Prevalence of Skin Tears in Elderly Patients: A Retrospective Chart Review of Incidence Reports in 6 Long-term Care Facilities
The incidence and prevalence of skin tears in long-term care (LTC) facilities has not been well established. To ascertain the point prevalence of reported skin tears, a retrospective review of incident reports was performed in 6 LTC facilities in western Pennsylvania from November 1, 2016 through December 31, 2016.
Report data, including resident age; gender; mobility limitations; skin tear location, number, and cause (if known); occurrence time (7 am to 3 pm, 3 pm to 11 pm, or 11 pm to 7 am nursing shift); and history of previous skin tears, were abstracted. All data were entered into a statistical analysis program and analyzed using descriptive statistics. Period prevalence was used to determine prevalence rate; an independent t test was used to compare the presence of skin tears between genders. Differences between location and cause of skin tears were evaluated using a multinomial test of related proportions. A test of proportions was used to evaluate skin tear occurrence time (nursing shift) differences. The overall point prevalence rate was 9% (N = 1253 residents) ranging from 6 to 28 skin tears per facility. The average age of residents with a skin tear (n = 119) was 83.5 years. The majority (111, 93%) had mobility limitations. Falls accounted for 38 skin tears (31.9%), followed by propelling in a wheelchair (18, 15.1%; X2 =7.14; P = .008). Forearm skin tears (37, 31.1%) occurred significantly more frequently than lower leg skin tears (19, 16%; P = .016). Significantly more skin tears occurred during the 7 am to 3 pm shift (47, 39.5%) and 3 pm to 11 pm shift (49, 41.2%) than during the 11 pm to 7 am shift (23, 19.3%; X2 = 5.78; P <.01). The results of this study confirm skin tears are a significant problem among elderly residents in LTC, especially because the reported rate is likely lower than the actual rate. Research to further elucidate the incidence and prevalence of skin tears and associated risk factors is needed to help develop evidence-based risk assessment, classification systems, treatment guidelines, and preventive measures.
Skin is the largest organ. Age-related changes, including thinning of the epidermis, reduced dermal thickness, and shrinking of subcutaneous fat, result in decreased elasticity, dryness, altered sensations and thermoregulation, greater absorption of topical products that can become irritants, skin sagging, and increased risk of separation at the epidermal-dermal junction.1
Skin tears (STs) are defined as the separation of the epidermis from the dermis (partial-thickness) or separation of the epidermis and dermis from underlying structures (full-thickness)2-5 caused by shearing, friction, or blunt trauma.2,4,6 STs are a common and (based on expert opinion) preventable,1,4,6 painful wound in long-term care (LTC) residents; they are multifactorial in etiology and thought to be underreported.7 A retrospective chart review by Malone et al7 of ST incident reports (N = 321) from an urban LTC facility, followed by a validation study comparing incident report results with a skin audit, suggested substantial underreporting with only 1 in 3 STs reported by incident report. STs also are thought to increase health care costs4,8-12; however, health care costs related to treating STs have not been researched. STs can be a source of infection and evolve into a chronic wound and are thought to reduce quality of life.4,5,11
ST classification systems. Three (3) ST classification systems have been identified in the literature: the Payne-Martin Classification System,2 the Skin Tear Classification System (STAR),3 and the International Skin Tear Advisory Panel instrument.5 A universal system of classifying STs has not been adopted. In addition to not being well defined, ST classification systems have not been well utilized in health care and in LTC facilities.
ST significance. According to Bryant and Nix,13 changes in aging skin impair the body’s ability to heal. If they follow a normal healing trajectory, Type 2 and Type 3 STs (as defined by the Payne-Martin Classification System) will take 14 to 21 days to heal.13 The increase in the elderly population as the baby boomer generation ages and potential increases in the number of residents in LTC have implications for the prevalence of STs and their associated burden.
Prevalence. Prevalence describes the burden of a disease or condition in a population and can be used to determine the need for services or attention to that disease or condition. Period prevalence indicates the occurrence of a disease or event in a population over a period of time,14 usually weeks, months, or years. Prevalence of STs in LTC elderly has not been well established.
Skin tear prevalence. Using the STAR system, a point prevalence study15 conducted in 2016 (N = 144) on an acute medical ward in Singapore reported a ST prevalence of 6.2%. LeBlanc et al6 conducted a cross-sectional quantitative study in a LTC facility in Canada (N = 113) using the Payne-Martin Classification system and found a ST prevalence of 22%. In 2012, a cross-sectional epidemiological study16 used the STAR classification system among hospitalized adult cancer patients in Brazil (N = 157) and noted a ST prevalence of 3.3%. A point-prevalence study by Santamaria et al17 examined wounds (including STs) of neonatal, pediatric, and adult inpatients in 83 Western Australia hospitals (N = 5800) over 2 years and reported a ST prevalence of 8% for the year 2007 and 11% for 2008. The Australian Department of Veterans’ Affairs18 performed a 6-month chart review of wounds among veterans in home care (N = 155) that yielded a ST prevalence of 19.5%. McErlean et al19 conducted a hospitalwide, cross-sectional study at an Australian hospital (N = 87) using the Payne-Martin Classification system and found a ST prevalence of 11%.
The purpose of this retrospective review of ST incident reports was to ascertain the prevalence of ST among the elderly in 6 LTC facilities in a region of southwestern Pennsylvania.
A retrospective chart review design was used to collect all study data from 6 LTC facilities in suburban southwestern Pennsylvania with a total of 1443 beds available (1253 occupied; the number of beds per facility ranges from 139 to 360). Institutional Review Board approval was obtained through Robert Morris University (Moon, PA) and the study was given an “exempt” status.
Elderly was defined as individuals 65 years and older with at least 1 functional impairment or any adult >75 years of age.20 Six (6) LTC facilities located near the researcher were contacted randomly by phone; all 6 agreed to participate. Informed consent was deemed unnecessary, but written permission was obtained from each of the facilities involved in data collection. Facilities were numbered 1 through 6 in alphabetical order by name. Incident reports documenting STs in elderly patients dated from November 1, 2016, to December 31, 2016, were included for data collection.
Instrument. A data collection sheet was developed for this study by the principal investigator. Each of the 6 facilities had its own incident reporting form. The data collection sheet was piloted by reviewing 5 incident reports and modified by the principle investigator to include only items available in the incident reports. No medical records were reviewed for this study; mobility limitations were observed. A ST classification system was not used by any of the 6 facilities participating in the study, and ST descriptions were not well documented; thus, ST classification was not obtained. The investigator and co-investigator reviewed 5 incident reports independently using the data collection sheet to establish interrater reliability. The choice of data collected was based on previous ST studies and on information obtained in the collection sheet piloting and included date of incident report, work shift (7 am to 3 pm, 3 pm to 11 pm, 11 pm to 7 am), gender, date of birth, number of STs, location of STs, cause if known, history of previous STs, and mobility issues (ie, whether residents used a cane, walker, wheelchair, or were nonambulatory). Mobility issues not addressed within the incident report were clarified with facility staff. Incident reports were completed during the shifts the ST occurred or was first observed. The data collection sheets were placed in a secure folder and kept in the possession of the principal investigator at all times during the data collection process.
Study data. All data were abstracted by the principal investigator, de-identified, and entered into SPSS, version 22.0 (IBM Corp, Armonk, NY).
Data analysis. Period prevalence was used to determine prevalence rate. Frequency tables were used to determine percentages for age, location, cause, and shift. An independent t test was used to compare number of STs between genders. A multinomial test of related proportions was used to evaluate the difference between location and cause of ST. A test of proportions was used to evaluate shift differences. The remaining data and history of previous STs were analyzed using descriptive statistics.
The total population of the 6 facilities was 1253 during the study period. From among all incident reports reviewed during the study period, 119 involved a ST. Two (2) ST incident reports were eliminated from further data analysis because the residents did not meet the definition of elderly. The average age of patients with a ST was 83.5 (range 65–103) years, 80 (67.2%) were female, 39 (32.8%) were male, 97 (81.5%) had a history of previous STs, and 111 (93.3%) had mobility issues. The greatest number of STs occurred on the 7–3 and 3–11 shifts (47 and 49 patients, respectively). Falls accounted for the greatest number of STs (38), followed by propelling in a wheelchair (18). The forearm was the most common location (37), followed by the lower extremity (19). In 32 of the incident reports, 12 patients (9 men and 3 women; 37.5%) had a recurrent ST. Of the 119 patients with a ST, 82.4% were 75 years old or above; 107 patients had 1 ST (89.9%) and 12 (10.1%) had 2 STs.
Overall study period prevalence was 9%. Facility 1 had a study period census of 134 with 22 documented STs for a 16% period prevalence. Facility 2 had a study period census of 201 with 6 documented STs for a 3% period prevalence. Facility 3 had a study period census of 264 with 21 documented STs for an 8% period prevalence. Facility 4 had a study period census of 219 and 21 documented STs for a 10% period prevalence. Facility 5 had a total study period census of 264 and 28 documented STs for a 11% period prevalence. Facility 6 had a total study period census of 171 with 21 documented STs for a period prevalence of 12%.
Results of an independent t test regarding gender and STs did not reach statistical significance; the mean number of STs for men and women were identical (M-1.10). Because patients could have multiple STs in different locations, a multinomial test of related proportions was conducted and showed the proportion of forearm tears (31.1%) was significantly greater than the proportion of lower leg tears (X2 = 5.78; P = .016) (see Table 1).
Regarding the 2 most common reasons for sustaining a ST, the proportion of STs caused by falls was significantly greater than the proportion of STs caused by propelling in wheelchair (X2 +7.14; P = .008) (see Table 1).
The 3–11 shift had the highest proportion of STs (41.2%), but this was not significantly different from the proportion of STs on the 7–3 shift. The 11–7 shift had the least number of STs (23), a significantly lower number than the 7–3 and 3–11 shifts (P <.01) (see Table 1).
The reported period prevalence rate of STs in elderly persons residing in LTC in a region of southwestern Pennsylvania was 9%. This rate is lower than reported in 1 LTC in Canada (22%),6 a Western Australian hospital in 2008 (11%),17 an Australian VA home care (19.5%),18 and an Australian hospital in 2004 (11%)19; it is higher than in an acute medical ward in Singapore (6.2%),15 hospitalized cancer patients in Brazil (3.3%),16 and Western Australian hospital patients in 2007 (8%).17 The current study findings are clinically significant and suggest STs in elderly persons in LTC are a problem that requires more attention. The 6-facility individual reported point prevalence ranged from 3% to 16%. The reason for this difference is unclear and could be related to reporting or care practices. A larger, multisite prospective study of prevalence across different settings is needed to determine the true extent of STs.
This study suggests STs occur more frequently in women than men, a finding supported by Amaral et al,16 Chang et al,15 LeBlanc et al,6 and Malone et al,7 although a study by Carville and Smith18 reported more STs in men than women. The average age of LTC residents with STs in this study was high (83.5), similar to results from Carville and Smith,18 Chang et al,15 LeBlanc et al, 6 Malone et al,7 and McGough-Csarny and Kopac.21 In a 1998 prospective descriptive study (N = 154) of STs in institutionalized elderly, McGough-Csarny and Kopac21 reported 72 (81.8%) had functional impairment, which was also supported in findings reported by Chang et al,15 LeBlanc et al,6 and Malone et al,7 concurring with the current study findings. The current study reported more STs on the upper body, which also was demonstrated in studies by LeBlanc et al,6 Malone et al,7 McErlean et al,19 and McGough-Csarny and Kopac.21 In terms of recurrence, 12 patients in the current study had recurring STs; more research is needed in this area. McGough-Csarny and Kopac21 showed 79.2% of patients (N =154) had a previous ST. In their cross-sectional, quantitative study among LTC patients in Canada, Leblanc et al6 found ST prevalence was noted to be statistically significant (X2 = 3.98; P = .46) with correction of continuity, the Pearson chi-square, suggesting the possibility of a relationship between presence of and a clinical history of a ST.
LeBlanc et al6 reported banging into equipment as the most frequent cause of ST (36%), whereas Malone et al7 reported that bumping into object (12%) and wheelchair use (12%) contributed equally to STs. McGough-Csarny and Kopac21 cited wheelchairs (29.9%) as contributing most frequently to ST development, contradicting the current study findings that the most frequent cause of ST was falls. In their hospital audit to determine ST prevalence, McErlean et al19 found 25% of STs were caused by falls.
STs were more frequently recorded on the 7–3 and 3–11 shifts when peak activities of daily living are occurring. The role of preventive measures during these active shifts require further investigation.
Need for classification system use. One of the many difficulties encountered by wound care consultants is the absence of a universally accepted and used ST classification system, which has been hypothesized to result in better identification, tracking, and treatment.22 A ST classification system was not used in any of the LTC facilities in this study. Researchers are calling for a common validated ST classification system to be adopted — according to LeBlanc et al,22 acceptance and use of a common classification system are paramount to future research. According to expert opinion, STs can be incorrectly diagnosed as pressure ulcers; LeBlanc et al22 propose use of a ST classification system may reduce this error. Unidentified STs can lead to wounds that do not follow a normal healing trajectory, delay provision of preventive measures, and increase health care costs.
Although ST research groups are investigating the possibility, a ST risk assessment tool has not yet been developed. A 3-stage prospective study was conducted by Newall et al23 to develop a ST risk assessment tool, ensure tool reliability, and validate the instrument in a metropolitan tertiary hospital in Western Australia. This study determined that the study tool had inadequate predictive validity and required further investigation. More research is needed to identify at-risk patients and associated factors and to evaluate the economic impact of ST on health care facilities, best practices in identification, risk factors, prevention, and treatment of ST, as well as education of all health care providers who care for individuals who develop ST. So far, little research has been conducted in this area. No studies were found about the impact of an ST on patient quality of life, thus representing another area of research that needs to be explored. Developing evidence-based practices through research is essential to the understanding, prevention, and treatment of ST.
Implications for Practice
STs require nursing time and attention, including assessment, documentation, and dressing changes that increase health care costs. This study highlights the importance of skin inspection, especially after falls, to assess for STs and institute appropriate treatments. Patients with repeat STs and mobility issues and the elderly should have routine skin inspection and protective measures initiated such as geri-sleeves.
Retrospective chart reviews have a number of limitations that include incomplete information, record inaccuracy, the inability to verify information, and reviewer bias.24 Incident reports may not have been completed on all residents who had STs, resulting in a lower, less accurate prevalence rate. Skin tears are considered underreported which could have influenced the prevalence rate found in this study. A larger population size, longer study period, and prospective skin inspections may have resulted in more robust results. Although a number of ST classification systems were noted in the literature, they are not well known and (in the principal investigators’ experience) not utilized in LTC. A common classification system might help health care providers to properly identify ST and develop treatment protocols.
Additional limitations include information collected on the incident reports varied from facility to facility, making collection of additional information such as risk factors, skin characteristics, treatments utilized, and preventive measures instituted difficult to obtain. Incident reports on patients whose age did not fit the definition of elderly were excluded, affecting results. The study was conducted during the winter months when residents are wearing long sleeved/layered clothing, which may have influenced study results. Most LTC facilities are required to report falls, which could account for the finding that STs were most commonly related to a fall. In a descriptive study, White25 found nurses were less likely to report ST unless wounds were severe, large, problematic, or associated with trauma such as a fall. Results of the facilities participating in the study may not be representative of other LTC facilities in Pennsylvania or other areas of the United States. Although the researcher does not recognize any bias in facility selection, this may have been a study limitation, because other facilities in the area were not invited to participate. ST prevalence may reflect poorly on the perception of quality of care within a facility4,9,21 and have direct implications for LTC facilities.
The results of a study to ascertain the prevalence of ST among elderly persons in LTC in western Pennsylvania highlighted that STs are common. During the 2-month study, the reported point prevalence rate in 6 facilities (N = 1253) was 9%. Most reported STs were related to a fall (38, 31.9%), occurred on forearm (37, 31.1%), and during 7–3 (47, 39.5%) and 3–11 (49, 41.2%) nursing shifts. Determining the reported prevalence of ST in LTC elderly underscores the need for more research and recognition of this problem, particularly because the actual point prevalence is probably higher than the rate observed in this study, which was based on incident reports. Further research such as prospective studies should include the development of evidence-based practices regarding risk factors and risk assessment tools, prevention, treatment, and research on ST impact on quality of life and health care costs. n
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Potential Conflicts of Interest: none disclosed
Dr. Hawk is a nurse practitioner and owner of Hawk Wound Care Consulting LLC, Pittsburgh, PA. Dr. Shannon is a nurse practitioner and owner of Shannon Wound Care Consultants LLC, Chicora, PA. Please address correspondence to: Joyce Hawk, DNP, CRNP, CWCN, 132 Berwyn Road, Pittsburgh, PA 15237; email: firstname.lastname@example.org.