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HL20: Diane Whitworth, RN—Eliminating Pressure Ulcers

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   December 13, 2011

In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of Diane Whitworth, RN, CWOCN.

This profile was published in the December, 2011 issue of HealthLeaders magazine.

 "It was a matter of realizing we did have an opportunity here and it was an issue across the country. And that we need to have the focus on what we can do here to make a difference."

Diane Whitworth, RN, CWOCN, began her healthcare career about 30 years ago as a candy striper—"back when candy stripers actually delivered patient care, such as helping patients eat and take a walk," she says. She then worked as a certified nursing assistant before starting her career as a wound ostomy and continence nurse roughly 22 years ago. During the past six years, Whitworth has become a champion in the nationwide effort to prevent hospital-acquired pressure ulcers.

"As I started seeing more and more pressure ulcers, that is what drove me," she says. "But in the back of my mind, I had my grandfather, who in his 80s, had to lose his foot because of a pressure ulcer." Her grandfather fell, fractured his hip, developed a pressure ulcer on his foot (which is common), and ended up having to have an amputation, Whitworth explains. "At the time it was an acceptable practice," she says. "Even being in healthcare, I thought, 'Well, that is one of the hazards of falling and breaking a hip.'"

In 2006, there were 503,300 pressure ulcer-related hospitalizations and pressure ulcers were the primary diagnosis in about 45,500 hospital admissions—up from 35,800 in 1993, according to the Agency for Healthcare Research and Quality. About one in 25 patient admissions with pressure ulcers as the primary diagnosis ended in death, AHRQ says. In addition, pressure ulcers are the second most common patient safety incident with a development rate of 36.05 incidents out of every 1,000 hospitalizations and HAPUs cost the healthcare system roughly $2.6 billion to treat, according to HealthGrades Seventh Annual Patient Safety in American Hospitals Study, which was released in March 2010.

In 2008, The Centers for Medicare & Medicaid Services stopped paying hospitals for the increased cost of care for stage three and four HAPUs, which it classifies as never events.

The statistics are staggering, says Whitworth. "These are patients that came to us without this issue, and this is what we have added on to their list of morbidities—if not mortality."

St. Mary's Hospital in Richmond, VA, part of the Bon Secours Health System, always looked at its HAPU statistics on a yearly basis, says Whitworth, who is the manager of the wound care team at St. Mary's. "But it wasn't a concentrated focus," she says. Then in 2006, some areas of the hospital were showing HAPU rates at 20%. The national average at the time was roughly 5%–6%, says Whitworth. "We said 'This is totally unacceptable.' We set up a goal and started our 'journey to zero.' It was a pretty lofty standard, but that was the vision."

Everyone in the hospital from board room and chief nurse executive-level to the bedside nurse is now focused on preventing HAPUs. Whitworth says there needs to be a commitment that the resources will be there for prevention. "For us, it is that we can have skin champions who can meet monthly for an hour and have skin care meetings," she says, adding that if a patient needs a different bed surface, the staff nurses are empowered to get it for them. They do not need to wait for approval from the wound care nurse, she says.

To ensure St. Mary's was doing everything it could to prevent HAPUs, it created an interdisciplinary team, including nurses, physicians, dietary, physical and occupational therapy, and quality staff, to review processes and guidelines. St. Mary's also brought in subject matter experts and conducted research reviews.

"It was a matter of realizing we did have an opportunity here, and it was an issue across the country—and that we need to have the focus on what we can do here to make a difference," says Whitworth.

When it comes to preventing HAPUs, making sure that patients are turned every two hours is a huge component, says Whitworth. The challenge is determining whether this is actually happening, or what to do for critically ill patients in pediatrics, for example, who can only be turned every 12–24 hours, she explains. Another area that is a huge concern is device related injuries such as oxygen tubing around ears. Lastly, making sure that the staff is onboard with the processes.

Historically, St. Mary's used what it calls a point prevalence and incidence report where, on a yearly basis, it examined everyone's skin across the whole hospital. It then came up with its HAPU rate—meaning these patients came into the hospital without a pressure ulcer and now they have one. It wasn't the best system, Whitworth concedes. "One snapshot, once a year is not the best way to determine what your patient population has." Now these evaluations are done quarterly.

In addition, as soon as a HAPU is identified, the wound care team and nurse manager are also notified. "We immediately start doing a review and make sure the interventions are correct or if we should escalate them," she says. The CNO also wanted to know about these events, Whitworth adds, so if one occurs it is included in the daily 10:30 a.m. huddle with the nurse managers, assistant director of nursing, and department heads. The huddle discusses what is going on throughout the facility, for example what is the ED looking like today.

If there is a HAPU, the staff nurse, nurse manager, and one of the wound care team show up and explain what is happening. "Within 24 hours, we already have a handle what we can do to prevent it—what process or education do we need," says Whitworth.


The hospital always had a skin and wound care committee that met monthly and focused on education and what the current HAPU issues were on the floor. But it wasn't focused on prevention, which is now its main focus, says Whitworth. It also expanded the committee to represent all units. It didn't have pediatrics, surgical services, or the emergency department represented, for example.

It is imperative for hospitals to identify HAPUs that are present on admission, she explains. If a patient comes into the ED with a heart attack, the focus is on the heart attack. But as soon as that patient is stable, St. Mary's set the standard that staff need to do a skin and risk assessment.

The hospital restructured its staff education process as well. St. Mary's wanted to know whether its staff could assess patients, do a grading scale, and score them appropriately. "If patients weren't scored correctly, we weren't putting in the interventions," says Whitworth. St. Mary's now has mandatory competencies and annual skills reviews solely on skin and pressure ulcer prevention.

Each unit also has a skin champion who performs process data collection on a weekly basis, she says. They look at the care of five patients on their unit and evaluate the processes the team excels in or needs to work on. Some units maybe good at turning but struggle with handoffs, Whitworth explains, so this brings it to the unit-level rather than setting a hospital-wide initiative to focus on turning.

Hospitals should ensure that HAPU processes are not duplicate work and that they are as user-friendly as possible, says Whitworth. For example, St. Mary's developed a list of interventions that staff should do based on the HAPU's level. The system is now automated in its electronic medical record, but they had a paper version prior to launching the EMR.

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.



Carrie Vaughan is a senior editor with HealthLeaders magazine. She can be reached at

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