CHHS13/584
Canberra Hospital Intensive Care Unit & Emergency
Department
Standard Operating Procedure
Pressure Injury Prevention and Management
Purpose
To recognise the risk factors and reduce the incidence of pressure associated injuries
occurring within the Intensive Care Unit and Emergency Department. This standard
operating procedure (SOP) provides staff with strategic direction and resources to improve
the safety of patients by:
 identifying the level of risk for pressure injury to patients
 implementing preventative strategies to reducing the risk of hospital acquired injury
 appropriately managing patients where pressure injuries cannot be prevented
Scope
This standard operating procedure relates to employees providing care to all patients within
the Health Directorate.
Procedure
Step 1- Pressure Injury Risk Assessment
 Pressure injury risk assessment using the designated tool (Waterlow or Braden Q)
must be completed for all patients as soon as possible after admission to Intensive
Care to identify those patients “at risk” of developing a pressure injury.

Pressure Injury Risk Assessment will be conducted on admitted patients in the
Emergency Department:
1. At 8 hours from time of arrival, where deemed (i) boarding in the ED awaiting
an inpatient bed or (ii) inpatients of the Emergency Medicine Unit
2. Considered at high risk of either arriving with or developing a pressure injury
3. Not currently undergoing resuscitation or other priority interventions
A risk assessment should be conducted:
o Within eight hours of admission to a Health Directorate service area
o Daily and if there is a significant change in the patient’s condition
Doc Number
CHHS13/584
Issued
October 2013
Review Date
October 2015
Area Responsible
Critical Care
Page
1 of 10
CHHS13/584
 Referral to appropriate health professionals such as Dietician and Occupational
Therapist as soon as possible for those patients identified at risk or with a pressure
injury. A Discharge Liaison Nurse (DLN) may be involved in the referral process
regarding discharge for high risk patients or patients with a known pressure injury
from ED; alternatively the referral may be communicated through documentation for
those patients being prepared for transfer into Canberra Hospital’s wards.
 The risk assessment should include identifying intrinsic and extrinsic factors that may
increase the patient’s risk pressure injury for Intensive Care patients. (AWMA, Pan
Pacific Clinical Practice Guidelines for the Prevention and Management of Pressure
Injury, 2012)
o Extrinsic
 pressure (most important extrinsic factor)
 impaired mobility
 impaired activity
 impaired sensory perception
 tissue tolerance
 friction
 shear
 moisture/microclimate
o Intrinsic
 nutrition,
 demographics,
 oxygen delivery,
 chronic illness,
 skin temperature



Appropriate interventions should be implemented and documented for the individual
risk factors indentified from the risk assessment tool.
If at risk, explain the need for referral to appropriate health professionals for further
review.
Emergency Department patients require a Warterlow or Braden Q score along with
preventative interventions documented. Immediate preventative interventions may
be constrained by patient acuity and/or ongoing assessment and investigations. If
pressure injury is identified, wound management plans may be initiated in the ED,
particularly focusing of offloading e.g. access to hospital bed with alternating air
mattress, turning regimes. A continuum of prevention and management needs can be
reviewed within the ward areas.
Step 2- Interventions
 A multifactorial and interdisciplinary team approach is needed to improve pressure
injury prevention and management.
 It is important to identify both intrinsic and extrinsic interventions.
 Interventions and plan of care will be determined by the risk assessment and risk
factors identified.
 Interventions and management include:
o Pressure injury risk assessment
o Skin integrity checks particularly over bony prominences and with or without
medical devices,
o Use moisturising creams to maintain an monitor skin integrity
o Reduce humidity and heat at skin interface and mattresses surface, by
removing ‘Kylies’ or additional linen
Doc Number
CHHS13/584
Issued
October 2013
Review Date
October 2015
Area Responsible
Critical Care
Page
2 of 10
CHHS13/584
o Control and eliminate excessive moisture e.g. incontinence measurements e.g.
IDC, faecal drainage system, Conveen skin management cleanser and barrier
creams
o Patient education when appropriately orientated
o Use of appropriate equipment and support surfaces such as constant low
pressure mattress/ alternating air mattresses and pressure relieving cushions
o Mobilisation
o Nutritional support
o Wound management including staging of pressure injury (Refer Diagram 1)
o Consider adhesive foam dressing as preventative measure e.g. sacrum/ heels
o Repositioning – frequency depending upon skin response with or without
assistance e.g. wardsman
o Document in clinical record and handover
(Refer Chart 1)
Hard Collars:
Miami J/ hard collars used in spinal precautions should be removed every 4 hours to inspect
the underlying skin and padding change when soiled. Areas include occipital, chin, ears,
mandible and suprascapula areas.
Refer: Spinal Precautions and Care of Adult Patients with Potential Spinal Injury (TCH
11:018).
NOTE: Not all patients are suitable for an alternating air mattress e.g. spinal injury,
fractures.
Seek medical clearance prior to use of alternating air mattress surfaces.
Foot Drop Splints, Zimmer Splints and Plaster of Paris Backslabs;
All splints should be removed and skin integrity checked once per shift. Plaster of paris
backslabs require a medical management plan documented for removal and regular review of
skin integrity e.g. facture blisters and pressure injury. Ensure splints and backslabs are
adequately padding and may require re-padding and/or relining to prevent damage to skin
integrity.
Nasogastric tube (NGT):
NGT tapes should be changed daily and as required. Inspect nares and underlying skin for
gins of pressure or trauma and re-secure in an alternative location. Ensure patient is not lying
on any tubing.
Endotracheal tube (ETT):
Use an endotracheal attachment device (ETAD) for patients who will be intubated for
>24hours. ETT should be repositioned in the mouth at least every 4 hours, or every time
mouth care is attended. Check for skin lesions on the lips and tongue. Cotton tapes would be
replaced every 24 hours; if wet or soiled or if too tight /loose. ETT should be repositioned at
each change. Cotton tapes are removed and replaced with ETADs as soon as possible
following emergency situations.
Non invasive ventilation (NIV) masks and Nasal Prongs:
NIV masks should be removed periodically as tolerated to reduce pressure injuries across the
nose, cheeks and chin. Use alternative oxygen flow delivery device while NIV mask is removed
and directly supervise any patient during the period of NIV mask removal. The NIV mask must
be replaced if any signs of hypoxia become evident.
Doc Number
CHHS13/584
Issued
October 2013
Review Date
October 2015
Area Responsible
Critical Care
Page
3 of 10
CHHS13/584
Pulse Oximeter sensor:
Avoid reinforcing the pulse oximeter sensor with tapes and do not place tapes
circumferentially around the probe and finger. Check skin integrity by removing probe and
inspect finger once per shift. Ensure skin integrity under the probe is check, cleaned and skin
dried once per shift. Disposable oxygen sensors may be reused after the patient’s finger is
cleaned and dried until the tape is unable to secure the oxygen sensor.
Graduated Compression Stockings (GCS) and Intermittent Pneumatic Compression (IPC):
GCS and IPC should be removed once per shift to inspect toes, heels and calves. Ensure
patient is not lying on any component of tubing.
Heating blankets:
These blankets should be removed when therapeutic skin temperate and selected core
temperature is reached.
Step 3- Education of Patient/ Carer
 On admission the information re risks and interventions should be a part of the
patient/carer’s orientation. E.g. information brochure if appropriate.
 If at risk, explain the need for referral to other health professionals.
Step 4- Pressure Injury Reporting
 If a pressure injury is noted on admission a RiskMan report must be completed.
 A RiskMan report is also required for any pressure injury noted during the course of
admission.
o Inform the patient/ carer of the injury particularly if acquired whist in hospital
o Discuss management plan with patient /carer
 Document and handover the ongoing management of the patient including the specific
preventative strategies to reduce the risk of further pressure injuries.
 Divisions are required to review any incidents of pressure injury and take appropriate
action.
Step 5- ICU Discharge Planning
 Planning for discharge should commence on admission at the time the risk assessment
is conducted.
 The interdisciplinary team needs to be an integral part of the discharge plan to enable
ongoing care of the pressure injury or risk.
 When required referral is made by each discipline to appropriate services such as
community nurse, dietitian, or occupational therapist.
 Ensure on transfer to ward areas that a documented prevention and management
plan encompasses risk assessment score, additional interventions required, e.g.
alternating air mattress, pressure injury assessment including, staging and
management plan.
Doc Number
CHHS13/584
Issued
October 2013
Review Date
October 2015
Area Responsible
Critical Care
Page
4 of 10
CHHS13/584
Evaluation
Outcome Measure
 A reduction in facility acquired pressure injuries
 Pressure injuries are documented in RiskMan
 The outcome of pressure injury is reduced in severity
Method
Audits are conducted at regular intervals
 A pressure injury prevalence study will be conducted annually and will facilitate:
o An annual prevalence and trended data
o Percent of hospital and community acquired injuries
o Compliance to completion of risk assessment
o Compliance to implementing appropriate interventions for patient/consumers
at risk
o Compliance to reporting in RiskMan
o Compliance to completing documentation
 Documented evidence that local pressure injury data from RiskMan and audits are
analysed and disseminated and appropriate actions taken to improve patient care
 Pressure injury data is reported to Pressure Injury Prevention and Management
Reference Group
 In depth review is used for any pressure injuries acquired in hospital at stage 3 and 4
 Pressure injuries are documented in RiskMan
Related Legislation, Policies and Standards



Pressure injury prevention and management - CHHS12/142
Spinal Precautions and Care of Adult Patients with Potential Spinal Injury (TCH
11:018)
Pressure injury prevention and management - CHHS12/141
Definition of Terms (only use this section if needed, delete if not needed)
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. (AWMA, Pan
Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury,
2012)
Risk Assessment Tool
Validated and formal scale or score used to help determine the degree of pressure injury
risk.
Common risk assessment tools include:




Waterlow Risk Assessment Tool
Braden Risk Assessment Scale
Braden Q Risk Assessment Scale (paediatric patients)
Norton Risk Assessment Score.
Doc Number
CHHS13/584
Issued
October 2013
Review Date
October 2015
Area Responsible
Critical Care
Page
5 of 10
CHHS13/584
Risk assessment tools should be used in conjunction with clinical judgement.
Any factor which exposes the skin to excessive pressure, or diminishes its tolerance to pressure, is
considered a “risk factor”.
Prevalence
Total number of a given population with pressure injuries.
Incidence
The proportion of at-risk patients who develop a new pressure injury over a specific period.
Extrinsic Risk Factors
Risk factors originating outside the body such as pressure and shear forces, friction and
moisture all impact on the skin ability to tolerate prolonged and sustained pressure.
Intrinsic Risk Factors
Risk factors originating within the body reduce the ability for underlying tissues such as the vascular
and lymphatic system to tolerate prolonged and sustained pressure.
Intrinsic risk factors include advancing age, chronic illness and conditions such as diabetes mellitus,
carcinoma, peripheral vascular disease, cardiopulmonary disease, lymphoedema, renal impairment,
low blood pressure, anaemia and smoking.
References

Australian Wound Management Association. Pan Pacific Clinical Practice Guideline
for the Prevention and Management of Pressure Injury. Cambridge Media Osborne
Park, WA: 2012.

European Pressure Ulcer Advisory Panel /National Pressure ulcer Advisory Panel.
Prevention and treatment of pressure ulcers: Washington DC: National Pressure
Ulcer Advisory Panel; 2009.

Australian Commission on Safety and Quality in Health Care- Standard 8 “Preventing
and Managing Pressure Injuries”

Australian Council on Healthcare Standards – Criteria 1.5.3 “The incidence and impact
of breaks in skin integrity, pressure ulcers and other non-surgical wounds are
minimised through wound prevention and management programs”

ACT Health Directorate Policy Pressure injury prevention and Management
Doc Number
CHHS13/584
Issued
October 2013
Review Date
October 2015
Area Responsible
Critical Care
Page
6 of 10
CHHS13/584
Attachments
Chart 1: Pressure Injury Prevention and Management Clinical Intervention Guideline
Doc Number
CHHS13/584
Issued
October 2013
Review Date
October 2015
Area Responsible
Critical Care
Page
7 of 10
CHHS13/584
Braden Q Risk Assessment Scale
Staging Pressure Injury
Doc Number
CHHS13/584
Issued
October 2013
Review Date
October 2015
Area Responsible
Critical Care
Page
8 of 10
CHHS13/584
Doc Number
CHHS13/584
Issued
October 2013
Review Date
October 2015
Area Responsible
Critical Care
Page
9 of 10
CHHS13/584
Images used with permission from Australian Wound Management Association Inc, 2012.
Disclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> specifically for
its own use. Use of this document and any reliance on the information contained therein by any third party is at
his or her own risk and Health Directorate assumes no responsibility whatsoever.
Doc Number
CHHS13/584
Issued
October 2013
Review Date
October 2015
Area Responsible
Critical Care
Page
10 of 10