PREVENTION & MANAGEMENT

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2 PRESSURE ULCER PREVENTION & MANAGEMENT Resource Guidelines Guide Revised and Updated 2009 The State of Queensland, Queensland Health, 2008 The Queensland Government supports and encourages the dissemination and exchange of information. Not withstanding, copyright protects this document. The State of Queensland has no objection to this material being reproduced or made available online or electronically, provided it is for personal, non-commercial use or use within your organisation, provided this material remains unaltered and the State of Queensland is recognised as the owner. Inquiries for commercial use should be addressed by to: or by mail to: The IP Officer, Asset Management Unit, Capital Works and Asset Management, Queensland Health, GPO Box 48, BRISBANE Disclaimer: Certain materials in this publication are distributed by Queensland Health as an information source only. The information is provided solely on the basis that readers are responsible for making their own assessment of the matters discussed herein. Queensland Health does not accept liability of any person for the information or advice provided in this publication or incorporated into it by reference or for loss or damages incurred as a result of reliance upon the material contained in these examples and reference files. ISBN The document is also available electronically at: 2

3 Foreword Pressure ulcers are a frequent and preventable cause of patient harm across Queensland Heath. Pressure ulcer prevention is a core program of the Patient Safety Centre. In collaboration with service providers from public and private, acute and community sectors we continually strive for best evidence care to prevent pressure ulcers. The Patient Safety Centre is pleased to present the Pressure Ulcer Prevention and Management Guidelines, Revised Edition. These guidelines have been reviewed and updated providing you with the latest evidence in prevention and treatment strategies. I sincerely hope that all members of the healthcare team will use these guidelines to inform and influence practice. I encourage you to discuss these guidelines with your colleagues, patients and their carers. Why not audit your practice and consider how your approach needs to change to deliver the best care possible? Your patients deserve nothing less. I commend these guidelines to you. Dr John Wakefield Senior Director, Patient Safety Centre 3

4 Introduction Pressure ulcers are recognised as largely preventable, adverse events and yet they continue to be a significant problem. Their management consumes a large percentage of health care resources and the impact of a single pressure ulcer is considerable both in terms of a patient s quality of life and the economic costs through extended hospital stays. 1 In Australia, pressure ulcers are estimated to cost $285 million per annum in lost opportunity costs alone. 2 In 1997, Young estimated the cost of a Stage 4 pressure ulcer at $61, The 2008, Queensland Health pressure ulcer audit across 137 Queensland Health hospitals and residential care facilities, reported a prevalence rate of 15.2%. 4 The occurrence of pressure ulcers is now captured as a clinical outcome measure by the Australian Council on Healthcare Standards. 5 Prevention is multifactorial and requires the vigilant, active involvement of staff, carers and patients across the continuum of care. 6 Accordingly, this guideline, originally published in 2004, has been reviewed to include new evidence. The purpose of these guidelines is to assist clinical teams by outlining specific, evidence based interventions for prevention, diagnosis and management of pressure ulcers. 4

5 Table of contents INTRODUCTION AETIOLOGY PRESSURE ULCER STAGING SYSTEM RISK FACTORS PATIENT ASSESSMENT Risk assessment Skin assessment Nutrition assessment Patient assessment summary PREVENTION STRATEGIES Maintenance of skin integrity Elimination of pressure, shear and friction Elimination of pressure, shear and friction Positioning and turn intervals for pressure re-distribution Positions for pressure redistribution Support systems Selecting a support surface Pressure devices classification Devices not recommended DOCUMENTATION TREATMENT PROTOCOLS Partnership with patients and families SPECIAL CONSIDERATIONS FOR TREATMENT Heel pressure ulcers Interventions Heel Blister Heels with necrotic tissue Infection and pressure ulcer intervention

6 8.3 Management of large cavity wounds TRAINING AND EDUCATION QUALITY MONITORING AND MEASUREMENT GLOSSARY OF TERMS REFERENCES APPENDICES Appendix 1. Modified Waterlow pressure ulcer risk assessment tool Appendix 2 Braden Q risk tool Appendix 3 Pressure ulcer management flowchart Appendix 4 Pressure devices flowchart Appendix 5 Sample pressure ulcer prevention policy ACKNOWLEDGEMENTS

7 1 Aetiology Pressure ulcers are any lesion caused by unrelieved pressure when soft tissue is compressed between a bony prominence and an external surface for a prolonged period. 7 Tissue damage may include skin, subcutaneous fat, deep fascia, muscle and bone. 8 Pressure is the major cause of tissue injury and to determine if the pressure is sufficient to cause an ulcer, the following factors are: intensity of pressure duration of pressure ability of tissue to tolerate pressure (tissue tolerance). 9 Prolonged pressure on a localised area of tissue results in occlusion of blood flow to the vascular and lymph vessels that supply oxygen and nutrients to the tissues. 10 This can result in tissue ischaemia and re-perfusion injury, leading to cell destruction and tissue death The pathogenesis of pressure ulcer development is dependent on a complex exchange of extrinsic and intrinsic variables which affect tissue tolerance (Refer to Table 1). This means, the relationship between intensity and duration of pressure is complex and 11, 12 other factors influence a patient s skin condition and capacity to tolerate pressure. Braden and Bergstrom s (1987) conceptual schema shows a framework to categorise risk factors with intrinsic and extrinsic factors. 9 Intrinsic factors are identified as those that affect the skin s supporting structures adversely and are; older age, circulatory disease, neurological disease, skin temperature, malnutrition, and chronic illness. 9,11,13-15 Extrinsic factors that affect tissue tolerance include pressure, friction, shear and moisture. 9 7

8 2 Pressure ulcer staging system Pressure ulcers are classed in accordance with the depth of tissue injury. The staging classification is under international review and will most likely be updated by the Australian Wound Management Association (AWMA) in Until then, Queensland Health recommends continued use of the existing format for staging of pressure ulcers (refer to Figure 1) 13 Stage 1: Observable pressure-related alteration(s) of intact skin whose indicators, as compared to adjacent or opposite area on the body, may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel) and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue or purple hues. 16 Stage 2: Stage 3: Stage 4: Partial thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures (eg. tendon or joint capsule). Undermining and sinus tracts may also be associated with Stage 4 pressure ulcers. Limitations of staging systems There are limitations to any classification system. AWMA 13 recommends the following points are considered when diagnosing and staging pressure ulcers: reactive hyperaemia may be mistaken for a Stage 1 ulcer. The presence of nonblanching erythema requires that patients are repositioned off this site and reassessed in 30 minutes before diagnosing a Stage 1 pressure ulcer Stage 1 ulcers may be difficult to identify in patients with dark coloured skin devitalised tissue (eschar or slough) can conceal the extent of tissue injury so should be removed to correctly stage the degree of pressure injury 17 the ulcer should be reclassified once debrided reverse staging of healing ulcers remains contentious 18 Note: Classification of pressure ulcers depends on visual observation of the tissues involved. Full assessment of the ulcer should also consider the location, ulcer description and the patient s general condition. 8

9 Figure 1 Pressure ulcer staging Reproduced with permission of Australian Wound Management Association. 13 9

10 3 Risk factors It is important to understand the risk factors in prevention and the treatment of ulcers. Pressure ulcer prevention aims to: reduce the degree and/or duration of pressure to which the patient is exposed reduce the impact of predisposing risk factors prevent existing ulcers from progressing to further tissue destruction prevent re-occurrence Patients identified with a combination of risk factors and/or co morbidities should have more aggressive forms of treatment. 19 Underlying causes must also be managed before pressure ulcers can heal. 20 Primary risk factors for pressure ulcer development include impaired mobility and activity, malnutrition, incontinence, alteration in level of consciousness and sensation. 9,13-15,21-24 Conditions that relate to these risk factors are found listed in Table 1. 10,19,25 There also appears to be a greater incidence of pressure ulcers among patients who have had surgery. 13 Where one risk factor is identified in the patient, it is possible that multiple will be present as many do not occur independently of each other. An example of this is older age, as it often is associated with a higher degree of morbidity, increased risk of hospitalisation, chronic illness, poor peripheral perfusion and reduced sensory perception. 13 These co morbidities may contribute to a patient s risk or impact on the ulcer s healing process (refer to Table 2). 13,19,21,25 Table 1 Risk factors alteration in mobility and activity contractures fractures injury neurological disease/deficit pain malnutrition dehydration oedema protein insufficiency weight loss obesity moisture drainage (fistulae, wounds) incontinence (urine, faeces) perspiration 10

11 Table 1 cont. alteration in sensation and consciousness central nervous system injury cerebrovascular disease degenerative neurological disease drugs eg. steroids, cytotoxics major surgery spinal cord injury Table 2 Contributing risk conditions co-morbidity conditions chronic heart failure chronic respiratory disease circulatory disease diabetes immune deficiency states impaired tissue oxygenation eg. anaemia, smoking metastatic carcinoma peripheral vascular disease 11

12 4 Patient assessment It is critical to systematically assess the patient for the following risk factors: health status pain status acute, chronic and terminal illness psychological factors co-morbidities eg. diabetes social factors mobility status continence status sensory impairment medication level of consciousness cognitive status systemic signs of infection skin assessment nutritional status wound assessment blood flow previous pressure damage 20, 27, 28 The following must also be considered: a patient s condition and care requirements can change at any time, so reassessment and revision of care plans is essential when there is a change in condition, mobility or activity 29 risk rating is just one item in the health team s toolbox and cannot be used in isolation. sound clinical judgement must always prevail assessment is not effective unless preventative measures are taken. Accordingly each identified risk factor will need to be managed where possible preventative measures include more than simply allocating a higher specification mattress/cushion. Organisational policies and protocols should clearly outline the roles and responsibilities of all health professionals and assign accountability for pressure preventative measures that must be undertaken for patients identified at risk. 4.1 Risk assessment Pressure ulcer risk assessment should be performed on presentation to a health facility and regularly throughout the patient s episode of care. A risk assessment tool identifies 30, 31 commonly recognised risk factors affecting a patient at any given time. Many tools are available offering consistent structure for assessment and documentation. Most tools use a rating scale to weight the severity of risk into categories of - no risk, low, medium or high risk. It must be noted that these tools are only an aid to pressure ulcer prevention 13, 31, 32 and should complement clinical judgement. 12

13 The risk assessment should address these risk factors; mobility, nutritional status, sensory impairment, consciousness, neurological status and incontinence (identified in Section 3), as well as a complete medical history, physical and psychosocial examinations. Any history of previous pressure damage should also be noted. Patients who show reduced mobility or diminished activity which results in them being unable to independently change their position to relieve pressure, should be placed in an at risk category. 14,15,27 Additional risk factors - such as impaired cognition and impaired sensory perception - place the patient at higher risk. Malnutrition and skin exposed to excess moisture are additional risk factors. 33 The National Pressure Ulcer Advisory Panel (NPUAP) recommends: 27 acute care: assess on admission, reassess at least every 24 hours or sooner if the patient s condition changes long-term care: assess on admission, weekly for four weeks, then quarterly and whenever the resident s condition changes home care: assess at the beginning of home care and at every nurse visit/ selfmanagement When assessing risk of pressure ulcer development, Queensland Health recommends: for adults: the Revised Waterlow Pressure Ulcer Risk Assessment Tool. See Appendix 1 30 for the paediatric population: the modified Braden Q Risk Scale. See Appendix 2. Both tools can be used in the hospital or community settings. The tools refer to a range of categories enabling ordered assessment of the patient s risk, status and care needs. While the scores are based on different ranges, both tools give a numerical score between low risk and very high risk. The Braden Q tool gathers a score based on 7 mutually exclusive categories. Potential total scores range from 7 to 28 points, the lower the score the higher the patient s risk for pressure ulcers. 34 In contrast, the higher the score derived using the Revised Waterlow risk tool, the higher the patient s risk for pressure ulcers. See Table 3 below. Table 3. Risk categories for the modified Braden Q risk scale and the revised Waterlow pressure ulcer risk assessment tool Risk tool Patient at risk / Moderate risk mild risk High risk Very high risk Waterlow Score > 10 Not applicable Score > 15 Score > 20 Braden Q* or below *based on the work of Curley et al 34 Further research is in progress relating to recommended risk tools for adult and paediatric settings. 13

14 The pressure ulcer management flowchart shown in Appendix 3 of this manual provides guidance for the appropriate steps to be taken, in accordance with the patient s level of risk and the health team s clinical judgement. 4.2 Skin assessment Skin assessment must be performed on admission and at least daily for patients who are considered to be at risk and include checking for non-blanching erythema, discolouration, blisters, and skin alteration compared with the adjacent area due to: pressure, shear or friction moisture arising from incontinence, wound exudate or excessive perspiration Immobile or insensate patients should be checked with each turn. Persistent redness evident at each turn, indicates a lower tissue tolerance and a need for increased repositioning. On inspection, pay particular attention to skin over bony prominences (as shown in Figure 2, page 18). Check parts of the body covered by anti-embolic stockings, areas of the body where pressure, friction and shearing is exerted in the course of daily activities and other areas affected by equipment, footwear and clothing. 35 These areas can include skin around or under prosthetics, orthotics, skin traction, oxygen appliances, intravenous (IV) access, tapes and other objects in contact with the skin. If it is found that the patient is incontinent, a full assessment and management plan must becompleted. Special care should be taken when assessing the patient s skin for signs of irritation or damage due to incontinence. Skin assessment should also include assessing and documenting existing wounds. Importantly, monitor the degree of damage and track any further deterioration over time. Also, track the effectiveness of treatment regimes and adjust protocols as appropriate. 4.3 Nutrition assessment Malnutrition occurs in approximately 30-35% of acute and 50% of residential patients in Queensland Health facilities. 23 A malnourished patient is twice as likely to have a pressure ulcer as a well nourished patient. 24 Malnutrition increases the odds of having more pressure ulcers and a greater severity. 24 Malnutrition risk screening tools identify patients who are malnourished or are at risk of becoming malnourished and may benefit from nutritional support. The Malnutrition Screening Tool (MST) 36 is a simple, quick and valid tool. The MST score has been integrated into the revised Waterlow Pressure Ulcer Risk assessment tool. It is composed of two questions, relating to recent intake and appetite, and recent, unintentional weight loss. The tools score range is 0-5. Patients scoring 2 or more are at risk of malnutrition. Patients identified at risk should be referred to a dietitian for nutritional assessment and management eg high protein/energy diet. 33 Providing nutritional support to patients at risk may reduce the occurrence of pressure ulcers by 25%

15 4.4 Patient assessment summary Patient assessment should be combined with the implementation of prevention measures. When to perform assessment: on presentation for clinical care in the home and/or health setting regularly throughout the patient's care depending on their risk status more frequently following a change in the patient s condition, or a significant event, eg. cardiovascular change, alteration in cognitive functioning and surgery at additional times as determined by the type of care, acute care, long term care or home care. Regular holistic assessment is an essential foundation to effective care across the continuum. 15

16 5. Prevention strategies Prevention strategies to reduce or modify pressure ulcer risk factors should be incorporated into the patient's management plan. All patients identified as at risk should have a plan of care incorporating measures such as pressure support systems (refer to Appendix 4), positioning, skin care and nutritional interventions. 38 The following prevention strategies reflect the consensus statements and recommendations outlined in the AWMA guidelines. 13 These strategies include: maintenance of skin integrity elimination of pressure, shear and friction implementation of pressure relieving positions and turning schedule, including repositioning intervals use of an appropriate support surface. 5.1 Maintenance of skin integrity Maintaining the integrity of the patient s skin is key to any prevention program.39 The normal ph of skin is The acidity in skin, normal flora and the natural antibacterial substances found in sebum, assist in limiting micro-organism growth. 11 Maintaining a stable skin ph discourages colonisation of bacteria and reduces the risk of infection. 39 Patients at risk should have daily skin inspections, or more frequently with greater attention to skin covering bony prominences and weight bearing areas. 40 A routine skin inspection is essential for early identification of skin damage which provides a foundation for care planning and evaluating interventions. It may be necessary to modify the care plan based on the findings of the skin inspection. Actions in maintaining skin integrity: Routinely assess skin conduct a head to toe skin assessment on admission and repeat daily, with particular focus on skin covering bony prominences not designed to support constant external pressure eg. sacrum, heels and greater trochanters (hips) 27,41 Refer to Figure 2 exclude other causes of redness or skin lesions such as; a venous or arterial ulcer, or continence associated dermatitis and reactive hyperemia exclude reactive hyperemia. When a red mark is found, relieve the pressure, check for blanching (the skin whitens under light finger pressure, which indicates the microcirculation is intact). Review in 30 minutes and the redness should have faded substantially. If the skin does not blanch or the hyperaemia (redness) does not fade, then a stage 1 pressure ulcer has been identified for patients at very high risk or are unable to reposition independently, re-assess skin on each turn. Increase frequency of 16

17 repositioning if persistent redness is noted assess patients carefully for compromised peripheral circulation and diabetes 25 assess patients with casts, traction and support stockings 38 Prevent exposure to excessive moisture or dryness Promote optimal skin hygiene Promote optimal nutrition document pre-existing ulcers in the medical record in terms of location, severity, description of ulcer and surrounding skin (refer to Section 6, Documentation) start continence training with toileting/bowel management routines when needed minimise skin exposure to urine or faeces, excessive sweating or wound drainage as these can increase the ph of the skin causing chemical damage, maceration and denuding of the skin 10,39,42 avoid skin contact with plastic surfaces as this can increase sweating and reduce the effectiveness of pressure devices 10,43 where possible, maintain a stable skin temperature 10,13,43 consider medical assessment (eg. medication review) of high risk patients in managing reversible cases of incontinence cleanse the skin gently using ph neutral cleansers, which will improve overall hygiene and stimulate circulation avoid hot water and using soap. Mild non-irritant cleansers should be used as alkaline products increase chemical and physical irritation 39,40,44 treat dry skin with appropriate moisturising creams 39,40,44 avoid vigorous rubbing or massaging over bony prominences 38,40,42 assess for recent unplanned weight loss and reduced/limited intake 36 encourage and monitor a balanced diet high in protein and energy for tissue maintenance and repair. 33,40,46,47 Avoid disrupting food intake at meal times and assist with feeding where required consult a dietitian where patients are (1)identified as at risk using the malnutrition Screening Tool and (2)when simple steps to improve nutrition are unsuccessful 47 17

18 Nasal opening and behind ears (from tubes) Fingers Clinical Equipment Toes ill fitting shoes Figure 2. Common pressure ulcer risk sites Artwork by John A. Craig, MD, from Clinical Symposia, vol 31, No 5. in Bryant: Acute and Chronic Wounds, 3rd ed.,

19 5.2 Elimination of pressure, shear and friction Damage to the skin is caused by pressure and/or shearing forces or friction, or a combination of these. The primary force for occlusion is pressure and the secondary is shear. 48 Shearing force occurs when a part of the body moves but the skins surface does not move against the supported surface. A cause of this can be if the patient slides down in the bed. 17 The shearing forces stretch and tear small blood vessels and lead to disruption of the local blood supply and result in ischaemia. 10,11,17 Friction occurs when two surfaces move in opposite direction. 11,17,47 It may cause epidermal stripping and infection. 10 Friction works together with gravity resulting in shearing. 10,11 Skin assessment is critical to understand the skin s tolerance to pressure, shear and friction. Patients who are immobile, inactive and elderly are at greatest risk. To eliminate or minimise pressure, shear and friction, correct positioning, transferring and handling techniques should be used. 38,42 Actions to eliminate pressure, shear and friction include: Protect against shear and friction Reduce heel pressure use aids that do not cause friction such as; hoists, transfer sheets, transfer boards, hover mats and slings 38 when transferring patients between bed and chair avoid using reusable plastic sheets/kylies as they can reduce immersion qualities of pressure redistribution mattresses protect skin from friction by using protective dressings or limb protectors 40,47 avoid massaging as it may create deeper tissue trauma through forces of friction and shear 19,40 use profiling beds and do not elevate the head of the bed more than 30 o (as appropriate to the patient s clinical condition) 47 use the knee bend function on the bed when the patient is sitting use slide sheets for passive limb exercises avoid using creased/torn/darned sheets ensure tubing and monitoring equipment is positioned correctly to avoid unrelieved pressure remove slings on completion of hoist transfers and do not allow patients to remain sitting on slings protect heels from pressure injury, especially patients confined to bed or with immobilised lower extremities 13 ensure there are palpable lower limb pulses. If unable to locate or palpate, refer for medical review 19

20 Reduce heel pressure cont Promote activity and mobility Optimise positioning and use appropriate patient handling techniques aim for total relief of pressure from heels, consider foam replacement mattresses with built-in heel protection use foam wedges, purpose built elevation devices or pillows to elevate heels. Note: gel or cushioned booties do not provide heel pressure reduction 13 ensure that the knee is not hyper extended which may lead to popliteal entrapment, occlusion of the popliteal vein and potentially, development of Deep Vein Thrombosis 49,50 prevent constricting the feet by using a bed cradle ensure activity and mobility status is maintained as per patient s medical condition and ability by encouraging early mobilisation following surgery or stroke 42 use aids with active rehabilitation and early ambulation to relieve pressure and improve circulation eg. trapeze, rollator, stick or walker 47 avoid using in fall-out /sling type chairs patients at risk should use an relevant pressure cushions educate the patient about the importance of repositioning regularly and encourage small frequent position changes, enough to minimise point pressure 29 consider distribution of weight, support of feet, postural alignment and anatomy when positioning chair bound patients 29 educate the patient on how to offload weight every fifteen minutes whilst seated. 27 consult with physiotherapist, podiatrist and occupational therapist where needed avoid direct pressure on bony prominences, tissue previously damaged or areas sensitive to pressure damage 38,42 for patients identified at risk, provide them with an appropriate support surface within 4 hours of admission (refer to Appendix 4) reposition at risk patients in accordance with a turning schedule use positioning aids such as pillows and foam wedges to maintain correct body alignment and to prevent direct contact of bony prominences 40 (refer to Section 5.3.1: Pressure relieving positions) avoid positioning directly on the greater trochanter when nursing patients on their side 38,40 assess fully chair-bound patients to ensure correct fitting of the chair and the pressure cushions used are designed for their specific needs. 47 Consult with an Occupational therapist and/or Physiotherapist for specialist advice. reposition/raise wheelchair-bound patients who are unable to support themselves, at least hourly 40 20

21 5.3 Positioning and turn intervals for pressure re-distribution When the patient is assessed at risk or unable to move independently and redistribute pressure, staff must assist regular repositioning and be careful to eliminate any shearing or friction forces to other areas of skin such as dragging heels along the sheet. 40 A care plan for turning and repositioning should include the use of positioning aids and pressure devices to minimise pressure on bony prominences. The Queensland Health Guidelines for Safer Patient Handling should be followed at all times and appropriate lifting aids and handling equipment used. 55 The repositioning schedule should consider the patient's medical condition, comfort, overall plan of care, as well as the support surface used. 53 It is recommended to start turns every two hours. Conduct a skin inspection of all pressure points to assess the success of the repositioning. 42,54 The turning and repositioning should be increased if the skin is discoloured or erythema is present when the patient is repositioned Positions for pressure redistribution To aid distributing pressure evenly it is important to maintain correct body alignment when lying or sitting. If the patient needs help turning, start and document a turning and repositioning schedule according to the patient s medical condition. Do not place the patient directly on their side at an angle of 90 0 as this places very high pressure on the trochanter. When positioning patients use the rule of 30 : if the head of the bed is to be elevated, limit the angle to 30 0 or less for side to side positioning, place the patient on a 30 0 lateral position to limit direct pressure on bony prominences. 29 Depending on the patient s clinical status and condition of their skin, the following positions may be considered for patients who are immobile or inactive and on pressure redistribution mattresses. 52 Position 1 Three quarter turn position To relieve pressure on sacrum, scapulae and right of the body: pillow under left ankle to cushion bony malleoli pillow supporting length of right leg. This should extend from the groin to just above the ankle. It protects the right knee from pressure and should allow dorsiflexion of the right ankle to take place pillow under thorax supporting right shoulder and arm and protecting the elbow from undue pressure pillow supporting head and neck For left side of the body, reverse directions Position drawings reproduced with the permission of Pam Hibbs 52 21

22 Position 2 To relieve pressure on left trochanter, left buttock, left elbow and heels: pillow extending from shoulders to hip under left side for support and to prevent rolling onto back pillow supporting left leg extending from buttock to just above the ankle leaving the heel free from any contact and taking the strain off left knee joint an additional pillow can be used to support the right ankle. For right side of the body reverse directions. Quarter turn position Position 3 Back position To relieve pressure behind the knees and heels: pillow under knees to relieve pressure on the back of the knees and take strain off ligaments and tendons. The pillow should extend from the back of the thigh to just above the ankle leaving the heel free from contact with the bed or pillow additional pillows may be used to support the arms and prevent pressure at the elbows pillows supporting head and neck Position 4 To relieve pressure from knees, heels and elbows, in patients who do not have access to contour beds, bolster the foot of the bed to prevent shearing forces and also place: pillow supporting head and neck pillow extending from mid-thigh to just above the ankle and leaving the heel free from contact and relieving strain from the knee joints pillows under each forearm - supporting the forearm and hand with the hand inclined upwards from the elbow. This may assist lymphatic drainage from the hands. Make sure elbows are free of all pressure Engage the knee break feature on the patient s bed if available to assist in prevention of shearing forces. Sitting position 22

23 5.4 Support systems Pressure redistribution devices and optimal positioning is used prevent the occurrences of pressure related injury and constant pressure on areas prone to pressure ulceration. 53 (Refer Appendix 4) Using pressure redistribution devices does not eliminate pressure ulcer risk. Pressure ulcer prevention requires thorough clinical care, regular positioning and ongoing assessment as well as the appropriate support surface. Correct positioning, turning and transferring techniques are important to reduce pressure and shear forces and encourage the redistribution of weight on support devices. Support surfaces should be chosen with consideration of the patient s clinical status. A dynamic support surface such as an alternating air device/mattress should be used if the patient cannot reposition without bearing weight on injured tissues or if a pressure ulcer is present Selecting a support surface When selecting a support surface assess: 13 if the patient is alert and able to change positions the patient s risk status site and stage of existing pressure ulcers types of transfers to be used on the support surface the transport mode and if the surface can be stabilised in the event of an emergency procedure such as cardiac pulmonary resuscitation (CPR) if mattress cover is impermeable to fluid if mattress has properties to reduce shear and friction the minimum and maximum patient weight limits for the device. It may be necessary to purchase/rent appropriate pressure redistribution equipment for bariatric patients. durability, cost and availability of a rental option the size and weight of equipment infection control principles; cleaning, storage, maintenance and regular testing of standard hospital mattress for fitness of use is completed 56 if it is suitable to use on profiling beds that a mattress replacement program is in place in accordance with the standards and guidelines 56 staff are appropriately trained. A summary of the equipment and its features, along with a list of equipment on the current Queensland Health Contract for Pressure Ulcer Prevention Devices can be found on the Patient Safety website. 23

24 5.4.2 Pressure devices classification The number of pressure redistributing support surfaces on the market has increased in recent years. There are products available to suit hospital/home beds, transport trolleys, chairs/wheelchairs, operating tables and radiology diagnostic rooms. 57 There is still a lack of reliable research data supporting the clinical practices recommended by the manufacturers. 41,42,53,57 Patient support systems can be categorised according to their clinical characteristics, that is, pressure redistribution features. Devices can be referred to by their clinical characteristics of constant low pressure and alternating pressure devices. 13,57 (see Table 4) Constant low-pressure devices redistribute the pressure at bony prominences over the body's surface area. 11 The device moulds to the body outline, maximising contact area and redistributing the patient s weight evenly. Device moulds reduce interface pressure over bony prominences. 13,42 Support surfaces should be dense enough that bony prominences do not 'bottom out'. 17 Alternating surfaces change the interface pressure on the skin over time by periodically deflating air cells under the body and redistributing the pressure on the soft tissue which encourages reperfusion of previously supported areas. 58 All devices have a limited life span 17 so mattress replacement programs are essential. The mattress should be replaced if are any signs of foam degeneration, or staining of the cover are visible. Mattress integrity should be checked at least annually. The replacement cycle of a constantly used mattress is approximately 5 years. To achieve effective pressure prevention and management, the clinician should be familiar with the range and types of pressure products available and their indications and contra-indications for use. Refer to Table 4. 24

25 Table 4 Classification of devices Constant low pressure devices Constant low pressure device characteristics/features include: foam, air overlays and mattresses (static air or low air loss devices) use of the devices must be in combination with a turning regimen relating to the patient s risk to eliminate pressure at frequent intervals and to allow the blood to circulate to ischaemic tissue, as low pressure on the skin can still cause tissue ischaemia and necrosis 17 tight/knotted wrinkle free bed linen produces a 'hammock' effect, reducing the pressure redistribution elements of the support system 43 plastic sheets, incontinence sheets and sheepskins between the patient and the surface reduce pressure redistribution qualities Viscoelastic Foam devices Static air devices porous polymer material that in proportion to the applied load and to the rate of loading 59 used on operating theatre and x-ray tables 38 available in a variety of sizes, density and thickness for use on beds and trolleys, or as chair cushions mattresses constructed from foams of different densities, providing low pressure profiles. 53 Mattresses of this type should replace the basic hospital vinyl mattress on beds and trolleys 17,32 (refer to the Appendix 4 for the Pressure devices flowchart) life expectancy of products is provided by the manufacturer. Queensland Health generally expects five years life for a mattress 56 foam device covers should be made of billowy or two-way stretch fabric, waterproof and vapour permeable 13 covers on Queensland Health mattresses must have a zip that opens to allow regular inspection of foam and cover quality are non-mechanical, non-powered support surfaces that do not move unless the patient moves may have interconnected chambers allowing air exchange between compartments when compressed. 60 Devices should be checked regularly and adjusted to the patient s body weight to avoid over/under inflation that may increase interface pressure 47 25

26 Low air loss devices Alternating pressure devices are available as an overlay, replacement mattress or specialty bed provide a continuous flow of air from the entire surface of the mattress, using a micro-porous material 11,60 are powerful motors providing the air necessary to maintain air cell inflation, despite constant air loss 13 maintain pressure within the air cells at the lowest possible level for the best patient support and body alignment 60 Alternating pressure devices characteristics/features include: dynamic and active pressure relief systems that require an electric power source supplied as pressure cushions, overlays, single or multi-layered mattress replacements some devices automatically adjust to patient weight and position change Alternating pressure devices generate alternating high and low pressures between an individual s body and the support surface 60 at regular intervals inflate and deflate groups of air filled cells placed across the mattress surface support the body with inflated cells, deflated cells reduce contact pressure, allowing oxygenation and nutrients to the tissues 60 have a great deal less tissue interface pressure when compared with a vinyl mattress 57 require checking of mattress for puncture, tubing kinking and noise factor the pressure redistribution qualities of the device are reduced by plastic sheets, incontinence sheets and sheepskins between the patient and the surface must have CPR and transport facility can be placed on top of a standard mattress or a replacement (in place of a standard mattress) are generally set to the patient s weight, a minimal weight requirement is set by manufactures 26

27 5.4.3 Devices not recommended Do not use doughnut type devices, water filled gloves/casks or sheepskins as pressure redistribution aids. 61 Doughnut shaped cushions may have adverse affects to the lymphatic drainage and circulation, increasing the risk of pressure ulcer development. 6,19,40,61 Water-filled gloves are not recommended due to little evidence 6, 38 supporting their use. Sheepskins and fibre-filled overlays may provide some comfort or protection from friction, however must not be used on top of pressure redistribution devices as they will limit the device s pressure redistribution properties. 27

28 5.5 Summary of prevention strategies assess all patients using the revised Waterlow Pressure Ulcer Risk Assessment Tool for Adults and the Braden Q Modified tool for Paediatrics assess the patient s nutrition, general medical condition and home environment involve relevant members of the multidisciplinary team and family Maintain skin integrity Eliminate pressure shear and friction Initiate positioning, turn schedule and support surface Document and communicate Conduct a systematic skin inspection daily for at risk patients for signs of impaired skin integrity Eliminate or minimise all potentially irritating skin substances Avoid direct contact between bony prominences with pillows or foam wedges Keep the head of the bed at the lowest elevation for the patient s condition Employ proper lifting and manual handling techniques Maximise patient s activity and mobilisation consistent with patient s medical condition and ability Multidisciplinary team referral: stomal therapy/ wound care consultant continence advisor physiotherapist occupational therapist dietitian rehabilitation engineer Stabilise skin and body temperature Relieve heel pressure in bedbound patients or with immobilised lower extremities Reposition patients according to their risk status and as frequently as skin s tolerance dictates Document clearly all risk assessments, interventions and outcomes Promote continence assessment/training and self-care independence Promote optimal nutritional status Allocate an appropriate support surface for identified level of risk. Use in conjunction with an individualised turning regimen Assess regularly responses to interventions Avoid prolonged uninterrupted sitting in a chair/ wheelchair (> two hours) Avoid positioning patients directly on the trochanter 28

29 6 Documentation Accurate documentation and communication allows for the timely intervention of preventative and therapeutic measures. This minimises the frequency of occurrence and the severity of pressure ulcers. All risk assessments/reassessments and interventions should be clearly documented in the patient's medical record and communicated to staff, patients, family and carers. This ensures a complete clinical picture of the patient s care, including clear outcome measures. 25 Clinical coders rely on an accurate record in the clinical chart of all pressure ulcers, the stage, location on the patient s body and whether it was present on admission to the facility. If the ulcer was present before patient was presented for care, then record the location/facility the patient was at when the ulcer developed. (Examples include another hospital, at home or at a long term care facility. ) During the patient s admission, their ongoing risk status, identified risk factors and pressure ulcer status will be reassessed and documented in the medical record. An incident report should be submitted to management every time a pressure ulcer is discovered. Documentation of the pressure ulcer will include 13, 19,25 stage of ulcer clinical appearance of the wound size of ulcer in cm (measured by tracing or photograph) - length, width, depth (insert sterile, cotton tipped applicator) exudate (ie. serous, purulent) odour eschar/necrotic tissue/granulation/epithelialisation pain: presence/absence condition of surrounding skin wound evaluation /progress via weekly remeasurement of the pressure ulcer The management plan should address 25,40 skin assessment and plan positioning program pressure redistribution devices 29 referrals to allied health/technical staff e.g. occupational therapist, podiatrist physiotherapist, dietitian or rehabilitation engineer 17

30 evaluation of patient outcomes to interventions. Assessment and documentation is an ongoing process. 7 Treatment Protocols The basic principle of caring for a patient with a pressure ulcer is: pressure must be relieved, optimal healing promoted, patient s general condition improved and interventions put in place to minimise further pressure ulcers. Treatment options can be grouped under primary (surgical) or secondary intention. 7.1 Partnership with patients and families While assessment of the patient and the wound site will influence the choice of treatment, the main factor will be based on the patient s wishes, treatment goals and the overall prognosis. The patient and health team must decide if the desired outcome is to provide comfort, maintain the wound without further deterioration or to heal. 62 Surgical intervention may be considered: when healing using secondary intention has failed to debride and accelerate healing to achieve a more robust repair. Surgical closure should be considered for wounds that are in high function areas. Early surgical referral and management in accordance with the surgeon assessment can support optimal outcomes for the patient. Surgical intervention is generally considered for stage 3 and 4 wounds and may involve any combination of debridement (with or without removal of bone tissue), closure, flap repair or grafting. 28 An effective pressure ulcer management plan is predicted on these principles and forms the basis for interventions 62 including : patient assessment including reference to an appropriate continence management plan wound assessment nutrition assessment and management control of infection surgical intervention or autolytic /debridement as per scope of practice total pressure relief of the wound or the operative site and development of a plan to increase tissue tolerance wound cleansing/product selection provision of pain management provision of appropriate redistribution device eg. mattress, cushion, wedge patient reassurance 30

31 ongoing evaluation of healing and regular reassessment documentation education and involvement of the patient home evaluation. Following the assessment and correcting of any underlying pathology, consider the pressure ulcer characteristics outlined in Table 5 when choosing a wound dressing. In general, dressing choice should be consistent with moist wound healing principles. 63 For generic categories of wound products suitable by pressure ulcer stage, refer to Table 5. A patient s medical condition and any complications may influence the rate of healing, but generally ressure ulcers should show signs of healing or be healed within two to four weeks. 62 Note: Healed wounds remain vulnerable to further breakdown. 25 Re-introduction of pressure to a healed area must be a gradual process and part of a planned and closely monitored regime. 31

32 Table 5 Wound care product categories - Stages 1 to 4* Note: only generic product names provided. Wound infection should be managed as per Section 8.2 Stage 1 Unbroken skin Stage 2 Superficial skin loss involving epidermis /dermis Stage 3 Shallow ulcers affecting dermis and sub dermal tissue Stage 4 Deep ulceration involving muscle/ tendon/bone/joint capsule Reactive N/A N/A N/A N/A Hyperaemia Necrotic N/A N/A N/A Amorphous hydrogel Hypertonic Saline N/A Hydrocolloid sheet, N/A N/A Hydrogel combination Hydrocolloid Honey Exudate Low Sloughy Granulating Epithelialisng Exudate High Exudate Low Exudate High Exudate Low Exudate High N/A N/A N/A N/A Hydrofibre Polyurethane foam Exudry Silver o nanocrystalline o ionic Silicone Cadexomer iodine silicone Hydrocolloid sheet Hydrogel Conformable hydrogel Silicone Hydrofibre Polyurethane or silicone foam Exudry Amorphous hydrogel Thin hydrocolloid / semi permeable film Silicon foam Hydrofibre Calcium Alginate Polyurethane foam Exudry Silver o Nanocrystalline o Ionic Silicone N/A Hydrofibre Calcium Alginate Polyurethane foam Silicone Exudry Silver N/A N/A N/A N/A N/A Hydrofibre Calcium Alginate Polyurethane foam Exudry Silver o Nanocrystalline o Ionic Silicone N/A Hydrofibre Calcium Alginate Polyurethane foam Exudry Silver o Nanocrystalline o Ionic Silicone N/A Goal Protect Protect Contain exudate Promote healing Protect surrounding skin from wound exudate by using a picture frame of hydrocolloid Contain exudate Promote healing Seal dressing with semi permeable film to maintain wound healing environment Rehydrate eschar Protect surrounding skin from wound exudate by using a picture frame of hydrocolloid Contain exudate Promote healing Seal dressing with semi permeable film to maintain wound healing environment *Courtesy of Wound Care Teams at Royal Brisbane and Women s Hospital and the Princess Alexandra Hospital. 32

33 8 Special Considerations for Treatment 8.1 Heel pressure ulcers Heel ulcers are the result of pressure, shear and friction in patients confined to bed or with immobilised lower extremities and with impaired peripheral circulation or altered sensation Interventions perform a thorough peripheral vascular assessment to confirm sufficient perfusion to achieve healing. Refer to a Vascular consultant or Medical Practitioner if required provide total relief of pressure from heels with foam wedges or inflatable air devices. Ensure that the knee is not hyper extended as it may lead to popliteal entrapment. Occlusion of the popliteal vein with the potential to develop of Deep Vein Thrombosis 49,50 assess the blister to determine treatment protocol. The heels may have a blister with intact skin or necrotic eschar. The following diagrams summarise the appropriate action for both cases Heel Blisters Blister with intact skin - Serous - Haemoserous Assess wound Appearance Soft to touch and no surrounding erythema: - Leave intact - Protect from further damage - Cover with semipermeable film or protective dressing - GOAL: Serous fluid will absorb Tense with surrounding erythema - De-roof blister (medical officer /wound specialist/ podiatrist) - Treat as per wound protocol for wound bed appearance (see Table 5) 33

34 8.1.3 Heels with necrotic tissue Non viable tissue must be removed as it is a source of infection. The debridement method must be based on the ulcer, the peripheral arterial supply and the patient s comfort. Current staging definitions state that when the wound involves necrotic tissue, staging cannot be confirmed until the wound base is visible. Therefore ulcers predominantly covered with eschar must be classified as Stage 4 until debrided. 13 NOTE: This definition is currently under review by the Australian Wound Care Association, and it is anticipated that a new definition will be announced in Heel with necrotic eschar Assess arterial supply is adequate for wound healing Arterial supply insufficient: Conservative management - Elevate - Prevent infection (antibacterial solution) - Protect from pressure - Do not cover Refer to Vascular Consultant for ongoing management and advice Assess by medical officer or Vascular Consultant Sharp debridement - By Medical Officer Arterial supply sufficient Discuss with medical team / plan for debridement Autolytic debridement Promote Moist Wound Healing 8.2 Infection and pressure ulcer intervention Infection is the most common cause of delayed healing. All pressure ulcers are contaminated with surface bacteria. However, when bacteria invade necrotic tissue infection may occur in the form of inflammation, increased exudate and malodour

35 8.2.1 Interventions evaluate ulcer/s for evidence of infection eg. cellulitis or sepsis 25 consider cellulitis if evidence of increased erythema or inflammation consider sepsis if patient is systemically unwell ie. fever, delirium, night sweats administer pain relief plan care in conjunction with care team. For rural and remote refer to Primary Clinical Care Manual. Local clinical indicators for wound infection include: increase in wound size exudate changes increased amount purulent increase in wound pain with erythema malodour General clinical indicators for wound infection include: malaise fever reduced appetite increased white cell countor C-reactive protein Information relating to Infection Control Guidelines can be found at Management of large cavity wounds Full thickness wounds that are highly exudating require packing to obliterate the dead space and absorb the excess exudate. 25 Investigate and treat infection. Wounds involving necrotic tissue require debridement either by autolysis or surgical debridement. Following removal of all necrotic tissue, consideration may be given to using negative pressure therapy. Negative pressure therapy devices assist in wound closure by applying localised negative pressure to draw the edges of the wound to the centre. Negative pressure therapy promotes granulating tissue and controls exudate by reducing interstitial oedema. Refer to the product guidelines for the appropriate clinical use. 35

36 9 Training and education Training and education programs for the prevention of pressure ulcers should be structured, organised and comprehensive. Staff at each hospital or community organisation should be offered education for pressure ulcer prevention and treatment during initial orientation and at other times as required. Ongoing education should be directed at all levels of health professionals, patients, families and carers involved in patient management in line with the ACHS EQuIP guidelines. The basic clinician education should include the following content: 6,13,38 patient assessment aetiology and risk factors risk assessment tools and their application uniform staging classification skin assessment and skin care selection of appropriate pressure redistributing equipment implementation of an individualised management program which includes discharge planning needs positioning/handling techniques techniques and content for patient/family education concepts of reflective practice principles of wound healing and product selection relevant policies and procedures documentation where to get further advice e.g. resource persons in hospital, professional associations and product representatives Patient and/or family education should include 38 : the causes of pressure ulcers areas that are common sites for pressures ulcers how to inspect and care for skin methods for pressure relief movement techniques where to find further advice and assistance if required an emphasis on the need for immediate visits to a health care professional should signs of damage be noticed care of equipment 36

37 10 Quality monitoring and measurement Health managers are responsible for maintaining high standards of care. Their accountability includes ensuring there are resources, educational programs and audit systems to support an effective pressure injury prevention program. 64 Research should be encouraged to examine the relative effectiveness of individual interventions and their impact on patient outcomes. Information about adhering to prevention policies and the relative success of prevention efforts can be gleaned from many sources: incident reports recorded in the organisation s incident monitoring system prevalence audits ICD coded data collated by the medical records staff for casemix regular and small quality audits that focus on specific indicators for best practice retrospective or prospective studies analysis of individual cases to determine the root cause of developed pressure ulcers equipment audits checking for proper allocation of equipment, condition and its clinical effectiveness. Incident monitoring is a systematic process to identify, analyse and report incidents that could have adverse consequences with the specific aim of preventing their recurrence. 66 Monitoring the number of pressure ulcers that have occurred does not change practice unless staff and carers understand why the ulcer developed and what specific measures are needed to prevent recurrence. To better understand the cause of each pressure ulcer, specific information needs to be collected immediately when first noted by a clinician or community carer. Information should include: location and stage of the ulcer a short description of the wound(s) to clarify and confirm the staging the risk assessment score at the time the pressure ulcer was discovered any prevention devices in use at the time that the ulcer was discovered interventions implemented when the pressure ulcer was discovered whether the ulcer developed in the home or the facility where the patient is currently receiving care (in hospital or aged care systems this is often referred to as present on admission ) history of admission eg. long period lying following a fall in home environment may lead to pressure area development This information should be consistent throughout organisations to monitor monthly pressure ulcer incidence rates and compare progress of pressure ulcer reduction. Strengths are highlighted and problem areas are then addressed through education, organisation and system changes and/or additional resources. 19 Many private and public organisations now work together to share knowledge and success stories from prevention programs. The clinical audit should form an important part of any organisation s quality improvement plan. Most importantly, a focus of all clinicians should be reflective practice. 6 Pressure 37

38 ulcer monitoring should address: monthly incidence reports both at a clinical and organisational level small but regular clinical audits focussing on specific areas of best practice that are known to prevent pressure ulcers medical coding audits to improve the rate and accuracy of medical records coding annual auditing of equipment/pressure devices Equipment auditing is critical. Devices represent a significant investment, and are justified in business cases because they provide clinical cost savings. It must be remembered that both the device and the clinical benefit have a limited lifespan. Using equipment that no longer provides pressure redistribution (or is inadequate for the patient s weight capacity) can cause patient harm by causing pressure ulcers. 38

39 15 Glossary of terms Amorphous Having no real or apparent crystalline form. Autolysis Destruction of tissue or cells by action of self-produced enzymes. Bioavailability The degree and rate at which a substance (as a drug) is absorbed into a living system or is made available at the site of physiological activity. Blanching hyperaemia Reddened areas turn white following application of finger pressure, indicating the microcirculation is intact. Bottoming out Flattening of the support surface by the body; test by placing outstretched hand (palm up) under mattress, below a bony prominence. Cellulitis Inflammation of the tissue identified by redness, heat, swelling and pain. Colonisation Presence of bacteria with no host reaction. C-Reactive protein (CRP) A marker of inflammation Denuding Loss of the epidermal layer of skin. Epithelialisation Regeneration of the epidermis across the wound surface. Erythema Redness of the skin surface produced by vasodilation Eschar Brown or black necrotic tissue covering or partially covering a pressure ulcer. Exudate Any fluid that has exuded out of a tissue or its capillaries because of injury or inflammation and is high in protein and white blood cells. Friction A force created by two surfaces in contact moving across each other. Granulation Healing tissue composed of newly formed capillaries and fibroblasts. 39

40 Hydrophilic Having a strong affinity for water. Hydrophobic Having a lack of affinity for water. Incidence The frequency of occurrence of any event or condition over a period of time and in relation to the population in which it occurs, as incidence of a disease. Ischaemia Deficiency of blood, due to obstruction or constriction of a blood vessel. Ischial tuberosity A bony swelling on the posterior part of the superior ramus of the ischium that gives attachment to various muscles and bears the weight of the body in sitting. Maceration Softening or destruction of skin due to soaking in fluid. Necrosis Death of tissue. Non-blanching hyperaemia Persistent redness when finger pressure is applied to an area of reactive hyperaemia, indicating disruption to the microcirculation. Pressure A perpendicular load or force exerted on a unit of area. Pressure Redistribution support surfaces The ability of a support surface to distribute load over the contact areas of the human body. This term replaces the prior terminology of Pressure Reduction and Pressure Relief Surfaces. Pressure ulcer An area of localised tissue damage caused by ischaemia arising from pressure. Prevalence The number of existing cases of a particular disease or condition in a given population at a designated time. Pyrexia Abnormal elevation of body temperature. Reactive hyperaemia A normal compensatory mechanism following an episode of reduced perfusion to the tissues as a result of pressure. Relief of pressure results in reddening of skin caused by blood rushing back into ischaemic tissues. Reperfusion The reinstitution of blood flow to tissues that have been traumatized, especially following a long period of crushing. 40

41 Risk factors Predisposing factors, both intrinsic and extrinsic, which increase a patient s probability of pressure injury. Key factors include mobility, nutrition, perfusion, age and sensory perception. Sebum A fatty secretion of the sebaceous glands of the skin. Sepsis Infection with disease-causing micro-organisms or other toxins in the bloodstream. Shear Skin trauma caused by tissue layers sliding on one another, resulting in disruption or angulation of blood vessels. Slough Stringy yellow, green, or grey debris within a pressure ulcer. Support Surface A specialised device for pressure redistribution designed for management of tissue loads, micro climate, and/or other therapeutic functions (i.e. any mattress, integrated bed system, mattress replacement system, overlay, seat cushion, or seat cushion overlay). Tissue interface pressure The pressure applied to the epidermis by the surface that is supporting it. Trochanter Either of the two bony processes below the neck of the femur. Tunnelling A passageway that lies beneath the surface of the skin and that is generally open at the skin level most of which is not visible. Undermining Separation of the tissue underlying intact skin along wound margins. 41

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45 Appendices Appendix 1. Modified Waterlow pressure ulcer risk assessment tool 45