The skin is the human body’s first line of defense against microorganisms and injury.1 Skin damage increases infection rates and pain, extends the length of hospitalization and other care, and increases costs as well as mortality.2 Causes of skin damage include disease, insufficient blood perfusion, abnormal oxygen saturation, and impaired mobility.3–5 A skin tear is a traumatic wound caused by mechanical forces, including the removal of adhesives. Severity may vary by depth (not extending through the subcutaneous layer).4–7 Studies have pointed out that the top three sites of skin tears among inpatients are areas where IV catheters are placed—the neck, forearms, and groin—with a prevalence ranging from 3.8% to 17.8%.7–10 In clinical practice, it is proven that barrier film can prevent skin tears effectively.11,12 Even though it is not covered by national insurance, barrier film is affordable ($1.50) and accessible to most patients in Taiwan.
This frequently encountered situation has motivated researchers to study whether applying a skin barrier film can reduce the incidence of skin tears. To determine the different kinds of skin tears and improve peripheral skin integrity of ICU patients, the authors compared skins tears among patients receiving central venous catheterization (CVC) as a reference for medical staff selecting tubing wound care methods.
A skin tear is an acute traumatic wound caused by friction or shear that results in separation of the epidermis, dermis, or subcutaneous tissues.3–5,13 Skin tears have many causes and are associated with disease progression in patients and contingent upon care knowledge and treatment experience of nursing staff.14,15 Prior studies have found the prevalence of skin tears in the acute care setting ranges from 0% to 11.4%, with the face, head, and neck as major sites.9,10,16–18 Risk factors include age (particularly older adults and infants), limited mobility, level of consciousness, stress, friction, humidity, nutrition status, drugs, bacterial or viral infection, history of chronic diseases, critical illness, and end-of-life status.6,9,10,16,18,19–22 In addition to the above risk factors, studies revealed 17.8% to 73.91% of skin tears were caused by removal of medical dressings.2,9,10 Hence, providing good care for treatment of skin tears is important. According to McErlean et al,18 wound exudate, the size and level of the skin tear, affected part of the body, tissue around the wound, and economic status should be considered in the care of skin tears.
Central venous catheterization is often seen in critical care units. According to the HICPAC (Hospital Infection Control Practices Advisory Committee) index, the “care bundle” should include selection of the types of tube, methods of placement, care of tube, and time of tube removal by using 2% chlorhexidine gluconate solution or povidone-iodine in alcohol for the maximum of the sterile surface. A checklist for the bundle care is then used to audit completeness.23
This study was a randomized controlled trial that recruited ICU patients who underwent CVC from a medical center in Taiwan from April 1, 2017 to March 31, 2018. During the enrollment period, a total of 463 participants received CVC. Participants who fulfilled the following inclusion criteria were enrolled in the study: (1) 18 years or older, (2) received CVC inserted into the jugular vein for fluid infusion, (3) had intact peripheral skin after CVC with no abrasion or edema, and (4) agreed to participate in this study (Figure 1). A total of 102 participants met these criteria and were included in the study. Exclusion criteria were as follows: (1) participants with a confirmed diagnosis of scabies, (2) participants with a confirmed diagnosis of skin-related diseases, (3) participants who were allergic to the components of the skin barrier film (hexamethyldisiloxane, polyphenylmethylsiloxane copolymer, isooctane, and acrylate terpolymer),24,25 and (4) participants whose CVC site was not the jugular vein. A total of 361 participants were excluded.
Sample size estimation was carried out using G*Power 3.1 (Heinrich Heine University Düsseldorf, Germany), with an effect size of 0.25, power of 0.8, and significance level of .05. The authors estimated that 95 participants were required and anticipated a dropout rate of 10%; therefore, a total of 102 participants were recruited to the study. Study participants were randomized into the experimental group or control group according to preassigned numbers. During the study period, two participants each from the experimental and control groups were discharged because of a change in their condition and dropped from the study. In the end, 98 participants remained (50 in the experimental group and 48 in the control group).
Dressing change protocol requires that gauze be changed every other day unless a wound is oozing. In the experimental group, the skin surrounding the site where the CVC would be inserted into the jugular vein was first disinfected using conventional means (alcohol 75% + 10% alcoholic beta iodine). After the skin was completely dry, a single package of sterile liquid skin barrier film with a radius of 5 cm at a point 2 cm from the CVC site was applied. One film was applied each time the dressing was changed. This skin barrier film (MGB0068100; 3M Health Care Limited, St Paul, Minnesota), available in medical supply stores in Taiwan, consists primarily of hexamethyldisiloxane, polyphenylmethylsiloxane, isooctane, and acrylate terpolymer. After the film had completely dried, the authors applied 2 × 2-in gauze, using adhesive tape to fix the dressing in place. The control group received conventional care with a solution of 75% alcohol and 10% alcoholic beta iodine for skin disinfection. After the skin had completely dried, 2 × 2-in gauze was applied before using adhesive tape to fix the dressing in place. Researchers then compared skin tear incidence between the control group (dry gauze) and experimental group (skin barrier film) (Figure 1).
The demographic data included age, sex, height, weight, and medical history. Disease characteristics included risk factors related to skin tears such as level of consciousness, albumin index, coagulation function, and severity of disease (Acute Physiology and Chronic Health Evaluation [APACHE] II score),26 so these variables were included in the analysis. The International Skin Tear Advisory Panel Skin Tear Classification System was used to classify skin tears (Table 1).7
Table 1. -
INTERNATIONAL SKIN TEAR ADVISORY PANEL SKIN TEAR CLASSIFICATION 2018
|Type 1: No skin loss
||Linear or flap tear that can be repositioned to cover the wound bed
|Type 2: Partial flap loss
||Partial flap loss that cannot be repositioned to cover the wound bed
|Type 3: Total flap loss
||Total flap loss exposing the entire wound bed
Reprinted with permission from Van Tiggelen H, LeBlanc K, Campbell K, et al. Standardizing the classification of skin tears: validity and reliability testing of the International Skin Tear Advisory Panel Classification System in 44 countries. Br J Dermatol 2020;183(1):146–54.
The APACHE II scoring system was developed by Knaus et al in 1985.27 It is derived from 12 clinical measurements that are obtained within 24 hours after admission to the ICU.
The institutional review board of the hospital approved this study (case no. 201600792A3). When transferring into the ICU, researchers randomly assigned participants into control and experimental groups. Participants who fulfilled the inclusion criteria were informed of the study process. If the participant was conscious and responsive, the researcher explained the purpose of the study and patient rights before offering the informed consent form to sign. If the participant was unconscious or incapable of consent, his or her legal agents (such as spouse, parents, siblings, or children) were invited to the consultation room for an explanation of the purpose of the study and participant’s rights before being asked to sign the informed consent forms. During the study period, participants had the right to withdraw from the study without any impact on the medical care they received.
The SPSS for Windows (version 17.0; SAS Institute Inc, Cary, North Carolina) statistical software suite was used for analysis. Under the Gaussian distribution check, the statistical methods used included descriptive statistics and χ2 tests. Independent t test was used to analyze the differences between the two groups. For survival analysis, comparison determined whether there was a difference in the incidence of skin tears after the two groups underwent CVC and received two different forms of dressing change. P = .05 was significant.
Most participants were between ages 51 and 75 years (57.1%). Participants aged 26 to 50 years and 76 years or older each accounted for 21.4%. Most of the participants were male (69.4%). Their mean body mass index was 24.3 ± 4.8 kg/m2. Of the CVC sites, 3.7% were at the right jugular vein. Most participants had kidney disease (29.9%) and hypertension (25.7%). Of the participants, 76.3% underwent endotracheal intubation, 86.7% were unconscious, 96.9% had an abnormal albumin index, and 76.5% had platelet index abnormalities. The mean APACHE II score was 23.5 ± 8.22. With regard to activities of daily living, 53.1% were completely dependent. There were no differences in general characteristics and disease characteristics between the two groups (Table 2).
Table 2. -
PARTICIPANT BASELINE DATA
|Age, mean ± SD (min-max), y
||61.5 ± 15 (28–92)
|Sex, n (%) Male Female
||68 (69.4)30 (30.6)
||36 (72.0)14 (28.0)
||32 (66.7)16 (33.3)
|Height, mean ± SD (min-max), cm
||162.4 ± 8.9 (140–180)
|Weight, mean ± SD (min-max), kg
||64.2 ± 14.1 (27–106)
|BMI, mean ± SD (min-max), kg/m2
||24.3 ± 4.8 (11.3–35.4)
|CVC position, n (%) Left Right
||16 (16.3)82 (83.7)
||6 (12.0)44 (88.0)
||10 (20.8)38 (79.2)
|Comorbidities, n (%) Heart disease Kidney disease Cancer Diabetes Hypertension Stroke
||19 (12.9)44 (29.9)18 (12.2)28 (19.0)37 (25.2)1 (0.7)
||9 (47.4)22 (50.0)10 (55.6)13 (46.4)17 (45.9)0 (0.0)
||10 (52.6)22 (50.0)8 (44.4)15 (53.6)20 (54.1)1 (100.0)
|Level of consciousness, n (%) Conscious Unconscious
||13 (13.3)85 (86.7)
||7 (14.0)43 (86.0)
||6 (12.5)42 (87.5)
|Abnormal albumin, n (%)
|Abnormal platelets, n (%)
|APACHE II, mean ± SD (min-max)
||23.5 ± 8.22 (5–43)
|ADL scale, mean ± SD (min-max)
||25.1 ± 26.1 (0–100)
|ADL stage, n (%) Mild dependence Moderate dependence Severe dependence Complete dependence
||3 (3.0)6 (6.1)37 (37.8)52 (53.1)
||1 (2.0)4 (8.0)23 (46.0)22 (44.0)
||2 (4.2)2 (4.2)14 (29.1)30 (62.5)
|Type III skin tear, n (%)
Abbreviations: ADL, activities of daily living; APACHE, Acute Physiology and Chronic Health Evaluation; BMI, body mass index; CVC, central venous catheter.
Analysis of Skin Tears
There were 9.2 dressing days (catheter days) in the experimental group and 9 dressing days in the control group, with an average of one dressing change per day for both groups. The experimental group and the control group received an average of 1.0 ± 0.02 and 1.06 ± 0.12 dressing changes per day, respectively. Participants in the experimental group who underwent the skin barrier film intervention could tolerate 14.45 days of gauze covering and taping after skin disinfection, and the incidence of skin tears was 22.0%. Participants in the control group could tolerate only 11.66 days of gauze covering and taping after skin disinfection, and their incidence of skin tears was 47.9% (Table 3). Kaplan-Meier curve analysis revealed that the application of a skin barrier film before CVC protected the skin effectively, substantially reducing the risk of skin tears (P < .01; Figure 2).
Table 3. -
DRESSING CHANGE FREQUENCY AND SKIN STATUS
|Dressing change frequency, n ± SD
||1.0 ± 2
||1.06 ± 12
|Once/d, n (%)
|Twice/d, n (%)
|Skin tear-free, n (%)
|Skin tear, n (%)
|Days without skin tear
|Proportion of skin tear-free days, %
The physiologic status of critically ill participants in this study was similar to that of patients in previous studies.28–30 The overall incidence of skin tears among the 98 critically ill patients who received CVC inserted into the jugular vein was 34.7%. These results are similar to those seen in prior studies. A study by Dai et al8 found an incidence of skin tears of 19.9% among 289 patients in an internal medicine ICU. Hsu and Chang9 found a skin tear prevalence of 28.89% among 90 patients in a critical care unit and observed that 31.8% of patients had skin tears on the face, head, and neck. This study found a high proportion of head and neck skin tears in the ICU, affecting 51.9% of patients who had medical tape applied to the face to fix the location of the endotracheal tube.
The study indicated that use of skin barrier film at the site of CVC insertion can increase skin strength in participants, effectively maintaining skin integrity and reducing the incidence of skin tears. These findings provide evidence that use of skin barrier film can decrease frequency of dressing changes, as well as increase patients’ comfort and reduce pain levels, findings consistent with the results of other studies.11,12,31
Prior studies, both local and foreign, examined only the extent of skin tears. This study revealed that patients in the experimental group had more skin tear-free days compared with the control group.
This was a cross-sectional study limited to the ICU of the division of gastroenterology and hepatobiliary medicine in a single medical center. Consequently, results represent only patients’ skin tear status at a certain time point. In addition, the authors could not conduct double-blind sampling. It is recommended that future studies include more study sites, such as hospitals and ICUs in different regions, using a longer follow-up duration for patients who received CVC or by including different skin sites.
Application of the skin barrier film can effectively delay the occurrence of skin tears and reduce their incidence by half. It is recommended that this protective measure be carried out on patients with CVCs inserted into the jugular vein to improve comfort and quality of care.
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