Model of Care for Prevention and Integrated Management of Pressure Injuries in People with Spinal Cord Injury and Spina Bifida


To promote a model of care which focusses on supporting self-management and education strategies for the person with Spinal Cord Injury (SCI) / Spina Bifida (SB) to take ownership over their skin integrity status in the first instance, but also to promote access to essential services and equipment in a timely and equitable manner and to strengthen processes for an integrated approach to care.


There are an estimated 6,500 individuals living in NSW with spinal cord injury (SCI) and spina bifida (SB), who have an overall lifetime incidence of pressure injury (PI) of more than 85%. The social and economic impact of PI on the individual, family and community is immense and can have long term physical and psychological consequences. The Model of Care promotes a prevention and early intervention integrated management approach which aims to identify and manage risk, and establish prevention and early intervention strategies with the aim of preventing deterioration and the need for extended hospitalisation.

Interest in PI is currently high with the release of the Australian Commission on Safety and Quality in Health Care Standard 8 Prevention and Management of Pressure Injuries and the Clinical Excellence Commission’s Pressure Injury Prevention and Management Policy. While these policies are aimed at care of the patient within health facilities, the Model of Care focusses more on the community setting, developing a specialist toolkit of resources for clinicians, clients and their carers, and facilitating a process for achieving integrated care. 


The Model of Care for Prevention and Integrated Management of Pressure Injuries incorporates the following:

  • Features of the Chronic Care Model.
  • Different levels of primary, secondary and tertiary prevention. 
  • The concept of risk stratification for health promotion with self-management support.
  • Early risk assessment, clinical decision support and care coordination with increasing levels of specialist support for management.

Three key principles that apply to every aspect of PI prevention and management across all care settings. They are:

  • Principle 1 - Self-management
  • Principle 2 - Timely and equitable access
  • Principle 3 - Integrated care.

Critical components underpinning success of the model in achieving a significant reduction in number and frequency of PIs and their impact on health care and support services as well as good outcomes for the individual are:

  • improved health promotion
  • earlier detection and intervention with improved assessment and decision support
  • timely access to equipment, care coordination and community supports and resources
  • responsive and knowledgeable health practitioners providing evidence based management and care
  • inter-sectoral collaboration with development of key partnerships that will bridge the gap between sectors and government departments.

The Model identifies three main ‘phases’ along the PI patient journey where interventions occur to either prevent occurrence, deterioration or recurrence of PI in this patient population.

  • Phase 1 – Health Promotion
  • Phase 2a – Intervention ( Stage II PI)
  • Phase 2b - Intervention ( Stage III PI)
  • Phase 3a - Restoration and rehabilitation
  • Phase 3b - Quality of life maintenance

Information is provided on what is required and how this can be achieved for each phase. Outcome measures for each phase are also provided.

Implementation plan and priorities will include:

  • Develop online decision support tool and resources
  • Work with LHDs/Networks to:
    • Identify ‘local champions’ and map local services, referral patterns/processes.
    • Define & test ‘best practice’ clinical pathways in 1-2 LHDs, and through this process produce a guide for others.
    • Develop strategies to ensure timely access to wound products, equipment & care to prevent PI / deterioration
    • Facilitate communication


In terms of hospital utilisation, the patient cohort is low volume, high cost (on a case basis), complex and relatively stable in terms of numbers. It is associated with a relatively long average length of stay. Referral and treatment patterns are often delayed due to inconsistent, fragmented services and difficulty for individuals in navigating the system. Data showing high rates of emergency admissions, late presentations with severe pressure injuries and recurrent admissions suggests there is considerable scope for improvement through prevention and earlier intervention, as well as better service co-ordination and streamlined management practices.

There is a lack of data regarding individuals managed for PI in the community and therefore costs for the management of PI in the community were not included. Further work involving a whole of government approach will be important for building community costs.

The nature of paediatric SCI is different to that in adults. The specific needs of children are not covered comprehensively in this model and should more detail be necessary regarding paediatric SCI, further work would be required.


The Model of Care was developed in consultation with a broad range of clinical experts, consumers and carers in both hospital and community care settings to explore the issues related to PI prevention and management across the lifespan and stages of pressure injuries. 

The project to develop the Model of Care was led by the Spinal Pressure Injury Prevention and Management Model of Care Steering Committee, the State Spinal Cord Injury Service Directorate and members of the Agency for Clinical Innovation Executive.

Key Dates

Pilot Sites

Hunter New England Local Health DistrictHunter New England Local Health District

Hunter Spinal Cord Injury Service (Newcastle) and Rural Spinal Cord Injury Service (Tamworth)

Northern Sydney Local Health DistrictNorthern Sydney Local Health District

Northern Sydney Home Nursing Service

Implementation Sites


Formative and summative evaluation of the pilot project will be undertaken.

Related Initiatives


Frances Monypenny
Network Manager, State Spinal Cord Injury Service
02 9464 4616

Chris Shipway
Director, Primary Care and Chronic Services
02 9464 4603

Page Top | Added: 3 July 2014 | Last modified: 7 June 2016

Frances Monypenny
Network Manager, State Spinal Cord Injury Service
02 9464 4616