Preventing and Managing Pressure Injuries8SA Health

National Safety and Quality Health Service Standards

Standard 8Preventing and

Managing Pressure Injuries

SA Health Accreditation Resource to support

Health Services

Standard 8: Preventing and Managing Pressure Injuries - SA Health Resource Guide to support Health Servicespage 1

Preventing and Managing Pressure Injuries

Clinical leaders and senior managers of a health service organisation implement evidence-based systems to prevent pressure injuries and manage them when they do occur.

Clinicians and other members of the workforce use the pressure injury preventing and management systems.

The SA Health Accreditation Resource is designed to be used in addition to the Australian Commission on Safety and Quality in Health Care’s resources when implementing the National Safety and Quality Health Service Standards. It contains a combination of resources (policies, guidelines and tools) developed by SA Health and assists health services in identifying examples of evidence to demonstrate how to meet individual actions.

These resources are working documents that can be used by health services in their planning for assessment against the National Safety and Quality Health Service Standards. Regular review and update will occur as required.

Further information is available in the Australian Commission on Safety and Quality in Health Care Safety and Quality Improvement Guide.

ContentsGovernance and systems for the prevention and management of pressure injuries 2

Preventing pressure injuries 4

Managing Pressure Injuries 6

Communicating with patients and carers 7

Useful links 8

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Preventing and Managing Pressure Injuries

Standard 8: Prevention and Management of Pressure Injuries

Criteria for the Preventing and Managing Pressure Injuries Standard

Governance and systems for the prevention and management of pressure injuriesHealth service organisations have governance structures and systems in place for the prevention and management of pressure injuries.

Actions required: Examples of evidence

8.1 Developing and implementing policies, procedures and/ or protocols that are based on current best practice guidelines.

C 8.1.1 Policies, procedures and/or protocols are in use that are consistent with best practice guidelines and incorporate screening and assessment tools.

SA Health Pressure Injury Prevention and Management Policy Directive and Guideline.

National Guidelines Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury. 2012. Pan Pacific Australian Wound Management Association.

Standards for Wound Management.

Online web-based education is available free for all SA Health staff by arrangement with WoundsWest.

The Prevention section of the Pressure Injury module is strongly recommended for clinical staff across all disciplines.

The Victorian Government Health Information web-based materials called Best care for older people everywhere – The toolkit can be accessed through SA Health, and includes SA specific resources.

This toolkit includes a domain – “Skin Integrity” that includes links to evidence-based resources. Five facts everyone should know about skin integrity.

Reports from audits, prevalence surveys and incident reporting.

C 8.1.2 The use of policies, procedures and/or protocols is regularly monitored.

Reviews of patient clinical records and case notes against Policy Directive.

Audit of clinical practice.

8.2 Using a risk assessment framework and reporting systems to identify, investigate and take action to reduce the frequency and severity of pressure injuries.

C 8.2.1 An organisation wide system for reporting pressure injuries is in use.

SA Health Pressure Injury Prevention and Management Policy Directive and Guideline recommends that all pressure injury developed or deteriorating during an episode of health care are considered to be incidents and reported to Safety Learning System.

Reports on audit and incident data about prevalence and incidence.

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Preventing and Managing Pressure Injuries

Actions required: Examples of evidence

C 8.2.2 Administrative and clinical data are used to regularly monitor and investigate the frequency and severity of pressure injuries.

Documentation of trends in pressure injury incidence, prevalence and severity.

Reports can be generated from the data entered in Safety Learning System into the pressure injury section and considered by the committee. Patients who develop a PI or have a PI that worsens during an episode of care can be considered to be a “sample” of all patients. Reports provide data about, for example, the proportion with current pressure injury assessment, and the interventions in place.

C 8.2.3 Information on pressure injuries is regularly reported to the highest level of governance in the health service organisation.

Agendas and minutes from local meetings that include routine reporting about pressure injuries.

C 8.2.4 Action is taken to reduce the frequency and severity of pressure injuries.

Relevant reports on analysis of pressure injury information.

Quality improvement plan that includes actions to address issues identified.

Education resources and records of attendance.

8.3 Undertaking quality improvement activities to address safety risks and monitor the systems that prevent and manage pressure injuries.

C 8.3.1 Quality improvement activities are undertaken to prevent pressure injuries and/or improve the management of pressure injuries.

Easy Guide to Clinical Practice Improvement – a guide for health care professionals

Implement and evaluate quality improvement strategies to reduce the frequency and harm from pressure injuries.

8.4 Providing or facilitating access to equipment and devices to implement effective prevention strategies and best practice management plans.

C 8.4.1 Equipment and devices are available to effectively implement prevention strategies for patients at risk plans for management of patients with pressure injuries.

Documentation of local system to ensure that aids, equipment, devices are available and appropriate (part of PI committee activities), for example mattress audit tools.

Equipment utilisation reports.

Clinical audit of equipment use.

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Preventing and Managing Pressure Injuries

Preventing pressure injuriesPatients are screened on presentation and pressure injury prevention strategies are implemented when clinically indicated.

Actions required: Examples of evidence

8.5 dentifying risk factors for pressure injuries using an agreed screening tool for all presenting patients within time frames set by best practice guidelines.

C 8.5.1 An agreed tool to screen for pressure injury risk is used by the clinical workforce to identify patients at risk of a pressure injury.

The agreed screening tool for SA is the Braden Scale or Braden Q for paediatrics.

For those at nutritional risk the MUST tool further screens for malnutrition.

The SA Health toolkit includes a draft form for screening using Braden Scale, skin assessment and planning preventative care for those at risk.

C 8.5.2 The use of the screening tool is monitored to identify the proportion of at-risk patients that are screened for pressure injuries on presentation.

Evaluation, audit and feedback processes to determine use of screening tool.

Data from Safety Learning System.

C 8.5.3 Action is taken to maximise the proportion of patients who are screened for pressure injury on presentation.

Feedback provided to the workforce on results or audit and actions to address issues identified.

Examples of improvement activities.

8.6 Conducting a comprehensive skin inspection in timeframes set by best practice guidelines on patients with a high risk of developing pressure injuries at presentation, regularly as clinically indicated during a patient’s admission, and before discharge.

C 8.6.1 Comprehensive skin inspections are undertaken and documented in the patient clinical record for patients at risk of pressure injuries.

See also 8.1

The SA Health toolkit includes a draft form for screening using Braden Scale, skin assessment and planning preventative care for those at risk. A teaching package will be developed to introduce this tool to staff.

Other tools are recommended in the Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury, Australian Wound Management Association 2012.

Best care for older people everywhere – The Toolkit contains a suite of evidence-based resources and tools to minimise functional decline in older hospitalised people. The skin integrity domain of The Toolkit includes a number of resources.

C 8.6.2 Patient clinical records, transfer and discharge documentation are periodically audited to identify at-risk patients with documented skin assessments

Data from patient clinical records and case notes.

Reports or analysis of trends relating to pressure injuries.

C 8.6.3 Action is taken to increase the proportion of skin assessments documented on patients at risk of pressure injuries.

Examples of improvement activities that have been implemented and evaluated.

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Preventing and Managing Pressure Injuries

Actions required: Examples of evidence

8.7 Implementing and monitoring pressure injury prevention plans and reviewing when clinically indicated.

C 8.7.1 Prevention plans for all patients at risk of a pressure injury are consistent with best practice guidelines and are documented in the patient clinical record.

The Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury, Australian Wound Management Association 2012. This is the agreed clinical guideline for SA Health.

Template for prevention plans.

C 8.7.2 The effectiveness and appropriateness of pressure injury prevention plans is regularly reviewed.

Data and reports from audit of patient clinical records for re-assessment and review of an individual’s pressure injury plan.

Documented review of policies and procedures.

D 8.7.3 Patient clinical records are monitored to determine the proportion of at risk patients that have an implemented pressure injury prevention plan.

Audit of patient clinical records that identify patients with a current injury prevention plan.

D 8.7.4 Action is taken to increase the proportion of patients at risk of pressure injuries who have an implemented prevention plan.

Feedback provided to the workforce on audit results.

Agenda, minutes and/or reports of relevant committee and meetings that detailed improvement actions taken.

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Preventing and Managing Pressure Injuries

Managing Pressure InjuriesPatients who have pressure injuries are managed according to best practice guidelines.

Actions required: Examples of evidence

8.8 Implementing best practice management and ongoing monitoring as clinically indicated.

C 8.8.1 An evidence-based wound management system is in place in the health service organisation.

SA Health has adopted the clinical guideline the Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury, Australian Wound Management Association 2012.

Standards for Wound Management.

This guideline provides guidance about pressure injury management including treatments, dressings, selection of equipment etc. It also has recommended tools for assessment of pain and classifying pressure injury Stages.

SA has permission for staff to complete the on-line, web based training available through Wounds West. There are modules about pressure injury management to promote healing and minimise complications.

C 8.8.2 Management plans for patients with pressure injuries are consistent with best practice and documented in the patient clinical record.

Audits of completed management plans in clinical records and case notes.

C 8.8.3 Patient clinical records are monitored to determine compliance with evidence-based pressure injury management plans.

Audit of patient clinical records for pressure injury wound assessment and management plans that comply with policy and guideline.

C 8.8.4 Action is taken to increase compliance with evidence based pressure injury management plans.

Feedback to workforce.

Orientation, training and education resources.

Examples of improvement activities that have been implemented.

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Preventing and Managing Pressure Injuries

Communicating with patients and carersPatients and carers are informed of the risks, prevention strategies and management of pressure injuries.

Actions required: Examples of evidence

8.9 Informing patients with a high risk of pressure injury, and their carers, about the risks, prevention strategies and management of pressure injuries.

C 8.9.1 Patient information on prevention and management of pressure injuries is provided to patients and carers in a format that can be understood and is meaningful.

Patient information that is available in a range of formats and languages.

The Victorian Government Health Information booklets ‘Move, move, move’ and ‘Preventing Pressure Injuries’ are the current recommended consumer information for SA.

The skin integrity domain of Best care for older people everywhere – The toolkit includes links to evidence-based resources and tools.

8.10 Developing a plan of management in partnership with patients and carers.

C 8.10.1 Pressure injury management plans are developed in partnership with patients and carers.

Evaluation and results of patient and carer experience.

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Preventing and Managing Pressure Injuries

Useful links

Australian Commission on Safety and Quality in Health Care Safety and Quality Improvement Guide http://www.safetyandquality.gov.au/our-work/accreditation/nsqhss/safety-and-quality-improvement-guides-and-accreditation-workbooks/

Easy guide to Clinical Practice Improvement http://www0.health.nsw.gov.au/resources/quality/cpi_easyguide_pdf.asp

SA Health – WoundsWest www.health.wa.gov.au/woundswest

SA Health – Best care for older people everywhere – The toolkit http://www.sahealth.sa.gov.au/wps/wcm/connect/Public+Content/SA+Health+Internet/Clinical+resources/Clinical+topics/Older+people/Care+of+older+people+toolkit/

Best care for older people everywhere – Skin integrity http://www.health.vic.gov.au/older/toolkit/09SkinIntegrity/index.htm

Braden Scale or Braden Q for paediatrics http://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+resources/safety+and+quality/preventing+and+managing+pressure+injuries

Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury, Australian Wound Management Association 2012 http://www.awma.com.au/publications/publications.php

Standards for Wound Management http://www.awma.com.au/publications/publications.php

The Victorian Government Health Information booklets http://www.health.vic.gov.au/pressureulcers/consumer.htm

For more information SA Health Preventing and managing pressure injuries Michele Sutherland, Manager Safety and Quality Priority Areas Telephone: 08 8226 9599 www.sahealth.sa.gov.au/safetyandquality

www.ausgoal.gov.au/creative-commons

© Department for Health and Ageing, Government of South Australia. All rights reserved. FIS: 13034.8. March 2013.