Pressure injuries are a topic not often mentioned when talking about the general healthcare of older adults in the community. But, for older Americans in hospitals, long-term care, and other care institutions, it’s a very different matter. As The Joint Commission said, “pressure injuries are significant health issues and one of the biggest challenges organizations face on a day-to-day basis.”
This is due to their high cost and significant impact on patients’ lives, as well as on the ability of providers to appropriately care for patients. Pressure injuries are one of the most common hospital-acquired conditions and cost an estimated $10 billion a year.
Good nutrition is a primary strategy for preventing pressure injuries and caring for them. Below is discussed how nutrition plays a role in a facility’s metrics and operational practices that promote quality care and patient safety.
New Hospital Quality Measure for Pressure Injury
In August 2024, the Centers for Medicare and Medicaid Services (CMS) released its final rule for the Hospital Inpatient Prospective Payments Systems (IPPS) for Acute Care Hospitals. As part of its rule, CMS added a new voluntary Hospital Harm–Pressure Injury (HH-PI) measure to incentivize hospital best practices and reduce hospital-acquired pressure injuries. The HH-PI quantifies the proportion of admitted inpatients ages 18 and older who develop a new stage II, III or IV, deep-tissue pressure injury or unstageable pressure injury. The measure will be available in 2025 for voluntary hospital reporting, but in 2027 is expected to become mandatory for hospital reporting.
Hospital-acquired pressure-injury prevention protocols are a cost-saving investment.
Nutrition status is one modifiable factor that needs to be addressed when implementing quality improvement initiatives for improving wound outcomes. Clinical recommendations supporting the HH-PI measure include a specific focus on nutrition that goes beyond screening to encompass conducting a comprehensive nutrition assessment, implementing a nutrition care plan, optimizing energy intake, meeting specific calorie and protein levels, and offering high-calorie, high-protein nutrition supplements when a normal diet alone cannot meet nutrition needs. The statement also identifies the importance of considering enteral or parenteral feeding, if needed.
Current Hospital Patient Safety Indicator for Pressure Injury
Even if hospitals do not choose to report on the HH-PI measure starting in 2025, there is a required patient safety measure that continues to capture data on pressure injuries in acute care hospitals. Specifically, the Patient Safety Indicator 03 (PSI 03) Pressure Ulcer Rate measure is part of the CMS Patient Safety Indicator 90 (PSI 90), a composite measure that gives hospitals a marker across a broad range of patient safety–related events. PSI 90 is integrated into pay-for-performance programs such as the Hospital Acquired Condition Reduction Program (HACRP) and the newly announced Transforming Episode Accountability Model, which starts in January 2026. Similar to its role in HH-PI, good nutrition care is critical for pressure injury metrics like the PSI 03.
There are important differences between the HH-PI quality measure and the PSI 03 patient safety indicator.
- HH-PI collects data on the incidence of patients who develop new stage II, III or IV, deep-tissue pressure injury, and unstageable pressure injuries, but excludes existing pressure injuries identified upon admission (within 24 hours for stage II, III, IV and unstageable, and 72 hours for deep-tissue pressure injuries).
- PSI 03 quantifies the prevalence of stage III, IV or unstageable pressure ulcers per 1,000 discharged patients ages 18 and older (excluding any patients with fewer than 3 days length of stay), so it documents prevalence of both new and existing pressure injuries.
Opportunities for Quality Improvement with the SPIPP Validated Practice Tool
For both the HH-PI quality measure and the PSI 03 patient safety indicator, prevention is key, to prevent new pressure injuries and prevent the worsening of existing pressure injuries and support healing. Opportunities for prevention can be strengthened with quality improvement protocols that are based on multidisciplinary collaboration and include validated practice tools. One practice tool validated by the National Pressure Injury Advisory Panel (NPAIP) that takes a multidisciplinary approach is the Standardized Pressure Injury Prevention Protocol Checklist (SPIPP-Adult) 2.0.
Starting with screening on admission, the SPIPP outlines patient care action steps in five areas:
- Risk factor assessment to guide risk-based prevention
- Skin/tissue assessment to identify signs of skin damage and pressure injury
- Preventive skin care management to address moisture and incontinence
- Redistribution of pressure
- Nutrition.
The SPIPP can be used to identify patients at risk for developing a pressure injury. If patients are admitted with a pressure injury, it can also be used to prevent pressure injuries from progressing. It is formatted as a checklist with a clear task list and completion confirmations. Tasks include informing the patient and/or family about pressure injury risk, consulting additional disciplines, and implementing specific evidence-based interventions.
The Nutrition section of the SPIPP aligns with the clinical recommendations of the HH-PI quality measure. The SPIPP also goes further to recommend consulting a dietitian and providing additional nutrients beyond calories and protein (i.e., multivitamins, arginine, glutamine, and HMB) as appropriate to patient care plans.
For the new HH-PI quality measure and the PSI 03 patient safety indicator, hospitals have the tools to begin working immediately to improve pressure injury prevention and care. Clinicians can start by engaging hospital Quality and Information Technology (IT) departments to include nutrition in pressure injury protocols, standardize the protocols, and then integrate the protocols into the institution’s electronic medical record.
Hospital-acquired pressure injury prevention protocols are a cost-saving investment. Best practice protocols like the SPIPP help decrease the incidence of hospital-acquired pressure injuries, support patient safety, and help prevent hospital harm, and most importantly, put the older adult patient at the center of care.
Amy Shepps, MBA, RDN is the director of corporate reimbursement for Abbott in Washington, DC.
Photo credit: Shutterstock/Josep Suria
Resources:
The Standardized Pressure Injury Prevention Protocol Checklist (SPIPP Adult Version) 2.0: https://anhi.org/resources/podcasts-and-videos/the-standardized-pressure-injury-prevention-protocol-checklist-spipp-adult-version
Adopting a Collaborative, Interdisciplinary Approach in Nutrition Care for Patients at Risk for Pressure Injuries: https://anhi.org/resources/podcasts-and-videos/nutrition-care-for-patients-at-risk-for-pressure-injuries
The Role of Nutrition in Pressure Injury Management in Patients with Diabetes: https://anhi.org/education/course-catalog/660A647071424506B58286CE3105BCB4
Nutrition and Wounds: Implementing an Evidence-based Plan of Care: https://anhi.org/education/course-catalog/A97E2FAAC85349D79B15FF8DA4EC6469
