Early identification of pressure injuries in people with dark skin tones: Qualitative perspectives from community-based patients and their carers

AIM

To examine the personal experiences and perceptions of people with dark skin tones and their carers, in relation to pressure injury.

DESIGN

Qualitative study using semi-structured interviews.

METHODS

Twenty-two interviews with people with dark skin tone and/or their family carers, who were known to and visited by community nurses for pressure area management or who had been identified as being at high risk for developing a pressure injury were carried out.

RESULTS

Thematic analysis of the interview transcripts revealed that skin discolouration towards a darker hue than usual was the commonest symptom identified by participants as a sign of altered skin integrity and potential pressure damage. Four main overarching themes were revealed through comprehensive analysis of the transcripts: (1) indicators of pressure injury; (2) experienced symptoms of pressure damage; (3) trust in healthcare workers; and (4) improving care for populations with dark skin tones.

CONCLUSION

The findings from this study clearly present how early-stage pressure damage is identified among people with dark skin tones.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

These findings have the potential to reduce health inequality by influencing and informing clinical policies and strategies in practice. Findings could also lead to the development of patient-informed educational strategies for nurses and health workers which will enable the early identification of pressure ulcers among people with dark skin tones. Further research is needed to better understand health disparities in relation to preventable patient safety harm.

IMPACT

The findings demonstrate the importance of engaging with and listening to the stories and experiences of people living with pressure damage to help in the early recognition of pressure injuries.

REPORTING METHOD

The Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines for qualitative research were followed.

PATIENT OR PUBLIC CONTRIBUTION

A project steering group reviewed information sheets for participants and checked the interview questions were relevant and suitable.

The correlation between sub-epidermal moisture assessment and other early indicators of pressure ulcer development: A prospective cohort observational study. Part 2. The correlation between sub-epidermal moisture assessment, temperature, epidermal hydration and pain

There is growing interest in the roles of temperature, epidermal hydration (EH) and pain in pressure ulcer (PU) development. Investigating correlations between these measures and sub-epidermal moisture (SEM) will address this knowledge deficit. A prospective observational study enrolled 60 surgical patients from February to November 2021. SEM, temperature, EH and pain were assessed using a SEM scanner, thermography imaging, skin hydration device and numeric pain intensity scale, respectively. Measurements were taken at the sacrum, both heels and a control site, before and after surgery for 3 days. Data were analysed using Pearson or Spearman's correlation. Of the participants, 50% were male with a mean age of 58 years (±13.46). Low positive/negative correlations between SEM and temperature were found at the sacrum. However, after removing outliers, these results were not statistically significant. Other sites and follow-up days showed negligible correlations. No evidence of a correlation, to low correlations between SEM and EH were observed, but unreliable due to little variation in EH at the heels. Pain showed negligible correlations with SEM. This study did not find consistent evidence of a correlation between SEM, temperature, EH and pain, highlighting the unreliability of temperature and EH for early PU detection. Post-operative pain may also confound accurate pain assessments.

Integrating technologies to enhance risk assessment for the early detection and prevention of pressure ulcers

Pressure ulcers (PU) are a globally recognised healthcare concern, with their largely preventable development prompting the implementation of targeted preventive strategies. Risk assessment is the first step to planning individualised preventive measures. However, despite the long use of risk assessment, and the >70 risk assessment tools currently available, PUs remain a significant concern. Various technological advancements, including artificial intelligence, subepidermal moisture measurement, cytokine measurement, thermography and ultrasound are emerging as promising tools for PU detection, and subsequent prevention of more serious PU damage. Given the rise in availability of these technologies, this advances the question of whether our current approaches to PU prevention can be enhanced with the use of technology. This article delves into these technologies, suggesting that they could lead healthcare in the right direction, toward optimal assessment and adoption of focused prevention strategies.

Prevalence and incidence of pressure injuries among nursing home residents with darker skin tones: A prospective cohort study

AIM

To measure the prevalence and incidence of nursing home-acquired pressure injuries in older adults residing in Sri Lankan nursing homes.

BACKGROUND

Pressure injury prevalence and incidence are indicators of safety and quality of care. A significant portion of the global population has a skin color dominated by the presence of melanin. Yet, the number of nursing home residents with darker skin tones who develop pressure injuries in nursing homes is relatively unknown.

DESIGN

Prospective multisite cohort study conducted in nine nursing homes in Sri Lanka. The sample comprised 210 residents aged ≥60 years old.

METHODS

Semi structured observations and chart audits were used to gather data from July to October 2023. Head-to-toe visual skin assessment to check for nursing home- acquired pressure injuries, Braden pressure injury risk scale and Fitzpatrick skin tone assessments were conducted on all recruited residents at baseline. All recruited residents were followed-up weekly for 12 weeks until detection of a new pressure injury, death, discharge, or transfer.

RESULTS

Pressure injury point prevalence at baseline was 8.1% (17/210). Cumulative incidence was 17.1% (36/210). Incidence density was 15.8 per 1000 resident weeks. Most nursing home-acquired pressure injuries were located on the ankle at baseline (29.4%; 5/17) and in the follow-up period (27.8%; 10/36). Stage I pressure injuries were most common: 58.8% (10/17) and 44.4% (16/36) at baseline and during follow-up respectively.

CONCLUSIONS

About one in six nursing home residents developed a new pressure injury over the 12-week follow-up period. Despite staff and resource constraints, there remains a need to focus on the prevention of pressure injuries in Sri Lankan nursing homes.

CLINICAL RELEVANCE

Studies on the burden of pressure injuries among darker skin tone nursing home residents are lacking and the current evidence available are predominantly from Western countries. The findings of this study highlight the need of targeted preventive measures for nursing home residents with darker skin tones.

Trends in inpatient burden from pressure injuries in the United States: Cross-sectional study National Inpatient Sample 2009-2019

Pressure injuries are a significant comorbidity and lead to increased overall healthcare costs. Several European and global studies have assessed the burden of pressure injuries; however, no comprehensive analysis has been completed in the United States. In this study, we investigated the trends in the burden of pressure injuries among hospitalised adults in the United States from 2009 to 2019, stratified by sociodemographic subgroups. The length of admission, total cost of hospitalisation, and sociodemographic data was extracted from the National Inpatient Sample provided by the Healthcare Cost and Utilisation Project, Agency for Healthcare Research and Quality. Overall, the annual prevalence of pressure injuries and annual mean hospitalisation cost increased ($69,499.29 to $102,939.14), while annual mean length of stay decreased (11.14-9.90 days). Among all races, minority groups had higher average cost and length of hospitalisation. Our findings suggest that while the length of hospitalisation is decreasing, hospital costs and prevalence are rising. In addition, differing trends among racial groups exist with decreasing prevalence in White patients. Further studies and targeted interventions are needed to address these differences, as well as discrepancies in racial groups.

Shedding new light for nurses: Enhancing pressure injury prevention across skin tones with sub-epidermal moisture assessment technology

AIM(S)

To assess the effectiveness of sub-epidermal moisture (SEM) assessment technology in the detection of early-stage pressure damage in a critical care unit (CCU) and dark skin tone patients and its impact on hospital-acquired pressure injury (HAPI) incidence.

DESIGN

Quality improvement study employing Kurt Lewin's change model emphasizing planning, implementation, evaluation and sustainable change.

METHODS

The study evaluated 140 adult patients admitted to the CCU over a 24-week period, from July to December 2022. Retrospective analysis of standard PI care pathways was performed in 90 patients admitted during a 12-week pre-implementation period. Fifty patients were admitted through the subsequent 12-week implementation period. SEM assessments were performed daily at the sacrum and heels and interventions were applied based on SEM assessments; SEM delta ≥0.6 indicating localized oedema or persistent focal oedema. Statistical analyses were performed on anonymized data.

RESULTS

Pre-implementation HAPI incidence was 8.9% (N = 8/90). All eight patients were African American with varying skin tones. A 100% reduction in HAPI incidence was achieved in the implementation period which included 35 African American patients. The relative risk of HAPI incidence was 1.6 times higher in the pre-implementation group.

CONCLUSION

Implementing SEM assessment technology enabled equitable PI care for all population types and resulted in a 100% reduction of PIs in our CCU. Objective SEM assessments detected early-stage PIs, regardless of skin tone and enabled providing interventions to specific anatomies developing tissue damage as opposed to universal preventive interventions.

IMPLICATIONS

PI care pathways relying on visual and tactile skin assessments are inherently biased in providing equitable care for dark skin tone patients. Implementing SEM assessments empowers healthcare practitioners in driving objective clinical interventions, eliminates bias and enables positive PI health outcomes.

IMPACT

Implementing SEM assessment technology had three main effects: it detected early tissue damage regardless of skin tone (detection effect), enabled anatomy-specific interventions (treatment effect) and prevented PIs across all population types (prevention effect). The authors have adhered to the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution. What does this paper contribute to the wider global clinical community? Addressing health inequities in pressure injury prevention; Demonstrated effectiveness across patient populations; Resource optimization and enhanced patient safety.

A systematic review on the impact of sub-epidermal moisture assessments on pressure ulcer/injury care delivery pathways

To assess all published studies which describe what happens to the delivery of pressure ulcer/injury (PI/PU) care pathways as a result of detecting raised sub-epidermal moisture (SEM) delta (∆ ≥ 0.6). We undertook a systematic review of the literature, and included original research studies using either a prospective or retrospective study design that report the impact that assessment using SEM assessments have on healthcare practitioners' delivery of PI/PU care pathways in adults at risk of developing PI/PUs. The review protocol was registered on PROSPERO (CRD42023416975). A literature search was conducted in May 2023, using PubMed, CINAHL, Scopus, Cochrane, EMBASE, Web of Science and Science Direct databases. Data were extracted using a data extraction tool including elements such as country, setting, sample size, intervention, control and quality appraisal was undertaken using the Evidence-based Librarianship. We identified nine papers published between 2017 and 2022. The majority of these studies were conducted in England (n = 6; 67%). The systematic review included studies conducted across multiple care settings including acute care, medical-surgical units, and palliative care, highlighting the importance of PI/PU prevention and management across diverse patient populations. The PI/PU care pathways implemented in the studies varied, but commonly included elements such as the application or increased use of pressure-redistributing mattresses/cushions, implementation of repositioning plans, management of incontinence and moisture, regular skin inspection, and assessment of patient mobility. Out of the nine studies identified, seven reported PI/PU incidence. A meta-analysis of seven studies (N = 18 451) demonstrated a statistically significant reduction in visual PI/PU development in favour of SEM-guided care pathways compared to usual care (the odds ratio = 0.36 [95% confidence interval: 0.24-0.53, p < 0.00001]). This systematic review provides evidence that implementing SEM assessments in patients at risk of developing PI/PUs prompts anatomy-specific clinical actions. The subsequent implementation of enhanced and targeted skin care interventions leads to consistent and sustained reductions in hospital-acquired PU incidence. The findings emphasise the importance of incorporating SEM assessments as part of comprehensive PI/PU prevention strategies in all care settings and patient populations. This systematic review is limited by the predominance of observational studies and variable study quality. Future research should focus on randomised trials in different care settings that monitor the efficacy of preventive interventions and their impact in reducing PI/PU incidence when implemented based on SEM assessments.

Understanding therapeutic radiographers' confidence in assessing, managing & teaching radiation induced skin reactions (RISR): A national survey in the UK

INTRODUCTION

The standard toxicity tools adopted for assessing Radiation Induced Skin Reactions (RISR) do not currently reflect how skin changes occur across all skin tones. A one size fits all approach is adopted currently for RISR assessment. The aim of this study was to understand what evidence-based practice and RISR tools are being used across the therapeutic radiography workforce and the levels of confidence in using these tools.

METHODS

A survey using Likert scales to assess confidence in RISR assessment and management was made available to 77 departments in the UK between August-November 2021. Descriptive statistics were used to understand respondents' confidence in assessing, managing, and teaching RISR between white, brown, and black skin tones; Fisher's exact test was used to assess the significance of differences between groups.

RESULTS

Complete responses were received from 406 therapeutic radiographers. Radiation Therapy Oncology Group (RTOG) was the most used RISR assessment tool (58% of respondents n = 237). Most respondents (74.2% n = 303) reported use of locally produced patient information on skin care, rather than the Society and College of Radiographers evidence-based patient leaflets. Confidence in assessing and managing RISR in white skin was higher than that in brown and black skin. Similarly, confidence was higher in teaching of appropriate RISR assessment and management in white skin tones when compared to brown and black skin.

CONCLUSION

White skin tones appear to be more confidently assessed and managed for RISR along with taught appropriate assessment and management, than brown and black skin tones in the sample of the workforce that responded.

IMPLICATIONS FOR PRACTICE

A greater understanding of the reasons for these differences is required but this study aims to instigate change and positive growth within this area.

Hematologic and Serum Biochemical Values Associated With Different Stages of Hospital-Acquired Pressure Injuries in Patients: A Retrospective Study

PURPOSE

The primary purpose of this study was to determine whether hematologic and serum biochemical values used as indicators of nutritional status, anemia, and/or infection were associated with the risk of hospital-acquired pressure injuries (PIs) and stage of PIs in patients.

DESIGN

A retrospective review of medical records.

SUBJECTS AND SETTING

Data were collected from medical records including official PI records and PI incident reports of inpatients at a teaching hospital in Taiwan between January 2019 and October 2020.

METHODS

We collected demographic variables of the inpatients and their hematologic and serum biochemical values within 1 day of PI occurrence (including the day of PI occurrence), 6 to 7 days before PI occurrence, and 13 to 14 days before PI occurrence.

RESULTS

Among the 309 inpatients with official PI records, 105 (34.0%) had Stage 1 PIs, 131 (42.4%) had Stage 2 or 3 PIs, and 73 (23.6%) had unstageable or suspected deep tissue injuries. After controlling for the type of department where PIs occurred and length of hospital stay up to the day of PI occurrence, we found significant differences in levels of hemoglobin (odds ratio [OR] = 0.47, P = .009) within 1 day of PI occurrence and in albumin (OR = 0.30, P = .001) 13 to 14 days before PI occurrence.

CONCLUSIONS

Study findings suggest that lower hemoglobin levels on the day of PI occurrence and lower albumin levels 2 weeks before PI occurrence resulted in a significantly higher risk of developing unstageable or suspected deep tissue injuries than of developing Stage 1 PIs.

Differences of bioelectrical impedance in the development and healing phase of pressure ulcers and erythema in mouse model

Pressure ulcers (PUs) are economically burdensome medical conditions. Early changes in pressure ulcers are associated with erythema. In this study, bioelectrical impedance was used to measure the differences between PUs and blanchable erythema. We divided 21 ICR mice into three groups: control, 1000 mmHg-1h, and 1000 mmHg-6h. Healthy skin, blanchable erythema, and PUs were induced on the dorsal skin. The results indicated an immediate increase in impedance, resistance, and reactance values in the pressure group after release, followed by a subsequent decrease until two days after release. Compared with the control group, impedance and reactance significantly increased by 30.9% (p < 0.05) and 30.1% (p < 0.01), respectively, in the 6 h-loading group immediately after release. One and two days after release, the 1 h-loading and 6 h-loading groups exhibited significantly different degrees of decline. One day after release, impedance and resistance decreased by 30.2% (p < 0.05) and 19.8% (p < 0.05), respectively, in the 1 h-loading group; while impedance, resistance, and reactance decreased by 39.2% (p < 0.01), 26.8% (p < 0.01), and 45.7% (p < 0.05), respectively, in the 6 h-loading group. Two days after release, in the 1 h-loading group, impedance and resistance decreased by 28.3% (p < 0.05) and 21.7% (p < 0.05), respectively; while in the 6 h-loading group, impedance, resistance, and reactance decreased by 49.8% (p < 0.001), 34.2% (p < 0.001), and 59.8% (p < 0.01), respectively. One and two days after release the pressure group reductions were significantly greater than those in the control group. Additionally, we monitored changes during wound healing. Distinguishing early PUs from blanchable erythema by noninvasive bioelectrical impedance technology may have applications value in early assessment of PUs.

What influences the inclusion of skin tone diversity when teaching skin assessment? Findings from a survey

BACKGROUND

Understanding the variances in visual skin changes across all skin tones is important in clinical care. However, the experiences of those teaching skin assessment to pre- and post-registrant nurses are unknown.

AIMS

To determine the barriers and facilitators experienced in teaching skin assessment across a range of skin tones to pre- and post-registrant nurses.

METHODS

A cross-sectional, mixed-methods online survey was undertaken throughout February and March 2023 based on the Theoretical Domains Framework of behaviour change.

FINDINGS

In this self-selecting sample, most participants were aware of why it was important to include all skin tones when teaching skin assessment and were professionally motivated to include this in their practice. However, resources and support are needed to overcome an unconscious bias in teaching skin tone diversity, resulting in a lack of availability of good quality photographs and educator confidence in their own skills. Educators not considering skin tone when selecting patient cases and relying on people with dark skin tones to highlight where practice is not inclusive may also lead to insufficient exposure for students.

CONCLUSION

There is some awareness of the importance of including diverse skin tones in teaching, but further education and resources are needed.

Integrating factors associated with complex wound healing into a mobile application: Findings from a cohort study

Complex, chronic or hard-to-heal wounds are a prevalent health problem worldwide, with significant physical, psychological and social consequences. This study aims to identify factors associated with the healing process of these wounds and develop a mobile application for wound care that incorporates these factors. A prospective multicentre cohort study was conducted in nine health units in Portugal, involving data collection through a mobile application by nurses from April to October 2022. The study followed 46 patients with 57 wounds for up to 5 weeks, conducting six evaluations. Healing time was the main outcome measure, analysed using the Mann-Whitney test and three Cox regression models to calculate risk ratios. The study sample comprised various wound types, with pressure ulcers being the most common (61.4%), followed by venous leg ulcers (17.5%) and diabetic foot ulcers (8.8%). Factors that were found to impair the wound healing process included chronic kidney disease (U = 13.50; p = 0.046), obesity (U = 18.0; p = 0.021), non-adherence to treatment (U = 1.0; p = 0.029) and interference of the wound with daily routines (U = 11.0; p = 0.028). Risk factors for delayed healing over time were identified as bone involvement (RR 3.91; p < 0.001), presence of odour (RR 3.36; p = 0.007), presence of neuropathy (RR 2.49; p = 0.002), use of anti-inflammatory drugs (RR 2.45; p = 0.011), stalled wound (RR 2.26; p = 0.022), greater width (RR 2.03; p = 0.002), greater depth (RR 1.72; p = 0.036) and a high score on the healing scale (RR 1.21; p = 0.001). Integrating the identified risk factors for delayed healing into the assessment of patients and incorporating them into a mobile application can enhance decision-making in wound care.

Detecting Early-Stage Pressure Injury in Patients With Dark Skin Tones Using an Enhanced Physical Assessment Technique and Halogen Lighting

PURPOSE

The purpose of this quality improvement project was to identify stage 1 pressure injuries (PIs) in patients with darker skin tones using an enhanced skin assessment (Skin Assessment for Dark Skin, SADS) and halogen lighting.

PARTICIPANTS AND SETTING

This quality improvement project was conducted on 3 units at a large university teaching hospital in Southeast Michigan. The project was originally designed so that participating patients were identified by bedside nurses as having sufficient melanin to obscure blanching on the hand/forearm using regular lighting, but this goal was not met. Data analysis is based on patients who self-identified as African American or Black, Native Hawaiian or Pacific Islander, Asian, American Indian, and Native Alaskan. Bedside nurses participating in this project were also asked to complete a questionnaire describing their knowledge and experiences with this project and assessment of early-stage PI in patients with darker skin tones.

APPROACH

The Iowa Model of Evidence-Based Practice was used to guide this quality improvement initiative. Following a trigger event, we reviewed pertinent literature and developed an enhanced technique for assessing patients with darker skin tones that involved use of halogen lighting (SADS) and documentation of findings. We selected units from our facility and taught nurses to apply the SADS approach. Data from the electronic medical record and a survey of participating nurses were used to compare findings before and after project implementation. Comparisons were based on descriptive data analysis.

OUTCOMES

Following implementation of the enhanced physical assessment, the participating units experienced a 6% decrease in the total number of facility-acquired PIs during the implementation period.

IMPLICATIONS FOR PRACTICE

The enhanced physical assessment, when paired with halogen lighting, enhanced identification of stage 1 PI in persons with dark skin. The assessment method was easy to teach, learn, and can be performed at the bedside as part of a shift assessment which routinely includes inspection of skin.

Structural racism in radiation induced skin reaction toxicity scoring

Racially motivated biases are often implicit and can go unnoticed, especially if your normal is white and adjustments are required to cater for 'others.' Current consent forms and grading tools within radiotherapy are not inclusive of all skin tones. This commentary highlights gaps in care within radiation induced skin reactions (RISR) assessment for people of colour. Healthcare professionals and patients are directed to look for visual cues such as redness for RISR, but this is not always visible on people with pigmented skin. Their skin may go darker than their normal or changes across the colour spectrum. The lack of understanding of these fundamental differences are leading to people of colour being oppressed through structural racism and racialised myths. Using inclusive terminology will allow for moving away from the current view of healthcare that white skin is the norm. People of colour deserve more than are currently offered in RISR toxicity assessment.

Validation of a sub-epidermal moisture scanner for early detection of pressure ulcers in an ex vivo porcine model of localized oedema

Pressure ulcers (PUs) remain a chronic health problem with severe impacts on healthcare systems. Early detection is crucial to providing effective interventions. However, detecting PUs currently relies on subjective tissue evaluations, such as visual skin assessment, precluding interventions prior to the development of visible tissue damage. There is an unmet need for solutions that can detect early tissue damage before visual and tactile signs occur. Assessments based on sub-epidermal moisture (SEM) measurements represent an opportunity for robust and objective early detection of PUs, preventing broken skin PUs in more high-risk patients at high-risk anatomical locations. While SEM assessment technology has been validated in computational, bench and tissue phantom models, validation in soft tissue was absent. In this study, we successfully validated the ability of a commercially available SEM assessment device to measure and detect sub-epidermal moisture changes in a novel ex vivo porcine soft tissue model of localised oedema. When controlled and incremental fluid volumes (Phosphate Buffer Solution) were injected into porcine soft tissues, statistically significant differences were found in SEM values between fluid-injected sites, representing an inflammatory oedematous condition, and healthy tissue control sites, as measured by the SEM device. The device provided reproducible readings by detecting localised oedema changes in soft tissues, reflecting the build-up of fluid as small as 1 ml into the underlying tissue. Spatial characterization experiments described the ability of the device technology to differentiate between healthy and oedematous tissue. Our findings validate the use of SEM assessment technology to measure and quantify localized oedema.

Representation of dark skin tones in foundational nursing textbooks: An image analysis

PURPOSE

This study aimed to analyze and quantify the representation of dark skin tones (DST) images/graphics across fifteen foundational and clinical nursing textbooks to understand the degree of portrayed diversity in current nursing texts.

BACKGROUND

The United States (U.S.) population is becoming more ethnically and racially diverse. There is a scarcity of nursing literature, studies, and educational materials on the assessment and early recognition of common skin assessment in patients with dark skin tones (DST). The underrepresentation of people with DST images in didactic material suggests that omissions of these images in educational resources may introduce bias in health care provider education and practice.

METHODS

Fifteen popular foundational and clinical nursing textbooks were selected and analyzed. All the photo images and drawn graphics in these textbooks were coded according to Fitzpatrick's skin phototype (FSP) scale, which categorizes skin tone as (a) "Light" or Fitzpatrick scale I or II, (b) "Medium" or Fitzpatrick scale III or IV, and (c) "Dark" or Fitzpatrick scale V or VI. The training was provided for data collectors before analysis to ascertain good inter-rater reliability (Cohen's kappa = 0.960 for light skin tone, Cohen's kappa = 0.899 for medium skin tone, and Cohen's kappa = 0.913 for dark skin tone).

RESULTS

Analysis of 14,192 photo images and drawn graphics depicting skin tone was completed across 15 foundational and clinical nursing textbooks. 12.3 % of photo images and 2.4 % of drawn graphics depicted dark skin tones, compared to 60.9 % of photo images and 82.8 % of drawn graphics that displayed light skin tones in these textbooks.

CONCLUSIONS

Nursing textbooks overrepresent light skin tones and underrepresent dark skin tones. While the approximate racial distribution of the U.S. population is 59.3 % non-Hispanic-White, 13.6 % Black/African American, and 26.6 % Person of Color, the images and graphics of skin tones represented 68 % light, 15 % medium, and 9.4 % dark.

RELEVANCE TO CLINICAL PRACTICE

All healthcare providers are expected and required to deliver competent clinical care to an increasingly diverse population. For teaching-learning, more visual representations of DST and comparative images between what to expect in dark, medium, and light skin tones can help improve knowledge deficits and increase health equity.

Using Technology to Detect Erythema Across Skin Tones

OBJECTIVE

To examine the effectiveness of the ColorMeter DSM III (ColorMeter; Cortex Technology) at grouping individuals by skin tone and measuring erythema/skin discoloration after erythema induction across skin tones.

METHODS

This pre/post experimental study induced erythema on a convenience sample of 61 healthy adults. Skin tone at baseline was measured using the ColorMeter, Munsell Soil Color Chart 5YR (Munsell), and Pantone SkinTone Guide (Pantone) and compared with the Eumelanin Human Skin Colour Scale (Eumelanin Scale) groupings. Erythema and melanin values on the arm immediately and after recovery time were compared with baseline values. Melanin was measured at five body regions on the face and arm.

RESULTS

Participants were predominantly women (64% [n = 39] women, 36% [n = 22] men) and young (mean, 28.8 ± 14.3 years); 5% (n = 3) were Hispanic, 26% (n = 16) Asian, 29% (n = 18) Black, 38% (n = 23) White, and 7% (n = 4) identified with more than one race. ColorMeter lightness (L*) and melanin measures were strongly correlated with both Munsell and Pantone values. Munsell skin tone groups were not aligned with Eumelanin Scale groupings. Most participants were in the Eumelanin intermediate-low group, and this changed depending on which body location melanin value was used. The change in erythema from baseline did not differ significantly across skin tone groups at the ulnar head, but on the forearm at the delayed time point, significant differences existed between light and both medium and dark skin tone groups (P = .001; 95% CI, 0.04-0.37).

CONCLUSIONS

The ColorMeter provides an effective objective measure of skin tone and erythema/discoloration across various skin tones and may improve on current standards for detection. The proposed Eumelanin Scale-Modified provides additional sensitivity for persons with medium skin tones.

A Novel Method to Determine Patient Skin Type: The Skin Analyzer

Measuring skin color for medical research in an objective and nonbiased manner usually requires expensive equipment such as spectrophotometry and requires the subject to be present in person. We present a novel method to measure skin color from photographs using the Skin Analyzer application as a more effective, accessible, and efficient alternative. A desktop application, the Skin Analyzer, was developed to convert skin samples collected from digital images to the L*a*b color space and uses those values to calculate an individual typology angle that correlates to a Fitzpatrick skin type. To assess accuracy in variable lighting, six known colors representing the six Fitzpatrick skin types were printed and photographed in 15 separate locations within the hospital. To account for user variability in sample selection, interrater reliability was calculated with data generated by 13 untrained users testing the app on six subjects. The accuracy of measuring known values, which is the classification accuracy, was calculated to be 80%. Krippendorff alpha test was used to evaluate interrater reliability. The obtained alpha of 0.84 indicates a high interrater reliability. The high accuracy and reliability make the Skin Analyzer a suitable method of objectively determining Fitzpatrick skin type from images. The app may be used to investigate the effects of skin tone in various areas of interest, especially in retrospective studies where skin colorimeters cannot be used.

Nutrition association with skin integrity and pressure injury in critically ill pediatric patients

BACKGROUND

Current research highlights the positive impact of nutrition therapy, particularly enteral nutrition, in critical illness. However, little attention is given to the impact of nutrition on skin integrity during critical illness. Skin integrity is at risk in critically ill children owing to necessary clinical therapies and challenges of providing nutrition therapy.

METHODS

We conducted a narrative literature review with three main thematic concepts to drive our literature search: the association of nutrition therapy with (1) skin integrity; (2) injury, wounds, and wound healing; and (3) differences of skin color. Using pertinent search and subject terms, PubMed, CINAHL, EMBASE, and SCOPUS databases were searched, yielding 316 articles. After removal of duplicates, articles were reviewed based on inclusion and exclusion criteria defined by the authors; only eight articles met the defined criteria to inform this review.

RESULTS

Large and important gaps exist in the current literature regarding an association between nutrition therapy, skin injury, and wound healing. Little to no attention was found for associations with skin color. The resulting narrative review addresses these topics and subtopics with additional references included that are independent of the original search strategy.

CONCLUSIONS

A dearth of evidence exists describing associations between nutrition and disruption of skin integrity in pediatric critical illness. Children with dark skin are at increased risk, as manifestation and identification of disruption to skin integrity may not be recognized. Research is needed to describe these associations and the impact of nutrition on skin integrity, including differences of skin color.

Modelling the cost-effectiveness of subepidermal moisture measurement as part of a process of assessment and intervention to prevent hospital-acquired pressure ulcers

Skin tissue assessment is traditionally used to identify early signs of pressure damage from changes observed at the skin surface. However, the early onset of tissue damage induced by pressure and shear forces is likely to be on soft tissues beneath the surface of the skin. Subepidermal moisture (SEM) is a biophysical marker for the detection of early and deep pressure-induced tissue damage. Measurement of SEM can detect early pressure ulcers up to 5 days before visible skin changes occur. The aim of this study was to evaluate the cost-effectiveness of SEM measurement compared with visual skin assessment (VSA). A decision-tree model was developed. Outcomes are the incidence of hospital-acquired pressure ulcers, quality-adjusted life-years (QALYs) and costs to the UK National Health Service. Costs are at 2020/21 prices. The effects of parameter uncertainty are tested in univariate and probabilistic sensitivity analysis. In a representative NHS acute hospital, the incremental cost of SEM assessment as an adjunct to VSA is -£8.99 per admission, and SEM assessment is expected to reduce the incidence of hospital-acquired pressure ulcers by 21.1%, reduce NHS costs and lead to a gain of 3.634 QALYs. The probability of cost-effectiveness at a threshold of £30 000 per quality-adjusted life year is 61.84%. Pathways that include SEM assessment make it possible to implement early and anatomy-specific interventions which have the potential to improve the effectiveness of pressure ulcer prevention and reduce healthcare costs.

Impact of race and ethnicity on length of stay, discharge location, and total charges for inpatients with skin ulcers in New York

BACKGROUND

Black patients receiving outpatient care for skin ulcers are less likely to see a physician and are at risk for higher stage pressure injuries. While racial/ethnic differences in outpatient treatment of skin ulcers have been described, this study aims to elucidate potential differences in the inpatient setting using publicly available data.

METHODS

We conducted a retrospective cohort study of the Statewide Planning and Research Cooperative System database, a de-identified, patient-level dataset for inpatient visits in New York between 2009 and 2021. Admissions were filtered by diagnosis-related group (APR-DRG) code 380 (skin ulcers).

RESULTS

Compared to non-Hispanic white patients, non-Hispanic black patients demonstrated longer mean LOS (8.15 vs. 7.48 days, p = 0.009), higher mean charges ($44,400 vs. $37,600, p < 0.001), and were more frequently discharged home without services (38.1% vs. 32.4%, p < 0.001). Black Hispanic patients had similar mean LOS (7.22 vs. 6.36 days, p = 0.133), similarly discharged home without services, and had higher mean charges ($45,800 vs. $36,700, p = 0.031). After adjusting for patient factors, non-Hispanic black patients had a longer LOS by 0.26 days (p = 0.028) with $2331 higher inpatient charges (p = 0.001) compared to non-Hispanic white patients.

CONCLUSIONS

The findings suggest racial and ethnic differences in hospitalizations for skin ulcers, with black patients experiencing greater LOS and charges. The reasons for these differences merit investigation, yet could be related to delays in outpatient care, more severe disease, presence of comorbid conditions, or complications requiring intensive inpatient services.

Inflammatory biomarkers in sebum for identifying skin damage in patients with a Stage I pressure ulcer in the pelvic region: A single centre observational, longitudinal cohort study with elderly patients

Pressure Ulcers (PU) are a major burden for affected patients and healthcare providers. Current detection methods involve visual assessments of the skin by healthcare professionals. This has been shown to be subjective and unreliable, with challenges associated with identifying erythema in darker colour skin. Although there exists a number of promising non-invasive biophysical techniques such as ultrasound, capacitance measurements, and thermography, the present study focuses on directly measuring the changes in the inflammatory status of the skin and underlying tissues. Therefore, in this study, we aim to analyse inflammatory cytokines collected through non-invasive sampling techniques to detect early signs of skin damage. Thirty hospitalised patients presenting with Stage I PU were recruited to evaluate the inflammatory response of skin at the site of damage and an adjacent healthy control site. Sebutapes were collected over three sessions to investigate the temporal changes in the inflammatory response. The panel of cytokines investigated included high-abundance cytokines, namely, IL-1α and IL-1RA, and low abundance cytokines; IL-6, IL-8, TNF-α, INF-γ, IL-33, IL-1β and G-CSF. Spatial and temporal differences between sites were assessed and thresholds were used to determine the sensitivity and specificity of each biomarker. The results suggest significant (P < .05) spatial changes in the inflammatory response, with upregulation of IL-1α, IL-8, and G-CSF as well as down-regulation of IL-1RA over the Stage I PU compared with the adjacent control site. There were no significant temporal differences between the three sessions. Selected cytokines, namely, IL-1α, IL-1RA, IL-8, G-CSF, and the ratio IL-1α/IL-1RA offered clear delineation in the classification of healthy and Stage-I PU skin sites, with receiver operating characteristic curves demonstrating high sensitivity and specificity. There were limited influences of intrinsic and extrinsic factors on the biomarker response. Inflammatory markers provided a high level of discrimination between the sites presenting with Stage I PU and an adjacent healthy skin site, in a cohort of elderly inpatients. Indeed, the ratio of IL-1α to IL-1RA provided the highest sensitivity and specificity, indicative that inflammatory homeostasis is affected at the PU site. There was a marginal influence of intrinsic and extrinsic factors, demonstrating the localised effects of the inflammation. Further studies are required to investigate the potential of inflammatory cytokines incorporated within Point of Care technologies, to support routine clinical use.

Sub epidermal moisture measurement and targeted SSKIN bundle interventions, a winning combination for the treatment of early pressure ulcer development

This study aimed to investigate the impact of sub epidermal moisture (SEM) measurement and targeted pressure ulcer (PU) prevention, versus visual skin assessment and usual care, on mean SEM delta scores and early pressure ulcer development in acute hospital patients. A quantitative quasi-experimental observational approach was used. A total of 149 at risk acute hospital patients took part, 78 treatment, and 71 control. SEM deltas were recorded daily for a maximum of 5 days using the SEM Scanner (Bruin Biometrics LLC, Los Angeles, California), on three sites: the sacrum, the right heel, and the left heel, with enhanced and targeted PU prevention interventions occurring in those with an elevated SEM delta scores in the treatment group. Intention to treat analysis was used to guide the final composition of results. SEM PU represents PU development as identified by 2 days of sustained abnormal SEM delta scores, ≥0.5, after day one. The mean number of days completed by participants was just under 4 days, participants had many different comorbidities, with the most common being: hypertension, cancer, and chronic obstructive pulmonary disease. Results showed that following the introduction of SEM guided targeted treatments, participants in the treatment group yielded a statistically significant reduction in mean SEM delta scores (MD: 0.49; 95% CI: 0.59, 0.39; P < .0001), and in the odds of developing a SEM PU (OR: 0.59, 95% CI: 0.24 to 1.00; P = .05). In the treatment group, none of the participants developed a visual PU, whereas, in the control group, 1.41% (n = 1/71) developed a visual PU. Based on all the results, the following is concluded, (1). There was a greater reduction in mean SEM delta scores among those cared for using SEM measurement and targeted PU prevention, versus those cared for using visual skin assessment and usual care, and (2). the mean SEM delta scores was statistically significantly lower at the study end for those who received targeted treatments based on abnormal SEM scores. More research is now needed in other and larger at-risk groups to further validate what was found in this study.

Assessment and Identification of Skin Disorders in Skin of Color: An Integrative Review

Skin assessment in patients with dark skin tones (DST) continues to be a challenge for many healthcare providers (HCP) because the visual cues are not always readily identified. For example, identification of early signs of pressure injury when subtle skin color changes are missed has the potential to cause harm and contribute to healthcare disparities. Appropriate wound management can begin only when the wound is correctly identified. For HCPs to identify early signs of skin conditions in DST patients, they must be provided education and effective tools enabling them to identify clinically relevant signs of skin damage in all patients. This article reviews basic anatomy of the skin; it focuses on differences seen in DST and reviews assessment strategies to assist the HCP to identify skin changes and conditions.

Skin Assessment in Patients with Dark Skin Tone

ABSTRACT

There is a scarcity of nursing literature, studies, and educational materials on the assessment and early recognition of both common and serious integumentary and general health issues in people with dark skin tones. Nurses must be exposed to such learning resources to be adequately prepared to care for patients with diverse skin tones and to help reduce health disparities and promote health equity. This article provides faculty, nursing students, and clinicians with basic information about the assessment of dark skin tone and calls for action in academia and professional practice to ensure nurses and nursing students can effectively perform skin assessments in all patients.

Accuracy of Thermographic Imaging in the Early Detection of Pressure Injury: A Systematic Review

OBJECTIVE

To verify the accuracy of thermographic images in the early detection of pressure injury (PI) in adult patients.

DATA SOURCES

Between March 2021 and May 2022, researchers searched 18 databases for relevant articles using nine keywords. In total, 755 studies were evaluated.

STUDY SELECTION

Eight studies were included in the review. Studies were included if they evaluated individuals older than 18 years who were admitted to any healthcare setting; were published in English, Spanish, or Portuguese; examined the accuracy of thermal imaging in the early detection of PI, including suspected stage 1 PI or deep tissue injury; and they compared the region of interest to another area or control group, or to the Braden Scale or Norton Scale. Animal studies and reviews, studies with contact infrared thermography, and those including stages 2, 3, 4, and unstageable PIs were excluded.

DATA EXTRACTION

Researchers examined sample characteristics and assessment measures related to image capture, including environmental, individual, and technical factors.

DATA SYNTHESIS

Across the included studies, sample sizes ranged from 67 to 349 participants, and patients were followed up for periods ranging from a single assessment up to 14 days, or until the appearance of a PI, discharge, or death. Evaluation with the infrared thermography identified temperature differentials between regions of interest and/or in comparison with risk assessment scales.

CONCLUSIONS

Evidence on the accuracy of thermographic imaging in the early detection of PI is limited.

Can technology change the status quo for pressure injury prevention?

Linked Article:  Jiang et al. Br J Dermatol 2022; 187:571–579.

Chronic wounds in persons living with dementia: An integrative review

BACKGROUND

Persons living with dementia (PLWD) are at risk for chronic wounds; however, they are rarely included in research.

OBJECTIVES

To inform practice and research directions, the aim of this integrative review was to identify and synthesise previous knowledge about the characteristics of chronic wounds in PLWD, in terms of chronic wound types, prevalence, setting and interventions.

DESIGN

A literature search was conducted for publications in English using PubMed, Web of Science and CINAHL. The minimum information required for inclusion was how many PLWD enrolled in the study had wounds.

METHODS

This integrative review followed the Whittemore and Knafl methodology. Data extraction and synthesis were guided by a directed content analysis, with a coding structure based on an initial review of the literature.

RESULTS

Thirty-six articles met the inclusion criteria. The majority were missing characteristics of PLWD including severity of dementia and race/ethnicity/nationality, and none mentioned skin tone. Most focused on pressure injuries in the nursing home and acute care setting. Few included information on interventions. Only one discussed challenges of wound care for a PLWD exhibiting aggression.

CONCLUSION

There is a gap in the literature regarding PLWD and chronic wounds other than pressure injuries that are common in older adults (e.g. diabetic foot ulcers, venous leg ulcers). Research is warranted among those PLWD who live alone and those who receive wound care from family caregivers to understand experiences. Knowledge can inform the development of future novel interventions for wound healing. Future research is needed regarding chronic wounds in those who exhibit behavioural and psychological symptoms of dementia.

RELEVANCE TO CLINICAL PRACTICE

Nurses that care for chronic wounds in PLWD can contribute their knowledge to include information in guidelines on best care practices and contribute their perspective to research teams for future research.

Pressure Injury Outcomes of a Prone-Positioning Protocol in Patients With COVID and ARDS

BACKGROUND

During the COVID-19 outbreak, standard methods for treating acute respiratory distress syndrome (ARDS) were used for patients presenting with ARDS. One such treatment method involves placing patients prone to improve oxygenation and reduce mortality risk. Challenges in preventing pressure injuries in patients placed prone have been reported, and no studies have explored the effects of including a certified wound and skin care nurse as part of the care team on the incidence of pressure injuries in SARS-CoV-2-infected patients with ARDS.

OBJECTIVES

To evaluate the association between including a certified wound and skin care nurse on a multiprofessional pronation team and prevention of pressure injuries in SARS-CoV-2-infected patients with ARDS.

METHODS

This multicenter observational cohort study used retrospective data from the electronic health record. The intervention group consisted of SARS-CoV-2-infected patients diagnosed with ARDS who were treated by a multidisciplinary prone-positioning team that included a certified wound and skin care nurse specialist. The comparison group of SARS-CoV-2-infected patients with ARDS was treated by a multidisciplinary prone-positioning team that did not include a certified wound and skin care nurse specialist.

RESULTS

As shown by multivariable logistic regression mixed-effect modeling, patients in the intervention group had a 97% lower adjusted odds ratio of a pressure injury developing than did patients in the comparison group (0.03 [95% CI, 0.01-0.14]; P < .001).

CONCLUSION

The inclusion of a certified wound and skin care nurse on a multiprofessional prone-positioning team significantly reduced the odds of pressure injuries developing in patients infected with SARS-CoV-2.

Pressure injuries and skin tone diversity in undergraduate nurse education: Qualitative perspectives from a mixed methods study

AIMS

To, firstly, explore student and academic nurse perceptions of classroom content about the assessment and identification of pressure injuries across skin tone diversity and, secondly, to describe the impact of classroom content on student nurse understanding of pressure injury in people with dark skin tones.

DESIGN

Qualitative case study employing focus groups and semi-structured interviews.

METHODS

Five higher education institutions in the United Kingdom were purposively chosen. At each of the five-case sites, one focus group with student nurses and one semi-structured interview with a nurse academic were conducted between May 2018 and April 2019. The participants' narratives were transcribed verbatim and analysed via thematic analysis.

RESULTS

Classroom learning was predominately framed through a white lens with white normativity being strongly reinforced through teaching and learning activities. This reinforcement of white normativity was evidenced through two main themes: (i) dominance of whiteness in the teaching and learning of pressure injuries in undergraduate nurse education and (ii) the impact and implications for student nurses of whiteness as the norm in pressure injury teaching.

CONCLUSION

Nurses responsible for the design and delivery of teaching and learning experiences for nursing students need to ensure meaningful teaching and learning experiences. This learning should assist future nurses to interrogate their complicity in a system of white dominance.

IMPACT

Nurse education delivered today influences and shapes nurses of the future. Nurses are the cornerstone of healthcare and play a significant role in the delivery of equitable healthcare. Nurse academics have a duty of care to inform and highlight health inequities in nursing and ultimately to enhance equity in care.

Clinical impact of a sub-epidermal moisture scanner: what is the real-world use?

OBJECTIVE

The presence of sub-epidermal moisture (SEM) over a bony prominence is indicative of incipient pressure ulcer (pressure injury/decubitus/bedsore) (PU). Early identification of patients at increased risk of PU can prompt interventions that reduce the incidence and severity of hospital (or community)-acquired PUs (HAPUs). This study evaluated the clinical utility of a SEM Scanner device in HAPU management.

METHOD

The study used a pragmatic 'real-world' approach. HAPU data before and during SEM Scanner use were obtained through routine audit. Patients had regular visual and daily SEM Scanner skin assessments over the sacrum and heels. Nursing care otherwise followed standard of care according to the established protocols of individual participating sites. HAPU incidence rates were determined and feedback gathered from health professionals on how the device influenced HAPU-related clinical decision-making.

RESULTS

There were 15 participating sites: 13 acute care, one palliative care and one community care setting. The sample size was 1478 patients. All sites reported a substantial reduction in mean HAPU incidence: 87.2% in acute care settings; 46.7% in the palliative care setting and 26.7% in the community care setting. A 100% incidence reduction was reported in 10 (66.7%) sites. In the palliative care setting, SEM Scanner results changed HAPU-related clinical decision-making for 40% of patients scanned. The community care site demonstrated a 82% change in clinical decision-making.

CONCLUSION

In this study, SEM analysis fitted seamlessly into routine skin assessment and enabled early identification of increased risk of tissue damage, with clinically important reductions in the incidence of HAPU across all participating sites.

Embedding skin tone diversity into undergraduate nurse education: Through the lens of pressure injury

OBJECTIVE

To explore health disparity in on-campus undergraduate nurse education through the analysis of teaching and teaching material exploring pressure injuries.

BACKGROUND

As a discipline, nursing espouses ideologies of inclusion, equity and valuing diversity. However, little is known about how these ideologies translate into clinical care. Pressure injury prevention is a routine aspect of nursing care; yet, there is evidence of inequity in relation to clinical care and patient assessment, as people with darker skin tones have a higher prevalence of severe pressure injuries before detection of damage occurs. Despite limited literature being available surrounding the topic of pressure injuries and skin tone diversity, it remains the responsibility of nurse educators to address contemporary issues and health disparity within the nursing curriculum.

DESIGN

A multiple method collective case study. The STROBE checklist was followed in reporting this study.

METHODS

Documentary and observational data of lectures regarding pressure injuries were collected during 2017 and 2018 from five Higher Education Institutes in England delivering approved nursing undergraduate programmes.

RESULTS

Documentary analysis confirmed all Higher Education Institutes overwhelmingly directed teaching and learning activities about pressure injury towards people with Caucasian skin tones. Observation of teaching indicated all teaching sessions only contained brief, separate and superficial information on people with pressure injuries and darker skin tones. There was no discursive language or awareness of colour or colour blindness.

CONCLUSION

Radical critique of all teaching and learning activities needs to occur, to help explore, improve and meaningfully and authentically include diversity and inclusivity in nurse education, and in particular, how people across the skin tone spectrum are included and represented in teaching and learning activities.

RELEVANCE TO CLINICAL PRACTICE

Critical examination of current teaching practice is crucial to address disparity and ensure care for people with darker skin tones is optimised. Nurse educators have a responsibility to educate for the care needs of all, as the quality of nurse education has a direct impact on care delivery and health disparity. This paper highlights the importance of addressing skin tone diversity and offers the opportunity for reflective practice, not just in formal education, but in clinical settings by preceptors and senior staff.

Optical coherence tomography for the investigation of skin adaptation to mechanical stress

BACKGROUND

Skin breakdown due to limb-socket interface stress is a significant problem for lower limb prosthesis users. While it is known that skin can adapt to stress to become more resistant to breakdown, little is understood about skin adaptation and few methods exist to noninvasively investigate it. In this study, we present novel, noninvasive imaging methods using Optical Coherence Tomography (OCT) to assess key features of the cutaneous microvasculature that may be involved in skin adaptation.

MATERIALS AND METHODS

Eight able-bodied participants wore a modified below-knee prosthetic socket for two weeks to stress the skin of their lower limb. Two OCT-based imaging tests were used to assess the function and structure, respectively, of the cutaneous microvasculature at multiple time points throughout the socket wear protocol.

RESULTS

A measurable reactive hyperemia response was reliably induced in the skin of study participants in the vascular function assessment test. The vascular structure assessment demonstrated excellent field-of-view repeatability, providing rich data sets of vessel structure. No statistically significant differences were found in any of the measurements when compared between time points of the adaptation protocol. The participants' limbs were likely not stressed enough by the able-bodied socket to induce measurable skin adaptation.

CONCLUSION

This study introduced new techniques to investigate skin adaptation to mechanical stress. If the key limitations are addressed, these methods have the potential to provide insight into the function and structure of the cutaneous microvasculature that previously could not be attained noninvasively.