Pressure-Injury-Prevention-and-Management-Policy-Implementation-Guide.pdf

PRESSURE INJURY PREVENTION AND MANAGEMENT
POLICY IMPLEMENTATION GUIDE
RELEASED JUNE 2014

INTRODUCTION
The NSW Health Pressure Injury Prevention and Management Policy (PD2014_007) is based on best practice
in alignment with the Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure
Injury 2012 . This document outlines the resources developed to assist with implementation of the revised
policy. Care planning and delivery should be consistent with this policy and best-practice guidelines and be
appropriate for the patient population.
It supports elements of the NSQHSS, Standard 8 Preventing and Managing Pressure Injuries which describes
evidence-based systems to prevent pressure injuries and manage them when they do occur. This includes:
 Health service organisations have governance structures and systems in place for the prevention and
management of pressure injuries.
 Patients are screened on presentation and pressure injury prevention strategies are when clinically
indicated.
 Patients who have pressure injuries are managed according to best-practice guidelines.
 Patients and/or carers are informed of the risks, prevention strategies and management of pressure
injuries.
The objective of the policy is to improve patient safety and the quality of clinical care. The underlying principles
of pressure injury prevention and management are aligned with NSQHSS - Standard 8 Preventing and
Managing Pressure Injuries.

GOVERNANCE
A senior manager and/or a governance group/committee is responsible for monitoring compliance with the
health service pressure injury policies, procedures and protocols, and ensuring there are systems in place to
monitor and analyse pressure injury data, and conducting relevant quality improvement activities.
The steps outlined below will assist:
Step 1: Establish a strong case for change
 Policy requirement
 Gather baseline pressure injury data
Step 2: Establish governance arrangements and a program team
 Identify executive sponsor and program stakeholders
 Consider creating an engagement and communication plan
Step 3: Recruit respected and influential leaders and champions
 Seek advice from others who have led organisational change programs
Step 4: Identify barriers and enablers of pressure injury prevention
 Brainstorm causes of inadequate or delayed recognition and treatment
 Consider actions to address barriers
 What are the enablers that will support the implementation?
A template for developing a local Pressure Injury Prevention Facility Implementation plan is included in the
appendices of this guide. An action plan template has also been developed for local use.

CLINICAL PRACTICE:
PREVENTING AND MANAGING PRESSURE INJURY
Risk assessment
As a minimum, all patients must undergo initial risk screening to inform the clinical risk assessment decision
making process. Risk assessment of patients using a validated tool is recommended and does not require a
separate screening process.