This is an extract from the original and full article was published in: International Wound Journal ISSN 1742-4801.
A cluster randomised controlled trial was conducted to evaluate the effectiveness of a twice-daily moisturising regimen as compared to ‘usual’ skin care for reducing skin tear incidence. Aged care residents from 14 Western Australian facilities (980 beds) were invited to participate.
Skin tears are defined as partial – or full-thickness skin injuries that result from shearing, friction or blunt trauma. Skin tears are the most common wounds found amongst older adults in hospitals, residential facilities and the community, and they are predominately located on the extremities.
Australians aged over 65 and 85 years account for 14⋅2% and 1⋅9% of the population, respectively, but those over 65 years will account for 25% of the population by 2056. The increasing proportion of older persons will potentially result in an exponential increase in the incidence of skin tears and greater demands for health resources. Similar demands can be anticipated in other countries given the unprecedented population ageing globally.
The study intervention involved the twice-daily application of a standardised commercially available, pH neutral (pH 5–6), perfume-free, moisturising lotion (Abena®) to body extremities in a gentle, downwards direction. The lotion was applied by care staff or by residents if they were able, in the morning and the evening, and preferably following bathing.
All staff within the 14 facilities received education on skin tear classification and reporting, and the staff in the 7 intervention facilities received additional education on the intervention regimen and its implementation in their facility. The education was repeated at regular intervals for protocol reinforcement and for the benefit of newly employed staff.
The study was conducted over 6 months from October 2011 to March 2012.
As soon as a skin tear occurred or was identified, the reason for its occurrence was discussed with the resident or staff on duty and the reporting staff member recorded a ‘contributory factor’ (skin condition, nutritional status, corticosteroid use, or a fall, shearing, and friction forces) as the hypothesised reason for the injury. It was possible to have multiple contributory factors recorded against any tear.
A total of 420 eligible residents enrolled in the intervention group and 564 residents enrolled in the control group. Amongst these residents, 424 (172 in the intervention group and 252 in the control group) had developed at least one skin tear and were included in the analysis.
Age and Gender
There was no statistical difference between both groups in regards to age (P=0⋅097) and gender (P=0⋅083). Overall, residents were predominately female (65⋅8%) and over 80 years of age. There were three male residents aged 40, 56 and 62 years who were recipients of high care (two in the intervention group and one in the control group).
In Australia, persons under 65 years with dementia or severe disability can be found in aged care facilities and thus they were included in the analysis.
Type of Residential Aged Care
The distribution of high- and low-care residents amongst the intervention and control groups was similar (P=0⋅917). Residents in the high-care facilities had significantly more skin tears in the control group than in the intervention group (n=813 versus n=362, P=0⋅018). There was no statistical difference between the control and intervention groups in low-care facilities in terms of skin tear numbers (n=133 versus n=88, P=0⋅762).
Skin Tear Incidence Rates
Of the 424 residents who developed skin tears, 172 (40⋅57%) residents were in the intervention group as compared to 252 (59⋅43%) residents in the control group. A total of 1396 skin tears were recorded among the 424 residents (mean=3⋅29 skin tears/resident SD±3⋅99, range=1–36).
The resident with the greatest number of skin tears in the control group had 36 skin tears, whereas the intervention group resident with the greatest number of tears had 26 skin tears over the 6-month period. In the intervention group, the average monthly incidence rate was found to be 5⋅76 per 1000 occupied bed days (a total of 450 skin tears over 6 months) as compared to 10⋅57 per 1000 occupied bed days (946 skin tears over 6 months) in the control group (P=0⋅004).
Skin tears were found on all anatomical locations, but those on the extremities equated to 93⋅27% of the total. The upper limbs had 53⋅8% of these skin tears, the lower limbs 39⋅47% and other sites 6⋅73%. There was no significant difference (P>0⋅599) between the intervention and control groups when anatomical locations were collapsed by upper limbs, lower limbs, face and trunk.
However, there was a significant difference between low-care and high-care residents in the control group (P=0⋅028, χ2). Residents in low care had more skin tears on the lower limbs (49⋅62%) than residents in high care (37⋅39%) and residents in high care had more skin tears on the upper limbs (55⋅23%) than those in low care (44⋅36%). There was no difference between type of care in the intervention group (P=0⋅232, χ2).
Location Where Skin Tears Occurred
Skin tears occurred most commonly in the residents’ bedrooms and the bathrooms. All other facility locations such as the lounge, dining room, activity area, corridor, entrance foyer or grounds represented less than a quarter of overall skin tear incident locations, and a small proportion of skin tears occurred whilst the residents were off-site.
Week Day and Time When Skin Tears Occurred
Overall, more skin tears occurred on a Saturday, whilst the least occurred on a Thursday. Skin tears occurred more frequently during peak manual handling times such as when residents were being transferred into and out of their beds or when they were being assisted with bathing.
Defining Usual Skin Care Practices
The results of the pre-study survey and interviews, which were conducted to identify usual skin care practices, showed that none of the facilities had pre-existing standardised skin-moisturising protocols that described the skin-moisturising lotions to be used or their frequency of application.
Employed carers most often moisturised the residents’ skin, and the frequency of application varied between carers and facilities, occurring either daily, twice daily or adhoc.
The post-study survey and interviews found significant changes in practice in the intervention group, associated with time of day and type of moisturiser used, as well as frequency of application, and these changes equated to the intervention protocol. The pre- and post-intervention staff survey results confirmed that the moisturising intervention was implemented as per the study protocol, and that the control group moisturising practices had changed little during the study.
The study found that the twice-daily application of moisturiser to the extremities of residents in aged care facilities as compared to ‘usual’ skin care practices reduced skin tear incidence by almost 50%. The pre- and post-study surveys, which identified the usual skin care practices, provided a degree of confidence that practice contamination had not occurred between the two groups, and the lower incidence rate in the intervention group was attributable to the intervention. Furthermore, the main contributory factor for skin tears in both groups was found to be fragile skin, which is largely contingent upon xerosis and age-related changes.
As is the case with other reports, skin tears were found to be more prolific on the extremities and they were predominately STAR category 1a and 1b, where the edges can be realigned to the normal anatomical position without undue stretching. Among the low-care residents, skin tears occurred more frequently on the lower limbs, which could be assumed to relate to knocks and falls suffered by frail ambulant individuals.
The more dependent high-care residents were found to have more skin tears on the upper limbs, and it is proposed that the arms are more at risk when dependent residents are being repositioned or transferred. This assumption was reflected in the finding that the most common facility location for injury was the residents’ bedrooms and that the injuries occurred during times when residents were most likely to be transferred out of, or into, bed. Similar associations have been made by other authors. Although not the focus of this study, beds, bed-rails, chairs and wheelchairs have been reported as high-risk factors for skin tears, and prudent selection and use of these devices is warranted, as is the selection and use of skin protective devices and manually handled assistive devices.
The study findings highlight the need for standardised twice-daily skin-moisturising protocols and mandatory staff education on skin tears and their prevention. Nonetheless, 450 skin tears occurred in the intervention group despite the intervention, and this indicates the need for more studies to test other interventions to further reduce the impact of these injuries on the well-being of individuals and health expenditure in general.
A limitation of this study was that the sample comprised frail elderly Caucasians, who lived in a country with high sun exposure. Therefore, the findings of this study cannot be generalised to other populations. The need to replicate the study amongst Asian and dark-skinned elderly populations as well as those who live in more temperate or humid climates is warranted to determine if the same results can be achieved.
The study determined that the simple and relatively inexpensive application of pH neutral, perfume-free moisturiser twice daily can substantially reduce skin tears among aged care residents. Given the high prevalence of skin tears reported in hospitals as well as aged care facilities and the community, it is strongly recommended that this practice be adopted and promoted across all sectors. A reduction in skin tears and their often considerable consequences will not only result in the improved well-being of individuals, but also reduce the health care burden for agencies and individuals.
Resource: This is an extract from the original and full article was published in: International Wound Journal ISSN 1742-4801
“The effectiveness of a twice-daily skin-moisturising regimen for reducing the incidence of skin tears” by Keryln Carville, Gavin Leslie, Rebecca Osseiran-Moisson, Nelly Newall & Gill Lewin