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OBJECTIVE Health systems are grappling with improving the quality and safety of health care. By setting clear expectations, there is an opportunity to configure care models to decrease the risk of adverse events and promote the quality of care. The US Centers for Medicare and Medicaid Services have used Patient Safety Indicator 90 (PSI90), a composite rate of hospital-acquired conditions (HACs), to adjust payments and score hospitals on quality since 2015. However, PSI90 may be associated with adverse prioritization for preventing some conditions over others.Our objective was to evaluate the time-dependent rates of HACs between 2013 and 2016 to assess the association of funding models on adverse events, particularly pressure injury. METHODS We analyzed a retrospective observational cohort of patients hospitalized in US Academic Medical Centers observed by the Vizient CDB/RM pre-post PSI90 implementation. Changes in HAC component rates of PSI90 between 2013 and 2016 were measured longitudinally using mixed-effects negative binomial regression modeling. RESULTS Regardless of whether the composite measure of patient outcomes was PSI90 or all HACs, in general, there was significant decrease after PSI90 was implemented, reflecting an association between PSI90 and CMS reimbursement policy. However, pressure injury rates increased by 29.4% (SE = 0.08; P < 0.05) during this time frame, the only HAC observed to increase related to PSI90. CONCLUSIONS Patient safety in hospitals will only thoroughly improve when hospitals are fully incentivized to practice prevention of all HACs rather than work around the harms that result from failed prevention efforts.

Catherine Milne and colleagues present the findings of their review, ccna2@juno.com

An optimal position of the patient during operation may require a compromise between the best position for surgical access and the position a patient and his or her tissues can tolerate without sustaining injury. This scoping review analysed the existing, contemporary evidence regarding surgical positioning-related tissue damage risks, from both biomechanical and clinical perspectives, focusing on the challenges in preventing tissue damage in the constraining operating room environment, which does not allow repositioning and limits the use of dynamic or thick and soft support surfaces. Deep and multidisciplinary aetiological understanding is required for effective prevention of intraoperatively acquired tissue damage, primarily including pressure ulcers (injuries) and neural injuries. Lack of such understanding typically leads to misconceptions and increased risk to patients. This article therefore provides a comprehensive aetiological description concerning the types of potential tissue damage, vulnerable anatomical locations, the risk factors specific to the operative setting (eg, the effects of anaesthetics and instruments), the complex interactions between the tissue damage risk and the pathophysiology of the surgery itself (eg, the inflammatory response to the surgical incisions), risk assessments for surgical patients and their limitations, and available (including emerging) technologies for positioning. The present multidisciplinary and integrated approach, which holistically joins the bioengineering and clinical perspectives, is unique to this work and has not been taken before. Close collaboration between bioengineers and clinicians, such as demonstrated here, is required to revisit the design of operating tables, support surfaces for surgery, surgical instruments for patient stabilisation, and for surgical access. Each type of equipment and its combined use should be evaluated and improved where needed with regard to the two major threats to tissue health in the operative setting: pressure ulcers and neural damage.

Deep tissue injury (DTI) can be difficult to diagnose because many other skin and wound problems can appear as purple skin or rapidly appearing eschar. The diagnosis of DTI begins with a thorough history to account for times of exposure to pressure, such as ‘time down’ at the scene or time during which the patient was flat and could not respond. Patients with light skin tones present with classic skin discolouration of purple or maroon tissue, a defined border around the area of injury, and often surrounding erythema is evident. Persistent erythema and hyperpigmentation, rather than blanching, should be used to determine pressure injury in dark skin tone patients. Differential diagnosis includes stage 2 pressure ulcers, incontinence‐associated dermatitis, skin tears, bruising, haematoma, venous engorgement, arterial insufficiency, necrotising fasciitis and terminal skin ulcers. Many skin problems can also have a purple hue or rapidly developing eschar, and a working knowledge of dermatology is needed.

Pressure ulcers occur with some frequency in the elderly, debilitated population in long-term–care facilities. Pressure ulcers cause morbidity and mortality and, by virtue of breaking the integumentary barrier, predispose to skin and soft-tissue infections. The latter often are deep and require lengthy medical and surgical therapy. Prevention depends on avoidance of pressure, as well as providing adequate nutrition and meticulous skin care.