Comparative effectiveness of quality improvement interventions for pressure ulcer prevention in U.S. academic hospitals

Objective: To compare the effectiveness of quality improvement (QI) interventions for hospital-acquired pressure ulcer (HAPU) prevention among U.S. academic medical centers of the University HealthSystem Consortium (UHC).;Methods: We surveyed UHC hospitals to longitudinally characterize adoption patterns of QI interventions for HAPU prevention between 2007-2008 in response to CMS nonpayment policy for HAPUs. Characterization was based on the QI best-practice framework for QI strategy which includes 25 QI interventions organized into four domains: Leadership; Staff; Information Technology; and Performance & Improvement. Survey data was merged to quarterly hospital-level HAPU incidence rates to measure the effect of each QI intervention at reducing HAPU incidence. Utilizing an effect size analysis, we calculated derivatives of overall HAPU reduction for each QI intervention. A t-test compared marginal effect size in the first three quarters following adoption to remaining periods of adoption for each hospital. An analysis of covariance (ANCOVA) tested the correlation between of QI interventions and HAPU incidence variability while controlling for Medicare policy, age, gender, length-of-stay, case-mix index, and intensive-care unit (ICU) admission.;Results: A representative sample of fifty-five UHC hospitals responded to the survey, of which 53 (96%) indicated use of QI interventions in HAPU prevention. All QI interventions fit within the QI best-practice framework, thereby validating its structure. The effect size analysis identified five QI interventions with clinically meaningful effectiveness by reducing HAPU incidence greater than 1 case per 1,000 patient admissions between 2007-2012, including: Leadership Initiatives; Visual Tools; HAPU Staging; Skin Care; and Patient Nutrition. The t-test returned that the greatest reductions in HAPU incidence occur earlier in the adoption process (p<0.05). The ANCOVA model found that Medicare policy and ICU admission are the primary indicators of variability in HAPU incidence.;Conclusion: The effect size analysis identified five QI interventions that have a meaningful effect on HAPU prevention in UHC hospitals. These QI interventions can be used in support of an evidence-based protocol for HAPU prevention. Many hospitals that began implementing QI interventions in response to CMS nonpayment policy experienced significant reductions in HAPU incidence immediately following initiation.