Gap Analysis Work Sheet
Prevention of Constipation in the Older Adult – Revised 2011
Gap Analysis:
Assessment and Management of Pressure Injuries for the Interprofessional Team, Third Edition, May 2016
Work Sheet
This guideline can be downloaded for free at:
http://rnao.ca/bpg/guidelines/pressure-injuries
The RNAO Toolkit: Implementation of Best Practice Guidelines, Second Edition is also available at:
http://rnao.ca/bpg/resources/toolkit-implementation-best-practice-guidelines-second-edition
Gap Analysis – March 2017 Page 3 of 7
Gap Analysis: Assessment and Management of Pressure Injuries for the Interprofessional Team
Date Completed:Team Members participating in the Gap Analysis:
· / ·
· / ·
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Completion of this gap analysis allows for the annual comparison of your current practice to evidence-based practices as regulated by the MOHLTC. See Appendix A for this and other regulations that apply to a skin and wound care program in your home.
RNAO Best Practice Guideline Recommendations / Met / Partially Met / Unmet / Notes(Examples of what to include: is this a priority to our home, information on current practice, possible overlap with other programs or partners) /
Practice Recommendations - Assessment
1.1 Conduct a health history, a psychosocial history, and a physical exam on initial examination and whenever there is a significant change in the person’s medical status.
(Level V Evidence)
1.2 Assess the risk for developing additional pressure injuries on initial examination and if there is a significant change in the person’s medical status using a valid and reliable pressure injury risk assessment tool.
(Level V Evidence)
1.3 Assess the person’s pressure injury using the same valid and reliable wound assessment tool on initial examination and whenever there is a significant change in the pressure injury.
(Level V Evidence)
1.4 Assess the person’s pressure injury for signs and symptoms of infection (superficial critical colonization/localized infection and/or deep and surrounding infection/systemic infection) using a standardized approach on initial examination and at every dressing change.
(Level V Evidence)
1.5 a) Screen all persons with pressure injuries for risk of malnutrition using a valid and reliable screening tool on first examination and if there is a delay in pressure injury healing.
b) Determine the nutritional status of all persons at risk for malnutrition using a valid and reliable assessment tool within 72 hours of initial examination, and whenever there is a change in health status and/or the pressure injury.
c) Perform a comprehensive nutrition assessment of all persons with poor nutritional status within 72 hours of initial examination, and if there is a change in health status or delayed healing.
(Level V Evidence)
1.6 Assess for pressure injury pain on initial examination and continue to monitor pain at subsequent visits, including prior to and after every wound care intervention, using the same valid and reliable tool consistent with the person’s cognitive ability.
(Level V Evidence)
1.7 Perform a vascular assessment (i.e., medical history, physical exam) of all persons with pressure injuries in the lower extremities on initial examination.
(Level V Evidence)
1.8 Conduct a mobility and support surface assessment on initial examination and whenever there is a significant change in the person’s medical condition, weight, equipment, mobility, and/or pressure injury healing.
(Level V Evidence)
Practice Recommendations – Planning
2.1 Obtain the referral or consultations required to plan and coordinate a pressure injury plan of care.
(Level V Evidence)
2.2 Develop a pressure injury plan of care that incorporates goals mutually agreed upon by the person, the person’s circle of care, and the interprofessional team.
(Level Ia Evidence)
Practice Recommendations – Implementation
3.1 Reposition the person at regular intervals (i.e. every two to four hours) based on person-centred concerns. While sitting, weight-shift the person every 15 minutes.
(Level V Evidence)
3.2 Position all persons with a pressure injury on a pressure redistribution support surface at all times. (Level V Evidence)
3.3 Implement an individualized nutritional plan of care in collaboration with the person and his/her circle of care that addresses nutritional requirements and provides adequate protein, calories, fluid, and appropriate vitamin and mineral supplementation to promote pressure injury healing.
(Level V Evidence)
3.4 Provide local pressure injury care consisting of the following, as appropriate:
· cleansing (level of evidence = V);
· moisture balance (healable) or moisture reduction (nonhealable, maintenance) (level of evidence = Ia–b, V);
· infection control (i.e., superficial critical colonization/localized infection and/or deep and surrounding infection/systemic infection) (level of evidence Ia-b, V); and
· debridement (level of evidence = V).
(Level Ia, Ib, V Evidence)
3.5 Provide electrical stimulation (when available) as an adjunct to best practice wound care in order to speed healing and promote wound closure in stalled but healable stage 2, 3, and 4 pressure injuries. (Level Ia Evidence)
3.6 Implement, as an alternative, the following treatments in order to speed closure of stalled but healable pressure injuries, as appropriate and if available:
· electromagnetic therapy (level of evidence = Ib),
· ultrasound (level of evidence = Ib), and
· ultraviolet light (level of evidence = Ib).
Do not consider the following treatment in order to speed closure of stalled but healable pressure injuries:
· laser therapy (not recommended)
(Level Ib Evidence)
3.7 Provide negative pressure wound therapy to people with stage 3 and 4 pressure injuries in exceptional circumstances, including enhancement of quality of life and in accordance with other person-/family-centred preferences.
(Level V Evidence)
3.8 Collaborate with the person and his/her circle of care to implement a pressure injury self-management plan.
(Level Ia Evidence)
3.9 Implement a person-centred pain management plan using pharmacological and non-pharmacological interventions.
(Level V Evidence)
Practice Recommendations – Evaluation
4.1 Use the initial risk assessment tool to reassess the person’s risk for developing additional pressure injuries on a regular basis and whenever a change in the person’s health status occurs.
(Level V Evidence)
4.2 Use the initial wound assessment tool to monitor the person’s pressure injuries for progress toward person-centred goals on a regular basis and at dressing changes.
(Level V Evidence)
Education Recommendations
5.1 Develop and implement comprehensive and sustainable interprofessional pressure injury education programs for clinicians and students entering health-care professions.
(Level V Evidence)
5.2 Assess health-care professionals’ knowledge, attitudes, and skills related to the assessment and management of existing pressure injuries before and following educational interventions using an appropriate, reliable, and validated assessment tool.
(Level IV, V Evidence)
System, Organization, and Policy Recommendations
6.1 Organizations must lead and provide the resources to integrate pressure injury management best practices into standard and interprofessional clinical practice, with continuous evaluation of outcomes.
(Level IV Evidence)
6.2 Lobby and advocate for investment in pressure injury management as a strategic quality and safety priority in jurisdictions in order to improve health outcomes for people with pressure injuries.
(Level V Evidence)
Appendix A
Applicable Ministry of Health and Long-Term Care Regulations for Skin and Wound Care
Required programs48. (1) Every licensee of a long-term care home shall ensure that the following interdisciplinary programs are developed and implemented in the home:
2. A skin and wound care program to promote skin integrity, prevent the development of wounds and pressure ulcers, and provide effective skin and wound care interventions.
(2) Each program must, in addition to meeting the requirements set out in section 30,
(a) provide for screening protocols; and
(b) provide for assessment and reassessment instruments. O. Reg. 79/10, s. 48 (2).
Section 30
30. (1) Every licensee of a long-term care home shall ensure that the following is complied with in respect of each of the organized programs required under sections 8 to 16 of the Act and each of the interdisciplinary programs required under section 48 of this Regulation:
1. There must be a written description of the program that includes its goals and objectives and relevant policies, procedures and protocols and provides for methods to reduce risk and monitor outcomes, including protocols for the referral of residents to specialized resources where required.
2. Where, under the program, staff use any equipment, supplies, devices, assistive aids or positioning aids with respect to a resident, the equipment, supplies, devices or aids are appropriate for the resident based on the resident’s condition.
3. The program must be evaluated and updated at least annually in accordance with evidence-based practices and, if there are none, in accordance with prevailing practices.
4. The licensee shall keep a written record relating to each evaluation under paragraph 3 that includes the date of the evaluation, the names of the persons who participated in the evaluation, a summary of the changes made and the date that those changes were implemented. O. Reg. 79/10, s. 30 (1).
(2) The licensee shall ensure that any actions taken with respect to a resident under a program, including assessments, reassessments, interventions and the resident’s responses to interventions are documented. O. Reg. 79/10, s. 30 (2).
Skin and wound care
50. (1) The skin and wound care program must, at a minimum, provide for the following:
1. The provision of routine skin care to maintain skin integrity and prevent wounds.
2. Strategies to promote resident comfort and mobility and promote the prevention of infection, including the monitoring of residents.
3. Strategies to transfer and position residents to reduce and prevent skin breakdown and reduce and relieve pressure, including the use of equipment, supplies, devices and positioning aids.
4. Treatments and interventions, including physiotherapy and nutrition care. O. Reg. 79/10, s. 50 (1).
(2) Every licensee of a long-term care home shall ensure that,
(a) a resident at risk of altered skin integrity receives a skin assessment by a member of the registered nursing staff,
(i) within 24 hours of the resident’s admission,
(ii) upon any return of the resident from hospital, and
(iii) upon any return of the resident from an absence of greater than 24 hours;
(b) a resident exhibiting altered skin integrity, including skin breakdown, pressure ulcers, skin tears or wounds,
(i) receives a skin assessment by a member of the registered nursing staff, using a clinically appropriate assessment instrument that is specifically designed for skin and wound assessment,
(ii) receives immediate treatment and interventions to reduce or relieve pain, promote healing, and prevent infection, as required,
(iii) is assessed by a registered dietitian who is a member of the staff of the home, and any changes made to the resident’s plan of care relating to nutrition and hydration are implemented, and
(iv) is reassessed at least weekly by a member of the registered nursing staff, if clinically indicated;
(c) the equipment, supplies, devices and positioning aids referred to in subsection (1) are readily available at the home as required to relieve pressure, treat pressure ulcers, skin tears or wounds and promote healing; and
(d) any resident who is dependent on staff for repositioning is repositioned every two hours or more frequently as required depending upon the resident’s condition and tolerance of tissue load, except that a resident shall only be repositioned while asleep if clinically indicated. O. Reg. 79/10, s. 50 (2).
(3) In this section,
“altered skin integrity” means potential or actual disruption of epidermal or dermal tissue. O. Reg. 79/10, s. 50 (3).
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