Hospital-Acquired Pressure Ulcers

Results From the National Medicare Patient Safety Monitoring System Study

Courtney H. Lyder, ND; Yun Wang, PhD; Mark Metersky, MD; Maureen Curry, MHA; Rebecca Kliman, MPH; Nancy R. Verzier, MSN; David R. Hunt, MD


J Am Geriatr Soc. 2012;60(9):1603-1608. 

In This Article

Abstract and Introduction


Objectives To determine the national and state incidence levels of newly hospital-acquired pressure ulcers (PUs) in Medicare beneficiaries and to describe the clinical and demographic characteristics and outcomes of these individuals.
Design Retrospective secondary analysis of the national Medicare Patient Safety Monitoring System (MPSMS) database.
Setting Medicare-eligible hospitals across the United States and select territories.
Participants Fifty-one thousand eight hundred forty-two randomly selected hospitalized fee-for-service Medicare beneficiaries discharged from the hospital between January 1, 2006, and December 31, 2007.
Measurements Data were abstracted from the MPSMS, which collects information on multiple hospital adverse events.
Results Of the 51,842 individuals in the MPSMS 2006/07 sample, 2,313 (4.5%) developed at least one new PU during their hospitalization. The mortality risk–adjusted odds ratios were 2.81 (95% confidence interval (CI) = 2.44–3.23) for in-hospital mortality, 1.69 (95% CI = 1.61–1.77) for mortality within 30 days after discharge, and 1.33 (95% CI = 1.23–1.45) for readmission within 30 days. The hospital risk–adjusted main length of stay was 4.8 days (95% CI = 4.7–5.0 days) for individuals who did not develop PUs and 11.2 days (95% CI = 10.19–11.4) for those with hospital-acquired PUs (P < .001). The Northeast region and Missouri had the highest incidence rates (4.6% and 5.9%, respectively).
Conclusion Individuals who developed PUs were more likely to die during the hospital stay, have generally longer hospital lengths of stay, and be readmitted within 30 days after discharge.


The development of pressure ulcers (PUs) has been associated with the quality of health care.[1,2] Hence, higher rates of PU development (PUD) may signal overall poor care by the healthcare system. The National Quality Forum (NQF) created hospital Never Events in 2003—events that should never occur during hospitalization.[1] The NQF believes that development of Stage III or IV PUs are such events. In the 13 states that have incorporated Never Events, hospitals can be financially penalized for not reporting individuals who develop Stage III or IV PUs in a timely manner. The federal government has also identified PUD as a public heath concern.[2] Most recently, the Centers for Medicare and Medicaid Services (CMS) made a significant policy decision not to pay for hospital-acquired Stage III and IV PUs.[3]

A major limitation of existing PU studies has been their small sample size (<200 participants). Thus, the ability to compare an individual hospital's incidence rate with national or state level data has been lacking. Clinicians' and policy makers' abilities to determine the effect of specific individual clinical characteristics on the risk of developing hospital-acquired PUs (HAPUs) and the effect of PUs on outcomes (e.g., hospital length of stay and mortality) has also been challenging. Without a good understanding of national and state incidence rates and an understanding of specific clinical characteristics, effective PU prevention in the Medicare population is difficult. There is no large database to help determine incidence of PUs among hospitalized Medicare beneficiaries as a basis for measuring improvement. Neither are there known published Medicare studies that have reported on HAPUs against which hospitals can benchmark at the national or state level. Given the increasing number of Medicare beneficiaries being admitted to hospitals and the concomitant potential for increases in PU incidence, a Medicare Patient Safety Monitoring System (MPSMS) study capitalized on abstracted data from a large sample of medical records of fee-for-service Medicare beneficiaries discharged in 2006/07 to address these gaps in knowledge.[4] The data for this study came from three national databases: the CMS National Claim History database, the CMS Claims History database, and the MPSMS. The purpose was to explore the overall incidence, prevalence, and clinical characteristics associated with Medicare beneficiaries who developed HAPUs and to determine rates in states and geographic regions.