Pressure Injury Prevention and Management

The Policy Directive outlines requirements for minimising the risk of pressure injuries through timely identification and management of modifiable risk factors and when pressure injuries are present appropriate treatment is provided. Document type Policy Directive Document number PD2021_023 Publication date 02 July 2021 Author branch Clinical Excellence Commission Branch contact (02) 9269 5500 Replaces PD2014_007 Review date 02 July 2026 Policy manual Not applicable File number H21/98626 Status Active Functional group Clinical/Patient Services Aged Care, Critical Care, Medical Treatment, Nursing and Midwifery Corporate Administration Governance, Information and Data Applies to Ministry of Health, Local Health Districts, Board Governed Statutory Health Corporations, Chief Executive Governed Statutory Health Corporations, Specialty Network Governed Statutory Health Corporations, Affiliated Health Organisations, Public Health System Support Division, Cancer Institute, Community Health Centres, NSW Ambulance Service, Dental Schools and Clinics, Public Hospitals Distributed to Ministry of Health, Public Health System, Divisions of General Practice, NSW Ambulance Service, Private Hospitals and Day Procedure Centres, Health Associations Unions, Tertiary Education Institutes Audience Allied Health Staff;Community Health staff;All Multipurpose Services (MPS) staff;All Clinical Staff and Executives;All Medical and Nursing Staff Policy Directive


About this document
Pressure injuries are a frequently occurring health problem and reduce quality of life through pain and discomfort. They are a costly, and often preventable with many individuals at risk due to aging, frailty, and multimorbidity. 1,2,3 The Australian Commission on Safety and Quality in Health Care (ACSQHC) has designated pressure injuries as a Hospital Acquired Complication (HAC). HAC is a complication for which clinical risk mitigation strategies may reduce, but not necessarily eliminate, the risk of a complication occurring. 4 Prevention of pressure injuries is the responsibility of all staff who work in health, regardless of location and position. Staff, patients and carers have a role to play in the prevention of pressure injuries. 3 The Policy Directive is revised in accordance with the International Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, 2019. 3 The Guideline is a collaboration between three partner organisationsthe European Pressure Ulcer Advisory Panel (EPUAP), the National Pressure Injury Advisory Panel (NPIAP) and the Pan Pacific Pressure Injury Alliance (PPPIA). The goal of the guideline is to provide an update of evidence-based recommendations for the prevention and treatment of pressure injuries. 3 The National Safety and Quality Health Service Standards (NSQHSS), Comprehensive Care Standard 5 , describes the systems and strategies to provide comprehensive care and identify risk of harm including the development of pressure injuries. This Policy also aligns with the Partnering with Consumers Standard, which ensures that systems are in place to design, deliver and evaluate care in partnership with consumers. 5 The Comprehensive Care Standard requires that:  Systems are in place to support clinicians to deliver comprehensive care  Integrated screening and assessment processes are used in collaboration with patients, carers and families to develop a goal-directed, comprehensive care plan  Safe care is delivered based on the comprehensive care plan, in partnership with patients, carers and family, including patients who are at the end of life  Patients at risk of specific harm are identified, and clinicians deliver targeted strategies to prevent and manage harm. 5 Evidence-based approaches to pressure injury prevention and management include:

Key definitions
Active support surface A powered support surface that produces alternating pressure through mechanical means, providing the capacity to change its load distribution properties with or without an applied load. This generally occurs through alternating of air pressure in air cells on a programmed cycle time. Also called an alternating pressure support surface or a dynamic support surface. 3

Bony prominence
An anatomical projection of bone. 3

Carers
People who provide care and support to family members and friends who have a disability, mental illness, chronic condition, terminal illness, an alcohol or other drug issue or who are frail aged.
Carers provide emotional, social or financial support. 6 Carers provide support for activities of daily living and include parents and guardians caring for children.

Classification of pressure injuries
Pressure injuries are classified using the National Pressure Ulcer Advisory Panel

Community Services
Services provided in the community setting and include but not limited to, Generalist Community Health Services, Palliative Care Services, Hospital in the Home, Child and Family Health Services, Chronic Care Services, Continence Services, Ostomy Services, Diabetes Services and Podiatry Services.

Mucosal pressure injury
Mucosal membrane pressure injuries are pressure injuries of the moist membranes that line the respiratory, gastrointestinal and genitourinary tracts. Mucosal pressure injuries are primarily caused by medical devices exerting sustained compression and shear forces on the mucosa. Classification systems for pressure injuries of the skin and underlying tissue cannot be used to categorize mucosal pressure injuries. 3

NSW public health facility
Any clinical unit or service that delivers public healthcare services. Health facilities include hospitals, multi-purpose services, emergency services, ambulatory care services, Aboriginal Medical Services and community health services and clinics.

Plan of care
Outlines the types and frequency of services required and the service provider details to meet care needs and mitigate identified risk factors.

Pressure Injury
Localised damage to the skin and/or underlying tissue, as a result of pressure or pressure in combination with shear and friction. Pressure injuries usually occur over a bony prominence but may also be related to a medical device or other object. 3,10

Pressure injury risk identification
A process to support identification of an individual's risk of developing a pressure injury.

Primary Care Provider
Primary healthcare providers include but are not limited to -General Practitioners, nurses (including general practice nurses, community nurses and nurse practitioners), allied health professionals, midwives, pharmacists, dentists, and Aboriginal Health Workers.

Risk screening
A process to support identification of an individual's risk of developing a pressure injury. 3

Reactive Support Surface
Powered or non-powered support surface with the capability to change its load distribution properties in response to an applied load. 11

Skin assessment
Examination of the entire skin surface from head to toe to check integrity and identify any characteristics indicative of pressure damage/injury. This entails assessment for erythema, blanching response, localised temperature changes compared to surrounding skin, oedema, induration and skin breakdown. Consider different skin tones. The skin beneath devices, prosthesis and dressings are to be checked when practical and safe to do so. 3

Staff
Any person working within the NSW Health system including clinicians, contractors, students and volunteers.

Unavoidable Pressure Injuries
Pressure injuries which occur despite consistent application of pressure injury prevention interventions. The implemented interventions were consistent with the patient's needs, goals, and recognised standards of practice, and there is evidence of monitoring and evaluation/revision of the interventions. 12

Wound-related pain
An unpleasant sensory and emotional experience associated with a pressure injury. Patients may use different words to describe pain including discomfort, distress and agony.8 Patients with cognitive impairment or expressive dysfunction may be unable to communicate their pain.

GOVERNANCE
Health services are to have a senior manager and/or a governance group responsible for the health service pressure injury policies, procedures and protocols, ensuring there are systems and processes in place to monitor and analyse pressure injury data and conduct/support relevant quality improvement activities. 5

PARTNERSHIP WITH PATIENTS AND/OR CARERS
Health services are to have systems to engage and partner with consumers and carers in care, to the extent that they choose. Education is to be provided to patients and their carers to address their pressure injury risk factors, and appropriate prevention and management strategies. This is to be supplemented with written information in plain language and resources for culturally and linguistically diverse populations. Information is easy to understand which will support partnerships.
Interpreters may be required for patients who are hearing impaired, those not fluent in English or whose preferred language is a language other than English. Health services are to have systems and processes appropriate for their patient populations, which identify risk factors and support care planning and shared decisionmaking.
Patients are to be screened for pressure injury risk as early as possible on presentation/admission:  Within 8 hours of presentation to a health facility for inpatient and Multi-Purpose Service (MPS) long stay facilities and NSW Health Residential Aged Care (RAC) facilities  At the first home visit or presentation for non-inpatient (community services, ambulatory facilities or clinics with clients at high risk) services.
Risk screening must consider the three primary predictors of pressure injury development: 1) Mobility/activity and neurological status -which can be restricted by the following but is not limited to physical limitations, over/under weight, sensory deficits, impaired cognition, low affect, demotivation, medication/anaesthetic or pain.
3) Skin status (as reported by the patient or the carer): a) General skin status relating to factors which may make the skin more vulnerable to pressure injury, e.g., redness, moisture, dryness, oedema b) Skin integrity including current and previous pressure injuries. 9 Patients with a history of or if a current pressure injury exists may be at risk of developing further pressure injuries.

Conduct skin assessment
When pressure injury risk factor/s are identified through the initial screening process, the patient is to have a documented skin assessment. Where skin assessment is outside the clinician's scope of practice, referral for skin assessment may be required. Ongoing, regular skin assessment appropriate to the care setting is required. See table 1 below.
In some situations, the patient may not give consent or is unsuitable to undergo a full skin assessment. The clinician must record in the medical record the reason why the skin assessment was not undertaken. In clinical situations when the risk of doing a skin assessment is outweighed by other risks to the patient or staff, the assessment is to take place as soon as practical after the risk is mitigated. Risks include: The skin assessment is to include a comprehensive head to toe assessment, focusing on skin overlying bony prominences including the occiput, sacrum, buttocks, heels, hips, pubis, thighs and torso. When the patient has a medical device the skin assessment is to include the skin under and around the device. For neonates, young children and critically unwell patients, the occiput requires careful attention. 3,10 Patients are to be reviewed if there is a change to a patient's health status or mobility, pre-operatively, as soon as feasible after surgery, postnatally prior to leaving the birthing setting, at transition of care, prior to discharge and if a pressure injury develops. If risks are identified, the plan of care is to be reviewed and ongoing skin assessment is required. If pressure injury risk factors are no longer present regular skin assessment is not required.

Prevention Strategies
Patients with risk factors for pressure injury, either with or without pressure injury, are to have:  Evidence based prevention strategies implemented as a priority within two hours of risk identification  Targeted interventions/strategies based on the risk factor(s) identified and reviewed regularly for their effectiveness.
Repositioning and/or early mobilisation schedule to prompt or assist repositioning as clinically indicated and using appropriate manual handling techniques and equipment. Patients are to be educated and encouraged to perform independent, pressure relieving manoeuvres when able.
 A 30-degree side lying position is to be used when repositioning individuals in bed.
Keep the head of the bed as flat as possible at no greater than 30-degrees elevation unless clinically necessary to facilitate breathing and/or prevent aspiration and ventilator-associated pneumonia. 3 The knee break function is to be used to prevent the patient from sliding down the bed to reduce shear forces. The torso to thigh angle is to be no greater than 30-degrees. 3

Pressure redistribution
 Mattress support surfaces which meet individualised requirements (i.e. weight, moisture, temperature, width, static or active surface types) are to be considered and regularly reviewed.
 Support surfaces (such as active and reactive) are to be used during care, including emergency departments, operating room, intensive care, dialysis units, and during transportation when clinically indicated and appropriate.
NB: In unstable spinal or pelvic fracture, active support surfaces are contra-indicated. This is regardless of the patient having identified risk factors for pressure injury or an existing pressure injury. Patients with unstable spinal or pelvic fracture are to stay on the appropriate non-powered support surface and receive regular pressure relief through lifting, as per spinal and pelvic fracture protocols.
 Seating support surfaces which meet the individualised requirements are to be considered and regularly reviewed.
 Other pressure redistribution and offloading equipment (e.g. repositioning devices or aids) are to be used according to individualised requirements and goals of care.
 Heels, Achilles tendon and popliteal vein are to be offloaded completely to distribute the weight of the leg along the calf. 3

Medical devices
 Devices/orthoses, compression therapy/stockings, casts/splint and other devices are to be correctly fitted, repositioned or removed regularly to have underlying skin inspected. Devices and orthosis need to be checked within 1-2 hours of first application to ensure there is no pressure. 10 The paediatric population is at increased risk of device related pressure injury.

Reduction of shear and friction:
 Prophylactic dressings -note dressing products do not reduce pressure  Appropriate manual handling techniques and equipment Pain Management ensures patients have adequate pain management to support early mobilisation and repositioning.
Education of patients/carers on the importance of regular repositioning and other prevention strategies which address risk factors.

Skin protection and moisture balance:
 Skin is cleaned and hydrated  Skin is protected from excessive moisture with a barrier product  Vigorous massage or rubbing of the skin is to be avoided as this can cause damage from shear and friction.
Continence management for persons with incontinence  A continence management plan is to be developed that facilitates individualised toileting, change of continence aids, and regular skin care.

NSW HEALTH PROCEDURE
 Highly absorbent continence products to protect the skin in individuals with or at risk of pressure injuries who have urinary and/or faecal incontinence. These need to be checked and changed regularly.
 Skin is to be cleansed after each episode of incontinence.
Adequate nutrition and hydration, is to be provided, including:  Consideration of adequacy of total energy (calorie), protein, fluid, vitamin and mineral intake Referral to health disciplines are to be made as clinically indicated for additional assessment and treatment.

Assess existing pressure injuries
Classification and assessment of pressure injuries is to occur when a pressure injury is identified, during serial wound management and on transfer of care (at the next dressing change). Pressure injuries are classified using the EPUAP/NPUAP 2009/2014 classification system.
Pain assessments are to be conducted to include pain management in the plan of care.

Managing existing pressure injuries
Plan of care that addresses risk factors and includes wound and pain assessment and management. The plan of care is to be reviewed by the multidisciplinary team within twenty-four hours of pressure injury identification wherever possible. If a pressure injury develops or an existing pressure injury significantly deteriorates (progresses to a more severe stage) the patient is to be reviewed.
Wound Management is to be provided or supervised by clinicians with knowledge, skills, and resources to provide treatment in accordance with best practice.

Monitor and document
Document in the medical record and complete wound chart(s) for pressure injuries, including if they were present on presentation or developed during the episode of care. Pressure injuries are to be notified through the incident management system if the injury was acquired during the current episode of care. Documentation is to include a pressure injury classification, anatomical location and dimensions. Capture and upload an image of the pressure injury as part of the documentation to monitor outcomes.

NSW HEALTH PROCEDURE
Wound reassessment is to occur as frequently as required, but at least weekly. Severe or a pressure injury that is not healing as anticipated, i.e. 25% reduction in four weeks 3 are to be reviewed by a clinician with expertise in wounds.
Consultations are to occur in a timely fashion with clinicians with expertise in wounds, medical or other health disciplines for their assessment, management and interventions. The use of virtual health to facilitate the consultation and reduce the need for patient or clinicians to travel is to be considered.
Pain is to be assessed and managed using best practice guidelines (using a validated pain tool) and documented.
Nutritional support is to be provided in accordance with NSW Health Nutrition Care Policy.
Prevention of additional pressure injuries as patients with a pressure injury are at a high risk of the injury worsening or developing other pressure injuries. See section 4.4 on prevention strategies.

Transition of Care
Transition of care for a patient at risk or with a pressure injury requires timely communication with health care providers taking over/resuming care, the patient and/or their carers, other community or residential services, equipment suppliers, and allied health clinicians. Communication is to include: Prevention strategies are to be used during transportation or transition of care for patients at risk or with an existing pressure injury. 3

RESOURCES
All health services are to have systems in place so that adequate expertise and resources, including equipment, devices and products, are available and accessible to provide best practice in pressure injury prevention and management.
Pressure injury prevention products, devices and equipment are to be purchased in accordance with NSW Health Procurement Guidelines and used in accordance with:

Monitoring
Health services are to have systems in place to:  Identify pressure injuries that develop during the episode of care  Review pressure injury data regularly, at a minimum quarterly  Ensure pressure injury data is communicated to the health service executive and those responsible for governance of clinical care  Analyse pressure injury data to inform care, quality improvement activities and monitor progress.