Pressure Injury Prevention and Treatment policy update
Purpose
Pressure injuries continue to be a significant health concern as the population ages and the complexity of care increases across all care settings. Early identification of persons at risk for pressure injury development and prompt intervention remains key to pressure injury prevention.
Policy Number
Background
Pressure injury prevention and treatment crosses all care areas in SH-SS. Policy reviewed and updated to meet accreditation ROPs and to incorporate suggested revisions from differing care areas. The policy was reviewed by the Wound Care Committee policy review team.
Key Message
- Clarification of Braden Scale assessment intervals in home care
- Care plans: Acute care can utilize Pressure Injury Prevention and Management Intervention Checklist OR Braden Scale Standard Care Plan. Long Term Care and Transitional Care to utilize newly developed Braden Scale Standard Care Plan for Personal Care Homes (PCH).
- Included table into policy to outline which supporting
documents are to be used in each care area. Key changes: Clients that are expected to be immobile for 2+ hours will need a Braden Scale assessment complete. For example, clients with an expected surgery greater than 2 hours in length, or a client in ER that has altered LOC and unable to reposition self. - Included high risk factors for surgical patients
| Braden Scale for Predicting Risk of Pressure Injuries | Pressure Injury Prevention and Management intervention Checklist | Pressure Injury Prevention and Management Individualized Care Plan Home Care | Health Care Aide Skin Observation Form | Home Care Attendant Skin Observation Form | Braden Scale Standard Care Plan for PCH | Wound and Skin Discharge Summary Form | |
| Acute Care | x | x | x | x | |||
| Outpatient Ambulatory Care Clinics | x *expected immobility over 2hrs or high risk | x (if required) | |||||
| Community Programs | |||||||
| Emergency Department/ Observation | x * expected immobility over 2hrs or high risk | x (if required) | |||||
| Home Care/ Palliative | x | x | x | x | |||
| LTC | x | x | x | x | |||
| SDS / OR Perioperative | x * expected immobility over 2hrs or high risk | x (if required) | |||||
| TCU | x | x | x | x |
- Health Care Aide Skin Observation Form and Home Care Attendant Skin Observation Form updated to include diagrams of feet for documentation
- Newly created pamphlet to be utilized in long term care and transitional care to be provided to residents and families regarding pressure injury prevention “Skin Health: Help us Protect Your Skin and Prevent Pressure Injuries: Information for you and your family”
- Audit process clarified
Recommendation(s)/Action Required
- Review policy with staff – “read only” changes
- Update supporting documents – Skin Observation forms, PCH pamphlet, Braden scale implementation in additional care areas, Braden Scale Care Plan for Personal Care Homes
Timeline:
As soon as possible after posted
Submitted by: L Cassan, Regional Lead – Acute Care & Chief Nursing Officer