Pressure injuries are a commonly occurring global health concern, which detrimentally impacts upon a person's quality of life. They are painful, costly, potentially life threatening and are often preventable. Pressure injuries have been designated by the Australian Commission on Safety and Quality in Health Care (ACSQHC) as a Hospital Acquired Complication (HAC).

The purpose of this policy is to outline requirements for minimising the risk of pressure injuries through the timely identification and management of modifiable risk factors, as well as implementing appropriate management strategies when a pressure injury is present.

Evidence based, standardised approaches to pressure injury prevention and management:

• Implementation of systems across Grampians Health Ballarat (GHB), which support clinicians in the delivery of pressure injury prevention and management, founded upon evidence based best practice.

• Timely identification of persons at an increased risk of sustaining a pressure injury, with the use of an internationally validated risk screening tool and communicating the identified risk with clinicians, as appropriate.

• Attending to regular skin assessments, with an increased frequency for those persons at increased risk of sustaining a pressure injury.

• Provision of a pressure injury prevention and management plan which guides clinical decision making, including the use of pressure redistributing devices and equipment.

• Engaging with the at-risk persons and/or their carer/family, providing education and developing, implementing and evaluating a care plan, tailored towards the person's preferences and goals.

Bony prominence: An anatomical projection of bone.

Braden Scale: An internationally validated risk screening tool used to identify adult persons at risk of sustaining a pressure injury.

Braden Q Scale: An internationally validated risk screening tool used to identify paediatric persons at risk of sustaining a pressure injury. To be used for persons aged 0-18 years. 

Carer: A person who supports and provides assistance for a family member or friend, who has an ongoing illness, disability or condition.

Clinician: A health care professional who is directly involved in a person's care.

Friction: A mechanical force that occurs when two surfaces move across one another, creating resistance between the skin and contact surface.

Person: Refers to a consumer, patient, client or resident.

Pressure Injury (PI): A localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction.

Pressure injury classification system: Pressure injuries are to be classified as per the international National Pressure Injury Advisory Panel (NPUAP) / European Pressure Ulcer Advisory Panel (EPUAP) Pressure Ulcer Classification System. Refer to Appendix 1.

Risk Screening: A process to support identification of a person's risk of developing a pressure injury.

Shear: A mechanical force created from a parallel load, which causes the body to slide against resistance between the skin and a contact surface. During this process the outer layers of the skin (the epidermis and dermis) remain stationary, whilst the deep fascia moves with the skeleton, thereby creating a distortion in the blood vessels and lymphatic system, between the dermis and deep fascia. This leads to thrombosis and capillary occlusion.

Skin assessment: Examination of the entire skin surface from head to toe, to assess a person's skin integrity and identify any characteristics of pressure injury/damage.

In light of the ACSQHC designating pressure injuries as a HAC, the National Safety and Quality Health Service (NSQHS) Standard, Comprehensive Care Standard, has stipulated several requirements for health service organisations to adhere to, in the prevention of pressure injuries and wound management. These systems and processes are to be consistent with evidenced based best practice guidelines.

Grampians Health Ballarat (GHB) have referred to these requirements, as well as the current international clinical guideline, Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, The International Guideline (3rd ed.), for evidenced based recommendations and best practice in the prevention and management of pressure injuries.

CLINICAL PRACTICE REQUIREMENTS

Conduct Screening:

• All persons are to be screened for pressure injury risk as soon as possible upon presentation/admission. At GHB, this is to occur within 8 hours of presentation to any department, unit, ward or facility across the organisation.

• A risk screening tool is to be used to identify a person's risk of sustaining a pressure injury and a full pressure injury risk assessment is to be undertaken. At GHB the Braden Scale and Braden Q Scale risk assessment tools are utilised to identify at-risk persons. The Braden Scale and Braden Q Scale identifies the risk factors of altered sensory perception, skin moisture, level of physical activity and mobility, nutritional status and degree of friction and shear.

• A clinical assessment is also to be undertaken. Persons with an existing pressure injury or a history of pressure injuries, are at an increased risk of sustaining either new or further skin injury/damage.

Conduct Skin Assessment:

• Documented skin assessments are to be attended to as early as possible upon the persons presentation/admission. At GHB, this is to occur within 8 hours of presentation to any department, unit, ward or facility across the organisation. Ongoing regular skin assessments are to be undertaken as per the GHB Clinical Practice Guideline: pressure injury risk assessment (CPG0196).

• The skin assessment performed includes an examination of the entire skin surface from head to toe, focusing on areas with bony prominences and under and/or around medical devices. The occiput requires particular observation when examining neonates, young children and the critically unwell person.

• Further skin assessments are to be attended as soon as possible postoperatively, postnatally, pre and post inter GHB transfer or if a change of condition is observed, as well as prior to discharge. If risks are identified, the pressure injury management plan is to be revised with appropriate intervention strategies implemented.

• On occasions a person may not provide consent for a full skin assessment or may be too clinically unstable for an assessment to be undertaken. In these situations, the clinician must record within the person's medical records an explanation for the omission.

Implement Prevention Plan: For at-risk persons or persons with an existing pressure injury, the plan is to:

• Be developed in collaboration with the person and/or carer, with documentation to support the person's/carer's involvement in the pressure injury prevention and management planning process.

• Be communicated verbally to clinicians during handovers and upon internal and external transfers, for ongoing care and are to be documented within the person's medical record.

• Reflect collaboration with multidisciplinary health care professionals as appropriate, ie: dietetic involvement.

• Include strategies aimed at preventing pressure injury development and optimising pressure injury healing. Strategies include implementing appropriate pressure redistributing equipment and devices, correctly fitting and regularly reviewing medical devices, prompted/assisted repositioning, incontinence management, skin hygiene and providing ongoing education and support to the person.

• Be reassessed and revised as appropriate, with modifications implemented if a change of risk is noted. Within the acute/subacute departments, the person is to be commenced on the Pressure Injury Management Plan (MR/202.5).

Assess Existing Pressure Injuries:

• Where an existing pressure injury is present, document the location, appearance and dimensions of the injury within the person's medical records. The stage of the pressure injury is to be included and staged as per the NPUAP/EPUAP Pressure Ulcer Classification System. This is to be reported within the GHB Hazard and Incident Reporting (VHIMS) system as early as possible.

• A pain assessment is to be conducted in conjunction with the pressure injury assessment and included within the plan of care.

Treat Existing Pressure Injuries:

• The plan of care for an existing pressure injury is to address the risk factors, including a wound and pain assessment. The person is to be reassessed if the existing pressure injury deteriorates or if new pressure injuries are sustained.

• Wound management is to be provided or supervised by clinicians with the required knowledge and skills and in accordance with best practice. All serious pressure injuries (stage 3, stage 4, unstageable, suspected deep tissue injury and mucosal pressure injury) are to be reviewed by a Wound Clinical Nurse Consultant, following notification from VHIMS or post a wound referral.

Monitor and Document:

• All risk screens, assessments, interventions, management plans and outcomes are to be documented within the person's medical record and within a Wound Assessment Chart (MR/202.0) in the acute/subacute/mental health departments or within the iCARE Wound Chart for residential facilities. Documentation is to include the anatomical location, wound dimensions and pressure injury classification.

• Reassessment of an existing pressure injury is to occur, to monitor for healing or deterioration. Ongoing assessments are to be undertaken as per the GHB Clinical Practice Guideline: pressure injury risk assessment (CPG0196).

• Quality indicators in routine monitoring is in place across the organisation, which regularly evaluate performance of processes and outcomes for pressure injuries, including pressure injury incidence and prevalence.

GHB has protocols and systems in place, easily accessible to clinicians, which provide persons with the required expertise and resources, in best practice prevention and management of pressure injuries. These include pressure redistributing equipment and devices. Clinicians across the organisation are provided with educational opportunities related to pressure injury prevention and management, in order to promote best practice in pressure injury prevention and management.