NATIONAL STANDARD 8 PREVENTING AND MANAGING PRESSURE INJURY

Matthew Wilson

Sutherland Hospital

PREVENTING ANDMANAGING

PRESSURE INJURY

Pressure Ulcer

Development

Pressure

Impaired Mobility

Impaired Activity

Impaired Sensory

Perception

Extrinsic Factors

Intrinsic Factors

Moisture

Friction

Demographics

Oxygen Delivery

Skin Temperature

Chronic Illness

Shear

NutritionTissue Tolerance

Source: Final Draft - Clinical Practice Guidelines for the Prevention of Pressure

Ulcers, March 1999

Support Surfaces

Skin Inspections

� Erythema,

� Elanching response

� Localised heat

� Oedema

� Induration

� Skin breakdown.

STAGE 1

STAGE I PRESSURE INJURY: NON-

BLANCHABLE ERYTHEMA

� 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 from 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.

Stage 1

STAGE 2

STAGE II PRESSURE INJURY: PARTIAL

THICKNESS SKIN LOSS

� Partial thickness loss of dermis presenting as a

shallow, open wound with a red-pink wound bed,

without slough.

�May also present as an intact or open/ruptured

serum-filled blister.

� Presents as a shiny or dry, shallow ulcer without

slough or bruising

Stage 2

Stage 2

STAGE 3

STAGE III PRESSURE INJURY: FULL

THICKNESS SKIN LOSS

� 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 and tunnelling

Stage 3

STAGE 4

STAGE IV PRESSURE INJURY: FULL

THICKNESS TISSUE LOSS

� Full thickness tissue loss with exposed bone,

tendon or muscle. Slough or eschar may be

present on some parts of the wound bed.

Stage 4

SUSPECTED DEEP TISSUE INJURY

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.

Suspected Deep Tissue Injury

SUSPECTED DEEP TISSUE INJURYSuspected Deep Tissue Injury

UNSTAGEABLE PRESSURE INJURY:

DEPTH UNKNOWN

� Full thickness tissue loss in which the base of the

PI is covered by 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.

Unstageable

Unstageable

10 NATIONAL STANDARDS

NATIONAL STANDARD 8

� Governance and systems

� Preventing pressure injury

�Managing pressure injury

� Communicating with patients and carers

Benefits of Standard 8

� Reduce avoidable pressure injuries

� Reduce cost for the organisation/state health

department

� Bring nurses/allied health to the forefront

� Potential increase of specialist wound care

positions

Where to start

� Identify key stakeholders

� Executive support

� Perform gap analysis

�Meet with key stakeholders

� Distribute task amongst key stakeholders

GOVERNANCE AND SYSTEMS

� Hospital Pressure Injury Prevention Committee

� Review of incident data (IIMS)

� Review of polices and procedures

� R/V of educational requirements

� R/V of current issues

GOVERNANCE AND SYSTEMS

� Best practice clinical audits

� Risk assessment

� Skin assessments

� Prevention plans

� Management plans

� Consumer engagements

IIMS STICKER

IIMS

IIMS – Waterlow Score & SAC Score

Waterlow Scores

No risk less than 5

Low risk less than 10

Medium risk 10 +

High risk 15 +

Very high risk 20 +

SAC

Score

Guidelines for SAC Scores

� New pressure ulcer including

� ↑ length of stay

and/or

� Requires surgery on pressure injury

� Any new grade 3 and 4 pressure injury

SAC 2

� New pressure injury

� Doesn’t ↑ length of stay

or

� Dosen’t require surgery on pressure injury

SAC 3

� Admitted to the health service with an

existing pressure injurySAC 4

GOVERNANCE AND SYSTEMS

� Point prevalence audits

� Prevalence

� Hospital acquired pressure injury

� Grade of pressure injury

� Waterlow

� Mattresses

� Wound assessment form

Other sources of pressure injury data

� Coded data through clinical information

� Simple monthly reports can be run

� Coders need to be trained around new pressure

injury staging system

PREVENTING PRESSURE INJURY

� New 7 day Waterlow review form

�Mattress system

�Waterlow competence

� Pt's are given information brochures on pressure

injury prevention.

Highlight quality activities

� Gurada heel introduced into operating theaters

�Waterlow, skin inspection and mattress add to

clinical handover

MANAGING PRESSURE INJURY

� New Wound Chart

�Wound care best practice

� Closer relationships with facilities on D/C

COMMUNICATING WITH PATIENTS AND

CARERS

� Patient and/or carer aware tick box on multiple

forms such as Wound Chart and 7 Waterlow

Review chart

�Move towards notifying pt/carers when IIMS

incident is logged

� Pressure Injury Prevention Handouts are

available for all patients

How to maintain change

� Feedback to key stakeholders

� Feedback to nursing staff at ward level

� Be transparent with results

IN SUMMERY

� Don’t panic

�Work through standard 8 systematically

� Establish group of stakeholders

�Move now to fill gaps in practice and resources

� Communicate with other hospitals to pool

resources