A risk model for the prediction of skin tears in aged care residents: A prospective cohort study

Effects of a leave-on product on the strength of the dermoepidermal junction: An exploratory, intraindividual, randomized controlled trial in older adults with dry skin

Background and Aims

Skin aging is associated with dry skin and a decrease of the strength of the dermoepidermal adhesion, which increases the risk for lacerations (skin tears). Application of leave-on products improves dry skin and seems to reduce skin tear incidence. The aim of this study was to measure the effects of a humectant containing leave-on product on the strength of the dermoepidermal junction in older adult participants with dry skin.

Methods

A randomized controlled trial using a split body design was conducted. One forearm was randomly selected and treated with a lipophilic leave-on product containing 5% urea for 8 weeks. The other forearm was the control. The parameters stratum corneum hydration (SCH), transepidermal water loss, pH, roughness, epidermal thickness and skin stiffness were measured at the baseline, Weeks 4 and 8. At Week 8, suction blisters were created and time to blistering was measured. Blister roofs and interstitial fluid were analyzed for Interleukin-1α, 6 and 8.

Results

Twelve participants were included. After 8 weeks treatment, SCH was higher (median difference 11.6 AU), and the overall dry skin score (median difference -1) and median roughness (Rz difference -12.2 µm) were lower compared to the control arms. The median group difference for Interleukin-1α was -452 fg/µg total protein (TP) in the blister roofs and -2.2 fg/µg TP in the blister fluids. The median time to blister formation was 7.7 min higher compared to the control arms.

Conclusion

The regular application of humectant containing leave-on products improves dry skin and seems to lower inflammation and contribute to the strengthening of the dermoepidermal adhesion. This partly explains how the use of topical leave-on products helps to prevent skin tears.

Skin Tear Management: A Multidisciplinary Education Project

OBJECTIVE

To identify the number of skin tears present at the authors' facility and evaluate a multidisciplinary educational intervention to support treatment of skin tears.

METHODS

The authors determined the prevalence of skin tears from an analysis of a wound audit dataset at Baycrest Health Sciences and compared it with the literature to inform the aims of the educational intervention. They developed an educational module and presented it to physicians and students at separate in-person sessions and to clinical care staff at a virtual session. Participants completed an evaluation survey after the education sessions to assess their knowledge and confidence with skin tear management and obtain their feedback about the session.

RESULTS

The prevalence of skin tears at Baycrest hospital was 5.6%, which was low compared with the values reported in the literature. For the 10 studies reviewed, the median prevalence was 8.8% (range, 3.0%-22.1%). A total of 7 physicians, 12 students, and 7 clinical care staff completed the evaluation survey. All of the physicians (100%), 43% of students, and 57% of clinical care staff could classify an image of a skin tear; 86% of physicians, 33% of students, and 43% of clinical care staff identified the correct skin tear complications; and 71% of physicians, 0% of the students, and 29% of clinical care staff selected the appropriate dressing. Participants reported moderate to considerable increases in knowledge and confidence in skin tear management.

CONCLUSIONS

This method of multidisciplinary teaching on skin tears was well received and useful in enhancing knowledge and confidence in identifying and treating skin tears.

Relationship between dry skin and pressure injury in older patients: A multicentre cross‐sectional survey in China

Dry skin and pressure injuries in older persons have become global health care problems. This was a multicentre, prospective cross-sectional study in 44 hospitals and 8 long term care institutions from 20 provinces, autonomous regions and municipalities in China and aimed to explore the relationship between the two skin problems in older patients. We mainly found 11 602 cases with dry skin and 1076 cases with pressure injuries in a total of 33 769 valid participants. The overall prevalence of dry skin and pressure injuries was 34.4% (95% confidence interval [CI] 33.9-34.9) and 3.1% (95% CI 2.9-3.3). Stage 2+ pressure injuries were the most (32.9%), followed by stage 1 (32.4%). The patients with dry skin had more pressure injuries than ones without dry skin (50.0% vs 33.9%). The patients with very severe and severe dry skin had more pressure injury risk (OR 2.22 and 1.90) and more stage 2+ pressure injury risk (OR 2.83 and 1.63). Other nine predictors associated with overall pressure injuries and stage 2+ pressure injuries. The area under receiver operating characteristic (ROC) curve of the predictive models of overall pressure injuries and stage 2+ pressure injuries were 0.89 (95% CI 0.88-0.90) and 0.91 (95% CI 0.90-0.92), respectively.

Skin tear prevalence in an Australian acute care hospital: A 10-year analysis

Hospital-acquired skin tear prevalence is under-reported; thus, the aim of this study was to analyse skin tear point prevalence and characteristics in a tertiary acute care hospital in Queensland, Australia, over a 10-year period. All consenting adult inpatients received a full skin inspection and skin tear category, site, cause, treatment, and whether it was documented as hospital- or community-acquired were recorded. Eleven prevalence audits were analysed with a total sample of 3626 patients. An overall pooled prevalence of 8.9% (95% confidence interval [CI] 7.5-10.4) with an associated hospital-acquired pooled prevalence of 5.5% (95% CI 4.5-6.7) was found. In total, 616 skin tears were reported, of which 374 (60.7%) were hospital-acquired. Over a third of patients (38.7%) had multiple skin tears and most patients (84.8%) with at least one skin tear were aged ≥70 years. The largest proportion of skin tears (40.1%) was those with no skin flap. Of those documented, most were caused by falls or collisions, suggesting combined skin tear and falls prevention strategies may be effective. Over a decade, there was a downward trend in hospital-acquired skin tear, which is encouraging. Skin tear prevalence is recommended as a measure of care quality with an emphasis on good quality documentation.

Epidemiología de los desgarros de piel: revisión bibliográfica

Objetivo:

Identificar y describir la epidemiología de los desgarros de piel (DP) en el contexto latinoamericano.

Método:

Revisión bibliográfica de estudios epidemiológicos publicados entre 1946 y mayo de 2021, en inglés, español y portugués, consultados en texto completo. Para la búsqueda, se utilizaron descriptores correspondientes a la estrategia PCC: Población (adultos), Concepto (epidemiología de los DP) y Contexto (hospitalario e institucional). Los estudios fueron recuperados de las bases de datos Scielo, Lilacs, Embase, Cinahl, Medline y BDEnf, y evaluados por dos revisores independientes. Los instrumentos STROBE y Newcastle-Ottawa fueron usados para evaluar la calidad de estudios de prevalencia e incidencia, respectivamente.

Resultados:

En total, 21 publicaciones fueron incluidas (siete de ellas, de origen latinoamericano). La prevalencia, reportada en 16 estudios, estuvo entre 0,97 y 28,7%. La incidencia, reportada en cinco estudios, varió entre 3,8 y 40%. Los factores de riesgo asociados al desarrollo de DP fueron: historia previa de la lesión, puntajes bajos en la escala de Braden, dependencia para actividades básicas de la vida diaria, y edad avanzada. En América latina, Brasil se destaca como el país con mayor número de publicaciones (n=5; 23,8%).

Conclusión:

La mayoría de los DP pueden ser considerados eventos adversos evitables, por lo tanto, los valores de incidencia y prevalencia encontrados son elevados. La caracterización de la situación epidemiológica de los DP posibilita la creación de protocolos y políticas públicas para su prevención y detección precoz.

Conflicto de interés:

Todos los autores son miembros del International Skin Tears Advisory Panel (ISTAP). CVBS es consultora técnica. CVSG es conferencista. KW es miembro del Canadian Pressure Injury Advisory Panel, consultor en centros de heridas en Canadá, y conferencista para varias empresas internacionales en la industria del cuidado de las heridas.

Epidemiología de los desgarros de piel: revisión bibliográfica

Objetivo:

Identificar y describir la epidemiología de los desgarros de piel (DP) en el contexto latinoamericano.

Método:

Revisión bibliográfica de estudios epidemiológicos publicados entre 1946 y mayo de 2021, en inglés, español y portugués, consultados en texto completo. Para la búsqueda, se utilizaron descriptores correspondientes a la estrategia PCC: Población (adultos), Concepto (epidemiología de los DP) y Contexto (hospitalario e institucional). Los estudios fueron recuperados de las bases de datos Scielo, Lilacs, Embase, Cinahl, Medline y BDEnf, y evaluados por dos revisores independientes. Los instrumentos STROBE y Newcastle-Ottawa fueron usados para evaluar la calidad de estudios de prevalencia e incidencia, respectivamente.

Resultados:

En total, 21 publicaciones fueron incluidas (siete de ellas, de origen latinoamericano). La prevalencia, reportada en 16 estudios, estuvo entre 0,97 y 28,7%. La incidencia, reportada en cinco estudios, varió entre 3,8 y 40%. Los factores de riesgo asociados al desarrollo de DP fueron: historia previa de la lesión, puntajes bajos en la escala de Braden, dependencia para actividades básicas de la vida diaria, y edad avanzada. En América latina, Brasil se destaca como el país con mayor número de publicaciones (n=5; 23,8%).

Conclusión:

La mayoría de los DP pueden ser considerados eventos adversos evitables, por lo tanto, los valores de incidencia y prevalencia encontrados son elevados. La caracterización de la situación epidemiológica de los DP posibilita la creación de protocolos y políticas públicas para su prevención y detección precoz.

Conflicto de interés:

Todos los autores son miembros del International Skin Tears Advisory Panel (ISTAP). CVBS es consultora técnica. CVSG es conferencista. KW es miembro del Canadian Pressure Injury Advisory Panel, consultor en centros de heridas en Canadá, y conferencista para varias empresas internacionales en la industria del cuidado de las heridas.

Skin tears in older adult residents of long-term care facilities: prevalence and associated factors

OBJECTIVE

To determine the prevalence of skin tears, and demographic and clinical factors associated with their presence in older adult residents of long-term care facilities.

METHOD

This observational, quantitative, cross-sectional, epidemiological study was conducted with older adult residents of three long-term care facilities in São Paulo, Brazil. For data collection, four instruments were used: a questionnaire assessing sociodemographic and clinical characteristics of the residents; and the Brazilian-Portuguese versions of the Mini-Mental State Examination, Skin Tear Audit Research (STAR) Skin Tear Classification System, and the Katz Index of Independence in Activities of Daily Living.

RESULTS

A total of 69 residents took part in the study. The prevalence of skin tears was 11.6%. Skin tears were significantly associated with the presence of haematoma (odds ratio, OR=9.159; p=0.017) and actinic purpura (OR=6.265; p=0.033), which increased the odds of skin tear development nine-fold and six-fold, respectively.

CONCLUSION

The findings agree with the international literature. Considering that this was the first epidemiological study on skin tears carried out in long-term care facilities for older adults in Brazil, its contribution lies in the systematisation of data collection and making data available on a field that has not yet been studied in this country.

Sampling the skin surface chemistry for diagnosis and prognosis

Skin and wound blotting are non‐invasive techniques used to sample the skin and wound surface chemistry, whereby a nitrocellulose membrane is applied to an intact or broken cutaneous surface to detect biomarkers. However, there has been no comprehensive review of the evidence for the techniques used and data obtained to date. The primary aim of this study was to review the utilities of surface blotting for the diagnosis and prognosis of physiological, pre‐disease, and pathological states. The secondary aim was to summarise the procedural steps. A systematic literature search was conducted on 9 July 2021 using Medline, Embase, and Google Scholar databases. Investigators used McMaster's Critical Review Form for Quantitative Studies to assess quality, then performed a narrative synthesis reporting according to Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. Twenty‐five studies were reviewed. Eighteen studies were of good quality, and seven were of moderate quality. These studies conducted skin and wound blotting on 176 animals and 1546 humans. Studies reported physiological and pathological states for diagnosis and prediction of conditions, including skin tears, wound healing, biofilm detection, and skin barrier function. The four steps for blotting are surface preparation, blot preparation, application and removal of blot, and analysis. This review demonstrates that blotting can determine the skin and wound surface chemistry using a versatile and reproducible technique. However, future research is needed to validate the technique and skin biomarkers identified.

Risk scoring tool for forearm skin tears in Japanese older adults: A prospective cohort study

[Aim] Because painful skin tears frequently occur in older patients, the prevention of skin tears is fundamental to improve their quality of life. However, a risk assessment tool for skin tears has not been established yet in Japan. Therefore, we aimed to propose a risk scoring tool for skin tears in Japanese older adult. [Methods] We conducted a prospective cohort study with 6-month follow-up in two long-term care hospitals in Japan. A total of 257 inpatients were recruited. Patient and skin characteristics were collected at baseline, and the occurrence of forearm skin tears were examined during follow-up. To develop a risk scoring tool, we identified risk factors, and converted their coefficients estimated in the multiple logistic regression analysis into simplified scores. The predictive accuracy of the total score was evaluated. [Results] Of 244 participants, 29 developed forearm skin tears during the follow-up period, a cumulative incidence of 13.5%. Senile purpura, pseudoscar, contracture, and dry skin were identified as risk factors for skin tears. Their weighted scores were 6, 4, 5, and 6, respectively. The area under the receiver operating characteristic curve of the total score was 0.806. At a cut-off score of 12, the sensitivity was 0.86, and the specificity was 0.67. [Conclusion] Our forearm skin tear risk scoring tool showed high accuracy, whereas specificity was low. This tool can contribute to prevent forearm skin tears in Japanese older adults.

Development of educational material for the prevention and treatment of friction injuries

Objective: to develop and validate an educational booklet to help health professionals to prevent and treat friction injuries. Method: methodological study. An integrative review of the literature of journals published between 2009 and 2019 was carried out in the main databases of Health Sciences. The evaluation of the educational booklet was conducted with 32 nurses, using the Delphi technique. The statistical analysis used was the Content Validity Index. Results: the judges considered the content of the educational booklet between the concepts “inadequate” and “adequate”, in the first assessment; after the corrections requested by the judges, the booklet was forwarded to the evaluators and the content of the educational booklet was rated between “adequate” and “totally adequate”. The overall Content Validity Index was 0.8118 in the first assessment and 1.0 in the second assessment. Conclusion: after the integrative literature review, the material was constructed and validated by professionals with experience in evaluating and treating individuals with wounds, obtaining consensus among the evaluators in the second evaluation.

Desenvolvimento de um material educativo para a prevenção e o tratamento das lesões por fricção

Objetivo: desenvolver e validar uma cartilha educativa para ajudar o profissional da saúde a prevenir e tratar da lesão por fricção. Método: estudo metodológico. Foi realizada revisão integrativa da literatura dos periódicos publicados entre 2009 e 2019 nas principais bases de dados de Ciências da Saúde. A avaliação da cartilha educativa foi conduzida com 32 enfermeiros, utilizando a técnica de Delphi. A análise estatística utilizada foi o Índice de Validade de Conteúdo. Resultados: os juízes consideraram o conteúdo da cartilha educativa entre os conceitos “inadequado” e “adequado”, na primeira avaliação; após as correções solicitadas pelos juízes, a cartilha foi reenviada aos avaliadores e o conteúdo da cartilha educativa foi avaliado entre “adequado” e “totalmente adequado”. O Índice de Validade de Conteúdo geral foi de 0,8118 na primeira avaliação e 1,0 na segunda avaliação. Conclusão: após a revisão integrativa da literatura, o material foi construído e validado por profissionais com experiência em avaliar e tratar de indivíduos com feridas, obtendo consenso entre os avaliadores na segunda avaliação.

ISTAP classification for skin tears: Validation for Brazilian Portuguese

The objective of this study was to evaluate interobserver reliability and the concurrent criterion validity of the adapted version of the International Skin Tear Advisory Panel (ISTAP) Skin Tear Classification System to Brazilian Portuguese. For the evaluation of interobserver reliability using the photograph database, 36 nurses classified 30 skin tears (STs) into three groups, according to its definitions (adapted version). For the evaluation through clinical application, 23 nurses classified 12 STs present in 8 thoracic and cardiovascular postoperative patients at a tertiary hospital in Sao Paulo, Brazil. For the data collection of patients, an enterostomal therapist nurse classified the ST found by simultaneously using the adapted ISTAP version and the Skin Tear Audit Research (STAR) Classification System to test the concurrent criterion validity. The average of 17.83 correct answers (SD = 5.03) resulted from 1080 photograph observations, with Fleiss κ = 0.279 (reasonable concordance level). The interobserver reliability in the clinical application resulted in a global correct answer percentage of 76.7% in 85 observations. The concurrent criterion validity was attested by the total correlation (r = 1) between ISTAP and STAR. The ISTAP classification for ST is a reliable instrument and also valid in Brazil, making it another option to be used in clinical practice.

Models for predicting skin tears: A comparison

A recently published model that predicted the risk of skin tears in older adults was compared with seven additional published models. Four models were excluded because of limitations in research design. Four models were compared for their relative predictive performance and accuracy using sensitivity, specificity, and the area under the curve (AUC), which involved using receiver-operating characteristic analysis. The predictive ability of the skin tear models differed with the AUC ranging between 0.673 and 0.854. Based on the predictive ability, the selection of models could lead to different clinical decisions and health outcomes. The model, which had been adjusted for potential confounders consisted of five variables (male gender, history of skin tears, history of falls, clinical skin manifestations of elastosis, and purpura), was found to be the most parsimonious for predicting skin tears in older adults (AUC 0.854; 81.7% sensitivity; 81.4% specificity). Effective models serve as important clinical tools for identifying older individuals at risk of skin tears and can better direct more timely and targeted prevention strategies that improve health outcomes and reduce health care expenditure.

Exploring the prevalence and management of wounds for people with dementia in long-term care

The prevalence of wounds and comorbidities such as dementia increase with age. With an ageing population, the likelihood of overlap of these conditions is strong. This study aimed to determine the prevalence of wound types and current management strategies of wound care for people with dementia in long-term care (LTC). A scoping literature review, a cross-sectional observational and chart audit study of residents in dementia specific facilities in LTC were conducted. The scoping review indicated that people with dementia/cognitive impairment are often excluded from wound related studies andof the nine studies included in this review, none looked at the prevalence of types of wounds other then pressure injuries. In the skin audit, skin tears were noted as the most common wound type with some evidence-based practice strategies in place for residents. However, documentation of current wound occurred in less than a third of residents with wounds. This is the first study to note the prevalence of different wound types in people with dementia and current management strategies being used across two dementia-specific facilities and a lack of research in this area limits evidence in guiding practice.

Clinical purpura and elastosis and their correlation with skin tears in an aged population

The previous research reported the results of a prospect cohort study that used logistic regression analysis to construct a risk prediction model for skin tears in individuals aged over 65 years. The model identified three baseline individual characteristics (male gender, history of STs, and history of falls) and two baseline skin manifestations (purpura and elastosis) that predicted the risk of dorsal forearm skin tears. This paper outlines the relationships between baseline skin manifestations and the risk of skin tears. Univariable logistic regression analysis was conducted of all the baseline data collected from the same-study participants to identify variables that significantly predicted purpura and elastosis at baseline. Amongst the 173 participants, 71 (41%) developed one or more skin tears, and in these participants, 52 (73.2%) displayed purpura, 41 (57.8%) had elastosis, and 30 (42.3%) exhibited both manifestations of the dorsal forearm at baseline. Four individual characteristics (age, history of skin tears, history of falls, and antiplatelet therapy) and three skin properties (pH, subepidermal low echogenicity band of the forearms, and skin thickness) were found to predict the risk of purpura. Conversely, three individual variables (age, gender, and smoking), three clinical skin variables (uneven skin pigmentation, cutis rhomboidalis nuchae, and history of actinic keratosis) and one skin property variable (collagen type IV) predicted the risk of skin elastosis. Progressive changes to the skin's structural and mechanical properties from the underlying effects of chronological ageing, and environmental and lifestyle-related influences increased the risk of purpura and elastotic skin manifestations and concomitantly increased risk of skin tears amongst participants.

A risk model for the prediction of skin tears in aged care residents: A prospective cohort study

The objective of this study was to construct a predictive model to identify aged care residents at risk of future skin tears. Extensive data about individual characteristics, skin characteristics, and skin properties were gathered from 173 participants at baseline and at 6 months. A predictive model, developed using multivariable logistic regression, identified five variables that significantly predicted the risk of skin tear at 6 months. These included: a history of skin tears in the previous 12 months (OR 3.82 [1.64-8.90], P = 0.002), purpura ≤20 mm in size (OR 3.64 [1.42-9.35], P = 0.007), a history of falls in the previous 3 months (OR 3.37 [1.54-7.41], P = 0.002), clinical manifestations of elastosis (OR 3.19 [1.38-7.38], P = 0.007), and male gender (OR 3.08 [1.22-7.77], P = 0.017). The predictive model yielded an area under the receiver operating characteristic curve of 0.854 with an 81.7% sensitivity and an 81.4% specificity. This predictive model could inform a simple but promising bedside tool for identifying older individuals at risk of skin tears.