Quality Measures

How We Report Pressure Ulcers

The pressure ulcers measure is based on the percentage of patients who had a hospital-acquired pressure ulcer, stage 2-or-greater.

Pressure ulcers, also called pressure sores or bed sores, can be caused by a patient lying or sitting in the same position for too long. They most often occur in bony areas, such as elbows, hips, heels, and elsewhere. Pressure ulcers can lead to serious and sometimes even life-threatening infections and to longer hospital stays.

The State of Maine requires each hospital to conduct a special survey, four times a year, where a team of nurses carefully inspects every patient in each adult inpatient care unit from head-to-toe as defined in 90-590 CMR Chapter 270, Uniform Reporting System for Health Care Quality Data Sets. The hospitals are required to submit a report to the Maine Health Data Organization on the number of patients examined and the number of patients who had a stage 2 pressure ulcer or greater. A sore becomes a stage 2 pressure ulcer when the skin has broken, worn away or formed an ulcer reaching the deeper skin layers. The count does not include pressure sores a patient already had when he or she recently entered the hospital.

Hospitals can reduce the number of pressure ulcers, or keep them from getting worse, by identifying patients at high risk, changing a patient’s position every two hours, using pillows or other pressure-relieving devices, making sure the patient’s skin stays clean and dry, and carefully monitoring the patient’s skin to spot minor sores and treat them before they get serious.

This measure was developed by the Joint Commission. It differs from a similar one created by the Agency for Healthcare Research and Quality (AHRQ), which relies on hospital discharge data instead of careful patient examinations. The data on CompareMaine covers the October 1, 2019 – September 30, 2020 reporting period. There is no known national benchmark.

CompareMaine uses the facility confidence interval (CI) associated with the pressure ulcer compared to the statewide CI for calculating the Quality Ratings shown on these measures. For more information, download the quality data reported on CompareMaine.

Note: Houlton Regional Hospital reported data for one quarter (October-December 2019), whereas the other hospitals reported for a 12-month period.