Care – Pressure Injuries

Pressure injuries continue to contribute to substantial client harm and potential extended lengths of stay. Timely screening, regular skin integrity assessments, access to specially trained healthcare professionals, and standardized treatment protocols are key to managing this risk. This document contains information entered by HIROC Subscriber healthcare organizations (acute and non-acute) in the Risk Register application to help you in your assessment of this risk.

Key Controls/Mitigation Strategies

• Policies, Procedures and Key Practices:
  • A risk assessment, prevention and management of pressure injury policy/procedure is in place, and updated to reflect current practice and terminology (injury vs. ulcer). The policy: 
    • Outlines how to perform a complete skin assessment 
    • Contains age-appropriate standardized risk assessment tools and prevention strategies
    • Identifies high risk patients and outline responsibilities when high risk patients are identified
    • Is aligned with Accreditation Canada Required Organizational Practices (ROP)
  • Pressure injury prevention patient care standard
  • Evidence-based best practice pathways; documentation; wound care practices and dressing changes
  • In Emergency Department, a skin assessment is done on admissions and assessing patients at risk for wounds
  • Pressure injury risk assessment is completed on admission and visible on electronic white board and discussed at bed rounds
  • Daily use of risk assessment tool for all inpatients on admission 
  • Inpatient purposeful rounding
  • Surface selection algorithm
  • The health team identifies patients at risk for wound and recommend surfaces at bed rounds
  • The health care team looks at patients at risk and uses heel protector boot to prevent heel wounds
  • Framework developed to look at consultation process 
  • Access to expert staff for assessing, treating and discussing complex pressure injury situations
  • Access for wound care consults as needed (Physician, Nurse Practitioner, Advanced Practice Nurse roles)
  • Certified wound/ostomy nurses, physiotherapists and plastic surgeons are available to consult with and coach staff
  • Interprofessional team, including plastic surgeons, wound/ostomy experts, nurses, physiotherapists meet regularly to monitor and oversee the Pressure Injury bundle implementation and data collection
  • Pressure ulcer risk assessment included as part of the daily electronic documentation and built into electronic medical record system
  • Electronic medical record auto-generates consult to Occupational Therapy if certain criteria are met within the nursing documentation
  • Skin and Wound care Committee in place
  • Community of Practice Related to Wounds
• Education and Training:
  • Patient education pamphlet/material developed and distributed to patients
  • Wound care education modules/E-learning module on pressure injury available to all staff
  • Education related to the prevention of ulcers including risk factors and interventions
  • Review of pressure injury reduction/prevention at orientation for all nursing hires
  • Staff Education annually
  • Dressing selection poster
  • A Turning & Positioning poster developed for patients who are at high risk of developing a pressure injury or patients with a pre-existing pressure injury
  • Budget includes the training of champions through advance wound care course and wound care specialist for consultation and coaching of complex wounds
• Equipment and Technology:
  • Review treatment products and updated product list to treat wounds
  • Adopt standardized, evidence-based formulary for wound care products; consider using products that minimize workload efforts (e.g. number of dressing changes)
  • Therapeutic surfaces
  • Pressure relief monitoring devices
  • Completion of International Pressure Ulcer/Injury Prevalence Survey with mattress supplier 
  • Rentals for special products (e.g. special air mattress) based on patient needs
  • Equipment to redistribute pressure is actively promoted and used on all inpatient units
  • In Emergency Department, specialty mattresses for patients at risk 
  • Use of "patient pads" for patients in Critical Care to reduce layers under patients 
  • Budget allocated for pressure reduction mattresses and other equipment
  • Multi-year bed replacement plan in place

Monitoring / Indicators

• Corporate audits of completion of pressure injury risk assessment and accompanying interventions and as needed based on incidence. 
• Review of documentation and accuracy of initial assessment
• Number of requests for wound consults audit results
• Pressure injury incidence and prevalence completed routinely and compared against national benchmarks
• Worsening pressure injuries
• Pressure ulcers (per 1000 patients) tracked and monitored on the hospital scorecard
• Rounding audits
• Serious safety, precursor and near miss events tracked, monitored and reviewed through the safety reporting system
• Standardized pressure injury chart review checklist used as part of incident analysis
• Corporate audits of completion of pressure injury risk assessment and accompanying interventions and as needed based on incidence.