Monitoring and reporting

Analyse pressure injury data to inform care, quality improvement activities and monitor progress.

  • Identify pressure injuries that develop during the episode of care
  • Review pressure injury data regularly, at a minimum quarterly
  • Ensure pressure injury data is communicated to the health service executive and those responsible for governance of clinical care.

Tools to support monitoring include:

Pre-existing pressure injuries do not require notification in the incident management system. These are to be documented in the medical record and wound chart.

Hospital/health service-acquired pressure injuries, which have developed after eight hours of presentation, are to be notified in the incident management system and communicated to the admitting medical team or primary care provider. Notification is also a requirement for pressure injuries that have deteriorated (progressed to a more severe pressure injury) since admission.

Unstageable pressure injuries and suspected deep tissue injuries require review for definitive staging. Where definitive staging is likely to occur after the transition of care, the health service is to communicate with the ongoing care provider to confirm staging. Definitive staging is to be entered into the medical record and the incident management system particularly for unstageable pressure injuries or suspected deep tissue injuries that are staged as a stage 3 or stage 4.

Hospital/Health Service-acquired pressure injuries are reviewed and recommendations reported and monitored in accordance with the Incident Management Policy. When a pressure injury occurs or deteriorates to a more severe injury during an episode of care, the patient and/or carer are informed in accordance with the Open Disclosure Policy.

Stage 3, stage 4, unstageable and suspected deep tissue pressure injuries which are hospital/health service-acquired are to have a clinician with expertise in wound management on the Incident Review Team, where possible.

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