Moving Towards Zero

Topic: Evolution of a Pressure Ulcer Prevention team’s efforts to prevent hospital acquired pressure ulcers in an academic medical center.

Background: The goal towards zero hospital acquired pressure ulcers requires constant and vigilant re-evaluation of the program and improvement efforts are ongoing. In 2008, the incidence of hospital acquired pressure ulcers at UTMB was 13%.  A reorganization of the prevention program resulted in decreases to 2% in 2011.  

Objective: The pressure ulcer prevention team is evolving the pup program working toward the institutional goal of zero hospital acquired pressure ulcers

Improvement Strategies:

Mattress and bed replacement for high risk areas with low air loss surfaces in the icu and alternating pressure mattress in acute care areas.

The acquisition of a wicking incontinence pad.

Education implemented for prevention of device related pressure ulcers

Daily reports of patients with pressure ulcer from the EMR is sent out to skin team and unit leadership for review.

Outcomes: Through revising the approaches and diligence in identifying multifaceted opportunities, an academic medical center wide approach with a goal of zero hospital acquired pressure ulcers was implemented.   2012 showed a consistent decrease in HAPU rates below 2% with an average of 1.8% and >80% of reporting units with zero HAPU.