Standard 8


Standard 8: Preventing and managing pressure injuries


Prevent patients from developing pressure injuries and effectively manage pressure injuries when they do occur.

Hospital Standards

Epworth is accredited under the National Safety and Quality Health Service Standards. These national standards apply to all health services organisations and state the minimum level of care – the national benchmark – that consumers can expect. Hospitals must report their performance against the standards on a regular basis and are also subject to periodic reviews and assessments.

For further information, refer to the National Safety and Quality Health Service Standards Guide (PDF).

Epworth Standards


At Epworth we want to provide excellent patient care. For this reason, we set our own, stricter benchmarks against each of the standards, and we measure our performance against these. The table below provides details of the national benchmark, the Epworth internal benchmark and our average result against each of the items.

​Standard 8: Preventing and managing pressure injuries
​National Benchmark
​Epworth HealthCare Internal Benchmark
​Epworth HealthCare Average 2014
​Epworth HealthCare Average 2015 Average FY 2015-16 †​ ​
​Hospital acquired pressure injuries rate ​0.57 ​0.57 ​0.70 0.81 #​ 0.92 #​
​Hospital acquired grade 3/4 pressure injuries rate ​0.18 ​0.00 ​0.01 0.01 #​ 0.01 #​

Rate=per 1,000 bed days.​

# A lower number is better.

† Figures for year ending 30/6/2016.



  • Our goal is to achieve a rate of 0 (zero) hospital acquired serious pressure injuries (Grade 3 or 4) and we are on our way to achieve this, with an annual average rate of 0.01, significantly better than the national benchmark.
  • Since introducing measures to monitor and reduce this type of injury, our performance has constantly improved and we will continue to monitor and look for ways to improve our care.

What we are working on

  • At Epworth, we encourage our staff to report incidents and near misses so that we can improve our safety. Increased reporting reflects our positive culture of self-reporting and continuous improvement, and increased staff awareness of the importance to be vigilant about pressure injuries. While our reporting is high, this is not translated into grade 3/4 pressure injuries, as our staff are dealing with pressure injuries at the very early indications.

  • Screening all patients for skin integrity on admission to identify at risk patients and ensure appropriate treatment.
  • Hourly rounding and patient safety conversations with nurses and the allied health team to ensure the patient and their family/carer understand the potential risk of pressure injuries and the importance of moving.
  • Revising the pressure injury risk assessment tool to be more comprehensive and inclusive of documented preventative strategies, and include nutrition which is an important part of wound healing.
  • An annual focus month to highlight the importance of pressure injury prevention
  • The creation of patient, family and carer information brochures outlining what patients can do to minimise their risk of pressure injuries and assist with adequate nutrition.
  • Process changes in theatre to minimise the risk of pressure injury for patients undergoing lengthy procedures.
  • Process changes in high risk areas such as intensive care units and emergency departments.
  • Additional pressure relieving devices made available including special mattresses and cushions.

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