1 Purpose Scope/Audience Definitions Associated Documents Objectives...3

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1 Pressure Injury Prevention and Management Policy Contents Purpose Scope/Audience Definitions Associated Documents Objectives Personnel responsible for pressure care within WCDHB Procedure Documentation Discharge Planning References... 5 Appendices 7. AWMA Flow Chart.2 WCDHB Flow Chart...3 Adapted Waterlow Scale..4 Skin Assessment..5 Adapted Glamorgan Pressure Ulcer Risk Assessment Scale for Children..6 Grading Pressure Injuries. Pressure Injury Prevention and Management Policy Page of 7 Document Owner: Occupational Therapy WCDHB-CLIN77 Version, Issued February 206 Master Copy is Electronic UNCONTROLLED DOCUMENT WEST COAST DISTRICT HEALTH BOARD

2 Pressure Injury Prevention and Management Policy. Purpose. Minimise the incidence and prevalence of pressure related injuries of West Coast District Health Board (WCDHB) patients through adequate risk assessment, risk management and appropriate treatment..2 Establish a consistent, systematic best-practice approach to pressure injury prevention and management across the WCDHB..3 Only the validated assessment tools and processes outlined in this policy are to be used to ensure consistency across the WCDHB..4 Support Health Services to comply with the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance (NPUAP/EPUAP/PPPIA) prevention and management guidelines..5 Increase the awareness of staff, patients and the public to the importance of pressure injury prevention and management strategies..6 Support the WCDHB to provide appropriate pressure reducing and relieving equipment to best suit patient needs. 2. Scope / Audience All WCDHB Clinical Staff. 3. Definitions Medical device/object: An item used in the care of a patient which may rub or exert pressure on the skin when in consistent contact (with the skin) and therefore likely to cause skin/tissue damage. Pressure Injury: A localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, shear and/or friction, or a combination of these factors. Skin assessment: General examination of the skin. Skin assessment includes examination of the entire skin surface to check integrity and identify any characteristics indicative of pressure damage/injury. This entails assessment for erythema, blanching response, localised heat, oedema, induration and skin breakdown. Check the skin beneath devices, prosthesis and dressings when practical. Pressure Injury Prevention and Management Policy Page 2 of 7 Document Owner: Occupational Therapy WCDHB-CLIN77 Version, Issued February 206 Master Copy is Electronic UNCONTROLLED DOCUMENT WEST COAST DISTRICT HEALTH BOARD

3 Pressure Injury Prevention and Management Policy 4. Associated Documents Initial Assessment Documentation- this includes the Adapted Waterlow Scale and Adapted Glamorgan Pressure Ulcer Risk Assessment Scale (attached). Nursing Care Plan/Pressure Care flowchart (attached)/ Lippincott Procedures (Pressure ulcer prevention, Pressure ulcer management and pressure dressing application) all available on the intranet Safety st and ACC treatment injury paper work. 5. Objectives 5. Ensure that the Waterlow Scale or Glamorgan Pressure Ulcer Risk Assessment Scale (Attached) is completed on all patients within 8 hours of admission and reviewed regularly (review based on patient acuity level) to identify at risk patents, specific risk factors and determine the effectiveness and necessity for interventions. 5.2 Water low Scale to be used across the WCDHB to ensure consistency. The only exception to this is Paediatrics, where the Glamorgan Pressure Ulcer Risk Assessment Scale should be used instead. 5.3 Staff are to follow the WCDHB pressure care flow chart (attached) and appropriate IDT members given referrals. 5.4 To have documented IDT pressure care recommendations that reduces/relieves pressure while promoting function and independence. Recommendations may include but is not limited to turning schedules, wound management, pressure reducing equipment, dietary advice and mobility schedules. 5.5 To protect against the adverse effects of external mechanical forces: pressure, friction, and shear. 5.6 To maintain ongoing education of health professionals/carers/support staff/patient/family in the prevention/treatment of pressure injuries. 5.7 For all pressure injuries to be regularly photographed (at least once weekly more frequently if indicated), with scale ruler. Photos are to include the date and site of injury. Photos are to be shared with appropriate health professionals e.g. DN for ongoing management post discharge, rest home if this is discharge destination. Pressure Injury Prevention and Management Policy Page 3 of 7 Document Owner: Occupational Therapy WCDHB-CLIN77 Version, Issued February 206 Master Copy is Electronic UNCONTROLLED DOCUMENT WEST COAST DISTRICT HEALTH BOARD

4 Pressure Injury Prevention and Management Policy 5.8 All pressure injuries that are sustained while the patient is in the WCDHB s care are reported using Safety st and ACC treatment injury paper work completed within the shift that they are identified. 5.9 Education is provided to patient and family around the prevention and management of pressure injuries. 5.0 Mattresses used by patients meet acceptable standards (cover, foam quality) and are no more than 0 years old. 6. Personnel responsible for pressure care within WCDHB IDT for pressure care includes: Doctors, Nurses, Dietitian, Physiotherapist, Occupational Therapist and Pharmacist. Refer to Lippincott procedures for further detail. 7. Procedure The WCDHB uses Lippincott procedures. Please refer to the appropriate Lippincott procedure, which can be found on the intranet: Pressure ulcer prevention Pressure ulcer management Pressure dressing application As per Lippincott guidelines the DHB must use a preferred assessment tool. For the WCDHB this is the adapted Water low scale for adults and Glamorgan Pressure Ulcer Risk Assessment Scale for children (attached). All patients should have daily skin assessments or as per acuity. Any pressure injuries should be graded and photographed. 8. Documentation Includes risk assessment/reassessments, pressure injury staging and the patient s plan of care should be clearly documented in the patient s clinical record. A patient s plan of care should address: Skin assessment and care Individualised positioning/turning schedules Redistribution (support) surface systems Pressure Injury Prevention and Management Policy Page 4 of 7 Document Owner: Occupational Therapy WCDHB-CLIN77 Version, Issued February 206 Master Copy is Electronic UNCONTROLLED DOCUMENT WEST COAST DISTRICT HEALTH BOARD

5 Pressure Injury Prevention and Management Policy Nutritional interventions Management/product selection Referrals to Allied Health as appropriate Evaluation of patient outcomes to interventions Discharge Planning Safety st and ACC documentation Mobility schedules Photography (refer to objective 5.7) Education for patients and families/carers /whanau 9. Discharge Planning Assess equipment needs for home. Determine who is responsible to fund and organise equipment e.g. ACC, Long term Residential Facilities, hospital Occupational Therapist. Equipment details need to be documented on discharge form. Appropriate referrals sent for community follow up e.g. district nurses. 0. References. Agency for Healthcare Quality and Research. (20). Preventing pressure ulcers in hospitals: A toolkit for improving quality of care (AHRQ Publication No EF) [Online]. Accessed December 202 via the Web at 2. Australian Wound Management Association. (202). Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury. Cambridge Media Osborne Park, WA. 3. Baranoski, S., & Ayello, E. A. (20). Wound care essentials: Practice principles (3rd ed.) Philadelphia, PA: Lippincott Williams & Williams. 4. Baranoski, S., & Ayello, E. A. (202). Wound care essentials: Practice principles ( 3rd ed.). Philadelphia, PA: Lippincott Williams & Williams. 5. Centers for Disease Control and Prevention. (2002). Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR Recommendations and Reports, 5(RR-6), -45. (Level I) 6. Institute for Clinical Systems Improvement. (202). Health care protocol: Pressure ulcer prevention and treatment protocol (3rd ed.) [Online]. Accessed December 202 via the Web at Pressure Injury Prevention and Management Policy Page 5 of 7 Document Owner: Occupational Therapy WCDHB-CLIN77 Version, Issued February 206 Master Copy is Electronic UNCONTROLLED DOCUMENT WEST COAST DISTRICT HEALTH BOARD

6 Pressure Injury Prevention and Management Policy review_and_comment_/p ressure_ulcer_treatment protocol.html (Level V) 7. Institute for Clinical Systems Improvement. (202). "Health care protocol: Pressure ulcer prevention and treatment protocol, 3rd ed." [Online]. Accessed June 203 via the Web at (Level VII) 8. Knox, D. M., et al. (994). Effects of different turn intervals on skin of healthy older adults. Advances in Wound Care, 7, 48-52, Levine, J., & Ayello, E. (200). Pocket guide to pressure ulcers. Princeton, NJ: NJHA HealthCare Business Solutions. 0. McInnes, E., et al. (20). Support surfaces for pressure ulcer prevention. Cochrane Database of Systematic Reviews, 20(4), Art. No. CD Moore, Z. H. & Cowman, S. (2005). Wound cleansing for pressure ulcers (review). Cochrane Database of Systematic Review, 2005(4), Art. No. CD National Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Group (EPUAP). (2009). Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. WashingtonDC: NPUAP. 3. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. (2009). "Prevention and treatment of pressure ulcers: Clinical practice guidelines" [Online]. Accessed December 202 via the Web at (Level VII) 4. National Pressure Ulcer Advisory Panel. (2007). "Pressure ulcer category/staging illustrations" [Online]. Accessed June 203 via the Web at 5. Patton, R. M. (200). Is diagnosis of pressure ulcers within an RN's scope of practice? American Nurse Today, 5(), Siegel J. D., et al. (2007). "2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings" [Online]. Accessed June 202 via the Web at (Level I) 7. Stratton, R. J., et al. (2005). Enteral nutrition support in prevention and treatment of pressure ulcers: A systematic review of meta-analysis. Ageing Research Reviews, 4, Sussman, C., & Bates-Jensen, B. (202). Wound care: A collaborative practice manual for health professionals (4 th ed.). Philadelphia, PA: Lippincott Williams & Williams. Pressure Injury Prevention and Management Policy Page 6 of 7 Document Owner: Occupational Therapy WCDHB-CLIN77 Version, Issued February 206 Master Copy is Electronic UNCONTROLLED DOCUMENT WEST COAST DISTRICT HEALTH BOARD

7 Pressure Injury Prevention and Management Policy 9. The Joint Commission. (202). Standard NPSG Comprehensive accreditation manual for hospitals: The official handbook. Oakbrook Terrace, IL: The Joint Commission. (Level I) 20. The Joint Commission. (203). Standard PC Comprehensive accreditation manual for nursing and rehabilitation centers: The official handbook.oakbrook Terrace, IL: The Joint Commission. (Level I) 2. World Health Organization. (2009). "WHO guidelines on hand hygiene in health care: First global patient safety challenge, clean care is safer care" [Online]. Accessed December 202 via the Web at (Level I) 22. Wound, Ostomy, and Continence Nurses Society. (200). "Guideline for prevention and management of pressure ulcers" [Online]. Accessed December 202 via the Web at Appendices Pressure Injury Prevention and Management Policy Page 7 of 7 Document Owner: Occupational Therapy WCDHB-CLIN77 Version, Issued February 206 Master Copy is Electronic UNCONTROLLED DOCUMENT WEST COAST DISTRICT HEALTH BOARD

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9 West Coast Pressure Care Flow Chart * Pressure Care Our Responsibility Clinical staff to assess all patients within 8 hours of admission. Complete: Adapted Water Low / Glamorgan scale for Paeds Skin Assessment Appropriate validated Nutritional Screening Tool Does patient have a Pressure Injury or have they developed one? No Waterlow score >0 Glamorgan score >0 No Yes Yes * Use Prevention Strategies * Use Prevention Strategies * Use Prevention strategies Grade Pressure Injury & photograph Start Wound Chart Refer to Occupational Therapy / Physio / Dietitian as appropriate Refer to appropriate Lippincott procedure Refer to Occupational Therapy / Physio / Dietitian as appropriate Regular repositioning Education to patient and family Encourage Independence & mobility Daily skin assessment e.g when showering DOCUMENT DOCUMENT DOCUMENT Refer to medical team and wound nurse for pain and wound management & additional management options RESCREEN AS PER ACUITY Wound Chart Photgraph Grade Waterlow / Glamorgan DOCUMENT RESCREEN AS PER ACUITY Waterlow / Glamorgan * LIPPINCOTT PROCEDURE ON INTRANET FOR PREVENTION/TREATMENT/DRESSING Developed by Pressure Care Working Group v3.0 Monday 8 April, 206

10 Patient Bradma WATERLOW PRESSURE SCORE RISK ASSESSMENT 0+ AT RISK 5+ HIGH RISK 20+ VERY HIGH RISK If the total score is 0 or above preventative nursing care is required and must be incorporated into the Plan of Care and be evaluated regularly. Appropriate IDT referrals to be sent. Circle score beside each category REVIEW DAILY Date Date Date Date Date Date Date Gender Male Female 2 Age Build/weight for height (see MUST for BMI) Skin type/visual risk area Continence Malnutrition Risk Mobility Special Risk Factors Average BMI Above average BMI Obese BMI >30 Below average BMI <20 Healthy Tissue paper Dry Oedematous Clammy (febrile) Discoloured Broken/spot Complete/catheterised Occasional incontinence Catheterised/incontinent of faeces Doubly incontinent MUST Score (Low Risk) = 0 MUST Score (Medium Risk) = MUST Score (High Risk) = 2 Fully mobile Restless/fidgety Apathetic Restricted Inert/traction Chair bound Smoking 0+/day Cytotoxic drugs, high dose steroids or anti-inflammatory drugs Orthopaedic surgery, below waist fracture, spinal Sensory deprivation (diabetes, paraplegia, CVA) Terminal cachexia TOTAL SCORE Waterlow Pressure Sore Assessment December 205- draft 2

11 Skin Assessment at West Coast District Health Board Skin assessments are a requirement for all patients this is one of the single most effective ways of identifying injuries and preventing further damage. What is a skin assessment: It is the general examination of the skin. Skin assessment includes examination of the entire skin surface to check integrity and identify any characteristics indicative of pressure damage/injury. This entails assessment for erythema, blanching response, localised heat, oedema, induration and skin breakdown. Check the skin beneath devices, prosthesis and dressings when practical. What to do: Conduct a head-to-toe skin assessment. Focus particular attention to skin overlying bony prominences including the sacral region, heels, ischial tuberosities and greater trochanters Darker skin tones may be more difficult to assess visually. Pay particular attention to localised heat, oedema and induration in patients with darker skin tones Observe the skin for pressure damage related to medical devices (e.g. braces, splints, harnesses, cervical collars, hip protectors). Where possible these devices should be removed to allow a comprehensive skin assessment at least daily or more frequently in high risk patients Ask the patient to identify areas of discomfort or pain associated with pressure and pay particular attention to assessment of these areas Documentation Document all skin assessments as soon as possible following admission and within a minimum of eight hours (or on initial home or clinic visit for patients seen in the community), on a daily basis and whenever there is a change in the patient s condition or as per acuity Please refer to the Pressure Care Flow Chart, found in the Pressure Care Prevention and Management policy for further required action.

12 Adapted Glamorgan Pressure Ulcer Risk Assessment Scale for Children

13 Adapted Glamorgan Pressure Ulcer Risk Assessment Scale for Children Guidance on Using the Glamorgan Scale A child s risk of developing a pressure injury should be assessed - Within 8 hours of admission - Every time there are changes in the patients acuity Mobility- Include the total of ALL relevant scores in this section Child cannot be moved without great difficulty or deterioration in condition add 20 to total score for this section. E.g. ventilated child who de-saturates with position changes, a child who becomes hypotensive in a certain position. Children with cervical spine injuries are limited in the positions they can lie in. Some children with contracture deformities are only comfortable in limited positions. General anaesthetic >2hours add 20 to total score for this section only on day of surgery E.g. a child who is on the theatre table may not have their position changed during an operation for a prolonged period and is placed on a firm surface for stability during the operation. Unable to change his/her position without assistance add 5 to total score for this section. E.g. a child may be unable to move themselves, but carers can move the child and change his/her position. Cannot control body movement add 5 to total score for this section. E.g. the child can make movements but these may not be purposeful (repetitive dyskinetic movements), the child is unable to consciously change his/her own position. Some mobility but reduced for age add 0 to total score for this section. The child may have the ability to change their own position but this is limited / restricted. E.g. a child with developmental delay, a child in traction who is able to make limited movements, or a child on bed rest. Normal mobility for age score 0 for this section. Mobility is appropriate for developmental stage. E.g. a new born baby is able to move his/her limbs but is not able to roll over; a year old is able to roll over, bottom shuffle or crawl, sit up and pull up to standing

14 Adapted Glamorgan Pressure Ulcer Risk Assessment Scale for Children Equipment / objects / hard surface pressing or rubbing on the skin add 5 to total score. Any object pressing or rubbing on the skin for long enough or with enough force can cause pressure damage. (These areas must be observed closely). E.g. Pulse oximeter probes, ET tubes, masks, tubing/wires, tight clothing (antiembolic stockings), plaster casts/splints Significant anaemia (Hb <90 g/l) If the haemoglobin has been measured during this admission and is below 90g/l score. If the haemoglobin is 90 g/l or above score 0. If the haemoglobin is unknown, write NK and score 0. Persistent pyrexia (temperature >38.0 ºC for more than 4 hours) If temperature is 38.0 ºC and above for more than 4 hours - score. If temperature is less than 38ºC and/or pyrexia lasts less than 4 hours - score 0. Inadequate nutrition (discuss with a dietician if in doubt) If a child is identified as being malnourished (exclude pre-op fasting) - score. A child who has a normal nutritional intake - score 0. Low serum albumin (<35 g/l) If serum albumin is less than 35 g/l - score. If serum albumin is 35 g/l or above score 0. If serum albumin has not been measured write NK and score 0. Incontinence (inappropriate for age) Inappropriate incontinence - score E.g. A 4 year old child who needs to wear nappies during the day and night. Include children with special needs in this category. Normal continence score 0 E.g. A 5 year old who is dry during the day but may be occasionally incontinent during the night, a 2 month old who needs to wear nappies during the day and night. Moisture lesions should not be confused with pressure ulcers.

15 Adapted Glamorgan Pressure Ulcer Risk Assessment Scale for Children Risk Score Document total score, however scores for individual risk factors should be acted on i.e. optimise nutrition and mobility. If the child scores 0 or higher, he/she is at risk of developing a pressure injury unless action is taken to prevent it. This action may include normal nursing care, such as frequent changes of position (document how often position is changed), encouraging mobilisation, lying the child on a standard foam pressure reducing hospital mattress or on an air-filled overlay or mattress, changing the position of pulse oximeter probes regularly, ensuring the child is not lying on objects in the bed such as tubing or hard toys. Suggested action is indicated in the WCDHB pressure care flow chart. Pressure Injury Record The diagram of the child on the Nursing Initial Assessment Form can be used to indicate the position of any skin lesions. If lesions are near to, or associated with any equipment such as BIPAP mask, nasogastric tube or splint, these should also be indicated. The skin lesions indicated in the diagram should be numbered so that they can be referred to in the table beside the diagram. Any existing or new pressure injuries should be documented, staged, incident reported and photographed. Stage any Pressure Injuries Please use the following NPUAP/EPUAP 2009 pressure ulcer classification system to stage lesions, no other grading tool should be used. Stage I. II, III, IV, un-stage able or suspected deep tissue injury. Adapted from the Glamorgan Risk Assessment Scale from the United Kingdom

16 Pressure Injury Grading Scale