Defining the Value of Preventive Skin CarePreventive skin care is important to the patients’...

*A prevention philosophy from smith&nephewSKINEQUITY™Knowledge. Protection. Results.

Defining the Value of Preventive Skin Care

*smith&nephewSECURA™

SECURA, a fundamentalingredient of SKINEQUITY™

Invest in PreventionSKINEQUITY™ is a prevention philosophy from Smith & Nephew that combines the SECURA™ Skin CareSystem with industry leading Medical education programs to improve clinical, emotional, and financialoutcomes in healthcare settings.

The Clinical NeedPressure ulcers pose a significant public healthproblem, with the incidence ranging from <1%to 38% in the acute setting and from 2.2% to23.9% in the long-term setting.1 Skin tissueinjuries deplete healthcare resources at analarming rate, with the expense of treating onecase ranging from $500 to $50,000.2 In anacute care setting, the average length ofhospital stay can increase by 4 to 17 daysamong patients with pressure ulcers andrelated complications.3

For patients, pressure ulcers cause great painand discomfort, decreasing quality of life.Infections, secondary to pressure ulcers, areassociated with increased morbidity—andeven mortality—in bed-bound individuals.Pressure ulcers can be demoralizing to bothpatients and staff.

The Emotional BenefitsThe development of a preventable pressureulcer devastates patients, families, and staff.Published literature suggests that goodpreventive care can result in less skinbreakdown and fewer pressure ulcers andleads to emotional benefits for patients,families, and caregivers. Good skin care canhave a positive impact on the patients’ overallhealth, including morale, self-esteem, andsusceptibility to pain and infection. Families arereassured when quality care is evident andgain confidence in the staff and facility.Caregivers are motivated when they see thedifference they can make. And a motivatedstaff leads to increased perceptions ofempowerment, employee satisfaction andlower staff turnover rates.

The Financial ReturnProactive preventive skin care programs delivera financial benefit by reducing overall treatmentcosts. Incremental costs associated with skinbreakdown and tissue damage, like increasedpatient morbidity and longer hospital stays, canbe minimized or even avoided. Consistentpreventive care decreases the likelihood that apatient will develop a life-threatening pressureulcer that could result in fines or lawsuits.

Clinical evidence now shows that establishingpreventive skin care protocols can significantlyreduce the incidence of pressure ulcers.4 TheFederal Government, through the Agency forHealthcare Research and Quality (AHRQ),developed and instituted guidelines for theprevention of pressure ulcers.

The goal of the SKINEQUITY™ preventionphilosophy is to educate caregivers about thebenefits of prevention and quality skin careproducts so that the incidence of pressureulcers and other skin breakdown can bereduced. This leads to improved patient care,motivated caregivers, and a reduction in totalhealthcare costs.

1

SKINEQUITY™Knowledge. Protection. Results.

Recognizing the Challenges of Preventive Care

Caregiver ownership, motivation andability to change behaviors are vital tosuccessful preventive care and theSKINEQUITY™ philosophy. Recognizing thecaregivers’ ability to make a differenceenhances the value of prevention and earlyintervention. Prevention and earlyintervention are investments in patients’overall health. Caregiver education enhancespatient care and outcomes. Caregivers aremotivated when the clinical and emotionaloutcomes can be experienced firsthand.Knowledge leads to results.

Staff shortages and turnover are ongoingchallenges in all healthcare settings. Thismakes education all the more crucial, ascaregivers are the front line for assessmentand early intervention. Educational tools, likeSKINEQUITY, are vital to maintaining aconsistently trained and motivated staff.

Hospitals and long-term care facilities faceincreasing scrutiny as patients and theirfamilies have access to more and morepublic information, including FederalGovernment statistics on the occurrence ofpressure ulcers. Implementing preventionprograms, like SKINEQUITY, can helpreduce the occurrence of pressure ulcersand other skin breakdown and may reducea facility’s exposure to liability. Successfulprevention programs can also createpositive relationships with patients andfamilies and can build communityreputation for the facility.

Providers face a constant threat of litigationrelated to the development of skinbreakdown and pressure ulcers.Implementing an effective preventive skincare program like SKINEQUITY may help limita facility’s exposure to liability.

2

Building a Strong Foundation

One goal of the SKINEQUITY™ preventionprogram is to empower caregivers byproviding consistent education, training, andhigh-quality products. Adopting the AHRQguidelines and staying current with the latestclinical research helps to ensure high-qualitycare. Topics addressed by the SKINEQUITY™program include:

skin anatomy and physiology

factors associated with aging and other at-risk skin

risk assessment tools and the use of riskscores

principles of wound prevention and earlyintervention

designing and implementing best-practiceskin care protocols

considerations in mechanical loading andsupport surfaces

clinically based in-services for preventioneducation and product training

continuing education unit–accreditededucation for nurses

prevention education specifically designedfor nursing assistants

The SKINEQUITY™ philosophy is an investmentin caregivers and patients that results inpositive clinical, emotional, and financialoutcomes.

1. Knowledge. With knowledge, caregiverscan prevent or reduce skin breakdown.Preventive skin care is important to thepatients’ quality of life.

Understanding the anatomy and physiologyof skin and what risk factors contribute tobreakdown empowers employees tointervene earlier and take ownership forpatient care.

2.Protection. All skin care products are notcreated equal. Skin does know thedifference. Protecting vulnerable skinmeans knowing what products to use andhow and when to use them. It is importantto know what ingredients to look for in skincare products—and which to avoid.

3.Results. Preventive skin care pays offclinically through improved outcomes andfewer complications, including a decreasedincidence of pressure ulcers. Financialbenefits are seen in shorter hospital stays,lower treatment costs, and less exposureto liability risk. Emotionally, when staffmembers see their efforts make adifference in patient care, it buildsteamwork, motivation, and ownership.

Research shows that organizational variables(resources, information, support) have a stronginfluence on behaviors and attitudes in theworkplace, and these changes in attitudeshave a positive impact on patient care.5

3


Recognizing Risk Factors for Skin Breakdown Healthy, intact skin provides a barrier against microorganisms and is crucial to patient welfare. Preventing skin breakdown begins with identifying patients at risk and recognizing the warning signs that can lead to breakdown.

Know

ledg

e

The risk for the development of skinbreakdown can be based on the presence ofintrinsic and extrinsic risk factors.Understanding and recognizing these factorsproactively, helps staff members provideoptimal care for patients at higher risk.

Intrinsic factorsIntrinsic factors are related to the patients’overall health status and include6:

Age—Skin changes considerably with age,making it more vulnerable to breakdown.Skin cell turnover slows. The compositionof sebum, an oily substance that seals inmoisture and creates the skin’s naturallyacidic environment, changes. Additionalchanges occur that make the skin thinnerand drier, compromising the skin’s ability toperform its barrier function and ward offinfection.

Poor nutrition—Improper nutrition,especially insufficient amounts of protein,fats, vitamins, minerals, and water, canimpede the skin’s ability to repair itself.Wounds pose additional challenges to apatient’s nutritional status. Wounds cancreate a stress response within the patient,resulting in catabolism, hypermetabolism,and decreased immune function. Thisincreased stress response requiresincreased nutritional requirements.

Medication—Prescription drugs may havedetrimental effects on the skin. Topicalsteroids are associated with thinning of theskin. Several classes of medications,including antihypertensives, tricyclicantidepressants, antihistamines, andothers, can increase the skin’s sensitivityto sunlight.

Sensory perception—Poor sensoryperception, such as that caused bydiabetic neuropathy, increases the risk ofpressure ulcer development. Patients maynot feel the discomfort that signals theonset of skin breakdown and, thus, fail toreposition themselves to reduce pressure.

Cognitive function—As mental statusdeclines, patients become unable tocommunicate their need for repositioning,toileting, or pain control.

Mobility—Limited movement predisposespatients to pressure ulcer developmentbecause they cannot repositionthemselves to maintain proper blood flow.

Health status—Patients with diabetes orcardiovascular disease are more likely todevelop pressure ulcers. This can becaused by decreased sensations andlimited feelings of pain in extremities, or byvascular complications that do not permitsufficient blood flow to oxygenate tissues.

Extrinsic factorsExtrinsic factors refer to stresses put on theskin by the patients’ surroundings andinclude:

• Pressure—Body weight can squeeze bloodvessels between the resting surface andbony prominences. This interrupts vitalblood flow that delivers oxygen and othernutrients to the skin and leads to tissueand skin breakdown. Reducing pressure byturning patients regularly, positioningpatients carefully, and suspending heelshelps reduce the risk of tissue damage.

4

• Friction—Friction occurs when the patients’body—usually the elbows or heels—rubagainst a rough surface, like a sheet.Friction can be reduced by repositioning apatient using a lift sheet, as shown to theright, rather than by sliding the patientacross the bed.

• Shear—Shear occurs when the head of thebed is raised. Although the skin and tissueremain stationary, the body’s skeleton isforced downward by gravity. This can twistand compress blood vessels, depriving theskin of oxygen and nutrients. Keeping thehead of the bed at an angle less than 30degrees is one way to reduce shear, unlessthe patient’s health status dictatesotherwise.

• Moisture—Moisture softens skin andweakens its integrity, causing it to breakmore easily. Effective management ofmoisture, whether due to wound exudate,ostomy fluids, perspiration, or incontinenceepisodes, is essential to keep patients fromdeveloping moisture-related skin problemslike maceration. Fecal incontinence causesa great risk of skin breakdown due toenzymes present in feces, which attack theskin and are further stimulated by thepresence of urine.

• Soap and water—Harsh detergents stripthe skin’s natural lipid layer andcompromise the natural barrier, the epidermis. Ionic surfactants can causeirritation, drying, and alter the skin’s pHlevel, which leaves skin susceptible tobreakdown.

pressure points

proper lifting

macerated skin

shear

Supine Position

Lateral Pressure

SittingPosition

Occiput1%

Scapula0.5%

SpinousProcesses

1%

Sacrum23%

Heel8%

Elbow3%

Trochanter15%

Knee6%

Malleolus7%

Elbow3%

Ischium24%

5


Know

ledg

e Assessment Tools Help Determine RiskA number of assessment tools have been developed to indicate a patient’s risk for developing apressure ulcer. The Braden Scale has been tested extensively.7 The Braden Scale comprises 6subscales that reflect sensory perception, skin moisture, physical activity, nutritional intake, friction andshear, and the ability to change and control body position. Each subscale is rated on a scale of 1 (low)to 4 (high), except for the friction and shear category, which is scored 1 to 3. Adult hospitalized patientswith a score of 16 or lower are considered to be at risk. In older populations, a score of 18 or lowermight be a more effective predictor of pressure ulcer formation.8

Risk assessment tools should be used to trigger interventions to reduce the incidence of tissuedamage. Perhaps more important than the total score, is the significance of a low score within any ofthe subsets. For example, if the patient scores low on the nutrition subset, a referral for dietaryconsultation may be recommended.

Because skin breakdown can occur quickly, patients should be assessed upon admission and atregular intervals.7 Patients determined to be at high risk should have a skin inspection every day orduring bathing. The primary caregivers should be familiar with the signs of tissue damage as well asemerging pressure ulcers. The following changes are examples of tissue damage that should beaddressed immediately:

Reddened or discolored (bluish or purplish)skin. Such discoloration may represent a stageI pressure ulcer, especially if accompanied bytemperature change (warm or cool) or changesin skin tone (firm or boggy).

6

Blistered heel. A blister on the heel isevidence of tissue damage. If the blister is aresult of pressure, it may be defined as astage II pressure ulcer.

Skin tears. Excessive dryness can lead toskin tears, which provide an entry point formicroorganisms. Moisturizing the skinregularly to replenish lost moisture mayreduce the likelihood of skin tears. Whentransporting or repositioning patients, usecaution to avoid skin tears. If skin tearsdevelop, cleanse gently and apply anonadherent dressing.

Black heel. Keep all black heels off the bedsurface. Assess the situation. A hard, blackcovering, called eschar, usually representsdeep tissue damage. Black heels must beassessed every day. Dry, intact eschar on theheel may be left in place. Intervention isrequired if the eschar is fluctuant (boggy) or ifexudate is present. Arterial status should beevaluated for any patient with evidence oftissue damage on the lower extremities.

Rashes. Rashes may be caused by a numberof things, including fungal infections. Allrashes should be evaluated and treatedappropriately. Keep the rash dry and watchfor any changes.

7


Clea

nse Cleansing: The First Step in Protection

“... a no-rinse cleanser in conjunction with a moisture barrier is a more skin-preserving and cost-effective incontinence care cleansing regimen than soap and water.” 9

Thorough, yet gentle cleansing, is vital tomaintaining skin integrity especially whencaring for incontinent patients. Traditional soapand water is often too harsh for fragile skin.Soap does not rinse well; it leaves a residue onthe skin. Also, most soap products have highpH levels, which can interfere with the skin’sacid mantle—a natural deterrent to bacterialinvasion. And soaps contain anionicsurfactants, which can irritate the skin andremove its natural lubricants. The use of soapis associated with transepidermal water lossand bar soap serves as a medium for bacteria.

The use of soap and water is also more timeconsuming than a no-rinse cleanser. One-step,no-rinse cleansers, such as those developedby Smith & Nephew, have been shown toprovide benefits over soap-and-water bathingby reducing dryness. In a 4-monthretrospective study, protocols that included ano-rinse cleanser resulted in a decline in theprevalence of skin tears from 23.5% to 3.5%when compared with the previously used soapand water regimens. Reductions in caregivertime and overall costs were also documented.10

Skin-friendly ingredients are essential foreffective, gentle cleansing without stressingvulnerable skin. Key points to consider include:

Surfactants. Some surfactants, such assodium laurel sulfate, utilize an ionic charge.These products strip the skin of natural oils,causing irritation and dryness and increasingthe risk for skin tears. SECURA™ cleansers usethe nonionic surfactant, polysorbate 20, tocleanse without causing irritation.

pH-balance. The skin’s normal pH level is 4.8to 5.6, or slightly acidic. Many cleansers candisrupt this balance, causing dryness andallowing for proliferation of bacteria. This isespecially critical in the perineal area, whereskin exposed to urine and feces can becomealkaline, raising the risk of dermatitis. AllSECURA™ cleansers are pH-balanced or pH-buffered to protect the skin’s acid mantle.

Antimicrobial properties. Skin exposed toexcessive moisture can become macerated,which reduces its integrity and makes it moresusceptible to infection. Antimicrobials areimportant ingredients because they helpprevent bacterial infection. Antimicrobial agentsalso eliminate odor-causing bacteria, which isimportant for patients, families, and caregivers.All SECURA™ cleansers include benzethoniumchloride, an antimicrobial proven effectiveagainst common pathogens such asStaphylococcus aureus as well as additionalstrains of staphylococci and streptococci.

The SKINEQUITY™ philosophy advocates 4 key steps for preventive skin care: cleanse, protect,moisturize, and treat. Product ingredients are equally important. Select high-quality products that areformulated with gentle, effective ingredients that will not harm fragile skin.

8cleanse protect moisturize treat


Ingredient Examples Attribute Benefit

Benzethonium Antimicrobial Reduces odorChloride agent Reduces growth

of microorganisms

Sodium Citrate pH-balanced: Integral to maintainingCitric Acid formulated to skin integrity

match skin’s Balanced pH maintains natural pH skin’s acid mantle

pH buffered: High pH can promotemaintains pH of growth of microorganismsformulation and cause skin dryness

Low pH can cause irritation

Polysorbate 20 Nonionic Primary cleansing agentsurfactant Minimal potential

for irritation

Glycerin Moisturizing Maintains properPropylene Glycol agents hydration after cleansingAloe

Polyquaternium Film-forming Leaves a thin film layerpolymers on skin to help maintain

skin integrity, retardmoisture loss

Table 1. Skin-Friendly Ingredients forEffective Skin Cleansers and Their Role in Prevention

SECURA™ Cleansers

SECURA™ Personal CleanserNo-rinse, one-step cleansing for perineum and

body saves timeAids in removal of urine, feces, or other foreign

materialGentle surfactants will not irritate skinContains an antimicrobial agent to reduce odorConditions and moisturizes skinpH-buffered to protect the skin’s acid mantle

SECURA™ Total Body Foam CleanserNo-rinse, high-density foam for one step

cleansingFor perineum, body, and hairAids in removal of urine, feces, or other foreign

materialGentle surfactants will not irritate skinContains an antimicrobial agent to reduce odorConditions and moisturizes skinpH-buffered to protect the skin’s acid mantleNo tears formula

SECURA™ Moisturizing CleanserNo-rinse, one-step cleansing for perineum and

body saves timeAids in removal of urine, feces, or other foreign

materialGentle surfactants will not irritate skinContains an antimicrobial agent to reduce odorConditions and moisturizes skinpH-balanced to protect the skin’s acid mantleContains aloe and glycerin to condition and

moisturize skinSafety evaluated for pediatric use

9

Cleansers

Prot

ectio

n Skin Protectants: Essential Protection Against Moisture “Moisture barriers, sometimes called skin protectants, are creamsor ointments that shield the skin from exposure to irritants ormoisture.” 11

Repeated exposure to moisture and irritantsfound in urine and fecal enzymes puts skin atconsiderable risk for breakdown. Fecalenzymes can irritate skin, causingaccelerated skin breakdown. The presence ofurine creates an alkaline environment, whichfurther accelerates the detrimental effects offecal enzymes. Urine can also affect theskin’s natural acid mantle, increasing skinpermeability. Many components of urine canalso promote the overgrowth ofmicroorganisms, which can lead to cutaneousirritation, inflammation, and infection.

Moisture, such as that caused by perspirationand exudate, reduces the strength of skinand increases damage due to friction. Whenskin becomes macerated or saturated withmoisture (like urine), it loses its ability to actas a barrier to protect against fecal enzymesand irritants found in urine. Skin protectantsprovide topical protection against externalmoisture. SECURA™ skin protectants seal outwetness and are for the treatment andprevention of rash associated with diaper useor continued exposure to urine and feces.

Skin protectants contain an active ingredientfor maximum efficacy. SECURA™ skinprotectants contain one or more of thesethree active ingredients:

• Dimethicone—A type of silicone. Thiscream is transparent upon application anddries quickly, allowing for visual inspectionof the skin. It leaves no residue, will notwash away, and is less likely to clog briefs.

• Petrolatum—A semitransparent ointmentthat protects and conditions the skin.

• Zinc oxide—Provides a high level ofprotection. This white paste or cream doesnot absorb and leaves a nontransparentlayer. Zinc oxide also provides conditioningand soothing properties.

Skin protectants may include one or more ofthese ingredients and should be applied afterevery incontinent episode. Smith & Nephewoffers three skin protectants and one ExtraProtective Cream. In addition to activeingredients, all SECURA™ skin protectantscontain moisturizing and conditioningingredients for time-saving, cost-effectiveskin care.

10


cleanse protect moisturize treat

ActiveIngredient Examples Attribute Benefit

Dimethicone Skin Protectant— Transparent uponmonograph level Helps treat and application—allows1% to 30% prevent diaper rash for visual inspection

Skin Conditioner— of the skinHelps prevent and Leaves no residuetemporarily protect and is less likely to chafed, chapped, clog briefscracked, or wind- Does not wash awayburned skin or lips Repels moisture

Moisturizes/conditions

Petrolatum Skin Protectant—For Protects andmonograph level treatment and prevent- conditions the skin30% to 100% ion of rash associated Semi-transparent

with diaper use orcontinued exposureto urine and feces

Zinc Oxide Cream Skin Protectant—For Provides a high levelmonograph level treatment and prevent- of protection1% to 25% ion of rash associated Leaves a white,

with diaper use or nontransparent layercontinued exposureto urine and feces

Zinc Oxide Skin Protectant—For Provides highest levelPaste treatment and prevent- of protectionmonograph level ion of rash associated For severe cases of 25% to 40% with diaper use or recurring diarrhea

continued exposure Protects maceratedto urine and feces skin

Table 2. Effective Skin ProtectantIngredients and Their Role in Prevention

SECURA™ Protective CreamContains 10% Zinc

For treatment and prevention of rash associatedwith diaper use or exposure to urine and feces

Helps seal out wetness

Removes easily with SECURA™ Personal Cleanseror Moisturizing Cleanser

Clove oil helps mask odor

Aloe, vitamin E, and allantoin moisturize andcondition the skin

Pediatrician tested for safety

SECURA™ Dimethicone ProtectantContains 5% dimethicone for maximum

protection

Protects minor skin irritation associated withdiaper rash and helps protect from wetness

Helps prevent and temporarily protects chafed,chapped, cracked, or windburned skin and lips

Removes easily with SECURA™ Personal Cleanseror Moisturizing Cleanser

Nongreasy; will not wash away

Absorbs quickly

Does not clog briefs

Propylene glycol moisturizes skin

Transparent application allows for visual skininspection

Conditions and soothes skin

SECURA™ Extra Protective Cream (EPC)Contains 30% Zinc

For treatment and prevention of rash associatedwith diaper use or continued exposure tourine and feces


Removed easily with SECURA™ Personal Cleanseror Moisturizing Cleanser

Provides a high level of protection for patientswith severe diarrhea

Will not wash away after repeated exposure tourine and feces

Contains karaya to absorb moisture and helpthe product adhere to weepy, macerated skin

Soothing

Nonsensitizing

Contains vitamin E

Maintains healthy skin11

SECURA™ Protectants

SECURA™ Protective OintmentContains 98% Petrolatum

For treatment and prevention of rash associated withdiaper use or exposure to urine and feces


Removes easily with SECURA™ Personal Cleanser orMoisturizing Cleanser

Clove oil helps mask odor

Vitamins A and E soothe and condition sensitive skin


Skin Protectants

Moi

stur

ize Moisturizing: Vital to Skin Integrity

“To reduce threats to skin integrity, identifying factors that have the potential for damaging the skin, particularly by causing dry skin, is essential.” 6

Many of the changes in skin that occur withaging manifest as dry skin, which affects asmany as 59% to 85% of people older than 64years.6 In addition to causing severediscomfort for patients, dry, cracked skin nolonger fulfills its important barrier function. Asskin ages, there is a change in thecomposition of sebum—a natural oil thatlubricates the skin, helps maintain the acidmantle, and assists in moisture retention.This further reduces the skin’s efficacy as abarrier, reducing its ability to protect itself.

As the skin becomes dry, it loses elasticity,making it more susceptible to skin tears,cracking, and fissures. An estimated 1.5million skin tears occur annually ininstitutionalized elderly patients.6 Broken skinmay increase the risk for infection by servingas an entry point for harmful bacteria andother microorganisms.

When choosing a moisturizer, look foringredients that maintain the skin’smoisture (humectants) or promote moistureretention (emollients). Apply moisturizersgently; avoid vigorous massage. Do notapply between the toes.

All SECURA™ moisturizers contain emollientsand humectants to hydrate and conditionthe skin. SECURA™ moisturizers arenongreasy and absorb quickly.

12



Moisturizers

SECURA™ MoisturizersSECURA™ Moisturizing Lotion

Use daily to moisturize dry skin Contains humectants and emollients to moisturize

and conditionGentle to sensitive skinMaintains healthy skinAbsorbs QuicklyFragrance free

SECURA™ Moisturizing CreamRestores moisture to very dry skinConditions, soothes, re-hydratesContains petrolatum and vitamin EAbsorbs quickly

Ingredient Examples Attribute Benefit

Glycerine Humectant Helps maintain skinPropylene moisture by attractingGlycol water to the skin

Cetyl Alcohol Primary: emulsifier Fatty alcohols maintainStearyl Alcohol Secondary: emollient stability by preventing

product separationSoftens and soothes

skin

Petrolatum Emollient Helps maintainDimethicone moisture retention in

the skin Softens and soothes

skin

Aloe Vera Conditioner Conditions andVitamin A moisturizes dry skinAllantoin

Vitamin E Antioxidant Maintains healthy skin

Table 3. Skin-Friendly Ingredients forEffective Moisturizers and Their Role in Prevention

13


Moisturizers

Trea

tmen

t Treat Fungal Infections With Early Intervention“Fungal infections are common in all age groups, including the elderly. However, proper therapy for these prevalent conditions leads to a better quality of life.” 12

Fungal infections are commonly caused bytinea corporis (ringworm), tinea cruris (jockitch), and tinea pedis (athlete’s foot) orCandida albicans (yeast). These superficialinfections pose a serious threat to skinintegrity and can cause discomfort in theform of burning and itching. Fungal infections,which usually appear as red, irritated patchesaccompanied by satellite lesions (lesionsoutside the primary margin of the rash)and/or raised vesicular pustules, should betreated at first onset.

Microorganisms flourish in a warm, moistenvironment. For this reason, fungalinfections are frequently seen surroundingthe perineum, the perineal area, and areassuch as the breast and inguinal skin folds.Use of antibiotics, which alter normal skinflora, may predispose patients to fungalinfections. Other health conditions, such asdiabetes or those that leave the patientimmunocompromised, can also increasepatients’ susceptibility to fungal infections.The irritation caused by these infectionsleads to rapid skin breakdown.

SECURA™ antifungal products are formulatedwith the active ingredient miconazole nitrate2%, proven effective against superficialfungal infections. In addition, the productsalso contain high-quality moisturizers andemollients to help relieve burning, itching,scaling, cracking, chafing, and rednessassociated with these conditions.

14



SECURA™ Antifungal TreatmentsSECURA™ Antifungal Greaseless

Contains 2% miconazole nitrateWater basedFor treatment of superficial fungal infections,

including jock itch (tinea cruris), ringworm(tinea corporis), athlete’s foot (tinea pedis),and yeast (Candida albicans)

Relieves burning, itching, scaling, cracking,chafing, and redness associated with theseconditions

Contains vitamin E and skin conditionersUse in areas not exposed to urine or fecesPediatrician tested for safety

SECURA™ Antifungal Extra ThickContains 2% miconazole nitrateFor treatment of superficial fungal infections,

including jock itch (tinea cruris), ringworm(tinea corporis), athlete’s foot (tinea pedis),and yeast (Candida albicans)

Relieves burning, itching, scaling, cracking,chafing, and redness associated with theseconditions

Contains vitamin E and skin conditioners Contains zinc oxide to protect skin from

exposure to urine and feces Contains karaya to control moisture and adhere

to weepy, macerated skinPediatrician tested for safety

Table 4. Effective Antifungal Ingredientsand Their Role in Prevention

Antifungals

15


Ingredient Example Attribute Benefit

Miconazole Antifungal Treats superficial fungalNitrate infections, including jock Final itch (tinea cruris),monograph ringworm (tinea level 2% corporis), athlete’s foot

(tinea pedis), and yeast (Candida albicans)

Relieves burning, itching, scaling, cracking, chafing, and redness associated with these conditions

Allantoin Conditioner Conditions and soothesdry skin

Vitamin E Conditioner Conditiones and Antioxidant moisturizes skin

Petrolatum Emollient Softens skinMaintains moistureretention

Cetyl Alcohol Primary: Fatty alcohol maintainsEmulsifier product stability by

preventing separationSecondary: Maintains moistureEmollient retention

Antifungals

30�

20�

10�

0

Occ

urre

nce

of B

reak

dow

n

0 2 4 6 8

24.2

Percent of Breakdown/Study Month

3.2 3.4 1.7 0.9

CHART 2: Incidence of New Skin Breakdown

Resu

lts

Clinical Results: PreventiveCare Can Improve OutcomesSKINEQUITY™ is a proactive preventionphilosophy about improving clinical, financial,and emotional outcomes. The connectionbetween an effective preventive skin careprogram and a reduction in the incidence ofpressure ulcers is well documented inpublished literature.

Specifically, prevention protocols have beenshown to decrease the incidence ofpressure ulcers in two long-term carefacilities. Neither facility had a standardizedtreatment protocol in place prior to thestudy’s onset. Eight months after theimplementation of a preventive careprogram, site 1 saw the incidence ofpressure ulcers decrease by 64% and site 2saw an 85% reduction in the incidence ofpressure ulcers during that time period.14

As seen below in Chart 1.

Similar reductions in the occurrence of skinbreakdown were seen at a 125-bed nursinghome that adopted a formalized preventivecare program that included use of Smith &Nephew skin care products. The preventionprogram was modeled after the AHRQguidelines and was implemented along withstaff education. The home’s residents wereassessed using the Braden Scale at baselineand at 2-month increments throughout the 8-month study. The occurrence of pressureulcers fell 87% in the first 2 months of theprogram’s implementation and was 96%lower 8 months after program implementationthan at baseline.4 As seen below in Chart 2.

30�

20�

10�

0

Perc

ent

8 Months Before 8 Months After 16 Months After

Site 1 Site 2

11.98

20.58

4.30 3.06 3.21 2.38

CHART 1: Incidence of Pressure Ulcers Beforeand After Implementing a Preventive Protocol

16

Achieving Clinical and Emotional Benefits“The implementation of a comprehensive pressure ulcerprevention program in nursing homes is a viable strategy tominimize the occurrence of pressure ulcers, and, as a result,reduce treatment costs, improve quality of life for residentsand staff, and avoid possible intervention by an outsidelicensing body.” 13

It only takes a few minutes a day to provide effective preventive skin care. Investing ina preventative skin care program and high quality skin care products, like SECURA™,may lead to positive clinical, emotional, and financial outcomes that can be quantified.

Emotional Benefits: EmployeeMotivation and Patient DignityWork environments must support employeesby providing information, resources, supportand the opportunity to learn and develop inorder to empower the workforce to changebehaviors and improve outcomes. Providingopportunities for nurses to obtain knowledge,resources to accomplish their roles, andadministrative and peer support, can lead toworkforce empowerment. Caregivers who aresupported by their organizations are moresuccessful in achieving organizational goalsthat can result in reduced staff turnover.

Research supports the assertion thatorganizational variables have a stronginfluence on behaviors and attitudes in theworkplace and these changes in attitudeshave a positive impact on patient careoutcomes.5

The SKINEQUITY™ philosophy focuses on therole of each caregiver and his or her ability tomake a difference and improve patient care.Knowledge, consistent education, andeffective products are vital tools that can helpmotivate caregivers to become involved andtake ownership for patient care. Andmotivated employees lead to lower staffturnover rates.

Quality-of-life benefits extend to patientsand their families. Prevention of skinbreakdown and fewer pressure ulcersrepresent the core of prevention programsand equate to higher levels of patientdignity and comfort. Preventive care canalso enhance family confidence about thecaregivers and the facility.

Reducing Mortality RatesPressure ulcers are more than painfulsores. In some cases, pressure ulcers maylead to more severe problems, includinginfections of the bone (osteomyelitis),cellulitis, and sepsis. As seen in one study,these infections have a mortality rategreater than 50%.15

Pressure ulcers are often associated withhigh mortality rates because they can occurmore frequently in frail, sick, and otherwisecompromised patients. In the hospital setting,mortality rates are significantly higher inpatients who develop a pressure ulcer.Compared with an appropriate at-riskpopulation, one study correlated thepresence of pressure ulcers with a twofoldincrease in mortality and the development ofa new ulcer during hospitalization or thepresence of a nonhealing ulcer with athreefold increase in mortality.16

The association between pressure ulcers andmortality rates demonstrates the importanceof a preventive skin care program to overallpatient health. Implementing a preventionskin care program like SKINEQUITY™ may helpreduce the incidence of pressure ulcers andassociated mortality rates.

17


Baseline occurrence rate: 13 breakdowns every 2 months

Total projected number of breakdowns at the end of 8 months: 13 x 4 (2-month assessment periods) = 52

Conservative estimate of treating 1 breakdown ......$5000

Estimate of treating total projected breakdowns at the end of 8 months:

52 breakdowns x $5000 ....................................$260,000

Actual Cost of Prevention Program

Skin care products ....................................................$8415

Pressure reduction surfaces (158 total residents x $35) ........................................$5530

Treatment nurse salary (50% of LPN* salary over study period) ..................$11,700

Total cost ............$25,645

Cost Savings

Conservative estimate of cost to treat ................$260,000

Actual cost of prevention program ........................$25,645

Total savings ........................................................$234,355

*Licensed practical nurse

Table 5. Cost-to-Treat Estimate

Resu

lts Financial Results: Containing Costs/Improving Outcomes“Findings support the implementation of comprehensive pressure ulcer prevention programs in extended-care facilitiesto decrease the dollar cost of care and the cost of humansuffering with a pressure ulcer.” 4

An effective preventive care program likeSKINEQUITY™ is an investment in staff andpatients. The upfront investment in educationand product training may seem significant atfirst, but the results can be measured in theform of clinical outcomes, emotional impact,and a lower total cost of care—especiallywhen compared with the increased cost oftreating complications related to skinbreakdown.

One study showed a decrease in total costsafter the adoption of a successful preventionprogram that included Smith & Nephewproducts. This 125-bed nursing homedemonstrated a 96% decrease in theoccurrence of skin breakdown as discussedon page 17. The costs of the preventionprogram were compared with an estimatedcost of treating ulcers and revealed anestimated cost savings of $234,355 for the8-month duration of the study (Table 5).4

18

Reducing Skin Tears and Associated CostsIn another study, an estimated annual costsavings of $2446 related to caregiver timeand overall costs was realized by usingprotocols that included a non-detergent, no-rinse cleanser, rather than soap andwater, for bathing bedridden residents in along-term care facility. Within the first threemonths of using the no-rinse bath procedure,skin tear prevalence rates decreased from23.5% to 3.5%. By the third month, no newskin tears occurred among the facility’s bed-bound residents.10

Reducing Length of HospitalStaysThe increased morbidity associated with thedevelopment of pressure ulcers translatesinto longer hospital stays. A study of 286patients admitted to a tertiary care hospitalexplored the relationship between pressureulcer development and the cost and length ofhospital stay. All patients were older than 55years, expected to be confined to a bed orchair or with a hip fracture, and expected toremain in the hospital at least 5 days. In thisstudy, patients who developed pressureulcers had hospital stays 2.4 times greaterthan those of patients who did not developpressure ulcers. For patients in this studywho developed pressure ulcers, hospitalstays were 17.6 days longer (mean) and costswere $23,364 higher (mean).3

The outcome of this study demonstrates thatpressure ulcers are associated with significantincreases in hospital costs and length of stay(LOS). The study suggests that interventions toprevent pressure ulcers in patients at risk canreduce hospital costs and LOS.

Avoiding PenaltiesThe Centers for Medicare and MedicaidServices, health insurers, and the public,are demanding more accountability on thepart of providers, such as hospitals, homehealth agencies, physicians, and long-termcare facilities. An effective preventionprogram may help facilities during stateinspections by improving patient outcomesand avoiding potential fines. Low pressureulcer rates can also enhance a facility’sreputation in the community.

Litigation Raises Overall Healthcare CostsThe increased attention to pressure ulcershas led to an increasing number of lawsuitseach year. Annually, more than 17,000pressure ulcer–related lawsuits are filed inthe US,17 with individual awards reachingmillions of dollars. In isolated incidents,caregivers have been charged with andconvicted of homicide after patients in theircare died as a result of an infected pressureulcer.18 These lawsuits are driving up the costof liability insurance and increasing the costof care nationwide.

A preventive care program like SKINEQUITY™may reduce the incidence of pressureulcers and the risks and costs associatedwith litigation.

19


Resu

lts

Increased PublicAwareness/ImprovedCommunity RelationshipsThere is increased public awareness aboutthe occurrence of pressure ulcers. The publichas more access to government statistics,and lawsuits are ubiquitous. Implementingpreventive skin care programs, likeSKINEQUITY™, may help reduce theoccurrence of pressure ulcers and can createpositive relationships with communities,patients, and families.

20

Prevention—A ProactiveInvestment That Makes SenseConsistent training, knowledge, and highquality, effective skin care products likeSECURA™, lead to clinical, emotional, andfinancial results for patients, their families,and caregivers. While SKINEQUITY™ cannoteliminate all pressure ulcers and threats ofliability, it may lead to a reduction in theincidence of pressure ulcers and skinbreakdown and, in turn, lead to reducedcosts and better patient outcomes.

For further information about the SKINEQUITY™ philosophy or forassistance in developing a preventive skin care protocol, visit ourWeb site at www.skinequity.com or call your Smith & NephewAccount Manager.

1. Pressure ulcers in America: prevalence, incidence, and implications for the future: an exec-utive summary of the National Pressure Ulcer Advisory Panel monograph. Adv Skin WoundCare. 2001;14:208-215.

2. Lyder CH, Yu C, Emerling J, et al. The Braden Scale for pressure ulcer risk: evaluating thepredictive validity in Black and Latino/Hispanic elders. Appl Nurs Res. 1999;12:60-68.

3. Allman RM, Goode PS, Burst N, Bartolucci AA, Thomas DR. Pressure ulcers, hospital com-plications, and disease severity: impact on hospital costs and length of stay. Adv WoundCare. 1999;12:22-30.

4. Regan MB, Byers PH, Mayrovitz HN. Efficacy of a comprehensive pressure ulcer preventionprogram in an extended care facility. Adv Wound Care. 1995;8(3):49-55.

5. Regan, M.B. (2002) Patient care outcomes and the relationship to staff nurses’ perceptionsof empowerment. Unpublished doctoral dissertation. University of Miami.

6. Bryant RA, Rolstad BS. Examining threats to skin integrity. Ostomy Wound Manage.2001;47(6):18-27.

7. Panel for the Prediction and Prevention of Pressure Ulcers in Adults. Pressure ulcers inadults: prediction and prevention. Clinical Practice Guideline number 3. Rockville, Md:Agency for Health Care Policy and Research, Public Health Service, US Department ofHealth and Human Services; 1992.

8. Bryant RA, Pieper B, Braden BJ, Morris DJ. Pressure ulcers. In: Bryant RA, ed. Acute andChronic Wounds. St. Louis, Mo: Mosby-Yearbook; 1992:105-163.

9. Byers PH, Ryan PA, Regan MB, Shields A, Carta SG. Effects of incontinence care cleansingregimens on skin integrity. J Wound Ostomy Continence Nurs. 1995;22:187-192.

10. Birch S, Coggins T. No-rinse, one-step bed bath: the effects on the occurrence of skintears in a long-term care setting. Ostomy Wound Manage. 2003;49:64-67.

11. Gray M, Ratliff C, Donovan A. Tender mercies: providing skin care for an incontinentpatient. Nursing. 2002;32(7):51-54.

12. Martin ES, Elewski BE. Cutaneous fungal infections in the elderly. Clin Geriatr Med.2002;18:59-75.

13. Regan MB. Saving residents, money—and facilities—with improved skin care. NursingHomes. 1995;44(9).

14. Nissen C, Martin K, et al. Partners: a strategy for improving wound and skin care clinicaloutcomes in long-term care. Poster presented at: Symposium on Advanced Wound Care; April 1998; Miami, Fla.

15. Byran CS, Dew CE, Reynolds KL. Bacteremia associated with decubitus ulcers. Arch InternMed. 1983;143:2093-2095.

16. Berlowitz DR, Wilking SV. The short-term outcome of pressure sores. J Am Geriatr Soc.1990;38:748-752.

17. Mayo Clinic, Rochester. Pressure ulcers: prevention and management. Available at:http://www.mayo.edu/geriatrics-rst/PU.html. Accessed January 7, 2003.

18. Di Maio VJ, Di Maio TG. Homicide by decubitus ulcers. Am J Forensic Med Pathol.2002;23:1-4.


References

SKINEQUITY™ Resources

SKINEQUITY™ offers support materials to help your facilityimplement a preventive skin care program.

OPTIONS—A continuing education program forlicensed nurses. Includes complimentary video, slides,and brochures that focus on assessment and earlyintervention related to skin breakdown and pressureulcer development.

PST (Practice Success Through Knowledge, Protection,Results)—Designed for nursing assistants, this educa-tional series is ideal for facilities with high staff turnover.Includes video, slides, poster and workbooks thatexplain and illustrate the steps of preventive skin care.Also includes a Skin Care Report Card.

Prevention Algorithms—These algorithms facilitate andstandardize preventive care and treatment. They can becustomized to fit any facility’s product formulary.

Technical Services—Information about products andingredients. Call Customer Care at 1-800-876-1261.

Clinical Resources—Call Customer Care at 1-800-876-1261 or ask your Smith & Nephew Account Managerabout Clinical Resource Support that can assist yourfacility with clinical and educational issues.

For further information about the SKINEQUITY™ philosophyor for assistance in developing a preventive skin care pro-tocol, visit our Web site at www.skinequity.com or call yourSmith & Nephew Account Manager.


Smith & Nephew11775 Starkey Road,P.O. Box 1970, Largo, Florida 33779Customer Care Center: 1-800-876-1261www.smith-nephew.com

©2003 Smith & NephewSKINEQUITY is a trademark of Smith & Nephew.SECURA is a registered trademark of Smith & Nephew.

SC-0208-0104

Defining the Value of Preventive Skin CarePreventive skin care is important to the patients’...

Documents

Transcript of Defining the Value of Preventive Skin CarePreventive skin care is important to the patients’...