Preventing and Managing Pressure Injuries1

Preventing and Managing Pressure Injuries1

The Victorian Department of Health is making this document freely available on the internet for health services to use and adapt to meet the National Safety and Quality Health Service Standards of the Australian Commission on Safety and Quality in Health Care. Each health service is responsible for all decisions on how to use this document at its health service and for any changes to the document. Health services need to review this document with respect to the local regulatory framework, processes and training requirements.

The author disclaims any warranties, whether expressed or implied, including any warranty as to the quality, accuracy, or suitability of this information for any particular purpose. The author and reviewers cannot be held responsible for the continued currency of the information, for any errors or omissions, and for any consequences arising there from.

Published by Sector Performance, Quality and Rural Health, Victorian Government, Department of Health

June 2014

Acknowledgements

The Department of Health Victoria acknowledges the contribution of medical and health specialists, Victorian health services, and members of the National Safety and Quality Health Service Standards: Educational Resources Project project team, Steering Group and Advisory Committee.

For the Preventing and Managing Pressure Injuries module, Regional Wounds Victoria provided specialist advice.

The Education Resources Project Steering Group members comprised:

Associate Professor Leanne Boyd, Steering Group Chair; Director of Education, Cabrini Education and Research Precinct, Cabrini Health

Ms Madeleine Cosgrave, Project Manager

Ms Susan Biggar, Senior Manager, Consumer Partnerships, Health Issues Centre

Mr. David Brown, Consumer representative

Dr Jason Goh, Medical Administration Registrar - Cabrini Health

Mr Matthew Johnson, Simulation Manager, Cabrini Education and Research Precinct, Cabrini Health

Ms Tanya Warren, Educator, Cabrini Education and Research Precinct, Cabrini Health

Ms Marg Way, Director, Clinical Governance, Alfred Health

Mr Ben Witham, Senior Policy Officer, Quality and Safety, Department of Health Victoria

The Education Resources Project Advisory Committee members comprised:

Associate Professor Leanne Boyd, Advisory Committee Chair; Director of Education, Cabrini Education and Research Precinct, Cabrini Health

Ms Madeleine Cosgrave, Project Manager

Ms Margaret Banks, Senior Program Director, Australian Commission on Safety and Quality in Health Care

Ms Marrianne Beaty, Oral Health National Standards Advisor, Dental Health Services Victoria)

Ms Susan Biggar, Senior Manager, Consumer Partnerships, Health Issues Centre

Mr David Brown, Consumer representative

Dr Jason Goh, Medical Administration Registrar, Cabrini Health

Ms Catherine Harmer, Manager,Consumer Partnerships and Quality Standards, Department of Health, Victoria

Ms Cindy Hawkins, Director, Monash Innovation and Quality, Monash Health

Ms Karen James, Quality and Safety Manager, Hepburn Health Service

Mr Matthew Johnson, Simulation Manager, Cabrini Health

Ms Annette Penney, Director ,Quality and Risk, Goulburn Valley Health

Ms Gayle Stone, Project Officer, Quality Programs,Commission for Hospital Improvement, Department of Health Victoria

Ms Deb Sudano, Senior Policy Officer, Quality and Safety, Department of Health Victoria

Ms Tanya Warren, Educator, Cabrini Health

Ms Marg Way, Director, Clinical Governance, Alfred Health

Mr Ben Witham, Senior Policy Officer, Quality and Safety, Department of Health Victoria

Preventing and Managing Pressure Injuries1

Contents

Preventing and Managing Pressure Injuries

Learning outcomes

National Standards

Aim of Standard 8

Policies and procedures

Preventing Pressure Injuries

Background

Principles of pressure injury prevention

Risk screening and assessment

Risk Factors

Comprehensive skin assessment

Pressure injury prevention strategies

Documentation and monitoring

Engaging with patients and carers

Pressure Injury Assessment and Management

Pressure injury assessment

Pressure injury classification

Management of pressure injuries

Documentation and monitoring

Audit and evaluation

Engaging patients and carers

Reporting adverse events

Summary

Glossary of terms

Test Yourself

Answers

References and Resources

Preventing and Managing Pressure Injuries1

Preventing and Managing Pressure Injuries

This module relates to the National Safety and Quality Health Service (NSQHS) Standard 8: Preventing and Managing Pressure injuries

Learning outcomes

On completion of this module, clinicians will be able to:

1. Outline the process for identifying risk of pressure injuries including frequency of assessment.
2. Describe preventative strategies to reduce the risk of pressure injuries.
3. Describe the principles of pressure injury management.
4. Describe the process for engaging patients and carers in pressure injury prevention.

National Standards

The Australian Commission on Safety and Quality in Health Care (ACSQHC) developed the 10 NSQHS Standards to reduce the risk of patient harm and improve the quality of health service provision in Australia. The Standards focus on governance, consumer involvement and clinically related areas and provide a nationally consistent statement of the level of care consumers should be able to expect from health services.

Aim of Standard 8

The intention of Standard 8: Preventing and Managing Pressure Injuriesis to prevent patients from developing pressure injuries and effectively manage them should they occur.

Standard 8 also relates to Standard 1: Governance for Safety and Quality in Health Service Organisations and Standard 2: Partnering with Consumers. The principles in these Standards are fundamental to all Standards andprovide a framework for their implementation.

ACSQHC, 2012

Table 1: Criteria to meet Standard 8 (ACSQHC, 2012)

Policies and procedures

There are numerous policies, procedures and resources within health care services to assist you with prevention and management of pressure injuries. It is important to access, read and adhere to systems, policies and procedures within your organisation.

Preventing Pressure Injuries

Background

There is increased risk of in-hospital complications in patients with a pressure injury and significant health care costs to both patients and health care services.

Pressure injuries are associated with:

• increased morbidity and mortality
• pain
• reduced mobility and loss of independence

Immobility associated with hospital admissions increases the risk of pressure injuries.

Older people in particular are at high risk due to decreased mobility, and other associated risk factors.

In most cases, pressure injuries are preventable.

ACSQHC, 2012;

Australian Wound Management Association (AWMA), 2012

Principles of pressure injury prevention

The Pan Pacific Clinical Practice Guideline for Prevention and Management of Pressure Injury (AWMA, 2012) outlines the following key messages in pressure injury prevention:

• most pressure injuries can be prevented
• they can occur in any patient, whether that patient has only some or all risk factors
• best practice in pressure injury prevention includes:

• vigilant screening
• comprehensive assessment
• implementing pressure injury prevention strategies
• evaluating effectiveness of pressure injury prevention strategies
• engaging patients in their own pressure injury prevention program

ACSQHC, 2012

Risk screening and assessment

A risk screening and assessment can be used to identify patients who are at risk of developing a pressure injury and require implementation of pressure injury prevention strategies.

It is important to note that some documents refer to risk assessmentand others to risk screeningwhich can be confusing. However, the intent of the risk screening and assessment process is to identify risk factors and highlight the need for comprehensive and ongoing skin assessment.

To minimise confusion, this document will refer to:

• risk screening and assessment as the process for identification of risk factors using a validated tool
• skin assessment as the process of conducting a head to toe examination of the skin

There a number of validated tools available thatassess a patient’s risk of developing a pressure injury. These include the Braden, Waterlow and Norton scales for adults and the Glamorgan, Braden Q and StarKid scales for paediatric patients.

Organisational policy will determine the tools used and frequency of screening in each health care service. It is important that you make yourself familiar with the specific tools you will be using.

Risk screening and assessment should occur on presentation, as soon as possible after admission (within 8 hours) and should also be repeated whenever there is a change in condition.

AWMA, 2012; ACSQHC, 2012

Risk Factors

Risk factors for pressure injuries can be grouped into two broad categories:

• those that contribute to increased exposure to pressure
• those that reduce the tissue’s tolerance to pressure

AWMA, 2012

Figure 1: Factors associated with increased risk or pressure injury

AWMA, 2012

increased exposure to pressure

Any reduction in a patient’s ability to change their own body position will increase a patient’s risk of developing pressure injuries. This can be a result of impaired mobility, activity or sensory perception. This may be caused by:

• neurological conditions and spinal cord injury
• cognitive impairment
• trauma and surgery
• obesity
• diabetes
• medications such as sedatives and hypnotics

reduction in tissue tolerance TO PRESSURE

The skin’s ability to tolerate the effects of pressure is affected by several factors including:

• friction and shear
• moisture
• effects of ageing such as reduced vascularity, sensation or lymphatic function
• chronic illness, e.g. diabetes or lymphoedema
• diseases that reduce oxygen delivery, e.g. cardiopulmonary and peripheral vascular disease, anaemia
• nutrition and hydration

AWMA, 2012

The more risk factors a patient has, the higher the risk of them developing a pressure injury. Some key risk factors will be discussed in more detail below.

effects of ageing

The most significant risk factor for development of a pressure injury is increasing age. This is caused by a reduction in skin thickness, subcutaneous fat and moisture content.

Older patients are more likely to experience cognitive impairmentwhich means that they may not be able to communicate pain from pressure or request assistance with changing position.

Older patients are also at risk of incontinence, which can increasethe likelihood of developing pressure injuries due to increased exposure to moisture.

AWMA, 2012

Improving Care of the Older Person, 2007

Poor nutrition and hydration

Poor nutrition and hydration can weaken the skin. Decreased energy intake and dehydration:

• reduce the skin’s tolerance to pressure friction and shear
• increase the risk of skin breakdown
• result in poor healing

Malnutrition is common and poorly recognised, occurring in 25 – 30% of hospitalised older patients.

Many older people are already at risk of under-nutrition on admission to hospital due to ageing and lifestyle. The impact of illness and hospitalisation may further compromise their nutritional status.

Hospitalisation can lead to an inability to access and consume food due to:

• inadequate supply of appetising food
• inadequate staffing for meal set up and assistance
• interruptions to mealtimes
• lethargy and effects of illness

Improving Care of the Older Person, 2007

Comprehensive skin assessment

A comprehensive skin assessment is required for patients who are at high risk of developing pressure injuries. This should occur within 8 hours of admission and daily thereafter.

ASQHC, 2013

What should be included?

A comprehensive skin assessment should include a complete head to toe inspection of your patient’s skin and hair observing:

• skin integrity
• temperature
• colour
• moisture and skin turgor
• any areas of pain or discomfort
• for pressure damage relating to devices such as splints and anti-embolic stockings.

(Where possible these devices should be removed at least once daily to complete a comprehensive skin assessment).

AWMA, 2012; Hess, 2010

Particular attention should be paid to bony prominences, especially the sacrum and heels, observing for indications of pressure injury such as:

• erythema
• blanching response
• localised heat
• oedema
• induration
• skin breakdown

Evaluation of other risk factors which contribute to pressure injury risk is also recommended including assessment of mobility and activity, continence, cognitive function, psychosocial issues, nutrition and extrinsic risk factors.

ACSQHC, 2012; AWMA, 2012

Screening for risk of malnutrition

There are a number of validated risk screening tools available. These tools usually include assessment of weight, height and BMI, as well as recent weight changes and food intake.

It is also important to conduct an assessment to check for any dental issues, medications or swallowing difficulties. These may impact on the patient’s ability to eat or drink. It is also important to understand your patient’s dietary requirements and preferences including cultural influences.

AWMA, 2012

Pressure injury prevention strategies

The Pan Pacific Clinical Practice Guideline for Prevention and Management of Pressure Injury (2012) outline evidence based pressure injury prevention strategies which should be included in the development of a pressure injury prevention plan.

AWMA, 2012; ACSQHC, 2012

Skin protection

Skin protection is fundamental to the prevention of pressure injury by protecting your patient’s skin from exposure to moisture, friction and shear.

This can be achieved in a number of ways including:

• encouraging and assisting patients with regular repositioning
• utilising pressure relieving support surfaces on beds, trolleys, operating tables and seat cushions
• promoting independent patient movement using assistance devices such as overhead bars
• implementing a continence management plan
• ensuring patient’s skin is thoroughly dried
• using pH balanced and water based skin emollients daily or twice daily to clean and moisturise skin
• avoid trauma to skin from devices such as wheel chair footplates, wheelie frames, bed rails and lifting machine parts

Tapes and adhesives should be avoided on fragile skin but if required:

• use tapes and dressings with a gentle adhesive that won’t cause trauma on removal (e.g. soft silicone dressings)
• consider using light tubular bandages to keep dressings in place
• apply the tape or dressing using gentle pressure to ensure it is firmly in place
• use caution and consider the use of adhesive removal wipes when removing dressings or tapes from fragile skin

Patient positioning

Patients who are unable to recognise pain from pressure or who are unable to reposition themselves require assistance with regular repositioning.

The frequency of repositioning should be determined by the patient’s risk of developing a pressure injury and other factors such as comfort, functional status and the support surface used.

When your patient is confined to bed, all bony prominences are exposed to high pressures. To relieve this pressure, you can position your patient slightly on either side. A 30 degree tilt to either side reduces pressure.

You can alternate your patient’s position from one side, to their back, and then to the other side (also known as ‘side to side’ nursing). Prone positioning your patient (laying them on their front) can be used as an alternative if medical reasons prevent the previous options.

If the patient is required to sit at an angle greater than 30 degrees in bed, they are at high risk of experiencing shear on the sacrum and coccyx. Patients should be supported to stop them slipping down the bed to reduce exposure to shear.

Always check the positioning of heels and bony prominences when repositioning and restrict time spent in seated positions without pressure relief.

optimise nutrition and hydration

Patients identified with malnutrition, or those found to be at risk, require referral to a dietician. A dietician or assistant will undertake a full nutritional assessment to ensure the nutritional needs of the patient are being met and can recommend supplements if required.

Nutrition can be optimised by ensuring:

• accessibility to a range of food choices
• the provision of assistance with meals as required (patient positioned correctly, packets opened, food cut up etc)
• monitoring of weight and dietary intake
• minimal interruptions and consideration of protected meal times

AWMA, 2012

Crowe &Brockbank, 2009

Patients with poor oral intake can be monitored using a food record chart, to enable an accurate record of their daily dietary intake. They should be weighed weekly.

Provision of support surfaces

The use of support surfaces is recommended to redistribute pressure on skin surfaces. Selection of support surfaces should be based on individualised patient assessment and requirements.

Recommendations include using a high specification reactive (constant low pressure) support foam mattress on beds and trolleys for those patients at high risk. Active (alternating pressure) support mattresses may be used as an alternative.

Mattresses and support surfaces should always be used in accordance with the manufacturer’s instructions.

Medical grade sheepskins should only be used when the mattress recommendations are not tolerated by patients or for comfort and palliative measures only. Sheepskins do not provide adequate pressure redistribution and should not be used on top of existing pressure relieving devices.

Support cushions should be used for patients when seated in a chair or wheelchair.

Devices used to prevent pressure injuries on heels need to be fitted correctly. If not fitted correctly, these devices will not only cease to provide pressure relief but can also cause harm.

AWMA, 2012

Documentation and monitoring

Skin assessment should be documented as soon as possible after admission, daily and whenever there is a change in condition. It is important to note that darker skin tones may be more difficult to visually assess.