Matthew Wilson, The Sutherland Hospital - Meeting Standard 8, Our Experience
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Transcript of Matthew Wilson, The Sutherland Hospital - Meeting Standard 8, Our Experience
NATIONAL STANDARD 8 PREVENTING AND MANAGING PRESSURE INJURY
Matthew Wilson
Sutherland Hospital
PREVENTING ANDMANAGING
PRESSURE INJURY
Pressure Ulcer
Development
Pressure
Impaired Mobility
Impaired Activity
Impaired Sensory
Perception
Extrinsic Factors
Intrinsic Factors
Moisture
Friction
Demographics
Oxygen Delivery
Skin Temperature
Chronic Illness
Shear
NutritionTissue Tolerance
Source: Final Draft - Clinical Practice Guidelines for the Prevention of Pressure
Ulcers, March 1999
Support Surfaces
Skin Inspections
� Erythema,
� Elanching response
� Localised heat
� Oedema
� Induration
� Skin breakdown.
STAGE 1
STAGE I PRESSURE INJURY: NON-
BLANCHABLE ERYTHEMA
� Intact skin with non-blanchable redness of a localised
area usually over a bony prominence.
� Darkly pigmented skin may not have visible
blanching; its colour may differ from the surrounding
area.
� The area may be painful, firm, soft, warmer or cooler
compared to adjacent tissue.
� May be difficult to detect in individuals with dark
skin tones.
Stage 1
STAGE 2
STAGE II PRESSURE INJURY: PARTIAL
THICKNESS SKIN LOSS
� Partial thickness loss of dermis presenting as a
shallow, open wound with a red-pink wound bed,
without slough.
�May also present as an intact or open/ruptured
serum-filled blister.
� Presents as a shiny or dry, shallow ulcer without
slough or bruising
Stage 2
Stage 2
STAGE 3
STAGE III PRESSURE INJURY: FULL
THICKNESS SKIN LOSS
� Full thickness tissue loss. Subcutaneous fat may
be visible but bone, tendon or muscle are not
exposed. Slough may be present but does not
obscure the depth of tissue loss. May include
undermining and tunnelling
Stage 3
STAGE 4
STAGE IV PRESSURE INJURY: FULL
THICKNESS TISSUE LOSS
� Full thickness tissue loss with exposed bone,
tendon or muscle. Slough or eschar may be
present on some parts of the wound bed.
Stage 4
SUSPECTED DEEP TISSUE INJURY
SUSPECTED DEEP TISSUE INJURY:
DEPTH UNKNOWN
� Purple or maroon localised area or discoloured,
intact skin or blood-filled blister due to damage of
underlying soft tissue from pressure and/or
shear. The area may be preceded by tissue that is
painful, firm, mushy, boggy, warmer or cooler as
compared to adjacent tissue.
� Deep tissue injury may be difficult to detect in
individuals with dark skin tone.
Suspected Deep Tissue Injury
SUSPECTED DEEP TISSUE INJURYSuspected Deep Tissue Injury
UNSTAGEABLE PRESSURE INJURY:
DEPTH UNKNOWN
� Full thickness tissue loss in which the base of the
PI is covered by slough (yellow, tan, grey, green
or brown) and/or eschar (tan, brown or black) in
the PI bed.
� Until enough slough/eschar is removed to expose
the base of the PI, the true depth, and therefore
the stage, cannot be determined.
Unstageable
Unstageable
10 NATIONAL STANDARDS
NATIONAL STANDARD 8
� Governance and systems
� Preventing pressure injury
�Managing pressure injury
� Communicating with patients and carers
Benefits of Standard 8
� Reduce avoidable pressure injuries
� Reduce cost for the organisation/state health
department
� Bring nurses/allied health to the forefront
� Potential increase of specialist wound care
positions
Where to start
� Identify key stakeholders
� Executive support
� Perform gap analysis
�Meet with key stakeholders
� Distribute task amongst key stakeholders
GOVERNANCE AND SYSTEMS
� Hospital Pressure Injury Prevention Committee
� Review of incident data (IIMS)
� Review of polices and procedures
� R/V of educational requirements
� R/V of current issues
GOVERNANCE AND SYSTEMS
� Best practice clinical audits
� Risk assessment
� Skin assessments
� Prevention plans
� Management plans
� Consumer engagements
IIMS STICKER
IIMS
IIMS – Waterlow Score & SAC Score
Waterlow Scores
No risk less than 5
Low risk less than 10
Medium risk 10 +
High risk 15 +
Very high risk 20 +
SAC
Score
Guidelines for SAC Scores
� New pressure ulcer including
� ↑ length of stay
and/or
� Requires surgery on pressure injury
� Any new grade 3 and 4 pressure injury
SAC 2
� New pressure injury
� Doesn’t ↑ length of stay
or
� Dosen’t require surgery on pressure injury
SAC 3
� Admitted to the health service with an
existing pressure injurySAC 4
GOVERNANCE AND SYSTEMS
� Point prevalence audits
� Prevalence
� Hospital acquired pressure injury
� Grade of pressure injury
� Waterlow
� Mattresses
� Wound assessment form
Other sources of pressure injury data
� Coded data through clinical information
� Simple monthly reports can be run
� Coders need to be trained around new pressure
injury staging system
PREVENTING PRESSURE INJURY
� New 7 day Waterlow review form
�Mattress system
�Waterlow competence
� Pt's are given information brochures on pressure
injury prevention.
Highlight quality activities
� Gurada heel introduced into operating theaters
�Waterlow, skin inspection and mattress add to
clinical handover
MANAGING PRESSURE INJURY
� New Wound Chart
�Wound care best practice
� Closer relationships with facilities on D/C
COMMUNICATING WITH PATIENTS AND
CARERS
� Patient and/or carer aware tick box on multiple
forms such as Wound Chart and 7 Waterlow
Review chart
�Move towards notifying pt/carers when IIMS
incident is logged
� Pressure Injury Prevention Handouts are
available for all patients
How to maintain change
� Feedback to key stakeholders
� Feedback to nursing staff at ward level
� Be transparent with results
IN SUMMERY
� Don’t panic
�Work through standard 8 systematically
� Establish group of stakeholders
�Move now to fill gaps in practice and resources
� Communicate with other hospitals to pool
resources