Newborn Pressure Injury Prevention and Management

SLHD: Royal Prince Alfred Hospital Guideline Women and Babies: Newborn Pressure Injury Prevention and Management

TRIM Document No

Policy Reference RPAH_GL2018_003

Related MOH/SLHD Policy N/A

Keywords Neonate, newborn infant, pressure injury

Applies to RPAH, Newborn Care

Clinical Stream(s)

Women’s Health, Neonatology

Date approved GM, RPA 08/102018

Date approved by RPA Policy Committee 01/05/2018

Author Angel Wai, CNS RPA Newborn Care

Status Active

Review Date October 2023

Risk Rating (At time of publication)

M

Replaces N/A

Version History V1

Date 08/10/2018

Sydney Local Health District – Royal Prince Alfred Hospital Policy No: RPAH_GL2018_003

Date Issued: October 2018

Compliance with this Guideline is Recommended 2

Women and Babies: Pressure Injury Prevention and Management

Contents SLHD - RPA Women and Babies: Newborn Pressure Injury Prevention and Management ... 4

1. Introduction ................................................................................................................ 4

2. The Aims / Expected Outcome of this Guideline ......................................................... 4

3. Risk Statement ........................................................................................................... 4

4. Scope ......................................................................................................................... 4

5. Resources .................................................................................................................. 4

6. Implementation ........................................................................................................... 5

7. Key Performance Indicators and Service Measures ................................................... 5

8. Consequences ........................................................................................................... 5

9. Key Points .................................................................................................................. 5

10. Guidelines ............................................................................................................... 6

Background ........................................................................................................................... 6

10.1 Skin injury is preventable ................................................................................. 6

10.2 Pressure injuries in neonatal population ........................................................... 6

10.3 Prevalence of neonatal skin injury / pressure areas ......................................... 6

10.4 Risk factors for pressure and skin injuries in infants ......................................... 6

10.5 Common sites of injury in neonatal population ................................................. 7

11. Pressure injury risk assessment tool ....................................................................... 8

11.1 Neonatal Skin Condition Score (NSCS) ........................................................... 8

11.2 Modified Glamorgan Pressure Injury Risk Assessment .................................... 9

12. Practice Guidelines ............................................................................................... 11

12.1 Assessment ................................................................................................... 11

12.2 Baseline assessments ................................................................................... 11

12.3 Infants born in RPAH ..................................................................................... 11

12.4 Ongoing assessment ..................................................................................... 11

13. Diagnosis .............................................................................................................. 12

13.1 Suspected pressure area ............................................................................... 12

13.2 Pressure Injury staging guide ......................................................................... 12

14. Prevention strategies ............................................................................................ 12

14.1 Skin protection ............................................................................................... 12

14.2 Repositioning ................................................................................................. 12

14.3 Medical devices ............................................................................................. 13

14.4 Supportive surfaces ....................................................................................... 13

15. Documentation ...................................................................................................... 14

15.1 Initial Assessments ........................................................................................ 14




15.2 Ongoing Assessment ..................................................................................... 14

15.3 Individualised Care Plan ................................................................................ 14

15.4 Photographic evidence .................................................................................. 15

16. Notification ............................................................................................................ 15

16.1 Referral and consultation ............................................................................... 15

16.2 Ongoing management and surveillance ......................................................... 15

16.3 Communication .............................................................................................. 15

16.4 Education ....................................................................................................... 16

17. Definitions ............................................................................................................. 16

18. Consultation .......................................................................................................... 17

19. References ........................................................................................................... 18

19.1 National Safety and Quality Health Service (NSQHS) Standards ................... 20

20. Appendix 1 ............................................................................................................ 21

Clinical practice flow chart for the prevention and management of pressure injuries for inpatient neonates ........................................................................................................... 21

21. Appendix 2: Pressure Injury Staging Guide ........................................................... 22




SLHD - RPA Women and Babies: Newborn Pressure Injury Prevention and Management

1. Introduction Neonatal skin and pressure injuries can cause pain, discomfort and long-term disfigurement; parental stress and anxiety; and increased healthcare costs.(1) With appropriate care and management most neonatal pressure injuries can be prevented. This practical guideline is developed to fulfil the requirement to achieve The National Safety and Quality in Health Care (NSQHC) standard on prevention and management of pressure injuries.(2) As part of the clinical governance, this practical guideline details the need for screening tools, risk assessment and management frameworks to prevent or minimise the risk of pressure injury.

This policy is based on the best available evidence and should be read in conjunction with the following documents:

1. Small Baby Protocol 2. CPAP Management (Nursing) 3. Mechanical Ventilation Practice Guideline 4. Heated, Humidified High Flow Nasal Cannula Oxygen (HHHFNC) Nursing

Management Guidelines 5. Nursing Management of High Frequency Oscillation (HFO) 6. Muscle relaxation 7. Hypoxic-Ischaemic Encephalopathy 8. Stoma Care Guideline 9. Neonatal Abstinence Syndrome 10. Identification and management of subgaleal haemorrhage 11. Thermoregulation in the High Risk Infant 12. Management of central lines

2. The Aims / Expected Outcome of this Guideline • Identify neonates most at risk • Prevent/reduce the incidence of neonatal skin and pressure injury • Early detection of neonatal skin or pressure injury to allow timely and appropriate

intervention • Recognise signs of worsening pressure injury, escalate if appropriate and facilitate

referral as required • Reduce adverse outcomes from neonatal pressure injury

3. Risk Statement SLHD Enterprise Risk Management System (ERMS) Risk # 93 Preventing and Managing Pressure Injuries

• Incidence and associated outcomes of neonatal pressure injuries • Risk factors for developing pressure injuries • Physiological and economic impact of pressure injury

4. Scope • This policy applies to RPA Women and Babies: Newborn Care

5. Resources • RPA Education Program

https://www.slhd.nsw.gov.au/rpa/neonatal%5Ccontent/pdf/guidelines/small_baby.pdf

https://www.slhd.nsw.gov.au/RPA/neonatal%5Ccontent/pdf/Nursing%20Guidelines/nCPAP_Management.pdf

https://www.slhd.nsw.gov.au/RPA/neonatal%5Ccontent/pdf/Nursing%20Guidelines/Ventilation.pdf

https://www.slhd.nsw.gov.au/RPA/neonatal%5Ccontent/pdf/Nursing%20Guidelines/HHFNC.pdf

https://www.slhd.nsw.gov.au/RPA/neonatal%5Ccontent/pdf/Nursing%20Guidelines/HHFNC.pdf

https://www.slhd.nsw.gov.au/RPA/neonatal%5Ccontent/pdf/Nursing%20Guidelines/High_Frequency_Oscillation.pdf

https://www.slhd.nsw.gov.au/RPA/neonatal%5Ccontent/pdf/Nursing%20Guidelines/Muscle_relaxation.pdf

https://www.slhd.nsw.gov.au/rpa/neonatal%5Ccontent/pdf/guidelines/nas.pdf

https://www.slhd.nsw.gov.au/rpa/neonatal%5Ccontent/pdf/guidelines/Subgaleal.pdf

https://www.slhd.nsw.gov.au/RPA/neonatal%5Ccontent/pdf/Nursing%20Guidelines/Thermalmanagement.pdf




• RPA Wound Link Committee • RPA Wound and Pressure Injury Committee (WAPIC)

6. Implementation • Implementation and coordination through RPA Newborn Care Education Program

o Clinical Nurse Educator and Clinical Nurse Consultant in conjunction with nominated staff champions.

7. Key Performance Indicators and Service Measures Regular audit and investigation of serious skin injury in the NICU is an important quality improvement measure.

• Monthly audit for compliance and documentation as per hospital guideline • Audit results to be presented in monthly Wound and Pressure Injury Committee

(WAPIC) meeting • Routine audit of medical records of infants identified “at risk” 3-monthly • IIMS notifications • All IIMS tabled and discussed at monthly Newborn Care QI Meetings

8. Consequences

Neonatal skin injury can cause discomfort, pain and suffering, parental distress, increased length of stay, nursing time and costs, infection, may result in disfigurement requiring long term treatment. In some extreme cases, infants suffer from significant pressure or skin injuries may require surgeries at the injury site. Infant mortalities are reported in some cases.(1)

9. Key Points

Key Points Level of evidence; Grade of recommendation

Pressure and skin injuries are avoidable in many instances.(3) LOE IV

GOR D

Neonates are vulnerable to develop pressure and skin injuries.(5-

9,11,12) LOE III-3

GOR C

Adequate strategies, including a validated screening tool must be implemented to prevent pressure and skin injuries in neonates.(14,15,30-32)

LOC IV

GOR C

Staff should use clinical judgement in conjunction of assessment tools rather than solely rely on assessment tools to identify infants who are at risk of pressure injury.(19)

LOC I

GOR C




10. Guidelines

Background

10.1 Skin injury is preventable Skin is a major organ of defence against infection in neonates. Maintaining skin integrity and preventing iatrogenic injury is a high priority in RPA Newborn Care. Most neonatal skin injuries are considered preventable even for infants who are particularly vulnerable.(3) Regular staff and parent education should be provided to enable improved understanding, knowledge and skill transfer regarding appropriate neonatal skin management. The RPA Newborn Care healthcare team recognises the importance of maintaining skin integrity in all newborns and employs support strategies to minimise the risk and prevent adverse outcomes.

10.2 Pressure injuries in neonatal population A pressure injury is ‘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’.(4)

However, the distinction between bony and non-bony prominences in neonates is very fine and hard to distinguish. The epidermis is fragile and only one or two cells thick in extremely preterm infants (EPTI) or extremely low birth weight (ELBW) infants.(5) The skin in these infants is structurally and functionally different from more mature infants. Immature skin structure and development, thinner muscle layer and lack of brown fat deposition reduce the distinction of ‘bony prominence’ in neonates. Areas where do not considered as non-bony prominence (such as nasal septum) are now at risk of developing pressure injuries.(6)

10.3 Prevalence of neonatal skin injury / pressure areas The prevalence of neonatal pressure related skin injury is estimated to be between 17 and 31%.(7,8) However, with the paucity of exclusive neonatal data in the literature, accurate prevalence is difficult to determine.

10.4 Risk factors for pressure and skin injuries in infants It is estimated that approximately 50% of pressure areas in infants and children are related to equipment and devices.(9) These factors could come from the infant itself (intrinsic) or due to external sources (extrinsic) (see Table 1 & 2 below).(10)

Table 1. Intrinsic factors leading to pressure injuries

Intrinsic risk factors Examples

Reduced mobility

• Muscle relaxation • Sedation • Multiple invasive devices

Impaired perfusion • Hydrops fetalis (foetal hydrops) • Therapeutic cooling for Hypoxic-Ischaemic Encephalopathy

(HIE) • Generalised oedema

Gestational age • EPTI (birth gestation <276 weeks) (see Small Baby Protocol)

Birthweight • ELBW (birthweight <1000 gms) (see Small Baby Protocol)




Dermatological condition

• Epidermolysis Bullosa (EB) • Harlequin

Sensory impairment • Anaesthetics

Persistently moist skin • High ambient humidity • Moisture trapping

Inadequate nutrition/hydration

• Nil by mouth • Weight lost

Hypoalbuminaemia

Table 2. Extrinsic factors leading to pressure injuries

Extrinsic risk factors Examples

Pressure

Shear forces

Friction

Requiring respiratory support

• Continuous Positive Airway Pressure (CPAP) • Non-invasive Intermittent Positive Ventilation (NIPPV) • Heated, Humidified High Flow Nasal Cannula (Hi-Flow,

HHHNFC)

IV extravasations • Vasoconstrictive agents (inotropes); • Hyperosmolar solutions (>12% glucose) • Medications (Calcium, lipids, acyclovir)

Invasive devices • All vascular accesses • Intercostal catheters (chest drains) • Endotracheal Tube (ETT)

Medical devices • Leads and cables • Monitoring

Birth injury/ trauma • Subgaleal haemorrhage • Haematoma • skin and tissue abrasions • Cephalohematomas

Chemical burns • Skin disinfectants • Topical agents

Medical adhesives • Tapes

Repetitive skin puncture • Venepunctures • ICC replacement

10.5 Common sites of injury in neonatal population

• A cohort descriptive study conducted in Queensland over a 2-year period found that indwelling vascular catheters, nCPAP devices and probes (SpO2 and temperature) were associated with 54.2% of skin/pressure injuries. 31.8% of reported injuries were not associated with any risk factors.(8)




• A Japanese study identified the nose as the most common pressure area for neonates.(7)

• An RCT done in Malaysian showed neonates are at risk of nasal injuries irrespective of whether nCPAP mask or prongs were used.(11)

• In an RCT Collins and colleagues found significantly less nasal injury in infants <32 weeks gestation who were randomised to high flow compared to nCPAP following extubation.(12)

• Common skin and pressure injuries sites are listed in Table 3 below.(10)

Table 3. Common skin breakdown and pressure area sites in infants

Common skin breakdown and pressure area sites in infants

Nasal septum, columellar, nares

Back of head, especially Occiput

Bony prominences (Heels, knees, ankles, elbows)

Neck folds

Any area under pressure

Nappy area

Any area near use of medical devices

11. Pressure injury risk assessment tool There are several pressure area risk assessment tools available, but they are developed specifically for adults and children. For example, the Braden Q was developed for children aged from 21 days to <18 years.(13) Even the Modified Braden Q was developed for infants from birth to <12 months of age, the gestational age of all infants recruited were not specified.(14,15)

Furthermore, only fewer of them have been adequately tested for reliability and validity in the neonatal population. Like Braden Q scale, the Neonatal Skin Risk Assessment Scale (NSRAS) is also based on the adult Braden Scale. The NSRAS was evaluated in a pilot study on a population of 32 neonates admitted to an NICU with gestation range 26-40 weeks (mean gestation 33 weeks). Inter-rater reliability between the 2 examiners (blind to each other’s scores) was 0.97. However, the reliability coefficients on some scales for NSRAS were low.(16)

Overall, all the pressure injury screening tools have high sensitivity but low specificity.(13-17) Therefore, it is an ongoing challenge for neonatal clinicians to interpret these results and decide which tool to use for screening and diagnostic of pressure injury in neonatal population. A recently published systematic review concluded that there are no evidences to suggest superiority of any risk assessment tools over the others in predicting pressure injury risk in infants and children.(19)

11.1 Neonatal Skin Condition Score (NSCS) The Neonatal Skin Condition Score (NSCS) developed by the Association of Women’s health, Obstetric and Neonatal Nurses (AWHONN) and the National Association of Neonatal Nurses (NANN) has been shown to be both a valid and reliable tool to assess neonatal skin.(20-22)




Table 4. AWHONN NEONATAL SKIN CONDITION SCORE (NSCS)

Dryness Erythema Breakdown Score

1 Normal no sign of dry skin

1 No evidence of erythema 1 None evident

2 Dry skin, visible scaling

2 Visible erythema, <50% body surface

2 Small, localized areas

3 Very dry skin, cracking/fissures

3 Visible erythema, ≥50% body surface

3 Extensive

Total score

Score 1-3 for each category with perfect score = 3, worst score = 9.

Scoring system adapted by AWHONN. Used with permission.(22)

11.2 Modified Glamorgan Pressure Injury Risk Assessment The development of the Glamorgan Pressure Injury risk assessment was based on a multicentre, perspective and observational study in within the neonatal and paediatric populations.(23) In the original study, it was found that the assessment tool had a 98.4% sensitivity (identifying infants who are at risk of pressure injury) and a 67.4% specificity (identifying infants who are not at risk of pressure injury) with scores in the high risk category as shown below in Table 5.(23,24) Of particular note is that inter-reliability was reported as being close to 100% in both original and subsequent studies.(25,26,27) There are two components in the modified version, mobility and equipment, and is shown in Table 4 and 5 below.(24)

Despite the lack of empirical data and vigorous testing of validity and inter-reliability of pressure risk assessments in the neonatal population, The Glamorgan Pressure Injury risk assessment is the preferred tool in many neonatal units across Australia due to simplicity, ease of use and minimal subjective evaluation/ high interrater reliability from clinicians.(19,24-

28)

Table 4. Modified Glamorgan Pressure Injury Risk Assessment(24)

Modified Glamorgan pressure injury risk assessment

Trigger factors Risk assessment Score

GA<32 weeks

° Vascular compromise or poor tissue perfusion (HIE, cooling, inotropes)

° Impaired neurological or sensory perception

° Immobility due to illness, sedation,

Infant cannot be moved without great difficulty or deterioration in condition i.e. PPHN, ventilated, desaturates on handling.

Poor peripheral perfusion: cold extremities, reduced capillary refill <2sec, cool mottled skin.

20




muscle relaxation

° Sepsis, dehydration, oedema

° Respiratory support especially ventilation and nasal/mask CPAP

° Post-surgery/Laser

Monitoring devices/cables/leads

° ETT, CPAP, HHF, low flow

° TCM, SpO2, ECG leads, temp probes

° Medical taping (IV, IA lines/splints, IG tubes, eye pads, ICCs

° Mattress/bed surface

Infant unable to change position without assistance or has reduced body movement i.e. carers can change infant’s position maintaining stable observations

15

Some mobility but reduced for age (infant has some ability to change their position but this is limited or restricted i.e. CPAP, nested, IV splints, fluids, chest drains

10

Normal mobility for age 0

Equipment/objects/hard surface pressing or rubbing on skin. Any object pressing or rubbing on skin long and hard enough to cause pressure damage

15

Action taken

Ensure care plan is implemented/reviewed for each identified area of concern.

Scores >30 – must commence Care Plan for Wound assessment and management if there are any areas of concern

Total score Max 35

Table 5. Modified Glamorgan Pressure Injury Risk Management Scale(24)

Modified Glamorgan pressure injury risk management scale

Risk score

Category Suggested action following Glamorgan Pressure injury Risk Assessment (Neonatal Skin Care Quick Assessment Guide).

0

Not at risk Continue to reassess daily and every time condition changes

10+

At risk Inspect skin at least twice a day. Relieve pressure by repositioning at least every 2-4 hours. Use a size and weight appropriate pressure redistribution surface if necessary. Re-site monitoring devices 2 - 4 hours.

15+

High risk Inspect skin with each repositioning. Reposition infant / equipment/ devices at least every 2- 4 hours. Relieve pressure before any skin discolouration develops. Use a size and weight appropriate pressure redistribution surface.

20+

Very high risk Inspect skin at least hourly if condition allows. Move or turn if possible, before skin becomes discoloured. Ensure equipment / objects are not pressing on the skin. Reposition equipment / devices at least every 2 hours if condition allows. Consider using specialised pressure relieving equipment if unable to reposition.




12. Practice Guidelines

12.1 Assessment A comprehensive skin assessment is part of a detailed newborn physical examination conducted by either the admitting medical officer (MO) or admitting nurse. The findings of this assessment are then documented and signed for in the infant’s Clinical Progress Notes (AMR 050.000). RPA Newborn Care health care team should include skin inspection into their routine examination.

There are two components to skin assessment within RPA Newborn Care: NSCS and the modified Glamorgan pressure injury risk assessment. The rationale behind is that Infants have perfect score in NSCS (3) do not mean they are not at risk of pressure injuries. Similarly, infants who are not at risk at pressure injuries do not mean they have good skin condition. RPA Newborn Care staff should also use their clinical judgement skill to assess the risk, rather than solely rely on tools.

12.2 Baseline assessments All infants admitted to RPA Newborn care must have a baseline skin assessment within 8 hours of admission.

12.3 Infants born in RPAH For infants born in RPA and admitted RPA Newborn directly after birth, comprehensive skin assessment should be done when transferring infants to incubator or open care. Clinicians should assess skin condition and integrity by using NSCS. Pay extra attention to infants born via instrumental deliveries (such as vacuum, ventouse, forceps and forceps liftout) as these infants are at risk of subgaleal haemorrhage and birth traumas.

For infants transferring to RPA Newborn Care from another ward (such as postnatal ward) after birth, note for signs or any existing pressure injuries during examination. Any pressure injuries noted on admission must be reported to the medical team and notified IIMS as ‘existing injury’ immediately.

Infants transferred from another facility (including home)

All infants transferred to RPA Newborn Care from another facility or home must have a comprehensive skin assessment done on admission. In addition to assessing skin condition and pressure injury risk, admitting staff should also look for any existing pressure injuries, especially those who have medical devices in situ and after a long-haul transfer. Any pressure injuries noted on admission must be reported to the medical team and notified IIMS as ‘existing injury’ immediately.

12.4 Ongoing assessment All infants remained as inpatient in RPA Newborn Care should have skin assessment done at least once per shift until discharge (either to postnatal ward, home or other facilities). Staff should look for any variation in skin integrity including redness, blanching, turgor, erythema, oedema, induration or breakdown during assessment.

Skin assessment should be performed in conjunction with routine standard care, such as nappy changes, weight and wash, or physical examination. Resting infants should not be disturbed to perform skin assessment to promote developmental care in RPA Newborn Care.

Comprehensive skin assessment should also be performed in infants whose condition has changed since last assessed. For example, post extubation, insertion or removal of medical devices that alters mobility and clinical deterioration.




13. Diagnosis

13.1 Suspected pressure area

If a pressure area is suspected, staff must conduct a detailed examination to determine whether it is a true pressure injury. The Infant must be repositioned to expose affected area for surveillance. Source of pressure, fiction or shear must be removed or repositioned to prevent further injury to non-affected skin. Staff must leave a minimum of 30-minute to 1-hour time frame before reassessing the affected area.

When reassessing the affected area, gently apply pressure for 5 seconds, then remove pressure and observe for tissue reperfusion. Blanching erythema excludes pressure injury whereas pressure injury remains non-blanchable. If in doubt, staff should consult senior staff members, team leader, Wound Link Nurse, Perinatal CNC, CNE or Wound Care CNC for further assessment (see Appendix 1).

13.2 Pressure Injury staging guide

All pressure injuries identified must be staged correctly. Staging pressure injuries in neonates is the same as adult. See appendix 3 and Pressure and Skin Injury Resource Folder for more information.(29)

14. Prevention strategies

Having effective preventative strategies in place is vital to reduce incidence of pressure injury in RPA Newborn Care. All RPA Newborn Care staff should be aware the following strategies and implement accordingly to protect infants against pressure and skin injuries.

14.1 Skin protection

• No tape directly on skin – use Comfeel®/Duoderm® between skin and tape (see Small Baby Protocol)

• Eucerin applied on ELBW babies’ skin during first week of life (see Small Baby Protocol)

• Age appropriate ambient humidity for ELBW/EPTI infants to prevent over-humidification, which increases risk of moisture associated skin damage (MASD) and infection (See Small Baby Protocol for weaning guideline)

• Soften tape before removal • Use medical adhesive removers to facilitate removal if needed. • Avoid removing tape at high angle (90o) to skin surface to prevent stripping.(30,31) • Adaptic Touch™ is available in the Dressing Bank for very fragile skin (Access via

NARMU, see Pressure and Skin Injury Resource Folder for details).

14.2 Repositioning

• Regular CPAP nasal prong and mask release – every I to 2 hours (refer to CPAP Management (nursing)).

• Regular positioning is important and effective to redistribute pressure point to prevent pressure injuries.

• Infants requiring minimal handling are most vulnerable to pressure injuries and should be repositioned regularly.

• A minimum 15° turn every 3-4 hours for very high-risk infants is highly recommended for pressure area care.(14,15,30,32)




14.3 Medical devices

• Hourly IV cannula/PICC/arterial/umbilical line site checks. • All vascular access must always be visible to visual inspection. • Avoid and/ or ensure infants are not lying on any medical devices. • Remove medical devices as soon as possible when no longer needed.

14.4 Supportive surfaces

• Use of constant low-pressure redistribution support o All infants should be nursed on a standard hospital cot mattress in a

designated cot, or standard incubator/open care mattress appropriate to device.

o Staff should be aware that the support surface in some of the mattresses used in RPA Newborn Care are on designated side only. Ensure infant is resting on the side designated by that device.

• Pressure distributing devices for very high-risk infants (see picture 1 and 2 below) o Air mattress or pressure redistributing mattress are available for very high-risk

infants. The following types of specialised mattresses are available in RPA Newborn Care. (NB. The Coziny Mattress has a weight limit of max 3.5kg)

Pic. 1 Roho Cushion

Pic. 2 Coziny Mattress)

o When these devices or supportive mattress are used, staff should ensure: The firmness of the mattress is appropriate for gestation. Regular repositioning is still required even these mattresses are used. Minimal layers of linen between mattress and the infant. Use

thin and single layer of linen between infant and the mattress to




optimise the benefit of these devices and/ or mattress (see picture 3 below).

Pic. 3 Sample linen layouts for infants using specialised pressure distributing

mattress

15. Documentation

All skin inspections and assessments must be documented in both the progress notes and eMR.

15.1 Initial Assessments

Document initial skin assessment in Initial Newborn Physical Examination, admission note and eMR for baseline assessment.

15.2 Ongoing Assessment

NSCS and Modified Glamorgan pressure injury risk assessment should be performed once per shift. Document both scores in progress note and update eMR every shift. Indicate reposition on either the MR581 – Neonatal Intensive Care Chart, or, MR582 – Newborn Care/High Dependency Form

15.3 Individualised Care Plan

Infants with the following circumstances should have individualised care plan in place to prevent pressure injuries.

For very high-risk infant

All infants score ≥ 6 on NSCS or ≥ 30 on Modified Glamorgan Pressure Injury Risk Assessment should have an individualised care plan in place to preserve skin integrity and prevent developing pressure injures. Care plan is available on eMR. Care plan will pop-up automatically once NSCS score ≥ 6 or score ≥ 30 on Modified Glamorgan Pressure Injury Risk Assessment. It will be mandatory required field for staff to complete.

It is optional for staff to print out the individualised care plan for the infant. However, staff should ensure the care plan is handed over each shift.

For infants with pressure injury

All pressure injuries identified in RPA Newborn Care must have a written care plan for ongoing assessment and management. The wound management plan must be discussed at each nursing handover and at the ward round. It is available on eMR.




15.4 Photographic evidence

All pressure injuries should have photos taken as reference and for ongoing management (see picture 4 below). RPA Newborn Care staff should obtain consent from parents before taking photos. When taking photo, place a measuring tape and patient identification near the injury site to identify the patient and the size of the injury. Ensure the photo is taken with clear focus and under adequate light exposure so that the injury is clearly identified. All photos must have time and date documented to identify when it was taken. Refer to the Pressure and Skin Injury Resource Folder for additional information and NSW Health Public Communication Procedures Policy PD2017_012

Photo courtesy of RPA Newborn Care, used with parental permission

Pic 4. Sample photo for pressure or skin injuries

16. Notification

All pressure injuries must be reported via IIMS system. IIMS reference number should be documented in the progress note. Refer to Resource Folder for more information. Forward the IIMS reference number to the Wound Link Nurse for RPA Newborn Care and NUM for follow-up and reference.

16.1 Referral and consultation The Wound Link Nurse for RPA Newborn Care is the first point of contact for suspected or confirmed pressure injuries. The Wound Link Nurse for RPA Newborn Care will work in collaboration with the medical team and NUM, CNE and Perinatal CNC to manage all pressure and skin injuries in RPA Newborn Care.

If consultation from Wound Care CNC is required the referral must be completed on the eMR. The medical team may consider further consultations such as plastics, vascular or general surgery..

16.2 Ongoing management and surveillance Unless otherwise specified, all reported pressure injuries must be reviewed once per shift until fully resolved. Timing of review depends on numerous factors such as dressing regime and the type of injuries.. If specific wound care products should not be removed unless indicated.

16.3 Communication Communication is important for preventing and managing pressure injuries in RPA Newborn Care. All pressure injuries identified in RPA Newborn Care must be reported to the medical team and the Nurse in-charge of the shift.

http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2017_012.pdf





Parents must be notified of the injury and provided with support, education and information regarding ongoing care.

16.4 Education The education team (including CNE, Perinatal CNC and Wound Link nurse) will provide ongoing education and support to staff and parents regarding pressure injuries and pressure injury prevention. A Resource Folder is also available for staff with additional information.

17. Definitions

Terminology Definition

Blanching erythema Reddened skin that blanches white under light pressure. May be difficult to visualise in darker skin tones.

Bony prominence An anatomical bony projection.

Carers Carers are people who provide unpaid care and support to family members and friends who have a disability, mental illness, chronic condition, terminal illness, an alcohol or other drug issue or who are frail aged.

Carers provide emotional, social or financial support. Carers include parents and guardians caring for children.

Erythema Redness of the skin caused by dilatation and congestion of the capillaries, often a sign of inflammation or infection. May be difficult to visualise in darker skin tones.

Extrinsic factors Originating outside of the body

Friction A mechanical force that occurs when two surfaces move across one another, creating resistance between the skin and contact surface.

Incidence The proportion of at-risk patients who develop a new pressure injury over a specific period.

Intrinsic factors Originating within the body

Moisture Moisture alters resilience of the epidermis to external forces by causing maceration, particularly when the skin is exposed for prolonged periods. Moisture can occur due to spilt fluids, incontinence, wound exudate and perspiration.

Must Indicates a mandatory action

Non-blanching erythema

Erythema that remains reddened when pressure is applied and removed.

Pain

An unpleasant sensory and emotional experience associated with a pressure injury. Patients may use varying words to describe pain including discomfort, distress and agony.

Positioning Position of normal body alignment to promote comfort, safety and relaxation, prevent deformities and reduce the effects of




tissue strain on skin.

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

Prevalence Total number of a given population with pressure injuries.

Pressure Injury Risk Assessment scale/tool

Formal scale or score used to help determine the degree of pressure injury risk. The tool must be appropriate for the patient population in accordance with best practice guidelines e.g. Waterlow, Braden, Norton for adult population and Braden Q or Adapted Glamorgan for neonatal/infant and paediatric population.

Reliability Measure of reproducibility of a measure

Repositioning Changing a patient’s body position to redistribute the pressure on the bony points that were in contact with the surface supporting the body. The frequency is determined by skin response, support surface in use and patient’s general condition.

Shear Shear is a mechanical force created from a parallel (tangential) load that causes the body to slide against resistance between the skin and a contact surface.

The outer layers of the skin (the epidermis and dermis) remain stationary while deep fascia moves with the skeleton, creating distortion in the blood vessels and lymphatic system between the dermis and deep fascia. This leads to thrombosis and capillary occlusion

Should Indicates a recommended action that should be followed unless there are sound reasons for taking a different course of action.

Staff For the purpose of this Policy staff refers to any person working within the NSW Health system including contractors, students and volunteers.

Support surface A surface on which the patient is placed to manage pressure load by distributing body weight pressure more effectively over the support surface. Support surfaces are classified as reactive (constant low pressure) or active (alternating pressure)

Surfaces. Includes bed, trolley and operating table mattresses and overlays; integrated bed systems; and seat cushions and overlays.

Validity How well a tool measures the concept it claims to measure.

18. Consultation This policy is developed in consultation with the following groups/committee/personnel:

• RPA Newborn Care Research Committee




• Wound CNC, RPAH

19. References 1. Sardesai SR, Kornacka MK, Walas W, Ramanathan R. Iatrogenic skin injury in the

neonatal intensive care unit. The Journal of Maternal-Fetal & Neonatal Medicine. 2011;24(2):197-203.

2. Australian Commission on Safety and Quality in Health Care. Safety and Quality Improvement Guide Standard 8: Preventing and Managing Pressure Injuries (October 2012). Sydney. ACSQHC, 2012.

3. Black JM, Edsberg LE, Baharestani MM, Langemo D, Goldberg M, McNichol L, Cuddigan J. Pressure ulcers: avoidable or unavoidable? Results of the national pressure ulcer advisory panel consensus conference. Ostomy-Wound Management. 2011 Feb 1;57(2):24.

4. Australian Wound Management Association. Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury. Cambridge Media Osborne Park, WA: 2012.

5. Evans NJ, Rutter N. Development of the Epidermis in the Newborn. Neonatology. 1986;49(2):74-80.

6. Rutter N. The immature skin. British Medical Bulletin. 1988;44(4):957-70 7. Fujii K, Sugama J, Okuwa M, Sanada H, Mizokami Y. Incidence and risk factors of

pressure ulcers in seven neonatal intensive care units in Japan: a multisite prospective cohort study. International Wound Journal. 2010;7(5):323-8.

8. August D, Edmonds L, Brown D, Murphy M, Kandasamy Y. Pressure injuries to the skin in a neonatal unit: Fact or fiction. Journal of Neonatal Nursing. 2014;20(3):129-137.

9. Willock J, Harris C, Harrison J, Poole C. Identifying the characteristics of children with pressure ulcers. Nurs Times. 2005;101(11):40-3.

10. Moon K, Pressure Injury Prevention and Management [internet] 2012 [Updated December 2012, cited 10 July 2017]; available from: https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Pressure_Injury_Prevention_and_Management/

11. Yong S-C, Chen S-J, Boo N-Y. Incidence of nasal trauma associated with nasal prong versus nasal mask during continuous positive airway pressure treatment in very low birthweight infants: a randomised control study. Archives of Disease in Childhood - Fetal and Neonatal Edition. 2005; 90(6).

12. Collins CL, Barfield C, Horne RSC, Davis PG. A comparison of nasal trauma in preterm infants extubated to either heated humidified high-flow nasal cannulae or nasal continuous positive airway pressure. European Journal of Pediatric. 2014;173(2):181-6.

13. Quigley SM, Curley MAQ. Skin Integrity in the Pediatric Population: Preventing and Managing Pressure Ulcers. Journal for Specialists in Pediatric Nursing. 1996;1(1):7-18.

14. McCord S, McElvain V, Sachdeva R, Schwartz P, Jefferson LS. Risk Factors Associated With Pressure Ulcers in the Pediatric Intensive Care Unit. Journal of Wound Ostomy & Continence Nursing. 2004;31(4):179-83.

15. McLane KM, Bookout K, McCord S, McCain J, Jefferson LS. The 2003 National Pediatric Pressure Ulcer and Skin Breakdown Prevalence Survey: A Multisite Study. Journal of Wound Ostomy & Continence Nursing. 2004;31(4):168-78.

https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Pressure_Injury_Prevention_and_Management/

https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Pressure_Injury_Prevention_and_Management/




16. Huffines B, Logsdon MC. The Neonatal Skin Risk Assessment Scale for Predicting Skin Breakdown in Neonates. Issues in Comprehensive Pediatric Nursing. 1997;20(2):103-14.

17. Curley, MA, Razmus, IS, Roberts, KE, Wypij, D, Predicting Pressure Ulcer Risk in Paediatric Patients – The Braden Q Scale. Nursing Research. 2003, 52,1:22-33.

18. Mc Lane KM, Gray M. Which Pressure Ulcer Risk Scales Are Valid and Reliable in a Pediatric Population? Journal of Wound Ostomy & Continence Nursing. 2004;31(4):157-60.

19. Kottner J, Hauss A, Schlüer A-B, Dassen T. Validation and clinical impact of paediatric pressure ulcer risk assessment scales: A systematic review. International Journal of Nursing Studies. 2013;50(6):807-18

20. Lund CH, Osborne JW, Kuller J, Lane AT, Lott JW, Raines DA. Neonatal Skin Care: Clinical Outcomes of the AWHONN/NANN Evidence-Based Clinical Practice Guideline. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2001;30(1):41-51.

21. Lund CH, Osborne JW. Validity and Reliability of the Neonatal Skin Condition Score. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2004;33(3):320-7.

22. Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). Neonatal Skin Care: Evidence-Based Clinical Practice Guideline 3rd ed. Washington USA: Johnson & Johnson; 2007

23. Willock J, Baharestani MM, Anthony D. The development of the Glamorgan paediatric pressure ulcer risk assessment scale. Journal of wound care. 2009; 18(1):[17-21].

24. King Edward Memorial/Princess Margaret Hospitals, NEONATAL SKIN CARE GUIDELINES [internet] [2014, cited: 17 July 2017], available from: http://www.kemh.health.wa.gov.au/services/nccu/guidelines/documents/Skin_care and_pressure_injury.pdf

25. Anthony D, Willock J, Baharestani M. A comparison of Braden Q, Garvin and Glamorgan risk assessment scales in paediatrics. Journal of Tissue Viability. 2010;19(3):98-105.

26. Willock J. Interrater reliability of the Glamorgan scale: overt and covert data. British Journal of Nursing. 2013 Nov 14;22.

27. Willock J, Anthony D, Richardson J. Inter-rater reliability of Glamorgan Paediatric Pressure Ulcer Risk Assessment Scale. Paediatric nursing. 2008; 20(7):[14-9]

28. Australian Commission on Safety and Quality in Health Care, Examples of data collection and audit tools used within inpatient and community settings and examples of paediatric pressure injury risk assessment tools within Australia [internet] [cited 17 July 2017]; available from: https://www.safetyandquality.gov.au/wp-content/uploads/2012/03/Standard-8-tools.pdf

29. Ministry of Health, Pressure Injury Prevention and Management (PD2014_007) 30. Rosen T, Gray M. Medical Adhesives and Patient Safety: State of the

ScienceConsensus Statements for the Assessment, Prevention, and Treatment of Adhesive-Related Skin Injuries. Journal of Wound Ostomy & Continence Nursing. 2013;40(4):365-80.

31. Lund C. Medical Adhesives in the NICU. Newborn and Infant Nursing Reviews. 2014;14(4):160-5.

32. Neilson J, Avital L, Willock J, Broad N. Using a national guideline to prevent and manage pressure ulcers: Julie Neilson and colleagues detail the updated National Institute for Health and Care Excellence guidance and its implications for senior nurses. Nursing Management. 2014 Apr 29;21(2):18-21.

http://www.kemh.health.wa.gov.au/services/nccu/guidelines/documents/Skin_care%20and_pressure_injury.pdf

http://www.kemh.health.wa.gov.au/services/nccu/guidelines/documents/Skin_care%20and_pressure_injury.pdf

https://www.safetyandquality.gov.au/wp-content/uploads/2012/03/Standard-8-tools.pdf

https://www.safetyandquality.gov.au/wp-content/uploads/2012/03/Standard-8-tools.pdf





33. Stansby G, Avital L, Jones K, Marsden G. Prevention and management of pressure ulcers in primary and secondary care: summary of NICE guidance. BMJ : British Medical Journal. 2014;348:g2592.

19.1 National Safety and Quality Health Service (NSQHS) Standards

Standard 1, Governance for Safety and Quality in Health Service Organisations

Standard 3, Preventing and Controlling Healthcare Associated Infections

Standard 8, Preventing and Managing Pressure Injuries

.




20. Appendix 1

Clinical practice flow chart for the prevention and management of pressure injuries for inpatient neonates




21. Appendix 2: Pressure Injury Staging Guide

Newborn Pressure Injury Prevention and Management

Documents

Transcript of Newborn Pressure Injury Prevention and Management