Evidence map›Paper›PMID 41265921›Full record

ArticleBMJ open quality2025

Implementation of a unit-specific quality improvement process for prevention of hospital-acquired pressure injuries.

Beth K Kern

Abstract read
In one paragraph

Article in BMJ open quality, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.

0numbers the graph read from it
0cells of the map it votes in
0citing papers in PubMed
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

0 citing papers in PubMed.

No citing paper in PubMed yet.

4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

1 author.

Beth K KernQuality, Regional Hospital of Scranton, Easton, Pennsylvania, USA Bethkkern@verizon.net.ORCID 0009-0009-8312-0406

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

Hospital-acquired pressure injuries (HAPIs) occur in 3%-34% of patients admitted to hospitals worldwide. Early intervention of an HAPI prevention process can help prevent or reduce HAPIs. The aim of this study was to develop a hospital unit-specific quality improvement process (QIP) focused on sacral HAPI prevention. A sudden increase in sacral HAPIs within an acute care intensive care unit (ICU) during 2022 at a 308-bed acute care hospital prompted concern with current practices in patient turning and repositioning. Within a Plan-Do-Check-Act format QIP in an adult ICU-specific QIP, the following areas were addressed (1) assessment planning using staff surveys, fishbone diagram, run chart data collection and failure mode effect analysis, (2) do processes with staff education, product utilisation that included glide sheets, 30° offloading wedges and drypads, and flow revamp, (3) ongoing data review through run chart interpretation and (4) acting within the multidisciplinary team to hold the gain. Following initial implementation of the 30° offloading wedges during January 2023, the rate of sacral HAPIs decreased from 18 to 4.6 per 1000 patient days per month. During a 3-month period that included full implementation of an ICU-specific QIP and use of glide sheets, 30° offloading wedges and drypads, the total number of sacral HAPIs decreased to one. Overall, the mean rate of sacral HAPIs per 1000 patient days per month decreased from 4.49±5.31 during 2022 to 2.30±2.21 during 2023, representing an approximate decrease of 50%. The total number of sacral HAPIs decreased from 24 in 2022 to nine in 2023. The improvement has been sustained with one HAPI noted for 2024 and zero HAPIs for 2025 through April. The implementation of an ICU-specific QIP and combined use of friction-reducing glide sheets, 30° offloading wedges and full body drypads was successful at decreasing the sacral HAPIs.

Indexed as

Iatrogenic DiseasePressure UlcerQuality ImprovementHumansIntensive Care UnitsEvidence-Based PracticePDSAPressure UlcerQuality improvementSafety culture

Identifiers

PMID41265921
PMCPMC12636874

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Registered trials

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.