1 Purpose Scope/Audience Definitions Associated Documents Objectives...3

Pressure Injury Prevention and Management

Policy

Pressure Injury Prevention and Management Policy Page 1 of 7 Document Owner: Occupational Therapy

WCDHB-CLIN77 Version 1, Issued February 2016 Master Copy is Electronic UNCONTROLLED DOCUMENT – WEST COAST DISTRICT HEALTH BOARD

Contents

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 Scale………. 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

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WCDHB-CLIN77 Version 1, Issued February 2016 Master Copy is Electronic UNCONTROLLED DOCUMENT – WEST COAST DISTRICT HEALTH BOARD

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.

All WCDHB Clinical Staff.

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.

1. Purpose

2. Scope / Audience

Pressure Injury Prevention and Management

Policy

Pressure Injury Prevention and Management Policy Page 3 of 7 Document Owner: Occupational Therapy

WCDHB-CLIN77 Version 1, Issued February 2016 Master Copy is Electronic UNCONTROLLED DOCUMENT – WEST COAST DISTRICT HEALTH BOARD

Initial Assessment Documentation- this includes the Adapted Waterlow Scale 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.

5.1 Ensure that the Waterlow Scale 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 Water low Scale 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. DN for ongoing management post discharge, rest home if this is discharge destination.

4. Associated Documents

Pressure Injury Prevention and Management

Policy

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WCDHB-CLIN77 Version 1, Issued February 2016 Master Copy is Electronic UNCONTROLLED DOCUMENT – WEST COAST DISTRICT HEALTH BOARD

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.

IDT for pressure care includes: Doctors, Nurses, Dietitian, Physiotherapist, Occupational Therapist and Pharmacist.

Refer to Lippincott procedures for further detail.

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 scale 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.

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  Redistribution (support) surface systems

6. Personnel responsible for pressure care within WCDHB

7. Procedure

Pressure Injury Prevention and Management

Policy

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 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

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.

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 Web at

9. Discharge Planning

Pressure Injury Prevention and Management

Policy

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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, 422-450.

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

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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

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?

Waterlow score >10 Glamorgan score >10

* Use Prevention Strategies Grade Pressure Injury & photograph

Start Wound Chart Refer to Occupational Therapy / Physio / Dietitian as appropriate

Refer to appropriate Lippincott procedure

* Use Prevention Strategies Refer to Occupational Therapy / Physio / Dietitian as appropriate

* Use Prevention strategies Regular repositioning Education to patient and family

Encourage Independence & mobility

Daily skin assessment e.g when showering

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

West Coast Pressure Care Flow Chart

DOCUMENT

RESCREEN AS PER ACUITY Waterlow / Glamorgan

*

Yes Yes

No No

DOCUMENT DOCUMENT DOCUMENT

Developed by Pressure Care Working Group v3.0 Monday 18 April, 2016

Waterlow Pressure Sore Assessment December 2015- draft 2

WATERLOW PRESSURE SCORE – RISK ASSESSMENT

If the total score is 10 or above preventative nursing care is required and must be incorporated into the Plan of Care and be evaluated regularly. Appropriate IDT referrals to be sent.

Circle score beside each category REVIEW DAILY Date Date Date Date Date Date Date

Gender Male Female 1 2 Age 14-49 50-64 65-74 75-80 81+ 1 2 3 4 5 Build/weight for height (see MUST for BMI) Average BMI 20-24.9 Above average BMI 25-29.9 Obese BMI >30 Below average BMI <20

0 1 2 3 Skin type/visual risk area Healthy Tissue paper Dry Oedematous Clammy (febrile) Discoloured Broken/spot 0 1 1 1 1 2 3 Continence Complete/catheterised Occasional incontinence Catheterised/incontinent of faeces Doubly incontinent 0 1 2 3 Malnutrition Risk

MUST Score (Low Risk) = 0 MUST Score (Medium Risk) = 1 MUST Score (High Risk) = ≥2

0 1 2 Mobility Fully mobile Restless/fidgety Apathetic Restricted Inert/traction Chair bound 0 1 2 3 4 5 Special Risk Factors Smoking 10+/day Cytotoxic drugs, high dose steroids or anti-inflammatory drugs Orthopaedic surgery, below waist fracture, spinal Sensory deprivation (diabetes, paraplegia, CVA) Terminal cachexia 1 3 3 5 8 TOTAL SCORE Patient Bradma

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

(anti-embolic 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.

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.