Pressure Ulcer Prevention in Organ Transplant Population

In 2012 the Transplant Surgical Service Unit experienced an increase incidence of HAPU.  Begining in the last quarter of 2011, the unit average of Pressure Ulcer Prevalence rate was 5% in each survey conducted. The primary aim of this project was to decrease the prevelance rate of HAPU to ZERO by the 1st Quarter of 2013. Through brainstorming, the DMAIC principles and GAP Analysis were utilized to create an algorithm and implement new processes. After the initial 6 month trial period (1st Q 2013), the Unit was able to achieve its objective of eliminating HAPU for 2 consecutive quarters. Since its inception the Unit has sustained ZERO HAPU for eight (8) consecutive quarters. This project demonstarted with proper education, better communication and reporting, proactive staff behaviors, and proper utilization of reources (WOC and Skin And Wound Assessment Team) pressure ulcers can be prevented.