Preventing pressure ulcers in Connecticut hospitals by using the plan-do-study-act model of quality improvement

Jt Comm J Qual Saf. 2004 Apr;30(4):205-14. doi: 10.1016/s1549-3741(04)30022-5.

Abstract

Background: Seventeen hospitals and the Peer Review Organization of Connecticut (Qualidigm) attempted to increase early identification of high-risk patients and utilization of pressure ulcer preventive measures.

Methods: A multihospital retrospective cohort study with medical record abstraction was used to obtain a total of 1,955 (baseline) and 891 (follow-up) patients aged 65 years and older discharged after treatment for pneumonia, cerebrovascular disease, or congestive heart failure with a length of stay > or = five days. During a nine-month period, the hospitals conducted four plan-do-study-act improvement cycles and shared their results in conference calls and group meetings.

Results: Statistically significant increases were noted from baseline (1/1/96-12/31/96) to follow-up (10/1/97-3/31/98) in identification of high-risk patients, repositioning of bed-bound or chair-bound patients, nutritional consults in malnourished patients, and staging of acquired Stage II pressure ulcers. Daily skin assessments occurred at a high rate in both periods. There were no statistically significant changes in other processes of care, pressure ulcer incidence, or mortality.

Discussion: Performance of four pressure ulcer prevention processes of care increased concurrently with a multifaceted improvement intervention.

Publication types

  • Comparative Study
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Cohort Studies
  • Connecticut / epidemiology
  • Female
  • Humans
  • Male
  • Multi-Institutional Systems / standards*
  • Outcome and Process Assessment, Health Care
  • Pressure Ulcer / complications
  • Pressure Ulcer / epidemiology
  • Pressure Ulcer / prevention & control*
  • Professional Review Organizations
  • Retrospective Studies
  • Total Quality Management / methods*