Preventing and Managing Pressure Injuries

Standard 8

Preventing and Managing Pressure Injuries

Criteria for the Preventing and Managing Pressure Injuries Standard:

Governance and systems for the prevention and management of pressure injuries

Health Service Organisations have in place governance structures and systems for the prevention and management of pressure injuries.

This criteria will be achieved by: / Actions required: / Examples of Victorian tools and resources that can be used to demonstrate an action is being met.
This is not a checklist, use only examples that show that you have met the Standards
C[1] / 8.1 Developing and implementing the policies, protocols or procedures are based on current agreed best practice guidelines / 8.1.1 Policies, protocols or procedures based on best practice guidelines are in use by the clinical workforce and regularly monitored / - Improving the environment for older people in Victorian emergency departments: Audit report 2009.
This report describes the findings of a project in which Victorian health services evaluated the emergency departments’ environment for older people using an audit tool developed by the Departmentof Health and the National Ageing Research Institute.
- 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 that could assist with meeting this standard.
C / 8.1.2 Policies, protocols and processes incorporate screening and assessment tools consistent with best practice
C / 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 / 8.2.1 An organisation wide system for reporting pressure injuries is in use
C / 8.2.2 Administrative and clinical data are used to regularly monitor and investigate the frequency and severity of pressure injuries
C / 8.2.3 Information on pressure injuries is regularly reported to the highest level of governance in the health service organisation
C / 8.2.4 Action is taken to reduce the frequency and severity of pressure injuries
C / 8.3 Undertaking quality improvement activities to address safety risks and monitor the systems that prevent and manage pressure injuries / 8.3.1 Quality improvement activities are undertaken to prevent pressure injuries and/or improve the management of pressure injuries
C / 8.4 Providing or facilitating access to equipment and devices to implement effective prevention strategies and best practice management plans / 8.4.1 Equipment and devices are available to effectively implement prevention strategies for patients at risk and management plans for patients with pressure injuries

Preventing pressure injuries

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

This criteria will be achieved by: / Actions requires: / Examples of Victorian tools and resources that can be used to demonstrate an action is being met.
This is not a checklist, use only examples that show that you have met the Standards
C / 8.5 Identifying risk factors for pressure injuries using an agreed screening tool for all presenting patients within timeframes set by best practice guidelines / 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 / - 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 that could assist with meeting this standard.
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
C / 8.5.3 Action is taken to maximise the proportion of patients who are screened for pressure injury on presentation
C / 8.6 Conducting a comprehensive skin inspection in timeframes set by best practice guidelineson patients with a high risk of developing pressure injuries at presentation, regularly as clinically indicated during a patients admission, and prior to discharge / 8.6.1 Comprehensive skin inspections are undertaken and documented in the patient clinical record for patients at risk of pressure injuries / - 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 that could assist with meeting this standard.
C / 8.6.2 Patient clinical records, transfer and discharge documentation are periodically audited to identify the proportion of at risk patients with documented skin assessments
C / 8.6.3 Action is taken to increase the proportion documented skin assessments undertaken
C / 8.7 Implementing and monitoring pressure injury prevention plans and reviewing when clinically indicated / 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 / - 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 that could assist with meeting these criteria for example:

Skin integrity booklet: Its maintenance and support
Clinical practice guidelines for the prediction and prevention of pressure ulcers

C / 8.7.2 The effectiveness and appropriateness of pressure injury prevention plans is regularly reviewed
D / 8.7.3 Patient clinical records are monitored to determine the proportion of at risk patients with a pressure injury prevention plan that has been implemented
D / 8.7.4 Action is taken to increase the proportion of prevention plans implemented for patients at risk of pressure injuries

Managing pressure injuries

Patients who have pressure injuries are managed according to best practice guidelines.

Communicating with patients and carers

Patients and carers are informed of the risks, prevention strategies and management of pressure injuries.

This criteria will be achieved by: / Actions required: / Examples of Victorian tools and resources that can be used to demonstrate an action is being met.
This is not a checklist, use only examples that show that you have met the Standards
D / 8.9 Informing patients with a high risk of pressure injury and their carers about the risks, prevention strategies and management of pressure injuries / 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 / - Achievements under Improving Care for Aboriginal and Torres Strait Islander Patient Program to ensure culturally appropriate information and mechanisms for relaying information to Aboriginal patients, carers and family will provide evidence of this action.
- 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 that could assist with meeting these criteria for example:

Move Move Move

D / 8.10 Developing a management plan in partnership with patient and their carers / 8.10.1 Pressure injury management plans are developed in partnership with patients and carers

Page 1Department of Health

[1]C indicates that the action is core for hospitals, which is critical to safety and quality and which must be met in order to meet the Standard.

D indicates that the action is developmental for hospitals, which are aspirational targets that health services will not be required to achieve in order to meet the Standard.