BDH-Klinik Elzach gGmbH

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Quality results

Treatment sector: Pressure ulcer (decubitus): prevention through nursing measures (DEK)

Information about this treatment area (documentation)

Designation	Pflege: Dekubitusprophylaxe
Shortcut	DEK
Number of cases	143
Documentation rate	100 %

Summary result:

In 2 of 2 quality characteristics, the quality objective was achieved.
No assessment is possible for any quality characteristic

Number of patients treated: 143

Quality objective achieved
Quality objective not achieved

The results in detail

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Quality criterion

Hospital result
and target area

Quality objective
achieved?

All information

Ratio of the actual number to the previously expected number of patients suffering from a pressure sore (decubitus) during hospitalisation (patients in whom pressure caused a reddening of the skin that could not be pushed away but the skin was still intact (degree of decubitus/ category 1) were not considered - individual risks of the patients were taken into account)

National result: 1,05
Hospital: 1,46

Target area: at most 2,32

Quality objective achieved

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Patients in whom a pressure sore (decubitus) developed in at least one place during their stay in hospital: The pressure sore reached down to the muscles, bones or joints and resulted in the mortification of muscles, bones or supporting structures (e.g. tendons or joint capsules) (decubitus grade/ category 4)

National result: 0,00 %
Hospital: Data protection

No information due to data protection

Sentinel Event

Quality objective achieved
Why?

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National result: 0,06 %
Hospital: Data protection

No information due to data protection

Evaluation is not available

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National result: 0,33 %
Hospital: 2,10 %

Evaluation is not available

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Code ID	52009
Result	1,46
Evaluation through structured dialogue	The result is in the target area - the quality target is therefore considered to have been fully achieved. (R10)
Population	1047
Events observed	28
Anticipated events	19,12
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	unverändert
National result	1,05
Target range (reference range)	<= 2,32 (95. Perzentil)
Confidence interval nationwide	1,04 - 1,06
Hospital confidence interval	1,02 - 2,10
Reference infection	No
Type of value	QI
Relation to the procedure	QSKH
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG

Code ID	52010
Result (%)	Data protection
Evaluation through structured dialogue	Although the result is not in the target area, the quality target is still considered to be achieved, since the deviation can be traced back to isolated documentation problems after examination by specialist committees. There are no indications of defects (U33)
Population	Data protection
Events observed	Data protection
Anticipated events	Data protection
Result trend compared with the previous reporting year	eingeschränkt/nicht vergleichbar
Comparison with the previous reporting year	unverändert
National result (%)	0,00
Target range (reference range)	Sentinel Event
Confidence interval nationwide (%)	0,00 - 0,00
Hospital confidence interval (%)	0,00 - 0,00
Reference infection	No
Type of value	QI
Relation to the procedure	QSKH
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG It should be noted that this computational result may not be influenced exclusively by the respective institution. So e.g. the disease severity or concomitant diseases of the patients have an influence on the result. The reference range indicates the range in which the results of an indicator are assessed as normal. A facility with a result outside the reference range is initially computationally conspicuous, which usually results in an analysis in the structured dialog. It should be noted that an indicator result outside the reference range is not synonymous with a poor quality of the facility in the quality aspect considered here. The deviation can also e.g. be traceable to incorrect documentation or to individual cases. Quality is assessed in the context of the structured dialogue with the institutions.

Code ID	521801
Result (%)	Data protection
Evaluation through structured dialogue
Population	Data protection
Events observed	Data protection
Anticipated events	Data protection
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	0,06
Target range (reference range)
Confidence interval nationwide (%)	0,06 - 0,06
Hospital confidence interval (%)	0,00 - 0,00
Reference infection	No
Type of value	TKez
Relation to the procedure	QSKH
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG

Code ID	52326
Result (%)	2,10
Evaluation through structured dialogue
Population	1047
Events observed	22
Anticipated events	0,00
Result trend compared with the previous reporting year
Comparison with the previous reporting year
National result (%)	0,33
Target range (reference range)
Confidence interval nationwide (%)	0,33 - 0,33
Hospital confidence interval (%)	1,39 - 3,16
Reference infection	No
Type of value	TKez
Relation to the procedure	QSKH
Reference to other QA results
Sorting
Risk-adjusted rate
Comments/explanations by the competent authority at national or state level
Comments/explanations by the hospital
Specialist note IQTIG