Skin Failure: An Emerging Concept

Effectiveness of specialised support surface modes in preventing pressure injuries in intensive care: A systematic review and meta-analysis

BACKGROUND

Patients in intensive care units (ICU) are at an increased risk of pressure injuries. In ICUs, specialised support surfaces are an intervention often used to prevent pressure injuries. This systematic review and meta-analysis aimed to ascertain the effectiveness of different specialised support surface modes for preventing pressure injuries to adult ICU patients.

METHODS

Ovid MEDLINE, Ovid Embase, EBSCO CINAHL, PEDro, Cochrane Library, Clinicaltrials.gov and eligible paper references were searched for appropriate studies. Studies were included if they investigated both dynamic support surface modes low-air-loss (LAL) and alternating pressure (AP), involved adult ICU patients (≥18 years old), and investigated pressure injury incidence. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Mixed Methods Appraisal Tool (MMAT) checklists were used for reporting and quality assessment. Risk ratios (RRs) with 95 % Confidence Intervals (CIs) were used to summarise pressure injury incidence. The pooled RR was calculated with the random-effects model using the Mantel-Haenszel method. Further secondary analysis examined length of stay (LoS) and severity of illness.

RESULTS

The four included studies involved 3,308 patients. These studies were heterogeneous in design. When AP surface mode was compared with LAL surface mode, there was no significant difference in the occurrence of pressure injury (8.9 % versus 10.9 %, RR 0.64). Mattress mode also had no direct association with length of stay and severity of illness.

CONCLUSION

This systematic review and meta-analysis found no significant difference in the effectiveness of LAL and AP support surface modes in preventing pressure injuries in adult ICU patients.

IMPLICATIONS FOR CLINICAL PRACTICE

Clinicians should remember that mattresses are just one element within strategies to prevent pressure injuries in ICUs. The equivocal findings of this systematic review highlight the complexity of preventing pressure injuries and underscore the importance of holistic nursing care.

Construction of a Risk Prediction Model for the Occurrence of Acute Skin Failure in Critically Ill Patients: A Prospective Study

BACKGROUND

The risk factors for acute skin failure (ASF), a serious complication of the skin, are not fully understood.

PURPOSE

This study was designed to explore the risk factors for ASF in critically ill patients and construct a clinical prediction model.

METHODS

Intensive care unit patients were prospectively observed and assigned into two groups: with and without ASF. A logistic regression model was constructed, and its predictive power and clinical utility were evaluated.

RESULTS

Of the 204 eligible patients enrolled as participants, 58 (28.43%) developed ASF. Sepsis, vasoactive drugs, and age were shown to be risk factors for ASF, whereas peripheral perfusion index ratio and albumin level were shown to be protective factors. The area under the receiver operating characteristic curve was 0.83. The maximum Youden index of the model was 0.39 (specificity: 0.87, sensitivity: 0.77). The Hosmer-Lemeshow test (p = .20) and calibration curve showed good fitness and predictive utility with respect to the model.

CONCLUSIONS

The developed model effectively predicts ASF risk, allowing for the early identification of high-risk patients. Identifying risk factors such as sepsis, vasoactive drugs, and age and considering protective factors such as peripheral perfusion index and albumin levels may help optimize care plans. Clinical staff should pay special attention to these factors and their impact on skin health in critically ill patients.

A survey of skin failure perceptions amongst pressure injury management staff in China: A cross-sectional study

This study sought to evaluate the perceptions of pressure injury (PI) management staff regarding skin failure (SF). Additionally, an analysis of influencing factors based on the collected data was conducted to establish a foundation for targeted SF training. A descriptive, cross-sectional survey was undertaken in October-November 2023, utilising a convenience sampling method involving selected management staff of PI from 16 provinces in China. A total of 501 nursing participants were included, exhibiting an overall perception level that was moderately low. Although the majority were aware of the possibility of SF (n = 417, 83.23%), only 60% reported an understanding of the fundamentals of SF, with the lowest level of comprehension observed in differentiating between SF and PI (n = 212, 42.31%). Overall attitudes were generally positive. Regarding behaviour, active learning was more prevalent (n = 340, 67.86%), but training is less (n = 287, 57.29%). Family education (n = 401, 80.04%) and nursing record monitoring (n = 426, 85.03%) demonstrated better behaviour. Further analysis revealed that training (t = 13.937, p < 0.001) and professional title (F = 4.681, p = 0.010) had a significant effect on participants' perceptions. These findings underscore that there remains a substantial lack of perception about SF amongst participants. Overall, participants exhibited a positive attitude towards SF, highlighting the need for future improvements in SF training.

Examining Violaceous Skin Discoloration during the COVID-19 Pandemic: Conducting Research in Resource Scarcity

OBJECTIVE

To describe the observed patterns and presentations of violaceous discoloration that appeared to be related to the COVID-19 disease process.

METHODS

This retrospective observational cohort study included adults who were COVID-19 positive with purpuric/violaceous lesions in pressure-adjacent areas of the gluteus without preexisting pressure injury. Patients were admitted to an ICU at a single quaternary academic medical center between April 1 and May 15, 2020. Data were compiled by review of the electronic health record. The wounds were described by location, tissue type (violaceous, granulation, slough, eschar), wound margin (irregular, diffuse, nonlocalized), and periwound condition (intact).

RESULTS

A total of 26 patients were included in the study. Purpuric/violaceous wounds were found predominantly on White (92.3%) men (88.0%) aged 60 to 89 years (76.9%) with a body mass index 30 kg/m2 or higher (46.1%). The majority of wounds were located on the sacrococcygeal (42.3%) and fleshy gluteal regions (46.1%).

CONCLUSIONS

Wounds were heterogeneous in appearance (poorly defined violaceous skin discoloration of acute onset), and the patient population had clinical characteristics similar to acute skin failure (eg, concomitant organ failures and hemodynamic instability). Additional larger population-based studies with biopsies may assist in finding patterns related to these dermatologic changes.

Results of the 2022 Wound Survey on Skin Failure/End-of-Life Terminology and Pressure Injuries

OBJECTIVE

To summarize the major findings of a survey first conducted in 2019 and repeated in 2022 and review new concepts (angiosomes and pressure injuries) and challenges due to the COVID-19 pandemic.

METHODS

This survey captures participants' ranking of agreement or disagreement with 10 statements on Kennedy terminal ulcers, Skin Changes At Life's End, Trombley-Brennan terminal tissue injuries, skin failure, and unavoidable/avoidable pressure injuries. The survey was hosted online by SurveyMonkey from February 2022 until June 2022. All interested persons were able to participate in this voluntary, anonymous survey.

RESULTS

Overall, 145 respondents participated. The same nine statements achieved at least 80% agreement (somewhat agree or strongly agree) as in the previous survey. The one statement that did not reach consensus also failed to reach consensus in the 2019 survey: "The concept of skin failure does not include pressure injuries."

CONCLUSIONS

It is the authors' hope that this will stimulate more research into terminology and etiology of skin changes in persons at end of life and encourage more research regarding terminology and criteria to define which skin lesions are unavoidable or avoidable.

Incidence of and Risk Factors for Self-load-related and Medical Device-related Pressure Injuries in Critically Ill Patients: A Prospective Observational Cohort Study

There are two types of pressure injuries: self-load-related pressure injuries (PIs) and medical device-related pressure injuries (MDRPIs), but the differences in risk factors between PIs and MDRPIs have not yet been clarified. If risk factors for PIs and MDRPIs differ, preventive interventions should take this into account. This is a prospective cohort study aimed to determine the cumulative incidence of PIs and MDRPIs in critically ill patients and to identify corresponding risk factors. The study included 1418 patients who were admitted to the critical care medical center of a single university hospital in Tokyo, Japan, between December 1, 2019, and August 31, 2020. The Kaplan-Meier method was used to calculate the cumulative incidence of PIs and MDRPIs. Furthermore, the Cox proportional hazards model was used to analyze the predictors in both the PI and MDRPI incidence and non-incidence groups. Predictors were based on data from the 0th disease day. The cumulative incidence of PIs and MDRPIs was 4.6/1000 person-days and 3.6/1000 person-days, respectively. Multivariate analysis using the Cox proportional hazards model showed that common risk factors for the occurrence of PIs and MDRPIs were possession of PI on admission, higher blood lactate, blood purification therapy, and positional restriction. The risk factors for PIs only were diabetes mellitus, septic shock, and a lower serum albumin level, while the risk factors for MDRPIs only were the D-dimer level and extracorporeal membranous oxygenation treatment. Therefore, prophylactic interventions need to consider these different risk factors. This article is protected by copyright. All rights reserved.

Skin injuries associated with severe life-threatening situations: A new conceptual framework

PURPOSE

To create a conceptual framework for skin injuries developing in patients whose lives are severely compromised or who are expected to die within a short period of time. To name and classify these types of skin injuries. To describe the clinical features of the different types of skin injuries that may occur in terminally ill and/or dying patients.

DESIGN

A sequential design with several different phases (a literature review, a nominal group, and a consensus conference) was used.

METHODS

Six experts with extensive knowledge of these types of injuries were selected for the nominal group. The traditional eight-phase nominal group technique was followed. The consensus conference consisted of participants voting on different options based on the statements elaborated with the expert panel summarizing the best scientific evidence available.

FINDINGS

Using all these elements, a conceptual framework was constructed to identify skin injuries associated with severe life-threatening situations (SI-SLTSs), defined as unpredictable and therefore unpreventable injuries indicating a serious threat to life or even imminent death. These injuries can occur in two forms: (a) as skin injuries associated with multiple organ dysfunction syndrome (SI-MODSs) or (b) as skin injuries associated with severe vasoconstriction (SI-ESVs). SI-MODSs develop very quickly and suddenly. They progress from superficial to deep stages abruptly, even within hours. The severity of the injuries does not reflect the care provided to the patient. Individuals suffering from these injuries have an irreversible clinical condition. SI-ESVs also appear in individuals who are in a very critical, even terminal, clinical condition. They are frequently treated in the ICU and may exhibit severe vasoconstriction due to their disease process (e.g., shock), sometimes exacerbated by vasoconstriction caused by various drugs (e.g., noradrenaline).

CONCLUSIONS

We have developed a conceptual framework for skin injuries developing in patients whose lives are severely compromised or who are expected to die within a short period of time and have named them SI-SLTSs, distinguishing between SI-MODSs and SI-ESVs.

CLINICAL RELEVANCE

This new conceptual framework may help clinicians understand the mechanisms and the pathophysiology of skin injuries that develop in terminally ill and/or dying patients associated with multi-organ failure. Through this new framework these injuries can be identified and differentiated from pressure injuries or other dependence-related skin lesions.

Understanding Skin Failure: A Scoping Review

OBJECTIVE

To map the use of the term "skin failure" in the literature over time and enhance understanding of this term as it is used in clinical practice.

DATA SOURCES

The databases searched for published literature included PubMed, Embase, the Cumulative Index for Nursing and Allied Health Literature, and Google Scholar. The search for unpublished literature encompassed two databases, Open Gray and ProQuest Dissertation and Theses.

STUDY SELECTION

Search terms included "skin failure," "acute skin failure," "chronic skin failure," and "end stage skin." All qualitative and quantitative research designs, editorial, opinion pieces, and case studies were included, as well as relevant gray literature.

DATA EXTRACTION

Data collected included author, title, year of publication, journal name, whether the term "skin failure" was mentioned in the publication and/or in conjunction with other skin injury, study design, study setting, study population, sample size, main focus of the publication, what causes skin failure, skin failure definition, primary study aim, and primary outcome.

DATA SYNTHESIS

Two main themes of skin failure were identified through this scoping review: the etiology of skin failure and the interchangeable use of definitions.

CONCLUSIONS

Use of the term "skin failure" has increased significantly over the past 30 years. However, there remains a significant lack of empirical evidence related to skin failure across all healthcare settings. The lack of quality research has resulted in multiple lines of thinking on the cause of skin failure, as well as divergent definitions of the concept. These results illustrate substantial gaps in the current literature and an urgent need to develop a globally agreed-upon definition of skin failure, as well as a better understanding of skin failure etiology.

Wound Care Consultation in Postacute/Long-term Care: Characteristics and Practice Implications

OBJECTIVE

To study the characteristics of residents in postacute (PA)/long-term care (LTC) facilities with wounds and prevalence of wound types other than pressure injuries (PIs).

METHODS

The authors conducted a retrospective review of all wound care consultations over 1 year at The New Jewish Home, a 514-bed academically affiliated facility in an urban setting. Investigators analyzed residents by age, sex, type of wound, presence of infection, and whether the resident was PA or LTC. Authors designated PIs as facility acquired or present on admission.

RESULTS

During the study period, 190 wound care consultations were requested; 74.7% of consults were for those in PA care. The average patient age was 76.3 years, and there were 1.7 wounds per resident receiving consultation. Of studied wounds, 53.2% were PIs, 15.8% surgical, 6.8% arterial, 6.3% soft tissue injury, 5.8% venous, 2.6% malignant wounds, and 2.1% diabetic ulcers; however, 11.6% of residents receiving consults had more than one wound type. In this sample, 13.2% of residents had infected wounds, and 76.2% of PIs were present on admission.

CONCLUSIONS

The wide variety of wounds in this sample reflects the medical complexity of this population. The transformation of LTC into a PA environment has altered the epidemiology of chronic wounds and increased demand for wound care expertise. These results challenge traditional perceptions of wound care centered on PIs. Given its importance, a wound care skill set should be required of all PA/LTC providers.

Facilitating Factors in the Proper Identification of Acute Skin Failure: A Systematic Review

BACKGROUND

Acute skin failure is a significant medical finding for both the critical care patient and the hospital. Proper identification is key to prevention and treatment, but diagnosis of acute skin failure in critical care patients is often missed. This diagnostic oversight may be due to a lack of knowledge about acute skin failure and its presentation.

OBJECTIVE

To investigate the literature for facilitating factors that would ease the identification of acute skin failure for clinicians.

METHODS

The research team conducted a systematic literature review via PubMed, CINAHL, and Academic Search Ultimate to collect data about acute skin failure and how it might be identified.

RESULTS

Ten common facilitation themes around acute skin failure and its identification were found in the literature. In total, 110 examples of facilitating factors were identified.

CONCLUSIONS

There is little factual information available regarding the identification of acute skin failure, and the literature is lacking in this area overall. Acute skin failure may develop in the body in a number of ways, and understanding commonalities that occur in patients who experience acute skin failure and applying that information to patients in the future may assist identification.

Risk Factors Associated with Skin Tear Development in the Canadian Long-term Care Population

BACKGROUND

Skin tears (STs) are prevalent wounds found in aging populations and in particular among those living in long-term care (LTC) settings. They are often misunderstood as expected outcomes of aging and as a result are frequently underrecognized and undertreated. Although many factors have been associated with ST development, there is little evidence to corroborate their roles as ST risks.

OBJECTIVE

To examine the risk factors associated with ST development in the Ontario LTC population.

METHODS

A prospective study design was used to explore the risk factors associated with ST development. A total of 380 individuals 65 years or older from four LTC facilities in Ontario were examined for STs at the beginning of the study and at week 4 to determine if STs had occurred.

RESULTS

The study found an ST prevalence of 20.8% and an incidence of 18.9%. History of an ST at baseline (relative ratio [RR], 1.84; 95% confidence interval [CI], 1.25-2.70; P = .002); the presence of skin changes associated with aging, ecchymosis, and hematomas (RR, 1.60; 95% CI, 1.43-1.79; P < .001); chronic disease (RR, 1.17; 95% CI, 1.03-1.32; P = .018); requiring assistance with activities of daily living (RR, 1.13; 95% CI, 1.08-1.18; P < .001); and displaying aggressive behavior (RR, 1.06; 95% CI, 1.02-1.10; P = .001) were key risk factors associated with ST development.

CONCLUSIONS

These results provide much needed Ontario data on the risk factors associated with ST development and can be used to support prevention programs mitigating ST risk.

Acute Skin Failure in the Critically Ill Adult Population: A Systematic Review

GENERAL PURPOSE

To present a systematic review of the literature conducted to define and extend knowledge of the risk factors, causes, and antecedent conditions of acute skin failure (ASF) in adult intensive care patients.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant should be better able to:1. Outline the background information helpful for understanding the authors' systematic review of ASF in adult intensive care patients.2. Summarize the results of the authors' review of the risk factors, causes, and antecedent conditions of ASF in adult intensive care patients.

ABSTRACT

To define and extend knowledge of the risk factors, causes, and antecedent conditions of acute skin failure (ASF) in the adult intensive care patient cohort.The Cochrane Library, Joanna Briggs Institute Evidence-Based Practice Database, PubMed, Medical Literature Analysis and Retrieval System, Cumulative Index of Nursing and Allied Health Literature, and Google Scholar.Studies were selected if they were qualitative or quantitative research that reported ASF in adult human patients in an ICU setting. The preliminary search yielded 991 records and 22 full texts were assessed for eligibility. A total of three records were included. Studies were appraised using the Mixed Methods Appraisal Tool.Data from the included studies were extracted by one reviewer and summarized in data collection tables that were checked and verified by a second reviewer.Study authors identified five independent predictors of ASF: peripheral vascular disease, mechanical ventilation longer than 72 hours, respiratory failure, liver failure, and sepsis. However, the term ASF was applied to retrospective cohorts of patients who developed severe pressure injuries. This, combined with the absence of evidence surrounding the assessment, clinical criteria, and diagnosis of ASF, could impact these variables' predictability relative to the condition.These results highlight a substantial evidence gap regarding the etiology, diagnostic biomarkers, and predictors of ASF. Further research focused on these gaps may contribute to an accurate and agreed-upon definition for ASF, as well as improved skin integrity outcomes.

Terminal Ulcers, SCALE, Skin Failure, and Unavoidable Pressure Injuries: Results of the 2019 Terminology Survey

GENERAL PURPOSE

To present the results of the 2019 study of healthcare professionals' consensus and opinions regarding terminology for terminal ulcers, Skin Changes At Life's End, skin failure, and unavoidable pressure injuries to improve clinical care and to foster research into current criteria for unavoidable skin changes at the end of life.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, NPs, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After completing this continuing education activity, the participant should be better able to:1. Explain the survey methodology and identify the consensus statements.2. Synthesize the open-ended questions and respondent comments and their implications for clinical care and research.

ABSTRACT

This article reports the results of a global wound care community survey on Kennedy terminal ulcers, Skin Changes At Life's End, Trombley-Brennan terminal tissue injuries, skin failure, and unavoidable pressure injury terminology. The survey consisted of 10 respondent-ranked statements to determine their level of agreement. There were 505 respondents documented. Each statement required 80% of respondents to agree (either "strongly agree" or "somewhat agree") for the statement to reach consensus. Nine of the 10 statements reached consensus. Comments from two additional open-ended questions were grouped by theme. Conclusions and suggested recommendations for next steps are discussed. This summary is designed to improve clinical care and foster research into current criteria for unavoidable skin changes at the end of life.

The Phenomenon of Trombley-Brennan Terminal Tissue Injury in a Neonate: A Case Study

BACKGROUND

Trombley-Brennan terminal tissue injury (TB-TTI), also known as skin failure, was first identified in 2009 among critically ill adults receiving palliative care. Identification of this skin injury can be misinterpreted as a pressure ulcer. However, this phenomenon is now accepted as an early sign of impending death among critically ill adults.

CLINICAL FINDINGS

This case study describes TB-TTI in a terminally ill infant in a neonatal intensive care unit evidenced by intact, 2-cm oval skin discoloration on the lateral side of both knees with rapid progression in size.

PRIMARY DIAGNOSIS

TB-TTI was identified on the day of death in an infant with a primary diagnosis of hypoxic-ischemic encephalopathy born at 32 weeks' gestation.

INTERVENTIONS

The neonatal intensive care unit (NICU) team mobilized the NICU advanced care team, institution's ethical council, and "Team Lavender" to provide infant comfort measures and emotional support to the family and care givers.

OUTCOMES

Infant death occurred 8 hours after TB-TTI was identified.

PRACTICE RECOMMENDATIONS

To our knowledge, this case study of TB-TTI in a terminally ill neonate in the NICU has not been previously described in the neonatal or pediatric population. Early recognition of the phenomenon can enable the healthcare team to provide timely emotional, spiritual, and psychosocial support to the family and allow time to "be present" with the infant at "end of life." Future work should explore additional signs of TB-TTI and the occurrence rate.

Palliative Wound Care: Less Is More

Palliative wound care is a philosophy of wound management that prioritizes comfort over healing and attends to the emotional distress these wounds can cause. Intervention strategies focus on management of symptoms such as pain, odor, bleeding, and exudate. Historic treatments such as honey, chlorine, and vinegar have gained renewed interest, and although well suited to the palliative setting, there is an increasing amount of research exploring their efficacy in other contexts. The lived experience of patients and caregivers facing these wounds is often stressful and isolating, and any treatment plan must address these issues along with the physical aspects of care.

An Introduction to Skin as an Interface: Implications for Interprofessional Collaboration and Whole-Person Care

GENERAL PURPOSE

To increase health care professionals' awareness and perceptions of the skin as one of the largest body organs with multidimensional aspects and significant implications for interprofessional collaboration in whole-person care.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant should be better able to:1. Apply physiologic and integumentary knowledge to assessing common skin variations and problems.2. Summarize the results of the authors' literature review of the evidence regarding the emotional, psychosocial, cultural, and spiritual aspects of skin health and disorders.

ABSTRACT

The skin reflects not only a person's physical state of health, but also the dynamic interplay of emotional and cultural influences. This article will increase health practitioner understanding of the skin and skin assessment by highlighting its multidimensional aspects and significant implications for interprofessional collaboration in whole-person care. Through a multidimensional assessment of the skin, practitioners can better understand the health story of each patient and intervene holistically to improve overall well-being and quality of life.

Definition and Characteristics of Chronic Tissue Injury: A Unique Form of Skin Damage

BACKGROUND

The purpose of this article is to examine the evidence related to a unique phenomenon of purple-maroon discoloration of the buttocks found in homecare patients and to recommend a label for this phenomenon.

CASES

Initially, we searched the literature to identify and retrieve any evidence related to this unique form of purple-maroon discoloration of the buttocks. No evidence was found. To illustrate the condition, we compared 4 cases of what we have labeled chronic tissue injury to 6 patients with purple-maroon discoloration of the buttocks from different causes.

CONCLUSION

Chronic tissue injury is characterized by a persistent purple-maroon discoloration located on the fleshy portion of the buttocks that does not improve or deteriorate. Unlike other causes of purple discoloration such as deep tissue pressure injury, there is minimal change in the discoloration over time. Additional research is needed to further our understanding of the histopathology of this phenomenon.