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41. Module 2: How To Manage Change | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/slides2.html
    October 01, 2017 - (Tool 2C) Present the assessment of current pressure injury prevention policies and procedures. … Slide 5: Expected Outcomes Begin to write a draft Pressure Injury Prevention Action Plan, tailored … Members who influence the areas involved in pressure injury prevention. … Slide 12: Collaboration Pressure Injury Implementation Team. Wound Care Team. … Wound Care Team: Interdisciplinary group of experts who provide day-to-day care of skin and wound needs

42. Final Progress Report: Reducing the Risk of Preventable Postpartum Lower Extremity Nerve Injuries (pdf file)
    www.ahrq.gov/sites/default/files/2025-03/toledo-report.pdf
    January 01, 2025 - included in the final model were parity, macrosomia, diabetes, percentage change in mean arterial pressure … The median percentage change in mean arterial pressure (MAP)was larger in patients who experienced nerve … (MAP) relative to baseline blood pressure, the total amount of anesthetic medications used, and whether … The median percentage change in mean arterial pressure was larger in patients who experienced nerve … Larger decreases in blood pressure may cause an increased incidence of nerve injury due to decreased

43. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4a_combo_psi03-pressureulcer-bestpractices.pdf
    January 01, 2012 - o Wound edges. … - terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure- injury/ Staff … Washington, DC: National Pressure Ulcer 5 Tool D.4a http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury … / http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury … / http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury

44. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4p_combo_pdi02-pressureulcer-bestpractices.pdf
    January 01, 2012 - hospital mattress.7,8-11 o Consider the use of foam overlay to reduce occipital pressures in children … /national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in- terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure … / http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury … / http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury … Medical device related pressure ulcers in hospitalised patients. Int Wound J 2010;7:358-65. 7.

45. Selected Best Practices and Suggestions for Improvement (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4b_pdi02-pressureulcer-bestpractices.pdf
    January 01, 2012 - hospital mattress.7,8-11 o Consider the use of foam overlay to reduce occipital pressures in children … /national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in- terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure … / http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury … / http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury … Medical device related pressure ulcers in hospitalised patients. Int Wound J 2010;7:358-65. 7.

46. Data Submission Dashboard (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/Pressure_Ulcer_Dashboard_Data_2024.xlsx
    January 01, 2024 - Documented within 24 hours of admission 0.9% 35 Stage/Category IV Unknown * * Suspected Deep Tissue Injury … Documented within 24 hours of admission 71.0% 2,897 Suspected Deep Tissue Injury No risk assessment … documented * * Suspected Deep Tissue Injury Not on admission, but documented after discovery or advancement … of pressure ulcer 78.6% 11 Suspected Deep Tissue Injury Not on admission, but documented before discovery … or advancement of pressure ulcer * * Suspected Deep Tissue Injury Unknown 69.4% 1,111 Unstageable

47. Low Tidal Volume Ventilation: Introduction, Evidence, and Implementation: Slide Presentation | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mvp/modules/technical/ltvv-intro-slides.html
    February 01, 2025 - Pressure limited. … Slide 22: LTVV in ARDS Large V t and the high pressures it generates were harmful 3,4 LTVV became the … to measure transpulmonary pressures clinically). … Trauma. Noncardiogenic shock. Multiple transfusions. Cardiopulmonary bypass. … Trauma. Pancreatitis. Post-circulatory arrest. Multiple transfusions. Severe burns.

48. Fallpxtool3O (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool3o.docx
    January 01, 2008 - A separate tool (Tool 3N, ‘Postfall Assessment, Clinical Review) covers how to assess and follow injury … requires ice, dressing, cleaning of wound, elevating of limb, or medication) __Moderate (requires suturing … Describe injuries; check all that apply Injury Yes No Site of Injury Abrasion/bruise/laceration … Orthostatic blood pressure Blood Pressure (mm Hg) Heart Rate (beats per minute) Systolic blood pressure … blood pressure (standing) Need for orthostatic Systolic blood pressure (sitting)* Heart rate

49. Data Submission Dashboard (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/Pressure_Ulcer_Dashboard_Data_2023.xlsx
    January 01, 2023 - admission Stage/Category IV 1.0% 33 4,835 Documented within 24 hours of admission Suspected Deep Tissue Injury … assessment documented Stage/Category IV 0.0% 0 4,835 No risk assessment documented Suspected Deep Tissue Injury … ulcer Suspected Deep Tissue Injury 65.8% 25 4,835 Not on admission, but documented after discovery … admission, but documented before discovery or advancement of pressure ulcer Suspected Deep Tissue Injury … Category III 9.7% 134 4,835 Unknown Stage/Category IV 2.3% 32 4,835 Unknown Suspected Deep Tissue Injury

50. Data Submission Dashboard (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/Pressure_Ulcer_Dashboard_Data_2022.xlsx
    January 01, 2022 - admission Stage/Category IV 1.0% 32 4,585 Documented within 24 hours of admission Suspected Deep Tissue Injury … assessment documented Stage/Category IV 0.0% 0 4,585 No risk assessment documented Suspected Deep Tissue Injury … ulcer Suspected Deep Tissue Injury 67.6% 25 4,585 Not on admission, but documented after discovery … Injury 71.0% 22 4,585 Not on admission, but documented before discovery or advancement of pressure … Category III 9.7% 133 4,585 Unknown Stage/Category IV 2.3% 31 4,585 Unknown Suspected Deep Tissue Injury

51. Data Submission Dashboard (xls file)
    www.ahrq.gov/sites/default/files/wysiwyg/npsd/Pressure_Ulcer_Dashboard_Data_2021.xlsx
    January 01, 2021 - admission Stage/Category IV 1.3% 25 3,026 Documented within 24 hours of admission Suspected Deep Tissue Injury … assessment documented Stage/Category IV 0.0% 0 3,026 No risk assessment documented Suspected Deep Tissue Injury … ulcer Suspected Deep Tissue Injury 67.9% 19 3,026 Not on admission, but documented after discovery … Injury 66.7% 14 3,026 Not on admission, but documented before discovery or advancement of pressure … /Category III 9.2% 91 3,026 Unknown Stage/Category IV 2.6% 26 3,026 Unknown Suspected Deep Tissue Injury

52. Impact of AHRQ’s Patient Safety Tools: Challenge Competition | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/about/challenge-competition.html
    February 01, 2024 - Toolkit for Improving Quality of Care to decrease Patient Safety Indicator 03 (PSI-03) (reportable pressure … injuries) by 92% and save an estimated $350,000 in avoidable costs. … Implementation focused on MU Health Care’s 390-bed University Hospital, the only level I trauma center … injury rates and PSI-03 among Vizient peers to the top decile over the course of 2 years. … Injuries by 92%."

53. Pressure Ulcer Prevention Toolkit (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module3/putoolkit_module3_tools.docx
    August 31, 2017 - Pressure Ulcer Prevention Toolkit Pressure Ulcer Prevention Toolkit Module 3 Tools 3A: Pressure Ulcer … If a skin disruption is found, the type of skin injury will need to be identified. … Since there are many different etiologies of skin wounds and ulcers, differential diagnosis of the skin … For example is it a skin tear, a pressure ulcer, or moisture-associated skin damage or injury? … A wound/ostomy nurse consult revealed he has a slightly pink coccyx area (base of spinal column).

54. Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/studies/index.html?page=164
    January 01, 2024 - year following the index self-injury. … Keywords: Trauma, Injuries and Wounds, Electronic Health Records (EHRs), Health Information Technology … Injuries and Wounds Ogletree AM , Mangrum R , Harris Y AHRQ Author: Bergofsky L Perfetto … paper, that demonstrates the value of applying engineering practices for prioritizing solutions for pressures … Keywords: Children/Adolescents, Racial and Ethnic Minorities, Emergency Department, Pain, Injuries and

55. Tool 3O: Postfall Assessment for Root Cause Analysis | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/root-cause.html
    January 01, 2013 - A separate tool ( Tool 3N, Postfall Assessment, Clinical Review ) covers how to assess and follow injury … pain; requires ice, dressing, cleaning of wound, elevating of limb, or medication) ___ Moderate (requires … Describe injuries; check all that apply Injury Yes No Site of Injury Abrasion … Orthostatic blood pressure Blood Pressure (mm Hg) Heart Rate (beats per minute) Systolic … blood pressure (supine)   Heart rate (supine) Can't obtain Refused Diastolic blood pressure

56. Appendix B. Prioritize Opportunities for Improvement | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/guide/apb.html
    October 01, 2017 - Pressure Injury Prevention Program Implementation Guide Appendix B. … Injury Prevention Program Implementation Guide Overview Get Ready Pressure Injury Prevention Program … Firm up your Implementation Team Leader, Core Team, Pressure Injury Team, and pressure injury champions … They might include ideas such as universal pressure injury precautions, pressure injury risk screening … Alternatively, you might decide to group ideas under the major categories in the pressure injury clinical

57. Pressure Ulcer Prevention Toolkit (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/putoolkit_module5_tools.docx
    August 02, 2017 - Pressure Ulcer Prevention Toolkit Pressure Ulcer Prevention Toolkit Module 5 Tools Action Plan Tool … to Measure Pressure Ulcer Rates and Pressure Ulcer Prevention Practices Tool 5C: Assessing Comprehensive … Assessment Tool 5D: Assessing Standardized Risk Assessment Tool 5E: Assessing Care Planning AHRQ Pressure … stakeholders and staff Root cause analysis is conducted for each fall with at least moderate level of injury … admission nursing assessment, subsequent nursing progress notes, or any notes specifically documenting pressure

58. Presentation: Program Overview
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mvp/ltvv-intro/ltvv-intro-slides.pptx
    January 01, 2017 - cc/kg)1 Additional studies and meta-analysis showed large tidal ventilation and the resulting high pressures … regulated volume controlled (PRVC) Pressure support (PS) Continuous positive airway pressure (CPAP) … #› AHRQ Safety Program for Mechanically Ventilated Patients 21 LTVV in ARDS Large Vt and the high pressures … Emerging Evidence5 Multi-hit theory Priming: initial insult → at risk for ARDS Pneumonia Sepsis Trauma … inhalation Pulmonary contusion Pulmonary vasculitis Sepsis Systemic inflammatory response syndrome Trauma

59. Low Tidal Volume Ventilation: Introduction, Evidence, and Implementation: Facilitator Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/mvp/modules/technical/ltvv-intro-fac-guide.html
    February 01, 2017 - There’s also a cyclical type of trauma that occurs, often called “atelectrauma.” … and adjust the ventilator to try to maintain the plateau pressures below 30 centimeters of water; and … There’s some sort of priming insult, such as pneumonia, sepsis, severe trauma, noncardiogenic shock, … Insults secondary to mechanical ventilation include ventilation-induced lung injuries. … Plateau pressures were significantly lower.

60. Facilitator Guide: Build Your SSI Prevention Bundle (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mvp/ltvv-intro/ltvv-intro-facguide.docx
    January 01, 2017 - There’s also a cyclical type of trauma that occurs, often called “atelectrauma.” … and adjust the ventilator to try to maintain the plateau pressures below 30 centimeters of water; and … There’s some sort of priming insult, such as pneumonia, sepsis, severe trauma, noncardiogenic shock, … Insults secondary to mechanical ventilation include ventilation-induced lung injuries. … Plateau pressures were significantly lower.