CMS MDS 3.0 Section M Skin Conditions in Long-term Care: Pressure Ulcers, Skin Tears, and Moisture-Associated Skin Damage Data Update

Medical Adhesive-Related Skin Injury at 10 Years: An Updated Consensus

Awareness of medical adhesive-related skin injury (MARSI) has increased in the decade since a foundational consensus report was published in 2013. Additional research has provided greater knowledge of the epidemiology of MARSI, along with its assessment, prevention, and management. To summarize knowledge generated in the past decade and review our current understanding of MARSI, a panel of nine clinical experts from four countries (United States of America, United Kingdom, Canada, and Brazil) convened to discuss the literature published since the initial 2013 document and develop updated recommendations for clinical practice. The group formulated 20 updated consensus statements covering the assessment, prevention, and management of skin injuries related to adhesive medical devices and proposed next steps to address remaining gaps in research and knowledge of this complex and clinically relevant condition.

Review of Medical Adhesive Technology in the Context of Medical Adhesive-Related Skin Injury

In clinical practice, a large variety of medical devices adhere to skin to perform their function. The repeated application and removal of these devices can lead to skin damage or medical adhesive-related skin injury. Awareness of this problem has increased in the past decade, and this adverse event can be prevented with appropriate selection of adhesive products and the appropriate techniques for application and removal. A wide variety of adhesives and backing systems have been developed to create medical devices with an array of attributes, so they can accomplish many different indications in the clinical setting and meet various needs, including doing the clinical job without damaging the skin and causing further patient complications. The selection of an adhesive product should take into consideration a patient's skin assessment and history of medical adhesive-related skin injury, and using only the minimal adhesive strength needed to perform the function while protecting the skin from damage.

Prevention and care for moisture-associated skin damage: A scoping review

OBJECTIVE

Moisture-associated skin damage (MASD) is an inflammatory skin condition caused by long-term exposure to a moist environment, which can compromise the integrity of the barrier and increase pain. This scoping review aimed to systematically analyze the research status of prevention and care for MASD.

METHODS

We conducted a scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. PubMed, MEDLINE, Scopus, Web of Science, CINAHL, and the Cochrane Database of Systematic Reviews were searched for relevant articles until March 2023.

RESULTS

Based on eligibility criteria, 34 research studies and review articles were included. The prevalence of MASD varies greatly in different medical environments and patient groups. The high-risk factors included prolonged exposure to excessive water, chemical irritation such as urine or feces, mechanical factors such as friction or improper removal of medical adhesives and local bacterial colonization. Prevention measures mainly include avoiding skin exposure to moisture, skin cleansing, moisturizing and the treatment of secondary bacterial infection.

CONCLUSION

A variety of factors have an impact on MASD. Nurses should select suitable tools to screen high-risk patients and take targeted preventive measures according to the related types of skin injury to reduce the incidence of MASD.

The Science of Skin: Measuring Damage and Assessing Risk

Significance: Healthy skin provides a barrier to contaminants. Breaches in skin integrity are often encountered in the patient health care journey, owing to intrinsic health issues or to various procedures and medical devices used. The time has come to move clinical practice beyond mere awareness of medical adhesive-related skin injury and toward improved care and outcomes. Recent Advances: Methods developed in research settings allow quantitative assessments of skin damage based on the measurement of baseline skin properties. These properties become altered by stress and over time. Assessment methods typically used by the cosmetic industry to compare product performance could offer new possibilities to improve clinical practice by providing better information on the status of patient skin. This review summarizes available skin assessment methods as well as specific patient risks for skin damage. Critical Issues: Patients in health care settings may be at risk for skin damage owing to predisposing medical conditions, health status, medications taken, and procedures or devices used in their treatment. Skin injuries come as an additional burden to these medical circumstances and could be prevented. Technology should be leveraged to improve care, help maintain patient skin health, and better characterize functional wound closure. Future Directions: Skin testing methods developed to evaluate cosmetic products or assess damage caused by occupational exposure can provide detailed, quantitative information on the integrity of skin. Such methods have the potential to guide prevention and treatment efforts to improve the care of patients suffering from skin integrity issues while in the health care system.

Current understanding of frictional dermatoses: A review

Human skin is continually exposed to internal and external forces, dynamic as well as static. The skin is normally flexible and can resist mechanical trauma due to friction, pressure, vibration, suction and laceration to a considerable degree. However, an excess of these forces can abnormally affect the structure and function of the skin, setting the stage for the development of a skin disorder. Repetitive trauma can cause lichenification, hyperpigmentation, erythema, scaling, fissuring, blisters, ulceration and chronic alterations. Frictional dermatoses is an under-recognised entity with no clear-cut definition and encompasses a variety of terms such as frictional dermatitis, frictional melanosis, frictional pigmentary dermatoses and certain other named entities, many of which are confusing. The authors propose to define frictional dermatoses as 'a group of disorders caused by repetitive trauma to the skin as a result of friction of varied aetiology which can have a wide range of cutaneous manifestations depending on the type of insult.' The exact prevalence of frictional dermatoses as a separate entity is unknown. Authors who conducted this review include a group of dermatologists and post graduate students from various institutions. Literature was reviewed through PubMed, Medscape, Medline, ResearchGate and Google Scholar using the terms 'frictional dermatitis,' 'friction and skin,' 'dermatoses and culture,' 'clothing dermatitis,' 'friction melanosis,' 'PPE induced dermatoses in COVID-19 era,' etc. A total of 122 articles were reviewed and 100 articles among them were shortlisted and included in the study, after removing duplications. The review was followed up with further deliberation which resulted in the formulation of a new definition and classification of frictional dermatoses taking into account the morphology, histopathological characteristics, anatomical region affected and the major predisposing factors. The rising incidence of mechanical dermatoses in the COVID-19 era was also emphasised.

Educating Certified Nursing Assistants to Communicate Skin Changes to Reduce Pressure Injuries

Pressure injuries (PIs) are common and costly complications in long-term care (LTC) residents. Educating and coaching certified nursing assistants (CNAs) to communicate early skin changes is a PI surveillance strategy that may influence PI outcomes. A communication guide related to Skin, Clean, Activity, and Nutrition was developed for CNAs to promote prompt upstream communication to licensed nurses. A pre-/post-intervention design measured PI knowledge and skills in 24 CNAs, and PI incidence was tracked over a 6-week time period. CNAs demonstrated improvement in their PI surveillance role, comfort in identifying and reporting skin changes, keeping skin clean and dry, and resident nutritional status. Baseline PI incidence of 9.6% decreased to 0% by Week 3, and no new PIs occurred over 6 weeks. CNAs developed role awareness and knowledge in primary PI surveillance and were instrumental in a team approach to decrease PIs in a LTC setting. [Journal of Gerontological Nursing, 47(8), 21-28.].

Association Between Skin Injuries in Medical Staff and Protective Masks Combined with Goggles During the COVID-19 Pandemic

OBJECTIVE

To explore the relationship between wearing protective masks and goggles and skin injuries in medical staff during the COVID-19 pandemic.

METHODS

Researchers conducted a cross-sectional, multicenter online survey. Respondents voluntarily completed the questionnaire on their smartphones. Ordinal and multinomial logistic regressions were used to identify factors related to skin injuries.

RESULTS

In total, 1,611 respondents wore protective masks combined with goggles in 145 hospitals in China; 1,281 skin injuries were reported (overall prevalence, 79.5%). Multiple concomitant skin injuries (68.5%) and injuries in four anatomic locations (24.0%) were the most common, followed by injuries in three (22.8%), two (21.7%), and one location (11.0%). Multinomial logistic regression indicated that sweating increased the risk of injuries in one to four anatomic locations (95% confidence interval for odds ratio 16.23-60.02 for one location and 38.22-239.04 for four locations), and wearing an N95 mask combined with goggles and a daily use longer than 4 hours increased the risk of injuries in four locations (95% confidence interval for odds ratio 1.18-5.31 and 1.14-3.93, respectively).

CONCLUSIONS

The prevalence of skin injuries among medical staff wearing protective masks combined with goggles was very high. These were mainly device-related pressure injuries, moisture-associated skin damage, and skin tears. The combination of various factors resulted in skin injuries at multiple sites. Preventing and managing sweating should be a focus for medical staff who wear protective masks combined with goggles for more than 4 hours.

Development and psychometric property testing of a skin tear knowledge assessment instrument (OASES) in 37 countries

AIM

To develop and psychometrically evaluate a skin tear knowledge assessment instrument (OASES).

DESIGN

Prospective psychometric instrument validation study.

METHOD

The skin tear knowledge assessment instrument was developed based on a literature review and expert input (N = 19). Face and content validity were assessed in a two-round Delphi procedure by 10 international experts affiliated with the International Skin Tear Advisory Panel (ISTAP). The instrument was psychometrically tested in a convenience sample of 387 nurses in 37 countries (April-May 2020). Validity of the multiple-choice test items (item difficulty, discriminating index, quality of the response alternatives), construct validity, and test-retest reliability (stability) were analysed and evaluated in light of international reference standards.

RESULTS

A 20-item instrument, covering six knowledge domains most relevant to skin tears, was designed. Content validity was established (CVI = 0.90-1.00). Item difficulty varied between 0.24 and 0.94 and the quality of the response alternatives between 0.01-0.52. The discriminating index was acceptable (0.19-0.77). Participants with a theoretically expected higher knowledge level had a significantly higher total score than participants with theoretically expected lower knowledge (p < .001). The 1-week test-retest intraclass correlation coefficient (ICC) was 0.83 (95% CI = 0.78-0.86) for the full instrument and varied between 0.72 (95% CI = 0.64-0.79) and 0.85 (95% CI = 0.81-0.89) for the domains. Cohen's Kappa coefficients of the individual items ranged between 0.21 and 0.74.

CONCLUSION

The skin tear knowledge assessment instrument is supported by acceptable psychometric properties and can be applied in nursing education, research, and practice to assess knowledge of healthcare professionals about skin tears.

IMPACT

Prevention and treatment of skin tears are a challenge for healthcare professionals. The provision of adequate care is based on profound and up-to-date knowledge. None of the existing instruments to assess skin tear knowledge is psychometrically tested, nor up-to-date. OASES can be used worldwide to identify education, practice, and research needs and priorities related to skin tears in clinical practice.

Skin tear prevalence and incidence in the long-term care population: a prospective study

Objective:

The World Health Organization estimates that between 2015 and 2050 the proportion of the world's population over 60 years old will nearly double from 12% to 22%. An often overlooked byproduct of ageing is the skin changes associated with it, which heighten the risk of developing skin tears. Despite this presumed increased risk, the true impact of skin tears across age groups and care settings is poorly understood. The purpose of the present study was to establish the prevalence and incidence of skin tears in the Ontario long-term care population.

Method:

A prospective study design was used to explore the prevalence and incidence of skin tears. Individuals from four long-term care facilities in Ontario were followed over four weeks. The participants were examined for skin tears at the beginning of the study and at week four to determine whether skin tears had occurred and to record the skin tear type and location.

Results:

A total of 380 individuals, aged 65 years and over, took part. The study found a skin tear prevalence of 20.8% and an incidence of 18.9% within four weeks. These results provide much needed data on the burden of skin tears in the long-term care population. Conclusion: The present study is an important first step towards developing a prevention programme targeting individuals at risk for skin tears in long-term care.

The Prevalence, Characteristics, and Prevention Status of Skin Injury Caused by Personal Protective Equipment Among Medical Staff in Fighting COVID-19: A Multicenter, Cross-Sectional Study

Objective: To investigate the prevalence, characteristics, and preventive status of skin injuries caused by personal protective equipment (PPE) in medical staff. Approach: A cross-sectional survey was conducted online for understanding skin injuries among medical staff fighting COVID-19 in February 8-22, 2020. Participants voluntarily answered and submitted the questionnaire with cell phone. The questionnaire items included demographic data, grade of PPE and daily wearing time, skin injury types, anatomical sites, and preventive measures. Univariable analyses and logistic regression analyses were used to explore the risk factors associated with skin injuries. Results: A total of 4,308 respondents were collected from 161 hospitals and 4,306 respondents were valid. The overall prevalence of skin injuries was 42.8% (95% confidence interval [CI] 41.30-44.30) with three types of device-related pressure injuries, moist-associated skin damage, and skin tear. Co-skin injuries and multiple location injuries were 27.4% and 76.8%, respectively. The logistic regression analysis indicated that sweating (95% CI for odds ratio [OR] 87.52-163.11), daily wearing time (95% CI for OR 1.61-3.21), male (95% CI for OR 1.11-2.13), and grade 3 PPE (95% CI for OR 1.08-2.01) were associated with skin injuries. Only 17.7% of respondents took prevention and 45.0% of skin injuries were treated. Innovation: This is the first cross-sectional survey to understand skin injuries in medical staff caused by PPE, which is expected to be a benchmark. Conclusion: The skin injuries among medical staff are serious, with insufficient prevention and treatment. A comprehensive program should be taken in the future.

Skin tears: prevention and management

Skin tears commonly occur at the extremes of age and are associated with skin changes in ageing skin. They are considered to be acute wounds caused by mechanical forces, such as blunt trauma. While the true prevalence and incidence of skin tears is unknown, the available evidence suggests that these wounds occur in all healthcare settings. Importantly, skin tears are preventable with the implementation of a risk-reduction programme, which includes twice-daily skin moisturisation. Where these injuries do occur, it is important to categorise the extent of damage as well as to choose the most appropriate dressing to avoid adding any risks for further trauma.

Professionals' Knowledge, Attitudes, and Practices Related to Pressure Injuries in Canada

BACKGROUND

Pressure injuries (PIs) represent a significant burden on the healthcare system and have a negative impact on the quality of life of those affected by these wounds. Despite best practice guidelines and other protocols to help healthcare facilities prevent PIs, the prevalence of PIs in Canada across all healthcare settings is concerning.

OBJECTIVE

To describe the pattern of PI prevention and identify national priorities and opportunities to address PIs.

METHODS

A descriptive, cross-sectional, online survey was created between August and December 2017 to explore Canadian healthcare professionals' knowledge, attitudes, and practices related to PIs.

RESULTS

In total, 590 surveys were completed. Eighty-five percent of respondents confirmed that PIs occur in their work environments, and 29% claimed PIs are a frequent occurrence. Most of the respondents (91%) confirmed that they were part of a team that treats PIs. Of the 590 participants, 90% confirmed that they are aware of PI prevention devices and technologies. Between 80% and 90% attest to using offloading devices including prophylactic dressings to prevent PIs, but only 20% instituted measures to address moisture-associated skin damage.

CONCLUSIONS

The findings from this survey have highlighted a disconnect between Canadian healthcare professionals' awareness of PIs and the implementation of best practices for PI prevention. It is evident that, although the majority of respondents were aware of PIs and related treatment protocols, barriers still exist that impede optimized care and treatment.

Prevalence and Analysis of Medical Device-Related Pressure Injuries: Results from the International Pressure Ulcer Prevalence Survey

OBJECTIVE

To examine the prevalence and characteristics of medical device-related pressure injuries (MDR PIs) in a large, generalizable database.

METHODS

This study is a retrospective analysis of the 2016 International Pressure Ulcer Prevalence data. Data were limited to US and Canadian facilities. Facilities included acute care, long-term care, rehabilitation, long-term acute care hospitals, and hospice. Analysis included 102,865 adult patients; 99,876 had complete data and were the focus of the analysis and are reported in the results below.

RESULTS

The overall PI prevalence was 7.2% (n = 7189), and the facility-acquired prevalence was 3.1% (n = 3113). The prevalence of MDR PIs was 0.60% (n = 601), which included both mucosal and nonmucosal MDR PIs. In this study, 75% of MDR PIs were facility acquired, whereas non-MDR PIs were most commonly present on admission. Facility-acquired MDR PIs formed 3 days faster than facility-acquired non-MDR PIs (12 vs 15 days; P < .05). By stage, most MDR PIs were superficial (58% were Stage 1 or 2), 15% were deep-tissue PIs, and 22% were full-thickness PIs (Stage 3 or 4 or unstageable). The most common anatomic locations for MDR PIs were the ears (29%) and the feet (12%). The most common devices associated with MDR PIs were nasal oxygen tubes, 26%; other, 19%; cast/splints, 12%; and continuous positive airway pressure/bilevel positive airway pressure masks, 9%.

CONCLUSIONS

Because MDR PIs form faster than non-MDR PIs, timely proactive assessment and prevention measures are critical. Most MDR PIs occurred at the face and head region, and the ears specifically. The most common devices linked with MDR PIs were oxygen tubing and masks, making assessment and prevention efforts critical for patients who require those devices.