Download Pressure Injury Prevention and Management Policy

Pressure Injury Prevention and Management
Policy
Contents
1 Purpose….………………..............................................................................................................2
2 Scope/Audience.....................................................................................................................2
3 Definitions……………………………………………….............................................................................2
4 Associated Documents ………………………………….....................................................................3
5 Objectives ……….…………….......................................................................................................3
6 Personnel responsible for pressure care within WCDHB…….................................................4
7 Procedure…………....................................................................................................................4
8 Documentation………………......................................................................................................4
9 Discharge Planning…………………………………………………………………………….……………………………..5
10 References……………………………..……………………………………………………….………………………………5
11 Appendices ……………………………………………………………………………………………………………………7
11.1 AWMA Flow Chart…………………………………………………………………………………………
11.2 WCDHB Flow Chart………………………………………………………………………………………..
11.3 Adapted Waterlow Pressure Area Risk Assessment Chart.…………………………….
11.4 Skin Assessment…………………………………………………………………………………………….
11.5 Adapted Glamorgan Pressure Ulcer Risk Assessment Scale for Children……….
11.6 Grading Pressure Injuries……………………………………………………………………………….
Pressure Injury Prevention and Management Policy
Page 1 of 7
Document Owner: Occupational Therapy
WCDHB-CLIN76 Version 1, Issued April 2016
Master Copy is Electronic
UNCONTROLLED DOCUMENT – WEST COAST DISTRICT HEALTH BOARD
Pressure Injury Prevention and Management
Policy
1.
2.
Purpose
1.1
Minimise the incidence and prevalence of pressure related injuries of West Coast
District Health Board (WCDHB) patients through adequate risk assessment, risk
management and appropriate treatment.
1.2
Establish a consistent, systematic best-practice approach to pressure injury
prevention and management across the WCDHB.
1.3
Only the validated assessment tools and processes outlined in this policy are to
be used to ensure consistency across the WCDHB.
1.4
Support Health Services to comply with the National Pressure Ulcer Advisory
Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury
Alliance (NPUAP/EPUAP/PPPIA) prevention and management guidelines.
1.5
Increase the awareness of staff, patients and the public to the importance of
pressure injury prevention and management strategies.
1.6
Support the WCDHB to provide appropriate pressure reducing and relieving
equipment to best suit patient needs.
Scope / Audience
All WCDHB Clinical Staff.
3.
Definitions
Medical device/object: An item used in the care of a patient which may rub or exert
pressure on the skin when in consistent contact (with the skin) and therefore likely to
cause skin/tissue damage.
Pressure Injury: A localised injury to the skin and/or underlying tissue usually over a
bony prominence, as a result of pressure, shear and/or friction, or a combination of
these factors.
Skin assessment: General examination of the skin. Skin assessment includes examination
of the entire skin surface to check integrity and identify any characteristics indicative of
pressure damage/injury. This entails assessment for erythema, blanching response,
localised heat, oedema, induration and skin breakdown. Check the skin beneath devices,
prosthesis and dressings when practical.
Pressure Injury Prevention and Management Policy
Page 2 of 7
Document Owner: Occupational Therapy
WCDHB-CLIN76 Version 1, Issued April 2016
Master Copy is Electronic
UNCONTROLLED DOCUMENT – WEST COAST DISTRICT HEALTH BOARD
Pressure Injury Prevention and Management
Policy
4.
Associated Documents
Initial Assessment Documentation- this includes the Adapted Waterlow Pressure Area
Risk Assessment Chart and Adapted Glamorgan Pressure Ulcer Risk Assessment Scale
(attached).
Nursing Care Plan/Pressure Care flowchart (attached)/ Lippincott Procedures (Pressure
ulcer prevention, Pressure ulcer management and pressure dressing application) – all
available on the intranet
Safety 1st and ACC treatment injury paper work.
5.
Objectives
5.1
Ensure that the Adapted Waterlow Pressure Area Risk Assessment Chart or
Glamorgan Pressure Ulcer Risk Assessment Scale (Attached) is completed on all
patients within 8 hours of admission and reviewed regularly (review based on
patient acuity level) to identify at risk patents, specific risk factors and determine
the effectiveness and necessity for interventions.
5.2
Adapted Water low Pressure Area Risk Assessment Chart to be used across the
WCDHB to ensure consistency. The only exception to this is Paediatrics, where
the Glamorgan Pressure Ulcer Risk Assessment Scale should be used instead.
5.3
Staff are to follow the WCDHB pressure care flow chart (attached) and
appropriate IDT members given referrals.
5.4
To have documented IDT pressure care recommendations that reduces/relieves
pressure while promoting function and independence. Recommendations may
include but is not limited to turning schedules, wound management, pressure
reducing equipment, dietary advice and mobility schedules.
5.5
To protect against the adverse effects of external mechanical forces: pressure,
friction, and shear.
5.6
To maintain ongoing education of health professionals/carers/support
staff/patient/family in the prevention/treatment of pressure injuries.
5.7
For all pressure injuries to be regularly photographed (at least once weekly –
more frequently if indicated), with scale ruler. Photos are to include the date and
site of injury. Photos are to be shared with appropriate health professionals e.g.
Pressure Injury Prevention and Management Policy
Page 3 of 7
Document Owner: Occupational Therapy
WCDHB-CLIN76 Version 1, Issued April 2016
Master Copy is Electronic
UNCONTROLLED DOCUMENT – WEST COAST DISTRICT HEALTH BOARD
Pressure Injury Prevention and Management
Policy
DN for ongoing management post discharge, rest home if this is discharge
destination.
6.
5.8
All pressure injuries that are sustained while the patient is in the WCDHB’s care
are reported using Safety 1st and ACC treatment injury paper work completed
within the shift that they are identified.
5.9
Education is provided to patient and family around the prevention and
management of pressure injuries.
5.10
Mattresses used by patients meet acceptable standards (cover, foam quality) and
are no more than 10 years old.
Personnel responsible for pressure care within WCDHB
IDT for pressure care includes: Doctors, Nurses, Dietitian, Physiotherapist,
Occupational Therapist and Pharmacist.
Refer to Lippincott procedures for further detail.
7.
Procedure
The WCDHB uses Lippincott procedures. Please refer to the appropriate Lippincott
procedure, which can be found on the intranet:
Pressure ulcer prevention
Pressure ulcer management
Pressure dressing application
As per Lippincott guidelines the DHB must use a preferred assessment tool. For the
WCDHB this is the Adapted Water low Pressure Area Risk Assessment Chart for adults
and Glamorgan Pressure Ulcer Risk Assessment Scale for children (attached).
All patients should have daily skin assessments or as per acuity.
Any pressure injuries should be graded and photographed.
8.
Documentation
Includes risk assessment/reassessments, pressure injury staging and the patient’s plan of
care should be clearly documented in the patient’s clinical record.
A patient’s plan of care should address:
 Skin assessment and care
 Individualised positioning/turning schedules
Pressure Injury Prevention and Management Policy
Page 4 of 7
Document Owner: Occupational Therapy
WCDHB-CLIN76 Version 1, Issued April 2016
Master Copy is Electronic
UNCONTROLLED DOCUMENT – WEST COAST DISTRICT HEALTH BOARD
Pressure Injury Prevention and Management
Policy
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9.
Redistribution (support) surface systems
Nutritional interventions
Management/product selection
Referrals to Allied Health as appropriate
Evaluation of patient outcomes to interventions
Discharge Planning
Safety 1st and ACC documentation
Mobility schedules
Photography (refer to objective 5.7)
Education for patients and families/carers /whanau
Discharge Planning
Assess equipment needs for home.
Determine who is responsible to fund and organise equipment e.g. ACC, Long term
Residential Facilities, hospital Occupational Therapist.
Equipment details need to be documented on discharge form.
Appropriate referrals sent for community follow up e.g. district nurses.
10. References
1. Agency for Healthcare Quality and Research. (2011). Preventing pressure ulcers in
hospitals: A toolkit for improving quality of care (AHRQ Publication No. 11-0053-EF)
[Online]. Accessed December 2012 via the Web at
http://www.ahrq.gov/research/ltc/pressureulcertoolkit/putoolkit.pdf
2. Australian Wound Management Association. (2012). Pan Pacific Clinical Practice
Guideline for the Prevention and Management of Pressure Injury. Cambridge Media Osborne
Park, WA.
3. Baranoski, S., & Ayello, E. A. (2011). Wound care essentials: Practice principles (3rd ed.)
Philadelphia, PA: Lippincott Williams & Williams.’
4. Baranoski, S., & Ayello, E. A. (2012). Wound care essentials: Practice principles ( 3rd ed.).
Philadelphia, PA: Lippincott Williams & Williams.
5. Centers for Disease Control and Prevention. (2002). Guideline for Hand Hygiene in
Health-Care Settings: Recommendations of the Healthcare Infection Control
Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand
Hygiene Task Force. MMWR Recommendations and Reports, 51(RR-16), 1-45. (Level I)
6. Institute for Clinical Systems Improvement. (2012). Health care protocol: Pressure ulcer
prevention and treatment protocol (3rd ed.) [Online]. Accessed December 2012 via the
Pressure Injury Prevention and Management Policy
Page 5 of 7
Document Owner: Occupational Therapy
WCDHB-CLIN76 Version 1, Issued April 2016
Master Copy is Electronic
UNCONTROLLED DOCUMENT – WEST COAST DISTRICT HEALTH BOARD
Pressure Injury Prevention and Management
Policy
Web at
http://www.icsi.org/pressure_ulcer_treatment_protocol__review_and_comment_/p
ressure_ulcer_treatment__protocol__.html (Level V)
7. Institute for Clinical Systems Improvement. (2012). "Health care protocol: Pressure
ulcer prevention and treatment protocol, 3rd ed." [Online]. Accessed June 2013 via
the Web at https://www.icsi.org/_asset/6t7kxy/PresUlcerTrmt-Interactive0112.pdf
(Level VII)
8. Knox, D. M., et al. (1994). Effects of different turn intervals on skin of healthy older
adults. Advances in Wound Care, 7, 48-52, 54-56.
9. Levine, J., & Ayello, E. (2010). Pocket guide to pressure ulcers. Princeton, NJ: NJHA
HealthCare Business Solutions.
10. McInnes, E., et al. (2011). Support surfaces for pressure ulcer prevention. Cochrane
Database of Systematic Reviews, 2011(4), Art. No. CD001735.
11. Moore, Z. H. & Cowman, S. (2005). Wound cleansing for pressure ulcers (review).
Cochrane Database of Systematic Review, 2005(4), Art. No. CD004983.
12. National Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer
Advisory Group (EPUAP). (2009). Prevention and Treatment of Pressure Ulcers: Clinical
Practice Guideline. WashingtonDC: NPUAP.
13. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory
Panel. (2009). "Prevention and treatment of pressure ulcers: Clinical practice
guidelines" [Online]. Accessed December 2012 via the Web at
http://www.npuap.org/Final_Quick_Prevention_for_web_2010.pdf (Level VII)
14. National Pressure Ulcer Advisory Panel. (2007). "Pressure ulcer category/staging
illustrations" [Online]. Accessed June 2013 via the Web at
http://www.npuap.org/pr2.htm
15. Patton, R. M. (2010). Is diagnosis of pressure ulcers within an RN's scope of
practice? American Nurse Today, 5(1), 20.
16. Siegel J. D., et al. (2007). "2007 guideline for isolation precautions: Preventing
transmission of infectious agents in healthcare settings" [Online]. Accessed June 2012
via the Web at http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf (Level
I)
17. Stratton, R. J., et al. (2005). Enteral nutrition support in prevention and treatment of
pressure ulcers: A systematic review of meta-analysis. Ageing Research Reviews, 4, 422450.
18. Sussman, C., & Bates-Jensen, B. (2012). Wound care: A collaborative practice manual for
health professionals (4th ed.). Philadelphia, PA: Lippincott Williams & Williams.
Pressure Injury Prevention and Management Policy
Page 6 of 7
Document Owner: Occupational Therapy
WCDHB-CLIN76 Version 1, Issued April 2016
Master Copy is Electronic
UNCONTROLLED DOCUMENT – WEST COAST DISTRICT HEALTH BOARD
Pressure Injury Prevention and Management
Policy
19. The Joint Commission. (2012). Standard NPSG.07.01.01. Comprehensive accreditation
manual for hospitals: The official handbook. Oakbrook Terrace, IL: The Joint Commission.
(Level I)
20. The Joint Commission. (2013). Standard PC.01.02.07. Comprehensive accreditation manual
for nursing and rehabilitation centers: The official handbook.Oakbrook Terrace, IL: The Joint
Commission. (Level I)
21. World Health Organization. (2009). "WHO guidelines on hand hygiene in health
care: First global patient safety challenge, clean care is safer care" [Online]. Accessed
December 2012 via the Web at
http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf (Level I)
22. Wound, Ostomy, and Continence Nurses Society. (2010). "Guideline for prevention
and management of pressure ulcers" [Online]. Accessed December 2012 via the Web
at http://guideline.gov/content.aspx?id=23868
11. Appendices
Pressure Injury Prevention and Management Policy
Page 7 of 7
Document Owner: Occupational Therapy
WCDHB-CLIN76 Version 1, Issued April 2016
Master Copy is Electronic
UNCONTROLLED DOCUMENT – WEST COAST DISTRICT HEALTH BOARD
West Coast Pressure Care Flow Chart
* Pressure Care – Our Responsibility
Clinical staff to assess all patients within 8 hours of admission.
Complete:
Adapted Water Low / Glamorgan scale for Paeds
Skin Assessment
Appropriate validated Nutritional Screening Tool
Does patient have a
Pressure Injury or have
they developed one?
Yes
* Use Prevention Strategies
Grade Pressure Injury &
photograph
Start Wound Chart
Refer to Occupational
Therapy / Physio / Dietitian as
appropriate
Refer to appropriate
Lippincott procedure
DOCUMENT
No
Waterlow score >10
Glamorgan score >10
No
Yes
* Use Prevention Strategies
Refer to Occupational
Therapy / Physio / Dietitian
as appropriate
DOCUMENT
* Use Prevention strategies
Regular repositioning
Education to patient and
family
Encourage Independence &
mobility
Daily skin assessment e.g
when showering
DOCUMENT
Refer to medical team and wound
nurse for pain and wound
management & additional
management options
RESCREEN AS PER ACUITY
Wound Chart
Photgraph
Grade
Waterlow / Glamorgan
*
RESCREEN AS PER ACUITY
Waterlow / Glamorgan
DOCUMENT
LIPPINCOTT PROCEDURE ON INTRANET FOR PREVENTION/TREATMENT/DRESSING
Developed by Pressure Care Working Group
v3.0
Monday 18 April, 2016
Skin Assessment at West Coast District
Health Board
Skin assessments are a requirement for all patients this is one of the single most
effective ways of identifying injuries and preventing further damage.
What is a skin assessment: It is the general examination of the skin. Skin
assessment includes examination of the entire skin surface to check integrity and
identify any characteristics indicative of pressure damage/injury. This entails
assessment for erythema, blanching response, localised heat, oedema, induration
and skin breakdown. Check the skin beneath devices, prosthesis and dressings
when practical.
What to do:
•
Conduct a head-to-toe skin assessment.
•
Focus particular attention to skin overlying bony prominences including the
sacral region, heels, ischial tuberosities and greater trochanters
•
Darker skin tones may be more difficult to assess visually. Pay particular
attention to localised heat, oedema and induration in patients with darker
skin tones
•
Observe the skin for pressure damage related to medical devices (e.g. braces,
splints, harnesses, cervical collars, hip protectors). Where possible these
devices should be removed to allow a comprehensive skin assessment at
least daily or more frequently in high risk patients
•
Ask the patient to identify areas of discomfort or pain associated with
pressure and pay particular attention to assessment of these areas
Documentation
•
Document all skin assessments as soon as possible following admission and
within a minimum of eight hours (or on initial home or clinic visit for
patients seen in the community), on a daily basis and whenever there is a
change in the patient’s condition or as per acuity
Please refer to the Pressure Care Flow Chart, found in the Pressure Care
Prevention and Management policy for further required action.
Adapted Glamorgan Pressure Ulcer
Risk Assessment Scale for Children
Adapted Glamorgan Pressure Ulcer
Risk Assessment Scale for Children
Guidance on Using the Glamorgan Scale
A child’s risk of developing a pressure injury should be assessed
- Within 8 hours of admission
- Every time there are changes in the patients acuity
Mobility- Include the total of ALL relevant scores in this section
Child cannot be moved without great difficulty or deterioration in condition –
add 20 to total score for this section.
E.g. ventilated child who de-saturates with position changes, a child who
becomes hypotensive in a certain position.
Children with cervical spine injuries are limited in the positions they can lie in.
Some children with contracture deformities are only comfortable in limited
positions.
General anaesthetic >2hours – add 20 to total score for this section only on
day of surgery
E.g. a child who is on the theatre table may not have their position changed
during an operation for a prolonged period and is placed on a firm surface for
stability during the operation.
Unable to change his/her position without assistance – add 15 to total score
for this section.
E.g. a child may be unable to move themselves, but carers can move the child
and change his/her position.
Cannot control body movement – add 15 to total score for this section.
E.g. the child can make movements but these may not be purposeful
(repetitive dyskinetic movements), the child is unable to consciously change
his/her own position.
Some mobility but reduced for age – add 10 to total score for this section.
The child may have the ability to change their own position but this is limited /
restricted. E.g. a child with developmental delay, a child in traction who is able
to make limited movements, or a child on bed rest.
Normal mobility for age –score 0 for this section.
Mobility is appropriate for developmental stage.
E.g. a new born baby is able to move his/her limbs but is not able to roll over; a
1 year old is able to roll over, bottom shuffle or crawl, sit up and pull up to
standing
Adapted Glamorgan Pressure Ulcer
Risk Assessment Scale for Children
Equipment / objects / hard surface pressing or rubbing on the skin – add 15
to total score.
Any object pressing or rubbing on the skin for long enough or with enough
force can cause pressure damage. (These areas must be observed closely).
E.g. Pulse oximeter probes, ET tubes, masks, tubing/wires, tight clothing (antiembolic stockings), plaster casts/splints
Significant anaemia (Hb <90 g/l)
If the haemoglobin has been measured during this admission and is below
90g/l – score 1.
If the haemoglobin is 90 g/l or above score 0.
If the haemoglobin is unknown, write NK and score 0.
Persistent pyrexia (temperature >38.0 ºC for more than 4 hours)
If temperature is 38.0 ºC and above for more than 4 hours - score 1.
If temperature is less than 38ºC and/or pyrexia lasts less than 4 hours - score 0.
Inadequate nutrition (discuss with a dietician if in doubt)
If a child is identified as being malnourished (exclude pre-op fasting) - score 1.
A child who has a normal nutritional intake - score 0.
Low serum albumin (<35 g/L)
If serum albumin is less than 35 g/L - score 1.
If serum albumin is 35 g/L or above – score 0.
If serum albumin has not been measured write NK and score 0.
Incontinence (inappropriate for age)
Inappropriate incontinence - score 1
E.g. A 4 year old child who needs to wear nappies during the day and night.
Include children with special needs in this category.
Normal continence – score 0
E.g. A 5 year old who is dry during the day but may be occasionally incontinent
during the night, a 12 month old who needs to wear nappies during the day
and night.
Moisture lesions should not be confused with pressure ulcers.
Adapted Glamorgan Pressure Ulcer
Risk Assessment Scale for Children
Risk Score
Document total score, however scores for individual risk factors should be
acted on i.e. optimise nutrition and mobility.
If the child scores 10 or higher, he/she is at risk of developing a pressure injury
unless action is taken to prevent it. This action may include normal nursing
care, such as frequent changes of position (document how often position is
changed), encouraging mobilisation, lying the child on a standard foam
pressure reducing hospital mattress or on an air-filled overlay or mattress,
changing the position of pulse oximeter probes regularly, ensuring the child is
not lying on objects in the bed such as tubing or hard toys.
Suggested action is indicated in the WCDHB pressure care flow chart.
Pressure Injury Record
The diagram of the child on the Nursing Initial Assessment Form can be used to
indicate the position of any skin lesions.
If lesions are near to, or associated with any equipment such as BIPAP mask,
nasogastric tube or splint, these should also be indicated. The skin lesions
indicated in the diagram should be numbered so that they can be referred to in
the table beside the diagram. Any existing or new pressure injuries should be
documented, staged, incident reported and photographed.
Stage any Pressure Injuries
Please use the following NPUAP/EPUAP 2009 pressure ulcer classification
system to stage lesions, no other grading tool should be used.
Stage I. II, III, IV, un-stage able or suspected deep tissue injury.
Adapted from the Glamorgan Risk Assessment Scale from the United Kingdom
Pressure Injury Grading Scale