Preventing Skin Tears in a Nursing and Rehabilitation Center: An Interdisciplinary Effort
Skin tears are traumatic wounds resulting from the separation of the epidermis from the dermis.1 They occur principally on the extremities of older adults as a result of friction alone or shearing and friction forces. Skin tears may be partial-thickness, separating the epidermis from the dermis ranging from a linear skin tear or flap-type tear (Category 1) to scant to moderate tissue loss (Category 2). They also may present as full-thickness wounds that separate both the epidermis and dermis from the underlying structures with complete tissue loss.2,3 Malone and colleagues1 estimate at least 1.5 million skin tears occur each year in institutionalized elderly. Individual facilities have reported skin tear prevalence rates ranging from 14% to 24%.2,4,5 Skin tears are painful and may lead to infection. Each skin tear increases caregiver time and facility costs.2,6
The Role of Skin Care in Skin Tear Prevention
In several studies involving elderly persons,2,4,7 dry skin (xerosis) has been associated with skin tears. Aging skin is vulnerable to skin tears because the dermal-epidermal junction is impaired. Healthy rete ridges interdigitate with dermal papilla from the dermis to help nourish and bond with the epidermis, preventing shearing and separating the skin layers (see Figure 1).
As rete ridges flatten with age, they become less effective in anchoring the epidermis to the dermis. Rete ridge flattening and other changes that occur with aging impair the ability of the skin to retain moisture, resulting in dry skin that is vulnerable to trauma. Skin cleansers can further alter the stratum corneum (the skin’s protective barrier layer) by reducing the thickness and number of cell layers and removing lipids and resident bacteria (normal flora). Harsh soap (especially one with a high pH) can dry the skin by interfering with its water-holding capacity.8
White and colleagues2 conducted a 6-month retrospective review of incident reports involving skin tears in a 120-bed long-term care facility. They found that, on average, 14% of the population sustained a skin tear each month. In a 12-month follow-up study, 85% of residents whose care plans included specific interventions to reduce skin tears (including moisturizing arms and legs twice a day) showed a decrease in skin tear incidence. No statistical analysis was performed and the type of lotion used was not disclosed.
A 4-month prospective study5 was conducted in a 173-bed long-term care facility to evaluate the effectiveness of an emollient soap compared to a non-emollient soap in reducing skin tears. The rate of skin tears decreased after residents switched from a non-emollient skin cleanser in the first and third month of the study to an emollient cleanser during the second and fourth months by 37% and 33%, respectively. This difference was not statistically significant but the author considered the rate decrease clinically significant and the emollient soap worth using to reduce the effects of skin breakdown.
A quasi-experimental pre-test/post-test study7 was conducted in two nursing homes (N = 136) to assess the effectiveness of skin care protocols on the occurrence of several preventable skin conditions. Baseline data collected over 3 months revealed skin tears to be the most common type of skin breakdown in both nursing homes. The researchers presented a 1-week educational program about skin care and the use of a pH-balanced body wash and moisturizing skin protectant followed by a 3-month trial of these products and protocols. The number of preventable skin conditions, including skin tears, decreased significantly (P =. 007).
Wilson and Nix9 found that moisturizers vary in effectiveness and frequency of application. In a prospective study in a long-term care facility, staff reported that multiple (more than twice daily) applications of a general moisturizer did not reduce the symptoms of xerosis in 16 residents with end-stage renal disease. When a product with a longer-lasting formulation was used, once-daily applications significantly reduced symptoms of dry skin, scratching, and erythema (P <0.001, P = 0.016, P <0.001, respectively).
To assess the clinical effectiveness of a preventive skin care protocol and ascertain the treatment costs of skin tears, pre-intervention retrospective and post-intervention prospective reviews of incident reports were conducted.
Study population. The study was conducted among all patients in the Wynscape Nursing and Rehabilitation Center, a 209-bed facility located in an urban community of Wheaton, Ill. The facility provides care to men and women who require rehabilitative and/or custodial care. Because skin assessment and subsequent treatment does not exceed regular patient care standards, written patient consent was not required.
Pre-intervention retrospective review. As part of a root cause analysis, a retrospective review of incident reports was conducted in January 2003. The Clinical Services Coordinator collected and analyzed data from incident reports submitted from April 2002 through April of 2003. Throughout the study, the Clinical Services Coordinator reviewed all incident reports involving skin tears, lacerations, and abrasions in case the skin tears were mislabeled. The Clinical Services Coordinator presented the data to the skin team comprised of four staff registered nurses (RNs), four certified nursing assistants (CNAs), a licensed physical therapist, a clinical dietitian, a social worker, a recreational therapist, and an ancillary staff member.
Fifteen-month concurrent study. Once presented with the data, the interdisciplinary Quality Improvement team (previously established to decrease the incidence of pressure ulcers) decided to initiate an ongoing skin tear incidence study after preventive interventions were implemented.
The first 4 months of the study (May through August 2003) were spent evaluating and implementing skin care products. Because the CNAs and patients were using the products, the Clinical Services Coordinator solicited their opinions via interviews and surveys; products selected included Gentle Rain® Extra Mild Sensitive Skin Moisturizing Body Wash and Shampoo (Coloplast Skin Health Division, Marietta, Ga) and Xtra-Care® All Body Lotion (Coloplast Skin Health Division, Marietta, Ga) for twice-daily application. The use of skin sleeves and padded side rails was initiated for all patients with a history of skin tears and staff education programs regarding risk identification and product use were implemented.
The Clinical Services Coordinator continued to review all incident reports involving skin tears, lacerations, or abrasions.
Data collection/analysis. For both the retrospective pre-intervention review and the subsequent 15-month post-intervention study, data were collected through incident reports completed by the nursing staff and analyzed by the Clinical Services Coordinator. A nosocomial skin tear was defined as a skin tear that was not documented within 24 hours of admission to the facility. All information collected was entered into a spreadsheet, kept confidential, and stored in a secure locked office. A statistician analyzed the data (number of skin tears per month) using a two-sample, independent t-test.10
Dressing costs calculations. Dressing supply costs were based on the facility’s purchase price for supplies. The facility used a standard dressing change protocol for all skin tears, which consisted of twice-daily cleansing with normal saline and application of Bacitracin ointment, followed by a non-adherent pad and Kerlix wrap (Tyco Health Care/Kendall, Mansfield, Mass) secured with tape.
Caregiver time costs were based on the facility’s average hourly salary for a registered nurse multiplied by 15 minutes — the average time it took for a nurse to complete a standard skin tear dressing change as timed by the Clinical Services Coordinator.
An estimated 10-day healing time was used to calculate total dressing supply costs. The 10-day healing time was based on chart audits conducted randomly by the Clinical Services Coordinator to estimate the average number of days dressing changes were performed on 10 patients with skin tears. The total projected dressing change costs per skin tear (two dressing changes per day for 10 days) then was multiplied by the average number of nosocomial skin tears per month.
During the 13-month retrospective pre-intervention review period, the number of patients with skin tears ranged from nine to 25 per month (Mean 18.77, 8.9 % of the facility’s population of 209 patients). After implementing the preventive interventions, the number of persons with skin tears ranged from two to 18 per month; Mean 8.73, 4.1 % of the facility’s population of 209 patients (see Figure 2). The observed decrease in the number of nosocomial skin tears was significant (t = 5.95, P <0.001, df 26).
Using the results obtained, the average monthly costs for skin tear management (labor and materials only; see Table 1) was projected to have decreased from $3,056.40 (twice-daily dressing changes of 18 skin tears for 10 days) to $1,358.40 (twice-daily changes of eight skin tears for 10 days) per month — a difference of $1,698 per month.
The findings confirm the results of earlier studies2,4,7 suggesting that the routine use of gentle pH-balanced cleansers and compatible moisturizers as part of an overall skin tear prevention and education program plays an important role in the prevention of skin tears.
In addition to the study duration (15 months) and careful data collection monitoring, involving the product users and front-line staff (eg, CNAs) who carry out many preventive interventions for skin care11 was believed to contribute to the success of the project and the encouraging, long-term results obtained. Studies show that user acceptability and ease of use are important factors that lead to compliance with skin care interventions and protocols.12-14
Conducting a dressing change cost analysis is an important consideration, not only because of the current economic climate in healthcare, but also because caregiver time is a critical concern in skin care intervention.
In addition to the effects of education, increased awareness on the part of caregivers, and improved skin care protocols, the number of nosocomial skin tears also may have decreased because of a Hawthorne effect (staff making quality improvements because they are being observed).10
This project was designed to examine the practical applications of nursing interventions for the purpose of decreasing skin tears in one facility. The number of subjects, settings, and lack of control groups and patient demographic data limit the external validity of the results obtained. In addition, it would have been interesting to compare data from patients who were provided proper skin cleansing and moisturizing techniques to those who used padding only.
The projected dressing supply and labor cost-savings related to skin tear dressing changes may have been partially offset by the cost of preventive interventions. Hence, the cost-effectiveness of this protocol of care could not be ascertained.
Skin tears are painful, can lead to infection, and may reflect the quality of care delivered in a facility. Effective prevention protocols reduce nursing time spent treating skin tears, completing incident reports, and notifying physicians and families of the occurrences. These variables, in addition to the direct labor and supply costs of assessments, documentation, and treatment, should be considered when designing skin tear prevention cost-effectiveness studies. The implementation of a skin care protocol using gentle cleansers and moisturizers along with staff education and use of protective padding for high risk patients led to a decrease in the number of skin tears in one facility. Studies to replicate and expand on the results obtained are needed.
The authors acknowledge and thank the skin team members for their time, assistance, professionalism, and effectiveness in implementing the protocol; the staff at Wynscape for the care they give the patients; and the facility administration for their support with the project. The authors also thank Stephen E. Bohnenblust, EdD, Professor, Department of Health, Minnesota State University, Mankato, Minn, for providing the statistical analysis and Coloplast Skin Health Division for providing financial support for manuscript development.
Financial disclosure: The authors received financial support from Coloplast Skin Health Division for manuscript development.