No-Rinse, One-Step Bed Bath: The Effects on the Occurrence of Skin Tears in a Long-Term Care Setting

   Skin tears cause pain for the individual and increase the cost of care for residents in long-term care facilities.¹ Each year, an estimated 1.5 million skin tears occur among the institutionalized elderly.² By the year 2030, the number of individuals at highest risk for developing these wounds (85 years of age and older) is estimated to reach 8.1 million people in the United States.¹ As the population ages, skin tears become a common concern for those providing care.

   Skin tears are defined as traumatic wounds resulting from a separation of the epidermis from the dermis due to friction or shearing.^1,3 Many intrinsic and extrinsic factors converge to increase an aging individual’s risk for acquiring skin tears. Aging individuals experience dermal and subcutaneous tissue loss as well as epidermal thinning.^1,2,4 Sebum composition changes, resulting in less skin surface moisture.² The skin’s elasticity is decreased and tensile strength weakens.¹ Dermal papillae and rete ridges flatten, causing altered cohesion of the dermal-epidermal junction and increasing the risk of separation due to mechanical trauma.^1,4 The risk of trauma is further increased by diminished sensation and reduced fluid intake. ⁵

   Extrinsic factors that increase the risk for mechanical trauma include the use of soap, bathing technique and water temperature, and hands-on care such as dressing, toileting, and bed-to-chair transfers.^1,2 Soap removes the skin’s natural lipids; it also decreases natural lubricants which leads to increased transepidermal water loss (measured as water vapor diffuses to the environment through the epidermis).^2,6
The purpose of this retrospective study was to determine the effects of bathing ritual changes on the occurrence of skin tears in bed-bound residents of a 72-bed, long-term care facility. Changes in nursing practice, patient care outcomes, and costs of care also were assessed.

Literature Review

   Although research regarding risk factors for skin tears or measures to prevent them is limited, the literature is growing. McGough-Csarny and Kopac¹ found the following six major risk factors for the development of skin tears: 1) advanced age, 2) sensory loss, 3) compromised nutrition, 4) history of previous skin tears, 5) cognitive impairment, and 6) dependency. Other risk factors included senile purpura, altered neuromuscular status, and polypharmacy.

   In their study, White, Karam, and Cowell⁵ found three groups of residents at high risk for skin tears. Residents who required care for all activities of daily living experienced the highest number of skin tears (48%). Residents who were independently ambulatory experienced the second highest number of skin tears (41%). Residents who were sight-impaired and required assistance with ambulation had the third highest number of reported skin tears (11%). Implementation of prevention measures resulted in a 50% decrease in the incidence of skin tears in that facility.

   In a 4-month prospective crossover study comparing the use of emollient soap (containing moisturizers) with nonemollient soap, Mason⁷ found that residents of a 173-bed, long-term care facility developed fewer skin tears when an emollient soap was used during bathing. When comparing the total rate of skin tears per resident, the rate of skin tears when emollient soap was used was 34.8% lower than when nonemollient soap was utilized.

   Plante and Regan⁸ conducted a controlled study among 64 residents of a long-term care facility to compare the effects of using a nondetergent, no-rinse cleanser to bathing with soap and water. After 4 weeks, a 60% reduction in the number of skin tears for the treatment group and a 64% decrease in the total number of skin tears were observed. By week 12, the total number of skin tears had decreased by 90%, with an 82% reduction in skin tears among the treatment group. Plante and Regan also monitored nursing time for the bath procedure. The average time for the soap-and-water bathing was 29 minutes, while the nondetergent, no-rinse bath time averaged 16 minutes. Cost savings for patients in the treatment group were $639.30 during the 12-week study period.

Study Background

   In an attempt to reduce the occurrence of skin tears, the staff of a 72-bed, long-term care facility elected to change from soap-and-water cleansing to a nondetergent, no-rinse cleanser (Nursing Care Personal Cleanser™, Smith and Nephew, Inc., Largo, Fla.) for bathing bed-bound residents who were unable to bathe themselves or be taken to the shower. Because clinicians were concerned about soap residue remaining on the skin following a traditional soap-and-water bed bath, protocols were changed to use the nondetergent cleanser. Nursing assistants performed the one-step, no-rinse bath. The cleanser is sprayed onto a washcloth or, for skin exposed to urine and feces, sprayed directly onto the skin and wiped with a washcloth.

   Standard skin tear treatment at the facility includes cleansing with a commercial wound cleanser, patting dry, applying a skin sealant, and covering the wound with a transparent film dressing. Dressings are changed every 3 to 5 days. The skin of all residents within the facility is monitored daily by the nursing assistant staff. Alterations in skin integrity are reported to the wound and skin care nurse, who assesses the residents and records findings in the resident?s medical record. The wound and skin care nurse completes a monthly report of all skin tears, skin rashes, and pressure ulcers. Nursing assistant education regarding pressure ulcer prevention, including training on proper positioning and handling techniques, use of lift sheets, turning schedules, and incontinence cleansers, moisturizers, and moisture barrier ointments/pastes for skin care, is provided.

   Study Method A 4-month retrospective study was conducted with the first month (January) coinciding with the change in bathing procedures. During this time, no other changes were made in the facility?s management of residents? nutrition, selection of support surfaces, incontinence, or other factors. Skin tears are documented weekly, but facility-wide point prevalence and incidence data are not routinely collected. Prevalence and incidence data were calculated per month using patient charts and the following facility data:
  1. Number of bed-bound residents in the facility for each month during the study
  2. Number of bed-bound residents with skin tears for the month
  3. Number of new residents with skin tears each month
  4. Total number of skin tears among bed-bound residents for the month.

   To determine nursing time involved in caring for skin tears, the wound care nurse monitored the time required for gathering supplies and completing a skin tear dressing change.

Results

   In January, when the new bath procedure was initiated, 23% of the facility?s residents required skilled care. The mean age of all the residents in the facility was 79.9 years and the skin tear prevalence among 29 bed-bound residents was 23.5% (number of bed-bound residents with skin tears as a percentage of total bed-bound residents). This was consistent with prevalence rates during the 11 months preceding the new bath procedure (range 25% to 39%). During the 4-month chart review, resident characteristics remained similar; for example, in April, the last month of chart review, the mean age of the residents was 82 years and 22.3% required skilled care. Within the first 3 months of using the no-rinse bath procedure, skin tear occurrence steadily declined. By April, no new skin tears occurred among the facility?s bed-bound residents. Prevalence rates declined from 23.5% to 3.5% (see Table 1). The total number of skin tears among bed-bound residents decreased from 13 to 1 during the study period.

   The cost of dressing supplies (skin sealant and transparent film) for treating skin tears in January was $223.08 (see Table 2). Due to the reduction in skin tear occurrence, by April, the cost of skin tear supplies for the facility had decreased to $19.26.

   A decrease in cost related to nursing time also was noted. The average time for changing dressings on skin tears within the facility is 4 minutes. Pre-study in January, dressing changes involved an average of 5.2 hours for the month. During the month of April, the average time for changing dressings was 0.4 hours (24 minutes).

Discussion

   The staff at this facility was pleased with the results obtained after implementing the new bath procedure. Changing to the nondetergent, no-rinse cleanser appeared to have played a role in reducing the incidence of skin tears. The results of this study are similar to those observed by Plante and Regan,⁸ who found a 90% reduction in total number of skin tears over 12 weeks. In this study, the prevalence of skin tears decreased by 85% and, during the last month of the study, no new skin tears developed.

Limitations

   This study was based on subjective observations (presence of skin tear or not, improvement in quality of life when skin tear-free) and estimates (eg, the average time elapsed in performing dressing changes on skin tears). Also, whether certain residents were more prone to skin tears than others was not taken into consideration. However, the observed reduction in the occurrence of skin tears provided raw data for the authors to determine that the new cleansing regimen had a positive impact.

Conclusion

   Changing from a regimen of soap-and-water bathing to a no-rinse, one-step bed bath produced a decrease in the number of skin tear occurrences among bed-bound residents in one long-term care facility as well as a subsequent decrease in costs for skin tear dressings and care. Additional prospective controlled studies, using point of prevalence and incidence data, are recommended to evaluate the effects of a non-detergent cleanser versus soap and water on all residents in long-term care (not just those who are bed-bound) and to include other risk factors for the development of skin tears.

References:

1. McGough-Csarny J, Kopac, CA. Skin tears in institutionalized elderly: an epidemiological study. Ostomy/Wound Management. 1998;44(suppl 3A):14S?25S.

2. Bryant R, Rolstad, B. Examining threats to skin integrity. Ostomy/Wound Management. 2001;47(6):18?27.

3. Payne RL, Martin ML. Defining and classifying skin tears: need for a common language. Ostomy/Wound Management. 1993;39(5):6?26.

4. Wysocki A, Bryant R. Skin. In: Bryant R, ed. Acute and Chronic Wounds: Nursing Management. St. Louis, Mo.: Mosby-Yearbook; 1992:1?30.

5. White M, Karam S, Cowell B. Skin tears in frail elders: a practical approach to prevention. Geriatric Nursing. 1994;15(2):95?99.

6. Byers P, Ryan P, Regan M, Shields A, Carta S. Effects of incontinence care cleansing regimens on skin integrity. JWOCN. 1995; 22(4):187?192.

7. Mason S. Type of soap and the incidence of skin tears among residents of a long-term care facility. Ostomy/Wound Management. 1997;43(8):26?30.

8. Plante L, Regan M. Impact of one-step, no-rinse bathing on cost of care and skin tear occurrence in the long-term care setting. Poster session presented at the annual meeting of the Association for Advancement of Wound Care. Atlanta, Ga.;1996.