Pressure injury is defined as a confined injury to the skin which may involve the deeper tissue and is frequently found over a bony prominence due to pressure, shear and/or friction singly or a combination of these reasons (Australian Wound Management Association, 2014). It is a common hospital-acquired problem which affects between 9.5 to 17.6% of individuals in hospital at any given point (Nguyen, Chaboyer, & Whitty, 2015). An estimated 4,313 pressure injuries occurred in patients in public hospitals of Australia in 2015–16. The rate of hospital-acquired pressure injuries in hospitals of Australia was 9.7 injuries per 10,000 hospitalisations in 2015–16 (Australian Commission on Safety and Quality in Health Care, 2018). Pressure injury is also one of the major comorbidity associated with various illnesses of old age. Healing of pressure injuries takes longer time which adversely affects the quality of life of older people by inflicting pain, disturbed sleep, mood disturbance restricting mobility, and susceptibility to infection (NSW Health; Clinical Excellence Commission, 2014). They also adversely affect rehabilitation, mobility and long-term quality of life (Clinical Excellence Commission).
Pressure injuries prolong the time in hospitals that influences the older people negatively and increase the cost of care both due to extension of stay in the health facility and/or more advanced care needs (National Pressure Ulcer Advisory Panel; European Pressure Ulcer Advisory Panel (NPUAP & EPUAP), 2009). The treatment cost across all states and severity in 2012-13 was estimated to be A$983 million per annum. Research has demonstrated decrease in incidence of pressure injury by some hospitals by taking preventive measures (Miles, Fulbrook, Nowick, & Franks, 2013). It suggests that the hospital-acquired pressure injuries can be prevented or reduced by providing patient care that mitigates avoidable clinical risks to patients.
This report is prepared to appraise the pressure injury prevention and management policy to assess the probable areas of improvement in context with improving health outcomes for older people. The analysis of the policy will provide the review of policy along with recommendations to update this policy. The review and recommendations will be supported by review literature to support the evidence-based practice.
The critical review of the NSW Health Pressure injury prevention and management policy (PD2014_007) (CEC, 2014), will emphasize on the education and awareness of care providers involved in management of the pressure injury. This policy is publicised on March 24, 2014 and is due to be reviewed on March 24, 2019. This policy is derived from the best practice guidelines corresponding with Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury 2012 (Australian Wound Management Association, 2012). The purpose of the policy is to reduce the prevalence of pressure injuries to NSW Health patients (CEC, 2014). Prevention of hospital acquired pressure injury is a work in progress. The National Safety and Quality Health Service Standards (NSQHS) are significant means of improved outcomes provisions for elderly patients (Australian Commission on Safety and Quality in Health Care, 2012). A recent survey in NSW revealed that in spite of Standard 8, only 60% of patients went through a detailed risk assessment involving skin assessment and a reliable tool within 8 hours of presentation to the hospital ( Clinical Excellence Commission, 2017). Prevention and management of pressure injury can be achieved by acting upon the Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. These provide detailed guidance on the actions needed to prevent pressure injury. However, for implementation of these Guidelines, an orgnaisational focus on policies, leadership from management and education is required (Doggett & Buck, 2018). Therefore, this policy should be updated to implement better pressure management practice by skilled professionals and support evidence based practice.
Identification of gaps- One of the significant aspect, which is lacking in the comprehensive care provision to pressure injury elderly patients, is the lack of knowledge among practitioners. The issue is education and training of the practitioners to prevent or minimise the development of pressure injuries among older people. This could be implemented by updating a new policy which enhances evidence based practice (Volunteering Australia, 2006).
Staff, patient and carer meeting: Regular meetings and debate among the staff members, patients and carer is essential to provide and receive feedback on the existing policy. It will offer clarity in information about the existing policy and strategies to prevent pressure injuries. The question will help to assess the understanding level and knowledge on current policy and prevention of pressure injury among older people. It will assist in determining the areas which needs improvement regarding pressure injuries (UOW, n.d.).
Team formation and consultation: A team of health care providers, which must include medical officer, pharmacist, physiotherapist, and nurses, will be developed. This team will examine the current pressure injury prevention policy and impact of practitioner’s skill and knowledge on its pressure injury management. This consultation team assists in exchanging information for updating the policy (University of Southern Queensland, n.d.).
Construction of draft of internal policy: The experts in the team in health facilities will develop the draft of new internal policy on pressure injury prevention based on the past policy. In this way, the experts will update the policy on pressure injury prevention and management. The updated policy will ensure safety and improve the care delivery associated with pressure injury among older people. Older people will be provided with quality care and services to maintain safety.
Expert staff review: The leaders, mangers and other experts in the team will review the policy to ensure that it includes all the factors associated with care providers awareness for pressure injury prevention practice. Further, the experts will also seek feedback to improve the quality of care and make sure that the facility has met the goals and objectives for further positive changes.
Final version: Lastly, the staff members and the expert team will make decision on final version of pressure injury prevention policy. After decision-making, the updated policy will be published in the internal system of institution as updated and modified version of pressure injury prevention policy. Therefore, all the staff members in the health facility will be informed about the updated policy and instructed to implement it in their practice. To make the implementation of updated policy more effective the staff member will be given training and educated. It will increase awareness among the staff to learn the new pressure injury prevention policy to ensure evidence based practice to reduce the incidence of pressure injuries.
A systematic review was conducted to identify the evidence based strategies of pressure injury prevention and management among older people. Databases such as ProQuest and CINHAL were used through University of Wollongong Library with full text English journal articles from 2009 to 2018. The key words used to search the articles were ‘pressure injury prevention’, ‘ pressure injury managment’, ‘pressure ulcer AND elderly people’ ‘knowledge AND pressure injury’, etc. Out of 26 relevant articles, 7 articles are used to identify the factors contributing in update of existing policy on pressure injury prevention with respect to the need of education programs on pressure ulcer prevention for healthcare providers.
A cross sectional study was conducted to assess and compare the quality of life associated with in elderly patients with pressure ulcers in home care, acute care facility, and long-term care facility [LTCF]. The study found that the elderly patients with pressure ulcers exhibited low scores on physical and social functioning and role physical and emotional. This finding shows a need for an environment which includes health care professionals prepared to execute strategies for pressure ulcer prevention (Maria, et al., 2015). Another study identifies the need of a zero-tolerance policy by the primary physician and the nurse regarding pressure ulcers. The study further suggests ongoing education of the healthcare providers and family members for effective prevention and management of pressure ulcers (Jaul & Menzel, 2014). Likewise, another study identified the need of educational program for healthcare providers. The study suggested that prevention of pressure ulcers in frail older people is a complex task and highlighted the significance of an organised educational programme that will include efficient clinical leadership and interprofesssional teamwork (Barry & Nugent, 2015).
A PRIME trial was conducted which included a 15-month pre- and post-intervention study to examine the efficacy of an unified pressure ulcer management framework including pressure ulcer risk assessment tools, Australian Wound Management Association (AWMA) guidelines, digital imaging and medical education in decreasing the incidence of pressure ulcer in residential aged care facilities. The findings of the trial revealed that PRIME system considerably decreased pressure ulcer incidence risk by 52%. The research concluded that the combined system is effective in lowering pressure ulcer incidence in the frail elderly population in residential aged care settings. It must be noted that one of the elements of the PRIME intervention was Pressure ulcer prevention education programme so; the significance of education program is established through this study (Santamaria, et al., 2009). A paper supported this argument by presenting the results of a 5-year pressure ulcer prevention programme at a Hospital in Australia. The programme consisted of several interventions and three hospital-wide point prevalence surveys were done for progress evaluation. It revealed that incidence of hospital-acquired pressure ulcers reduced from 6.6% in 2010 to 6% in 2012 and 2.5% in 2014. The findings exhibited the efficiency of the comprehensive programme of pressure ulcer prevention which was based on research and education (Santamaria, et al., 2015).
Nurses play a vital role in the prevention of pressure injuries therefore, a multi-centered, cross-sectional study was done to evaluate the knowledge and attitude of nurses towards pressure injury prevention evidence-based guidelines. Paper-based questionnaires were asked to undergraduate nursing students in seven universities across five states of Australia. Results revealed a lack of knowledge about prevention strategies to decrease the amount and duration of pressure/shear, and lower confidence in their ability to prevent pressure injury. Therefore, the study established the need of implementation of a detailed approach to enhancing knowledge about pressure injury prevention and management knowledge among Australian nurses (Usher, et al., 2018). Another study which was used to examine knowledge of nurses about pressure ulcer management to identify knowledge gaps. The findings revealed deficits in pressure ulcer knowledge among nurses (Lawrence, Fulbrook, & Miles, 2015). Therefore, it can be concluded that there is a lack of knowledge among healthcare providers regarding pressure injury prevention strategies and its guidelines. So, it is justified to update the Pressure injury prevention and management policy to include organized education programs in a firmer manner.
After the literature review and the consultation activities, the new pressure injury prevention and management policy needs to be implemented. Following action plan will be used to implemented.
|
Task/Activity |
Resources |
Timeframe |
Outcome measures of success |
|
Conduction of survey |
A survey should be organised to gather data regarding knowledge of staff about pressure injury prevention and management |
One month before implementation of policy |
Discussion with healthcare providers to raise awareness |
|
Engagement of staff |
A poster should be prepared to pressure injury prevention and management to motivate the staff regarding implementation of policy in their practice |
Bimonthly |
Staff participation should be assessed through attendance and feedback should be sought from the staff members |
|
Provision of training and education |
The training program and education sessions will assist in upgrading the existing knowledge and raising awareness regarding pressure injury prevention and management among older people |
Monthly |
A questionnaire can be prepared to evaluate knowledge level of knowledge among nurses regarding new policy adherence. |
|
Conduction of meeting |
Meeting should be organised for the multidisciplinary team members to deliberate regarding the updated policy and its impact on the health outcomes of the older people. |
Biweekly |
Analysis should be done to assess the reduction in prevalence of pressure injuries among older people and active participation in prevention and management. |
|
Data collection |
Data should be collected about incidence of pressure injuries in older people |
Once in a month |
Decrease in the number of pressure injuries |
|
Post-survey conduction |
A post-implementation survey should be conducted to evaluate the knowledge regarding pressure injury prevention and effectiveness of policy |
After one month of implementation of policy |
Assessment of improvement of knowledge level on pressure injury prevention and seek positive feedback on policy |
The efficiency of policy will be assessed using audit tool to ensure implementation of policy and knowledge of staff members regrading prevention of pressure injury prevention and management (Grace, et al., 2017). The audit tool will assist in assessing and monitoring whether the goals of the updated policies are met or not. A monitoring and auditing framework will be constructed which is mentioned in appendix 2. Timely monitoring of reported pressure injury incidence in the healthcare facility will be gathered from routinely collected data sets. Incidence data will show the occurrence of new cases within a health facility and will be an indication of quality of care. This data will demonstrate pressure injuries acquired within the current facility. The quality and totality of routinely collected data are not equal to that of dedicated data collection (such as a point prevalence survey), but routine data will facilitate trend evaluation closer to real time (e.g., monthly statistics can be derived), backing up quality improvement plans, with less need of resources.
Conclusion
Pressure injury is a comorbidity which extends the hospital stay and increases complications for patients by causing pain, restricting mobility and reducing the overall quality of life. A critical review of the pressure injury prevention and management policy was done. The review revealed that the policy needed stronger pointers for educative programs for health care providers who are involved in pressure injury prevention and management among older adults. Therefore, the need for updating this policy was justified on the basis of evidence based research (APSC, 2008). It was found in the literature search that there is a lack of knowledge among healthcare providers regarding pressure injury prevention and its guidelines. A consultation with consumers and colleagues to develop the new or updated policy was done and the consultation activities are mentioned which led to the development of final draft of the updated policy. An action plan for implementation of the policy along with the recommendations about how to measure successful implementation of the updated policy are provided which will be useful in future update. In addition, critiquing process on pressure injury prevention and management policy was useful in understanding the requirements for future evidence based practices. Also, it was an opportunity to learn the skills and upgrade knowledge to review and update the policy. I learnt the importance of review of policy to update the new system and knowledge regarding pressure injury prevention among older people. The gap in the policy could be identified through the literature review. Therefore, being a health care professional I learned that it is important to analyze and monitor the health policies to maintain and provide quality of care to the older people.
References
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Australian Commission on Safety and Quality in Health Care. (2012). National Safety and Quality Health Service Standards. Sydney: ACSQHC.
Australian Commission on Safety and Quality in Health Care. (2018). PRESSURE INJURY. ACSQH.
Australian Wound Management Association. (2012). Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury. WA: Cambridge Media.
Australian Wound Management Association. (2014). Prevention and treatment of pressure ulcers: clinical practice guideline.
Barry, & Nugent. (2015). Pressure ulcer prevention in frail older people. Nursing Standard, 30(16), 50-60.
CEC. (2014). Policy Directive: Pressure Injury Prevention and Management. Sydney: NSW Health.
CEC. (2014). PRESSURE INJURY PREVENTION AND MANAGEMENT: POLICY IMPLEMENTATION GUIDE.
Clinical Excellence Commission. (2017). 2016 NSW Pressure Injury Point Prevalence Survey Report (2017). Sydney.
Clinical Excellence Commission. (2014). Clinical Excellence Pressure Injury Prevention Project Monitoring & Auditing Framework. Sydney: NSW Government.
Clinical Excellence Commission. (n.d.). PRESSURE INJURY PREVENTION PROJECT. NSW Government.
Doggett, & Buck. (2018, January 4). A new approach to pressure injuries needed – Wounds Australia. Retrieved from https://croakey.org/a-new-approach-to-pressure-injuries-needed-wounds-australia/
Grace, F. C., Meurk, C. S., Head, B. W., Hall, W. D., Harris, M. G., & Whiteford, H. A. (2017). An analysis of policy success and failure in formal evaluations of Australia’s national mental health strategy (1992–2012). BMC Health Serv Res, 17.
Jaul, & Menzel. (2014). Pressure Ulcers in the Elderly, as a Public Health Problem. J Gen Practice, 2.
Lawrence, Fulbrook, & Miles. (2015). A Survey of Australian Nurses’ Knowledge of Pressure Injury/Pressure Ulcer Management. J Wound Ostomy Continence Nurs, 42(5), 450-60.
Maria, Francescato, Oliveria, Felipe, Yara, & Masako. (2015). Health-Related Quality of Life in Elderly Patients With Pressure Ulcers in Different Care Settings. Journal of Wound, Ostomy and Continence Nursing, 42(4), 352-59.
Miles, Fulbrook, Nowick, & Franks. (2013). Decreasing pressure injury prevalence in an Australian general hospital: A 10-year review. Wound Practice & Research. Journal of the Australian Wound Management Association, 21, 148-56.
National Pressure Ulcer Advisory Panel; European Pressure Ulcer Advisory Panel (NPUAP & EPUAP). (2009). Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Washington DC: NPUAP.
Nguyen, Chaboyer, & Whitty. (2015). Pressure injury in Australian public hospitals: a cost-of-illness study. Aust Health Rev, 39(3), 329-336.
NSW Health; Clinical Excellence Commission. (2014). Pressure Injury Prevention and Management Policy. NSW Health & CEC.
Santamaria, Carville, Prentice, Ellis, Ellis, Lewin, & Newall. (2009). Reducing pressure ulcer prevalence in residential aged care: results from phase II of the PRIME trial. Wound Practice and Research, 17(1), 12-22.
Santamaria, N., McCann, J., O’Keefe, S., Rakis, S., Sage, S., Tudor, H., . . . Morrow, F. (2015). Clinical innovation: results from a five-year pressure ulcer prevention project. Wounds International, 6(3), 12-16.
University of Southern Queensland. (n.d.). Process Review Policy and Procedure. Retrieved from University of Southern Queensland: https://policy.usq.edu.au/documents/13454PL
UOW. (n.d.). Develop and Review Policy. Retrieved from University of Wollongong: https://www.uow.edu.au/about/policy/develop/index.html
Usher, Woods, Brown, Power, Lea, Hutchinson, . . . Miller. (2018). Australian nursing students’ knowledge and attitudes towards pressure injury prevention: A cross-sectional study. International Journal of Nursing Studies, 81, 14-20.
Volunteering Australia. (2006). Volunteering policy consultation framework. Melbourne: Volunteering Australia.
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