Evidence mapPaperPMID 40263259Full record

ArticleSpinal cord series and cases2025

A root cause analysis of community-acquired pressure injuries in persons with spinal cord injuries.

Chad M Osteen, Autumn Smith, Brian Bartle, Reside L Jacob, Frances Weaver, Sherri L LaVela, Elizabeth Burkhart

Abstract read
In one paragraph

Article in Spinal cord series and cases, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.

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0cells of the map it votes in
0citing papers in PubMed
field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

0 citing papers in PubMed.

No citing paper in PubMed yet.

4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

7 authors.

Chad M OsteenCenter of Innovation for Complex Chronic Healthcare (CINCCH), Department of Veterans Affairs, Edward Hines Jr. VA Hospital, Hines, Illinois, USA. Chad.Osteen@VA.gov.ORCID 0000-0001-7559-0090
Autumn SmithCenter of Innovation for Complex Chronic Healthcare (CINCCH), Department of Veterans Affairs, Edward Hines Jr. VA Hospital, Hines, Illinois, USA.
Brian BartleCenter of Innovation for Complex Chronic Healthcare (CINCCH), Department of Veterans Affairs, Edward Hines Jr. VA Hospital, Hines, Illinois, USA.
Reside L JacobCenter of Innovation for Complex Chronic Healthcare (CINCCH), Department of Veterans Affairs, Edward Hines Jr. VA Hospital, Hines, Illinois, USA.
Frances WeaverCenter of Innovation for Complex Chronic Healthcare (CINCCH), Department of Veterans Affairs, Edward Hines Jr. VA Hospital, Hines, Illinois, USA.ORCID 0000-0002-5495-4649
Sherri L LaVelaCenter of Innovation for Complex Chronic Healthcare (CINCCH), Department of Veterans Affairs, Edward Hines Jr. VA Hospital, Hines, Illinois, USA.
Elizabeth BurkhartCenter of Innovation for Complex Chronic Healthcare (CINCCH), Department of Veterans Affairs, Edward Hines Jr. VA Hospital, Hines, Illinois, USA.ORCID 0000-0002-3255-1953

Funding

HSRD VA I01 HX002329
6 · The paper itself

Abstract

STUDY

designMulti-phase root cause analysis (RCA)

objectivesDetermine the root cause of why veterans developed a novel CAPrI following the completion of the CAPP-FIT intervention from the providers and veterans' perspectives.

settingA Midwest Veteran Health Administration (VHA) facility SCI clinic.

methodsRCA using Five Why's method and chronology mapping for veterans with spinal cord injury who developed a novel community-acquired pressure injury (CAPrI) following use of a decision support tool to prevent CAPrIs, called the Community Acquired Pressure Injury Prevention-Field Implementation Tool (CAPP-FIT). Data sources include the electronic health record and veteran responses to the CAPP-FIT.

resultsKey themes emerged describing differing provider/veteran perspectives and barriers that led to the development of a novel CAPrI. Themes included (1) disagreement in level of care needed due to complexity of needs or differing priorities; (2) focus on education and treatment over prevention; (3) barriers in accessing VHA care; and (4) veteran and informal resource engagement.

conclusionCAPrI's develop quickly, and some can be prevented. Improving the speed that veterans gain access to critical services (e.g., caregiver and specialists), as well as improving communication at the system level (i.e., across VHA facilities and to private facilities) can decrease the risk of CAPrI's.

Indexed as

Pressure UlcerRoot Cause AnalysisSpinal Cord InjuriesFemaleHumansMaleMiddle AgedUnited StatesUnited States Department of Veterans AffairsVeterans

Identifiers

PMID40263259
PMCPMC12015524

What Socratic holds

Textmetadata
Read underepoch 390

Registered trials

None linked

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the Socratic graph.