Standards 8: Preventing and Managing Pressure Injuries
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Standards 8: Preventing and Managing Pressure Injuries
Clinical leaders and senior managers of the 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 prevention and management systems.
The intention of this Standard is to:
Prevent patients from developing pressure injuries and effectively managing pressure injuries when they do occur.
Context
It is expected that this Standard will be applied in conjunction with Standard 1, ‘Governance for Safety and Quality in Health Service Organisations’ and Standard 2, ‘Partnering with Consumers’.
Criteria to achieve the Preventing and Managing Pressure Injuries Standard:
Governance and systems for the prevention and management of pressure injuries
Preventing pressure injuries
Managing pressure injuries
Communicating with patients and carers
Criterion: Governance and systems for the prevention and management of pressure injuries
Health service organisations have governance structures and systems in place for the prevention and management of pressure injuries.
C/D / This criterion will be achieved by: / Actions required / Examples of evidence that can be used to demonstrate an action is being met.This is not a checklist. Use only those examples that show that you have met the Standards / Self assessment /
C / 8.1 Developing and implementing policies, procedures and/or protocols that are based on current best practice guidelines
/ 8.1.1 Policies, procedures and/or protocols are in use that are consistent with best practice guidelines and incorporate screening and assessment tools / · Policies, procedures and/or protocols that are evidence based and consistent with best practice guidelines and incorporate screening and assessment tools
· Audit of clinical practice and the tools and procedures employed to identify individuals at risk
· Evaluation reports of the organisations’ pressure injury prevention program that includes the use of policy, procedures and/or protocols and areas that require modification and education requirements
· Reports tracking trends over time may benchmark high performing agencies / MM
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(i) Evidence-based clinical practice guidelines, such as the Australian Wound Management Association Clinical Practice Guidelines for Pressure Ulcer Prevention and Management are readily available and accessible to the clinical workforce: www.awma.com.au
C / 8.1.2 The use of policies, procedures and/or protocols are regularly monitored / · Policies, procedures and/or protocols are available to the workforce
· Observation audit of the use of policies, procedures and/or protocols
· Patient clinical record reviewed against policies, procedures and/or protocols
· Audits, prevalence surveys and/or incident reporting are conducted and findings inform organisational prevention and management policies, procedures and/or protocols
· Agenda papers, meeting minutes and/or reports of relevant committees that detail improvement actions / MM
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(i) A health service where there is a high risk of pressure injuries may routinely undertake a comprehensive assessment of all patients for pressure injuries. Low risk services may undertake a simple screening process and only fully assess patients indentified to be at risk of pressure injuries. This would be reflected in the organisation’s policies, procedures and/or protocols
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 / · Incident reporting forms and processes included in policies, procedures and/or protocols
· Reports on pressure injuries and interventions to manage pressure injuries
· Education resources and training attendance record related to pressure injury reporting systems
· Agenda papers, meeting minutes and/or reports of relevant committees / MM
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C / 8.2.2 Administrative and clinical data are used to regularly monitor and investigate the frequency and severity of pressure injuries / · Process to extract information and regular reports form administration and clinical data on pressure injuries
· Quality improvement plans that require routine review of pressure injury incidence, prevalence and management information
· Agenda papers, meeting minutes and/or reports of relevant committees with delegated responsibilities for pressure injuries such as clinical risk committees and the senior executive
· Reports on trends in pressure injuries
· External reports to owners, regulators, insurers and departments
· Feedback to clinical workforce on incidence and prevalence, monitoring proformas, trends, changes to policy, procedure and/or protocols and review schedules / MM
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(i) Pressure injury data collected may include:
· number of pressure injuries
· stage of pressure injuries
· pressure injury prevention strategies in place at time of injury
· management strategies implemented
C / 8.2.3 Information on pressure injuries is regularly reported to the highest level of governance in the health service organisation / · Agenda papers, meeting minutes and/or reports of relevant committees includes information and data on pressure injuries
· Pressure injury prevalence and/or incidence reports are routinely tabled at senior executive and clinical governance meetings within the organisation / MM
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C / 8.2.4 Action is taken to reduce the frequency and severity of pressure injuries / · Pressure injury prevention plans describe consultation with relevant stakeholders
· Data used to track trends over time and changes from actions taken
· Reports benchmarking performance in the management of preventable pressure injuries against high performing services
· Education resources and training attendance records on changes to policies, procedures and/or protocols following review of pressure injury incidents
· Risk register or log that includes actions to address identified risks
· Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail improvement actions taken
· Quality improvement plan includes actions to address issues identified
· Examples of improvement activities that have been implemented and evaluated
· Communication material developed for the workforce and/or patients / MM
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(i) Educational topics to prevent and manage pressure injuries may include:
· manual handling to prevent shear and friction
· aetiology and risk factors for pressure injuries
· application of risk assessment tools
· skin assessment
· selection and/or use of support surfaces
· development and implementation of an individualised program of skin care
· repositioning to decrease risk of tissue breakdown
· documentation pressure injuries assessment and management
· incident reporting
C / 8.3 Undertaking quality improvement activities to address safety risks and monitor the system 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 / · Risk register or log that includes actions to address identified risks
· Amended policies, procedures and/or protocols and guidelines
· Observational audits of use of screening assessment tools
· Report on usage rates of specified products and equipment
· Data collected pre and post interventions
· Agenda papers, meeting minutes and/or reports of relevant committee(s) that details improvement actions
· Quality improvement plan includes actions to address issues identified
· Examples of improvement activities that have been implemented and evaluated
· Communication material developed for the workforce and/or patients / MM
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NM - add to action plan
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 plans for the management of patients with pressure injuries / · Agenda papers, meeting minutes and/or reports of relevant committee responsible for evaluating the efficacy of products, equipment and devices
· Inventories of equipment and audits of clinical use
· Maintenance log of equipment and devices / MM
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Criterion: Preventing pressure injuries
Patients are screened on presentation and pressure injury prevention strategies are implemented when clinically indicated.
C/D / This criterion will be achieved by: / Actions required / Examples of evidence that can be used to demonstrate an action is being met.This is not a checklist. Use only those examples that show that you have met the Standards / Self assessment /
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 / · Pre admission assessment tool
· Orientation and ongoing education resources on the use of pressure injury screening for the relevant clinical workforce
· Schedule of training and attendance records for relevant clinical workforce
· Audit of patient clinical record for use of screening assessment / MM
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(i) Policies, procedures and/or protocols should include criteria that assist the clinical work force determine the need to screening and or assessment. This will be risk based.
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 / · Audit of patient clinical record for compliance with screening requirement
· Observational audit of the use of screening tool / MM
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NM - add to action plan
C / 8.5.3 Action is taken to maximise the proportion of patients who are screened for pressure injury on presentation / · Risk register or log that includes actions to address identified risks
· Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail improvement actions taken
· Quality improvement plan includes actions to address issues identified
· Examples of improvement activities that have been implemented and evaluated
· Communication material developed for the workforce and/or patients / MM
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NM - add to action plan
C / 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
/ 8.6.1 Comprehensive skin inspections are undertaken using an agreed assessment tool and documented in the patient clinical record for patients at risk of pressure injuries / · Assessment tool is included in policies, procedures and/or protocols
· Report on use of assessment tool provided to clinical workforce
· Audit of patient clinical record for completed assessment tool and timing of assessments / MM
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C / 8.6.2 Patient clinical records, transfer and discharge documentation are periodically audited to identify at-risk patients with documented skin assessments / · Policies, procedures and/or protocols specify the nature and frequency of patient clinical record audits
· Audit of patient clinical record that shows at risk patients with documented skin assessments
· Agenda papers, meeting minutes and/or reports of relevant committees include information relating to the audit of patient clinical records
· Report to clinical workforce on audit / MM
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C / 8.6.3 Action is taken to increase the proportion of skin assessments documented on patients at risk of pressure injuries / · Provision of infrastructure, instruments, and other equipment necessary to comply with policy, protocol and procedures are accessible to the workforce
· Risk register or log that includes actions to address identified risks
· Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail improvement actions taken
· Quality improvement plan includes actions to address issues identified
· Examples of improvement activities that have been implemented and evaluated
· Communication material developed for the workforce and/or patients / MM
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NM - add to action plan
C / 8.7 Implementing and monitoring pressure injury prevention plans including review 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 / · Policies, procedures and/or protocols reference sources and are consistent with national guidelines
· Log of availability and use of pressure injury prevention devices
· Audit of patient clinical records for compliance with policies, procedures and/or protocols / MM
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C / 8.7.2 The effectiveness and appropriateness of pressure injury prevention plans are regularly reviewed / · Patient clinical record for review of an individual’s pressure injury prevention plan
· Reports on the prevalence and/or incidence of pressure injury within the organisation
· Documented review of policies, procedures and/or protocols
· Agenda papers, meeting minutes and/or reports of relevant committee(s) / MM
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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 record identifies patients with documented injury prevention plans
· Report on patients with completed pressure injury prevention plans / MM
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D / 8.7.4 Action is taken to increase the proportion of patients at risk of pressure injuries who have an implemented prevention plan / · Same evidence options as 8.5.3 / MM
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Criterion: Managing pressure injuries
Patients who have pressure injuries are managed according to best practice guidelines.
C/D / This criterion will be achieved by: / Actions required / Examples of evidence that can be used to demonstrate an action is being met.This is not a checklist. Use only those examples that show that you have met the Standards / Self assessment
C / 8.8 Implementing best practice management and ongoing monitoring as clinically indicated / 8.8.1 An evidence-based wound management system is in place within the health service organisation / · Policies, procedures and/or protocols describe the evidence-based wound management system to be used
· Agenda papers, meeting minutes and/or reports of relevant committee(s) with responsibilities for implementing and monitoring the wound management system
· Education resources and training attendance data managing pressure injuries
· Observational audit that evidence-based guidelines are accessed by the clinical workforce
· Reports from clinical data systems
· Audits of patient clinical records / MM
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(i) Evidence-based clinical practice guidelines are the Australian Wound Management Association: Clinical Practice Guidelines for Pressure Ulcer Prevention and Management; and standards such as the Australian Wound Management Association Standards for Wound Management
C / 8.8.2 Management plans for patients with pressure injury management plans are consistent with best practice and documented in the patient clinical record / · Policies, procedures and/or protocols outline the pressure injury management plan documentation requirements for individuals at risk of pressure injury
· A management plan form that specifies the care required, requires the designation of responsibilities for care, and states the frequency of turning, equipment needs, need for referrals and expected outcomes / MM
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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 completed pressure injury management plans / MM
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C / 8.8.4 Action is taken to increase compliance with evidence-based pressure injury management plans / · Same evidence options as 8.5.3 / MM
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NM - add to action plan
Criterion: Communicating with patients and carers