Pressure Injury Prevention and Management Policy Owner (initiating the document): Dr Amanda Ling Contact name and number: Rachel Dennis (Ph: 9222 2197) Version: 1.5 Approved by: Professor Bryant Stokes, A/Director General Date: November 2013 File number WA DoH registered file
Acknowledgements The WA Health Pressure Injury Prevention and Management Policy was prepared for WA Health by WoundsWest on behalf of the WA Pressure Injury Forum, where it was agreed that WA Health would benefit from a state-wide policy for the prevention and management of pressure injuries. This policy is based on the South Australian Health Pressure Injury Prevention and Management Policy Directive, 2013. Suggested Citation WA Health Pressure Injury Prevention and Management Policy, 2013. Document Control Version Effective date Author Comment 1.0 24 Jun 2013 Initial draft developed by WoundsWest 1.2 09 Aug 2013 Reviewed by Pressure Injury Forum working party 1.3 27 Aug 2013 Reviewed by WoundsWest 1.4 10 Sep2013 Reviewed by Office of Safety and Quality in Healthcare 1.5 24 Oct 2013 Further editing by the Office of Safety and Quality in Healthcare
Contents 1 Policy monitoring and review... 1 2 Policy scope... 1 3 Policy purpose... 1 4 Related WA Health Policies... 1 5 Principles of Pressure Injury Prevention and Management... 1 5.1 Evidence-based care... 1 5.2 Patient and carer involvement... 2 5.3 Leadership and complete team involvement... 2 5.4 Resources to support pressure injury and management... 2 5.5 Continuous improvement... 2 6 Clinical Practice... 2 6.1 Screening and Assessment... 2 6.2 Prevention Strategies and Management of Pressure Injuries... 3 6.3 Care Planning and Documentation... 3 7 Reporting of Pressure Injury Incidents... 3 8 Responsibilities... 4 8.1 Health Service Chief Executives... 4 8.2 Hospital Executives, Clinical Directors, Heads of Services/Departments and other senior managers... 4 8.3 WA Health employees... 4 9 References... 5 Appendix A - Glossary... 6 Appendix B - Other sources of information... 9
1 Policy monitoring and review This policy will be reviewed at least every three years by the Office of Safety and Quality in Healthcare, Performance Activity and Quality, in collaboration with the WA Pressure Injury Forum. The next review should occur by December 2016. 2 Policy scope All WA Health employees or persons who provide health services on behalf of WA Health must adhere to this policy. 3 Policy purpose The purpose of this policy and accompanying guideline is to: Establish a consistent and evidence-based approach to pressure injury prevention and management across WA Health in accordance with the Australian Commission on Safety and Quality in Healthcare, National Safety and Quality Health Service Standards: Preventing and Managing Pressure Injuries Standard 8. Promote systematic and proactive risk identification and evidence-based management in order to reduce the incidence and prevalence of pressure injuries and to prevent or delay complications arising from them. 4 Related WA Health Policies Implementation of the Australian Health Service Safety and Quality Accreditation Scheme and the National Safety and Quality Health Service Standards in Western Australia (OD 0410/12) Clinical Incident Management Policy 2012 5 Principles of Pressure Injury Prevention and Management 5.1 Evidence-based care Screening, assessment, prevention strategies and wound management are provided in accordance with: WA Health Pressure Injury Prevention and Management Guideline; Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury; Standards for Wound Management; Australian Commission on Safety and Quality in Health Care; 1
National Safety and Quality Health service Standards: Preventing and Managing Pressure Injuries Standard 8; and, Relevant accreditation standards. 5.2 Patient and carer involvement All organisations and services in WA Health are to ensure that patients and carers are: Informed of the risk associated with pressure injuries; Engaged in care planning for both prevention and management; Provided with appropriate information about prevention and management of pressure injuries; and, Encouraged to provide feedback about services. 5.3 Leadership and complete team involvement Leaders in WA Health are to provide a systematic approach to the prevention and management of pressure injuries and encourage the implementation of best practice guidelines. 5.4 Resources to support pressure injury and management Evidence-based wound management should be provided by staff with appropriate skills and knowledge, using appropriate materials to optimise healing and prevent or delay complications. WA Health and employers are required to provide: Employees with access to pressure injury policies, procedures, referral information and other resources relevant to their role. Employees with access to regular education and training programs; and, Systems to ensure competence, monitoring and review of the performance of employees, and the effectiveness of the training strategies. 5.5 Continuous improvement Appropriate data is to be gathered and analysed to monitor performance in relation to the prevention and management of pressure injuries, and to facilitate planning and the development of strategies to improve performance. 6 Clinical Practice 6.1 Screening and Assessment 6.1.1 To identify patients who are at risk, a formal pressure injury risk screening and assessment of skin and nutrition should be undertaken for all patients within eight hours of presentation. For some patients these assessments should be supplemented by 2
clinical judgement that takes account of the likelihood of rapid deterioration such as in palliative or cachexic patients with failure of one or more systems. 6.1.2 The frequency of repeated assessment will depend on the patients identified level of risk, health and mobility status. 6.1.3 Risk assessment should be repeated whenever there is a change in the patients condition and on the patients discharge. 6.1.4 Skin assessments should be conducted at least daily or more frequently for high risk patients. 6.2 Prevention Strategies and Management of Pressure Injuries 6.2.1 All patients with a known pressure injury(s) are deemed to be at high risk. A formal pressure injury risk screening and assessment of skin and pain should be undertaken as soon as possible after presentation and a management plan developed and documented within eight hours. Prevention and management strategies should include consideration of the handover of management that was in place prior to presentation. 6.2.2 After observation of a new pressure injury(s), prevention and wound management strategies are to be implemented as soon as possible and a management plan developed and documented within eight hours. 6.2.3 All at risk patients should be provided with appropriate prevention interventions including, but not limited to equipment within time frames that minimise risk. These interventions will result in reduced exposure to pressure, shear and friction, and strategies to maintain and improve tissue tolerance. Where equipment is provided, its use should be monitored for safety and effectiveness. 6.3 Care Planning and Documentation 6.3.1 Documentation of screening, assessment and management strategies should be maintained. Communication of the level of risk, the care plan and effectiveness of the care is to be part of all handover occasions, including discharge and transfer. This information should be available to all relevant members of the multidisciplinary team, as well as patients and carers. 7 Reporting of Pressure Injury Incidents 7.1 Systems are to be in place to ensure ongoing monitoring and reporting of pressure injuries through the Clinical Incident Monitoring System (CIMS). Analysis of CIMS data can be used to inform practice improvement. 7.2 A report will be made to CIMS for: Any pressure injury (stage 2 or above) that arises during care; and, 3
Any pressure injury that existed on admission and has deteriorated significantly (progressed to the next stage) during care. 7.3 If a pressure injury occurs during care, the patient and carer will be informed in accordance with Open Disclosure principles. 7.4 All incidents should be investigated to the level required by the Clinical Incident Management Policy (2012). 8 Responsibilities 8.1 Health Service Chief Executives Allocate sufficient human and material resources (including equipment), within their area of control, to enable effective prevention and management of pressure injuries ; Support the design and development of care systems where pressure injury prevention and identification is embedded sustainably in practice and delivered in a manner consistent with the pressure injury guidelines; and, Ensure the health services within their area of control have systems in place which facilitate effective notification, management and practice improvement. 8.2 Hospital Executives, Clinical Directors, Heads of Services/Departments and other senior managers Provide organisational governance and leadership in relation to pressure injury prevention and management; Develop, implement and monitor local processes that support employees and other persons providing health services on behalf of WA Health, to reduce health care acquired pressure injuries; Ensure the availability of education and training in pressure injury prevention and management; and, Ensure that relevant data is being collected to monitor performance in relation to pressure injury prevention and management. 8.3 WA Health employees Take appropriate action to ensure they are preventing pressure injuries and treating pressure injuries according to best practice; and, Ensure that pressure injuries are reported to CIMS in accordance with the Clinical Incident Management Policy (2012). 4
9 References 1) SA Health Pressure Injury Prevention and Management Policy Directive, 2013. Available: www.sahealth.sa.gov.au 2) Department of Health, Western Australia. Clinical Incident Management Policy. (2012). Perth: Patient Safety Surveillance Unit, Performance Activity and Quality Division. 3) Australian Commission on Safety and Quality in Health Care. Safety and Quality Improvement Guide Standard 8: Preventing and Managing Pressure Injuries (October 2012). Sydney. 4) Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury, 2012. Australian Wound Management Association, Cambridge Media Osborne Park, WA: ISBN Online 978-0-9807842-3-7 http://www.awma.com.au/publications/publications.php#pipm 5
Appendix A - Glossary Carer Clinical practice guideline Friction Incident Malnutrition Moisture Patient Pressure Injury Prevention strategies Repositioning Risk Screening / risk assessment a family member, significant other, guardian or friend who has an interest in, contributes to or is responsible for, the care of a patient. systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. a mechanical force that occurs when two surfaces move across one another. In relation to pressure injuries friction creates resistance between the skin and contact surface the person is lying or sitting on. any event or circumstance which could have (near miss) or did lead to unintended and / or unnecessary mental or physical harm to a person and/or to a complaint, loss or damage. a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue / body form (body shape, size and composition) and function and clinical outcome. alters resilience of the epidermis to external forces by causing maceration, particularly when the skin is exposed for prolonged periods. Moisture can occur due to spilt fluids, incontinence, wound exudate and perspiration. refers to a person receiving healthcare. The term patient has been used for the purpose of this document and ease of reading only. It is intended to also include consumers, clients, residents and other people, however titled, receiving healthcare from a clinician or other healthcare provider. 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. strategies or interventions designed to reduce the chance of a patient developing a pressure injury. These will also be used to provide conditions to optimise healing of an existing pressure injury. changing a patient s body position to redistribute the pressure on the tissue overlying bony prominences that were in contact with the surface supporting the body. The frequency is determined by skin s response, support surface in use and patient s general condition. Select position(s) to promote comfort, safety and relaxation, prevent deformities and reduce the effects of tissue strain on skin. use of a formal tool, score or scale to help determine the level or degree of risk of pressure injury, as indicated by a score. 6
Seating cushion Senior Nurse/Midwife Shear Skin Assessment Stages of Pressure Injury reactive (static) or active (dynamic) cushions on a chair for pressure redistribution purposes depending on size of service this includes the senior nurse e.g. shift coordinator; after hours Nurse Manager; Clinical Nurse Manager (CNM); after hours CNM; DON/HSM. a mechanical force created from a parallel (tangential) load that causes the body to slide against resistance between the skin and a contact surface. The outer layers of the skin (the epidermis and dermis) remain stationary while deep fascia moves with the skeleton, creating distortion in the blood vessels and lymphatic system between the dermis and deep fascia. This leads to thrombosis and capillary occlusion. general examination of the skin, looking for existing lesions or factors that may indicate reduced tissue tolerance. Stage I pressure injury: intact skin with non-blanchable redness of a localised area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its colour may differ form the surrounding area. The area may be painful, firm, soft, warmer or cooler compared to adjacent tissue. May be difficult to detect in individuals with dark skin tones. May indicate at risk persons (a heralding sign of risk); Stage II pressure injury: partial thickness loss of dermis presenting as a shallow, open wound with a red-pink wound bed, without slough. May also be present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry, shallow injury without slough or bruising (note: bruising indicates suspected deep tissue injury). Stage II PI should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation; Stage III pressure injury: full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. The depth of Stage III PI varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Stage III PIs can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III PIs. Bone or tendon is not visible or directly palpable; Stage IV pressure injury: full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. The depth of Stage IV PI varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Stage IV PIs can be shallow. Stage IV PI can extend into muscle and/or supporting structures (e.g. fascia, tendon or joint capsule) making osteomyelitis 7
possible. Exposed bone or tendon is visible or directly palpable; Unstageable pressure injury: Depth Unknown - full thickness tissue loss in which the base of the PI is covered with slough (yellow, tan, grey, green or brown) and/or eschar (tan, brown or black) in the PI bed. Until enough slough/eschar is removed to expose the base of the PI, the true depth, and therefore the stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body s natural biological cover and should not be removed; Suspected deep tissue injury: Depth Unknown purple or maroon localised area or discoloured, intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tone. Evolution may include a thin blister over a dark wound bed. The PI may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. Support surface a surface on which the patient is placed to manage pressure load by distributing body weight pressure more effectively over the support surface. Includes beds, trolleys and operating table mattresses and overlays; integrated bed systems; and seat cushions and overlays Active support surface: a powered support surface that produces alternating pressure through mechanical means, thereby providing the capacity to change its load distribution properties with or without an applied load. This generally occurs through alternation of air pressure in air cells on a programmed cycle time. Also called an alternating pressure support surface or a dynamic support surface. Reactive support surface: a support surface which, in response to applied pressure, distributes interface pressure over a wider body area through immersing and enveloping the patient. May be referred to as static support surface or a constant low pressure support surface. Tissue tolerance the ability of skin and underlying tissues to endure pressure without experiencing any adverse effects. 8
Appendix B - Other sources of information WoundsWest. http://www.health.wa.gov.au/woundswest/home/ SA Health. http://www.sahealth.sa.gov.au/ Standards For Wound Management, 2010. Australian Wound Management Association, Cambridge Publishing, West Leederville WA. Evidence based practice guidelines for the dietetic management of adults with pressure injuries, 2011, Trans Tasman Dietetic Wound Care Group, Dietitians Association of Australia. Victorian Government Health Information http://www.health.vic.gov.au/pressureulcers/education.htm Wound and Lymphoedema Management, 2010. World Health Organization. Pressure Ulcer Treatment Quick Reference Guide 2009. EPUAP and NPUAP www.epuap.org/guidelines Final_Quick_Treatment.pdf Australian Charter of Healthcare Rights. Getting Started Kit: Prevent Pressure Ulcers, How-to Guide 2008. 5 Million Lives Campaign. Institute for Healthcare Improvement; Cambridge, MA. Pressure Ulcers: Prevention and Management 2011. The Joanna Briggs Institute. Pressure Area Care: Management 2012. The Joanna Briggs Institute. Queensland Health. http://www.health.qld.gov.au/ DAA Evidence Based Practice Guidelines for Nutritional Management of Malnutrition in Adult Patients Across the Continuum of Care, 2009. Dietitians Association of Australia. 9
This document can be made available in alternative formats on request for a person with a disability. Department of Health 2013