1 INTRODUCTION

As a cause of patient harm, hospital-acquired skin tears present a challenge for health care organisations. Although most skin tears are relatively minor injuries, they cause pain and decrease quality of life for those affected.1 Contributing factors include reduced mobility, cognition and sensation, the need for transfer on hospital equipment,1, 2 malnutrition3 and conditions that affect the ability of the skin to resist shear, friction and blunt force, including frail skin in the elderly and altered skin condition from illness, poor hygiene or inadequate skin care.4 For those with altered immunity or poor health status, skin tears may become infected or develop into chronic wounds.5 Treatment of skin tears consumes valuable health care resources6 including the cost of wound dressings and staff resources and, in the hospital setting, may increase length of stay.1

Internationally, skin tear point prevalence in long-term aged care settings has been reported between 3.0% and 20.8%.5, 7-10 However, prevalence in this setting is not generalisable to other settings, and it is difficult to quantify the prevalence of hospital-acquired skin tear as it is underreported5 and most prevalence studies do not differentiate between community- and hospital-acquired skin tear. In a systematic review,11 skin tear prevalence in the hospital setting was reported between 3.3% and 22%; however, the data were obtained from six relatively old studies published between 2004 and 2014; of which two were Australian.12, 13 In the largest Australian study,13 which surveyed 5801 patients, skin tear prevalence was 7.9% and 10.8% in consecutive years. Significantly, skin tear represented between 11.9% and 16.7% of all hospital-acquired wounds and was the largest group of wounds in the aged care cohort.13 In the earlier, much smaller, study (n = 187), skin tear prevalence was 10.7%.12 More recent studies in acute hospital settings have reported skin tear point prevalence of 8.1% over 6 years in Australia (n = 2197)3 and 11.4% in Denmark (n = 202).14 In the latter study, a history of previous skin tears, risk of falling and ecchymosis were found to be statistically significantly associated with skin tear, however only wounds on limbs were reported, suggesting that true prevalence may have been higher.14 All of these studies appear to have included community-acquired (or present on admission [POA]) skin tears in their results. In a Singaporean study across two medical wards (n = 144),15 hospital-acquired skin tear point prevalence of 6.2% was reported, with the majority found on the lower extremities (57%) and a large proportion (43%) of the most severe skin tear category (skin flap absent); however, skin tears were classified as hospital-acquired because there was no nursing documentation to indicate otherwise. The lack of clarity around documentation and reporting of skin tear prevalence has been noted as reflecting a lack of focus on skin tear prevention.4, 16

Given the context described above, the aim of this study was to analyse hospital-acquired skin tear point prevalence over a 10-year period in an acute hospital setting.

2 METHODS 2.1 Design

A hospital-wide annual audit was used to collect skin tear data. Approval for use of the audit data for research was granted by the relevant data custodians and ethical approval was obtained from the study hospital's research ethics committee (HREC/16/QPCH/171).

2.2 Setting and sample

The setting was a 630-bed tertiary general hospital in south-east Queensland, Australia in which annual skin integrity audits were conducted as part of a larger state-wide hospital audit. For the purpose of this study, all adult (≥18 years) inpatients who provided consent for a full skin inspection on the day of each annual audit were included. Because of incomplete audits, mental health and palliative care patients were excluded.

2.3 Data collection

Skin tear data were collected annually hospital-wide on a single audit day in March from 2009 until 2011, when data were also collected in November to align with the state-wide Queensland Bedside Audit (Queensland Health, 2012),17 and subsequently in October or November from 2012 to 2018. This resulted in 11 audit events across the 10 years. Audits were conducted across all wards within the hospital and all adult inpatients were invited to participate. Data were collected on a paper-based audit form by trained multidisciplinary auditors, who had undergone a mandatory 4-hour training program to correctly identify, categorise, and record skin tears. All skin tears were validated and classified by specialised wound management nursing and podiatry staff who had undergone additional 4-hour training and assessment. On each audit day, a team of over 100 auditors worked in pairs to collect data on all audit items, which included conducting a full body (head to toe) skin inspection to identify skin tears.

Patient demographics, wound location and cause, and compliance with treatment and incident-reporting on the hospital's wound assessment form were recorded. Skin tears were classified as community-acquired if documented in the patient's medical records as being POA to the hospital, or hospital-acquired if occurrence followed admission. For best practice, in the absence of documentary evidence in the patient's records to indicate a skin tear was POA, it was categorised as hospital-acquired. Skin tears were categorised using the five-category Skin Tear Audit Research (STAR) classification system described elsewhere.18

2.4 Data analysis

Data were entered manually into an Excel database and imported into SPSS for analysis. Prevalence was calculated as: (numerator/denominator) × 100%,19 where: numerator = number of eligible consenting hospital inpatients at the time of audit who had at least one skin tear; denominator = total number of eligible hospital inpatients at the time of the audit who consented to a skin inspection. Meta-analysis of the prevalence studies was performed using the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information software. Random effects modelling was applied to obtain pooled estimates of proportion. Prior to calculation of overall effect size, data were transformed using Freeman-Tukey double arcsine transformation. Skin tear categories are reported according to both the STAR18 and the more current best practice International Skin Tear Advisory Panel (ISTAP)4 classification systems, with the STAR sub-categories combined to equate to the relevant ISTAP category (ie, STAR 1a and 1b = ISTAP 1 skin flap present, 2a and 2b = 2 partial skin flap, 3 = 3 skin flap absent).

3 RESULTS 3.1 Sample

The total audit sample included in the 10-year analysis was 3625, with a mean annual sample size of 330 (range 274-394). Of the 328 patients who had at least one skin tear, most were male (n = 180; 54.9%), the mean age was 79.7 years (SD 10.8; median 81.5, IQR = 74.0-87.0) with a large majority (84.8%) aged 70 years or more (see Table 1).

TABLE 1. Skin tear prevalence Audited item and measures used 2009 2010 2011-1 2011-2 2012 2013 2014 2015 2016 2017 2018 Overall Consented to skin inspection n 333 351 361 394 313 274 301 328 332 324 314 3625 Skin tear prevalence % (n) 8.7 (30) 5.7 (20) 13.3 (50) 9.9 (39) 11.2 (35) 8.0 (22) 9.0 (27) 11.0 (36) 8.1 (27) 6.2 (20) 7.0 (22) 9.1 (328) Male proportion with skin tear % (n) 53.3 (16) 55.0 (11) 44.0 (22) 56.4 (22) 65.7 (23) 63.6 (14) 51.9 (14) 61.1 (22) 55.6 (15) 55.0 (11) 45.5 (10) 54.9, 95% CI 49.3-60.4 (180) aHospital-acquired skin tear prevalence % (n) 6.7 (22) 4.3 (14) 11.0 (36) 7.9 (26) 7.3 (24) 4.3 (14) 5.2 (17) 5.2 (17) 4.0 (13) 4.0 (13) 3.4 (11) 5.7 (207) aCommunity-acquired (POA) skin tear prevalence % (n) 3.7 (12) 2.1 (7) 4.6 (15) 4.3 (14) 4.6 (15) 2.7 (9) 4.0 (13) 6.4 (21) 4.9 (16) 3.0 (10) 3.4 (11) 3.9 (143) Skin tear sample: mean age (SD) 79.7 (10.3) 82.0 (9.6) 81.4 (13.8) 82.0 (7.1) 81.0 (11.5) 77.1 (10.9) 81.5 (9.4) 74.9 (12.4) 80.8 (6.4) 77.8 (9.1) 76.2 (11.0) 79.7 (10.8) Skin tear sample: age ≥70 years % (n) 86.7 (26) 90.0 (18) 88.0 (44) 92.3 (36) 88.6 (31) 72.7 (16) 85.2 (23) 75.0 (27) 92.6 (25) 80.0 (16) 72.7 (16) 84.8, 95% CI 80.4-88.5 (278) Skin tear total n 52 31 104 79 63 35 57 69 49 40 37 616 Hospital-acquired skin tear % (n) 53.8 (28) 77.4 (24) 76.0 (79) 81.0 (64) 74.6 (47) 62.9 (22) 42.1 (24) 31.9 (22) 55.1 (27) 52.5 (21) 43.2 (16) 60.7, 95% CI 56.7-64.6 (374) Community-acquired (POA) skin tear % (n) 46.2 (24) 22.6 (7) 24.0 (25) 19.0 (15) 25.4 (16) 37.1 (13) 57.9 (33) 68.1 (47) 44.9 (22) 47.5 (19) 56.8 (21) 39.3, 95% CI 35.4-43.3 (242) Abbreviations: CI, confidence interval; POA, present on admission. 3.2 Prevalence

Annual point prevalence ranged from 5.7% in 2010 to 13.3% in 2011 (see Table 1). Within 11 audits across 10 years, a total of 328 patients had at least one skin tear giving a pooled prevalence estimate of 8.9% (95% confidence interval [CI] 7.5-10.4) (see Figure 1A). Hospital-acquired point prevalence ranged from 3.4% in 2018 to 11.0% in 2011 (see Table 1). Across the 10 years, a total of 207 patients developed at least one hospital-acquired skin tear, giving a pooled prevalence estimate of 5.5% (95% CI 4.5-6.7) (see Figure 1B); and 143 patients were admitted to hospital with at least one POA skin tear, giving a pooled prevalence estimate of 3.9% (95% CI 3.2-4.6) (see Figure 1C). A total of 22 patients had both hospital- and community-acquired skin tears. As shown in Figure 2, although there was an overall trend of increased POA skin tears, hospital-acquired skin tear prevalence fell over the same period.

A, Forest plot—all skin tears. B, Forest plot—hospital-acquired skin tears. C, Forest plot—community-acquired skin tears

Skin tear prevalence trend

3.3 Skin tear characteristics

A cumulative total of 616 skin tears was found, of which 374 (60.7%) were hospital-acquired. The proportions of skin tears by category were similar for hospital- and community-acquired skin tears, with the largest proportions in STAR18 category 3 (see Table 2), occurring mostly on the lower limbs (see Table 3). Injuries occurred on the upper and lower limbs in similar proportions (46.3% and 48.8%, respectively), with the largest proportion occurring on the lower leg (30.9%) (see Table 3). Most STAR category 1A/1B (57.7%, n = 90) and STAR category 2A/2B (64.8%, n = 138) skin tears occurred on the upper limbs, but the majority of category 3 (51.4%, n = 127) skin tears occurred on the lower limbs (see Table 4). Nearly two-thirds of patients (61.3%, n = 201) had only one skin tear. Of the remainder (n = 127) with multiple skin tears, most had two (41.7%, n = 53) or three (33.0%, n = 42) skin tears (range 2-13). Falls and collisions (also known as blunt trauma4) were the main documented causes of injury (see Table 5). Other causes of injury included accidental injuries (unspecified) caused by health care staff (2.6%, n = 12) or the patient (including violent behaviour) (3.4%, n = 21).

TABLE 2. Skin tear category Skin tear category n (%) Overall total STAR category 1A 1B 2A 2B 3 ISTAP category 1 2 3 Hospital-acquired 26 (7.0) (54.2) 64 (17.1) (59.3) 13 (3.5) (54.2) 125 (33.4) (66.1) 146 (39.0) (59.1) 374 (100) (60.7) Category sub-total 90 (24.1) (57.7) 138 (36.9) (64.8) Community-acquired 22 (9.1) (45.8) 44 (18.2) (40.7) 11 (4.5) (45.8) 64 (26.4) (33.9) 101 (41.7) (40.9) 242 (100) (39.3) Category sub-total 66 (27.3) (42.3) 75 (31.0) (35.2) Total 48 (7.8) (100) 108 (17.5) (100) 24 (3.9) (100) 189 (30.7) (100) 247 (40.1) (100) 616 (100) (100) Category sub-total 156 (25.3) (100) 213 (34.6) (100) TABLE 3. Skin tear site (missing = 1) Skin tear site n (%) Overall total Upper limb Lower limb Other Upper arm Elbow Forearm Hand Upper leg Knee Lower leg Foot Head Shoulder Trunk Other Hospital-acquired 27 (7.2) (54.0) 42 (11.2) (50.0) 69 (18.4) (65.1) 30 (8.0) (66.7) 24 (6.4) (58.5) 23 (6.1) (45.1) 124 (33.2) (65.3) 12 (3.2) (66.7) 4 (1.1) (57.1) 4 (1.1) (66.7) 9 (2.4) (100) 6 (1.6) (75.0) 374 (100) (60.7) Site sub-total 168 (44.9) (58.9) 183 (48.9) (61.0) 23 (6.1) (76.7) Community-acquired 23 (7.0) (46.2) 42 (17.1) (50.0) 37 (3.5) (34.9) 15 (33.4) (33.3) 17 (39.0) (41.5) 28 (11.6) (54.9) 66 (27.4) (34.7) 6 (2.5) (33.3) 3 (1.2) (42.9) 2 (0.8) (33.3) 0 (0) (0) 2 (0.8) (25.0) 241 (100) (39.3) Site sub-total 117 (48.5) (41.1) 117 (48.5) (39.0) 7 (2.9) (23.3) Total 50 (8.1) (100) 84 (13.7) (100) 106 (17.2) (100) 45 (7.3) (100) 41 (6.7) (100) 51 (8.3) (100) 190 (30.9) (100) 18 (2.9) (100) 7 (1.1) (100) 6 (1.0) (100) 9 (1.5) (100) 8 (1.3) (100) 615 (100) (100) Site sub-total 285 (46.3) (100) 300 (48.8) (100) 30 (4.9) (100) TABLE 4. Skin tear category by site (missing = 1) Skin tear category n (%) Overall total STAR category 1A 1B 2A 2B 3 ISTAP category 1 2 3 Upper limb category 28 (9.8) (59.6) 49 (17.2) (45.4) 13 (4.6) (54.2) 90 (31.6) (47.6) 105 (36.8) (42.5) 285 (100) (46.3) Sub-total 90 (24.1) (57.7) 138 (36.9) (64.8) Lower limb category 17 (5.7) (36.2) 56 (18.7) (51.9) 9 (3.0) (37.5) 91 (30.3) (48.1) 127 (42.3) (51.4) 300 (100) (48.8) Sub-total 66 (27.3) (42.3) 75 (31.0) (35.2) Other category 2 (6.7) (4.3) 3 (10.0) (2.8) 2 (6.7) (8.3) 8 (26.7) (4.2) 15 (50.0) (6.1) 30 (100) (4.9) Sub-total 156 (25.3) (100) 213 (34.6) (100) Total category 47 (7.6) (100) 108 (17.6) (100) 24 (3.9) (100) 189 (30.7) (100) 247 (40.2) (100) 615 (100) (100) Sub-total 155 (25.2) (100) 213 (34.6) (100) TABLE 5. Cause of injury Skin tear injury cause n (%) Total Fall Collision Transfer Other Unknown Hospital-acquired 51 (13.6) (30.0) 52 (13.9) (70.3) 14 (3.7) (87.5) 48 (12.8) (63.2) 209 (55.9) (74.6) 374 (100) (60.7) Community-acquired (POA) 119 (49.2) (70.0) 22 (9.1) (29.7) 2 (0.8) (12.5) 28 (11.6) (36.8) 71 (29.3) (25.4) 242 (100) (39.3) Total 170 (27.6) (100) 74 (12.0) (100) 16 (2.6) (100) 76 (12.3) (100) 280 (45.5) (100) 616 (100) (100) 3.4 Wound dressings

Most skin tears were protected with a foam dressing (81.1%, n = 488), of which Mepilex Border™ was used most of the time (95.5%, n = 466). Foam dressings were used most frequently across all five STAR skin tear categories (range 65.9%-86.3%). A small proportion of wounds was not dressed (6.6%, n = 41), of which a third (34.1%, n = 14) was category 3. Two wounds (categories 1B, 2B) were found with fixation tape applied only.

4 DISCUSSION

To our knowledge, this is the first long-term, cross-sectional study of adult skin tear prevalence in an acute hospital setting. The pooled prevalence of 8.9% found in our study is similar but lower than that reported in an earlier 2-year Australian state-wide point-prevalence study across 83 acute care settings (9.5%)13 and a single point-prevalence study in a Danish hospital (11.4%).14 Although our results show a decreasing trend in overall skin tear prevalence, in the main this is because of the fall in hospital-acquired skin tears. The downward trend of hospital-acquired skin tear over 10 years is encouraging, but the pooled prevalence of 5.5% indicates that it is an enduring and significant problem. Although there are no other long-term studies with which to compare our hospital-acquired results, only one other study has reported hospital-acquired skin tear point prevalence, yielding a similar but higher prevalence of 6.6% in a Singaporean hospital;18 however, only two medical wards were included in the sample.

In our sample, the mean age of patients with skin tear was 80 years, with 85% aged 70 or above, and most were male (55%). These variables are consistent with the skin tear predictor model developed by Rayner et al20; however, their model was based on an aged care sample. Other predictor variables in their model were histories of skin tear and falls, skin elastosis and purpura. Our results are congruent with other studies showing older age is associated with skin tears.3, 14, 21 While this reflects age-related skin changes,2 Australians may also be affected by photoaging, characterised by skin elastosis.7, 9 In a large, Chinese multicentre study (n = 13 176) across nine hospitals, male gender was associated with skin tear incidence (odds ratio [OR] = 1.69, P = .008), although older age was not.22 In a Danish hospital point-prevalence study, the mean age of those with skin tear was 85 years, which was significantly higher than those without (P < .001).14 In that study, prevalence was higher in females (14.4%) than males (8.2%), but the difference was not statistically significant. The main predisposing factor associated with skin tear was previous skin tear (OR = 9.3, P = .001).14

In our study, the greatest proportion of skin tears was found in STAR18 category 3 (no skin flap) (40.1%), with similar proportions found in both hospital- and community-acquired sub-sets, and there was a notably larger proportion of hospital-acquired STAR category 2B skin tears (33.4%) compared with those community-acquired (26.4%). By comparison, Chang et al15 reported a similar but higher proportion of STAR category 3 skin tears (43%), while a much greater proportion of ISTAP4 category 2 skin tears (72.5%) was found by Bermark et al14 In stark contrast, within Australian residential aged care settings, only one (3.7%) STAR category 3 skin tear was found, with the majority in STAR categories 1A and 1B (74.0%).9 As in other studies,14, 15, 21 we found most skin tears on the limbs, in similar proportions across upper and lower limbs. In the hospital setting, staff education should focus attention on appropriate manual handling and transfer techniques of patients, especially with regard to limb protection of older adults whose frail, thinner skin, is more easily damaged by shear and friction forces.