Policy Directive - slhd.nsw.gov.aucontent/pdf/Nursing...... Identify infants who are at risk of ......

Sydney Local Health District Guideline No: SLHD_PD2018_ Royal Prince Alfred Hospital Date Issued:

Compliance with this Guideline is recommended of 23

Policy Directive

RPA Women and Babies: Pressure Injury Prevention and Management

Document No:

Functional Sub-Group:

Corporate Governance Clinical Governance

Summary: Identify infants who are at risk of developing pressure injuries by using validated assessment tools; initiate early interventions to prevent pressure injuries infants and manage pressure injuries appropriately with resources available

Equip criteria: National Standard 1 Governance for Safety and Quality in Health Service Organisations National Standard 8 Preventing and Managing Pressure Injuries National Standard 9 Preventing and Responding to Clinical Deterioration in Acute Health Care

Policy Author: Angel Wai, Clinical Nurse Specialist, RPA Newborn Care Jan Polverino, Perinatal CNC, SLHD

Consultation: Neonatal Research Group

Approved by: Executive Director

Publication (Issue) Date:

Next Review Date:

Note: Sydney Local Health District* (SLHD) was established on 1 July 2011 following amendments to the Health

Services Act 1997 which included renaming the former Sydney Local Health Network (SLHN). The former

SLHN was established 1 January 2011, with the dissolution of the former Sydney South West Area Health

Service (SSWAHS).



Table of Contents RPA Women and Babies: Pressure Injury Prevention and Management ............................................... 1

1. Introduction .................................................................................................................................... 4

2. Policy Statement ............................................................................................................................. 5

3. Background ..................................................................................................................................... 5

3.1 Skin injury is preventable ........................................................................................................ 5

3.2 Pressure injuries in neonatal population ................................................................................ 5

3.3 Prevalence of neonatal skin injury / pressure areas ............................................................... 5

3.4 Risk factors for pressure and skin injuries in infants .............................................................. 6

3.5 Common sites of injury in neonatal population ..................................................................... 7

4. Pressure injury risk assessment tool ............................................................................................... 7

4.1 Neonatal Skin Condition Score (NSCS) .................................................................................... 8

4.2 Modified Glamorgan Pressure Injury Risk Assessment .......................................................... 8

5. Practice Guidelines ........................................................................................................................ 10

5.1 Assessment ........................................................................................................................... 10

5.1.1 Baseline assessments .................................................................................................... 10

5.1.1.1 Infants born in RPAH ................................................................................................ 11

5.1.1.2 Infants transferred from another facility (including home) ..................................... 11

5.1.2 Ongoing assessment ..................................................................................................... 11

5.2 Diagnosis ............................................................................................................................... 11

5.2.1 Suspected pressure area ............................................................................................... 11

5.2.2 Pressure Injury staging guide ........................................................................................ 12

5.3 Prevention strategies ............................................................................................................ 12

5.3.1 Skin protection .............................................................................................................. 12

5.3.2 Repositioning ................................................................................................................ 12

5.3.3 Medical devices ............................................................................................................. 12

5.3.4 Supportive surfaces ....................................................................................................... 13

5.4 Documentation ..................................................................................................................... 14

5.4.1 Initial Assessments ........................................................................................................ 14

5.4.2 Ongoing Assessment ..................................................................................................... 14

5.4.3 Individualised Care Plan ................................................................................................ 14

5.4.3.1 For very high-risk infant ............................................................................................ 14

5.4.3.2 For infants with pressure injury ................................................................................ 14

5.4.4 Photographic evidence ................................................................................................. 14

5.5 Notification ........................................................................................................................... 15

5.6 Referral and consultation ..................................................................................................... 15



5.7 Ongoing management and surveillance ............................................................................... 15

5.8 Communication ..................................................................................................................... 16

5.9 Education .............................................................................................................................. 16

6. Performance Measures ................................................................................................................. 16

7. Consequences ............................................................................................................................... 16

8. Key Points ...................................................................................................................................... 16

References ............................................................................................................................................ 18

Appendix 1 Clinical practice flow chart for the prevention and management of pressure injuries for

inpatient neonates ............................................................................................................................ 20

Appendix 2 Glossary(4,27).................................................................................................................... 21

Appendix 3 Pressure Injury Staging Guide(27) .................................................................................... 23



1. Introduction

Neonatal skin and pressure injuries can cause pain, discomfort and long-term disfigurement;

parental stress and anxiety; and increased healthcare costs.(1) With appropriate care and

management most neonatal pressure injuries can be prevented. This practical guideline is

developed to fulfil the requirement to achieve The National Safety and Quality in Health

Care (NSQHC) standard on prevention and management of pressure injuries.(2) As part of the

clinical governance, this practical guideline details the need for screening tools, risk

assessment and management frameworks to prevent or minimise the risk of pressure injury.

This policy is based on the best available evidence and should be read in conjunction with

the following documents and policies:

1. Small Baby Protocol

2. CPAP Management (Nursing)

3. Mechanical Ventilation Practice Guideline

4. Heated, Humidified High Flow Nasal Cannula Oxygen (HHHFNC) Nursing

Management Guidelines

5. Nursing Management of High Frequency Oscillation (HFO)

6. Muscle relaxation

7. Hypoxic-Ischaemic Encephalopathy

8. Stoma Care Guideline

9. Neonatal Abstinence Syndrome

10. Identification and management of subgaleal haemorrhage

11. Thermoregulation in the High Risk Infant

12. Management of central lines

Risks Addressed by this Policy

Corporate and Clinical risks

Incidence and associated outcomes of neonatal pressure injuries

Risk factors for developing pressure injuries

Physiological and economic impact of pressure injury

The Aims / Expected Outcomes of this Policy

1. Identify neonates most at risk

2. Prevent/reduce the incidence of neonatal skin and pressure injury

3. Early detection of neonatal skin or pressure injury to allow timely and appropriate intervention

4. Recognise signs of worsening pressure injury, escalate if appropriate and facilitate referral as required

5. Reduce adverse outcomes from neonatal pressure injury

https://www.slhd.nsw.gov.au/rpa/neonatal%5Ccontent/pdf/guidelines/small_baby.pdf

https://www.slhd.nsw.gov.au/RPA/neonatal%5Ccontent/pdf/Nursing%20Guidelines/nCPAP_Management.pdf

https://www.slhd.nsw.gov.au/RPA/neonatal%5Ccontent/pdf/Nursing%20Guidelines/Ventilation.pdf

https://www.slhd.nsw.gov.au/RPA/neonatal%5Ccontent/pdf/Nursing%20Guidelines/HHFNC.pdf

https://www.slhd.nsw.gov.au/RPA/neonatal%5Ccontent/pdf/Nursing%20Guidelines/HHFNC.pdf

https://www.slhd.nsw.gov.au/RPA/neonatal%5Ccontent/pdf/Nursing%20Guidelines/High_Frequency_Oscillation.pdf

https://www.slhd.nsw.gov.au/RPA/neonatal%5Ccontent/pdf/Nursing%20Guidelines/Muscle_relaxation.pdf

https://www.slhd.nsw.gov.au/rpa/neonatal%5Ccontent/pdf/guidelines/nas.pdf

https://www.slhd.nsw.gov.au/rpa/neonatal%5Ccontent/pdf/guidelines/Subgaleal.pdf

https://www.slhd.nsw.gov.au/RPA/neonatal%5Ccontent/pdf/Nursing%20Guidelines/Thermalmanagement.pdf



2. Policy Statement

This policy will:

Identify infants who are at risk of developing pressure injuries in RPA Newborn Care

Explain how to use risk assessment tools and categorise pressure sores in infants

admitted to RPA Newborn Care

Describe the procedure for managing suspected and confirmed pressure injuries in

RPA Newborn Care

Describe available and appropriate treatment options relevant to the injuries

3. Background

3.1 Skin injury is preventable

Skin is a major organ of defence against infection in neonates. Maintaining skin integrity and

preventing iatrogenic injury is a high priority in RPA Newborn Care. Most neonatal skin

injuries are considered preventable even for infants who are particularly vulnerable.(3)

Regular staff and parent education should be provided to enable improved understanding,

knowledge and skill transfer regarding appropriate neonatal skin management. The RPA

Newborn Care healthcare team recognises the importance of maintaining skin integrity in all

newborns and employs support strategies to minimise the risk and prevent adverse

outcomes.

3.2 Pressure injuries in neonatal population

A pressure injury is ‘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’.(4)

However, the distinction between bony and non-bony prominences in neonates is very fine

and hard to distinguish. The epidermis is fragile and only one or two cells thick in extremely

preterm infants (EPTI) or extremely low birth weight (ELBW) infants.(5) The skin in these

infants is structurally and functionally different from more mature infants. Immature skin

structure and development, thinner muscle layer and lack of brown fat deposition reduce

the distinction of ‘bony prominence’ in neonates. Areas where do not considered as non-

bony prominence (such as nasal septum) are now at risk of developing pressure injuries.(6)

3.3 Prevalence of neonatal skin injury / pressure areas

The prevalence of neonatal pressure related skin injury is estimated to be between 17 and

31%.(7,8) However, with the paucity of exclusive neonatal data in the literature, accurate

prevalence is difficult to determine.



3.4 Risk factors for pressure and skin injuries in infants

It is estimated that approximately 50% of pressure areas in infants and children are related

to equipment and devices.(9) These factors could come from the infant itself (intrinsic) or

due to external sources (extrinsic) (see Table 1 & 2 below).(10)

Table 1. Intrinsic factors leading to pressure injuries

Intrinsic risk factors Examples

Reduced mobility

Muscle relaxation

Sedation

Multiple invasive devices

Impaired perfusion Hydrops fetalis (foetal hydrops)

Therapeutic cooling for Hypoxic-Ischaemic Encephalopathy (HIE)

Generalised oedema

Gestational age EPTI (birth gestation <276 weeks) (see Small Baby Protocol)

Birthweight ELBW (birthweight <1000 gms) (see Small Baby Protocol)

Dermatological condition Epidermolysis Bullosa (EB)

Harlequin

Sensory impairment Anaesthetics

Persistently moist skin High ambient humidity

Moisture trapping Inadequate nutrition/hydration

Nil by mouth

Weight lost Hypoalbuminaemia

Table 2. Extrinsic factors leading to pressure injuries

Extrinsic risk factors Examples

Pressure

Shear forces

Friction

Requiring respiratory support

Continuous Positive Airway Pressure (CPAP)

Non-invasive Intermittent Positive Ventilation (NIPPV)

Heated, Humidified High Flow Nasal Cannula (Hi-Flow, HHHNFC)

IV extravasations Vasoconstrictive agents (inotropes);

Hyperosmolar solutions (>12% glucose)

Medications (Calcium, lipids, acyclovir)

Invasive devices All vascular accesses

Intercostal catheters (chest drains)

Endotracheal Tube (ETT)

Medical devices Leads and cables

Monitoring



Birth injury/ trauma Subgaleal haemorrhage

Haematoma

skin and tissue abrasions

Cephalohematomas

Chemical burns Skin disinfectants

Topical agents

Medical adhesives Tapes

Repetitive skin puncture Venepunctures

ICC replacement

3.5 Common sites of injury in neonatal population

A cohort descriptive study conducted in Queensland over a 2-year period found that

indwelling vascular catheters, nCPAP devices and probes (SpO2 and temperature)

were associated with 54.2% of skin/pressure injuries. 31.8% of reported injuries

were not associated with any risk factors.(8)

A Japanese study identified the nose as the most common pressure area for

neonates.(7)

An RCT done in Malaysian showed neonates are at risk of nasal injuries irrespective

of whether nCPAP mask or prongs were used.(11)

In an RCT Collins and colleagues found significantly less nasal injury in infants <32

weeks gestation who were randomised to high flow compared to nCPAP following

extubation.(12)

Common skin and pressure injuries sites are listed in Table 3 below.(10)

Table 3. Common skin breakdown and pressure area sites in infants

Common skin breakdown and pressure area sites in infants

Nasal septum, columellar, nares

Back of head, especially Occiput

Bony prominences (Heels, knees, ankles, elbows)

Neck folds

Any area under pressure

Nappy area

Any area near use of medical devices

4. Pressure injury risk assessment tool

There are several pressure area risk assessment tools available, but they are developed

specifically for adults and children. For example, the Braden Q was developed for children

aged from 21 days to <18 years.(13) Even the Modified Braden Q was developed for infants

from birth to <12 months of age, the gestational age of all infants recruited were not

specified.(14,15)



Furthermore, only fewer of them have been adequately tested for reliability and validity in

the neonatal population. Like Braden Q scale, the Neonatal Skin Risk Assessment Scale

(NSRAS) is also based on the adult Braden Scale. The NSRAS was evaluated in a pilot study

on a population of 32 neonates admitted to an NICU with gestation range 26-40 weeks

(mean gestation 33 weeks). Inter-rater reliability between the 2 examiners (blind to each

other’s scores) was 0.97. However, the reliability coefficients on some scales for NSRAS

were low.(16)

Overall, all the pressure injury screening tools have high sensitivity but low specificity.(13-17)

Therefore, it is an ongoing challenge for neonatal clinicians to interpret these results and

decide which tool to use for screening and diagnostic of pressure injury in neonatal

population. A recently published systematic review concluded that there are no evidences

to suggest superiority of any risk assessment tools over the others in predicting pressure

injury risk in infants and children.(19)

4.1 Neonatal Skin Condition Score (NSCS)

The Neonatal Skin Condition Score (NSCS) developed by the Association of Women’s health,

Obstetric and Neonatal Nurses (AWHONN) and the National Association of Neonatal Nurses

(NANN) has been shown to be both a valid and reliable tool to assess neonatal skin.(20-22)

Table 4. AWHONN NEONATAL SKIN CONDITION SCORE (NSCS)

Dryness Erythema Breakdown Score

1 Normal no sign of dry

skin

1 No evidence of erythema 1 None evident

2 Dry skin, visible

scaling

2 Visible erythema, <50%

body surface

2 Small, localized areas

3 Very dry skin,

cracking/fissures

3 Visible erythema, ≥50%

body surface

3 Extensive

Total score

Score 1-3 for each category with perfect score = 3, worst score = 9.

Scoring system adapted by AWHONN. Used with permission.(22)

4.2 Modified Glamorgan Pressure Injury Risk Assessment

The development of the Glamorgan Pressure Injury risk assessment was based on a

multicentred, perspective and observational study in within the neonatal and paediatric

populations.(23) In the original study, it was found that the assessment tool had a 98.4%

sensitivity (identifying infants who are at risk of pressure injury) and a 67.4% specificity

(identifying infants who are not at risk of pressure injury) with scores in the high risk

category as shown below in Table 5.(23,24) Of particular note is that inter-reliability was

reported as being close to 100% in both original and subsequent studies.(25,26,27) There are



two components in the modified version, mobility and equipment, and is shown in Table 4

and 5 below.(24)

Despite the lack of empirical data and vigorous testing of validity and inter-reliability of

pressure risk assessments in the neonatal population, The Glamorgan Pressure Injury risk

assessment is the preferred tool in many neonatal units across Australia due to simplicity,

ease of use and minimal subjective evaluation/ high interrater reliability from clinicians.(19,24-

28)

Table 4. Modified Glamorgan Pressure Injury Risk Assessment(24)

Modified Glamorgan pressure injury risk assessment

Trigger factors Risk assessment Score

GA<32 weeks

Vascular compromise or poor tissue

perfusion (HIE, cooling, inotropes)

Impaired neurological or sensory

perception

Immobility due to illness, sedation,

muscle relaxation

Sepsis, dehydration, oedema

Respiratory support especially

ventilation and nasal/mask CPAP

Post-surgery/Laser

Monitoring devices/cables/leads

ETT, CPAP, HHF, low flow

TCM, SpO2, ECG leads, temp probes

Medical taping (IV, IA lines/splints, IG

tubes, eye pads, ICCs

Mattress/bed surface

Infant cannot be moved without great

difficulty or deterioration in condition i.e.

PPHN, ventilated, desaturates on

handling.

Poor peripheral perfusion: cold

extremities, reduced capillary refill <2sec,

cool mottled skin.

20

Infant unable to change position without

assistance or has reduced body movement

i.e. carers can change infant’s position

maintaining stable observations

15

Some mobility but reduced for age (infant

has some ability to change their position

but this is limited or restricted i.e. CPAP,

nested, IV splints, fluids, chest drains

10

Normal mobility for age 0

Equipment/objects/hard surface pressing

or rubbing on skin. Any object pressing or

rubbing on skin long and hard enough to

cause pressure damage

15

Action taken

Ensure care plan is implemented/reviewed for each identified area of concern.

Scores >30 – must commence Care Plan for Wound assessment and management if

there are any areas of concern

Total

score

Max 35



Table 5. Modified Glamorgan Pressure Injury Risk Management Scale(24)

Modified Glamorgan pressure injury risk management scale

Risk score

Category Suggested action following Glamorgan Pressure injury Risk

Assessment (Neonatal Skin Care Quick Assessment Guide).

0

Not at risk Continue to reassess daily and every time condition changes

10+

At risk Inspect skin at least twice a day. Relieve pressure by

repositioning at least every 2-4 hours. Use a size and weight

appropriate pressure redistribution surface if necessary. Re-

site monitoring devices 2 - 4 hours.

15+

High risk Inspect skin with each repositioning. Reposition infant /

equipment/ devices at least every 2- 4 hours. Relieve

pressure before any skin discolouration develops. Use a size

and weight appropriate pressure redistribution surface.

20+

Very high risk Inspect skin at least hourly if condition allows. Move or turn if

possible, before skin becomes discoloured. Ensure

equipment / objects are not pressing on the skin. Reposition

equipment / devices at least every 2 hours if condition

allows. Consider using specialised pressure relieving

equipment if unable to reposition.

5. Practice Guidelines

5.1 Assessment

A comprehensive skin assessment is part of a detailed newborn physical examination

conducted by either the admitting medical officer (MO) or admitting nurse. The findings of

this assessment are then documented and signed for in the infant’s Clinical Progress Notes

(AMR 050.000). RPA Newborn Care health care team should include skin inspection into

their routine examination.

There are two components to skin assessment within RPA Newborn Care: NSCS and the

modified Glamorgan pressure injury risk assessment. The rationale behind is that Infants

have perfect score in NSCS (3) do not mean they are not at risk of pressure injuries.

Similarly, infants who are not at risk at pressure injuries do not mean they have good skin

condition. RPA Newborn Care staff should also use their clinical judgement skill to assess the

risk, rather than solely rely on tools.

5.1.1 Baseline assessments

All infants admitted to RPA Newborn care must have a baseline skin assessment within 8

hours of admission.



5.1.1.1 Infants born in RPAH

For infants born in RPA and admitted RPA Newborn directly after birth, comprehensive skin

assessment should be done when transferring infants to incubator or open care. Clinicians

should assess skin condition and integrity by using NSCS. Pay extra attention to infants born

via instrumental deliveries (such as vacuum, ventouse, forceps and forceps liftout) as these

infants are at risk of subgaleal haemorrhage and birth traumas.

For infants transferring to RPA Newborn Care from another ward (such as postnatal ward)

after birth, note for signs or any existing pressure injuries during examination. Any pressure

injuries noted on admission must be reported to the medical team and notified IIMS as

‘existing injury’ immediately.

5.1.1.2 Infants transferred from another facility (including home)

All infants transferred to RPA Newborn Care from another facility or home must have a

comprehensive skin assessment done on admission. In addition to assessing skin condition

and pressure injury risk, admitting staff should also look for any existing pressure injuries,

especially those who have medical devices in situ and after a long-haul transfer. Any

pressure injuries noted on admission must be reported to the medical team and notified

IIMS as ‘existing injury’ immediately.

5.1.2 Ongoing assessment

All infants remained as inpatient in RPA Newborn Care should have skin assessment done at

least once per shift until discharge (either to postnatal ward, home or other facilities). Staff

should look for any variation in skin integrity including redness, blanching, turgor, erythema,

oedema, induration or breakdown during assessment.

Skin assessment should be performed in conjunction with routine standard care, such as

nappy changes, weight and wash, or physical examination. Resting infants should not be

disturbed to perform skin assessment to promote developmental care in RPA Newborn Care.

Comprehensive skin assessment should also be performed in infants whose condition has

changed since last assessed. For example, post extubation, insertion or removal of medical

devices that alters mobility and clinical deterioration.

5.2 Diagnosis

5.2.1 Suspected pressure area

If a pressure area is suspected, staff must conduct a detailed examination to determine

whether it is a true pressure injury. The Infant must be repositioned to expose affected area

for surveillance. Source of pressure, fiction or shear must be removed or repositioned to

prevent further injury to non-affected skin. Staff must leave a minimum of 30-minute to 1-

hour time frame before reassessing the affected area.

When reassessing the affected area, gently apply pressure for 5 seconds, then remove

pressure and observe for tissue reperfusion. Blanching erythema excludes pressure injury

whereas pressure injury remains non-blanchable. If in doubt, staff should consult senior



staff members, team leader, Wound Link Nurse, Perinatal CNC, CNE or Wound Care CNC for

further assessment (see Appendix 1).

5.2.2 Pressure Injury staging guide

All pressure injuries identified must be staged correctly. Staging pressure injuries in

neonates is the same as adult. See appendix 3 and Pressure and Skin Injury Resource Folder

for more information.(29)

5.3 Prevention strategies

Having effective preventative strategies in place is vital to reduce incidence of pressure

injury in RPA Newborn Care. All RPA Newborn Care staff should be aware the following

strategies and implement accordingly to protect infants against pressure and skin injuries.

5.3.1 Skin protection

No tape directly on skin – use Comfeel®/Duoderm® between skin and tape (see Small

Baby Protocol)

Eucerin applied on ELBW babies’ skin during first week of life (see Small Baby

Protocol)

Age appropriate ambient humidity for ELBW/EPTI infants to prevent over-

humidification, which increases risk of moisture associated skin damage (MASD) and

infection (See Small Baby Protocol for weaning guideline)

Soften tape before removal

Use medical adhesive removers to facilitate removal if needed.

Avoid removing tape at high angle (90o) to skin surface to prevent stripping.(30,31)

Adaptic Touch™ is available in the Dressing Bank for very fragile skin (Access via

NARMU, see Pressure and Skin Injury Resource Folder for details).

5.3.2 Repositioning

Regular CPAP nasal prong and mask release – every I to 2 hours (refer to CPAP

Management (nursing)).

Regular positioning is important and effective to redistribute pressure point to

prevent pressure injuries.

Infants requiring minimal handling are most vulnerable to pressure injuries and

should be repositioned regularly.

A minimum 15° turn every 3-4 hours for very high-risk infants is highly

recommended for pressure area care.(14,15,30,32)

5.3.3 Medical devices

Hourly IV cannula/PICC/arterial/umbilical line site checks.

All vascular access must always be visible to visual inspection.

Avoid and/ or ensure infants are not lying on any medical devices.

Remove medical devices as soon as possible when no longer needed.



5.3.4 Supportive surfaces

Use of constant low-pressure redistribution support

o All infants should be nursed on a standard hospital cot mattress in a

designated cot, or standard incubator/open care mattress appropriate to

device.

o Staff should be aware that the support surface in some of the mattresses

used in RPA Newborn Care are on designated side only. Ensure infant is

resting on the side designated by that device.

Pressure distributing devices for very high-risk infants (see picture 1 and 2 below)

o Air mattress or pressure redistributing mattress are available for very high-

risk infants. The following types of specialised mattresses are available in RPA

Newborn Care. (NB. The Coziny Mattress has a weight limit of max 3.5kg)

Pic. 1 Roho Chsuion

Pic. 2 Coziny Mattress)

o When these devices or supportive mattress are used, staff should ensure:

The firmness of the mattress is appropriate for gestation.

Regular repositioning is still required even these mattresses are used.

Minimal layers of linen between mattress and the infant. Use thin and

single layer of linen between infant and the mattress to optimise the

benefit of these devices and/ or mattress (see picture 3 below).



Pic. 3 Sample linen layouts for infants using specialised pressure distributing mattress

5.4 Documentation

All skin inspections and assessments must be documented in both hard copy and

electronically.

5.4.1 Initial Assessments

Document initial skin assessment in Initial Newborn Physical Examination, admission note

and eMR for baseline assessment.

5.4.2 Ongoing Assessment

NSCS and Modified Glamorgan pressure injury risk assessment should be performed once

per shift. Document both scores in progress note and update eMR every shift. Indicate

reposition in ICU or HDU chart.

5.4.3 Individualised Care Plan

Infants with the following circumstances should have individualised care plan in place to

prevent pressure injuries.

5.4.3.1 For very high-risk infant

All infants score ≥ 6 on NSCS or ≥ 30 on Modified Glamorgan Pressure Injury Risk

Assessment should have an individualised care plan in place to preserve skin integrity and

prevent developing pressure injures. Care plan is available on eMR. Care plan will pop-up

automatically once NSCS score ≥ 6 or score ≥ 30 on Modified Glamorgan Pressure Injury Risk

Assessment. It will be mandatory required field for staff to complete.

It is optional for staff to print out the individualised care plan for the infant. However, staff

should ensure the care plan is handed over each shift.

5.4.3.2 For infants with pressure injury

All pressure injuries identified in RPA Newborn Care must have a written care plan for

ongoing assessment and management. Such wound management plan must be handed over

at each nursing handover and discussed at the ward round. It is available on eMR.

5.4.4 Photographic evidence

All pressure injuries should have photos taken as reference and for ongoing management

(see picture 4 below). RPA Newborn Care staff should obtain consent from parents before



taking photos. When taking photo, place a measuring tape and patient identification near

the injury site to identify the patient and the size of the injury. Ensure the photo is taken

with clear focus and under adequate light exposure so that the injury is clearly identified. All

photos must have time and date documented to identify when it was taken. Refer to the

Pressure and Skin Injury Resource Folder for additional information.

Photo courtesy of RPA Newborn Care, used with parental permission

Pic 4. Sample photo for pressure or skin injuries

5.5 Notification

All pressure injuries must be reported via IIMS system. IIMS reference number should be

documented in the progress note. Refer to Resource Folder for more information. Forward

the IIMS reference number to the Wound Link Nurse for RPA Newborn Care and NUM for

follow-up and reference.

5.6 Referral and consultation

The Wound Link Nurse for RPA Newborn Care is the first point of contact for suspected or

confirmed pressure injuries. The Wound Link Nurse for RPA Newborn Care will work in

collaboration with the medical team and NUM, CNE and Perinatal CNC to manage all

pressure and skin injuries in RPA Newborn Care.

If consultation from Wound Care CNC is required, fill in the referral form in eMR. It is up to

the medical team’s discretion to if further consultations such as plastic, vascular and general

surgical consult is required. Medical consult form will be completed by the medical team.

5.7 Ongoing management and surveillance

All reported pressure injuries must be reviewed regularly until fully resolved. Timing of

review depends on numerous factors such as dressing regime and the type of injuries.

Unless otherwise specified, all identified skin or pressure injuries must be accessed at least

once per shift. If specific wound care products are used, do not undo the dressing unless

indicated as it can affect wound healing.



5.8 Communication

Communication is important for preventing and managing pressure injuries in RPA Newborn

Care. All pressure injuries identified in RPA Newborn Care must be reported to the medical

team and the Nurse in-charge of the shift.

Parents must be notified with the injury. PRA Newborn Care Staff should also provide

support and education to parents regarding ongoing care.

5.9 Education

The education team (including CNE, Perinatal CNC and Wound Link nurse) will provide

ongoing education and support to staff and parents about risk to pressure injuries and

preventive measure to reduce incidence of pressure injuries in RPA Newborn Care. Resource

Folder is also available for staff with additional information and training information.

6. Performance Measures

Regular audit and investigation of serious skin injury in the NICU is an important quality

improvement measure.

Monthly audit for compliance and documentation as per hospital guideline

Audit results to be presented in monthly Wound and Pressure Injury Committee

(WAPIC) meeting

Routine audit of medical records of infants identified “at risk” 3-monthly

IIMS notifications

All IIMS tabled and discussed at monthly Newborn Care QI Meetings

7. Consequences

Neonatal skin injury can cause discomfort, pain and suffering, parental distress, increased

length of stay, nursing time and costs, infection, may result in disfigurement requiring long

term treatment. In some extreme cases, infants suffer from significant pressure or skin

injuries may require surgeries at the injury site. Infant mortalities are reported in some

cases.(1)

8. Key Points

Key Points Level of evidence; Grade of recommendation

Pressure and skin injuries are avoidable in many instances.(3) LOE IV GOR D

Neonates are vulnerable to develop pressure and skin injuries.(5-

9,11,12) LOE III-3 GOR C

Adequate strategies, including a validated screening tool must be LOC IV



implemented to prevent pressure and skin injuries in neonates.(14,15,30-32)

GOR C

Staff should use clinical judgement in conjunction of assessment tools rather than solely rely on assessment tools to identify infants who are at risk of pressure injury.(19)

LOC I GOR C



References

1. Sardesai SR, Kornacka MK, Walas W, Ramanathan R. Iatrogenic skin injury in the neonatal

intensive care unit. The Journal of Maternal-Fetal & Neonatal Medicine. 2011;24(2):197-203.

2. Australian Commission on Safety and Quality in Health Care. Safety and Quality

Improvement Guide Standard 8: Preventing and Managing Pressure Injuries (October 2012).

Sydney. ACSQHC, 2012.

3. Black JM, Edsberg LE, Baharestani MM, Langemo D, Goldberg M, McNichol L, Cuddigan J.

Pressure ulcers: avoidable or unavoidable? Results of the national pressure ulcer advisory

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content/uploads/2012/03/Standard-8-tools.pdf

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http://www.kemh.health.wa.gov.au/services/nccu/guidelines/documents/Skin_care_and_pressure_injury.pdf

https://www.safetyandquality.gov.au/wp-content/uploads/2012/03/Standard-8-tools.pdf

https://www.safetyandquality.gov.au/wp-content/uploads/2012/03/Standard-8-tools.pdf

https://webmail.health.nsw.gov.au/owa/redir.aspx?C=Rv36iDK4I263wlj8Ku2vfo_jFR7PBV977iNphqoMIgDtzHVxEGLVCA..&URL=http%3a%2f%2fintranet.sswahs.nsw.gov.au%2fSSWPolicies%2fpdf%2fSLHD%2fSLHD_PD2013_052.pdf



Appendix 1 Clinical practice flow chart for the prevention and management of pressure injuries for inpatient neonates

Chart adapted from flow chart in NSW Health Policy Directive PD2014_007 dated 24-Mar-2014, Pressure Injury Prevention and Management Policy, Appendix 10 p12

Complete IIMS notification for each new PI as per SLHD policy

Notify MO, NUM, Wound Link Nurse, In-charge, CNE and CNC

Perform skin inspection and pain assessment at each care

Take image (ask parent’s permission) if needed

Complete wound care-plan

Develop care plan in consultation with Wound Link Nurse, Perinatal CNC, Wound care CNC, CNE

Inform MO/Neonatologist on duty

Inform parents

Implement prevention strategies appropriate to level of risk e.g. more frequent repositioning, positioning aids, air mattress

Make referrals if appropriate e.g. Plastics team, Wound CNC

Write detailed documentation in patient health care record and include images

Communicate PI risk and management at each handover of shift and transfer of care

Perform comprehensive skin assessment and document findings once per shift and/ or if condition changes

Implement strategies to reduce risk of developing PI

Parent education to reduce risk of PI

Complete baseline full body skin assessment, including NSCS, Modified Glamorgan Pressure

Injury Risk Assessment and Pain assessment on admission (within 8 hours of admission), then at

least once per shift. Notify team leader if NSCS ≥ 6 or Glamorgan Scale ≥ 30. Document results

in progress note and eMR.

Does the infant have impaired

skin integrity or an existing PI?

Is the infant ‘At

Risk’?

Reassess:

If there is a change in health status/mobility

If a PI develops

No No

Mo

nit

ori

ng/

Co

mm

un

icat

ion

/

Do

cum

enta

tio

n

Yes Yes

Infant admitted to Newborn Care

Ris

k

Ass

essm

ent

Trea

t ex

isti

ng

PI



Appendix 2 Glossary(4,27)

Terminology Definition

Blanching erythema Reddened skin that blanches white under light pressure. May be difficult to visualise in darker skin tones.

Bony prominence An anatomical bony projection.

Carers Carers are people who provide unpaid care and support to family members and friends who have a disability, mental illness, chronic condition, terminal illness, an alcohol or other drug issue or who are frail aged. Carers provide emotional, social or financial support. Carers include parents and guardians caring for children.

Erythema Redness of the skin caused by dilatation and congestion of the capillaries, often a sign of inflammation or infection. May be difficult to visualise in darker skin tones.

Extrinsic factors Originating outside of the body

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

Incidence The proportion of at-risk patients who develop a new pressure injury over a specific period.

Intrinsic factors Originating within the body

Moisture Moisture alters resilience of the epidermis to external forces by causing maceration, particularly when the skin is exposed for prolonged periods. Moisture can occur due to spilt fluids, incontinence, wound exudate and perspiration.

Must Indicates a mandatory action

Non-blanching erythema

Erythema that remains reddened when pressure is applied and removed.

Pain

An unpleasant sensory and emotional experience associated with a pressure injury. Patients may use varying words to describe pain including discomfort, distress and agony.

Positioning Position of normal body alignment to promote comfort, safety and relaxation, prevent deformities and reduce the effects of tissue strain on skin.

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

Prevalence Total number of a given population with pressure injuries.

Pressure Injury Risk Assessment scale/tool

Formal scale or score used to help determine the degree of pressure injury risk. The tool must be appropriate for the patient population in accordance with best practice guidelines e.g. Waterlow, Braden, Norton for adult population and Braden Q or Adapted Glamorgan for neonatal/infant and paediatric population.

Reliability Measure of reproducibility of a measure

Repositioning Changing a patient’s body position to redistribute the pressure on the bony points that were in contact with the surface supporting the body. The frequency is determined by skin response, support surface in use and patient’s general condition.

Shear Shear is a mechanical force created from a parallel (tangential) load that causes the body to slide against resistance between the skin



and a contact surface. The outer layers of the skin (the epidermis and dermis) remain stationary while deep fascia moves with the skeleton, creating distortion in the blood vessels and lymphatic system between the dermis and deep fascia. This leads to thrombosis and capillary occlusion

Should Indicates a recommended action that should be followed unless there are sound reasons for taking a different course of action.

Staff For the purpose of this Policy staff refers to any person working within the NSW Health system including contractors, students and volunteers.

Support surface A surface on which the patient is placed to manage pressure load by distributing body weight pressure more effectively over the support surface. Support surfaces are classified as reactive (constant low pressure) or active (alternating pressure) surfaces. Includes bed, trolley and operating table mattresses and overlays; integrated bed systems; and seat cushions and overlays.

Validity How well a tool measures the concept it claims to measure.



Appendix 3 Pressure Injury Staging Guide(27)

Policy Directive - slhd.nsw.gov.aucontent/pdf/Nursing...... Identify infants who are at risk of ......

Documents

Transcript of Policy Directive - slhd.nsw.gov.aucontent/pdf/Nursing...... Identify infants who are at risk of ......