Graduated colour tape measure: Development and demonstration of this tool in a case series of neonatal skin injuries

A scoping review and narrative synthesis of neonatal skin injury severity scales

BACKGROUND

Mechanical force skin injuries are common for critical care patients, especially neonates. Currently, identification and severity assessments of injuries are dependent on clinical experience and/or utilization of severity tools. Compared with adults, neonates sustain skin injuries in different anatomical locations and have decreased layers of healthy tissue (from 0.9 to 1.2 mm) creating questions around direct application of adult injury severity scales reliant on visual assessment.

AIMS

The aim of this scoping review (ScR) was to investigate severity scales used to report hospital acquired skin injuries for neonates.

METHODS

This study utilized the 2015 Joanna Briggs Institute methodology for scoping reviews and is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews extension. PubMed, CINAHL, COCHRANE Central, Scopus, and the reference lists of included studies were searched for studies published between 2001 and 2023, that included severity scales use within neonatal population. Two authors independently identified studies for full review, data extraction, and quality assessment.

RESULTS

A systematic database search returned 1163 records. After full test review of 109 studies, 35 studies were included. A majority of studies included were cohort or action research and conducted in the United States of America. Most studies (57%, n = 20) reported skin injuries acquired throughout the body, 14 (40%) of the studies reported the nasal area alone and one study reported no anatomical location. A total of nine severity scales or combination of scales were utilized within studies (n = 31) and four studies did not report a scale. Various versions of scales from the National Pressure Ulcer Advisory Panel (n = 16), European Pressure Ulcer Advisory Panel (n = 8) or Neonatal Skin Condition Score (n = 4) were reported, compared with locally developed classifications/scales (n = 4). Scales were predominantly of ordinal grouping (74%, n = 26) or categorical assessment (14%, n = 5). Only one scale from 2004 was validated for neonates.

CONCLUSION

Neonatal skin injuries will continue to be reported subjectively until severity scales are consistently applied or other measurements are identified to support assessment. Additionally, without skin injury assessment uniformity, critical examination of effectiveness of skin care treatment practices will have subjective comparison. This review suggests there is a need for consistent skin assessment and severity scales that are valid for the neonatal population and their unique skin considerations.

Securing peripheral intravenous catheters in babies without applying adhesive dressings to the skin: a proof-of-concept study

BACKGROUND

Most babies admitted to a Neonatal Intensive Care Unit (NICU) require a peripheral intravenous catheter (PIVC). PIVCs are secured using splints and adhesive dressings applied to the skin. Removing the dressings causes skin injury, pain, and risks infection. We designed the Pēpi Splint, which supports PIVCs without the application of adhesive dressings to the skin. We sought to determine the effectiveness and acceptability of the Pēpi Splint using a proof-of-concept design.

METHODS

Eligible babies were > 1000 g and > 30 weeks' corrected gestation admitted to Wellington Regional NICU and who required a PIVC. All babies received the same care as those not in the study, with the addition of the Pēpi Splint. Primary outcomes were the proportion of babies in which the Pēpi Splint secured the PIVC for the required time and proportion of babies who experience an adverse event. Secondary outcomes were the acceptability of the Pēpi Splint as reported by the parents.

RESULTS

Thirty-eight babies, median (range) birth weight 2625 g (396-4970) and gestation 37wk (22-41). When the Pēpi was applied the postnatal weight was 2969 g (1145 - 4970) and gestation 37wk (29 - 41). The Pēpi Splint held the PIVC secure for 34/38 babies (89%), for a duration of 37 h (6 to 97). There were no adverse events. Of the four babies reported to have unsecure PIVCs, two were due to the securement two were displaced during feeding. Fifty-eight parents responded to a questionnaire (32 mothers, 26 fathers). Of these parents 52 (90%) would participate again and 52 (90%) would recommend participating to others. Overall, clinicians reported the Pēpi Splint was easy to use 33/38 (87%).

CONCLUSION

The Pēpi Splint safely secures PIVCs without adhesive dressings being applied to the skin and is acceptable to both parents and clinicians. Our findings provide support for a larger multicentred randomised controlled trial.

TRIAL REGISTRATION

Registered with the Australian and New Zealand Clinical Trials Registry Reference ACTRN12620001335987 .

Fresh Perspectives on Hospital-Acquired Neonatal Skin Injury Period Prevalence From a Multicenter Study: Length of Stay, Acuity, and Incomplete Course of Antenatal Steroids

The objective of this study was to explore neonatal skin injury period prevalence, classification, and risk factors. Skin injury period prevalence over 9 months and χ2, Mann-Whitney U, and independent-samples t tests compared injured and noninjured neonates, with P values less than .05 considered statistically significant. Injury prediction models were developed using Classification and Regression Tree (CART) analysis for the entire cohort and separately for those classified as high or low acuity. The study took place in 3 Australian and New Zealand units. Neonates enrolled (N = 501) had a mean birth gestational age of 33.48 ± 4.61 weeks and weight of 2138.81 ± 998.92 g. Of the 501 enrolled neonates, 206 sustained skin injuries (41.1%), resulting in 391 injuries to the feet (16.4%; n = 64), cheek (12.5%; n = 49), and nose (11.3%; n = 44). Medical devices were directly associated with 61.4% (n = 240) of injuries; of these medical devices, 50.0% (n = 120) were unable to be repositioned and remained in a fixed position for treatment duration. The strongest predictor of skin injury was birth gestation of 30 weeks or less, followed by length of stay of more than 12 days, and birth weight of less than 1255 g. Prediction for injury based on illness acuity identified neonates less than 30 weeks' gestation and length of stay more than 39 days were at a greater risk (high acuity), as well as neonates less than 33 weeks' gestation and length of stay of more than 9 days (low acuity). More than 40% of hospitalized neonates acquired skin injury, of which the majority skin injuries were associated with medical devices required to sustain life. Increased neonatal clinician education and improved skin injury frameworks, informed by neonatal epidemiological data, are vital for the development of effective prevention strategies.

Randomised controlled pilot trial comparing low dose and very low- dose microdrop administration of phenylephrine and cyclopentolate for retinopathy of prematurity eye examinations in neonates

AIMS

To determine ifVery low dose mydriatic eye microdrop regimen sufficiently dilates the pupil (above 4.1 mm) compared with the currently used low dose mydriatic eye microdrop regimen.Cardiovascular, gastrointestinal and respiratory adverse effects occur following eye drop instillation.

METHODS

Seventeen premature infants were recruited into this prospective, randomised controlled pilot trial in January 2017 to November 2018. Data were collected from the single-centre Neonatal Intensive Care Unit, Dunedin Hospital, New Zealand. The inclusion criteria were birth weight less than 1500 g or gestational age less than 31 weeks, or any premature infant requiring red reflex testing. Infants were randomised to receive either phenylephrine 1% or 0.5% and cyclopentolate 0.2% or 0.1%, 1 microdrop in both eyes. Efficacy outcome measures were pupil size at retinopathy of prematurity eye examination (ROPEE) and ophthalmologist rating of ease of screen.

RESULTS

All participants had sufficient pupillary dilation for a successful ROPEE. Ophthalmologists rated the ROPEE as easy for 90% of all examinations. Pupil dilation measurements at the time of examination, mean±SD, 4.8±0.2 (95% CI 4.5 to 5.2) mm for treatment A and 5±0.2 (95%CI 4.6 to 5.4) mm for treatment B (p=0.61). There were no statistically significant differences between the groups for safety data.

CONCLUSIONS

Very low dose microdrop administration of phenylephrine and cyclopentolate appears to be effective at sufficiently dilating the neonatal pupil for ROPEEs. Low dose and very low dose microdrop mydriatic regimens may also reduce the risk of unwanted adverse effects associated with these medicines.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (reference ACTRN12616001266459p).

Neonatal skin assessments and injuries: Nomenclature, workplace culture and clinical opinions-Method triangulation a qualitative study

AIM AND OBJECTIVE

To explore and establish the language, clinical opinions and workplace culture around neonatal skin injury nomenclature. Specifically, what nomenclature is used to describe, define, identity and communicate neonatal skin injuries including (a) terms, (b) locations, (c) associated risks and (d) mechanical forces.

BACKGROUND

Skin injuries are affirmed or denied based on visual assessment with findings reported by language rather than measurements. However, if language or nomenclature is ambiguous, assessments could be misinterpreted effecting healthcare delivery.

DESIGN

Qualitative enquiry including applied discourse analysis and between-method triangulation, within a larger exploratory mixed-methods study.

METHODS

Data were collected over two years from four sources: literature, documents, interviews/focus groups and free text injury assessments. Data analysis included content analysis, selective coding and thematic analysis. The collective data were further explored using discourse analysis and triangulation to achieve collective conclusions about opinions, emotions, feelings, perceptions and workplace cultures. The COREQ checklist provided structure for the reporting of study methods, analysis and findings.

RESULTS

A total of 427 data points were collected from literature, documentation and two clinical data sources. Data convergence revealed that neonatal skin injuries are described by numerous terms with preferences for "injury," "trauma" or "redness." Injuries occur in over 20 anatomical locations and risks for injuries included hospitalisation, specific treatments and prematurity. Essential medical devices, clinical condition, lack of clinician experience and overactive neonates were uniquely associated risks. There was incongruency between sources. The literature and documents empathise pressure as the primary force related to skin injury, while varied forces were identified within interviews, focus groups and free text injury assessments.

CONCLUSIONS

The variety of unique terms, locations and risks for injury indicate the need for updated neonatal skin injury frameworks. If frameworks and policies continue to be created without the empirical knowledge of neonatal clinicians, misrepresentation of neonatal skin injury locations and risk will continue to dominate the literature.

RELEVANCE TO CLINICAL PRACTICE

The recognition and management of neonatal skin injuries are related to language used to describe assessments in the absence of diagnostic confirmation, which has implications for both the neonate and the healthcare team.