-
www.ahrq.gov/hai/tools/mvp/modules/technical/ltvv-fact-sheet.html
January 01, 2017 - Emerging evidence links protective tidal ventilation to decreased incidence of acute lung injury (ALI … Use at least 5 cm H2O positive end expiratory pressure (PEEP).
Why wait? … not yet have ARDS and particularly those with risk factors to prevent progressive development of lung injury … Ventilator-associated lung injury in patients without acute lung injury at the onset of mechanical ventilation … What tidal volumes should be used in patients without acute lung injury?
-
www.ahrq.gov/patient-safety/settings/hospital/index.html
February 01, 2025 - Preventing Pressure Ulcers in Hospitals is a toolkit that assists hospital staff in implementing effective … pressure ulcer prevention practices through an interdisciplinary approach to care. … Pressure Injury Prevention in Hospitals Training Program supports the training of hospital staff on … how to implement AHRQ's Preventing Pressure Ulcers in Hospitals Toolkit. … injury prevention.
-
www.ahrq.gov/sites/default/files/2024-05/sarcevic-report.pdf
January 01, 2024 - , and (4) patients with external injuries. … 1(0-3) 0(1-3)
Injury 0(0-2) 0(0-1)
External 0.014 0.053 <.001* <.001* 0.92 0.13
No injury 1(0-1.5) … with penetrating injuries and those with a blunt injury. … Of 187 patients, 111 (59.4%)
had external injuries. … without external injuries (p<.001, Table 1).
-
psnet.ahrq.gov/node/49524/psn-pdf
November 01, 2006 - LMA use have been reported.(6) The
most common complications include aspiration and unintended local trauma … with
LMAs and high peak inspiratory pressures, allowing for inspired gases to insufflate the stomach … LMA use can also lead to injuries secondary to high cuff pressure and volume during prolonged
procedures … These increased intra-cuff pressures can cause a significant damage to surrounding tissues. … the pyriform sinus, which is where the recurrent laryngeal nerve enters, rendering it vulnerable to injury
-
effectivehealthcare.ahrq.gov/sites/default/files/related_files/pressure-ulcer-prevention_disposition-comments.pdf
May 08, 2013 - There is no discussion of the spinal cord
injury population. … Include Deep Tissue Injury. … There are dressings used on the heels to reduce
friction injury and the sacrum to reduce shear, pressure … making the side rail ineffective
None of the trials of support surfaces/beds reported risk of
falls/injuries … A pressure ulcer is localized injury to the skin and/or underlying
tissue, usually over a bony prominence
-
psnet.ahrq.gov/web-mm/too-hot-comfort
May 19, 2015 - Commonly used agents that cause severe extravasation injuries include antineoplastic, inotropic, or osmotically … Use to Promote Wound Healing In contrast, the wound healing literature generally supports the use … Treating chronic and acute wounds with warming: review of the science and practice implications. … Local heat increases blood flow and oxygen tension in wounds. Arch Surg. 1987;122:221-225. … March 5, 2025
WebM&M Cases
Under Pressure: Tracheostomy
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/puh-assessment.docx
June 02, 2025 - AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Healing
On-Time Pressure Ulcer Assessment … The On-Time Pressure Ulcer Assessment incorporates elements from the Bates-Jensen Wound Assessment Tool … In partial thickness wounds it can occur throughout the wound bed as well as from the wound edges. … In full thickness wounds it occurs from the edges only. … Stage 3
Stage 4
Unstageable
Suspected Deep Tissue Injury
-
www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK2_T1-Medical_Care_Referral_Form.pdf
May 01, 2014 - Positive culture
If yes, positive for:_______________________________
CURRENT VITAL SIGNS
Blood pressure … New or increasing pus draining from wound
Y N ? New breakdown
Y N ? … New or expanding redness around wound
Y N ? Pain / tenderness
Y N ? Warmth
Y N ? … Suspected minor injury Yes No ?
Suspected serious injury Yes No ?
-
psnet.ahrq.gov/issue/roi-fall-prevention-intervention-invest-little-save-lot
September 13, 2017 - Falls and falls with injury are significant sources of morbidity and mortality and can have substantial … This study showed that after implementing the Fall TIPS program, falls and falls with injury decreased … November 3, 2021
Trauma resuscitation errors and computer-assisted decision support. … Shift-to-shift nursing handover interventions associated with improved inpatient outcomes - falls, pressure … injuries and medication administration errors: an integrative review.
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-203-fullreport.pdf
April 10, 2017 - Ulcer Advisory Panel (EPUAP) — “A pressure ulcer is localized injury to the skin and/or
underlying … ulcers are a serious iatrogenic injury. … They may have
preexisting wounds or altered skin integrity due to a variety of factors related to their … Are pressure ulcers preventable? A survey of experts. Adv
Skin Wound Care 2001; 14(5):244-8. … Unavoidable Pressure Injury. J Wound Ostomy
Continence Nurs 2014; 41(4): 313-34.
-
psnet.ahrq.gov/sites/default/files/2024-09/final_spotlight_case_open_wound_of_the_elbow_slides_09.19.2024.pptx
January 01, 2024 - healing.2
17
17
General Approach to Wounds (4)
Eliciting the mechanism of injury will identify factors … the possibility of injury to deeper structures causing neurovascular injuries, fractures, or, for the … , arterial injury, open fracture, and foreign material.4,5
19
19
General Approach to Wounds (6) … Wounds should be irrigated with moderate pressure (5-8 psi) irrigant to reduce bacterial counts and flush … Primary closure versus delayed closure for non bite traumatic wounds within 24 hours post injury.
-
psnet.ahrq.gov/node/47788/psn-pdf
March 06, 2019 - Medical device-related pressure ulcers: a systematic
review and meta-analysis. … Medical device-related pressure ulcers: A systematic review and
meta-analysis. … https://psnet.ahrq.gov/issue/medical-device-related-pressure-ulcers-systematic-review-and-meta-analysis … Hospital-acquired pressure ulcers are considered never events and represent a significant source of … This systematic review and meta-analysis found a pooled incidence of 12% for pressure injuries
related
-
hcup-us.ahrq.gov/reports/annualreport/HAR_2005.pdf
January 01, 2005 - or internal injury
Intracranial injury (brain injury)
Superficial injury, contusion (bruise)
Fracture … (arms and legs)
Open wounds of head, neck, and trunk
Joint disorders and dislocations, trauma-related … (arms and legs)
Open wounds of head, neck, and trunk
Joint disorders and
dislocations, trauma-related … (brain injury)
234 Crushing injury or internal injury
235 Open wounds of head, neck, and trunk
236 … Open wounds of extremities (arms and legs)
239 Superficial injury, contusion (bruise)
240 Burns
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/functional-specifications.docx
February 10, 2014 - The vendor determines the methodology to assign unique IDs to resident wounds. … :
· 1, 2, 3, 4, U (Unstageable) or Suspected Deep Tissue Injury (sDTI)
Most Recent Assess Ulcer Stage … Display as 1, 2, 3, 4, U (Unstageable) or Suspected Deep Tissue Injury (sDTI)
Ulcer Origin
Wound Assessment … :
Stage 1, 2, 3, 4, U (Unstageable) or Suspected Deep Tissue Injury (sDTI)
Ulcer Origin
Wound Assessment … Display as 1, 2, 3, 4, U (Unstageable) or Suspected Deep Tissue Injury (sDTI).
-
www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/chartbooks/patientsafety/qdr2015-ptschartbook.pdf
March 04, 2016 - Achievable
Benchmark: 2.2%
Importance: Nursing home residents who experience falls resulting in major injuries … are at
higher risk of death and disability, as well as emotional trauma that can affect functional … The home health team should regularly change wound dressing and teach the patient about
wound care … Only
Insignificant
Injury
Temporary
Injury
Permanent,
Minor Injury
Permanent,
Significant Injury … Only
Insignificant
Injury
Temporary
Injury
Permanent,
Minor Injury
Permanent,
Significant Injury
-
psnet.ahrq.gov/web-mm/chest-tube-complications
September 27, 2023 - did not recover spontaneous circulation for more than 30 minutes and sustained severe anoxic brain injury … For example, the trauma surgery service did not routinely perform a clamping trial before chest tube … the most common complication), recurrent pneumothorax, infection (including empyema), organ or vessel injury … Complications following thoracic trauma managed with tube thoracostomy. Injury. 2012;43:46-50. … Complications of tube thoracostomy for acute trauma. Am J Surg. 1980;140:738-741.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/ltvv-mvpguide.pdf
January 01, 2017 - (so-called ZEEP)6-15 and limiting plateau pressures to < 30 cm/H2O (as
compared with 10–12 mL/kg and … to be beneficial in patients at risk for
ARDS, such as those with sepsis, pneumonia, or traumatic injuries … tidal volumes in the 6–8 mL/kg PBW range
along with the avoidance of ZEEP6-13,24 and limiting plateau pressures … admitted to the ICU already have risk factors for ARDS, such as pneumonia,
sepsis, noncardiogenic shock, trauma … Tidal volume
and plateau pressure use for acute lung injury from
2000 to present: A systematic literature
-
hcup-us.ahrq.gov/reports/factsandfigures/figures/2005/2005_2_4.jsp
January 01, 2005 - 192
Umbilical cord complication
216.7
8.676
2.0
0.014890
7,100
175
193
Trauma … complications following abortion)
2.7
0.175
2.6
0.110958
12,800
831
235
Open wounds … examination/evaluation
16.7
4.161
*
*
*
*
98
Essential hypertension (high blood pressure … 246
Fever of unknown origin
86.4
4.815
3.4
0.073659
13,300
507
244
Other injuries … during pregnancy)
220.3
8.652
3.5
0.043953
12,000
324
236
Open wounds of extremities
-
psnet.ahrq.gov/node/866839/psn-pdf
September 25, 2024 - causing neurovascular injuries, fractures, or, for the torso, hemopneumothorax or intra-abdominal injury … Wounds should be irrigated with moderate pressure (5-8 psi)
irrigant to reduce bacterial counts and … manage potential foreign bodies, clinicians should have a low threshold for involving an experienced
trauma … Consulting Editor, AHRQ’s Patient Safety Network (PSNet)
Professor
Department of Surgery, Division of Trauma … Primary closure versus delayed closure for non bite traumatic
wounds within 24 hours post injury.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hacreport-2019.pdf
January 01, 2019 - due to
procedures, as well as pressure ulcers/pressure injuries and falls. … ulcers/pressure injuries increased from 2014 to 2015 and then decreased somewhat from
2015 to 2016 … Ulcers/
Pressure Injuries
21.7 23.5 22.7 23.0 6% 17.4
Surgical Site
Infections
2.5 2.5 2.5 … Pressure Ulcers/Pressure Injuries
Surgical Site
Infection
NHSN SSIs for 17 procedures w/CDC SCIP … Ulcers/Pressure
Injuries
Surgical
Site
Infection
NHSN SSIs for 17
procedures
w/CDC SCIP+5