site protection, securement and skin integrity: skin care

3M Health Care AcademySM

© 3M 2015. All Rights Reserved


Site Protection, Securement and Skin Integrity: Skin Care Considerations for Vascular AccessDana McReynolds

3M Critical and Chronic Care Solutions Division

Author: Debra Thayer MS, RN, CWOCN

Lead Technical Service Specialist

3M Critical and Chronic Care Solutions Division


© 3M 2015. All Rights Reserved 2

Disclosure

Dana McReynolds is an employee of 3M Company



Objectives

Describe the significance of skin damage at vascular access sites

Explain the mechanism of injury for at least 2 types of MARSI

Describe four key steps for MARSI prevention



Why are we concerned with skin around a vascular access site?

Epidermis is the critical physical barrier to

entry of irritants and pathogens

1. Wysocki AB. Anatomy and Physiology of Skin and Soft Tissue. In Bryant, RA and Nix DP eds. Acute and Chronic Wounds: Current Management Concepts. 4th ed. St Louis, MO: Elsevier Mosby; 2012: 40-62.2. Roth,RR and James WD Microbial Ecology of the Skin. Annu. Rev. Microbiol. 1988; 42: 441-464.3. Abad, CL and Safdar, N. Catheter-related Bloodstream Infections. Infectious Disease. (Special Edition) 2011. McMahon Publishing

Epidermis skin layer






Skin damage disrupts/destroys normal

structural, chemical and microbial barrier1



Skin Cells Removed






Skin damage disrupts/destroys normal

structural, chemical and microbial barrier1

Increased risk of infection2,3

Additional adverse outcomes:

▪ Pain and discomfort

▪ Potential inability to adhere dressing/devices

▪ Potential need to move vascular access device



Skin Cells Removed

Damaged Skin



How often does this happen?

Prevalence of MARSI at PICC sites-

study in Oncology population n=419

Total MARSI prevalence=29.8% (125)

Mechanical=58% (73)

Contact dermatitis=31% (39)

MASD=8% (11)

Folliculitis=1.6% (2)

Zhao H et al J Vasc Access 2017. Nov 8:0. doi:10.5301/jva.5000805



For every complex problem there is an answer that is clear, simple, and wrong.

H. L. Mencken

When skin damage happens, there is a tendency to blame…



CONCLUSION: “It is increasingly

common for vascular access

specialists to report superficial skin

damage at infusion sites, especially

with central venous access devices

that require repeated dressing

changes. Systemic factors such as

age, multiple and complex

comorbidities and chemotherapeutics,

and interventions specific to catheter

insertion and management can all

contribute to skin injury.”Thayer D. Skin Damage Associated with Intravenous Therapy: Common Problems and Strategies for Prevention. J of Infusion Nurs.2012; 36(6): 390-401.



Understanding MARSI at Vascular Access Sites



• Results from a 2012 Consensus Conference• Who? • 23 Key Opinion Leaders with specialized expertise across

disciplines

• What? • Establish consensus statements regarding the assessment,

prevention and treatment of adhesive skin injury• Not specific to vascular access

• How?

• 2-day moderated discussion and Consensus-decision making

process

Where did “MARSI” come from?



Finally, a definition

“A medical adhesive-related skin injury is an

occurrence in which erythema and/or other

manifestation of cutaneous abnormality (including,

but not limited to, vesicle, bulla, erosion, or tear)

persists 30 minutes or more after removal of the

adhesive.”McNichol L, Lund C, Rosen T, Gray M. J Wound Ostomy Continence Nurs. 2013; 40(4): 365-380.



Several Common Forms of MARSI

MARSI

FolliculitisMacerationMechanicalIrritant Contact

DermatitisAllergic Contact

Dermatitis



Irritant Contact Dermatitis (ICD)

Image courtesy of R. Huneke-Rosenberg



Barrier disruption → increased risk of permeation

•Excessive hydration (e.g.

maceration)

• Loss of normally tight junctions

•Skin disease

•Damage (e.g. stripping)

•Extremes of age e.g. <27 weeks

gestation, the very old

•Characteristics of topical

• Size/structure of molecule



http://www.hse.gov.uk/skin/imagelibrary.htm

Allergic Contact Dermatitis

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjsufS42PXLAhVEWx4KHXCUDCcQjRwIBw&url=http://www.hse.gov.uk/skin/imagelibrary.htm&bvm=bv.118443451,d.dmo&psig=AFQjCNELUrA9IUD2vYVfxdtmtKc9xFotdQ&ust=1459883621942976



But!

“Any topically applied chemical substance

has the potential to induce an irritant or

hypersensitization reaction in any individual

at some time.” Shelanski, Phillips and Potts. Intl J Dermatol 1996 35(2); 138.



Inflammation

Increased

permeability of

Stratum corneumpH changes

Maceration-the result of excessive hydration



Friction contributes to skin damage

When skin is wet



“Mechanical” injury results when the

skin to adhesive attachment

is stronger than the

skin to skin attachment

skin

adhesivebacking



MARSI-“Stripping” Detachment of:-individual layers of the epidermis or

-the entire epidermis from the dermis

Referred to as a “skin tear”

Stratum Corneum



• Mechanism of Damage

• Adhesive to skin attachment > skin-skin attachment

• Shear force

• Epidermis pulls away from dermis

• Secondary to “strapping” (i.e. stretching) &/or edema/distention

MARSI-Tension Blisters



Collagen Elastin

Fat

Normal changes of aging increase risk

Image from www.consumerguides.com



Preventing MARSI at Vascular Access Sites



1) Understanding and recognizing risk factors

Underlying illnessImmuno-suppressionTreatment of medical

conditionsSkin Changes a/w

Sun Exposure Extremes of age



Available adult data-not specific to Vascular Access

1Farris MK, J WOCN;42(6):589-598; 2Konya, J Clin Nurs 2010;19:1236-42

Elderly

21%Median daily MARSI

rate1

• A 28-day prevalence study of adult patients in an acute care setting found the median daily prevalence of all medical adhesive-related skin injuries was 21.1% for patients 65 to 74 years1

• Elderly patients admitted to a long-term care facility (n=155, 65 years and older) had a 15.5% cumulative incidence rate for adhesive-related skin injuries2

26

Collagen Elastin

Fat



Available peds data-not specific to VA

1McLane KM, J WOCN 2004;31:168-78; 2Noonan C, Pediatr. Nurs. 2006;21 (6):445-53;

27

Pediatric

Prevalence of skin tears in a pediatric

population of patients with skin

breakdown1

• 1-day skin prevalence audit in a university-affiliated children’s hospital audited 252 patients (average age= 4.5 years, range 0.6-11yrs) Findings: 8% had epidermal stripping from tape products2

• A large chart review across 9 hospitals and 1,064 children reported skin tear prevalence of 17% , the second most common skin breakdown after diaper dermatitis1

17%• Functional skin maturity @ approx.

34 weeks gestation

• < 27 weeks @ high risk for adhesive

injury

• Thin stratum corneum

• Weak epidermal-dermal junction

• Stunted rete ridges

• Minimal fat

• Note! Healthy full-term babies have

good barrier function



Vascular access specific data emerging

28

Oncology study-patients with PICCs

Age ≥50yo

Hematologic malignancies

Zhao H et al J Vasc Access 2017. Nov 8:0. doi:10.5301/jva.5000805



2) Understand and address key causal factors

Type of adhesive Skin Preparation Application Technique Removal Technique

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://solutions.3m.co.za/wps/portal/3M/en_ZA/EU-Skin-Wound-Care/Home/Brands/Tegaderm/CHG/&ei=JqfbVK-DOIKpgwTl24DADg&bvm=bv.85761416,d.eXY&psig=AFQjCNFSVNuqSgVRkfrpJcd_fV1Izzh3UA&ust=1423767687094152

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://solutions.3mphilippines.com.ph/wps/portal/3M/en_PH/SWC/main/brands/tegadermiv/&ei=E6jbVLmgMo_igwSOiIOwAQ&bvm=bv.85761416,d.eXY&psig=AFQjCNFI4oVlYV7Fo7RWGiMsl5yWwfwlRg&ust=1423767941677885



•Wrong adhesive for clinical need

•No (or inadequate) skin preparation

• Incorrect or careless application

• Incorrect or careless removal

Preventable causes of MARSI



Adhesive Technology

Backing Technology

Clinical Performance

• Adhesion level• Conformability• Breathability• Gentleness• Ability to stretch • Ability to tear

Step 1: Selecting the Right Adhesive Product



Silicone adhesive Acrylate adhesives

If silicone adhesives are gentler, then why don’t we use them more often?



Step 1: Selecting the Right Adhesive Product

3 main categories used for vascular access:Dressings for site protection

Device securement Tape for tubing support and stabilization

Select the most appropriate adhesive product based on intended

purpose…location…and ambient conditions present at…site.

Skin moisture/wetness is major consideration



Step 2) Prepare the skin

Clip excess hair with clipper or sterile scissorsDo not shave

Gorski L, Hadaway L, Hagle ME, McGoldrick M, Orr M, Doellman D. Infusion therapy standards of practice. J Infus Nurs. 2016; 39(suppl 1):.S64



Allow antiseptic prep to dry completely!!!

How long you ask?

As long as it takes!

or

Rickard C, Ullman A, Marsh N, anmf.org.au May 2017; 24(16)



Forms a protective interface between the adhesive and skin Adhesive removal removes barrier film, not epidermal cells

This

Not this

Best Practice: protect skin with an alcohol-free barrier film



Medical Adhesives and Patient Safety: State of the Science: Consensus Statements for the Assessment, Prevention, and

Treatment of Adhesive-Related Skin InjuriesJournal of Wound Ostomy Continence Nursing. 2013;40(4):365-380.

Central Vascular Access Device (CVAD) Stabilization Standard 37, page S72-74

• Apply barrier solutions to skin exposed to adhesive dressing to reduce risk of Medical Adhesive-Related Skin Injury (MARSI). (Level I)

Gorski L, Hadaway L, Hagle ME, McGoldrick M, Orr M, Doellman D. Infusion therapy standards of practice. J Infus Nurs. 2016; 39(suppl 1):S1-S159.

What is the basis for this?



Barrier films vs.Tackifiers

• Barrier films

• Chemistry=

• Polymer(s) dissolved in a solvent

• Intended effect

• Form an interface between adhesive

coating and skin

• Allow adhesion

• Protect skin by acting as sacrificial

substrate-film is removed vs. cells*

*ability to do this will vary depending on formulation

• Adhesion promoters (aka

“Tackifiers”)

• Chemistry=

1. gum mastic, alcohol and methyl

salicylate (oil of wintergreen) +/-

acetone (various brands) or

2. Balsamic resin from specific bark

(benzoin tincture)

• Intended effect

• Enhance/increase adhesion

• Concern-known potential for sensitization



“Limit or avoid substances, such as compound tincture of benzoin, which increases the stickiness of adhesives”.

McNichol L, et al. J Wound Ostomy Continence Nurs. 2013; 40(4): 365-380.

Best Practice recommendations re: tackifiers

“Compound tincture of benzoin should not be used due to increased

risk of MARSI because it may increase the bonding of adhesives to skin, causing

skin injury when the adhesive based [engineered stabilization device] (ESD)

is removed" (Level I-highest recommendation)

Gorski L,et al. J Infus Nurs. 2016;39 (suppl 1): S 73,82.



1-Hunter, K. Personal communication. Thayer D. J Infus Nurs. 2012; 35(6): 390-401.

Step 3) Apply the adhesive product properly

Downward

pull

Diagonal pull

Hunter’s Turgor Restriction-related Skin Injury Theory

Stretching



Firm pressure applied to the surface of

medical tape will activate adhesive and

increase surface area contact

Medical Adhesives Are Pressure Sensitive

Step 3) Apply the adhesive product properly



Step 4) Remove the adhesive product properly

Importance of peel angle




Importance of peel line




Technique for removing transparent film dressings

Tape methodStretch method



18.Consider use of medical adhesive removers

to minimize discomfort and skin damage

associated with removal of adhesive

products.

Not addressed by INS standards

No best practice identified for vascular access



Skin damage associated with infusion therapy…

• increases risk of colonization and infection

• systemic and therapy-related factors contribute

―its not just about adhesives and allergy

•prevention is key!

―several simple interventions can make a difference!



Thank you!

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