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Name
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Percentage of Residents Who Had a Newly Occurring Stage 2 to 4 Pressure Ulcer
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Short/Other Names
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PRU09

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Description
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Percentage of residents who had a newly occurring stage 2 to 4 pressure ulcer
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Interpretation
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A high number indicates a higher percentage of residents who had a newly occurring stage 2 to 4 pressure ulcer on their target assessment; thus a lower percentage is desirable.
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HSP Framework Dimension
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Health System Outputs: Safe

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Areas of Need
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Living With Illness, Disability or Reduced Function

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Geographic Coverage
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Newfoundland and Labrador, New Brunswick, Nova Scotia, Ontario, Manitoba, Saskatchewan, Alberta, British Columbia, Yukon

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Reporting Level/Disaggregation
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Province/Territory, Region, Facility, Corporation, Sector (residential and hospital-based continuing care)

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Indicator Results
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https://www.cihi.ca/sites/default/files/document/ccrs-quick-stats-2017-2018-en-web.xlsx

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<div role="button" class="expandableTitle" aria-controls="identifyingInfoRegion">Identifying Information</div>
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Name
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Percentage of Residents Who Had a Newly Occurring Stage 2 to 4 Pressure Ulcer
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Short/Other Names
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PRU09

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Description
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Percentage of residents who had a newly occurring stage 2 to 4 pressure ulcer
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Calculation: Description
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Residents who had a pressure ulcer at stage 2 to 4 on their target assessment and no pressure ulcer at stage 2 to 4 on their prior assessment

Unit of Analysis: Resident

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Calculation: Geographic Assignment
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Place of service

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Calculation: Type of Measurement
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Percentage or proportion

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Calculation: Adjustment Applied
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The following covariates are used in risk adjustment:
Individual Covariates:

–Age younger than 65

–Personal Severity Index (PSI): Subset 1—Diagnoses

–More dependence in toileting

–Resource Utilization Group (RUG): Cognitive Impairment

Facility-Level Stratification:

–Case Mix Index (CMI)

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Calculation: Method of Adjustment
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Stratification, direct standardization, indirect standardization
Standard Population:
3,000 facilities in 6 U.S. states and 92 residential care facilities and continuing care hospitals in Ontario and Nova Scotia

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Denominator
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Description:
Residents with valid assessments
Inclusions:
1. Residents with valid assessments. To be considered valid, the target assessment must

a. Be the latest assessment in the quarter

b. Be carried out more than 92 days after the Admission Date

c. Not be an Admission Full Assessment

As this is an incidence indicator, the resident must also have had an assessment in the previous quarter, with 45 to 165 days between the target and prior assessments. If multiple assessments in the previous quarter meet the time period criteria, the latest assessment is selected as the prior assessment.
Exclusions:
1. Residents who had a pressure ulcer greater than or equal to stage 2 (M2a = 2 or higher) on their prior assessment

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Numerator
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Description:
Residents who had a pressure ulcer at stage 2 to 4 on their target assessment and no pressure ulcer at stage 2 to 4 on their prior assessment
Inclusions:
1. Residents who had a pressure ulcer on their target assessment (M2a = 2 or higher)

2. Residents with valid assessments. To be considered valid, the target assessment must

a. Be the latest assessment in the quarter

b. Be carried out more than 92 days after the Admission Date

c. Not be an Admission Full Assessment

As this is an incidence indicator, the resident must also have had an assessment in the previous quarter, with 45 to 165 days between the target and prior assessments. If multiple assessments in the previous quarter meet the time period criteria, the latest assessment is selected as the prior assessment.
Exclusions:
1. Residents who had a pressure ulcer greater than or equal to stage 2 (M2a = 2 or higher) on their prior assessment

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Rationale
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CCRS quality indicators were developed by interRAI (www.interrai.org), an international research network, to provide organizations with measures of quality across key domains, including physical and cognitive function, safety and quality of life. Each indicator is adjusted for resident characteristics that are related to the outcome and independent of quality of care. The indicators can be used by quality leaders to drive continuous improvement efforts. They are also used to communicate with key stakeholders through report cards and accountability agreements.

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Interpretation
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A high number indicates a higher percentage of residents who had a newly occurring stage 2 to 4 pressure ulcer on their target assessment; thus a lower percentage is desirable.

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HSP Framework Dimension
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Health System Outputs: Safe

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Areas of Need
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Living With Illness, Disability or Reduced Function

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Targets/Benchmarks
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None

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References
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Canadian Institute for Health Information. CCRS Quality Indicators Risk Adjustment Methodology. 2013.

Canadian Institute for Health Information. When a Nursing Home Is Home: How Do Canadian Nursing Homes Measure Up on Quality? 2013.

Health Quality Ontario. Long-Term Care Benchmarking Resource Guide. 2013.

Health Quality Ontario. Results From Health Quality Ontario's Benchmark Setting for Long-Term Care Indicators. 2017.

Health Quality Ontario. Health Quality Ontario Indicator Library. Accessed October 4, 2017.

Hirdes JP, Mitchell L, Maxwell CJ, White N. Beyond the "iron lungs of gerontology": Using evidence to shape the future of nursing homes in Canada. Canadian Journal on Aging. 2011.

Hirdes JP, Poss JW, Caldarelli H, et al. An evaluation of data quality in Canada's Continuing Care Reporting System (CCRS): Secondary analyses of Ontario data submitted between 1996 and 2011. BMC Medical Informatics and Decision Making. 2013.

Jones RN, Hirdes JP, Poss JW, et al. Adjustment of nursing home quality indicators. BMC Health Services Research. 2010.

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Data Sources
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CCRS

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Available Data Years
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Type of Year:
Fiscal
First Available Year:
2003
Last Available Year:
2017

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Geographic Coverage
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Newfoundland and Labrador, New Brunswick, Nova Scotia, Ontario, Manitoba, Saskatchewan, Alberta, British Columbia, Yukon

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Reporting Level/Disaggregation
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Province/Territory, Region, Facility, Corporation, Sector (residential and hospital-based continuing care)

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Update Frequency
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Every year

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Indicator Results
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Web Tool:
Quick Stats
URL: https://www.cihi.ca/sites/default/files/document/ccrs-quick-stats-2017-2018-en-web.xlsx

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Updates
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Not applicable

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Caveats and Limitations
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The Continuing Care Reporting System (CCRS) frame does not currently contain all facilities in all provinces and territories that make up the CCRS population of interest. Users should be cautious when interpreting results from CCRS, as the population covered by CCRS may not be representative of all continuing care facilities across Canada.

Coverage is incomplete in the following jurisdictions:

– Manitoba (includes all facilities in Winnipeg Regional Health Authority only)
– New Brunswick
– Nova Scotia

Indicators are risk-adjusted to control for potential confounding factors.

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Trending Issues
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Since 2003, the number of facilities and jurisdictions submitting to CCRS has been increasing. With the addition of new jurisdictions, it is possible that differences in care practices may affect indicator rates; however, changes to the underlying population would be controlled for using risk adjustment. There is also evidence to suggest that trending and use of data from the entire time series is not an issue and that data quality is consistent over time (Hirdes et al., 2013).

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Comments
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The CCRS quality indicators use four rolling quarters of data for calculations in order to have a sufficient number of assessments for risk adjustment. Since residents are assessed on a quarterly basis, each resident can contribute to the indicator up to four times.

Although the CCRS quality indicators are reported publicly at the provincial/territorial level only, indicator results are available at other levels (facility, corporation, region) to data submitters in the CCRS eReports application. Data in CCRS eReports is updated on a quarterly basis.

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