Worsened Pressure Ulcer in Long-Term Care
Lower is better. It means that a lower percentage of residents had a stage 2 to 4 pressure ulcer that worsened.
This indicator examines the percentage of residents whose stage 2 to 4 pressure ulcer had worsened since the previous assessment. It is calculated by dividing the number of residents whose stage 2 to 4 pressure ulcer worsened by the number of all residents with valid assessments (excluding those who had a stage 4 ulcer on their prior assessment) within the applicable time period.
Unit of Analysis: Resident
Residents with valid assessments
Residents who have a pressure ulcer at stage 2 to 4 on their target assessment and for whom the stage of pressure ulcer is greater on their target assessment than on their prior assessment
Data
The CCRS eReports provide authorized users with secure and timely access to key clinical administrative information from the Continuing Care Reporting System (CCRS). The reports are available to organizations submitting data to CCRS, their health authorities and ministries of health, and are updated on a quarterly basis. The Integrated interRAI Reporting System Long-Term Care (IRRS LTC) Secure Reporting tool aggregates pan-Canadian long-term care data from LTC homes. Authorized users can explore organization-level data, compare results with peers within and across jurisdictions and see trends over time.
Methodology
Name
Worsened Pressure Ulcer in Long-Term Care
Short/Other Names
Percentage of Residents Whose Stage 2 to 4 Pressure Ulcer Worsened (PRU06)
Description
This indicator looks at the number of long-term care residents whose stage 2 to 4 pressure ulcer had worsened since the previous assessment. Pressure ulcers can happen when a resident sits or lies in the same position for a long period of time. Immobility may be due to many physical and psychological factors, neurological diseases like Alzheimer's and improper nutrition or hydration. Careful monitoring is required to ensure good quality of care.
Rationale
Long-term care quality indicators were developed by interRAI, an international research network, to provide organizations with measures of quality across key domains, including physical and cognitive function, safety and quality of life. Each indicator is adjusted for resident characteristics that are related to the outcome and independent of quality of care. The indicators can be used by quality leaders to drive continuous improvement efforts. They are also used to communicate with key stakeholders through report cards and accountability agreements.
Interpretation
Lower is better. It means that a lower percentage of residents had a stage 2 to 4 pressure ulcer that worsened.
HSP Framework Dimension
Health system outputs: Safe
Areas of Need
Living With Illness, Disability or Reduced Function
Targets/Benchmarks
CIHI: None
Health Quality Ontario (external): 1% for long-term care
Available Data Years
to (fiscal years)
Geographic Coverage
- Newfoundland and Labrador
- New Brunswick
- Nova Scotia
- Ontario
- Manitoba
- Saskatchewan
- Alberta
- British Columbia
- Yukon
Reporting Level/Disaggregation
- Province/Territory
- Region
- Facility
- Corporation
- Sector (residential and hospital-based continuing care)
Indicator Results
Web Tool:
Your Health System: In Depth
PDF:
Accessing Indicator Results on Your Health System: In Depth (PDF)
Web Tool:
Quick Stats
Web Tool:
CCRS eReports (RAI-MDS 2.0) via My Services (log in)
Web Tool:
IRRS LTC Secure Reporting tool via My Services (log in)
Update Frequency
Monthly (IRRS LTC Secure Reporting tool)
Quarterly (CCRS eReports)
Annually (Quick Stats)
Annually (Your Health System)
The Latest Results update date refers to the latest results publicly available. More recent results are available in the secure reporting tools (CCRS eReports and IRRS – LTC Secure Reporting).
Latest Results Update Date
Updates
Not applicable
Description
This indicator examines the percentage of residents whose stage 2 to 4 pressure ulcer had worsened since the previous assessment. It is calculated by dividing the number of residents whose stage 2 to 4 pressure ulcer worsened by the number of all residents with valid assessments (excluding those who had a stage 4 ulcer on their prior assessment) within the applicable time period.
Unit of Analysis: Resident
Type of Measurement
Percentage or proportion
Denominator
Description:
Residents with valid assessments
Inclusions:
- Residents with valid assessments. To be considered valid, the target assessment must
- Be the latest assessment in the quarter
- Be carried out more than 92 days after the Admission Date
- Not be an Admission Full Assessment (RAI-MDS 2.0) or First Assessment (interRAI LTCF)
As this is an incidence indicator, the resident must also have had an assessment in the previous quarter, with 45 to 165 days between the target and prior assessments. If multiple assessments in the previous quarter meet the time period criteria, the latest assessment is selected as the prior assessment.
Exclusions:
- Residents who had a stage 4 ulcer (RAI-MDS 2.0: M2a = 4; interRAI LTCF: L1 = 4, 5) on their prior assessment (cannot get worse)
Numerator
Description:
Residents who have a pressure ulcer at stage 2 to 4 on their target assessment and for whom the stage of pressure ulcer is greater on their target assessment than on their prior assessment
Inclusions:
- Residents with a stage 2 to 4 pressure ulcer (RAI-MDS 2.0: M2a = 2, 3 or 4; interRAI LTCF: L1 = 2, 3 , 4 or 5)
- Residents with valid assessments. To be considered valid, the target assessment must
- Be the latest assessment in the quarter
- Be carried out more than 92 days after the Admission Date
- Not be an Admission Full Assessment (RAI-MDS 2.0) or First Assessment (interRAI LTCF)
As this is an incidence indicator, the resident must also have had an assessment in the previous quarter, with 45 to 165 days between the target and prior assessments. If multiple assessments in the previous quarter meet the time period criteria, the latest assessment is selected as the prior assessment.
Exclusions:
- Residents who had a stage 4 ulcer (RAI-MDS 2.0: M2a = 4; interRAI LTCF: L1 = 4, 5) on their prior assessment (cannot get worse)
Method of Adjustment
Stratification, direct standardization, indirect standardization
Standard Population:
3,000 facilities in 6 U.S. states and 92 residential care facilities and continuing care hospitals in Ontario and Nova Scotia
Adjustment Applied
Covariates used in risk adjustment:
Individual covariates: Resource Utilization Group (RUG); late loss of activities of daily living (ADLs); age younger than 65
Facility-level stratification: Case Mix Index (CMI)
Geographic Assignment
Place of service
Data Sources
Caveats and Limitations
This measure uses data collected by long-term care facilities using the Resident Assessment Instrument–Minimum Data Set 2.0 (RAI-MDS 2.0) and submitted to the Continuing Care Reporting System (CCRS) or using the interRAI Long-Term Care Facilities (interRAI LTCF) assessment and submitted to the Integrated interRAI Reporting System (IRRS).
Certain provinces and territories have transitioned to or are in the process of transitioning to the newer interRAI LTCF assessment instrument (see Trending Issues for more information). For a number of years, the national average will be based on both assessment instruments. To support inclusion of interRAI LTCF assessment data in public reporting, CIHI has completed an analysis to understand similarities and differences between the 2 assessment instruments. Overall, indicator results are comparable and appropriate to be trended over time and across instruments. Performance allocations and top results for 3 indicators (Restraint Use, Worsened Pressure Ulcers and Worsened Depressive Mood) are currently not provided for jurisdictions that are using the interRAI LTCF. Preliminary analysis suggests that there may be differences between results for these indicators based on the assessment instrument used, which may affect performance allocations. More data is required to draw firm conclusions, as these differences may also be related to other factors (e.g., improvements in education and coding practices) or to a real change in the measure of quality.
Trending Issues
The number of long-term care homes and jurisdictions submitting data to CIHI varies over time and has been generally increasing. Furthermore, as long-term care homes transition from the RAI-MDS 2.0 to the interRAI LTCF, there may be changes in data coverage that can impact the results (see more details below). Time series changes must be interpreted carefully, particularly when comparing the national average over time and when comparing provincial/territorial averages over the transition to the new assessment instrument. Please note that indicator results are risk-adjusted to control for population differences (factors that are beyond the facility’s control but can affect resident outcomes) to enable more appropriate and fair comparisons of the actual quality of care. Please refer to the CCRS Quality Indicators Risk Adjustment Methodology in the References section for more information.
Use of interRAI LTCF: As jurisdictions transition to/adopt the interRAI LTCF, there may be disruptions or delays in data submission to CIHI, which can impact the coverage of data and therefore indicator results. A summary of interRAI LTCF transition/adoption by jurisdiction is provided below for reference:
- Nova Scotia completed the transition in 2022 and started submitting data to IRRS in 2022. This is the first year that Nova Scotia’s results based on IRRS data are included in public reporting.
- New Brunswick completed adoption between 2016 and 2017 and started submitting data to IRRS in 2019.
- Saskatchewan completed the transition in 2019 and 2020 and started submitting data to IRRS in 2020.
- Alberta started the transition in 2021; the transition is ongoing. Currently, only data from the RAI-MDS 2.0 (CCRS) is submitted to CIHI and included in reporting.
CIHI recognizes that the COVID-19 pandemic has affected many long-term care homes across Canada, including their ability to complete assessments and/or submit data to CIHI. Available data may vary by jurisdiction and facility. Results should be interpreted in the context of the COVID-19 pandemic.
References
Canadian Institute for Health Information. CCRS Quality Indicators Risk Adjustment Methodology (PDF). 2013.
Health Quality Ontario. Long-Term Care Benchmarking Resource Guide (PDF). 2013.
Health Quality Ontario. Results From Health Quality Ontario's Benchmark Setting for Long-Term Care Indicators (PDF). 2017.
Health Quality Ontario. Health Quality Ontario Indicator Library. Accessed October 4, 2017.
Hirdes JP, Mitchell L, Maxwell CJ, White N. Beyond the "iron lungs of gerontology": Using evidence to shape the future of nursing homes in Canada. Canadian Journal on Aging. 2011.
Hirdes JP, Poss JW, Caldarelli H, et al. An evaluation of data quality in Canada's Continuing Care Reporting System (CCRS): Secondary analyses of Ontario data submitted between 1996 and 2011. BMC Medical Informatics and Decision Making. 2013.
Jones RN, Hirdes JP, Poss JW, et al. Adjustment of nursing home quality indicators. BMC Health Services Research. 2010.
How to cite:
Canadian Institute for Health Information. Worsened Pressure Ulcer in Long-Term Care. Accessed April 25, 2025.
If you would like CIHI information in a different format, visit our Accessibility page.
Comments
The long-term care quality indicators use 4 rolling quarters of data for calculations in order to have a sufficient number of assessments for risk adjustment. Since residents are assessed on a quarterly basis, each resident can contribute to the indicator up to 4 times.
General criteria for public reporting of long-term care indictors in Your Health System are as follows:
Data for this indicator is also available in the Quick Stats product Profile of Residents in Residential and Hospital-Based Continuing Care, which includes province-/territory-level results for both the residential and hospital-based continuing care sectors. Please consult the Quick Stats product for more information.