Abstract
The aims of the study were to determine the prevalence of skin tears in the extremities and to explore factors associated with development of skin tears in inpatients at a Danish hospital. The study was designed as a point prevalence survey and included 202 patients in the age range 19–99 (mean: 70·7, SD: 16·5). The patients were assessed for presence of skin tears, numbers, locations and previous skin tears. Data were collected using a data collection sheet developed for a previous study. The survey team consisted of four specialist nurses. Data were collected over a period of 24 hours spread over 3 days. Of the 202 patients, 23 had skin tears, yielding a prevalence of 11·4%. In total, 40 skin tears were observed. Multiple logistic regression analysis showed that previous skin tears (odds ratio (OR): 9·3, 95% confidence interval (CI): 2·6–33·4, P < 0·001), ecchymosis (OR: 5·6, CI: 1·4‐23·2, P < 0·017) and risk of falling (OR: 3·8, CI: 1·2‐12·0, P < 0·021) were significantly associated with development of skin tears. The prevalence of skin tears in this study (11·4%) matches other international observations. The following risk factors were recognised: previous skin tear, ecchymosis and risk of falling. These factors could be used to identify patients requiring prevention of skin tears.
Keywords: Ecchymosis, Prevalence, Risk factors, Skin tears
Introduction
In Denmark, a skin tear is a type of wound that is often misjudged and mistreated. Skin tears are wounds caused by shear, friction and/or blunt forces resulting in separation of skin layers. Depending on the level of tissue damage, they can be classified as partial‐ or full‐thickness wounds 1.
Researchers suggest that skin tears are more prevalent than pressure ulcers and burns 2. Danish studies of pressure ulcers in six hospitals report a prevalence rate of 15–25% 3. Skin tears are common acute wounds, which in our experience are often unnoticed as they are shallow traumatic wounds, occurring mainly in elderly people. Treatment of skin tears in the elderly can be difficult and is known to be associated with prolonged hospitalisation and increased health care costs 4, 5.
The literature on prevalence of skin tears shows mostly data from Australia, Canada, Asia and the United States 6. A systematic review reported skin tear prevalence of between 3·3% and 22% in hospital settings 6. One of the lowest rates, 3·9%, was found in a cross‐sectional study (n = 410) in a long‐term medical facility at a hospital in Japan. The highest rate was found in a cross‐sectional study (n = 113) from Canada with patients in long‐stay institutions, with a prevalence at 22%.
Factors related to skin tear risk may be expected to emerge particularly in association with the aging population. Skin changes associated with aging, presence of oedema, higher concurrent risk of pressure injury development, dependence on care from others, cognitive impairment and aggressive behaviour are all viewed as factors that may contribute to skin tear development. 7, 8, 9. Skin tears are painful and can reduce the quality of life 1.
Recent studies have focused on skin characteristics that contribute to predicting skin tear development, such as the presence of ecchymosis, previous skin tear and oedema 8.
Some authors indicate that skin tears are common wounds found in the elderly population and affect their well‐being and quality of life 10, 11. They conclude that in the long‐term care setting, skin tears substantially impact the nursing workload, and it is possible that they are not treated as seriously as they should be by the staff. They further claim that skin tears are complex wounds requiring additional research and a need to focus on prevention.
Until 2014, there were no Danish studies or guidelines on skin tears. Since then, the International Skin Tear Advisory Panel (ISTAP) has been translated into Danish and validated 12, and a prevalence study in a Danish nursing home has been undertaken. That study, of 128 residents, showed a prevalence of 4·6% 13.
The aim of the present study was to determine the prevalence of skin tears in the extremities and explore factors associated with the development of skin tears in inpatients at a Danish hospital.
Methods
Study design, sample and settings
The study was designed as a point prevalence study and was conducted at a university hospital in Copenhagen, Denmark. The study included patients from cardiological, neurological, respiratory, endocrinology, geriatric and orthopaedic departments and from intensive care units. Departments such as abdominal surgery, palliative care, wound healing and dermatology were not included. Inclusion criteria were patients older than 15, who understand Danish and who agreed to participate. The criteria for exclusion were unwillingness to participate and inability to provide consent.
The study was conducted in accordance with the ethical principles laid down in the Declaration of Helsinki 14. The study has been approved by Danish Data Protection Agency (J.nr. BFH‐2016‐077). Under the rules of the Danish National Committees on Biomedical Research Ethics, this study needed no further approval. Confidentiality and anonymity of the participants were guaranteed before they entered the study. At each department, all patients were invited to participate in the study and received verbal and written information. Participants could withdraw from the study at any time.
Surveyors and data collection
The survey team consisted of four specialist nurses from the hospital's Dermatology Department and Wound Healing Centre. During the survey, the nurses were paired in two teams (one wound and one dermatology nurse in each team). The nurses were familiar with the ISTAP classification system because they had participated in the translation into Danish and validation 12 and in the prevalence study at the Danish nursing home 13. Data were collected over 3 days for a total period of 24 hours. All data collected were coded before being keyed in. The datasheets were stored securely and destroyed after the statistical analyses had been completed.
The data were collected by using a data collection sheet developed for a previous study (Figure 1, Datasheet) 13. The datasheet contained demographic data and clinical information. Type of skin tear was classified by the Danish ISTAP classification (Figure 2). Previous skin tears were observed as linear, angled or curved scars, as shown in Figure 3.
Figure 1.
Datasheet.
Figure 2.
International Skin Tear Advisory Panels Skin Tear Classification.
Figure 3.
Scars after previous skin tears.
Risk of fall was described according to a Barthel Index < 10, fall within the past 3 months, visual impairment (not reading without glasses), dizziness or reduced balance. Nutritional risk was defined as insufficient calorie intake, weight loss within the past 3 months or body mass index (BMI) < 20. The medical data were obtained from the patients' records. Risk of pressure ulcer was described by the Braden scale, where a score lower than 19 indicated a risk 15. Behaviour was registered by Richmond Agitation and Sedation Score (RASS score), and the AVPU Scale (alert, voice, pain, unresponsive) was used to describe the level of consciousness aspect. These scales have been validated.
Statistics
Student's t‐test was used to test differences between patients with skin tears and those without skin tears (nominal data). Fisher's exact test was used to investigate associations between presence of skin tears and categorical data. To identify factors predisposing to skin tears, a forward multivariate binary logistic regression analysis was performed. Odds ratios (ORs) with corresponding 95% confidence intervals (CIs) are presented. P‐values are two‐sided and considered to indicate statistical significance at values of < 0·05. Statistical analyses were performed using IBM SPSS Statistics, version 22.0 (IBM Corp., Armonk, NY, USA).
Results
Prevalence of skin tear and its location
In total, 253 patients, who were hospitalised during the observation, were assessed for eligibility regardless of the presence of skin tears. Of these, 9 patients were incapable of giving informed consent, 40 were not present – for example, because of examinations at other departments – and two had insufficient data. Therefore, 202 patients participated in the study. The patients varied in age from 19 to 99 years; mean age 70·7 (SD: 16·5). Demographic data and frequencies of skin tears are summarised in Table 1.
Table 1.
Demographics and frequencies of skin tears (n = 202)
| Mean | SD | n (%) | ||
|---|---|---|---|---|
| Gender | Male | 98 (48·5) | ||
| Female | 104 (51·5) | |||
| Age (range in years) | 19–99 | 70·7 | 16·5 | |
| Patients with skin tear | 23 (11·4) | |||
| Total skin tears observed | 40 | |||
|
7 (17·5) | |||
|
29 (72·5) | |||
|
4 (10) | |||
|
22 (55) | |||
|
18 (45) | |||
| Patients with previous skin tears | 46 (22·8) |
Skin tears were detected in 23 patients, yielding a point prevalence of 11·4%. Prevalence varied greatly among departments (specialities), ranging from 0% to 31·6% (Table 2). Forty skin tears were observed. Six patients had more than one skin tear. Skin tear type 1 accounted for 17·5%, type 2 for 72·5% and type 3 for 10% (Table 1). Of the skin tears, 22 (55%) were located on the upper extremities and 18 (45%) on the lower extremities.
Table 2.
Prevalence variation among departments
| Type of department | Total no. of patients incl. | No. of patients with skin tear | Prevalence (%) |
|---|---|---|---|
| Respiratory medicine | 21 | 0 | 0 |
| Cardiological medicine | 42 | 7 | 16·7 |
| Endocrinological medicine | 13 | 1 | 7·7 |
| Neurological medicine | 43 | 4 | 9·3 |
| Geriatric medicine | 19 | 6 | 31·6 |
| Orthopaedic surgery | 62 | 5 | 8·1 |
| Intensive care | 2 | 0 | 0 |
| 202 | 23 | 11·4 |
Multiple logistic regression analysis showed that previous skin tears (odds ratio (OR): 9·3, 95% confidence interval (CI): 2·6–33·4), risk of falling (OR: 3·8, CI: 1·2–12·0) and ecchymosis (OR: 5·6, CI: 1·4–23·2) were significantly associated with skin tear development (Table 3). Ecchymosis was defined as having one or more areas of subcutaneous bleeding larger than 3 cm2. In the total study population, the frequency of previous skin tears was 22,8% (Table 1).
Table 3.
Multi‐logistic regression analysis of predisposing factors associated with the development of skin tears
| 95% CI for EXP(B) | ||||
|---|---|---|---|---|
| Sig. of change | OR | Lower | Upper | |
| Previous skin tear | 0·001 | 9·3 | 2·6 | 33·4 |
| Ecchymosis | 0·017 | 5·6 | 1·4 | 23·2 |
| Risk of falling | 0·021 | 3·8 | 1·2 | 12·0 |
The analysis included the variables age, gender, Braden score, chronic lung disease, diabetes mellitus, oedema at lower extremities, use of prednisolone/anticoagulant /acetylsalicylic acid (ASA) dementia, walking aids, bed guard, eating sparingly and body mass index (BMI). Significant associations are presented as OR, odds ratio; 95% CI, confidence interval.
In the analysis of the influencing factors, we found several significant parameters in the group of patients with skin tears (Table 4). Older age (84·7% versus 68·9%, P < 0·0005*), use of prednisone spray for more than one year (21·7% versus 6·1%, P < 0·023*), impaired memory/dementia (34·8% versus 12·8%, P < 0·012*), risk of falling (69·9% versus 28·5%, P < 0·0005*), use of walker (87·0% versus 49·7%, P < 0·001*), bed guard rails (47·8% versus 22·3%, P < 0·019*), nutritional risk (60·9% versus 33·3%, P < 0·011*) and low Braden score (16·0% versus 19·1%, P < 0·005*) were more common in this group. Risk of falling was assessed on the basis of various data, for instance, the Barthel index, which showed 81 (40·1%) patients at risk of falling. The Richmond Agitation and Sedation Score showed that most of the patients were alert and calm (n = 194, 96%), while a few were restless (n = 5, 2·5%) or agitated (n = 3, 1·5%).
Table 4.
Univariate analysis of differences related to patients with and without skin tears
| Baseline characteristics (n = 202) | Patients with skin tear n = 23 (%) | Patients without skin tear n = 179 (%) | P‐value |
|---|---|---|---|
| Age (n = 202) | 84·696 (SD 10·24) | 68·933 (SD 16·3262) | <0·0005* |
| Male (n = 98) | 8 (34·8) | 90 (50·3) | 0·188 |
| Female (n = 104) | 15 (65·2) | 89 (49·7) | 0·188 |
| Previous skin tear (n = 46) | 19 (82·6) | 27 (15·1) | <0·0005* |
| With ecchymosis (n = 63) | 20 (87·0) | 43 (24·0) | <0·0005* |
| Chronic pulmonary lung disease (n = 46) | 8 (34·8) | 38 (21·2) | 0·184 |
| With oedema in the extremities (n = 67) |
9 (39·1) |
58 (32·4) | 0·638 |
| Diabetes mellitus (n = 37) | 4 (17·4) | 33 18·4) | 1·000 |
| Braden score (n = 202) | 16·043 (SD 3·8669) | 19·084 (SD 3·6824) | <0·0005* |
| Use prednisone tablet >3 months (n = 12) | 4 (17·4) | 8 (4·5) | ND |
| Use prednisone spray >1 year (n = 16) | 5 (21·7) | 11 (6·1) | 0·023* |
| Use anticoagulant/ACE, tablet (n = 84) | 9 (39·1) | 75 (41·9) | 1·000 |
| Impaired memory/dementia (n = 31) | 8 (34·8) | 23 (12·8) | 0·012* |
| Risk of falling (n = 67) | 16 (69·9) | 51 (28·5) | <0·0005* |
| Use walker (n = 109) | 20 (87·0) | 89 (49·7) | 0·001* |
| Use wheelchair (n = 54) | 9 (39·1) | 45 (25·1) | 0·209 |
| Bed guard rails during night (n = 51) | 11 (47·8) | 40 (22·3) | 0·019* |
| Nutritional risk (n = 73) | 14 (60·9) | 59 (33·3) | 0·011* |
P‐values of less than 0·05 were considered significant. ND, no sufficient data.
Discussion
This study is the first prevalence investigation of skin tears in a Danish hospital and revealed a prevalence of 11·4%. There are only a few other studies of skin tear prevalence at hospitals outside Denmark. One study from Australia showed a similar prevalence of 11·0% 16, but another Australian study showed a higher prevalence at 19·8% 17. A study from Brazil among hospitalised oncology patients showed a prevalence of 3·3% 18. The mean age is not described, but only 27% of the patients were older than 70. The difference in these three studies compared with this study could be explained by a different mean age.
In our study, prevalence varied greatly among clinical specialties, ranging from 0% to 31·6%. The highest prevalence was in the geriatric and cardiological departments. This could be due to the high frequency of risk factors, such as older age, risk of fall and treatment with anticoagulants, but the cause of this variation was not explored at department level. A previous study also showed high variations among departments 16.
Among patients with skin tears, the most common locations were the extremities, as described in this and three other studies 16, 17, 18. The locations also match the occurrence among patients in residential care settings 13, 17, 19. One author suggests that the dependent patient primarily sustains upper extremity skin tears acquired during routine activities in daily life, whilst the independent patient primarily sustains skin tears on the lower extremity, caused when transferring from wheelchairs or tub chairs 20.
Identifying risk factors is important in order to achieve an effective strategy for the prevention of skin tears. Several studies describe differences between populations with and without skin tears. Only one study has described factors associated with the development of skin tears by multivariate analysis, identifying previous skin tears and a 6‐point decrease in the total score on the Braden scale as causal factors 9. We showed three predisposing factors: previous skin tear, ecchymosis and risk of falling, to be associated with the development of skin tears.
The frequency of previous skin tears in this study population may be higher than reported. The definition of previous skin tears does not include skin tears resulting in wounds that affect only the superficial layer of the epidermis (without leaving scars). The presence of ecchymosis is only described in studies of elderly, and therefore, our result is not comparable. It is not possible to compare the risk of falling's influence on the development of skin tears between studies because the parameters in risk of falling are described differently in different studies.
Many studies describe age as a risk factor as a crude association. The populations in these studies are mostly elderly and housed in rehabilitation or nursing homes. In our study, the age range was lower, between 19 and 99 years, with a mean age at 70·7.
Aggressive, agitated, hyperactive and restless behaviour may contribute to the development of skin tears. Nevertheless, these forms of behaviour are difficult to observe in a point prevalence study because behaviour can vary during the day.
Study limitations
The sample in this study was limited in size (202 patients), consisting of patients from selected departments only at one hospital. We excluded departments such as palliative care, wound healing and dermatology because of the size of these departments (very few patients). The department of abdominal surgery was excluded for two reasons: lack of time and the expectation of a low risk in this category of patients. If we had included these departments, we would probably have had a lower prevalence at the hospital. Fifty‐one patients were excluded for different reasons. These patients might have influenced the prevalence in the study. A larger study that comprises a wider range of hospitals and bigger‐sized departments is needed to determine the extent of skin tears and factors that contribute to their development in hospital settings.
Conclusion
The prevalence of skin tears (11·4%) in this study matches other international observations and showed an association between the risk factors, previous skin tear, ecchymosis and risk of falling. These factors could be used to identify patients requiring prophylactic action.
Acknowledgements
The authors thank all of the patients who participated in the study and the staff in the departments involved for their kind cooperation and support.
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