Development and psychometric property testing of a skin tear knowledge assessment instrument (OASES) in 37 countries.

AIM: To develop and psychometrically evaluate a skin tear knowledge assessment instrument (OASES). DESIGN: Prospective psychometric instrument validation study. METHOD: The skin tear knowledge assessment instrument was developed based on a literature review and expert input (N = 19). Face and content validity were assessed in a two-round Delphi procedure by 10 international experts affiliated with the International Skin Tear Advisory Panel (ISTAP). The instrument was psychometrically tested in a convenience sample of 387 nurses in 37 countries (April-May 2020). Validity of the multiple-choice test items (item difficulty, discriminating index, quality of the response alternatives), construct validity, and test-retest reliability (stability) were analysed and evaluated in light of international reference standards. RESULTS: A 20-item instrument, covering six knowledge domains most relevant to skin tears, was designed. Content validity was established (CVI = 0.90-1.00). Item difficulty varied between 0.24 and 0.94 and the quality of the response alternatives between 0.01-0.52. The discriminating index was acceptable (0.19-0.77). Participants with a theoretically expected higher knowledge level had a significantly higher total score than participants with theoretically expected lower knowledge (p < .001). The 1-week test-retest intraclass correlation coefficient (ICC) was 0.83 (95% CI = 0.78-0.86) for the full instrument and varied between 0.72 (95% CI = 0.64-0.79) and 0.85 (95% CI = 0.81-0.89) for the domains. Cohen's Kappa coefficients of the individual items ranged between 0.21 and 0.74. CONCLUSION: The skin tear knowledge assessment instrument is supported by acceptable psychometric properties and can be applied in nursing education, research, and practice to assess knowledge of healthcare professionals about skin tears. IMPACT: Prevention and treatment of skin tears are a challenge for healthcare professionals. The provision of adequate care is based on profound and up-to-date knowledge. None of the existing instruments to assess skin tear knowledge is psychometrically tested, nor up-to-date. OASES can be used worldwide to identify education, practice, and research needs and priorities related to skin tears in clinical practice.

Skin tears: prevention and management.

Skin tears commonly occur at the extremes of age and are associated with skin changes in ageing skin. They are considered to be acute wounds caused by mechanical forces, such as blunt trauma. While the true prevalence and incidence of skin tears is unknown, the available evidence suggests that these wounds occur in all healthcare settings. Importantly, skin tears are preventable with the implementation of a risk-reduction programme, which includes twice-daily skin moisturisation. Where these injuries do occur, it is important to categorise the extent of damage as well as to choose the most appropriate dressing to avoid adding any risks for further trauma.

Use of Thermal Imaging to Identify Deep-Tissue Pressure Injury on Admission Reduces Clinical and Financial Burdens of Hospital-Acquired Pressure Injuries.

A deep-tissue pressure injury (DTPI) is a serious type of pressure injury that begins in tissue over bony prominences and can lead to the development of hospital-acquired pressure injuries (HAPIs). Using a commercially available thermal imaging system, study authors documented a total of 12 thermal anomalies in 9 of 114 patients at the time of admission to one of the study institution's ICUs over a 2-month period. An intensive, proven wound prevention protocol was immediately implemented for each of these patients. Of these 12 anomalies, 2 ultimately manifested as visually identifiable DTPIs. This represented a 60% reduction in the authors' institution's historical DTPIs/HAPI rate. Because these DTPIs were documented as present on admission using the thermal imaging tool, researchers avoided a revenue loss associated with nonreimbursed costs of care and also estimated financial benefits associated with litigation expenses known to be generated with HAPIs.Using thermal imaging to document DTPIs when patients present has the potential to significantly reduce expenses associated with pressure injury litigation. The clinical and financial benefits of early documentation of skin surface thermal anomalies in anatomical areas of interest are significant.

Comparing Human Amniotic Allograft and Standard Wound Care When Using Total Contact Casting in the Treatment of Patients with Diabetic Foot Ulcers.

OBJECTIVE: This prospective, randomized study compared two treatments for diabetic foot ulcers: total contact cast and a skin substitute versus total contact cast and standard wound care. PARTICIPANTS: Researchers screened 270 adult outpatients in a Midwestern wound care clinic for inclusion. Adults 18 years or older with type 1 or 2 diabetes and a diabetic foot ulcer located on the plantar surface larger than 0.5 cm in area were invited to participate if they had not demonstrated a 50% reduction in wound area following 4 weeks of standard treatment. Thirteen patients were randomized into two intervention groups. The majority of the participants had type 2 diabetes. INTERVENTIONS: Group A treatment: total contact cast and a skin substitute (human amniotic allograft); group B treatment: total contact cast and standard wound care. OUTCOME MEASURES: Mean ulcer surface area, time to closure, recurrence rates, satisfaction with total contact casting, infection, and hemoglobin A1c were measured. RESULTS: The majority of participants experienced wound closure during the course of the study (92.3%). Two participants did not achieve closure, both of whom had Charcot foot. Group A, which had a higher mean hemoglobin A1c at study outset, experienced a longer mean time to closure (29.50 days) compared with group B (26.20 days). The 90-day recurrence rates were different for the two groups, with only one recurrence for group A (14.29%) but five recurring ulcers in group B (83.33%). CONCLUSIONS: Although significance was not established because of sample size, there was a definite trend toward significance that merits further investigation with human amniotic allograft.

Reexamining the Literature on Terminal Ulcers, SCALE, Skin Failure, and Unavoidable Pressure Injuries.

GENERAL PURPOSE: To synthesize the literature regarding skin injuries that are found in patients at the end of life and to clarify the terms used to describe these conditions. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After completing this continuing education activity, you should be better able to:1. Define the terms used to describe pressure injuries and skin changes at the end of life.2. Discuss the concept of skin failure as applied to end-of-life skin injuries and implications for practice. ABSTRACT: This article synthesizes the literature regarding the concepts of "terminal" skin injuries that are found in patients at the end of life, including Kennedy terminal ulcers, Skin Changes At Life's End, Trombley-Brennan terminal tissue injuries, and skin failure. Also included is a discussion of avoidable and unavoidable pressure injuries as defined and differentiated by the Centers for Medicare & Medicaid Services and the National Pressure Ulcer Advisory Panel. To help clarify the controversy among these terms, a unifying concept of "skin failure" that may occur with an acute illness, chronic illness, or as part of the dying process is proposed. This proposed concept of skin failure is etiologically different than a pressure injury, although pressure injury and skin failure can occur concomitantly. These proposed concepts require further research and validated diagnostic criteria. Consensus around appropriate terminology is essential to reduce confusion among stakeholders and ensure appropriate patient care.

Relative Temperature Maximum in Wound Infection and Inflammation as Compared with a Control Subject Using Long-Wave Infrared Thermography.

OBJECTIVE: The purpose of this retrospective case series was to determine whether a long-wave infrared thermography (LWIT, or thermal imaging) camera can detect specific temperature changes that are associated with wound infection and inflammation as compared with normal control subjects with similar anatomical wound locations. DESIGN: A retrospective, observational, collective, multiple case series of patients who underwent digital and thermal imaging of wounds in various states. SETTING: The subjects were selected from multiple sites including an outpatient wound care clinic, a wound care physician's office, a rehabilitation hospital, and a home healthcare organization. PATIENTS: Six subjects were selected for inclusion, including 2 each for the infection, inflammation, and normal control groups. MAIN OUTCOME MEASURE: The study collected relative temperature maximums as obtained and recorded by LWIT and digital imaging. MAIN RESULTS: In this case series, the authors demonstrate the use of an FDA-approved Scout (WoundVision, Indianapolis, Indiana) dual-imaging long-wave infrared and digital cameras to analyze images of wounds. In the 2 cases with clinically diagnosed wound infection, LWIT showed an elevation of temperature as evidenced by a maximum temperature differential between the wound and healthy skin of +4° C to 5° C. Also, LWIT was able to identify relative thermal changes of +1.5° C to 2.2° C in subjects presenting with clinical signs of inflammation. In addition, LWIT was able to show that the normal control subjects without diagnosis of infection or signs of inflammation had relative temperature differentials of +1.1° C to 1.2° C. Finally, LWIT could detect adequate treatment of infected wounds with antibiotics as evidenced by a return to normal temperature differences gradient of +0.8° C to 1.1° C, as compared with normal control subjects with wounds in the same anatomical location. CONCLUSIONS: Long-wave infrared thermography can collect and record objective data, including relative temperature maximums associated with infection, inflammation, and normal healing wounds.

A Reliability Study Using a Long-Wave Infrared Thermography Device to Identify Relative Tissue Temperature Variations of the Body Surface and Underlying Tissue.

OBJECTIVE: This study assesses the ability of the Scout (WoundVision LLC, Indianapolis, Indiana), an FDA-approved visual and thermal imaging device and software analysis tool, to provide clinicians with a reliable and reproducible way to incorporate long-wave infrared thermography and relative temperature differential into clinical wound assessment by consistently identifying control areas against which to measure wound temperature. METHODS: This laboratory-based study utilized 3 adult wound care professionals experienced in control area selection. Twenty-six previously collected wound images were used for the study. The 3 readers placed a control area on each of the 26 wounds 3 different times (n = 78 independent placements) to establish within-reader agreement. To establish between-reader agreement, the readers again placed a control area on each of the 26 wounds (n = 26 independent placements). OUTCOME MEASURES: This study evaluates 2 aspects of the Scout device's reliability: (1) within- and between-reader agreement of initial patient encounter control area images and (2) between-reader agreement of follow-up encounter control area images. RESULTS: The control area measurements were very consistent both within (percent coefficient of variation [%CV] approximately 1%) and between readers (%CV approximately 2%). The average maximum temperature within-reader %CV was 1.14% and the between-reader variation was %CV 1.97%. The average minimum temperature had a within-reader %CV of 1.1% and the between-reader coefficient of variation was 2.01%. The within- and between-reader average difference in mean temperature was 0.14° C and 0.29° C, respectively. The largest mean temperature difference observed within-readers was 0.68° C, and the smallest difference was 0.01° C. The largest difference observed in between-reader mean temperature was 0.96° C, and the smallest was 0.03° C. CONCLUSIONS: This study demonstrates that clinicians can repeatedly and reliably perform a relative temperature differential analysis using the Scout device to determine an appropriate control area for wound temperature assessment.

The VCU Pressure Ulcer Summit: The Search for a Clearer Understanding and More Precise Clinical Definition of the Unavoidable Pressure Injury.

This article reports the findings of the Unavoidable Pressure Ulcer Committee (of the VCU Pressure Ulcer Summit) that was tasked with addressing key issues associated with pressure injuries that are unavoidable or unpreventable. Our goals were (1) to clarify nomenclature and descriptions surrounding "terminal ulceration," (2) to describe the medical complications and comorbid conditions that can lead to skin failure and/or terminal ulceration, (3) to describe the variable possible causes of unavoidable pressure injuries, and (4) to present clinical cases to exemplify pressure injuries considered to be unavoidable.

A Multimodality Imaging and Software System for Combining an Anatomical and Physiological Assessment of Skin and Underlying Tissue Conditions.

OBJECTIVE: The timely and accurate assessment of skin and underlying tissue is crucial for making informed decisions relating to wound development and existing wounds. The study objective was to determine within- and between-reader agreement of Scout Visual-to-Thermal Overlay (WoundVision LLC, Indianapolis, Indiana) placement (moving the wound edge trace from the visual image onto the wound edge signature of the infrared image). MATERIALS AND METHODS: For establishing within- and between-reader agreement of the Scout Visual-to-Thermal Overlay feature, 5 different readers overlaid a wound edge trace from the visual image and placed it onto the congruent thermal representation of the wound on a thermal image 3 independent times. Forty different wound image pairs were evaluated by each reader. All readers were trained by the same trainer on the operation of the Scout prior to using the software features. The Scout Visual-to-Thermal Overlay feature allows clinicians to use an anatomical measurement of the wound on the visual image (area and perimeter) to extract a congruent physiological measurement of the wound on the thermal image (thermal intensity variation data) by taking the wound edge trace from the visual image and overlaying it onto the corresponding thermal signature of the same wound edge. RESULTS: The results are very similar both within- and between-readers. The coefficient of variation (CV) for the mean PV both within- and between-readers averages less than 1%, 0.89 and 0.77 respectively. When converted into degrees Celsius across all 5 readers and all 3 wound replicates, the average temperature differential is 0.28° C (). The largest difference observed was 0.63° C and the smallest difference observed was 0.04° C. CONCLUSIONS: The Scout software's Visual-to-Thermal Overlay procedure, as implemented in this study, is very precise. This study demonstrates that the thermal signature of wounds may be delineated repeatedly by the same operator and reproducibly by different operators. Thus, clinicians can integrate a criterion standard visual (anatomical) assessment with a congruent physiological assessment to provide them with knowledge relating to the presence or absence of blood flow, perfusion, and metabolic activity in the wound, periwound, and wound site.

The Art of Dressing Selection: A Consensus Statement on Skin Tears and Best Practice.

PURPOSE: To provide information about product selection for the management of skin tears. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to:1. Explain skin tear (ST) risk factors and assessment guidelines.2. Identify best practice treatments for STs, including the appropriate dressings for each ST type. ABSTRACT: To aid healthcare professionals in product selection specific for skin tears, the International Skin Tear Advisory Panel conducted a systematic literature review and 3-phase Delphi consensus with a panel of international reviewers to provide the best available evidence for product selection related to the treatment of skin tears.

Evidence-based guidelines for pressure ulcer management at the end of life.

It is important to develop an individualised plan of care for people at the end of life to prevent pressure ulcers, and to treat them if they do occur. This article discusses patient and risk assessment, prevention and care for pressure ulcers for the palliative care patient and the recommendations given in the palliative care section of the Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline (National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance, 2014).

Accuracy and Reproducibility of the Wound Shape Measuring and Monitoring System.

Nineteen known area shapes simulated wounds and were measured using 3 methods and orientations (n = 57). Equivalence and accuracy were tested for ruler length × width and the WoundVision length × width and tracing functions. The WoundVision Coefficient of Individual Agreement value and accuracy were closest to the actual area (Psi_R = 0.77; 95% confidence interval, 0.528-1.016).

Comparison of standardized clinical evaluation of wounds using ruler length by width and Scout length by width measure and Scout perimeter trace.

The study objective was to examine precision in wound measurement using a recently Food and Drug Administration-approved Scout (WoundVision, LLC, Indianapolis, Indiana) device to measure wound length (L) and width (W). Wound perimeter and a ruler measurement of L and W were also made. Images of 40 actual patient wounds were measured using the Scout device. All 3 techniques (length, width, perimeter) demonstrated acceptable within and between reader precision; however, the best precision was in wound perimeter measurement.

Unavoidable pressure injury: state of the science and consensus outcomes.

In the vast majority of cases, appropriate identification and mitigation of risk factors can prevent or minimize pressure ulcer (PU) formation. However, some PUs are unavoidable. Based on the importance of this topic and the lack of literature focused on PU unavoidability, the National Pressure Ulcer Advisory Panel hosted a multidisciplinary conference in 2014 to explore the issue of PU unavoidability within an organ system framework, which considered the complexities of nonmodifiable intrinsic and extrinsic risk factors. Prior to the conference, an extensive literature review was conducted to analyze and summarize the state of the science in the area of unavoidable PU development and items were developed. An interactive process was used to gain consensus based on these items among stakeholders of various organizations and audience members. Consensus was reached when 80% agreement was obtained. The group reached consensus that unavoidable PUs do occur. Consensus was also obtained in areas related to cardiopulmonary status, hemodynamic stability, impact of head-of-bed elevation, septic shock, body edema, burns, immobility, medical devices, spinal cord injury, terminal illness, and nutrition.

A descriptive cross-sectional international study to explore current practices in the assessment, prevention and treatment of skin tears.

This study presents the results of a descriptive, cross-sectional, online international survey in order to explore current practices in the assessment, prediction, prevention and treatment of skin tears (STs). A total of 1127 health care providers (HCP) from 16 countries completed the survey. The majority of the respondents (69·6%, n = 695) reported problems with the current methods for the assessment and documentation of STs with an overwhelming majority (89·5%, n = 891) favouring the development of a simplified method of assessment. Respondents ranked equipment injury during patient transfer and falls as the main causes of STs. The majority of the samples indicated that they used non-adhesive dressings (35·89%, n = 322) to treat a ST, with the use of protective clothing being the most common method of prevention. The results of this study led to the establishment of a consensus document, classification system and a tool kit for use by practitioners. The authors believe that this survey was an important first step in raising the global awareness of STs and to stimulate discussion and research of these complex acute wounds.

DOMINATE Wounds.

Chronic wounds are a significant health problem worldwide. Often they are initially managed with various focal treatments until a specialist becomes involved, sometimes weeks or months after treatment has begun. Even at the specialist level, practices and guidelines are inconsistent due to a lack of high-level evidence. A disease management system for chronic wounds that is simple, practical, and adoptable by a variety of wound care practitioners is needed. Such a system would guide wound care providers to address the critical aspects of wound care in a prioritized, systematic sequence, leading to faster healing of simple wounds, and timely advancement to more complex therapies for wounds that require such treatment. This paper describes an empirically developed wound care management system that has been successfully implemented and provides evidence-based rationale for each of its components. Relatively simple and practical, this system organizes an approach to any type of wound, routine or complex.