SCALE: Skin Changes at Life's End Final Consensus Statement: October 1, 2009©

Dermatological Issues Among Individuals Receiving Palliative Care - A Review

Skin disorders among individuals receiving palliative care may be associated with the primary condition or underlying comorbidities and patients may experience pruritus, discomfort or pain. Common conditions include xerosis, pressure ulcers, intertrigo, superficial fungal infections, telogen effluvium, pruritus, herpes zoster, eczematous disorders and edema. During end-of-life care, there is reduced skin perfusion and metabolism hence leading to susceptibility to infection, pressure and injury. Other factors affecting the skin include limited mobility, nutritional deficits and immunosuppression. Although treatment strategies for each skin condition are usually aligned with standard protocols, considerations among these patients include limited life-expectancies, potential treatment burden, drug-drug interactions as well as comfort-directed rather than cure-directed therapy. For patients with xerosis cutis, the regular use of moisturisers is recommended. The management and prevention of pressure ulcers include the strategies of skin assessment and care, pressure redistribution, nutrition and hydration and ulcer care. Superficial fungal infections require treatment with appropriate topical and/or systemic antifungals while antivirals and adjunctive treatment can be prescribed for herpes zoster. Treatment and symptom control of skin disorders in this population can improve quality of life and patients' comfort level.

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.

Prevention of skin tears: intrinsic and extrinsic factors

Skin tears are traumatic wounds caused by mechanical forces, which can be caused by the removal of adhesive dressing. Although they are common - especially in individuals with vulnerable skin, such as older people - their prevalence is underestimated, they are often misdiagnosed and they have a high risk of developing into complex, chronic wounds. However, skin tears are largely preventable. There are a number of intrinsic and extrinsic factors relating to skin tears and preventive strategies that may be undertaken. Health professionals, patients and caregivers/family members should aim to manage modifiable intrinsic and extrinsic factors to promote and maintain skin integrity to prevent skin tears. Where a skin tear does occur, an evidence-based approach should be taken to management, with referral to specialist care if necessary.

Development of a Wound Assessment Tool for Use in Adults at End of Life: A Modified Delphi Study

BACKGROUND

Some patients at end of life (EOL) develop wounds known as Kennedy terminal ulcers, terminal ulcers, and Skin Changes At Life's End. However, there is ambiguity around the defining wound characteristics of these conditions and a lack of validated clinical assessment tools available to identify them.

OBJECTIVE

To gain consensus on the definition and characteristics of EOL wounds and establish the face and content validity of a wound assessment tool for use in adults at EOL.

METHODS

Using a reactive online Delphi technique, international wound experts reviewed the 20 items in the tool. Over two iterative rounds, experts assessed item clarity, relevance, and importance using a four-point content validity index. The content validity index scores were calculated for each item, with a level of 0.78 or higher signifying panel consensus.

RESULTS

Round 1 included 16 panelists (100.0%). The agreement for item relevance and importance ranged from 0.54% to 0.94%, and item clarity scored between 0.25% and 0.94%. Following round 1, four items were removed, and seven others reworded. Other suggestions included changing the tool name and including Kennedy terminal ulcer, terminal ulcer, and Skin Changes At Life's End in the EOL wound definition. In round 2, the now 13 panel members agreed with the final 16 items included and suggested minor wording changes.

CONCLUSIONS

This tool could provide clinicians with an initially validated tool to accurately assess EOL wounds and gather much needed empirical prevalence data. Further research is needed to underpin accurate assessment and the development of evidence-based management strategies.

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.

Interactive Evidence-Based Pressure Injury Education Program for Hospice Nursing: A Quality Improvement Approach

PURPOSE

The purpose of this quality improvement (QI) project was to develop and implement an interactive, evidence-based pressure injury (PI) education program and evaluate the impact on frontline hospice nursing staff knowledge and practice.

PARTICIPANTS AND SETTING

The QI setting was a 12-bed inpatient hospice unit in a tertiary care Veterans Affairs (VA) Medical Center in Cleveland, Ohio. Nineteen licensed and unlicensed hospice nursing staff participated in this pre-/postworkshop project.

APPROACH

Chart audit determined baseline PI incidence and prevalence on the inpatient hospice unit. Interviews with key leaders informed the need to develop and implement innovative PI education opportunities. A literature review determined existing standards regarding the benefits of PI education for nursing staff but did not reveal measurable targets in hospice settings. We developed a PI education intervention based on Kolcaba's Theory of Comfort framework and a Plan-Do-Study-Act (PDSA) performance improvement model. Education was delivered in 7 workshops, lasting 2 hours each. Knowledge, practice, and comfort for inpatient hospice nursing staff were evaluated at baseline and 8 weeks following the final refresher visit. Workshop satisfaction was collected once using standard program evaluation forms after final workshop delivery.

OUTCOMES

We observed a significant improvement in staff PI knowledge (P = .001) and practice (P = .001) after initial workshop attendance and repeat engagement (P = .001). There was a large magnitude of effect for overall knowledge change (d = 1.04); similarly PI care planning and practice showed a large magnitude of effect and significant improvement (P = .001, d = 2.64). Staff comfort with job duties was stable with low effect size (mean 4.52, d = 0.04), and satisfaction with the workshop education was high (100% agreement with trainer effectiveness).

IMPLICATIONS FOR PRACTICE

We found that frontline hospice nursing staff knowledge and practice improved after attendance at our evidence-based PI education program. Results of this QI project have stimulated ongoing discussion on how to sustain this program in our hospice setting.

Defining and Describing Terminal Ulcers in Adults at End of Life: An Integrative Review

OBJECTIVE

The authors identify and synthesize the published primary literature on unavoidable skin breakdown and end-of-life wounds known as terminal ulcers.

DATA SOURCES

Sources were identified through a systematic search of the Cochrane Library, Medline, ProQuest, EMBASE, CINAHL complete, and PubMed databases.

STUDY SELECTION

The date limiters were set between 1984 and 2020 to locate primary qualitative, quantitative, and/or mixed-methods studies on terminal ulcers.

DATA EXTRACTION

Investigators examined 180 sources and ultimately included four quantitative studies in this review. All were conducted in the US and published between 1989 and 2019. Retrospective chart audits of deceased patients' medical files were undertaken in three of the studies, and prospective observations were used in the fourth.

DATA SYNTHESIS

Descriptive and inductive content analyses were conducted. Three categories emerged: (1) distinguishing the ulcer development patterns, (2) identifying the ulcer characteristics, and (3) delivering specialized and individualized end-of-life care.

CONCLUSIONS

Limited primary evidence has been published on terminal ulcers. Pressure injuries and terminal ulcers have similar appearances, but their development differs significantly. The lack of a specific terminal ulcer assessment tool and staging system increases the risk of these unavoidable end-of-life wounds being incorrectly assessed and managed as pressure injuries. Further research on terminal ulcers is needed to inform clinical practice and ensure specialized care is delivered to patients who develop these wounds.

Pressure ulcers at the end of life

Skin compromise at the end of life (SCALE) is not a new concept. The development of SCALE at the end of life is often deemed unavoidable and a result of multiorgan failure resulting in tissue hypoperfusion, which leads to depletion of oxygen and nutrients for the skin. Pressure ulcers, formed due to pressure, shearing or continuous friction, are also common at the end of life. The goal of care for patients with pressure ulcers at the end of life is usually wound management and good quality of life, rather than wound healing. Nurses must assess all pressure ulcers or SCALE at the end of life holistically and consider treatment and management based on the patient's condition.

Is it time to re-evaluate the inevitability of ulcers at the end of life?

BACKGROUND

The prevention of pressure injuries/ulcers (PI/PUs) in patients at the end of life is achievable, albeit challenging. Objective diagnostic tools, such as sub-epidermal moisture (SEM) scanning, support healthcare practitioners' clinical judgment in preventing PI/PUs.

AIM

A pragmatic study was conducted to assess the feasibility of preventing PI/PUs using SEM technology as an adjunct to routine care in a 22-bed inpatient hospice.

METHODS

Daily SEM scanning was introduced to support the device-trained practitioners' clinical judgment in detecting developing, non-visible PI/PUs. Preventive interventions were initiated by clinical judgment informed by Waterlow scores, visible, tactile skin and tissue assessments and scanner readings.

RESULTS

Prior to the study, the incidence of PI/PUs was 9%. The 6 month study period reported a 4.8% PI/PU incidence, 7/146 consenting patients developed a PI/PU, resulting in a 47% reduction in incidence rates.

CONCLUSION

Preventing the development of PI/PUs is possible with clinical judgment aided by SEM data.

Kennedy terminal ulcer and other skin wounds at the end of life: An integrative review

AIMS

To undertake an integrative literature review to identify, analyse and synthesize current literature on the Kennedy terminal ulcer (KTU) and other unavoidable skin injuries that appear at the end of life regardless of the healthcare context in which they occur.

METHODS

Integrative review following the Whittemore and Knafl methodology. The search was carried out in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus. It was limited to articles in English, French, Portuguese and Spanish. As there is little scientific production on the subject, no restrictions were applied regarding publication date.

RESULTS

Only 17 articles met the inclusion criteria. These articles were reviewed and analysed. Four relevant issues emerged: Skin failure, SCALE, Kennedy Terminal Ulcer, Trombley-Brennan: different names for the same problem; the defining characteristics and physiopathology of KTU; the differences between KTU and other injuries; and the care approach for KTU and other unavoidable injuries at the end of life.

CONCLUSIONS

We identified gaps regarding the physiopathology of KTU since the current knowledge is based only on hypotheses. There is also a large gap in the knowledge about care approaches, perhaps because care plans are not recorded. Despite this, it is clear that the main objective in this situation at the end of life would be to prioritize patient comfort and quality of life.

Characteristics of Critically Ill Adults With Sacrococcygeal Unavoidable Hospital-Acquired Pressure Injuries: A Retrospective, Matched, Case-Control Study

PURPOSE

To identify characteristics of critically ill adults with sacrococcygeal, unavoidable hospital-acquired pressure injuries (uHAPIs).

DESIGN

Retrospective, matched, case-control design.

SUBJECTS/SETTING

Patients admitted to adult intensive care units (ICUs) at an urban academic medical center from January 2014 through July 2016.

METHODS

Thirty-four patients without uHAPI were matched to 34 patients with sacrococcygeal uHAPI. Time points of interest included admission to the ICU, the week preceding the definitive assessment date, and hospital discharge status. Variables of interest included length of stay, any diagnosis of sepsis, severity of illness, degree of organ dysfunction/failure, supportive therapies in use (eg, mechanical ventilation), and pressure injury risk (Braden Scale score).

RESULTS

All 34 sacrococcygeal pressure injuries were classified as uHAPI using the pressure injury prevention inventory instrument. No statistically significant differences were noted between patients for severity of illness, degree of organ dysfunction/failure, or pressure injury risk at ICU admission. At 1 day prior to the definitive assessment date and at discharge, patients with uHAPI had significantly higher mean Sequential Organ Failure Assessment (SOFA) scores (greater organ dysfunction/failure) and lower mean Braden Scale scores (greater pressure injury risk) than patients without uHAPI. Patients with uHAPI had significantly longer lengths of stay, more supportive therapies in use, were more often diagnosed with sepsis, and were more likely to die during hospitalization.

CONCLUSION

Sacrococcygeal uHAPI development was associated with progressive multiorgan dysfunction/failure, greater use of supportive therapies, sepsis diagnosis, and mortality. Additional research investigating the role of multiorgan dysfunction/failure and sepsis on uHAPI development is warranted.

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.

Pressure Injury Prevention and Wound Management for the Patient Who Is Actively Dying: Evidence-Based Recommendations to Guide Care

Preventing pressure injuries and wound deterioration can be challenging for the patient at the end of life. Pressure injuries are often deemed unavoidable when a patient is actively dying; however, the time frame for this process is variable. As the skin fails in an actively dying patient, interventions should align with the patient and family's goals. This integrative literature review defines essential concepts to pressure injury and wound management during this final stage of life including (1) actively dying, (2) end of life, (3) palliative care, and (4) comfort measures. We also provide clinically relevant, evidence-based recommendations for pressure injury prevention and wound management of the patient who is actively dying.

End-of-Life Care for Neonates: Assessing and Addressing Pain and Distressing Symptoms

One of the most essential components of end-of-life (EOL) care for neonates is assessing and addressing distressing symptoms. There is limited evidence to guide neonatal EOL symptom management and therefore significant variety in treatment (1-4). EOL neonatal palliative care should include identifying and relieving distressing symptoms. Symptoms to manage at neonatal EOL may include pain using both non-pharmacologic and pharmacologic comfort measures, respiratory distress, secretions, agitation and neurologic symptoms, nutrition and gastrointestinal distress, and skin care. Also of equal importance is communication surrounding familial existential distress and psychosocial care (1, 5-7). Institutions should implement a guideline for neonatal EOL care as guidelines have been shown to decrease variability of interventions and increase use of pharmacologic symptom management (4). Providers should consult with palliative care teams if available for added multidisciplinary support for family and staff, which has been shown to enhance EOL care in neonates (8, 9).

Reducing pressure ulcers in care homes in Barnet: a quality improvement project

Pressure ulcers are increasingly seen as an untoward event for patients. While there has been a strong focus on patients in the acute sector, community services have also had to be increasingly innovative in addressing this issue. Carers in care homes in the London borough of Barnet were identified as needing additional support to improve their knowledge and skills surrounding pressure ulcer prevention and treatment. An informal pilot training session showed that carers felt better equipped in terms of identifying new pressure ulcers and were able to escalate issues to district nurses in record time. Subsequently, there was a noticeable reduction in the reporting of pressure ulcers of categories 2 and above. In the present article, the authors describe the quality improvement project undertaken at Barnet care homes to prevent pressure ulcers.

Kennedy Terminal Ulcers: A Scoping Review

Kennedy terminal ulcers, a subset of pressure injuries, are associated with the dying process. This scoping review aimed to identify and map the published literature on Kennedy terminal ulcers in terms of its definition, prevalence, assessment, treatment, management, health care costs, and quality of life for patients in all health care settings. Using the Arksey and O'Malley scoping review framework, we systematically searched the Cochrane Library, CINAHL, EMBASE, MEDLINE, and ProQuest databases and 5 guideline repositories between 1983 and 2018. The following search terms were used: Kennedy ulcers, Kennedy terminal ulcers, terminal ulcer, skin failure, and Skin Changes at Life's End. Data were extracted using a purposely developed data collection tool. Initial searches yielded 2997 sources, with 32 included in this review. Most Kennedy terminal ulcer literature was published by nurses in the United States. Kennedy terminal ulcer prevalence data are limited, with no validated assessment tools available. Kennedy terminal ulcers may be misclassified as pressure injuries, potentially resulting in financial penalties to the institution. This scoping review revealed significant knowledge and clinical practice gaps in patient assessment, management, and treatment of Kennedy terminal ulcers. Timely patient education may help them to make informed care and quality end-of-life decisions. Further research is needed to inform clinical practice to improve patient care.

Nurses' decision-making about cancer patients' end-of-life skin care in Wales: an exploratory mixed-method vignette study protocol

INTRODUCTION

Patients with cancer are at high risk of developing pressure ulcers at the end of life as a result of their underlying condition or cancer treatment. There are many guidelines which set out best practice with regard to end-of-life skin care. However, the complexity of palliative cancer care often means that it is challenging for nurses to make the appropriate person-centred decisions about end-of-life skin care. This study seeks to explore the perceived importance that nurses place on different factors in their end-of-life skin care for patients with cancer. The utility, face validity and content validity of a prototype decision-making tool for end-of-life skin care will also be evaluated.

METHODS AND ANALYSIS

A mixed-method design will be used to gather data from primary and secondary care nurses working in different hospitals and local authority areas across Wales. Clinical vignettes will be used to gather qualitative and quantitative data from nurses in individual interviews. Qualitative data will be subject to thematic analysis and quantitative data will be subject to descriptive statistical analysis. Qualitative and quantitative data will then be synthesised, which will enhance the rigour of this study, and pertinently inform the further development of an end-of-life skin care decision-making tool for patients with cancer.

ETHICS AND DISSEMINATION

Ethical approval to undertake the study has been granted by Cardiff University School of Healthcare Sciences Research Governance and Ethics Screening Committee. Informed consent will be obtained in writing from all the participants in this study. The results of this study will be disseminated through journal articles, as well as presentations at national and international conferences. We will also report our findings to patient and public involvement groups with an interest in improving cancer care, palliative care as well as skin 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.

Prelude to Death or Practice Failure? Trombley-Brennan Terminal Tissue Injury Update

In 2012, we published a study in this journal exploring the emergence of unique skin changes in end-of-life patients admitted to a palliative care unit. The purpose of the study was to describe the skin changes and identify the relationship between these changes and time of death. In the above study of 80 patients, the skin changes were found to be unique and different from Kennedy terminal ulcers and deep tissue injuries. Median time from identification of skin changes and death was 36 hours. The phenomenon was named as Trombley-Brennan terminal tissue injury. The current article presents findings that include the study of additional 86 patients. The results further validate the phenomenon and its relationship with time of death.

Prevalence, incidence and associated factors of pressure ulcers in home palliative care patients: A retrospective chart review

BACKGROUND

Terminally ill patients are at high risk of pressure ulcers, which have a negative impact on quality of life. Data about pressure ulcers' prevalence, incidence and associated factors are largely insufficient.

AIM

To document the point prevalence at admission and the cumulative incidence of pressure ulcers in terminally ill patients admitted to an Italian home palliative care unit, and to analyse the patients' and caregivers' characteristics associated with their occurrence.

DESIGN

Retrospective chart review.

SETTING/PARTICIPANTS

Patients ( n = 574) with a life expectancy ⩽6 months admitted to a palliative home care service were included in this study.

RESULTS

The prevalence and incidence rates were 13.1% and 13.0%, respectively. The logistic regression models showed body mass index ( p < 0.001), Braden score at risk ( p < 0.001), Karnofsky Performance Scale index <30 ( p < 0.001), patients' female gender, patients' age >70 and >1 caregiver at home as the dichotomous variables predictors of presenting with a pressure ulcer at time of admission and during home palliative care.

CONCLUSION

The notable pressure ulcers' incidence and prevalence rates suggest the need to include this issue among the main outcomes to pursue during home palliative care. The accuracy of body mass index, Braden Scale and Karnofsky Performance Scale in predicting the pressure ulcers risk is confirmed. Therefore, they appear as essential tools, in combination with nurses' clinical judgment, for a structured approach to pressure ulcers prevention. Further research is needed to explore the home caregivers' characteristics and attitudes associated with the occurrence of pressure ulcers and the relations between their strategies for pressure ulcer prevention and gender-related patient's needs.

Pilot parallel randomised controlled trial of protective socks against usual care to reduce skin tears in high risk people: 'STOPCUTS'

BACKGROUND

Skin tears are common in older adults and those taking steroids and warfarin. They are traumatic, often blunt injuries caused by oblique knocks to the extremities. The epidermis may separate from the dermis or both layers from underlying tissues leaving a skin flap or total loss of tissue, which is painful and prone to infection. 'Dermatuff™' knee-length socks containing Kevlar fibres (used in stab-proof vests and motorcyclists' clothing) aim to prevent skin tears. The acceptability of the socks and the feasibility of a randomised controlled trial (RCT) had not been explored.

METHODS

In this pilot parallel group RCT, 90 people at risk of skin-tear injury from Devon care homes and primary care were randomised to receive the socks or treatment as usual (TAU). The pilot aimed to estimate parameters to inform the design of a substantive trial and record professionals' views and participants' acceptability of the intervention and of study participation.

RESULTS

Participants were randomised from July 2013 and followed up until February 2015. Community participants were easier to recruit than care homes residents but were 10 years younger on average and more active. To recruit 90 participants, 395 had to be approached overall as 77% were excluded or declined. Seventy-nine participants (88%) completed the trial and 27/44 (61%) wore the socks for 16 weeks. There were 31 skin tear injuries affecting 18 (20%) of the 90 participants. The TAU group received more injuries, more repeated episodes, and larger tears with greater severity. Common daily diary reasons for not wearing the socks included perceived warmth in hot weather or not being available (holiday, in hospital, bed rest). Resource use data were obtainable and indicated that sock wearing gave a reduction in treatment costs whilst well-completed questionnaires showed improvements in secondary outcomes.

CONCLUSIONS

This pilot trial has successfully informed the design and conduct of a future definitive cost-effectiveness RCT. It would need to be conducted in primary care with 880 active at-risk, elderly patients (440 per arm). Skin tear incidence and quality of life (from EQ5D5L) over a 4-month period would be the primary and secondary outcomes respectively.

TRIAL REGISTRATION

ISRCTN, ISRCTN96565376.

Pediatric Skin Failure

BACKGROUND

The phenomenon of skin failure as distinct from pressure ulcers has been documented in the adult literature. However, in the pediatric population, skin injury continues to be grouped indiscriminately as various types of pressure ulcers.

OBJECTIVE

To identify and describe the phenomenon of skin failure in critically ill children.

METHODS

Retrospective chart review of 19 patients who had serious skin injuries develop. Organ dysfunction scores, medications, pressure ulcer prevention techniques used, and laboratory values in the 7 days leading up to the development of a skin lesion were evaluated.

RESULTS

At the start of the evaluation period, all patients (N = 19) had pressure ulcer prevention measures in place before the development of a serious skin injury. All of the skin lesions were full-thickness injuries on the day they were identified (as opposed to the more gradual progression from simple to complex skin injuries typically seen in pressure ulcers). As predicted, 18 of 19 patients had multiple organ dysfunction syndrome (MODS) in the week leading up to the skin injury. All patients with MODS had at least 2 dysfunctional systems, and 12 patients had 4 or more dysfunctional systems. Of the 19 patients, 8 (42%) progressed to death, compared with 1.8% in our general pediatric intensive care unit population.

CONCLUSION

Although the traditional paradigm is that pressure ulcers are preventable, a subset of pressure ulcers in critically ill children may actually represent acute skin failure as a consequence of MODS.

Cultural adaptation, content validity and inter-rater reliability of the "STAR Skin Tear Classification System"

AIMS

to perform the cultural adaptation of the STAR Skin Tear Classification System into the Portuguese language and to test the content validity and inter-rater reliability of the adapted version.

METHODS

methodological study with a quantitative approach. The cultural adaptation was developed in three phases: translation, evaluation by a committee of judges and back-translation. The instrument was tested regarding content validity and inter-rater reliability.

RESULTS

the adapted version obtained a regular level of concordance when it was applied by nurses using photographs of friction injuries. Regarding its application in clinical practice, the adapted version obtained a moderate and statistically significant level of concordance.

CONCLUSION

the study tested the content validity and inter-rater reliability of the version adapted into the Portuguese language. Its inclusion in clinical practice will enable the correct identification of this type of injury, as well as the implementation of protocols for the prevention and treatment of friction injuries.

Pilot randomised controlled trial of protective socks against usual care to reduce skin tears in high risk people "STOPCUTS": study protocol

Background

Skin tears are traumatic injuries occurring mostly on the extremities due to shearing and friction forces that separate the epidermis and the dermis from underlying tissues. They are common and occur mostly in older adults and those taking medications that compromise skin integrity. Pretibial skin tears can develop into leg ulcers, which require lengthy, expensive treatment to heal. Traumatic injuries are the second most common type of wounds after pressure ulcers in care homes and are the commonest reason for older adults to require the attention of a community nurse. Common causes of skin tear injuries are bumping into furniture and other obstacles, using mobility aids, transfer to/from wheelchairs, getting in and out of bed and falls. No effective preventative measures currently exist but knee-length, protective socks are now available that contain impact-resistant Kevlar fibres (of the type used in stab-proof vests) and cushioning layers underneath.

Methods/design

In this pilot parallel group, randomised controlled trial, 90 people at risk of skin-tear injury will be randomised with equal allocation to receive the intervention or usual care. They will be recruited from care homes and from the community via general practices and a research volunteer database. Pilot outcomes include recruitment, eligibility, attrition, ascertainment of injuries and completion of outcome measures. Acceptability of the intervention and of study participation will be explored using semi-structured interviews. The proposed primary outcome for the future definitive trial is skin tear-free days. Secondary outcomes are skin tear severity, health status, specific skin-tears quality of life, capability and fear of falling, measured at baseline and the end of the study and in the event of a skin tear.

Discussion

The results of this study will be used to inform the development and design of a future randomised controlled trial to assess the effectiveness and cost-effectiveness of a unique and innovative approach to skin tear prevention.

Approval was granted by the NRES - Cornwall and Plymouth Research Ethics Committee (13/SW/013). Dissemination will include publication of quantitative and qualitative findings, and experience of public involvement in peer-reviewed journals.

Trial registration

Current Controlled Trials: ISRCTN96565376

The role of barrier protection ain pressure ulcer prevention

This article considers the anatomy and physiology of the skin, the natural protection the skin provides in relation to barrier protection and the importance of barrier protection in pressure ulcer prevention. The current national pressure ulcer agenda including high impact actions and the SSKIN care bundle, along with their implementation within one NHS Health Care Trust are discussed.

Wound bed preparation 2012

BACKGROUND

The concept of wound bed preparation is a holistic approach to wound diagnosis and treatment of the cause, patient-centered concerns and optimizing the components of local wound care (débridement, infection and persistent infection, moisture balance) before edge effect for healable but stalled chronic wounds. This article has introduced the concepts of healable, nonhealable and maintenance wounds. Additionally, clinical criteria (mnemonic NERDS and STONEES) are provided on the use of topical agents for critical colonization or systemic antimicrobials for deep and surrounding infection.

OBJECTIVE

To present a holistic, evidence-informed approach to chronic wound care management.

METHODS

This article reviews the scientific evidence base, and forms an expert consensus of key opinion leaders to the Wound Bed Preparation model.

RESULTS AND CONCLUSION

This article provides clinicians with evidence-informed wound caring approaches translating the evidence base into practice.

Epidermolysis bullosa and chronic wounds: a model for wound bed preparation of fragile skin

Epidermolysis bullosa (EB) is a group of inherited diseases with 4 subtypes. This disorder is a model for fragile skin, with some affected individuals having chronic, difficult-to-heal wounds. The care of wounds in people with EB can be guided by the Wound Bed Preparation paradigm. The treatment of chronic EB wounds is outlined with a quick reference guide of 12 consensus recommendations created by a panel of 11 experts. These recommendations were reviewed by a computer-facilitated modified Delphi process where 15 external reviewers (68.8% of whom reported having 11 or more years' experience with EB care). Inclusion of recommendations was contingent on 80% agreement from reviewers.