Increased reporting of patients suffering delayed diagnosis and pressure injuries were largely behind an increase in public hospital adverse events, shows the the 2016-17 Learning from adverse events report released today by the Health Quality and Safety Commission. But the number of falls leading to injuries continues to decrease.

Jane McGeorge, the NZNO’s nursing and professional services manager said it was pleased to see the small decrease in patient falls. But it was concerned about the number of reports of nurse sensitive indicators like the failure to respond to deteriorating patients and the increase in reports of other indicators like pressure injuries and hospital acquired infections.

The Commission report records the health care adverse events reported to them by district health boards (DHBs) and other health care providers.

A total of 542 non-mental health* adverse events were reported by DHBs in 2016–17 up from 520 in 2015–16, 525 in 2014-15 and 454 in 2013-14. Of the 542 adverse events reported by DHBs, 79 people died however the Commission said the deaths were not necessarily directly related to the adverse event. (*Mental health and behaviour-related adverse events are now reported via the Office of the Director of Mental Health annual report).

Commission chair Professor Alan Merry said the adverse events report reflects a steady improvement in reporting culture towards increased transparency and taking action based on learnings from system failings. The Commission also believed that at present New Zealand’s adverse event levels were “broadly comparable” to Australia and the United Kingdom.

Merry believed the steep upswing in reported pressure injuries – from about 15 last year to 51 this year – might reflect a “concerted effort across the sector to raise awareness of the impact and devastating harm of those injuries”. “This attention is particularly important given evidence shows pressure injuries are highly preventable.”

He also believed the increase in healthcare associated infections (HAIs) – up from three last year to 16 this year – was due to the Commission highlighting the issue leading to additional reporting.

“This may reflect both an improvement in reporting culture and awareness-raising through the work the Commission and sector are doing as part of the Surgical Site Infection Improvement programme.”

The adverse event statistics also showed for the second year running an increase in clinical management events and a decrease in falls adverse events

The largest sub-group of clinical management events is delayed diagnosis or treatment – including delays in referrals and follow-up by specialty services – with 70 reports. Thirty of those reports related to cancer or suspected cancer with the majority of DHBs having reports in these areas. There were also 24 events relating to ophthalmology from a number of DHBs.  In the separate reporting area of failing to recognise, rescue or manage deteriorating patients there were 26 events reported.

MacGeorge said NZNO believed indicators like pressure injuries, deteriorating patients and HAIs needed to be monitored specifically, “not as part of a homogenous group as they are barometer of quality of care and typically observed in an under-resourced system”.  She said NZNO was working to have the safe staffing Care Capacity Demand Management system operating in all DHBs to ensure hospitals were safe for patients and staff.

“The underfunding of the health service has led to understaffed hospitals and lean resources but with a new government promising reinvestment we expect the situation for patients and health staff to improve,” Jane MacGeorge said.

Harm from falls still make up the majority of adverse events reported by DHBs – making up 39 per cent of all adverse events reported – but the number has fallen to 210 after peaking at around 275 in 2014-15. “The Commission recognises the tremendous effort across the sector in achieving an ongoing improvement in falls figures; reducing harm from falls is not easy to achieve and sustain as there is no single solution,” said the report.

2016-2017 DHB Adverse Event Reports:

• 282 clinical management events (including 70 for delayed diagnosis or treatment and 51 for pressure injuries)
• 210 falls resulting in serious harm, including 77 where the patient broke their hip
• 19 medication-related events
• 16 healthcare associated infections
• 15 other events (such as dietary management and documentation).

Other providers reported 86 adverse events in 2016–17:

• New Zealand Private Surgical Hospitals Association: 52
• ambulance services: 28
• aged residential care: one report relating to pressure injuryprimary health organisations: one event, relating to serious harm from a fall
• hospice: two events; one pressure injury and one serious harm from a fall
• community service: two events.

Merry said adverse events in health care can have a huge impact on the person involved and their whānau, family and friends.

“I would like to acknowledge the people affected by the tragic events outlined in this report. Partnering with consumers and whānau in the review and learning process is pivotal to improving quality and safety.”

Prof Merry says research shows consumers who have been affected by an adverse event offer a unique perspective on that event. “Consumers may be able to perceive care transition and process issues, including service quality, that occur before, during and after adverse events, that are less likely to be identified by providers”.

MacGeorge said NZNO thanked the Commission for their work to produce recent and relevant data and said the changes to the national adverse events reporting policy – which came into effect on July 1 this year – were also progressing well.  She congratulated the Commission on the increased focus on outcomes of serious events for the consumer, increased engagement with whānau and extending coverage to the whole health and disability sector.

“We appreciate the culture of learning that allows us to find meaningful ways to improve patient safety while identifying workforce and, resource and system issues that are a barrier to safe care and safe staffing,” she said.

A copy of the full adverse events report is available online at https://www.hqsc.govt.nz/our-programmes/adverse-events/publications-and-resources/publication/3111/

HQSC “Q & A” on Adverse Events

What is an adverse event?

An adverse event is an incident that results in harm to people using health and disability services. Adverse events resulting in serious harm or death are reported by health and disability providers, guided by the Commission’s National Reportable Events Policy.[1] The policy was updated on 1 July 2017, but adverse events discussed in this year’s report are based on the 2012 policy.

Are providers required to report?

DHBs are required to report adverse events to the Commission in accordance with the policy guidance. Many non-DHB health providers – such as private surgical hospitals, aged residential care facilities, disability services and hospices – voluntarily provide information.

How accurate is the adverse events data?

The 2016–17 report explains the process for adverse events reporting to provide clarity and context to the numbers reported. The Commission believes that in some categories the number of reported adverse events is an increasingly accurate picture of the actual number of adverse events that occur. The number of broken hips in hospital reported by DHBs in this report, for instance, closely aligns with numbers included in the NMDS (National Minimum Dataset), which records information produced by public hospitals when a patient is discharged.

The adverse events reported increasingly reflect the evolving maturity of organisations to include broader types of events and to recognise the systemic influences contributing to their occurrence.

At a major nursing conference recently, I went along to a session on ‘Intentional Rounding’.

I know, I should have known better. I should have listened to all the alarm bells ringing. I should have re-read Willis et al.’s exquisite paper (2015), Rounding, Work Intensification and New Public Management. I should have looked for a session on urine drinking or a ‘concept analysis’ of 1990s Models of Nursing, but I didn’t.

The aberration that is ‘Intentional Rounding’ (IR) has come to exemplify almost everything that is wrong with our amazing profession.

Where to start is the big problem.

Who came up with that doozie of a name and what on earth would ‘non-intentional rounding’ look like?

Is that a kind of nursing somnambulism, or do we perhaps still have nurses who know the value of staying close to and knowing important things about their patients, and don’t need an institutionalised ‘model’ or new ‘initiative’ to tell them when and how to do this?

Back at the nightmare.

As an earnest nurse described the tick-box straitjacket that Intentional Rounding has donned, we discovered that a key assumption of IR is that nurses are fundamentally stupid and that trusting their professional judgment would be a grievous error in terms of patients’ safety.

To stop them from making such an error and to ‘prove’ to someone that nursing has actually happened, the entire process is infantilised into yet another tick box and pointless checklist that will become further fodder for ‘The Regulatory Beast’ that must be fed (Nursing Standard 2012).

All of this is bad enough, but when I saw the actual ‘tick box’ that IR relies on, I almost fell off my chair.

Delicate readers, nurses who perhaps trained more than a few years ago, or those who are or were Ward Sisters / Charge Nurses may need to look away at this point.

Not only are nurses deemed too stupid or untrustworthy to check and connect with their patients because that is their job, they apparently won’t manage to do this without the ‘correct tools’ – i.e. a four-box checklist.

If could possibly get worse, it did.

We learned that this checklist has to be alliterated to the ‘4 Ps’ to make it even more child-friendly, so that the nurses we charge with the responsibility of people’s lives won’t forgetty-wetty any of the four boxy-woxies.

They are, and believe me, I am not making a word of this up:

1) Pain

Ask the patient if they are in any pain. Wonderful. Thank goodness nurses have a ‘tool’ to help them do this.

2) Position

Always good to make sure that Mrs Smith isn’t hanging out of her bed or maybe not the best idea to have Mr Bloggs with his emphysema and congestive heart failure lying as flat as a pancake.

3) Possessions

Does Mrs Smith have her handbag handy and can Mr Bloggs reach his slippers, phone or water jug?

All of this so far is not a whit different from what your nurse tutor or clinical teacher would have told you was involved in ‘leaving the patient comfortable’ after you’d done anything with them.

Can we have a drum roll please for #4…..

4) Potty

Yes, you read this correctly. Have they been to the toilet recently or do they need any help to go now?

It is almost beyond human comprehension. How many patients out there above the age of two, noticing that their nurse has just ticked a box called ‘potty’ would not leap out of the bed and throw that nurse directly out of their room and with our applause?

I just did not believe this until I did a simple google search of ‘potty’ and ‘rounding’ and there it is, in file after file, document after document, all lauding this wonderful new ‘patient safety’ initiative and its required ‘4Ps’, dashboards and toolkits (all available at a price, of course).

A few days after the conference I was having tea with the nurse who was more like a hero than a mentor to me and who had been a Ward Sister of a busy medical ward ‘back in the day’. I wish someone could have filmed me trying to explain the concept of a ‘new nursing initiative’ that involved nurses going round their patients and checking that all is well, to a nurse whose generation of colleagues did that as easily and regularly as breathing.

One of the smartest nurses and women I have ever known simply could not grasp what I was talking about and you could see the puzzled look of “But isn’t that what we’ve always done?” spread across her face.

One of the many tragedies of the IR débâcle is that somehow, nurses and nursing took its eye off the ball so dramatically that we had to endure the spectacle of British PM, David Cameron, standing up in the House of Commons in 2012 to tell nurses that they need to go round their patients regularly to see how they were as part of ‘quality’ nursing care (Kirkup 2012).

The shame still burns like lava.

What happened? Did a memo come round from somewhere, saying that nurses must stop ‘rounding’ and checking on their patients? Did senior nurses visiting wards and units stop asking the nurse in charge ‘How is everyone today?’ or ‘Please take me round the ward?’

So now we have yet another checklist and boxes to tick that allegedly improve care, safety, quality or whatever and another mini-empire will spring up of IR toolkit-sellers, IR trainers and accreditors, perhaps levels of IR expertise (Senior IR Facilitator anyone?)

Don’t laugh. Remember the nonsense of Lean/Six Sigma Black Belts etc?

IR becomes almost the endgame of a movement that has sought to render all of nursing as little more than a series of documents to sign or boxes to check – a movement that has equal measures of distrust and contempt for the very idea of professional nursing judgment.

IR will now of course need its own ‘body of knowledge’ and research careers will be built on studying this ‘innovation’ about which ‘little is known’.

Further comment is superfluous.

This blog artifice by the Monash University nursing professor and consultant was first published on Ausmed.

The hospital has swapped using an antibiotic cream applied in the nose before and after cardiac surgery – to prevent staphylococcus aureus (staph) surgical site infections – and replaced it with an antiseptic iodine nasal swab instead.

The change to the ‘anti-staph’ infection prevention bundle was initiated by infection prevention and control (IPC) clinical nurse specialist Karen Corban with the support of her mentors cardiothoracic surgeon Sean Galvin and microbiologist Professor Tim Blackmore.

Corban said the project arose when she chose to audit the hospital’s cardiac surgery anti-staph bundle as part of an IPC quality improvement course being offered through the Health Quality and Safety Commission (HQSC) and linked to its national surgical site infection (SSI) improvement project.

Wellington Hospital had introduced an anti-staph bundle two years ago, targeted at reducing cardiac SSIs, that included an antiseptic body wipe (chlorhexidine) and also applying mupirocin (also known as Bactroban) antibiotic cream in the nose before and after surgery.

Corban said the audit showed up low compliance with the mupirocin ointment component of the bundle, which involved applying the antibiotic cream the night before surgery and then twice a day for five days. A brain storming session with ward staff found non-compliance was due to a number of reasons including the cream going missing and not all staff being aware of the need for the twice-daily regime. Staff questioned why there wasn’t something that only needed to be done once to reduce the risk of nasal bacteria causing SSIs.

Looking for an answer she turned to her mentors Galvin, who was part of the HQSC’s group looking at preventing cardiac SSI, and Blackmore, who was leading the DHB’s antimicrobial stewardship project. At the same time late last year HQSC put out an anti-staph bundle discussion paper that examined the latest literature and suggested that an antiseptic nasal swab containing an iodine product could be just as effective as mupirocin. (See related research articles below).

Corban said using an antiseptic rather than an antibiotic was also seen to reduce the risk of patients becoming resistant to mupirocin and meant the antibiotic cream could be saved for when it was needed to fight an infection. Using povidone-iodine swabs to decolonise the nose was also much cheaper with iodine swabs costing around 80c each compared to $50 per tube of antibiotic ointment. Corban said the swabs also reduced the need for some laboratory tests and in total the swabs could save around $100 per patient so the project had already saved about $25,000 since it got underway in January.

Another advantage was that the swabs only needed to be done once – about one to two hours before the patient went to theatre – and provided cover for 12 hours.

So the decision to swap from the antibiotic cream to swabbing from the start of this year was backed by nurses who felt they were being listened to and saw the swabbing as a more practical alternative. She said the move had also been supported by HQSC which was exploring different options for introducing anti-staph bundles to DHBs across the country.

Corban said part of the project was developing a process for carrying out the antiseptic swabbing that including testing it out by inserting swabs up her own nose and the nose of a fellow IPC nurse specialist. “When we taught the process we gave everyone a swab that they could do themselves, or utilise on each other, so they knew what it felt like to be a patient and have that up their nose.”

The swabbing process involves one swab in the first nostril for 30 seconds, followed by another swab for 30 seconds in the second nostril and then repeated with a further 30 second swab to each nostril.

An important part of the antiseptic swabbing was amount of contact time with the mucosa so Corban developed a swabbing technique and pattern that takes 30 seconds to complete so nurses don’t have to keep an eye on a fob watch.

Corban, an ex-cardiothoracic charge nurse, followed up the swabbing training by coming in to the ward 6.30am every morning for five days a week for 20 weeks to observe pre-surgery swabs being given. She then followed it up with two months of observing five swabs a week and now is down to three-monthly checking of swabbing technique.

A staph aureus information sheet was developed for registered nurses plus an information sheet for patients about the process. She also surveyed a 100 patients with more than 90 per cent of them reporting the swab process was neither pleasant or unpleasant and it was found to be well-tolerated.

The DHB does about 550 cardiac surgeries a year but is now looking to roll out the anti-staph bundle to orthopaedic surgery.

Corban, who has a masters in public health, said the success of anti-staph bundle project has also seen her invited by HQSC to join its anti-staph bundle working group.

Further reading:

Discussion paper: Anti-staphylococcal bundle to reduce surgical site infections in orthopaedic and cardiac surgery (November 2016), HQSC

Anti-staphylococcal bundle to reduce surgical site infections in orthopaedic and cardiac surgery (March 2017) HQSC

Beboko S, Green D & Awad S (2015) Effect of a Preoperative Decontamination Protocol on Surgical Site Infections in Patients Undergoing Elective Orthopedic Surgery With Hardware Implantation. JAMA Surg. 2015;150(5):390-395. doi:10.1001/jamasurg.2014.3480

Anderson MJ, David M, Scholz M et al (2015) Efficacy of Skin and Nasal Povidone-Iodine Preparation against Mupirocin-Resistant Methicillin-Resistant Staphylococcus aureus and S. aureus within the Anterior Nares. Antimicrobial Agents and Chemotherapy 59(5)

This learning activity is relevant to the Nursing Council registered nurse competencies 1.1, 1.4, 2.1-2.4, 2.6, 2.8-2.9.

Learning outcomes

Reading and reflecting on this article will enable you to:

• further your understanding of how the quality of clinical service delivery is measured in your workplace
• review your understanding of skin tear injuries and their significance for the individual concerned.

Introduction

Henry had been living in an aged residential care facility for several years. He was now frail and confused, requiring assistance with almost all aspects of daily living. Paul, Henry’s son, visited him at least twice weekly, and on a recent visit noticed that his lower arm was bandaged. Staff were unable to tell Paul what had happened to Henry’s arm, and there was no wound assessment or treatment plan. According to the wound register, Henry had two other skin tears on his legs, but the status of these wounds was unclear.

When the registered nurse removed Henry’s arm bandage, two large and inflamed skin tears (each with a partial flap loss) were found. Skin closure strips had been used on both injuries and then covered with dry dressings, which had adhered to the wounds. Henry moaned loudly and kept trying to move his arm away when the areas were being redressed¹.

Although skin tears represent more than half of all skin injuries in older adults, they have been described as forgotten wounds², receiving little attention or research.

Skin injuries such as skin tears are often regarded as inevitable, and remain underappreciated, under-reported and essentially invisible³. Yet nurses working with older adults in all clinical settings are likely to encounter skin tears on a very regular basis.

The factors that contribute to the quality of nursing service delivery for older adults are complex, and singling out just one measure alone cannot offer a valid representation of the quality of service delivery. However exploring events and injuries such as skin tears in more depth enables clinical staff and management to identify opportunities for improving service delivery and reducing potential/actual distress and injury for older adults.

Skin tears revisited

Skin tears are “wounds caused by shear, friction, and/or blunt force, resulting in separation of skin layers. A skin tear can be partial thickness (separation of the epidermis from the dermis) or full thickness (separation of both epidermis and dermis from underlying structures)”⁴. (Refer to the STAR Skin Tear Classification System [see Box 1 Next page]⁵ and the learning activities associated with this article for further information on skin tear classifications and management). Although there are a number of commonly recognised classification tools for assessing and documenting skin tears, international research suggests these are not used regularly⁶.

Internationally, information on the skin tear prevalence and incidence rates are limited². It has been suggested that under-reporting occurs because of a primary focus on pressure injuries, and that iatrogenic skin injuries, such as skin tears, and incontinence-associated dermatitis, are regarded as an inevitable part of ageing³. The New Zealand prevalence rate (number of new and current skin tears) is unknown⁷.

ACC accepts claims for primary injuries that include skin damage, injury or tears related to treatment by a registered health practitioner, but it cannot provide data specific to skins tears. Between 2011 and 2016 the number of accepted treatment-related claims for skin damage, injury or tears varied between 161 and 239 per year, with an average of 181 claims per year.

Since data was collected in 2005, 79 per cent of accepted claims for this primary treatment injury relate to individuals aged over 65 years of age. Nursing is the lead ‘context’ of these injuries and the top three treatment events that resulted in the injury are firstly removal of dressings/wound care; secondly patient transfer, and lastly removal of strapping⁸.

Australian researchers identified an incidence rate of 10.6 per 1,000 occupied bed days in their control group of residents in aged care facilities, while another study identified a 20 per cent prevalence rate in adults aged over 80 years living in the community⁹.

The skin of older adults is particularly vulnerable to injury, and iatrogenic skin injuries result from complex, multifactorial and interconnected threats³. Tissue tolerance is affected by:

• advancing age
• pre-existing health status and comorbidities
• level of nutrition
• medications
• perfusion
• oxygenation
• mobility
• sensory perception³.

Environmental factors, such as staff turnover, skill mix, and knowledge and care practices all have the potential to exacerbate skin tear rates.

Skin tear outcomes

Skin tears range from relatively minor to extensive and complex wounds, although they may be perceived by some as minor injuries¹⁰. Like any wound, they are a potential site of infection, especially in the frail elderly, as well as impacting on the person’s quality of life. Skin tears can be painful, as the superficial nerve endings are usually affected¹⁰ and have the potential to become chronic wounds.

The management of skin tear injuries further adds to staff workloads and care delivery costs. When older adults experience skin tears on a regular basis, keeping track of multiple injuries and their healing status can prove challenging. This is especially so when these wounds may not require daily changes of dressing if appropriate dressings are used, meaning there is an increased potential for them to be overlooked.

The experience of a skin injury, such as a skin tear, is unique and specific to each individual injury, and can impact on all aspects of the person’s wellbeing³. Ongoing skin tears can be a very visible and unwelcome reminder for both individuals and their families of physical deterioration. When a person experiences multiple skin tears over time, they also have the potential to cause family members to question the quality of service delivery.

BOX 1

STAR Skin Tear Classification System Guidelines

1. Control bleeding and clean the wound according to protocol.
2. Realign (if possible) any skin or flap.
3. Assess degree of tissue loss and skin or flap colour using the STAR Classification System.
4. Assess the surrounding skin condition for fragility, swelling, discolouration or bruising.
5. Assess the person, their wound and their healing environment as per protocol.
6. If skin or flap colour is pale, dusky or darkened reassess in 24-48 hours or at the first dressing change.

STAR Classification System

1. Category 1a

A skin tear where the edges can be realigned to the normal anatomical position (without undue stretching) and the skin or flap colour is not pale, dusky or darkened.

2. Category 1b

A skin tear where the edges can be realigned to the normal anatomical position (without undue stretching) and the skin or flap colour is pale, dusky or darkened.

3. Category 2a

A skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap colour is not pale, dusky or darkened.

4. Category 2a

A skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap colour is pale, dusky or darkened.

5. Category 3

A skin tear where the skin flap is completely absent.

From: STAR Skin Tear Classification Tool developed by Skin Tear Audit Research (STAR). Silver Chain Group Limited, Curtin University. Revised 4 February 2010. Reprinted August 2012. You can download full STAR tool and glossary at: www.woundsaustralia.com.au/wa/resources.php

Is our service up to standard?

Measuring the quality of care is a complex and multifaceted undertaking.

All healthcare services in New Zealand are regularly assessed against the Health and Disability Sector Standards (2008)¹¹. Compliance with these standards includes having a plan for measuring the quality of services, which may involve monitoring quality indicators (see Box 2), complaints, service user satisfaction surveys, and responses to identified issues.

New Zealand’s Health Quality and Safety Commission¹² has developed a set of quality markers that track progress over time in the health and disability sector relating to four key priority areas – falls, healthcare associated infections, surgical harm and medication safety.

A Standards New Zealand Working Party developed specific clinical indicators for individuals requiring aged care or dementia care in 2005 (see Box 2)¹³. Indicators include pressure injuries, falls, urinary tract infections and staffing hours but not skin tear rates. However, skin tear rates should be included as a clinical indicator for any organisation providing services to older adults because of the frequency of these injuries, their impacts on individuals, and the many opportunities for preventing/minimising their occurrences.

Monitoring skin tear injury rates provides a valuable overview of service delivery, while auditing individual cases (tracer methodology) offers a window into systems and processes. The Ministry of Health¹⁴ suggests that examining the journey of a specific client/resident/patient facilitates understanding of the care that is being provided and shows if staff know how to deliver care, tests systems and processes and their function and validates the individual’s journey and outcomes (p.4).

A detailed review of just one service user’s experience with a skin tear injury can provide a range of valuable information, including:

• wound management practices and consistency with service policies – systems and processes for assessing/classifying/evaluating and reporting on wound progress; evidence-based wound management practices (e.g. not using skin closures on skin tears¹⁵); use of appropriate wound care products; monitoring for infection; checking that wounds are regularly monitored until they heal
• assessment and care planning – short-term plans related to the skin injury and its associated clinical requirements, such as analgesia, enhanced nutrition; strategies to minimise risk of skin injuries or further injuries, such as avoiding soaps and using skin moisturisers twice daily⁹, and the use of appropriate transfer equipment, for example, slider sheets
• capturing relevant data – initial and ongoing documentation in the clinical record related to the injury; completion of an accident/incident report; open disclosure to the individual and/or family; analysis of incident and accident data; mechanisms for responding to findings, reporting results to staff, actioning any identified deficits.

In conjunction with reviewing individual cases, an analysis of skin tear injury rates across the service can tell us about environmental factors that may contribute to these injuries, such as the times of day the injuries occur; the skin tear site; staff skill mix and ratios; staff education and knowledge deficits. These are modifiable factors the organisation can work towards addressing.

BOX 2: Indicators for safe aged care

An indicator is a measure or flag against which some aspect of a standard can be assessed. Indicators generally simplify and quantify complex phenomena and aid the communication of information about those phenomena. Indicators are information tools. They summarise data on complex issues to indicate the overall status and trends on those issues. Indicators are generally measures that link the processes of care with desirable outcomes¹³ (p.13-14).

Conclusion

Unfortunately, skin tears are a common occurrence for many older adults, resulting in pain, distress, and the potential for chronic wounds. Skin tear injuries result from many interlinked factors relating to the individual, the environment, and care practices. Some of these factors are modifiable, such as patient handling procedures, and others, such as significant frailty, are not.

While it is important that skin tears are prevented when possible, and when they occur are carefully and appropriately managed using best practice, these injuries also offer a picture into the quality of care received by individuals and a patient cohort. Rather than being a forgotten and inevitable wound for older adults, skin tears should be a key reminder of the complexity of care for this growing population.

View the PDF of this learning activity here >>

About the authors:

• Lesley Batten RN PhD is a senior researcher at Massey University, Palmerston North.
• Marian Bland RN PhD is a healthcare auditor.

This article has been peer reviewed by:

• Julie Betts RN MN, who is a wound care nurse practitioner at Waikato District Health Board.
• Rebecca Aburn RN MN, who is an infection prevention and control nurse specialist at Southern District Health Board with a special interest in wound care.

Recommended resources

• The International Skin Tears Advisory Panel website includes a range of resources, including the Skin Tear Resource Kit, a skin tear decision algorithm, and consensus statements relating to the prevention, prediction, assessment and treatment of skin tears. www.skintears.org
• The New Zealand Health and Safety Commission website includes comprehensive information on evaluating health quality.
  www.hqsc.govt.nz/our-programmes/health-quality-evaluation
• Pharmac’s 2015 Seminar Series focusing specifically on wounds is available via You Tube. The first part of the fourth video in this series, titled From skin tears to leg ulcers, covers a range of information relevant to skin tear prevention and management.
  www.youtube.com/watch?v=JKme8c9KyB4
• The Skin Safety Model proposed by Campbell, Coyer and Osborne offers a new perspective on older adults’ vulnerability to skin injuries and outlines a framework for skin care and the promotion of skin integrity. CAMPBELL J, COYER F & OSBORNE S (2016). The skin safety model: reconceptualising skin vulnerability in older patients. Journal of Nursing Scholarship 48(1) 14-22.
  http://onlinelibrary.wiley.com/doi/10.1111/jnu.12176/full
• Detailed information on the selection of wound products for skin tears can be found in the following article: LEBLANC K, BARANOSKI S & LANGEMO, D et al (2015) The art of dressing selection: a consensus statement on skin tears and best practice. Advances in Skin and Wound Care 29(1) 32-46.
• Information relating to the prevention of skin tears is outlined by: SUSSMAN G & GOLDING M (2011). Skin tears: should the emphasis be only their management?
  Wound Practice and Research 19(2), 66-70.

References

1. Personal anecdote as told to Marian Bland.
2. LEBLANC K & BARANOSKI S (2014) Skin tears: the forgotten wound. Nursing Management 45(12) 36-46.
3. CAMPBELL J, COYER F & OSBORNE S (2016) The skin safety model: reconceptualising skin vulnerability in older patients. Journal of Nursing Scholarship 48(1) 14-22. http://onlinelibrary.wiley.com/doi/10.1111/jnu.12176/full
4. INTERNATIONAL SKIN TEARS ADVISORY PANEL (2015). www.skintears.org
5. SILVER CHAIN GROUP & CURTIN UNIVERSITY (2007) STAR skin tear classification system. Retrieved from www.woundsaustralia.com.au/publications/2010_wa_star-skin-tear-tool-g-04022010.pdf
6. HOLLISTER AND INTERNATIONAL SKIN TEARS ADVISORY PANEL (2013). Skin tear resource kit. www.skintears.org/pdf/Skin-Tear-Resource-Kit.pdf
7. MILNER E (2013). Simple tear but complex wound. Nursing Review 13, 18-19. www.hqsc.govt.nz/assets/Falls/10-Topics/Milner-Nursing-Review-Nov-2013-Skin-tears.pdf
8. ACC TREATMENT INJURY DATA FROM 1 JULY 2005. [Skin treatment injury data emailed by ACC to Nursing Review on 21 April 2017 following request for information.]
9. CARVILLE K, LESLIE G, OSSEIRAN-MOISSON R, NEWALL N & LEWIN G (2014). The effectiveness of a twice-daily skin-moisturising regimen for reducing the incidence of skin tears. International Wound Journal 11, 445-53.
10. STEPHEN-HAYNES J & CARVILLE K (2011). Skin tear made easy. Wounds International 2(4). Retrieved from www.woundsinternational.com/media/issues/515/files/content_10142.pdf
11. MINISTRY OF HEALTH (2016a). Service standards. www.health.govt.nz/our-work/regulation-health-and-disability-system/certification-health-care-services/services-standards.
12. HEALTH QUALITY AND SAFETY COMMISSION NEW ZEALAND (2016). Health Quality and Safety Indicators. www.hqsc.govt.nz/our-programmes/health-quality-evaluation/projects/health-quality-and-safety-indicators
13. STANDARDS NEW ZEALAND AND MINISTRY OF HEALTH (2005) New Zealand Handbook – indicators for safe aged-care and dementia-care for consumers. SNZ HB 8163:2005.
14. Ministry of Health (2014). Tracer methodology revisited. HealthCert Bulletin: Information for Designated Auditing Agencies 11, 4. www.health.govt.nz/system/files/documents/pages/healthcert-bulletin-11-april-2014.pdf
15. LEBLANC K, BARANOSKI S & LANGEMO, D et al. (2015). The art of dressing selection: a consensus statement on skin tears and best practice. Advances in Skin and Wound Care 29(1) 32-46.
16. NURSING COUNCIL OF NEW ZEALAND (2012)  Competencies for registered nurses. Retrieved January 2016 from www.nursingcouncil.org.nz/Publications/Standards-and-guidelines-for-nurses