Quality Improvement

Reducing harm

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Pressure injury prevention

Pressure injury prevention

What is a pressure (ulcer) injury?

A pressure injury is an injury to the skin and/or the tissues under the skinConstant pressure on an area of skin reduces blood supply to the area.  Over time, it can cause the skin to break down and form an open sore (ulcer).  Pressure injuries are more likely to form if a person is in hospital and is confined to a chair or bed.

Value: With CompassionPressure injuries most often form on the skin over bony areas where there is little cushion between the bone and the skin.  Most pressure sores form on the lower part of the body, including over the tailbone and on the back along the spine, on the buttocks, on the hips, and on the heels.  Other common spots are the back of the head, the backs of the ears, the shoulders, elbows, and ankles, and between the knees where the legs rub together.

Pressure injuries can range from red areas on the surface of the skin to severe tissue damage that goes deep into muscle and bone.  These can be classified (graded) according to the extent of tissue damage:


Pressure ulcer classification

Grade 1: Non-blanchable erythema

Non-blanchable erythema of intact skin. Discolouration of the skin, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin.

Grade 1 pressure ulcer

Grade 2: Blister

Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister.

Grade 2 pressure ulcer

Grade 3: Superficial ulcer

Full thickness skin loss involving damage of subcutaneous tissue that may extend down to, but not through, underlying fascia.

Grade 3pressure ulcer

Grade 4: Deep ulcer

Extensive destruction of tissue, muscle, bone, or supporting structures with or without full thickness skin loss.

Grade four pressure ulcer

What is the impact of a pressure injury?

Pressure injuries can be hard to treat and slow to heal.  Other problems, such as bone, blood, and skin infections, can develop when pressure sores do not heal properly.

Pressure injuries result in significant financial costs (to health services and patients), significant social cost in terms of pain, discomfort, decreased mobility, loss of independence, social isolation and lost work time.


What are we trying to achieve?

For 2012/2013 our goals were:

  • Consistency of practice across the DHB, e.g. risk assessment and regular checks.
  • Developing universal precautions for pressure injuries.
  • Development of nursing staff skills to be able to assess pressure injuries accurately and consistently.
  • Reduce overall hospital acquired pressure injuries by 10%.

What have we done?

  • Staff involved with acute clinical care have undertaken education about pressure injury assessment and prevention.
  • Staff follow a Clinical Practice Guideline (see flowchart below) to assess a patient’s risk of developing a pressure injury and to manage their care.
  • Staff undertake pressure assessment of all patients within 8 hours admission.

Pressure Injury Flowchart

Reference:  Pan Pacific Clinical Practice Guideline for the Prevention & Management of Pressure Injury 2011


How are we doing?

Each clinical area undertakes a monthly audit of randomly selected patients. 

This audit evaluates the following to measure compliance to the pressure injury prevention programme:

  • number of patients with pressure injuries (either on admission or acquired in hospital)
  • number of patients risk assessed as per the guideline
  • number of patients who have received the appropriate care as per the Guideline risk score

Our results

The following control charts[1] (graphs) track our compliance to the pressure injury prevention programme:

1. Patients with pressure injury per 100 patients (acquired in hospital)

Pressure Injuries per 100 Patients Chart


2. Percentage (%) of compliance to patients risk assessed within specified time frame

% Compliance of Patients Risk Assessed


3. Percentage (%) of compliance to receiving appropriate bundle of care

% Compliance of Patients Receiving Appropriate Bundle of Care


4. Percentage (%) of compliance to patients with the correct care plans implemented

% Compliance of Patients with Correct Care Plans


  1. The control charts represent variation in the data analysed.  The control limits are derived from this variation and do not, therefore, indicate the desired performance limits.  The processes or outcomes analysed may thus indicate stability, trends and shifts only, as interpreted from present variation.  The goal of quality improvement is to reduce such process variation and improve process performance.