Introduction
A skin tear (ST) is defined as a wound caused by shear, friction, and/or blunt force causing separation of the layers of the skin.1 Skin tears are usually preventable and have a high propensity for developing into chronic wounds.2 They most commonly occur in persons at the extremes of age and in those who are critically or chronically ill. Although STs tend to be underreported, they are hypothesized to be highly prevalent and particularly troublesome for the elderly population.1 Individuals suffering from STs complain of increased pain that, when combined with the comorbid conditions prevalent in this group, tends to negatively impact health-related quality of life.3,4
Payne and Martin5 studied the epidemiology of STs and reported a 2.23% incidence rate in a group of long-term care (LTC) residents 55 years and older. In the United States, retrospective prevalence studies in the LTC population have reported prevalence rates ranging from 16% to 33%.6-9 Between 1996 and 2011, 4 prevalence studies were conducted in Australian LTC facilities; reported prevalence rates varied from 10% to 54%.10-13
A Canadian prospective study reported an ST prevalence of 22%.14 Lopez and colleagues13 also investigated potential risk factors for ST occurrence. They found that male gender, having aggressive behavior, and residing in an LTC facility was associated with a higher likelihood of developing an ST.14 A wound audit of 4 Canadian LTC facilities identified prevalence rates of 14.7% and 15.8% for STs and pressure ulcers, respectively; Woo and LeBlanc15 (unpublished data) also hypothesized a possible association between risk factors attributed to pressure ulcers and STs.
Gradual changes in the skin occur with aging; they are particularly evident in persons 65 years and older that render the skin more susceptible to shear, friction, and/or blunt force trauma.2,16-18 These changes include flattening of the epidermal-dermal junction, reduced vascularity of the dermis, impaired collagen synthesis, elastosis (accumulation of abnormal levels of elastin in the dermis owing to photoaging), senile purpura, deterioration of the sweat and sebaceous gland secretion, and xerosis (dry skin).19 These naturally occurring skin changes can be potentiated by certain medications prescribed for chronic illnesses prevalent in older adults. One example are the anticoagulants that can result in ecchymosis and increased fragility of the skin.2,19
Skin tears in the elderly may be attributable to multiple causes. White and colleagues9 observed that individuals who are dependent on others for total care seem to be at the greatest risk for STs. Independent ambulatory patients seem to be at the second highest risk, and the majority of their STs occur on the lower extremities.
Although precise cost estimates have not been studied, the high prevalence of STs, and their propensity for evolving into chronic wounds, contributes to the costs associated with these typically preventable wounds. The costs of managing an ST is roughly comparable to the cost of managing a stage 2 pressure ulcer.2,17
Preventing STs
In order to develop an effective protocol for ST prevention, healthcare professionals must address modifiable skin changes associated with aging. Preventive interventions recommended for prevention of STs include routine assessment of the patient's skin on admission and reassessment when the patient's condition changes, clothing (long sleeves and pant legs, knee-high socks) designed to reduce ST risk, shin guards for patients with repeated STs of the shins, safe patient handling techniques, education of family and facility staff, consultation with the dietitian to ensure adequate hydration and nutrition, protection of individuals at high risk for self-injury during routine care.1 Twice-daily enhancement of the skin's moisture barrier (also referred to as moisturizing dry skin) is also recommended.1-3,7
Wilson and Nix20 evaluated the effectiveness of routine moisturizing on the reduction of xerosis; they concluded that xerosis can be reduced with routine moisturizing. However, this study used a relatively small sample size (n = 16), and subjects were not randomly allocated to treatment group. In addition, Wilson and Nix did not directly evaluate the effect of the intervention on ST occurrences. The purpose of this Evidence-Based Report Card (EBRC) was to systematically identify and review evidence concerning moisturizing skin in older adults (>60 years of age) as one nursing strategy to prevent STs.
Question
Is twice-daily skin moisturizing more effective than no regular moisturizing routine in the prevention of STs in the elderly population?
Methods
A literature search was systematically (Figure) performed using CINAHL and PubMed/MEDLINE to identify documents meeting the following inclusion criteria: 60 years of age or older, literature representing prevention of STs, articles written in English or French, and publications between 1990 and 2015. Search terms included skin tears or lacerations or abrasions and prevention and dry skin (xerosis) and moisturizing (emollients, creams, ointments, lotion, administered topical, silicone, glycerin, petrolatum, dimethicone).
The initial search yielded 483 articles, which after removal of duplicates resulted in a total of 446 documents meeting the search criteria. Abstract review narrowed the search to 52 articles. A review of the full text of these resulted in the exclusion of 49 articles that did not specifically evaluate the efficacy of daily moisturizing on the skin and the prevention of STs. Following this review, 3 articles were found to be pertinent for this EBRC.
Levels of evidence for the studies were determined using the ranking system developed for EBRCs.21 The Strength of Recommendations for Treatment (SORT) statements we generated also used the taxonomy adopted for EBRCs,21 which is based on the design and strengths of the studies' designs and methods and the consistency of results across studies.
Findings
Daily Skin Moisturizing Versus No Regular Moisturizing
We identified 3 studies that met the inclusion criteria (Table 1).2,6,22 Carville and colleagues2 compared twice-daily skin moisturizing to usual routine care in the reduction of STs. Hunter and associates26 measured differences in ST occurrences before and after implementation of routine skin moisturizing as part of a larger skin care protocol. Bank and Nix6 evaluated the effect of an ST protocol, which included twice-daily skin moisturizing, on ST occurrences in an LTC facility.
Carville and colleagues2 conducted a clustered randomized controlled trial to evaluate the effectiveness of a twice-daily moisturizing regimen as compared to "usual" skin care for reducing ST incidence. Residents from 14 Western Australian LTC facilities (980 beds) were invited to participate. The facilities were sorted into pairs and matched for the number of beds and whether they provided high or low level of care. One facility from each matched pair was then randomized to the intervention group. The number of beds and participants was relatively equal in the control and intervention groups and was determined to be sufficient to detect a significant difference in incidence rates between the 2 groups. The potential source of variance from residents being clustered in LTC facilities was small and therefore was excluded in the analysis. Results were based on comparisons between residents in the study, disregarding their location in a specific LTC facility.
The intervention was twice-daily application of a commercially available, standardized pH-neutral, perfume-free moisturizer to the arms and legs. Residents in control facilities received usual care, which was described as ad hoc treatment or no standardized skin-moisturizing regimen. The components of usual care were determined from a combination of care staff surveys and management interviews. Data collection occurred over a 6-month period.
The distribution of high- and low-care residents amongst the intervention and control groups was similar (P = .917). One thousand three hundred ninety-six STs were reported in 424 residents (mean +/- SD = 3.29 +/- 3.99 STs per resident; range, 1-36). Residents in the control group of the high-care facilities had the most STs of all the groups. The incidence of STs in the intervention group was 172/424 (40.57%) residents compared to 252/424 (59.43%) residents in the control group. The authors did not report the statistical significance of this finding.
The average monthly occurrence rate per 1000 occupied bed days in the intervention group was 5.76 (0.576%) (a total of 450 STs over 6 months) as compared to 10.57 per 1000 (1.057%) occupied bed days (946 STs over 6 months) in the control group (P = .004). The application of a moisturizer twice daily reduced the occurrence of STs per 1000 occupied bed days by almost 50%.
We identified 2 studies that used a quasi-experimental pretest/posttest design to assess effects of a moisturizer on STs; both studies showed a lower rate of STs in those using a moisturizer. However, neither study specified whether the STs observed were new or existing (Table 1). Hunter and colleagues22 assessed the effectiveness of a skin care education program and protocol including the application of a skin moisturizer on skin breakdown in 2 LTC facilities. They evaluated 136 adults residing in 2 LTC facilities. A weeklong educational program about skin care and the use of a pH-balanced bodywash and moisturizing skin protectant was followed by a 3-month trial of these products and protocols. During the 3-month trial, the bodywash and the skin moisturizer were incorporated into routine care (at least once daily and up to 3 times per day). Participants' skin was assessed weekly. The rate of preventable skin conditions, including STs, decreased significantly (ST preintervention: 23.5%; ST postintervention: 12.5%; P = .007).
Bank and Nix6 assessed the clinical effectiveness of a preventive skin care protocol in an LTC and rehabilitation facility. The study design included a 13-month retrospective preintervention data collection period, followed by a 15-month postintervention ST incidence data collection period on 209 participants. The preventive skin care protocol included staff education, skin sleeves, padded side rails, gentle skin cleansers, and routine daily use of skin moisturizers. Nosocomial ST data were obtained by reviewing incident reports. Following implementation of the prevention protocols, the number of STs decreased from a mean of 18.7 to a mean of 8.73 per month (P < .001).
Summary of Findings
* Routine twice-daily skin moisturizing did not significantly result in a lower incidence of STs in LTC residents compared to usual care in one study. However, the occurrence of STs per 1000 occupied beds was 50% less and statistically significant when a moisturizer was applied twice daily when compared to usual care (Level of Evidence B).
* Skin tear prevention programs that included skin moisturizing reduced the rate of STs in LTC (Level of Evidence B).
SORT Statement
Moisturizing the skin of LTC residents twice daily as part of an ST prevention program is recommended (SORT level 2). Level of recommendation 2 is based on mixed results of one level A study and consistent results from 2 level B studies.
Clinical Implications
Considered collective, current evidence provides some support for routine use of products that enhance the skin's moisture barrier for prevention of STs in aged adults residing in LTC settings.2,6,22 Skin tear research remains in its infancy, and much of the clinical practice literature is based on expert opinion. The strength of evidence supporting this recommendation is limited by the absence of statistical testing of the difference in overall incidence between the treatment and control groups in the strongest study,2 and the study's unexplained use of an outcome adjusted for the number of occupied beds in the LTC facility. The methods of the studies indirectly show that programs of education for LTC care staff that include ST etiology, assessment, and classification are feasible and potentially beneficial. Cost savings associated with dressing supplies and labor costs may be other benefits of ST prevention. The findings of this EBRC cannot be generalized beyond the LTC population; further research is required to determine the applicability of this clinical recommendation to diverse populations within different care settings.
References