Why care about skin tears?
Tune in to our NZ Wounds Awareness Week special, with Wendy and Mandy as they discuss the latest research and best practice documents relating to skin tear prevention and management.
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Welcome to Smith & 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 cost of wounds.
Hello, I'm Ruth Timmins from Smith & Nephew. Welcome and thank you for listening. It's New Zealand Wound Awareness Week and today's episode is 'Why Care About Skin Tears' with our special guests, wound experts Wendy White and Mandy Pagan, joining us from New Zealand. Wendy is a credential wound clinician and qualified educator with over 30 years of wound and skincare specific clinical expertise from a wide range of settings and in private practice. Mandy is the current president of the New Zealand Wound Care Society and has been a clinical nurse specialist in wound care for over 15 years. So, welcome to both of you and thank you for joining us today for this podcast discussing this very important topic. So Mandy, like Australia, I see New Zealand is having a Wound Awareness Week. Can you tell us a bit about this?
Yes, kia ora Ruth and Wendy, and listeners. It's a real privilege to be here today with you all representing the New Zealand Wound Care Society. Yes, it's a very exciting time for us. This is the first time we've actually had a Wound Awareness Week in New Zealand. The week is based on the Wound Australian model, and thank you so much to Wounds Australia for kindly sharing your resources with us. So, we have, in New Zealand, partnered with our Accident Compensation Corporation, or ACC for short. And we're going to focus on a new topic each year and this year is obviously focused on skin tears and we're going to run the week from 24-30 August.
OK. So, why did you choose this topic?
Yes, well, as we know, skin tears are a really common, painful and preventable skin and tissue injury, and obviously we know they really have higher rates occurring in neonates and older adults due to their compromised skin. We want to raise awareness with the public and the health care professionals on how to prevent and manage these injuries, and to prevent a non-healing wound. As a wound specialist, I often receive late referrals for people with chronic lower leg wounds caused by a skin tear. Healing is compromised due to the underlying comorbidities such as arterial venous disease. If these were identified early and best practice treatment was provided, we could have actually prevented a chronic wound developing. We know that non-healing wounds greatly affect a person's quality of life and places additional financial burden on an already strained health care system.
So, how will you raise skin tear awareness in New Zealand?
Yeah, so we're going to promote this day throughout New Zealand and we've really pulled on our key stakeholders such as ACC, the Health Quality and Safety Commission, Age Concern, looking at our consumers, our primary healthcare organisations, College of Gerontology Nursing, and primary healthcare nurses. Also importantly, our aged care facilities and through our membership.
If you go to our New Zealand Wound Care Society website, you can actually access all of these resources our team have developed, and special thanks to Liz, Kate, and Maria for doing this. It basically includes a healthcare professional poster and you can download this and print it as handouts or an A3 poster size. But also, we're going to be circulating posters to all aged care facilities in New Zealand and also to our committee members who will circulate these in the areas throughout New Zealand. We have also developed a consumer skin tear information sheet that is available from New Zealand Doctor.
So, anyone, including consumers in New Zealand, can register for this freely and download it. Then, very specially, on 24 August, we have a free webinar on skin tears and we'll be covering an overview of what they are, prevention, assessment, and management. This recorded webinar can then be used for further education by participants. So please get involved and visit our website so you can download this.
You know what, I just wanted to let you know Mandy, when New Zealand and the group in New Zealand put their mind to something, you guys do it so well, and I wanted to congratulate you with not only your subject matter or your focus for Wounds Awareness Week in New Zealand but the way that you have worked together across the continuum and these resources, not only for those providing care but those who could potentially be those living with skin tears. So, my congratulations to all.
Thank you, Wendy.
Yeah. So, I mean, we know skin tears are the most common skin injury in residential aged care facilities. So, how can we prevent these injuries in this high-risk group?
Yes, it is a very vulnerable group and in 2019, I co-authored a pilot research study looking at implementing a skin and wound care program into hospital level aged care facilities and this is actually published in the Wound Practice and Research journal.(1) This involved conducting pre-knowledge questionnaires and focus group work with nurses and, very importantly, health care assistants. Staff identified the need for a standard skincare regime and skin prevention and management plan. Practice issues included using large tubs of creams that were often contaminated with skin cells and that's from double-dipping. Also, creams were often decanted into little unlabelled containers, not knowing what they were and, of course, becoming contaminated also. So, we developed a standard skincare formulary that included a soap substitute, a moisturiser, and a barrier for incontinence to help standardise management and also looking at dressing regimes for skin tears. We actually included the ISTAP skin classification tool (2) . In post focus groups, nurses reported they preferred this ISTAP classification tool, as it was easier to understand compared to the STAR and this was also supported, sorry, by post knowledge testing.
Yeah, it's really interesting, isn't it? Mandy, I take myself back to 2001 where I did a national registered nurse looking at their opinions, their knowledge base and their practice in residential aged care. (3)And, you know, it's really sad to sort of say that the findings were quite similar and here we are nearly two decades later after skin tears as an injury were never in the literature before 1991, but we have come down the track but we still need to do this better, don't we? And I think we've been, in Australia and New Zealand, we've been on a real journey with this and I think we were really lucky in the mid to late 2000s that so much work was being undertaken by Curtin University and Silver Chain and this development of the STAR classification tool.(4)
They also embraced and used the earlier definition from Payne-Martin. And for the first time, we began to have some, I guess, direction of how we could be preventing, classifying, and managing. So, as that was shared from Australia across to New Zealand, I think there will be many people that will attest that once adopted and once educated and once people are using, that this was a system that we were quite used to using. And in fact, in 2010 and 2011 when the international group sort of got together and there was, for the first time consensus, they took a survey, an international survey of users from around the world, and they found that in our region, Australia, New Zealand, Japan, a little bit of Southeast Asia, they were actually quite used to STAR and used to that approach but outside of that region, they found that there were many people not using assessment skills and tools and also, they weren't aware of what was available.(5)
And I think what we see Mandy, is like a transient workforce, don't we? You know, that you could have introduced someone to a tool a couple of years ago but now they don't work there anymore and there's now new staff. So it's not surprising to find that we continually have people that haven't seen something, they haven't been exposed to it, they don't understand it. And I guess this international survey, if you were to summarise what the international group found, was that there was a lack of use of a standardised classification and that they wanted something to be simple. So by 2013, that's when we started to see this introduction on a global perspective of, could this simple category system of one, with no skin loss, two, with some skin loss when you're able to reposition the flap, and then three, when there is no flap and it's a complete open wound.
So, it's been an interesting transition and I guess, really, that global momentum has continued to grow with the 2018, I think it was, the best practice document from ISTAP(2) looking at the recommendations for the prevention and management of skin tears in the aged, and then they followed that up as an international group in 2020 with the best practice (6) recommendations for holistic sort of strategies to promote and maintain skin integrity.
And then, of course, the lead of that group at the moment, Professor Beekman from Ghent University, they're continuing that research of that classification system that you guys are using. I have been told that definitely the direction from the international group is that if people are using one approach and they're using it well, and it's embedded in their systems and documentation, will continue to use it. If there's an opportunity to introduce and this is going to help and aid, then consider using the ISTAP tool versus the STAR.
I guess the bottom line is that there's this thought process that whether we're doing wound skin research, that it has been suggested that we can still be comparing the findings of these two. I think it's really important that the B flaps that were part of the STAR, this was right back in the origins, wasn't it, when silicon and gentle and sort of atraumatic dressings were either just entering markets but they certainly weren't widely used and widely available. So, it's been a really interesting sort of historical journey that we've been on both locally and globally relating to skin tears in this very high-risk group.
So Mandy, you mentioned in your study a skincare regime was developed. So, did the skincare regime reduce skin tear rates?
Well actually Ruth, it did. It was...the regime was actually only applied once a day, and I know with a lot of the research coming through talks about a twice daily moisturising regime,(7) but we actually even found even a daily application was enough to reduce skin tear rates in this population, in these two facilities. And this was actually sustained post-program because they keep implementing the skin care regime. Staff are very excited. A healthcare worker said they could see the difference in the residents' skin.
It just looks so much more healthy and better, and also, it really empowered our healthcare assistants because they are the ones that are predominately applying the creams. They are predominately the ones bathing and showering our residents, and they're the ones providing those skin inspections. So they're vital including in any of what we do. So, they understand the process but also to escalate if things aren't going well, or in fact, you know, we have a lot of residents with other skin conditions such as eczema and we do know sometimes a moisturising regime may feed this and make it worse. So, we do actually obviously have to get the diagnosis right. But generally, overall, it was great. And then, the healthcare assistants were actually pulling the nurses up and telling them what to use and how to use the regime. So, that was really exciting. I thought it was fantastic.
Yeah, you know, what's really interesting about what you've said is that it really does take the team approach, doesn't it? It takes everyone working together, inclusive of the individual potentially being taught these strategies and I've noticed that that's a bit of an emphasis as well too, of self-care and the role of the carer, but all of us working together, even down to the management and facilities who will choose to invest and make sure that these products are available and you're in a really lucky sort of set up, really, aren't you, in New Zealand, Mandy, that you are being supported with these strategies to make sure that you have the product there available to use and to improve the quality of their ageing skin.
Yes, in New Zealand, we do have a government agency called PHARMAC and certainly a lot of creams and those are subsidised, so that makes it more affordable, but also, they can be prescribed which obviously when they're prescribed, they are then used and utilised for residents as well. But of course, there's always better creams and lotions out there and we're always looking at better methods or ways of actually looking after people's skin. So, we constantly are looking and obviously learning about different types of creams also.
So, apart from the skincare regime, what are some of the other preventative actions we can take to prevent skin tears?
You know, I think it's really important to actually understand what your skin tear rates are. And look, this could be even in community aged care facility and district health boards and hospitals, but also feeding it back to your staff, is really important. Audit and feedback are really powerful to help effect change. And also, doing a root cause analysis and that's basically a simple thing, applying the five whys, and this is putting down a specific problem that you have or what you're trying to prevent, such as, obviously, skin tears, and asking why the problem occurred.
And then write underneath this, lots of whys until you can't ask anymore why-questions up to maybe five times and then you can have a look at what major contributing factor is. So, then you actually can work on it towards maybe implementing better management and prevention plans. But obviously, health care workers, we can cause these injuries. It's really important, short, filed nails, minimising jewellery. Anything like that can actually cause severe skin tears in this compromised population and obviously, that safe environment. When we are doing a lot of activities with these residents and people in their homes, it's during those contact times that they're at higher risk of developing these injuries. So, it's doing those really important safe handling techniques and reducing the risk of that friction and sheer actions as well. Using your slide sheets and you guys know how to use those. Encourage the individual to wear protective footwear but also long sleeve clothing and obviously, trousers over the legs but also utilising arm and skin protectors can also help. Falls prevention, really important. And obviously, we have a lot of these injuries and actually very dramatic injuries and horrendous injuries are caused from falls. But obviously, looking at nutrition and hydration also. That's vital, and smoking cessation because we know that is not good for skin health. But also review of medications. A lot of these people are on polypharmacy, a lot of medications and these can affect skin health or actually increase their risk of confusion and falls leading to skin tears.
Yeah, it isn't just one thing, is it? It's like everything in skin and wound care, it's multi-modal and you can't just do one thing and think that that's the answer or the panacea for this quite complex problem, isn't it? And, you know, I'm looking at the resource that you've developed with your partners in New Zealand for raising the awareness and let's talk about skin tears, and you look at things that are related specifically to them, to their skin, to their health, the tools that are available to help you with your preventative strategies and I think, again, there's been this very comprehensive way of looking how can we do this better and how can we reduce the number of these injuries, and of course, reduce the number of them that transition onto slow or non-healing wounds.
So, should we avoid adhesive skin closure strips for these wounds?
Well, actually, with the study that I did, it was a revelation really for the staff to actually not to use them at all or obviously minimal use is what we obviously recommend. We know with this really fragile compromised skin, they can actually increase the risk of skin trauma on removal and actually cause another skin tear. And if they're applied under tension, they can actually cause blistering and compromise the blood flow to their skin flap. And non-elastic strips do not allow for swelling and they can compromise circulation again to the skin flap. Often, I see in practice, that they're put too closely together. This then trips the drainage, the wound cannot drain which, of course, it will. It's a trauma injury, so it will have exudate levels. And also, you can't actually see the skin tear. So, you cannot do a visual assessment of this because they are covered too much in the skin closure strips. But look, there are places sometimes that, yes, we may need to use them especially injuries on the face and head because it's really difficult to apply dressings to this challenging area but also, thinking about how they should be used. I mean, they have no absorbency. So they should be applied skin-to-skin not skin-wound-skin. They have no absorption, so it just does all healing properties. Also to consider, and this is really for a lot of our older persons coming to emergency departments, that we really want to avoid sutures and staples as well. And of course, our silicone dressings now provide wonderful options to actually provide flap-securing and to actually, we actually don't need to be using these adhesive strips like we used to.
Yeah, and it's a challenge, isn't it because we can get so caught in a practice yet once - did you find Mandy, that when you were able to share these messages about some of the downsides of when we do choose to use this modality. Did that sort of make sense to people? I mean, one of the common things that we would always see as well was potentially secondary trauma on removal of those blood-soaked and stacked up, thick and hard layers, with then unfortunately, some moisture collection underneath. And so, that risk of secondary tearing and on this very compromised skin is real, isn't it? So, I think giving those strategies and those reasons to those, will make a huge difference in actually changing direction of practice across the board in New Zealand.
Absolutely and I think sadly, often the packs, they come with quite a lot of sort of closure strips in the packaging, and staff sort of feel when they open it, they should use every strip and that's not what it's about. And so, it is. It's just changing practice and questioning what we're doing and, of course, preventing further trauma.
And look, I wanted to just add to that as well too. I must admit that I have seen on the small number of occasions, skin tear injuries that were so significant in their size that there was no, sort of, suitable product within the formulary that would have actually dressed it or managed it or covered it appropriately and safely. So, I think the instructions that you gave about its correct application, the way they were always meant to be used, but just noting that on the odd occasion you may come across a wound that just falls out of your dressing size but it doesn't happen that often. But, you know, just worth noting.
So, Mandy, what would be your top three take-home messages for our listeners today for this topic?
Yes. Well, there's probably 20 Ruth, but we will break it down to three. OK.
So, obviously, prevention is key but really, we want to do individual assessments. So, we're actually looking at the risk factors important to that person and then putting that plan in place and putting in that skincare regime. Please, just moisturise that skin but also involve your residents and all your patients, consumers, to moisturise themselves. They can reach their arms, so please get them involved, you know, if you can and they can moisturise their face also. But also your health care assistants, they must be involved. They are pivotal, they are doing the hands-on care, they are fantastic, what they provide in looking after that person for us and we need to actually empower them and give them good standard regimes that they can follow and implement. So my second take-home message is develop a standard skin tear dressing formulary. So this is important so staff know what to use in the area and obviously, again, as we've already discussed to avoid or minimise the use of those adhesive dressings but also the adhesive closure strips. And early referral, please. I'd love to see these people as soon as they have this occur like a serious injury to the leg or upper limb, obviously, to actually prevent their chronic, non-healing wound developing. Especially we have, we talked about other comorbidities, you know, oedema, venous and arterial diseases. We really have to get to these people early and start a regime incredibly early and shifting oedema if we can get this healing quicker.
So, Wendy, what would be your three take-home messages today?
Well, I'm like Mandy. It was sort of hard to really think but look, for me, it's gentle hands, gentle hands, gentle hands. You know, understanding the changing anatomy of advanced ageing skin and this disconnect and this fragility and their risk of the formation of senile purpura. You know, they are a skin tear injury waiting to happen. So, a take-home for me is just make sure that we know what the definition of this injury is, that we understand that it is traumatic injury, it does involve forces of friction, shear, or a blunt bang or a knock. And by knowing that, we understand that it's going to be when their skin comes in contact with an object or when it comes in contact with our hands, or the activities that our hands are doing. And it's what we choose to stick on to the skin and how we choose to remove things, how we choose to handle them. So, I guess my sort of summary of that is I'm constantly telling myself to slow down and to be gentle.
And, Mandy, you flagged about the fact that you really want to see these wounds not move on to those difficult complex wounds and we know that the ISTAP best practice, for the very first time, put forward this thing about a more complicated skin tear and they did talk about the more complicated the skin tear can be is often related to the complexity of the person that it's on and that it can sometimes, and very often, be associated with the anatomy of the lower leg.(2) And you did allude to this but that's a real take-home for me, that complex people can produce complex wounds even though historically, skin tears can be perceived as simple. I don't think they're simple at all. There are a break to the integrity. So, just think about the person and particularly, think about those legs with the impact of oedema and the vascular system, as Mandy alluded to. So we were pretty similar in that as a take-home. And I guess finally, is that nutrition and hydration, as was one of those key preventative interventions. It is often the thing that we think of last when things have gone awry or they're just not going well and we think, oh gee, we better look at that. There is recognition now that sound and balanced nutrition and hydration is part of maintaining the health of skin and that those presenting with frequent recurrence, multiple tears on their body or those that you just get one skin tear resolved and that afternoon, they've got another one, don't overlook nutrition, nutritional screening and appropriate interventions. This link between these kinds of injury and risk of malnutrition or malnutrition is now confirmed. So, that's my take-home message. Don't think of nutrition last, think of it quite early. So, they are my three.
Thank you Wendy and thank you again, Amanda, and thank you for listeners for joining us today to hear your insights and expertise into this very key area and some practical tips how we can take the latest evidence back to the clinical setting. So, be sure to tune in for our next podcast, and we'll see you then.
Happy Wound Awareness Week, New Zealand.
Thanks, Australia. You too.
Thank you again. Bye for now.
Nurses have told us how using ALLEVYN Life foam dressings and the One More Day kit has helped them reduce home visits while providing confidence to patients and carers on how dressings work and when they need to be changed. For more information, contact your local Smith & Nephew representative or email us at firstname.lastname@example.org.
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1. Pagan, M. & Harvey, P. Implementing a pilot skin and wound care programme in two residential aged care facilities. Wound Practice and Research Journal, 27(4), 184-192
2.LeBlanc K et al. Best practice recommendations for the prevention and management of skin tears in aged skin. Wounds International 2018. Available to download from www.woundsinternational.com
3. White, W. Skin tears: a descriptive study of the opinions, clinical practice and knowledge base of RNs caring for the aged in high care residential facilitiesPrimary Intention 2001; 9(4):138-149.
4. Carville, K. et al. STAR: a consensus for skin tear classification. Primary Intention 2007; 15: 18-28.
5. LeBlanc K, Baranoski S, Christensen D et al (2013) International Skin Tear Advisory Panel: A tool kit to aid in the prevention, assessment, and treatment of skin tears using a Simplified Classification System. Adv Skin Wound Care 26(10): 459-76
6. Beeckman D et al (2020) Best practice recommendations for holistic strategies to promote and maintain skin integrity. Wounds International. Available online at www.woundsinternational.com
7. Finch K, Osseiran-Moisson R, Carville K, Leslie G, Dwyer M. Skin tear prevention in elderly patients using twice-daily moisturiser. WoundPract Res [Internet] 2018;26(2):99–109
- Posters for healthcare workers can be downloaded in A3 or A4 format from https://www.nzwcs.org.nz
- FREE Skin Tear Education Webinar available via https://www.nzwcs.org.nz
- Please register on the NZ Doctor website for the FREE skin tear patient Information sheet https://nzdoctor.co.nz/everybody-patient-sheets
MWoundCare. BEd. RN. Plast Cert. MACN. FWA
Fellow Wounds Australia
Wendy has 30 years of wound & skin care specific clinical expertise from a wide range of settings and in private practice. She is a qualified educator and has delivered quality education, clinical and professional support services in national and international arenas including healthcare, residential, government, industry and insurance settings for the past 13 years.Wendy’s areas of wound related clinical interest, research or publication include skin tear prevention and management, minimising wound related pain (including low resource setting), assessment & differentiation of neuropathic pain, wellbeing when living with a wound, clinicians as advocates, person engagement & partnerships, pressure injury prevention & management frameworks for change and advancing debridement knowledge & practice skills acquisition training programs. Wendy is a recipient of a Wounds Australia Fellowship (previously known as the Australian Wound Management Association), in recognition of her contribution to clinical practice, education, research and leadership in wound management throughout Australia, and the Asia Pacific region.
MHSc, PGDip Wound Care, RN
Southern District Health Board, Invercargill, New Zealand
President of the NZ Wound Care Society
Kia ora, I have been nursing for 30-years and have been employed as a clinical nurse specialist in wound care for over 15-years. I lead nurse-led wound clinics that provide practical training and critical reflection to advance practice. My role involves treating all wound aetiologies, encompassing community, primary and secondary health care settings. I am the current president of the NZ Wound Care Society, and member of the Leg Ulcer Advisory Group involved in updating the ANZ Clinical Practice Guideline for Prevention and Management of Venous Leg Ulcers. I am passionate about education and my published work is focused on sharing practical knowledge to ultimately improve patient outcomes. My work ethos is beautifully summarised by the quote "Tell me and I forget, teach me and I may remember, involve me and I learn."