgical procedures. Little is known, however, about the cost-effectiveness of VTE prophylaxis strategies in people undergoing these procedures. Aim: The aim of this work was to assess the cost-effectiveness of these strategies from the English National Health Service perspective to inform NICE guideline (NG89) recommendations. Materials and Methods: Cost-utility analysis, using decision modeling, was undertaken to compare 15 VTE prophylaxis strategies for eTHR and 12 for eTKR, in addition to "no prophylaxis" strategy. The analysis complied with the NICE Reference Case. Structure and assumptions were agreed with the guideline committee. Incremental net monetary benefit (INMB) was calculated, vs. the model comparator (LMWH+ antiembolism stockings), at a threshold of £20,000/quality-adjusted life-year (QALY) gained. The model was run probabilistically. Deterministic sensitivity analyses (SAs) were undertaken to assess the robustness of the results. Results: The most cost-effective strategies were LMWH for 10 days followed by aspirin for 28 days (INMB = £530 [95% CI: -£784 to £1,103], probability of being most cost-effective = 72%) for eTHR, and foot pump (INMB = £353 [95% CI: -£101 to £665]; probability of being most cost-effective = 18%) for eTKR. There was considerable uncertainty regarding the cost-effectiveness ranking in the eTKR analysis. The results were robust to change in all SAs. Conclusions: For eTHR, LMWH (standard dose) for 10 days followed by aspirin for 28 days is the most cost-effective VTE prophylaxis strategy. For eTKR, the results are highly uncertain but foot pump appeared to be the most cost-effective strategy, followed closely by aspirin (low dose). Future research should focus on assessing cost-effectiveness of VTE prophylaxis in the eTKR population.

Understanding the global causes and costs of patient harm

John Tingle, Reader in Health Law at Nottingham Trent University, discusses the Organisation for Economic Co-operation and Development's report on the economics of patient safety.