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The effectiveness of treatments for skin tears in older people: a systematic review protocol

Source:

JBI Evidence Synthesis

November 2014, Volume :12 Number 11 , page 127 - 140 [Free]

Authors

  1. Peters, Micah D J BHSc, MA(Q), PhD

The objective of this systematic review is to identify and establish the effectiveness of treatments for skin tears in older people.

 

More specifically, the objectives are:

 

* to identify the effectiveness of different treatments to promote healing and minimize infection; and

 

* to reduce secondary morbidity and mortality associated with skin tears in older adults (>60 years) in hospital, residential care, nursing home and community settings.

 

 

This systematic review will address three specific questions across the healthcare contexts listed above:

 

What are the effective interventions to promote the healing of skin tears among older adults?

 

What are the effective interventions to minimize skin tear infection among older adults?

 

What are the effective interventions to reduce skin tear associated secondary morbidity and mortality among older adults?

 

 

Background: Skin tears are common injuries that frequently occur in the older adult population.1-4 For the purposes of this review, older adults have been defined as men and women aged 60 years and older as this age group seems to be affected by the greatest number of skin tears, according to a previous literature review.5 This age group has also been chosen in line with the position of the United Nations and the World Health Organization who note that chronological age may be unsuitable when considering the health experiences of all populations.6 One of the major factors that leads to such a high incidence and prevalence of skin tears among older adults is the aging process and the effects that this has on the skin. These effects include thinning and weakening of the epidermis due to atrophy which in turn causes a reduction in the cohesiveness between the layers of the skin.5 Aging skin is also at an increased risk of skin tears due to reduced blood supply and a decrease in subcutaneous fat. The reduction in the number of nerve endings in the skin also lessens the ability of the older adult to perceive tactical (and temperature) stimulation which may result in an increased likelihood of incidental injuries that directly cause skin tears.7 These physiological changes are further exacerbated in people aged 80 and above, and may also be compounded by the increased prevalence of chronic conditions and other predisposing factors for skin tears that lead to this group of older adults being at a particularly high risk of experiencing skin tears.8

 

Skin tears are commonly not considered to be major wounds among older people, potentially due to their prevalence and association with normal aging processes.3 Despite this, it must be recognized that skin tears cause significant associated pain and discomfort, prolonged hospital stays and reduced mobility.8,9 Skin tears can lead to infection and compromized vascular status which can then increase secondary morbidity and mortality risks for sufferers.10 Payne and Martin also point out that there is an increased cost associated with poor or untimely management and treatment of skin tears.11

 

The International Skin Tear Advisory Panel (ISTAP) defines skin tears as wounds caused by shear, friction and/or blunt force that result in the separation of skin layers. Recent research with 1127 health care providers from 16 countries indicates that equipment injury during patient transfer, such as bumps on wheelchairs, side-rails and beds as well as falls, are the main causes of skin tears.12 Separation may be "partial thickness" in reference to the separation of the epidermis from the dermis, or "full-thickness" defined as the separation of the epidermis and the dermis from underlying skin structures.13,14 While the prevention of skin tears is generally a primary focus of nursing care - the prevalence of skin tears is equal to or higher than pressure ulcers14 - it is also important that health care professionals are prepared to treat and manage skin tears.15 Prior to the treatment of skin tears, adequate wound assessment is vital as coexisting factors such as patient nutrition, pain management and wound conditions are all involved in the selection of the most appropriate dressing and care.15,16

 

Many types of skin and wound care interventions can be employed to manage, treat and promote healing for skin tears. Often, product selection will depend upon not only wound assessment but also upon the particular institution.15 A recent survey indicates that current treatment and management options for skin tears are diverse and include steri-tape/strips, film dressings, hydrogel and hydrocolloid dressings, foam dressings, petroleum gauzes, skin glue and liquid bandages, tape and gauze, and topical ointments.12 Non-adhesive dressings are the most popularly used types of dressing.12 Current best practice suggests that certain dressing types such as hydrogel, alginate, lipido-colloid-based mesh, foam dressing, soft silicone, absorbent clear acrylic dressing or non-adhesive impregnated gauze be considered, dependent upon the characteristics of the wound bed.15 Dressings such as hydrocolloids and transparent films are not recommended due to the risk of additional injury to the skin.15 At this stage however, these best practice recommendations are based upon consensus rather than evidence derived from a systematic review.

 

The review authors have conducted a preliminary search of the JBI COnNECT+ database, the Cochrane and, Embase, CINAHL and MEDLINE via PubMed and Prospero and found no preceding or in-progress systematic reviews addressing the effectiveness of treatment interventions for skin tears among older adults. Research with healthcare providers has also indicated a significant need for clear evidence-based resources for the treatment of skin tears.12 Due to this absence, this systematic review is vital and will provide healthcare professionals and researchers with up-to-date, evidence-based information and guidance.

 

Article Content

Inclusion criteria

Types of participants

This systematic review will consider studies that include older adult participants aged 60 years and over in hospital, residential care, nursing home and community settings. Studies conducted in the general population of residential aged care centers without age restrictions will also be considered as the vast majority of participants will be aged 60 years and over. Both male and female participants will be eligible participants for this review. Participants may have one or multiple skin tears in any location from any cause and that may be classified as any degree of skin tear according to the Payne Martin or STAR skin tear classification systems. It may be necessary to subdivide the participants into those aged between 60 and 79 and those aged 80 and over due to an increased risk of skin tears in people aged 80 and above as a result of further pronounced physiological changes to the skin. Participants with comorbidities and those in acute care settings will not be excluded.

 

Types of interventions

This review will consider studies that evaluate different treatment interventions for skin tears. These may include dressings, films and gauzes, topical gels, creams, foams or ointments and any other treatment intervention used in the literature as relevant to the outcomes of this review. Other factors that influence skin tear healing will also be recorded if and when available, including, but not limited to, the setting in which the intervention is undertaken, timing and method of intervention.

 

Types of controls

This review will consider studies that utilize any form of control or comparator (i.e. treatment as usual, before-after data and head-to-head comparisons).

 

Types of outcomes

This review will consider studies that include the following outcome measures:

 

* Healing time defined as the length of time from treatment application to resolution of the skin tear. Including but not limited to measurement of wound size and changes in wound tissue.

 

* Incidence of infection of the skin tear. Including but not limited to measurement of level of bacterial impairment.

 

* Secondary morbidity resulting from skin tears.

 

* Mortality resulting from skin tears.

 

 

Types of studies

This review will consider both experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies and analytical cross sectional studies for inclusion. In the absence of such studies or high-quality evidence through these methodological approaches, the review will also consider descriptive epidemiological study designs including case series, individual case reports and descriptive cross sectional studies for inclusion.

 

In the absence of experimental studies, observational studies and descriptive studies reporting on the effectiveness of interventions for skin tears in older adults, expert text and opinion sources will be sought including clinical guidelines and recommendations as well as expert consensus statements.

 

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Only studies published in English will be considered for inclusion in this review as the reviewers will not have the capacity to translate publications in other languages. Studies published between 2000 and October 2014 will be considered for inclusion. This time period has been chosen to ensure that the evidence is up to date and relevant to current settings and clinical practice.

 

The databases to be searched include:

 

* MEDLINE (via PubMed)

 

* Embase

 

* CINAHL

 

* Cochrane Central Register of Controlled Trials (CENTRAL)

 

* Scopus.

 

 

The search for unpublished studies will include:

 

* ProQuest Dissertations and Theses

 

* Google Scholar

 

* MedNar

 

* Australian Wound Management Association (AWMA)

 

* Wounds International

 

* Skintears.org

 

* National Institute for Health and Care Excellence (NICE)

 

* Agency for Healthcare Research and Quality (AHRQ) National Guideline Clearing House

 

* Centers for Disease Control and Prevention (CDC).

 

 

Initial keywords to be used will be:

 

skin tears, epidermis, wound, aged adult, aged person, older adult, older person, residential aged care, healing, management, treatment, dressing

 

Assessment of methodological quality

Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I ).

 

If textual papers are included, they will be selected for retrieval and assessed by two independent reviewers for authenticity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Narrative, Opinion and Text Assessment and Review Instrument (JBI-NOTARI) (Appendix I ).

 

Any disagreements that arise between the reviewers in relation to the assessment of methodological quality of studies will be resolved through discussion or with a third reviewer.

 

Data collection

Data will be extracted from included papers with quantitative study designs using the standardized data extraction tool from JBI-MAStARI (Appendix II ).

 

If textual papers are included in this review, data will be extracted from papers using the standardized data extraction tool from JBI-NOTARI (Appendix II ).

 

The data extracted from all papers will include specific details pertaining to the interventions, populations, study methods and outcomes of significance to the review question and its objectives.

 

Data synthesis

Extracted quantitative data will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different quantitative study designs included in this review if deemed appropriate and useful. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate. Subgroup analysis on the basis of participant age (60-79 years and >80 years) will be conducted if possible to the increased risk of skin tears to older adults over 80 because of augmented physiological changes to the skin and the implications that this may have on the effectiveness of different treatments. Subgroup analysis will also be undertaken based upon presence of relevant co-morbidities such as type 2 diabetes and peripheral vascular disease if this information is available. Heterogeneity will be assessed using I2 to determine whether subgroup analysis is appropriate.

 

If included, textual papers will, where possible, be pooled using JBI-NOTARI. This will involve the aggregation or synthesis of conclusions to generate a set of statements that represent that aggregation, through assembling and categorizing these conclusions on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the conclusions will be presented in narrative form.

 

Conflicts of interest

The authors declare no competing interests in relation to this systematic review.

 

Acknowledgements

The authors have no acknowledgements.

 

References

 

1 Bank D, Nix D. Preventing skin tears in a nursing and rehabilitation center: an interdisciplinary effort. Ostomy Wound Manage. 2006;52(9):38-40, 4, 6. [Context Link]

 

2 Payne RL, Martin ML. The epidemiology and management of skin tears in older adults. Ostomy Wound Manage. 1990;26:26-37. [Context Link]

 

3 Morey P. Skin tears: A literature review. Primary Intention: Aust J Wound Manage. 2007;15(3):122. [Context Link]

 

4 Sussman G, Golding M. Skin tears: should the emphasis be only their management? Wound Practice & Research. 2011;19(2):66. [Context Link]

 

5 Ratliff CR, Fletcher KR. Evidence to Support and Treatment. Ostomy Wound Manage. 2007;53(3):32-42. [Context Link]

 

6 WHO. Active Aging: A Policy Framework: Noncommunicable Diseases and Mental Health Cluster Noncommunicable Disease Prevention and Health Promotion Department. Ageing and Life Course. 2002. [Context Link]

 

7 R G Sibbald, Krasner D. Skin changes at the end of life consensus statements. Adv Skin Wound Care. 2009;23(5):237-9. [Context Link]

 

8 Holmes RF, Davidson MW, Thompson BJ, Kelechi TJ. Skin tears: care and management of the older adult at home. Home healthcare nurse. 2013;31(2):90-101. [Context Link]

 

9 Vandervord JG, Tolerton SK, Campbell PA, Darke JM, Loch-Wilkinson AM. Acute management of skin tears: a change in practice pilot study. Int Wound J. 2014. [Context Link]

 

10 Stephen-Haynes J, Carville K. Skin tears made easy. Wounds International. 2011;2(4):1-6. [Context Link]

 

11 Payne R, Martin M. Defining and classifying skin tears: need for a common language. Ostomy Wound Manage. 1993;39(5):16-20, 2-4, 6. [Context Link]

 

12 Leblanc K, Baranoski S, Holloway S, Langemo D, Regan M. A descriptive cross-sectional international study to explore current practices in the assessment, prevention and treatment of skin tears. Int Wound J. 2014;11(4):424-30. [Context Link]

 

13 LeBlanc K, Baranoski S. Skin tears: state of the science: consensus statements for the prevention, prediction, assessment, and treatment of skin tears(C). Adv skin wound care. 2011;24(9):2-15. [Context Link]

 

14 Carville K, Lewin G, Newall N et al. STAR: a consensus for skin tear classification. Primary Intention: Aust J of Wound Manage. 2007;15(1):18. [Context Link]

 

15 LeBlanc K, Baranoski S. Skin tears: Best practices for care and prevention. Nursing. 2014. 2014;44(5):36-46. [Context Link]

 

16 LeBlanc K, Baranoski S, Holloway S, Langemo D. Validation of a new classification system for skin tears. Adv Skin Wound Care. 2013;26(6):263-5. [Context Link]

Appendix I: Appraisal instruments[Context Link]

Appendix II: Data extraction instruments[Context Link]

 

Keywords: skin tears; wound care; aged care; Skin; epidermis; tears; tearing injury; wound; aged adult; aged adults; aged person; aged people; elderly older adult; older adults; older person; older people; residential aged care; healing; recovery; management

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