OBJECTIVE:This study aimed to evaluate the location-specific and time-sensitive trajectories of pressure injuries (PrIs) stages using real-world electronic health record (EHR) datasets. APPROACH:Using a dataset of 29,475 patients with records of PrIs documented from 2015 to 2023, we developed four PrI patient sub-cohorts with common PrI locations, including coccyx, buttocks, sacrum and heel. We estimated transition intensities between three PrI states: stage 1, stage 2, and a severe stage in each group. Stages and transition paths were derived from domain knowledge provided by clinical experts and The National PrI Advisory Panel (NPIAP) guidelines. RESULTS:The trajectory analysis suggested that stage 2 serves as a "gateway state" in all four locations, meaning that once a PrI reaches stage 2, the likelihood of transiting to severe stages increases significantly. The commonly used Braden Scale and its sub-components are more likely to be associated with transitions from stage 2 to severe stages, suggesting that manual risk assessment tools are suboptimal for predicting early-stage PrI transitions. Further, we observed race-dependent variations across injury location groups. INNOVATION:To our knowledge, this is the first study to introduce multi-state trajectory analysis in PrI research. Our model can investigate PrI status in a dynamic manner, which fills an important gap in the field. CONCLUSION:Our findings underscore the lack of time-sensitive information in existing PrI risk assessment tools, revealing a critical gap in their ability to capture the dynamic nature of PrI progression. Clinical decision support using time sensitive data is needed for delivering personalized, timely, and effective PrI prevention.
Introduction:Family engagement is a cornerstone of neonatal care. Few multisite quality improvement efforts using robust quality metrics focused on family engagement have occurred in the neonatal intensive care unit (NICU) setting. We aimed to increase the following measures of NICU family engagement by 20% or more of baseline within 2 years without disparities by maternal race/ethnicity or preferred language in Massachusetts NICUs: (1) multidisciplinary family meetings within 7 days; (2) social work consultations within 7 days; (3) assessment of families' unmet basic needs; (4) any mother's milk at discharge; (5) more than 50% participation in skin-to-skin care; and (6) training in discharge skills 48 hours or more before discharge. Methods:We used an Institute for Healthcare Improvement Breakthrough Series framework of multisite quality improvement, which included collaborative, large-scale meetings and training interspersed with local quality work. From January 2021 to December 2022, we collected data on 459 infants admitted for 14 days or more. We examined family engagement measure rates quarterly using run charts and compared overall rates by maternal race/ethnicity and preferred language using χ2 tests. We performed pilot data collection on parent-reported measures. Results:Forty-seven plan-do-study-act cycles were conducted. We found increases in training on discharge skills (from 57% to 90%) and in the assessment of unmet basic needs (from 39% to 96%). Many drivers occurred more often among infants with non-White and non-English-speaking mothers. Conclusions:Massachusetts NICUs implemented multiple interventions to increase family engagement. Our development and testing of chart-abstracted and family-reported measures of family engagement across a wide variety of topics may be generalizable to other NICUs working in this area.
