Action 5.21

Use the screening processes in Action 5.10 to identify patients at risk of pressure injuries and plan for comprehensive care. Use Action 5.12 to ensure that the risk factors and a decision about the need for comprehensive and ongoing skin inspections are documented. Ensure that processes for preventing pressure injuries are based on best-practice guidelines and that details of prevention strategies are communicated to the team caring for at-risk patients.

Prevention and Treatment of Pressure Ulcers: Clinical practice guideline is the relevant best-practice guidelines. These guidelines outline the components of, and techniques for, comprehensive skin and tissue inspections.

Implement a comprehensive wound management system that describes the protocols and processes for patient care when a patient’s pressure injury has been identified. Include the assessment, treatment, monitoring and documentation of pressure injuries.

Ensure that assessment of pressure injuries incorporates:

• The use of a validated risk assessment tool
• The use of a pressure injury classification system
• Assessment of pain using validated self-reporting tools such as verbal descriptor, visual analogue or numerical scales
• Ongoing assessment that evaluates the effectiveness of the wound management plan.

Ensure that treatment addresses:

• Pain management
• Wound management
• Adjunctive treatment options such as heel elevation, prophylactic dressings or electrotherapy
• Referral to allied health services when indicated, including dietetics or occupational therapy.

Conduct ongoing assessments of pressure injury risks and pressure injury healing, and documentation of all management plans, treatments and interventions provided.

For many day procedure services, pressure injuries may not be a major area of patient harm. However, pressure injuries can happen to older patients, or patients of any age who have one or more of the following risk factors: immobility, lack of sensory perception, poor nutrition or hydration, excess moisture or dryness, poor skin integrity, reduced blood flow, limited alertness, or muscle spasms. Even treatments of short duration may cause or contribute to a pressure injury.

Evidence-based strategies to prevent pressure injuries exist and should be applied if screening identifies patients that are at risk, procedures or recovery take an extended time, or there have been incidents of pressure injuries in the service in the past 12 months.

Screening processes (see Action 5.10) should identify those patients at risk. Monitoring of pressure injuries will allow day procedure services to understand the risks and causal factors leading to pressure injuries, thus allowing prevention and harm minimisation strategies to be implemented.

Examples of evidence

Select only examples currently in use:

• Data on pressure injuries from the previous 12 months
• Pre-admission screening documents addressing pressure injury risk
• Policy documents about preventing and managing pressure injuries that are consistent with best-practice guidelines
• Training documents about managing pressure injuries
• Committee and meeting records regarding responsibilities for overseeing the wound management system
• Reports from clinical data systems that capture progress or outcomes relating to pressure injury wounds
• Audit results of healthcare records for compliance with policies, procedures or protocols on management of pressure injuries and wounds
• Feedback provided to the workforce about the results of audits, and actions to deal with issues identified
• Observation of best-practice guidelines that are used by the clinical workforce.

Use the screening processes in Action 5.10 to identify patients at risk of pressure injuries and plan for comprehensive care. Use Action 5.12 to ensure that the risk factors and a decision about the need for comprehensive and ongoing skin inspections are documented. Ensure that processes for preventing pressure injuries are based on best-practice guidelines and that details of prevention strategies are communicated to the team caring for at-risk patients.

Prevention and Treatment of Pressure Ulcers: Clinical practice guideline is the relevant best-practice guidelines. These guidelines outline the components of, and techniques for, comprehensive skin and tissue inspections.

Implement a comprehensive wound management system that describes the protocols and processes for patient care when a patient’s pressure injury has been identified. Consider the assessment, treatment, monitoring and documentation of pressure injuries.

Ensure that assessment of pressure injuries incorporates:

• The use of a validated risk assessment tool
• The use of a pressure injury classification system
• Assessment of pain using validated self-reporting tools such as verbal descriptor, visual analogue or numerical scales
• Ongoing assessment that evaluates the effectiveness of the wound management plan.

Ensure that treatment addresses:

• Pain management
• Wound management
• Adjunctive treatment options such as heel elevation, prophylactic dressings or electrotherapy
• Referral to allied health when indicated, including dietetics or occupational therapy.

Conduct ongoing assessments of pressure injury risks and pressure injury healing, and documentation of all management plans, treatments and interventions provided.