Standardizing the classification of skin tears: validity and reliability testing of the International Skin Tear Advisory Panel Classification System in 44 countries

BACKGROUND

Skin tears are acute wounds that are frequently misdiagnosed and under-reported. A standardized and globally adopted skin tear classification system with supporting evidence for diagnostic validity and reliability is required to allow assessment and reporting in a consistent way.

OBJECTIVES

To measure the validity and reliability of the International Skin Tear Advisory Panel (ISTAP) Classification System internationally.

METHODS

A multicountry study was set up to validate the content of the ISTAP Classification System through expert consultation in a two-round Delphi procedure involving 17 experts from 11 countries. An online survey including 24 skin tear photographs was conducted in a convenience sample of 1601 healthcare professionals from 44 countries to measure diagnostic accuracy, agreement, inter-rater reliability and intrarater reliability of the instrument.

RESULTS

A definition for the concept of a 'skin flap' in the area of skin tears was developed and added to the initial ISTAP Classification System consisting of three skin tear types. The overall agreement with the reference standard was 0·79 [95% confidence interval (CI) 0·79-0·80] and sensitivity ranged from 0·74 (95% CI 0·73-0·75) to 0·88 (95% CI 0·87-0·88). The inter-rater reliability was 0·57 (95% CI 0·57-0·57). The Cohen's Kappa measuring intrarater reliability was 0·74 (95% CI 0·73-0·75).

CONCLUSIONS

The ISTAP Classification System is supported by evidence for validity and reliability. The ISTAP Classification System should be used for systematic assessment and reporting of skin tears in clinical practice and research globally. What's already known about this topic? Skin tears are common acute wounds that are misdiagnosed and under-reported too often. A skin tear classification system is needed to standardize documentation and description for clinical practice, audit and research. What does this study add? The International Skin Tear Advisory Panel Classification System was psychometrically tested in 1601 healthcare professionals from 44 countries. Diagnostic accuracy was high when differentiating between type 1, 2 and 3 skin tears using a set of validated photographs.

Clinical evaluation of an automated turning bed

PURPOSE

The purposes of this study were to assess client comfort and sleep quality, client physiologic response (skin and respiratory status), the effect on the need for caregiver assistance, and cost when using an automated turning bed.

DESIGN

Nonexperimental, evaluative study.

SAMPLE

Twenty-four adult home or long-term care resident subjects who had a degenerative disease, spinal cord injury, stroke, cerebral palsy, or back surgery.

METHODS

Each subject agreed to use the automated turning bed for four weeks. Researchers completed a demographic survey and skin assessment, and assessed each subject for pressure ulcer risk and for the need of assistance of a care giver for turning before and after the four weeks of using the turning bed. Subjects rated the turning bed in terms of comfort and sleep quality.

FINDINGS

Subjects rated the turning bed as more comfortable than their own bed and expressed satisfaction at the pain relief attained when on the turning bed. While using the turning bed, there was a significant improvement in sleep quality. No skin breakdown or deterioration in respiratory status occurred. Fewer subjects required the assistance of a caregiver for turning when on the turning bed.

CONCLUSION

This automated turning bed shows great promise in meeting a need for patients with limited mobility whether they are homebound or in a residential community.

IMPLICATIONS FOR NURSING RESEARCH

Future studies that further investigate use of the turning bed for postoperative back patients while still in the acute care setting are indicated. Replicative studies with a larger sample size are also indicated.

Decreasing the prevalence of pressure ulcers using agency standards

Home care patients either have or are at high risk for pressure ulcers. This article describes the outcome of a study that examined the effects of pressure ulcer prevention and treatment standards on the prevalence rate of a home healthcare agency's client caseload. Implications for practice and further research also are discussed.

Pressure ulcer incidence in an acute care setting

The purpose of this prospective study was to determine the incidence of pressure ulcers and to examine factors related to pressure ulcer development in patients in an acute care setting. Adult medical and surgical patients who were free of pressure ulcers at admission were assessed within 36 hours of admission and then three times per week for 2 weeks or until discharge. Instruments included a demographic data form, a skin assessment form, and the Braden Scale for Predicting Pressure Sore Risk. Most subjects had 46 assessments completed. The sample consisted of 149 subjects, with a pressure ulcer incidence rate of 13.4% (n = 20). Subjects who acquired pressure ulcers had lower hemoglobin levels (t = 2.17, p = 0.03), spent more time in bed (t = 3.90, p = 0.0001), and spent less time in a chair (t = 3.2, p = 0.002) than those who did not acquire pressure ulcers. A stepwise logistic regression analysis was used to calculate risk of pressure ulcer development. In the final model, hemoglobin level and hours spent in bed continued to be predictors of pressure ulcer development (chi 2 = 9.306, df = 2, p = 0.0095). All 20 subjects who acquired pressure ulcers were further categorized into groups with stage I (n = 12) or stage II (n = 8) ulcers. Patients with stage I pressure ulcers were primarily receiving post-surgical care (67%), whereas patients who acquired stage II ulcers had medical conditions that affected tissue perfusion, such as respiratory diseases (50%) and diabetes mellitus (12%).

Skin care strategies in a skilled nursing home

1. Pressure ulcers continue to be a serious problem in nursing home settings. They are significant as a source of discomfort and disability among nursing home residents, as well as a source of financial concern for the institutional agencies responsible for resident care. 2. Prevention and intervention at the earliest stages of pressure ulcer development offer the most effective approaches to mediating the human and economic costs imposed by pressure ulcers. 3. Strategies that are effective in reducing both the development and severity of pressure ulcers can be successfully implemented in long-term care settings. Further studies are needed that will provide additional support for the strategies and protocols used in this study.

Evaluation of pressure ulcer prevalence rates for hospice patients post-implementation of pressure ulcer protocols

Hospice patients may be particularly at risk for pressure ulcer development due to several factors. Identifying populations at risk for pressure ulcer development, such as hospice patients, and providing prevention and risk protocols for these populations can substantially reduce the prevalence and incidence of pressure ulcers. However, are hospice patients prone for skin breakdown despite prevention and treatment efforts? This study examines the prevalence of pressure ulcers in hospice patients following the implementation of pressure ulcer prevention and treatment protocols. Levine's theory of conservation of structural integrity formed the theoretical framework for this descriptive study. A midwestern hospital-based hospice agency was the site for this study. All patients 18 years of age and older were included in the study. Pressure ulcer prevalence audits were done at four, eight, 12, and 18 months after protocols were outlined by the hospice staff. Results of the audits revealed prevalence rates of 14.8 percent, 8.5 percent, 13.6 percent, and 23.8 percent, at each of the aforementioned audits. 10 of 15 patients who were pressure ulcer positive were males; the sacral location was most common (seven of 19 ulcers occurred sacrally) with the ischial location being the next common (six of 19 ulcers were ischially located). No ulcers occurred above the waist or in patients below 51 years of age. Recommendations from this study urge that particular prevention attention be given to protocols which address "sitting," due to the predominance of ulcers located in the sacral and ischial regions. In addition, the author concludes that perhaps, pressure ulcers may occur in this population despite the best of efforts to prevent them.

Relationship between body weight, body position, support surface, and tissue interface pressure at the sacrum

This descriptive, comparative study examined the relationship between three body positions, body weight, and tissue interface pressure measurement on three support surfaces among residents who were 65 years of age or older. The support surfaces included the Sof. Care bed cushion, Biogard foam mattress, and hospital mattress. Subjects included 12 ideal body-weight and six less-than-ideal body-weight individuals from a long-term care facility in a Mid-western state. Results indicated no significant difference in sacral tissue interface difference between ideal body weight and less-than-ideal body weight subjects. However, the sacral measurements were significantly greater in the supine position than those taken in the Fowler's and semi-Fowler's positions. A significant interaction was found between position and support surface with subjects in Fowler and semi-Fowler positions on the Sof. Care Surface exhibiting the lowest mean tissue interface pressure at the sacrum.

Variables associated with hypotension in postoperative total knee arthroplasty patients receiving epidural analgesia

The purpose of the study was to identify variables that may place the total knee arthroplasty patient receiving epidural analgesia at risk for hypotension postoperatively. A review of medical records of this convenience sample of 99 subjects was conducted in this retrospective, descriptive, correlational study. Variables predictive of postoperative hypotension using stepwise multiple regression included low postoperative systolic BP on the nursing unit the day of surgery (R2 = .26, p less than .001), low diastolic BP in postanesthesia room (R2 = .31, p less than or equal to .01), low hemoglobin the third postoperative day (R2 = .37, p less than or equal to .01), use of diuretics preoperatively (R2 = .40, p less than or equal to .05), and total fluid intake first day postoperatively (R2 = .43, p less than or equal to .05). These variables accounted for 43% of the variability in the occurrence of hypotension. Identification of variables predictive of hypotension should provide direction for future care givers and researchers.

The relationship of age, gender, and exercise practices to measures of health, life-style, and self-esteem

A study of 478 adults from a rural-urban region was conducted to determine differences in health and life-style measures based on age, gender, and exercise involvement that would provide data to incorporate in healthy-living programs. Pender's Health Promotion Model provided the framework for the study. Significant results related to age, gender, exercise, and initiation and maintenance of health-promoting practices were found.