One of St. Mary's most successful initiatives to preventing pressure ulcers is its critical event analysis tool. Staff members use this tool immediately when a HAPU develops, while it is still a stage one or stage two. "We don't even get to stage three or four because we already determined that that was way too late," says Whitworth.
The tool helps staff determine whether they did everything they could do to prevent it. And what interventions they should be doing now. For example, did they get nutrition involved early enough? Did they do a risk assessment? Is the patient on a proper support surface?
The hospital's HAPU rates dropped from 20% in 2006 to 2% in 2007, and is now around 0.5%. "We started out on a six-lane highway. We had so much out there to improve—we got the low-hanging fruit and improved dramatically in a short amount of time," says Whitworth.
St. Mary's has also hit the elusive zero for a few months at a time. A key element of reaching that goal is knowing what you have in-house on a daily basis, she says. "I don't have to wait for quarterly visit. I can tell you I haven't had any [HAPUs] for 30 days."
This article appears in the December 2011 issue of HealthLeaders magazine.