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Building information for systematic improvement of the prevention of hospital-acquired pressure ulcers with statistical process control charts and regression
  1. William V Padula1,
  2. Manish K Mishra2,
  3. Christopher D Weaver3,
  4. Taygan Yilmaz4,
  5. Mark E Splaine5
  1. 1Center for Pharmaceutical Outcomes Research, University of Colorado, Aurora, Colorado, USA
  2. 2Leadership Preventive Medicine Program, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
  3. 3State University of New York Upstate Medical University, School of Medicine, Syracuse, New York, USA
  4. 4Harvard Vanguard Medical Associates, Visual Services Department, Boston, Massachusetts, USA
  5. 5The Dartmouth Institute for Health Policy and Clinical Practice, Center for Leadership and Improvement, Dartmouth College, Hanover, New Hampshire, USA
  1. Correspondence to Mark E Splaine, Center for Leadership & Improvement, The Dartmouth Institute for Health Policy and Clinical Practice, 35 Centerra Parkway, Lebanon, NH, 03766 USA; mark.e.splaine{at}


Objectives To demonstrate complementary results of regression and statistical process control (SPC) chart analyses for hospital-acquired pressure ulcers (HAPUs), and identify possible links between changes and opportunities for improvement between hospital microsystems and macrosystems.

Methods Ordinary least squares and panel data regression of retrospective hospital billing data, and SPC charts of prospective patient records for a US tertiary-care facility (2004–2007). A prospective cohort of hospital inpatients at risk for HAPUs was the study population.

Results There were 337 HAPU incidences hospital wide among 43 844 inpatients. A probit regression model predicted the correlation of age, gender and length of stay on HAPU incidence (pseudo R2=0.096). Panel data analysis determined that for each additional day in the hospital, there was a 0.28% increase in the likelihood of HAPU incidence. A p-chart of HAPU incidence showed a mean incidence rate of 1.17% remaining in statistical control. A t-chart showed the average time between events for the last 25 HAPUs was 13.25 days. There was one 57-day period between two incidences during the observation period. A p-chart addressing Braden scale assessments showed that 40.5% of all patients were risk stratified for HAPUs upon admission.

Conclusion SPC charts complement standard regression analysis. SPC amplifies patient outcomes at the microsystem level and is useful for guiding quality improvement. Macrosystems should monitor effective quality improvement initiatives in microsystems and aid the spread of successful initiatives to other microsystems, followed by system-wide analysis with regression. Although HAPU incidence in this study is below the national mean, there is still room to improve HAPU incidence in this hospital setting since 0% incidence is theoretically achievable. Further assessment of pressure ulcer incidence could illustrate improvement in the quality of care and prevent HAPUs.

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  • Competing interests None.

  • Ethics approval Ethics approval was provided by Dartmouth College Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement All data utilised for the analyses are available by request, providing compliance with HIPAA regulations. Patient charts and billing data are stored on a secured computer in MS Excel. SPC chart analyses are stored in Excel, and coding and logs of regression analyses are stored in Stata data files.