Exploring the prevalence of skin tears and skin properties related to skin tears in elderly patients at a long‐term medical facility in Japan

The identification of appropriate skin tear prevention guidelines for the elderly requires clinicians to focus on local risk factors such as structural alterations of the epidermis and dermis related to skin tears. The aim of this cross‐sectional study is to explore the prevalence of skin tears and to explore skin properties related to skin tears in elderly Japanese patients at a long‐term medical facility. After doing the prevalence study, 18 participants with skin tears and 18 without were recruited and an evaluation of their skin properties using 20‐MHz ultrasonography, skin blotting and also Corneometer CM‐825, Skin‐pH‐meterPH905, VapoMeter, Moisture Meter‐D and CutometerMPA580 was undertaken. A total of 410 patients were examined, the median age was 87 years and 73·2% were women. The prevalence of skin tears was 3·9%, and 50% of skin tears occurred on the dorsal forearm. The changes in skin properties associated with skin tears included increased low‐echogenic pixels (LEP) by 20‐MHz ultrasonography, decreased type IV collagen and matrix metalloproteinase‐2, and increased tumour necrosis factor‐α by skin blotting. In conclusion, this study suggests that increased dermal LEP, including solar elastosis, may represent a risk factor for skin tears; this indicates that skin tear risk factors might not only represent chronological ageing but also photoageing.     

Malnutrition is independently associated with skin tears in hospital inpatient setting—Findings of a 6‐year point prevalence audit

Skin tears cause pain, increased length of stay, increased costs, and reduced quality of life. Minimal research reports the association between skin tears, and malnutrition using robust measures of nutritional status. This study aimed to articulate the association between malnutrition and skin tears in hospital inpatients using a yearly point prevalence of inpatients included in the Queensland Patient Safety Bedside Audit, malnutrition audits and skin tear audits conducted at a metropolitan tertiary hospital between 2010 and 2015. Patients were excluded if admitted to mental health wards or were <18 years. A total of 2197 inpatients were included, with a median age of 71 years. The overall prevalence of skin tears was 8.1%. Malnutrition prevalence was 33.5%. Univariate analysis demonstrated associations between age (P ˂ .001), body mass index (BMI) (P < .001) and malnutrition (P ˂ .001) but not gender (P = .319). Binomial logistic regression analysis modelling demonstrated that malnutrition diagnosed using the Subjective Global Assessment was independently associated with skin tear incidence (odds ratio, OR: 1.63; 95% confidence interval, CI: 1.13‐2.36) and multiple skin tears (OR 2.48 [95% CI 1.37‐4.50]). BMI was not independently associated with skin tears or multiple skin tears. This study demonstrated independent associations between malnutrition and skin tear prevalence and multiple skin tears. It also demonstrated the limitations of BMI as a nutritional assessment measure.     

Prevalence of skin tears in the extremities in inpatients at a hospital in Denmark

The aims of the study were to determine the prevalence of skin tears in the extremities and to explore factors associated with development of skin tears in inpatients at a Danish hospital. The study was designed as a point prevalence survey and included 202 patients in the age range 19–99 (mean: 70·7, SD: 16·5). The patients were assessed for presence of skin tears, numbers, locations and previous skin tears. Data were collected using a data collection sheet developed for a previous study. The survey team consisted of four specialist nurses. Data were collected over a period of 24 hours spread over 3 days. Of the 202 patients, 23 had skin tears, yielding a prevalence of 11·4%. In total, 40 skin tears were observed. Multiple logistic regression analysis showed that previous skin tears (odds ratio (OR): 9·3, 95% confidence interval (CI): 2·6–33·4, P < 0·001), ecchymosis (OR: 5·6, CI: 1·4‐23·2, P < 0·017) and risk of falling (OR: 3·8, CI: 1·2‐12·0, P < 0·021) were significantly associated with development of skin tears. The prevalence of skin tears in this study (11·4%) matches other international observations. The following risk factors were recognised: previous skin tear, ecchymosis and risk of falling. These factors could be used to identify patients requiring prevention of skin tears.     

Swedish translation and validation of the international skin tear advisory panel skin tear classification system

The aims of this study were to translate the International Skin Tear Advisory Panel (ISTAP) classification system for skin tears into Swedish and to validate the translated system. The research process consisted of two phases. Phase I involved the translation of the classification system, using the forward‐back translation method, and a consensus survey. The survey dictated that the best Swedish translation for “skin tear” was “hudfliksskada.” In Phase 2, the classification system was validated by health care professionals attending a wound care conference held in the spring of 2017 in Sweden. Thirty photographs representing three types of skin tear were presented to participants in random order. Participants were directed to classify the skin tear types in a data collection sheet. The results indicated a moderate level of agreement on classification of skin tears by type. Achieving moderate agreement for the ISTAP skin tear tool is an important milestone as it demonstrates the validity and reliability of the tool. Skin tear classification typing is a complex skill that requires training and time to develop. More education is required for all health care specialists on the classification of skin tears.     

Identification of risk factors associated with the development of skin tears in hospitalised older persons: a case–control study

To identify the risk factors associated with the development of skin tears in older persons four hundred and fifty three patients (151 cases and 302 controls) were enrolled in a case–control study in a 500‐bed metropolitan tertiary hospital in Western Australia between December 2008 and June 2009. Case eligibility was defined by a skin tear on admission, which had occurred in the last 5 days; or, a skin tear developed during hospitalisation. For each case, two controls who did not have a skin tear and had been admitted within 1 day of the case, were also enrolled. Data collected from the nursing staff and inpatient medical records included characteristics known, or hypothesised, to be associated with increased vulnerability to skin tears. Data analysis included a series of multivariate stepwise regressions to identify a number of different potential explanatory models. The most parsimonious model for predicting skin tear development comprised six variables: ecchymosis (bruising); senile purpura; haematoma; evidence of a previously healed skin tear; oedema; and inability to reposition oneself independently. The ability of these six characteristics to predict who among older patients could subsequently develop a skin tear now needs to be determined by a prospective study.     

Implementation of pressure ulcer prevention best practice recommendations in acute care: an observational study

Pressure ulcers are a common but preventable problem in hospitals. Implementation of best practice guideline recommendations can prevent ulcers from occurring. This 9‐year cohort study reports prevalence data from point prevalence surveys during the observation period, and three practice metrics to assess implementation of best practice guideline recommendations: (i) nurse compliance with use of a validated pressure ulcer risk assessment and intervention checklist; (ii) accuracy of risk assessment scoring in usual‐care nurses and experienced injury prevention nurses; and (iii) use of pressure ulcer prevention strategies. The prevalence of hospital‐acquired pressure ulcers decreased following implementation of an evidence‐based prevention programme from 12·6% (2 years preprogramme implementation) to 2·6% (6 years postprogramme implementation) (P < 0·001). Audits between 2003 and 2011 of 4368 patient medical records identified compliance with pressure ulcer prevention documentation according to best practice guidelines was high (>84%). A sample of 270 patients formed the sample for the study of risk assessment scoring accuracy and use of prevention strategies. It was found usual‐care nurses under‐estimated patients' risk of pressure ulcer development and under‐utilised prevention strategies compared with experienced injury prevention nurses. Despite a significant reduction in prevalence of hospital‐acquired pressure ulcers and high documentation compliance, use of prevention strategies could further be improved to achieve better patient outcomes. Barriers to the use of prevention strategies by nurses in the acute hospital setting require further examination. This study provides important insights into the knowledge translation of pressure ulcer prevention best practice guideline recommendations at The Northern Hospital.     

Preventing and managing skin tears: a review.

Skin tears are an increasingly common problem in frail elders, and the wound, ostomy, and continence (WOC) nurse must be knowledgeable regarding both prevention and management of these lesions. A literature review was conducted to identify current concepts regarding management of skin tears. Articles reviewed provided numerous suggested interventions and protocols. Recurring themes were prevention of skin tears whenever possible and management of existing lesions with products that manage the exudate, maintain a moist surface, and prevent additional trauma.     

A novel way to treat skin tears

Skin tears are one of the most commonly treated wounds in the elderly population. In their most basic form, they are essentially traumatic random pattern flaps. We postulate that the injured blood flow to these skin flaps should be ignored and the tissue should be treated as a skin graft. A case report is presented of an 86‐year‐old female with an 8 × 3·5 cm skin tear to her right upper extremity after a hip fracture. In addition to conventional wound closure strips re‐approximating the tissues, a disposable negative pressure wound therapy device was placed to act as bolster. Upon its removal on day 5, the opposed skin tear tissue was found to be 100% viable. We therefore propose that this update may be an improvement over classical skin tear treatments and should be followed up with a case series.     

Acute management of skin tears: a change in practice pilot study

Skin tears are an increasingly common injury occurring in the elderly population and have significant associated morbidity secondary to poor wound healing, prolonged hospital stays and reduced mobility. There has been a shift in practice for the acute management of skin tears within our institution, which has resulted in improved outcomes and reduced morbidity for this common and debilitating injury. Review of past and current practices including cost analyses has led to the establishment of a management protocol for the hospital and wider area health service with the aim to reduce the burden of disease amongst our ever‐expanding elderly population.     

The practice of out-lying patients is dangerous: a multicentre comparison study of nursing care provided for trauma patients

Pressure for acute hospital beds is a national problem with many acute trauma patients being admitted to non-trauma wards. This prospective multicentre questionnaire study of 220 qualified trauma and non-trauma nurses aims to compare the quality of nursing care that trauma patients receive when admitted to trauma wards and non-trauma wards. The questions included the nursing management of common fractures and post-operative conditions. The completed questionnaires were scored and the results analysed. Hundred percent of the questionnaires were completed and returned. The trauma nurses conveyed the importance of ice (85%) and elevation (97%) in the initial management of limb fractures. This compares with ice (10%) and elevation (50%) on the outlying wards. Trauma nurses correctly monitor for potentially devastating post-operative complications and compartment syndrome 87% of the time compared with 42% on outlying wards. Spinal injuries are managed appropriately 88% of the time on trauma wards compared with 36% on outlying wards. Trauma patients receive better nursing care when admitted to a trauma ward and are nursed by trauma nurses. Many of the out-lying wards provide sub-optimal trauma nursing care and a few are positively dangerous. We suggest that trauma patients should not be nursed on outlying wards.     

糖尿病联络护士在非糖尿病病区护理风险管理中的作用

目的探讨糖尿病联络护士在非糖尿病病区护理风险管理中的作用。方法于全院各病区选取护士1～2人共63人组成糖尿病联络护士小组,其接受系统培训后由其对本病区护士进行再培训,对患者进行健康教育和管理。结果干预后全院护士对糖尿病相关知识及操作技能掌握程度显著提高(均P<0.01),非专科住院糖尿病患者对糖尿病相关知识掌握情况显著改善(均P<0.01),糖尿病护理缺陷从2008年6起下降至2011年0起。结论糖尿病联络护士的设立有利于提高非专科的糖尿病护理水平。     

Skin tears and risk factors assessment: a systematic review on evidence‐based medicine

Skin tears represent a common condition of traumatic wounds, which may be encountered in some categories of individuals at the extremes of age, such as infants and the elderly. Despite the high prevalence and cost of these lesions, there has been little investigation into the risk factors that lead to this condition. The aim of this review was to systematically evaluate the main risk factors involved in development of skin tears. We planned to include all the studies dealing with risk factors related to skin tears. Only publications in English were considered. We excluded all the studies that did not properly fit our research question and those with insufficient data. Of the 166 records found, 24 matched our inclusion criteria. After reading the full‐text articles, we decided to exclude seven articles because of the following reasons: (1) not responding properly to our research questions and (2) insufficient data; the final set included 17 articles. From a literature search, we found the following main issues related to risk factors, which have been described in detail in this section: age‐related skin changes, dehydration, malnutrition, sensory changes, mobility impairment, pharmacological therapies and mechanical factors related to skin care practices. Our findings clearly show that in frail populations (especially infant and elderly), the stratification risk, as a primary prevention strategy, is an effective tool in avoiding the development of chronic wounds. The development and the implementation of prevention strategies based on appropriate knowledge of the risk factors involved and the adoption of correct techniques during skin care practices could reduce or even avoid the onset of skin tears.     

Exploring the prevalence and management of wounds for people with dementia in long‐term care

The prevalence of wounds and comorbidities such as dementia increase with age. With an ageing population, the likelihood of overlap of these conditions is strong. This study aimed to determine the prevalence of wound types and current management strategies of wound care for people with dementia in long‐term care (LTC). A scoping literature review, a cross‐sectional observational and chart audit study of residents in dementia specific facilities in LTC were conducted. The scoping review indicated that people with dementia/cognitive impairment are often excluded from wound related studies andof the nine studies included in this review, none looked at the prevalence of types of wounds other then pressure injuries. In the skin audit, skin tears were noted as the most common wound type with some evidence‐based practice strategies in place for residents. However, documentation of current wound occurred in less than a third of residents with wounds. This is the first study to note the prevalence of different wound types in people with dementia and current management strategies being used across two dementia‐specific facilities and a lack of research in this area limits evidence in guiding practice.     

实施压疮患病率调查持续改进压疮管理

目的了解住院患者压疮患病率,为压疮管理及监测提供依据。方法采用修正的美国护士协会护理质量指征委员会设计的压疮患病率调查表,组织伤口小组成员、科护士长、护士长和护理研究生组成的30个小组对1所三级甲等医院61个病区的2913例患者进行调查。结果住院患者压疮患病率为1．78％,院内压疮患病率为1．54％,排除Ⅰ期压疮（28例）,压疮患病率为0．82％;168例患者有压疮风险评估和复评,其中压疮患病39例,占23．21％;135例有采取减压措施的护理记录,仍发生压疮36倒,占26．67％;197例患者采取了压疮预防措施,其中135例（68．53％）有压疮风险评估。结论住院患者压疮患病率低于国外相关研究,护理人员执行压疮护理记录意识欠缺。护理管理者需转变管理理念,建立非惩罚性压疮管理制度;正确认识压疮患病率,加强过程管理;完善压疮监控制度,提升压疮护理水平。     

Pressure injury prevention and management practices among nurses: A realist case study

The prevention and management of a pressure injury is a nurse‐sensitive quality indicator in hospitals. Prevention and management of pressure injury practices have been found to be suboptimal despite the availability of interventions. Currently, there is a poor understanding of the mechanisms behind these interventions. The aim of the study was to explain a realistic portrayal of nurses' current practices to prevent and manage pressure injuries in one public hospital in Singapore. A realistic case study design was adopted. Twenty‐four nurses were recruited. Audio‐recorded interviews were transcribed verbatim to facilitate thematic analysis. Prevention and management was generally facilitated through the timely escalation of care, effective communication, support from the wound nurses, and bridging of the knowledge‐practice gap. However, factors such as nurses' intrinsic characteristics and organisational support may affect the outcomes of these facilitators. Overall, nurses strive to achieve patient safety, where pressure injuries are prevented to the best of their abilities. This study provides causal links between contextual factors, mechanisms of the prevention and management, and the outcomes achieved. Further refinement and testing of the specific mechanisms are needed and will contribute to a better understanding of how nurses prevent and manage pressure injuries.     

Practice versus knowledge when it comes to pressure ulcer prevention

Purpose: This study was completed to determine the current knowledge and documentation patterns of nursing staff in the prevention of pressure ulcers and to identify the prevalence of pressure ulcers.Methods: This pre-post intervention study was carried out in three phases. In phase I, 67 nursing staff members completed a modified version of Bostrom's Patient Skin integrity Survey. A Braden Scale score, the presence of actual skin breakdown, and the presence of nursing documentation were collected for each patient (n = 43). Phase II consisted of a 20-minute educational session to all staff. In phase III, 51 nursing staff completed a second questionnaire similar to that completed in phase I. Patient data (n = 49) were again collected using the same procedure as phase I.Results: Twenty-seven staff members completed questionnaires in both phase I and phase III of the study. No statistically significant differences were found in the knowledge of the staff before or after the educational session. The number of patients with a documented plan of care showed a statistically significant difference from phase I to phase III. The number of patients with pressure ulcers or at risk for pressure ulcer development (determined by a Braden Scale score of 16 or less) did not differ statistically from phase I to phase III.Conclusion: Knowledge about pressure ulcers in this sample of staff nurses was for the most part current and consistent with the recommendations in the Agency for Health Care Policy and Research guideline. Documentation of pressure ulcer prevention and treatment improved after the educational session. Although a significant change was noted in documentation, it is unclear whether it reflected an actual change in practice.     

Collagenase treatment of Dupuytren’s contracture using a modified injection method

Background and purpose — Treatment of Dupuytren’s contracture (DC) with collagenase Clostridium histolyticum (CCH) consists of injection followed by finger manipulation. We used a modified method, injecting a higher dose than recommended on the label into several parts of the cord, which allows treatment of multiple joint contractures in 1 session and may increase efficacy. We studied the occurrence of skin tears and short-term outcome with this procedure.

Patients and methods — We studied 164 consecutive hands with DC, palpable cord, and extension deficit of ≥ 20º in the metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joint (mean patient age 70 years, 82% men). A hand surgeon injected all the content of 1 CCH vial (approximately 0.80 mg) into multiple spots in the cord and performed finger extension under local anesthesia after 1 or 2 days. A nurse recorded skin tears on a diagram and conducted a standard telephone follow-up within 4 weeks. A hand therapist measured joint contracture before injection and at a median of 23 (IQR: 7–34) days after finger extension.

Results — A skin tear occurred in 66 hands (40%). The largest diameter of the tear was ≤ 5 mm in 30 hands and > 10 mm in 14 hands. Hands with skin tear had greater mean pretreatment MCP extension deficit than those without tear: 59º (SD 26) as opposed to 32º (SD 23). Skin tear occurred in 21 of 24 hands with MCP contracture of ≥ 75º. All tears healed with open-wound treatment. No infections occurred. Mean improvement in total (MCP + PIP) extension deficit was 55º (SD 28).

Interpretation — Skin tears occurred in 40% of hands treated with collagenase injections, but only a fifth of them were larger than 1 cm. Tears were more likely in hands with severe MCP joint contracture. All tears healed without complications. Short-term contracture reduction was good.     

传染病专科医院新型冠状病毒肺炎护理应急管理体系构建与实施

目的构建传染病专科医院应对新型冠状病毒肺炎护理应急管理体系,并分析实施效果。方法在新型冠状病毒肺炎疫情暴发期间,迅速构建集管理、培训、调配、救护、感染防控为一体的整体化重大传染病疫情护理应急管理体系,并严格实施。结果从2020年1月21日设置新型冠状病毒肺炎发热门诊和隔离病区,至3月2日发热门诊共接诊发热患者2 330例次;隔离病区收治确诊患者58例,治愈出院56例,转院2例。无医务人员感染。结论护理应急管理体系的建立与有效实施,能够提升传染病专科医院新型冠状病毒肺炎应急救治能力。     

无陪护模式病房不同能级护理人员承担工作项目调查

目的了解山东省三级综合性医院无陪护模式病房不同能级护理人员承担工作项目情况,为实现护理人力资源优化管理提供基础和依据。方法自行设计无陪护模式病房临床护理人员能级对应相关情况调查表,对山东省6所三级医院无陪护模式病房551名护理人员承担部分工作项目情况进行调查。结果不同能级护理人员承担各护理工作项目有所侧重(均P<0.01),但均承担所有工作项目;基础护理、执行治疗是主要的临床护理工作,分别占23.81%、22.00%;临床教学及科研所占的比重最少,分别占8.17%、2.51%;无陪护模式病房护理工作的主力是大专学历、初级职称及工龄不足3年的护士。结论护理人力资源配置的不合理及利用低效率并存,护理管理者应制定科学的护理人力资源配置标准,并根据不同岗位的专业技术要求配备相应能力的护士,从而优化护理人力资源管理。     

Evaluation of a multifactorial approach to reduce the prevalence of pressure injuries in regional Australian acute inpatient care settings

The aim of the study was to compare the changes in the prevalence of pressure injuries from 2008 to 2014 in relation to staff behaviour in acute/subacute inpatient care settings. In 2008, the large regional health district Hunter New England Local Health District implemented an initiative called the Crystal Model which resulted in changes in their policy and an e‐learning education program for all nursing staff. A retrospective cross sectional study compared data from the 2008, 2010 and 2014 point prevalence surveys of PI in acute services. These were collected as part of an annual pressure injury prevention and management quality audit for adult inpatients. The total number of participants included 1407 participants in 2008, 1331 participants in 2010 and 1199 participants in 2014. From 2008 to 2014 there was a 15.7% decrease in percentage of patients with hospital‐acquired pressure injuries and the percentages of each stage of pressure of injury 1–4 decreased. From 2008 to 2014 the completion and documentation of risk assessment, the documentation of repositioning and the implementation of pressure‐relieving equipment increased. A multifactorial model can reduce the prevalence of pressure injuries in acute inpatient settings. The theories of knowledge translation and the modified Theory of Planned Behaviour can be utilised to analyse changes in health professionals habituated pressure injury prevention practice