Medical Adhesive-Related Skin Injury (MARSI) Laurie McNichol, MSN, RN, GNP, CWOCN, CWON-AP Past President, National Pressure Ulcer Advisory Panel (NPUAP) Past President, Wound Ostomy Continence Nurses Society (WOCN®) Clinical Nurse Specialist/WOC Nurse Cone Health Greensboro, North Carolina USA LMcNichol, 2015 Objectives Identify key assessment points needed to accurately differentiate medical adhesive related skin injury (MARSI) from related causes of skin injuries including moisture associated skin damage and medical device related pressure injuries Describe strategies to prevent medical adhesive related skin injury (MARSI) LMcNichol, 2015 Disclosure Ms. McNichol is a member of the 3M Speaker’s Bureau on this topic She received no guidance from 3M in the development of this educational presentation LMcNichol, 2015 Background The consensus conference described in this presentation was a 2-day roundtable discussion held December 10-11, 2012 in St. Paul Minnesota and was made possible by an unrestricted educational grant from 3M, St. Paul Minnesota. The three-member Task Force investigating this problem were gerontological CNS, L. McNichol, neonatal CNS, C. Lund and dermatologist, Dr. T. Rosen. The manuscript referred to in this presentation was published in the J Wound Ostomy and Continence Nurs. 2013 July/August; 40(4):365-380 LMcNichol, 2015 Why Are We Talking About This? “Isn’t this just something that happens?” “Some people have fragile skin and we need to use adhesives-it can’t be helped.” “It’s no one’s fault.” LMcNichol, 2015 Today’s Focus: Patient Experience Part of a patient’s evaluation of their care experience pertains to management of (and protection from) pain A “matter-of-fact” attitude regarding injury is generally not understood/appreciated Most consumers are fearful of injury/error while in our care LMcNichol, 2015 Today’s Focus: Cost of Care Skin injury results in increased cost of care Average cost associated with injuries has not been explored, so we do not know to what extent these injuries impact cost of care LMcNichol, 2015 Today’s Focus: Culture of Patient Safety Patient centered outcomes translates to adverse events trending downward, e.g. Falls Pressure ulcers Catheter-associated UTIs Surgical site infections etc. LMcNichol, 2015 A Future Category: Skin Injury? If proper technique for application and/or removal of adhesive products is not used, tissue trauma can occur, impacting patient safety, quality of life and increasing healthcare costs LMcNichol, 2015 Medical Adhesive Related Skin Injury (MARSI) LMcNichol, 2015 Consensus Conference Three colleagues formed a Task Force and convened to study the problem in July 2012. It was decided to form a consensus panel on this topic A facilitator was identified Twenty interdisciplinary key opinion leaders with specialized expertise were invited to participate in a consensus conference Twenty-five (25) guideline statements were written LMcNichol, 2015 Consensus Panel Twenty (20) Representatives: Nurses*, Physicians, Physical Therapists, an Electrophysiologist, and an Infection Prevention Specialist *Specialty nurses: WOC (3), Orthopedic, Neonatal/pediatric, ICU, Gerontology, Oncology, Palliative/Hospice, Pulmonary, Infection Prevention, Dermatology Geographic and Practice diversity. All reviewed 31 key publications prior to meeting. Outcomes of Consensus Conference: 2 Definitions Definition of Medical Adhesives (abbreviated from US Food and Drug Administration's Definition) “A medical adhesive is a product used to approximate wound edges or to affix an external device (i.e., tape, dressing, catheter, electrode, pouch, or patch) to the skin.” Definition of a Medical Adhesive-Related Skin Injury (MARSI) “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.” *We have to name something in order to study it, to discuss it and ensure we are talking about the same thing. Two Concepts Embraced 1. Medical Adhesive Mechanics Pressure sensitive: firm pressure “activates” the adhesive Over time, adhesive warms and flows to “fill in” the gaps between the adhesive and the irregularities of the skin surface, increasing the strength of the bond Two Concepts Embraced (continued) 2. Time is of the Essence The length of time for maximum adhesion differs. Softer adhesives such as silicone have a lower surface tension and fill in the gaps quickly, maintaining the same level of adherence over time. Other adhesives, such as acrylates, act more slowly and their adherence increases over time. Mechanical Skin tears Epidermal stripping Tension injuries MARSI Maceration Folliculitis Contact Dermatitis Allergic Dermatitis Mechanical Injury: Skin Tears Skin tears Wounds caused by shear, friction and/or blunt force resulting in separation of skin layers; can be partial or full thickness LeBlanc K , Baranoski S . Skin tears: state of the science: consensus statements for the prevention, prediction, assessment, and treatment of skin tears . Adv Skin Wound Care. 2011 ; 24 (9)( suppl 1 ): 2-15 . Mechanical Injury: Skin Tears Skin tears result when the skin-to-adhesive attachment is stronger than the skin cell-to-skin cell interaction Epidermal layers separate or the epidermis separates completely from the dermis Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). Neonatal skin care. 2nd ed. Evidencebased clinical practice guideline. Washington, DC: AWHONN;2007. Mechanical Injuries: Epidermal Stripping Epidermal Stripping Removal of one or more layers of the stratum corneum occurring following removal of adhesive tape or dressings; lesions are frequently shallow and irregular in shape and the skin may appear shiny; open lesions may be accompanied by erythema and blister formation Cutting KF . Impact of adhesive surgical tape and wound dressings on the skin, with reference to skin stripping . J Wound Care . 2008 ; 17 ( 4 ): 157-158 , 160-162 . Mechanical Injuries: Tension Injuries/Blisters Tension injuries or blisters Injury (separation of the epidermis from the dermis) caused by shear force as a result of distension of skin under an unyielding adhesive tape or dressing, inappropriate strapping of tape or dressing during application, or when a joint or other area of movement is covered with an unyielding tape. Koval KJ , et al. Tape blisters following hip surgery: a prospective, randomized study of two types of tape. J Bone Jt Surg Am Ser A. 2003 ; 85 (10): 1884-1887 . Maceration Maceration Changes in the skin resulting from moisture being trapped against the skin for a prolonged period; skin appears wrinkled and white/gray in color; softening of the skin results in increased permeability and susceptibility to damage from friction and irritants Folliculitis Folliculitis Inflammatory reaction in hair follicle caused by shaving or entrapment of bacteria; appears as small inflamed elevations of skin surrounding the hair follicle; may be nonsuppurative (papules) or contain pus (pustules) Irritant Contact Dermatitis Medical adhesive products are a common cause of nonallergic, irritant contact dermatitis. Such reactions are more likely to occur with extended exposure and reflect the shape of the irritant. Some increase in incidence is noted when skin sealants do not dry prior to adhesive application. Dermatitis from medical devices, implants, and equipment. In: Reitschel RL, Fowler JF Jr, eds. Fisher’s contact dermatitis. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:336-41. Allergic Dermatitis A cell-mediated immunologic response to a component of the adhesive with reaction extending beyond the area of exposure The incidence of true allergic dermatitis is not known; suspected allergic dermatitis should be considered for referral and/or appropriate investigation (such as patch or scratch tests) Usatine RP, Riojas M. Diagnosis and management of contact dermatitis. Am Fam Physician. 2010;82(3):249-255. Widman TJ, Oostman H, Storrs FJ. Allergic contact dermatitis from medical adhesive bandages in patients who report having a reaction to medical bandages. Dermatitis. 2007;19(1):32-37. 25 Consensus Statements 1. Assessment (4 statements) 2. Prevention (18 statements) General Selection Application/Removal Electrodes Infection Prevention 3. Treatment (2 statements) 4. Future Research (1 statement) A New Task: Make the Statements Relevant to the WOC Nursing Community In the Spring of 2015, 3 colleagues decided to seek consensus among WOC nurses on a few of these statements made relevant to WOC practice Stephanie Yates, Laurie McNichol and Dr. Mikel Gray Process: A webinar to introduce the term, literature review and goals 380 WOC nurses registered and participated Feedback revealed that about half recalled the initial work/were familiar with the term Announced a Symposium at 2015 WOCN Annual Conference where both live participants and a virtual audience could participate in MARSI Consensus Statement development pertaining to WOC practice WOCN Annual Conference San Antonio, TX Symposia with 300 live participants 277 Virtual participants Goal: 1 General Statement 2 Ostomy related statements 2 wound related statements 2 continence related statements Consensus Statement #1 (General) Key assessment points needed to accurately differentiate MARSI from MASD and MDRPU are: Use of adhesive in area of injury Shape of tissue injury Patient report of injury Patient history of previous sensitivity Previous products used in the area of injury Hair removal technique (in affected area) Adhesive removal technique Patient history of exposure to moisture I agree with the statement as written. 1 = Yes 2 = No Statement 1 Approval (92%) Consensus Statement #2 Ostomy When applying an ostomy skin barrier, use gentle warming hand pressure to initiate the adhesion process into the contours of the skin. I agree with the statement as written. 1 = Yes 2 = No Statement 2 Approval (93%) Consensus Statement #3 Ostomy Limit or avoid use of additional tackifiers (adhesive enhancers) under ostomy products. I agree with the statement as written. 1 = Yes 2 = No Statement 3 Approval (83%) We ran out of time! So…. A webinar to finish our intended statements was planned Announced that we would finish electronically 140 people registered for webinar Task Force sent proposed statements out to registered participants via Survey Monkey Participants gave suggestions for modifications to statements to Task Force Task Force added another General Statement Webinar to Determine Remaining Consensus Statements: August 12, 2015 Consensus Statement #4 Continence Consider non-adhesive tube securement devices for indwelling urinary catheters I agree with the statement as written. Vote 1 = Yes 2 = No Agree 88.5% Disagree 11.5% Consensus Statements Consensus Statement #5 Continence Follow manufacturer’s recommendations for removal of adhesive-based catheter securement devices (e.g., alcohol or commercially available adhesive removers or releasers) I agree with the statement as written. Vote 1 = Yes 2 = No Agree 96.8% Disagree 3.2% Consensus Statements Consensus Statement #6 Wound When applying adhesives in areas where edema is expected, schedule dressing changes at shorter intervals. I agree with the statement as written. Vote 1 = Yes 2 = No Agree 82% Disagree 18% Consensus Statements Consensus Statement #7 Wound When applying adhesives in areas where movement is expected, choose an adhesive with a stretchable backing I agree with the statement as written. Vote 1 = Yes 2 = No Agree 97.7% Disagree 2.3% Consensus Statements One more general statement was needed pertaining to medical adhesive removal. Consensus Statement #8 General Using two hands, remove adhesives at a low angle, parallel to skin, slowly while supporting the skin at the skin-tape interface Vote I agree with the statement as written. 1 = Yes 2 = No Agree 92.6% Disagree 7.4% Next Steps Communicate to WOC nursing community that we have specialty-specific MARSI Consensus Statements Incorporate MARSI into our language, practice and documentation Educate others using new nomenclature Next Steps Best practice guidelines: Correct usage Risk factors Standardized treatment strategies Dissemination Manuscript is being developed regarding process, results for submission to a WOC Nursing journal Poster abstracts reflect new nomenclature Educational programs are incorporating content regarding categories of MARSI in core curriculum WOC Core curriculum wound textbook includes this terminology We’re Looking to YOU! 1. Share these statements. 2. Challenge the status quo. 3. Talk about MARSI; heighten awareness 4. Write about your clinical experiences. 5. Include MARSI in your Prevalence and Incidence studies. 6. Change practice MARSI Manuscript McNichol, L., Lund, C., Rosen, T., Gray, M. Medical Adhesives and Patient Safety: State of the Science: Consensus Statements for the Assessment, Prevention, and Treatment of Adhesive-Related Skin Injuries. J Wound Ostomy and Continence Nurs. 2013 July/August; 40(4):365-380 Conclusions We must acknowledge the phenomena and seek ways to change it Questions? [email protected] Thank You! Enjoy the rest of your day.