Tips and tricks for the prevention and management of Medical Adhesive-Related Skin Injury (MARSI)

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Join us to hear from Global skin integrity expert Prof Dimitri Beeckman, who discusses the impact on patients of Medical Adhesive- Related Skin Injury, and how to implement prevention and management strategies to improve outcomes.

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SPEAKER:

Welcome to Smith and Nephew’s Closer to Zero podcast, bi-monthly podcast with leading experts in wound care hosted by Smith and Nephew, helping health care professionals in reducing the human and economic costs of wounds.

RUTH:

Hello and welcome to today's podcast. Today we're talking about medical adhesive related skin injuries. We're really privileged to have our special guest, Professor Dimitri Beeckman, who’s a Professor of Nursing Science at Ghent University in Belgium and Orebro University in Sweden. He's the current president of the European Pressure Ulcer Advisory Panel and the International Skin Tear Advisory Panel and a council member of the European Wound Management Association.

And, you know, Dimitri, you're a specialist in skin integrity and research around this topic. And so we're really happy that you're able to share with us today. So welcome.

PROFESSOR DIMITRI BEECKMAN:

Thank you, Ruth. It's a pleasure to be here.

RUTH:

So, I guess to start off with on this topic, because I think perhaps it's a little bit under sort of estimated or there's not such a great awareness of this as a topic. Can you just explain what medical adhesive related skin injury, or MARSI as we shorten it too, is and, you know, what are the implications for clinical practice?

PROFESSOR DIMITRI BEECKMAN:

Yes, sure. That's a very good opening question. Well, actually, the MARSI or the medical adhesive related skin injuries, they develop or they occur when there is superficial skin layers that are removed by the application or the use of a medical adhesive. And in clinical practice, so what we can see, it's the development of erythema.

Sometimes even accompanied by the manifestation of a skin trauma that can be a reaction. And that also includes the development of, let's say, small blisters, vesicles, bullae, even wound development, skin erosion. More severely, we can see even skin tears.

And what's most, and not most but important, is when we define a skin tear or a MARSI, that it is related to a certain time between the removal of the medical adhesive and the presence or the occurrence of the reaction. So there is some consensus that it will persist longer than 30 minutes after the removal of the adhesive.

We also have to realise that those MARSI's they do not only affect the integrity of skin, but they also can have an impact on pain levels. Of course, the risk of infection because there is denudation of the skin, there is separation of skin layers and it can potentially increase the wound size.

For example, in peri-wound skin damage and it can delay wound healing. So it is a significant problem in our clinical practice. There is not that much awareness in clinicians or by clinicians. So increasing the awareness is really, really fundamental.

I briefly discussed about the importance of skin stripping, for example, by the removal of skin layers. But there are other categories of MARSI's as well, and that's what we call the more dermatitis reactions. And we, well, defined two types. There is the irritant contact dermatitis and the allergic contact dermatitis.

In the allergic contact dermatitis, there is an allergic reaction towards the certain components within the adhesive. And irritant contact dermatitis means that there is no real allergic reaction but there is the development of, for example, oedema, not oedema, but erythema associated with the application of the device.

So we have to differentiate between the different types of MARSI, the types and the subtypes. And that might be somewhat difficult in our clinical practice. And then the third group of MARSI's are what we call, let's say, the more miscellaneous.

These are associated with maceration and with folliculitis. So MARSI itself as a concept has been discussed in the literature, let's say, the last five to 10 years. But still, there is no real consensus on how to define the concept because there are so many subtypes. So that's quite a lengthy answer, I think, to your question there Ruth.

RUTH:

Oh, thank you for explaining that, Dimitri. I think that's made it really clear and obviously the impact on the patient and so on. So, you know, obviously we're using adhesives on patients in all sorts of settings and, you know, from small, you know, having a blood test, for example, right through to surgical procedures through to ICU. So how big a problem is this, would you say?

PROFESSOR DIMITRI BEECKMAN:

Well, it's a good question but quite difficult to answer. The main reason for this is that we don't have an international or a national standard for reporting. So the overall incidence, prevalence is unknown. We realise that there are health care facilities that do organise quality improvement projects, and as part of these quality improvement projects, they collect data about MARSI.

But that is mainly at a local level. So merging those data and comparing those data is currently not possible because there is no overall reporting system. What we also know is that this skin condition is actually underreported, OK.

So there are some reports indicating that in some cases, it can go up to a prevalence of 25%, even 54%. So it's not a small problem. And even then with these figures, we know that there is a lot of underreporting. But it's important also to mention, is that there are certain vulnerable populations. And in this case, so these are, well, mostly the patients in the extremes of age.

So that means the neonatal population and children because of the known or not mature skin. And then the elderly population or the population of older people because of their, let's say, compromised skin due to the ageing process.

But again, the size of the problem or an accurate estimate of the size of the problem is currently impossible due to the lack of that standard.

RUTH:

OK, thank you. But, you know, I think most of us who've been in clinical practice will know how often this problem occurs and so it is probably very commonly dealt with. But what are some of the risk factors that should be considered, would you say, Dimitri?

PROFESSOR DIMITRI BEECKMAN:

Well, as I mentioned before, there are several more vulnerable groups. And so these patients are in the extremes of age. Being neonatal, neonates and children and then the elderly or the older population. And we know that in the elderly, there is a lot of age-related dermal fragility. Infants, for example, in the neonatal intensive care, they have an underdeveloped epidermis.

So that is a significant and important risk factor. We've got malnutrition and dehydration, which are intrinsic factors. The presence of incontinence and moisture because that will impact maceration of the skin.

So and if you apply additionally, a medical adhesive on a wet skin, so that might increase the risk of maceration but also skin stripping and even the development of incontinence associated dermatitis. So that's a compromised skin. There are certain medications of which we know that they impact the perfusion of the skin but also the, for example, the elasticity or the proliferation of skin cells.

And these are corticosteroids and radiation, and also chemotherapy. Patients with more dermal pathology like, for example, eczema, we know that they are at risk of MARSI development as well if a medical adhesive is applied.

And of course, and I think that's one of the most important patients with risk, that's those patients that require frequent dressing changes. Because these dressing changes, of course, so you lift the dressing, you remove the dressing so that might affect the skin integrity. So, and this is really a summary of the different risk factors.

So the list is much longer. The most important to remember is that there are intrinsic risk factors and extrinsic risk factors. And that the most important extrinsic risk factor is the use of the adhesives, specifically tapes and dressings.

RUTH:

OK, thank you for outlining that. And perhaps, you know, I understand there is a very recent best practice recommendation sort of document on MARSI. Can you perhaps give us a little bit of an overview of that document?

PROFESSOR DIMITRI BEECKMAN:

Yes, there is an interesting document published by the Journal of Wound Care about medical adhesive related skin injuries (1). And in that document, they make a summary of the different stages in the preventative process, from the risk assessment up to the level of the application and the removal of the adhesive.

So I will try to give you an overview. But before starting with this overview, I just want to mention the three important components in your preventative strategy. The first one is the careful selection of the adhesive products, the second one is the correct application of the adhesive product and the third one is the considerations to make when you remove the adhesive products.

So these are the three cornerstones of proper prevention. So at the level of risk assessment, we recommend a routine assessment in all patients before an adhesive is applied and an additional assessment at each change of the adhesive being a dressing, being a tape and the early observation of signs for skin damage. So that's the first step in your preventative approach.

The second step is prepare the skin before the application of the adhesive. Clean skin, dry skin, maybe even considering of clipping or trimming the hair. And avoid the use of products that dry the skin because a dry skin, again, is an additional risk factor for skin for MARSI development.

The third consideration is the selection of the medical adhesive. Always connect with the patient's skin type. Why is the adhesive needed? What's the individual's risk of skin damage when I apply the adhesive? And do I need to repeatedly remove and reapply the adhesive in that patient? So these are interesting questions to ask yourself before applying the adhesive.

The third component in your preventative strategy is application and removal. Always follow the manufacturer's instructions when applying or removing an adhesive medical device.

When you apply it, the skin should always be in full contact with the dressing. Do not apply with tension or stretching and apply in the correct orientation. Use gentle pressure to smooth the adhesive product into place without any gaps or wrinkles. So that's for the application part.

For the removal part, we recommend to not use a one swift action. So that means we have to support the skin, we have to keep the dressing horizontal to the skin and we recommend to remove it slowly. So not in one swift action. Remove the adhesive in the direction of the hair growth, keep the tape or the dressing parallel to the skin and push the skin away from the tape with the other hand.

So these are all, let's say, practical recommendations when removing an adhesive product. In some cases, we can even consider the application of a skin barrier product before the adhesive is applied. In that case, we recommend the use of alcohol-free products.

Please consider the presence of infection because if there is infection, the application of a skin barrier product may be contraindicated. An important recommendation as well is that the barrier products must be left to dry before covering the adhesive or before the skin is covered by the medical adhesive.

So always let the barrier product dry before you apply something to the skin. And then at a more general level, we recommend to maintain optimal skin health by using appropriate washing and cleansing techniques, avoiding water and soap washing and no, let's say, rough rubbing of the skin because that's additional skin damage.

So just to summarise, there are three important elements in this prevention plan. So first of all, the gentle application, the gentle removal and the use of gentle products. So what we know from the literature is that foams and gentle and silicone tapes, they're more gentle to the skin.

And while cloth tape will adhere more strongly to the skin, it can tear the skin. So an important recommendation for a clinician is if you apply a tape, reconsider the use of silicone tape or a foam.

Tapes with a stretching ability or a stretch ability, they are more appropriate and even excellent to go over joints and areas that are prone to oedema because they, this will reduce the risk for tension injuries or blister formation. And in some cases, you can consider the use of a tubular netting or a gauze to secure the dressing in place rather than a tape.

Because if you apply a tape, it might, there is always a risk to add to the compromised or the fragile skin. So these are three recommendations of preventative level of which I think that they are helpful and can guide you in your clinical decision making.

RUTH:

That's some really great advice there. And also, Dimitri, would you say that the use of adhesive removers has a role to play in preventing MARSI?

PROFESSOR DIMITRI BEECKMAN:

Yes, that's a good question. Yes. There is a role of adhesive removers to be applied because, well, they will help you in that gentle approach towards removing of the adhesives. So, my answer to this is yes.

RUTH:

Thank you. And how would we go about documenting or categorising MARSI?

PROFESSOR DIMITRI BEECKMAN:

That's a good question, Ruth. First of all, I need to, well, to say that we don't have a national or an international standards or a local reporting system for MARSI. We even do not have an adequate clinical coding. And that impacts, of course, the comparison of data between different regions, between different organisations, between different countries. We don't have a separate classification system for MARSI.

We do have a classification system for skin tears, but we don't have a classification system for MARSI as a concept. So what I think is important is that in clinical practice, there is an increase of the awareness of the existence and the importance that MARSI play in our day-to-day care.

So recognition of MARSI as a problem, recognising the different types being the mechanical MARSI, being skin stripping, skin tearing, tension injury, the dermatitis caused by an allergic reaction or more an irritant contact dermatitis, the recognition of maceration caused by the accumulation of moisture and the application of, or the covering by a medical adhesive and, of course, the folliculitis.

So first of all, I think in terms of documentation and classification, we need to go into more increased awareness and recognition of the different types of MARSIs.

But again, we don't have a national standard. What we do know is that in many healthcare facilities, there are local projects, quality improvement projects. So they measure the presence of MARSI, the different types, and then they develop certain, let's say, strategies to reduce the impact that MARSI's have on clinical practice. But they all use a different reporting system.

So again, merging the data and comparing the data currently is not possible. So what do we recommend in terms of classification and documentation? So all MARSIs, they should be documented in the patient’s file and in a local reporting system.

If we document MARSI, it should include the photograph of the injury that is taken at the time that it occurred or when it was first observed. So it's not enough just to have like a written description of the MARSI, but it also should include the photograph. And besides documentation, also the patient and the family, they should be informed about the presence of the injury.

So that's my, let's say, reply, lengthy reply to the importance of classification and documentation.

RUTH:

Yeah, and that's really interesting, I think, isn't it? That perhaps it isn't documented as often as perhaps it should be, and that is a very important point, isn't it?

So what would be your take-home messages today for our listeners, Dimitri? Because we've covered quite a lot of ground there and it is a big topic. So, you know, what would be some of your take-home points?

PROFESSOR DIMITRI BEECKMAN:

So first take-home message is that MARSI, they are an adverse skin reaction, some cases even damage caused by the use of a medical adhesive that is applied on the skin. So that's my first take-home message. That's a kind of a definition.

The second one is that MARSIs, they can occur in anyone who needs a medical adhesive. So everyone needs proper assessment, skin assessment before and during the application of a medical adhesive. A third take-home message is that MARSI, they are actually largely preventable if we apply prevention, timely and on a continuous basis.

Skin examination of all patients prior to the application of the adhesive and as long as the medical adhesive is in place is truly fundamental. And then maybe a last take-home message is related to knowledge, awareness and attitudes towards this problem. So we recommend the use of, or the application of proper education and ongoing support for patients and health care professionals when it comes to recognition, identification and prevention of MARSI.

RUTH:

Well, thank you, Dimitri. That's, I think, really given us some food for thought and hopefully raising the awareness of this issue and the impact it does have on patients and health care resources. So thank you so much for sharing with us today.

And to our listeners, there will be some resources available attached to the podcast. And please join us for our next podcast shortly. So thank you, Dimitri, and we'll speak soon. Thank you.

PROFESSOR DIMITRI BEECKMAN:

Thank you. Bye bye.

(MUSIC PLAYS)

SPEAKER:

Medical adhesive related skin injuries are largely avoidable with a good prevention strategy. (1) Find out how Smith and Nephew can augment your prevention protocol with our skin integrity solutions. These include SECURA™ No Sting Barrier Film, REMOVE™ Adhesive Remover and our silicone tapes and dressings such as ALLEVYN™ Foams and OPSITE FLEXIFIX™ Gentle. For more information, contact your local Smith and Nephew representative or email us at profed.anz@smith-nephew.com.

SPEAKER:

The information presented in this podcast is for educational purposes only. It is not intended to serve as medical advice. Products listed outline with care are examples only. Product selection and management should always be based on comprehensive clinical assessment. The detailed product information including indications for use, contraindications, precautions and warnings, please consult the products applicable, instructions for use prior to use. Closer to Zero. The only target worth aiming for.

References:

1. Fumarola S, Allaway R, Callaghan R, Collier M, Downie F, Geraghty J, Kiernan S, Spratt F. Overlooked and underestimated: medical adhesive-related skin injuries. Best practice consensus document on prevention. J Wound Care 2020; 29(Suppl 3c):S1–S24.

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Speakers

Prof. Dimitri Beeckman

Prof. Dimitri Beeckman is Professor of Nursing Science at Ghent University (Belgium) and Örebro University (Sweden). He is Visiting Professor at the Royal College of Surgeons in Ireland, Monash University (Australia) and the University of Southern Denmark. He is the President of European Pressure Ulcer Advisory Panel (EPUAP), the International Skin Tear Advisory Panel (ISTAP) and a council member of the European Wound Management Association (EWMA). He is the Programme Director of the Masters in Nursing and Midwifery at Ghent University. He leads the Skin Integrity Research Group (SKINT) at Ghent University and the Swedish Centre for Skin and Wound Research (SCENTR) at Örebro University. He specialises in skin integrity research, clinical trials, education, implementation, instrument development and psychometrics. He is the author of over 150 scientific publications and has presented his research in more than 60 countries. He is on the Editorial Board of the Journal of Wound, Ostomy and Continence Nursing, the Journal of Tissue Viability, International Journal of Nursing Studies Advances, Systematic Reviews and BMC Geriatrics. He holds international fellowships such as at Sigma Theta Tau International Honour Society of Nursing and at European Academy of Nursing Science.

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