Wound, ostomy, and continence (WOC) nurses have long been advocates for pressure injury prevention. Some days (most days!) we feel like our voices are falling on deaf ears from nursing and hospital administration. We commiserate with colleagues at local meetings and national conferences, wondering why we cannot seem to make any headway in keeping our patients free from the development of hospital-acquired pressure injuries (HAPIs).

Some of the more seasoned members of our specialty recall celebrating the hope that our voices would finally be heard by hospital administration after the Centers for Medicare & Medicaid Services (CMS) implemented the Hospital Acquired Conditions Initiative (HACI) in 2008, including all stages of pressure injuries.1 Finally, there was a tangible, financial incentive for hospitals to prevent pressure injuries. Throughout the Five Million Lives Campaign in 2006-2008, the Institute for Healthcare Improvement also targeted pressure injuries, offering a How-to-Guide: Prevent Pressure Ulcers. The introduction of the Pressure Ulcer Prevention and Treatment Guidelines published by the United States and European National Pressure Ulcer Advisory Panels and the Pan-Pacific Pressure Injury Alliance in 2009 provided evidence-based recommendations to support our efforts. The CMS Partnership for Patients Initiative provided funding in 2011 for 17 Hospital Engagement Networks (HEN) to identify and disseminate best practices for several hospital-acquired conditions, including pressure injuries. As the colead for the Ascension Health HEN Pressure Ulcer Prevention Team, I witnessed firsthand how strong hospital leadership support could achieve clinical improvements within the hospital where I was working at that time. We seemed to finally be on track with protecting our patients!

Subsequent CMS programs including the Hospital Value-Based Purchasing (HVBP) program (2012) and Hospital-Acquired Conditions Reduction Program (HACRP) (2014) were designed to include additional financial incentives for preventing pressure injuries and other hospital-acquired conditions.1 Both programs include financial penalties based on hospital performance in multiple categories, including stage 3, 4, and unstageable pressure injuries.1 So, are these programs working as intended?

An analysis of data from the Hill-Rom International Pressure Injury Prevalence Survey demonstrated a significant reduction in overall pressure injuries since 2008, but the rates plateaued from 2015 to 2019.2 VanGilder and colleagues2 suggest that the initial declines were likely attributed to the CMS initiative and the new international guidelines. A 2020 report from the Agency for Healthcare Research and Quality (AHRQ) noted, that between 2014 and 2017, national efforts to reduce hospital-acquired conditions resulted in decreased rates for nearly all of the conditions measured with the exception of pressure injures, with a 6% increase.3 Why have we not seen continued decline in pressure injury rates?

Questions have also been raised regarding the processes used by hospitals and CMS to collect data and calculate rates for these programs. The HACI, HACRP, and HVBP programs use administrative discharge data generated by hospital coders.1 In comparison, AHRQ issues reports on pressure injury rates based on the Medicare Patient Safety Monitoring System (MPSPS), a standardized chart-based surveillance system. A comparison between data from CMS and AHRQ systems to better understand the limitations of the CMS data collection system revealed that CMS system based on administrative data only captured approximately one-twentieth of the incidence found through the chart-based surveillance.1 Recent comparisons between HAPI cases identified by our Quality Department based on coding and our clinical database maintained by our Wound Care Team yielded similar large discrepancies. Could that explain the perceived lack of administrative support for HAPI prevention?

William Padula, current president of the National Pressure Injury Advisory Panel (NPIAP), and several of his colleagues suggest that hospitals have learned that they can go for the "low-hanging fruit" by focusing on measures involving smaller populations and impacted by simpler prevention guidelines, resulting in improvement on those measures.4,5 For example, catheter-associated urinary tract infections (CAUTIs) involve a much smaller population of patients with indwelling catheters and a few well-established strategies to reduce the risk of infection. In comparison, virtually all patients are at risk for developing pressure injuries and the prevention measures are more diverse and costly to implement. They utilize the term "complexity bias" to describe the process by which "health care organizations overcomplicate the reduction in iatrogenic injuries by breaking them down into many parts that address limited components of the greater problem."4^(p221) Padula and colleagues4,5 recommend that hospitals begin to recognize that many clinical outcomes have overlapping risk factors that could be addressed by a more unified approach. For example, a program designed to improve mobility could impact not only pressure injury development but also measures related to falls, deep vein thrombosis, CAUTIs, sepsis, and readmissions.4,5

Several changes in the CMS payment systems have been proposed, including rewards for good performance rather than penalizing hospitals for poor outcomes, since the penalties may not actually save money overall when considering the ongoing care provided to manage these chronic wounds.4 Additionally, the HAPI measures should be risk-adjusted and differentiate between less severe stage 1 to 2 pressure injuries and more significant stage 3 to 4 and unstageable pressure injuries.1 Given the identified discrepancies between administrative data and clinical data, a surveillance system based on periodic in-person assessment would provide more accurate measures.1 In the interim, WOC nurses need to collect pressure injury incidence data within their facility to demonstrate to administration the true extent of patients impacted. We need to partner with our clinical colleagues addressing other hospital-acquired conditions to demonstrate how a return to the basics (patient assessment, getting patients out of bed and ambulating for toileting needs, regular bathing and perineal cleansing, and assisting patients with meals and snacks to promote a nutritious intake) can achieve the ultimate goal of keeping patients safe and maximizing their functional ability.

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