Abstract
The aims of this randomised controlled study were to determine whether the application of silicone adhesive dressings with standard preventive care would reduce the impairment of skin integrity and to evaluate the subepidermal moisture (SEM) value in anatomical locations to predict impairment of skin integrity. Of the 71 intensive care unit patients enrolled, 35 and 31 were randomly assigned to the intervention and control groups, respectively. The SEM value was measured at each site (the coccyx, sacrum, and both buttocks) repeatedly three times at every dressing change. Collected data were analysed by multivariate linear regression, and least square means analysis was used to compare the SEM value at the sites of pressure injury (PI) and blanching erythema. There were fewer PIs (1 vs 9) and incidences of blanching erythema (5 vs 6) in the intervention group than in the control group (P = 0.006). The SEM value and difference of the SEM value from the initial value was higher in the group with PIs than in the group without PIs (P < 0.0001 and P = 0.001, respectively). There was a statistically significant difference in the incidence of impaired skin integrity between the groups. The SEM value may be an indicator for detecting impairment of skin integrity.
Keywords: intensive care unit, pressure injury, randomised controlled trial, silicone adhesive dressing
1. INTRODUCTION
The incidence and prevalence of pressure injury (PI) are sensitive nursing quality indicators that can be used to evaluate the quality of nursing. The incidence of PI provides validated evidence for evaluation of the effectiveness of nursing interventions for pressure ulcer prevention activities and serves as a reliable reference to compare the performance before and after quality improvement activities. Various nursing strategies for preventing incidence and prevalence of PIs can contribute to the improvement of nursing quality.
In addition, the initial accurate diagnosis of a PI is an important nursing task in the clinical setting because it provides fundamental data to nurses, so they can perform appropriate nursing interventions to prevent progression to the severe stage of PI in intensive care unit (ICU) patients who have many risk factors at an early stage. Patients in the ICU have a high severity of disease and low consciousness because of the use of medications such as sedatives.1 Their condition makes it difficult to change their positions regularly.2 These patients are also more likely to develop skin damage than other patients because of nutritional imbalance, oedema, hypoxia, and hypoperfusion as a result of the use of medical devices, such as ventilators and hypodermal therapy. The use of therapeutic medical devices, such as continuous renal replacement therapy, a ventilator, and hypothermia, and the use of various medications, such as sedatives, analgesics, and vasopressors, are the reasons why ICU patients have an increased risk of developing PIs.3 Critically ill patients are at risk of PIs owing to immobility, impaired sensations, insensible fluid loss, urinary or faecal incontinence, perspiration, and skin loss.4 Therefore, intertrigo, incontinence‐associated dermatitis, and PIs caused by friction and moisture from skin folds are common skin problems in ICU patients.5 Many patients who are maintained with the head of their bed elevated to 30° because of enteral feeding or respiratory problems in the ICU are subject to increased shear forces and friction.6
The incidence of PIs in the ICU was reported to be 12.3%‐46.5.7 The incidence of PIs was 28.2% in the neurological ICU, and the rates of prevalence of PIs were 23.7% and 37.5% in the ICU in South Korea.8, 9, 10 Of the patients admitted to the ICU, 33.3% developed PIs on the first to third day after admission. Stage 2 PIs occurred in 75% of patients, and stage 1 PIs occurred in 25%.10 According to previous studies, the application of a prophylactic dressing has been suggested to prevent PI in ICU patients, and it has been recently reported that prophylactic dressings can help reduce the incidence of PIs associated with medical devices.11, 12 However, there has been insufficient evidence that a certain type of dressing is more effective than other dressings for preventing pressure injuries.12
It is important to apply prophylactic dressings to reduce the incidence of PIs as positive outcomes have been reported with preventive interventions, but it is also necessary to evaluate the outcome after performing appropriate nursing interventions. Accurate diagnosis of PIs after appropriate preventive nursing intervention is an important factor in evaluating nursing quality. Monitoring the incidence and prevalence of PI is one of the well‐known, reliable, and validated quality indicators for evaluating nursing outcomes. An accurate diagnosis of PI involves a visual assessment of the patient's skin condition, such as ischaemic tissue change.
However, it has been reported that the accuracy of visual discrimination of stage 1 PIs using clinical photographs was 55% to 55.8%, and the accuracy increased to 74% to 74.1% after the nurses received training.13, 14 It has been suggested that there is a limit to visual discrimination in correctly diagnosing the stage of PI in clinical practice. The early detection of stage 1 PIs is a predictive factor for assessing the effect of preventive interventions and preventing the PIs from becoming severe; thus, early detection could reduce the prevalence of PIs.
The relationship between change in the subepidermal moisture (SEM) value and skin assessment by visual discrimination was investigated in order to predict the occurrence of PIs as a non‐invasive and objective physiological index.15, 16 The SEM value is a measurement of localised oedema and skin damage caused by pressure. The use of the SEM value has been studied for blanching erythema and stages 1 and 2 PIs and for its discriminatory ability to differentiate between intact skin and tissue with pressure‐induced skin damage; the SEM value has been suggested as one of the objective indicators for predicting the occurrence of PIs.15, 16, 17
The purposes of this study were to evaluate the effect of maintaining skin integrity, including the prevention of PI, by applying a silicone foam dressing, which is easy to remove and reapply without damaging the skin of patients in the ICU, and to investigate the SEM values in anatomical locations to predict the development of PI and blanching erythema.
2. METHODS
Informed consent was obtained from the participants or their proxy. Study approval was obtained from the relevant institutional review board (No. 2015‐1532‐001).
This randomised controlled trial screened 71 critically ill patients who were admitted to the ICU in two acute hospitals in South Korea from June 2016 to October 2017. Inclusion criteria were patients who did not have incontinence‐associated dermatitis or PIs before study participation, those with intact skin (Braden Scale score < 18), and those with four or more of the following: cardiac arrest during the current admission; diabetes mellitus/shock within 48 hours; weeping oedema; use of traction; use of sedative drugs, vasopressors, or paralytics for more than 48 hours; use of mechanical ventilation for more than 48 hours; liver failure; malnutrition (prealbumin level < 20, albumin level < 2.5, or nil per os > 3 days); quadriplegia or spinal cord injury; and age older than 65 years. Exclusion criteria were patients with a contraindication to changing positions, those with an existing PI on admission, and those younger than 18 years.
Patients who met the study inclusion criteria were randomly allocated to either the control group (n = 31) that received standard PI prevention strategies or the intervention group (n = 35) that received standard care along with the application of a silicone adhesive dressing (Allevyn Gentle Border, Smith & Nephew, Mölndal, Sweden) on the sacrum and buttocks every 3 days. Five patients were subsequently excluded because of incomplete data or failure to remain in the ICU for at least 48 hours.
2.1. Data collection and study procedures
The data collected for each patient were obtained from electronic medical records. These data consisted of demographic information, reason for admission, comorbidities, physiological variables, and time of initiation of mechanical ventilation. The Braden Scale score and risk factors for PI, including cardiac arrest, use of vasopressors for more than 48 hours, weeping oedema or systemic oedema, use of traction, liver failure, diabetes mellitus, use of paralytic agents or sedative drugs, mechanical ventilation for more than 48 hours, spinal cord injury, and history of PI, were evaluated by trained nurses in the ICU. The research team showed the nurses how to apply the prophylactic dressing on the sacrum, coccyx, and both buttocks. PIs were classified as stages 1, 2, 3, and 4; suspected deep tissue injury; or unstageable based on clinical practice guidelines from the National Pressure Ulcer Advisory Panel.
All patients were monitored every 3 days during their ICU stay by trained nurses to assess whether PIs had developed. When determining the presence of PI, nurses removed the applied dressings partially to evaluate the patient's skin condition visually, and then, they reapplied the dressing afterwards.
The SEM values of the sacrum, coccyx, and both buttocks were measured every 3 days. However, blanching erythema of the sacrum and coccyx was evaluated by visual assessment only. The measurement of the SEM value was performed by an observer using the Delfin MoistureMeter D (Delfin Technology, Ltd, Kuopio, Finland).
2.2. Statistical analysis
We determined the sample size using a two‐group comparison of the proportion power calculation. The significance levels and power for the required sample size were calculated using two‐tailed tests. In the intervention group, the development rate of PIs (p1) was projected to be 10%, and in the control group, it was projected to be 35% (p2). With power set at 80% and an alpha of 0.05, 36 patients would be required for each group to meet the criteria of our power analysis and allow for a 20% dropout rate in each group.
The homogeneity of the intervention and control groups was tested using the χ 2 test or Fisher exact test for categorical variables and independent t test for numerical variables. In addition, the risk factors for PI and blanching erythema were assessed. The χ 2 test was also used to determine the development of PIs and blanching erythema based on the effect of the prophylactic dressing between the groups. To determine differences of the SEM value between the groups, multivariate linear regression analysis was used to compute least squares means for the two groups after adjusting for the covariates. The difference of the SEM value was estimated by least squares means after being adjusted by patients' body mass index, albumin level, Braden Scale score, and continence as covariates. The paired t test was used to compare SEM values between sites of PIs and blanching erythema and three other observed sites of intact skin with prophylactic dressing in the same patient. All statistical analyses were conducted using SAS software, version 9.4 (SAS Institute Inc., Cary, North Carolina), and we designated statistical significance as a P‐value <0.05.
3. RESULTS
Patients' mean age was 61.03 ± 17.44 years, and their mean Braden Scale score was 14.29 ± 2.53. Mean Braden Scale scores were 13.40 ± 2.03 and 15.29 ± 2.69 in the intervention and control groups, respectively. No significant differences were found between the two groups, except for the Braden Scale score (Table 1).
Table 1.
Homogeneity of variables between the intervention and control group (n = 66)
| Variable | Total, mean ± SD or n (%) | Intervention group (n = 35), mean ± SD or n (%) | Control group (n = 31), mean ± SD or n (%) | P‐value |
|---|---|---|---|---|
| Gender | ||||
| Male | 34 (52.52) | 19 (54.29) | 15 (48.39) | 0.632 |
| Female | 32 (48.48) | 16 (45.71) | 16 (51.61) | |
| Age (y) | 61.03 ± 17.44 | 62.34 ± 16.92 | 59.54 ± 18.16 | 0.520 |
| BMI (kg/m2) | 22.77 ± 5.08 | 23.08 ± 6.34 | 22.42 ± 3.23 | 0.598 |
| Use of inotropic drugs | 1.80 ± 0.40 | 1.77 ± 0.42 | 1.83 ± 0.37 | 0.500 |
| Albumin level (mg/dL) | 3.14 ± 0.68 | 3.16 ± 0.63 | 3.10 ± 0.72 | 0.766 |
| Braden Scale score | 14.29 ± 2.53 | 13.40 ± 2.03 | 15.29 ± 2.69 | 0.002 |
| Haemoglobin level (mg/dL) | 11.86 ± 2.16 | 11.65 ± 2.39 | 12.09 ± 1.87 | 0.417 |
| SEM value | ||||
| Coccyx | 55.39 ± 16.31 | 55.31 ± 16.35 | 57.61 ± 16.44 | 0.572 |
| Sacrum | 54.56 ± 15.03 | 52.11 ± 15.38 | 57.32 ± 14.36 | 0.162 |
| Right buttock | 47.95 ± 12.56 | 47.68 ± 13.42 | 48.25 ± 11.72 | 0.856 |
| Left buttock | 49.80 ± 11.02 | 49.08 ± 11.09 | 50.61 ± 11.06 | 0.578 |
| Bristol stool type | 4.80 ± 2.14 | 4.94 ± 2.16 | 4.64 ± 2.12 | 0.576 |
| Stool frequency (n) | 1.02 ± 1.35 | 1.25 ± 1.50 | 0.74 ± 1.12 | 0.124 |
| Diagnosis | ||||
| Cardiovascular disease | 10 (15.15) | 8 (22.86) | 2 (6.45) | 0.437 |
| Respiratory disease | 8 (12.12) | 4 (11.43) | 4 (12.90) | |
| Neurovascular disease | 27 (40.91) | 14 (40.00) | 13 (41.94) | |
| Nephrologic disease | 3 (4.55) | 2 (5.71) | 1 (3.23) | |
| Cancer | 9 (13.64) | 3 (8.57) | 6 (19.35) | |
| Other | 9 (13.64) | 4 (11.43) | 5 (16.13) | |
| Cardiac arrest | ||||
| Yes | 0 (100) | 0 (100) | 0 (100) | — |
| No | 66 (100) | 35 (100) | 31 (100) | |
| Shock | ||||
| Yes | 8 (12.12) | 4 (11.43) | 4 (12.90) | 1.000 |
| No | 58 (87.88) | 31 (88.57) | 28 (87.10) | |
| Oedema | ||||
| Yes | 1 (1.52) | 1 (2.86) | 0 (0) | 1.000 |
| No | 65 (98.48) | 34 (97.14) | 31 (100) | |
| ABR | ||||
| Yes | 61 (92.42) | 31 (88.57) | 30 (96.77) | 0.360 |
| No | 5 (7.58) | 4 (11.43) | 1 (3.23) | |
| Liver failure | ||||
| Yes | 4 (6.06) | 1 (2.86) | 3 (9.68) | 0.335 |
| No | 62 (93.94) | 34 (97.14) | 28 (90.32) | |
| DM | ||||
| Yes | 22 (33.33) | 13 (37.14) | 9 (29.03) | 0.485 |
| No | 44 (66.67) | 22 (62.86) | 22 (70.97) | |
| Sedation >48 h | ||||
| Yes | 17 (25.76) | 10 (28.57) | 7 (22.58) | 0.579 |
| No | 49 (74.24) | 25 (71.43) | 24 (77.42) | |
| Use of a ventilation >48 h | ||||
| Yes | 23 (34.85) | 15 (42.86) | 8 (25.81) | 0.147 |
| No | 43 (65.15) | 20 (57.14) | 23 (74.19) | |
| Use of restraints | ||||
| Yes | 29 (43.94) | 20 (57.14) | 9 (29.03) | 0.022 |
| No | 37 (56.06) | 15 (42.86) | 22 (70.97) | |
| History of pressure ulcer | ||||
| Yes | 3 (4.55) | 3 (8.57) | 0 (0) | 0.241 |
| No | 63 (95.45) | 32 (91.43) | 31 (100) | |
| Albumin level | ||||
| >3.3 mg/dL | 26 (39.39) | 16 (45.71) | 10 (32.26) | 0.264 |
| ≤3.3 mg/dL | 40 (60.61) | 19 (54.29) | 21 (67.74) | |
| NPO >3 d | ||||
| Yes | 10 (15.15) | 5 (14.29) | 5 (16.13) | 0.835 |
| No | 56 (84.85) | 30 (85.71) | 26 (83.87) | |
| Braden Scale score | ||||
| >19 | 3 (4.55) | 0 (0) | 3 (9.68) | 0.002 |
| 15‐18 (low risk) | 29 (43.94) | 11 (31.43) | 18 (58.06) | |
| 10‐14 (high risk) | 33 (50.00) | 24 (68.57) | 9 (29.03) | |
| <9 | 1 (1.52) | 0 (0) | 1 (3.23) | |
| Faecal incontinence | ||||
| Yes | 42 (63.64) | 22 (62.86) | 20 (64.52) | 0.889 |
| No | 24 (36.36) | 13 (37.14) | 11 (35.48) | |
| Feeding | ||||
| Yes | 36 (54.55) | 22 (62.86) | 14 (45.16) | 0.150 |
| No | 30 (45.45) | 13 (37.14) | 17 (54.84) | |
| Use of antibiotics | ||||
| Yes | 48 (72.73) | 26 (74.29) | 22 (70.97) | 0.763 |
| No | 18 (27.27) | 9 (25.71) | 9 (29.03) | |
| Use of steroids | ||||
| Yes | 19 (28.79) | 10 (28.57) | 9 (29.03) | 0.967 |
| No | 47 (71.21) | 25 (71.43) | 22 (70.97) | |
| Haemoglobin level | ||||
| <10 mg/dL | 13 (20.00) | 9 (26.47) | 4 (12.90) | 0.427 |
| 10‐12 mg/dL | 35 (53.85) | 17 (50.00) | 18 (58.06) | |
| ≤13 mg/dL | 17 (26.15) | 8 (23.53) | 9 (29.03) | |
| Faecal continence | ||||
| Yes | 45 (70.31) | 21 (63.64) | 24 (77.42) | 0.228 |
| No | 19 (29.69) | 12 (36.36) | 7 (22.58) | |
| Urinary incontinence | ||||
| Yes | 45 (83.33) | 26 (92.85) | 19 (73.08) | 0.072 |
| No | 9 (16.67) | 2 (7.14) | 7 (26.92) |
ABR, absolute bed rest; BMI, body mass index; DM, diabetes mellitus; NPO, nil per os; SEM, subepidermal moisture.
Eleven PIs developed during this study. Of 35 patients, 5 developed PIs that were classified as stage 1 in the intervention group. Of 31 patients, 9 in the control group developed PIs that were classified as stage 1. Overall, 11 of 66 patients were diagnosed as having blanching erythema (intervention group: 5/35 patients, control group: 6/31 patients) (Table 2).
Table 2.
Effects of the prophylactic silicone adhesive dressing on skin integrity
| Variable | Total, n (%) | Intervention group (n = 35), n (%) | Control group (n = 31), n (%) | P‐value |
|---|---|---|---|---|
| Developed a skin problem | ||||
| Yes | 20 (30.8) | 5 (14.7) | 15 (48.4) | 0.003 |
| No | 45 (69.2) | 29 (85.3) | 16 (51.6) | |
| Occurrence of impaired skin integrity | ||||
| Developed PI (stage 1) | 10 (15.2) | 1 (2.9) | 9 (29.0) | 0.006 |
| Developed blanching erythema | 11 (16.7) | 5 (14.2) | 6 (19.4) | |
| Intact skin | 45 (68.1) | 29 (82.9) | 16 (51.6) | |
PI, pressure ulcer.
There was a statistically significant difference between the groups regarding the development of impaired skin integrity (14.7% vs 48.4%, P < 0.003). Compared with the control group, the intervention group especially showed a significantly lower incidence of PIs (2.9% vs 29%, P < 0.006) and blanching erythema (14.2% vs 19.4%) (Table 2).
The least squares mean of the SEM values of the sites of impaired skin integrity was 69.60, and the difference of the SEM value from the baseline value was 13.65, which was higher in the intervention group than in the control group. Those values were significantly different between the groups with and without impaired skin integrity (P < 0.0001 and P = 0.001, respectively). In addition, the least squares mean of the SEM values and difference of the SEM value were statistically significantly different between patients with PIs and blanching erythema and those without PIs and blanching erythema (P < 0.0001 and P = 0.024, respectively) (Table 3).
Table 3.
Comparison of the least square mean of the subepidermal moisture (SEM) value and mean difference of the SEM value between the groups
| Least square means | |||||
|---|---|---|---|---|---|
| Variablea | SEM | P‐value | Difference of the SEM value | P‐value | |
| Impaired skin integrity | Yes (n = 21) | 69.60 | <0.0001 | 13.65 | 0.001 |
| No (n = 45) | 46.64 | 2.56 | |||
| Development of PI | (n = 10) | 73.23 | <0.0001 | 15.49 | 0.024 |
| Development of blanching erythema | (n = 11) | 70.38 | 14.09 | ||
| Intact skin | (n = 45) | 43.21 | 2.30 | ||
PI, pressure ulcer.
Adjusted variables: body mass index, Braden Scale score, albumin level, and continence.
When comparing the SEM value (71.77 ± 13.75 vs 54.43 ± 8.92, P = 0.0001) and difference of the SEM value (14.73 ± 8.97 vs 2.43 ± 8.80, P = 0.0002) of the site of impaired skin integrity on the day of occurrence with three other sites of intact skin in the same patient, a significantly high SEM value was found. Patients with PIs and blanching erythema especially showed a higher SEM value of the site of impaired skin integrity than of the three other sites of intact skin on the day of PI development (81.20 ± 12.35 vs 57.10 ± 6.79, P = 0.0001) and blanching erythema (69.18 ± 11.85 vs 52.00 ± 10.20, P = 0.0003) (Table 4).
Table 4.
Comparison of the mean subepidermal moisture (SEM) value at site of pressure ulcers and mean difference of the SEM value among three observed sites on the day of occurrence of impaired skin integrity
| Variable | SEM value, mean ± SD | P‐value | Difference of SEM value, mean ± SD | P‐value | |
|---|---|---|---|---|---|
| Impairment of skin integrity | Developed site | 71.77 ± 13.75 | 0.0001 | 14.73 ± 8.97 | 0.0002 |
| 3 other sites | 54.43 ± 8.92 | 2.43 ± 8.80 | |||
| Pressure injury (stage 1) | Developed site | 81.20 ± 12.35 | 0.0001 | 14.06 ± 8.97 | 0.129 |
| 3 other sites | 57.10 ± 6.79 | 6.90 ± 10.33 | |||
| Blanching erythema | Developed site | 69.18 ± 11.85 | 0.0003 | 14.73 ± 8.97 | 0.0001 |
| 3 other sites | 52.00 ± 10.20 | −1.64 ± 4.55 | |||
4. DISCUSSION
This study's results showed that silicone adhesive dressings (Allevyn Gentle Border, Smith & Nephew) were useful for reducing the incidence of PIs and blanching erythema and that the SEM value could be an indicator for detecting skin injury with visual discrimination when diagnosing PIs.
The prophylactic dressing was also effective in preventing PIs in previously reported research studies.4, 6, 11, 18, 19, 20 This finding suggests that using the silicone adhesive dressing as a prophylactic dressing may reduce the development of PIs and prevent blanching erythema from progressing to stage 1 PI.
Prior research suggests that not all localised erythema is non‐blanching and that not all temporary erythema is blanching.21, 22 Although transient erythema (reactive hyperaemia) is referred to as a compensation mechanism of ischaemic events in subdermal tissue, localised blanching or non‐blanching erythema is regularly considered an indicator of ischaemic tissue change because of pressure. The early detection and prevention of blanching erythema resulting from ischaemic tissue change is also important in reducing the development of PIs. The application of prophylactic dressings plays a pivotal role in preventing ischaemic tissue events and maintaining skin integrity; for example, the dressings serve as a preventive strategy and can help reduce shearing force and friction.
The present study also demonstrated a higher SEM value for sites of impaired skin integrity than for three other sites of intact skin in the same patients. Thus, compared with patients with intact skin, those with impaired skin integrity may have a higher SEM value. The diagnosis of PI and blanching erythema depends on visual discrimination in the clinical setting. The higher SEM value of the affected site could reflect ischaemic tissue change caused by pressure, which is similar to a visual indicator. One study reported that a higher SEM value was found in patients with stage 1 PI and erythema than in those with intact skin, and a higher SEM value was observed as the condition progressed beyond stage 2.15 Our finding that the SEM value was much higher in stage 1 PIs than in blanching erythema is similar to the results of a previous study.15
The sites of impaired skin integrity where PIs occur and the inflammatory reaction in the epidermis and dermis cause a change in the interstitial fluid.16 The SEM value may be a non‐invasive, reliable method for predicting the development of PIs, and it is currently used in PI prevention programmes.23
High SEM values were consistent with the visual differential diagnosis, and the results were similar to those reported when the SEM value was higher, indicating that PIs or skin erythema were more likely to occur after 1 week. However, there is a limit to the comparison with previous studies because the period of occurrence of the PIs could not be predicted because the period from occurrence of blanching erythema to PI development was not measured.
According to previous research, the SEM value was higher in stage 1 PIs compared with normal skin, and it became higher as the skin impairment progressed beyond stage 2. Further research is necessary to confirm the difference of the SEM value between blanching erythema and non‐blanching erythema with visual discrimination and to evaluate how to prevent blanching erythema from becoming severe PIs based on the changing SEM value.
4.1. Study limitations
This study has a few limitations. Participants in this study were patients in the ICU at two acute hospitals; thus, there is limitation in generalising our research study findings. There is also a limitation in the evaluation of impaired skin integrity because PIs and blanching erythema were assessed over a short period. In this study, only differences in SEM values between blanching erythema, PIs, and normal skin were observed. Further study is needed to determine how the SEM value changes over time when blanching erythema progresses to PIs in order to provide direct evidence that there may be a difference in SEM values between PI and blanching erythema.
5. CONCLUSIONS
Here, the incidences of PI and blanching erythema were lower when the silicone adhesive dressing was applied with standard preventive interventions. The prophylactic dressing was effective for reducing the development of impaired skin integrity because of pressure and shearing force. The SEM values of sites of developed PIs and blanching erythema were higher than the initial value and the value at three other sites of intact skin in the same patients. Therefore, the SEM value may be used to diagnose PIs at an early stage and enable physicians to perform appropriate interventions to prevent PIs. Additional research is needed to reinforce the effect of prophylactic dressing on impaired skin and to investigate the difference of the SEM value based on ischaemic tissue changes caused by pressure, including reactive hyperaemia and non‐blanching erythema.
ACKNOWLEDGEMENTS
This research was supported by Smith and Nephew. We acknowledge the research nurses who worked in the intensive care unit and provided assistance with the study preparation and data collection.
Lee YJ, Kim JY, Shin WY. Use of prophylactic silicone adhesive dressings for maintaining skin integrity in intensive care unit patients: A randomised controlled trial. Int Wound J. 2019;16(Suppl. 1):36–42. 10.1111/iwj.13028
Funding information Smith and Nephew
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