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Abstract
Introduction Sick preterm neonates are most vulnerable to developing skin injuries. Despite sound knowledge and application of evidence-based practices for preventing medical adhesive-related skin injury (MARSI), the incidence of MARSI was 30 events per 1000 adhesive application days in our unit.
Aims and objectives We aimed to reduce the median MARSI rate from the existing 30 per 1000 MARSI days to <5 per 1000 MARSI over 5 months from June 2023 to October 2023.
Material & methods With the point-of-care quality improvement (QI) approach, a prospective study was planned to reduce the incidence of MARSI among sick very preterm newborns (<32 weeks gestational age) and eventually improve overall skin condition during hospital stay. Sequential Plan—Do—Study—Act cycles were implemented based on the identified risk factors recognised during recurring team discussions.
Results We demonstrated a reduction in the MARSI rate from 30 events per 1000 adhesive applications (during baseline assessment) to zero events per 1000 adhesive applications at the end of the study period. It was temporally related to the assessment of skin risk stratification at admission using a validated tool, regular assessment of neonatal skin condition score based on the skin risk stratification, and reinforcement of MARSI prevention bundle by application of barrier spray. Awareness regarding ‘skin injury prevention’ bundles was continually generated among healthcare professionals. The MARSI rate remained <5 events per adhesive application in the sustenance phase over 6 months.
Conclusion Implementing evidence-based skin care practices resulted in a significant reduction in iatrogenic cutaneous injury events in very preterm neonates.
- Paediatrics
- Risk management
- Critical care
- Team training
- Patient Care Bundles
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Preterm skin is extremely fragile and susceptible to skin injuries even during routine care. Medical adhesive-related skin injuries (MARSI) contribute to the majority of iatrogenic skin injury events encountered in neonatal intensive care unit. Prediction and prevention of MARSI remain the cornerstone of MARSI management.
WHAT THIS STUDY ADDS
Modest interventions like skin risk stratification and periodic skin condition assessment along with reinforcement of skincare bundle reduce the burden of MARSI in intensive care units.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This quality improvement project provided a mechanism to reinforce evidence-based skincare guidelines and develop dedicated policy changes, especially for prevention of MARSI in very preterm neonates and thus would help in preventing further complications like infection, pain and excessive weight/transepidermal water loss.
Introduction
Medical adhesives comprise an integral part of the care in the intensive care unit across all specialities. They are applied and removed several times a day. Inevitably, iatrogenic skin injury following medical adhesive application is a frequently encountered challenge in intensive care units. In the neonatal intensive care unit (NICU), premature and term neonates seeking medical attention are exposed to adhesives for various indications like during fixation of critical life support devices such as endotracheal tubes (ETs), intravenous and arterial catheters, and chest tubes, as well as those used for monitoring like ECG electrodes, pulse oximeter probes and temperature sensors.
The neonatal skin injury rate documented during NICU stay has been reported to be around 9.25%–41.5%.1 Furthermore, the injury was around 57% in neonates with gestational age between 24–27 weeks as compared with a meagre 3% in term neonates.2 With less functionality and underdeveloped anatomical integrity (thin stratum corneum and fragile dermo-epidermal junction), sick preterm neonates are most vulnerable to injury during adhesive removal. A breach in skin integrity results in the loss of barrier function, thus acting as a portal of entry for pathogenic microbes. Such injuries are also known to cause longstanding skin disfigurements in about a quarter of the affected neonates.2
Over time, skin care management has evolved from treating skin injury to preventing it in the first place. The preventive measures encompass routine skin assessment based on the skin physiology and exposed risk factors at the given gestational age and age of life, and adherence to skin-friendly evidence-based ‘good practices’ during day-to-day care. The use of medical adhesive application during routine care is a necessity and cannot be curtailed. Hence, prevention and early identification of medical adhesive-related skin injury (MARSI) events remain cornerstones of the MARSI reduction strategy. Despite sound knowledge and application of evidence-based practices for preventing iatrogenic skin injury, the incidence of MARSI was 30 events per 1000 adhesive application days during baseline assessment in our unit. We planned a quality improvement initiative to reduce the incidence of MARSI events in very preterm neonates admitted to our NICU.
Methods
A quality improvement study was initiated to reduce the incidence of MARSI among very preterm neonates (<32 weeks of gestation) and eventually improve overall skin condition during hospital stay over a period of 5 months (June–October 2023). The methodology was framed abiding by the point-of-care quality improvement guide.3 The study complied with the international Standards for Quality Improvement Reporting Excellence 2 guidelines.4
Study setting and problem identification
Our hospital caters to around 1500 deliveries annually. Of the 40% of mothers who deliver prematurely before 37 weeks’ gestation, 7% constitute very preterm births. The newborn unit comprises a nine-bedded Level III NICU and a nine-bedded Level II NICU apart from Kangaroo mother care and rooming-in areas. There are around 500 admissions (including outborn neonates) to the NICU every year. On admission to the NICU, very preterm neonates are either nursed in radiant warmers or incubators based on the gestational age and availability. In our unit, transparent semipermeable dressings are used for the fixation of intravascular lines (intravenous cannula, peripherally inserted central catheters (PICC), umbilical lines), orogastric (OG) tubes, skin thermistor probes, urinary catheters and as a base layer for ET fixation, as and when indicated. Similarly, hydrocolloid dressings are used as barriers for the nasal interface of continuous positive airway pressure delivery devices. Silicone tapes are used to fix nasal cannula for high/low flow oxygen delivery to prevent its displacement. For the final fixation of ETs and chest drainage tubes, adhesives with acrylate bottom and fabric top (Elastoplast) are applied. Chest leads use gel adhesives. Regular change in positioning and rotation of pulse oximeter probes are instructed and meticulously documented. Caregivers practise the application of emollient (coconut oil) during each nursing shift and while removing a medical adhesive. The correct application and removal technique of medical adhesive are routinely demonstrated to nursing officers during teaching sessions and small group discussions. Applying an alcohol-free skin barrier film with barrier spray without affecting the adhesion of the barrier was encouraged in our unit but not consistently followed by the staff. Appropriate measures were taken for quick recovery at the identification of a MARSI event. Despite the stated good practices, MARSI events were regularly encountered, especially in sick and extremely preterm neonates.
Team formation
A multidisciplinary team was constituted with a consultant as the overall project-in-charge; one resident physician in charge of protocol development, plan execution and data collection; two nursing supervisors for supervising the implementation of planned cycles and organisation of Information, Education, and Communication (IEC) activities; and four nurses for peer training. The participation of parents, caregivers and nurses during the synthesis of the study protocol was encouraged and acknowledged during team meetings.
Operational definition
For our study, a MARSI event was defined as the occurrence of erythema and/or other manifestation of cutaneous abnormality (including, but not limited to, vesicle, bulla, erosion or tear) (figure 1) that persists 30 min or more after removal of the medical adhesive.5
Medical adhesive-related skin injuries encountered during baseline data collection period.
Smart aim
We aimed to reduce the incidence of MARSI events in very preterm neonates (gestational age <32 weeks) to <5 per 1000 adhesive application days from the baseline median MARSI rate of 30 events per 1000 adhesive application days over 5 months (June 2023–October 2023).
Problem analysis
The major risk factors responsible for MARSI events were scrutinised during recurring team discussions using the root cause analysis by fishbone diagram (figure 2). The foremost risk factors identified were (1) lack of skin risk stratification at admission, (2) no precise documentation of skin condition and (3) lack of expertise regarding the preventive strategies for MARSI. Key driver diagram was made and change ideas were discussed (figure 3). Plan—Do—Study—Act (PDSA) cycles were planned in succession considering these factors.
Fishbone analysis addressing the factors contributing to medical adhesive-related skin injury (MARSI).
Driver diagram depicting the key drivers and change ideas for reduction of MARSI rate. IEC, Information, Education, and Communication; SRAMT, skin risk assessment and management tool.
Project indicators
The primary outcome indicator was the MARSI rate during a particular period derived from the total number of MARSI events reported per 1000 observed adhesive application days. We calculated ‘adhesive application days’ by taking the aggregate of adhesives in the neonates per day. For instance, the number of adhesive application days in a neonate with adhesives used for ET tube, OG tube, central catheters and peripheral cannula, on a particular NICU day, would add up to 4 adhesive application days for that day. The study team collected the details of adhesive application types and sites in enrolled neonates daily during ‘MARSI inspection rounds’ in a structured proforma. The cumulative number of adhesive applications was eventually used to calculate the primary outcome indicator. The process indicators were the proportion of neonates with skin risk stratification assessment at birth using a validated tool, the proportion of days with skin condition score documentation in eligible neonates while being cared in the NICU, and the proportion of days with application barrier application as a part of the MARSI prevention bundle, during the first, and second and third PDSA cycles, respectively. Run charts were displayed periodically to encourage the team. The balancing outcome was the ease of performance of these strategies, which was assessed using a Likert scale-based questionnaire that was answered by the nursing staff. Accidental displacement of indwelling catheters, following the introduction of change ideas, if any, was noted.
Baseline assessment
Basic demographic data along with delivery details, the number, type and site of adhesive application were collected in all eligible neonates in a predesigned proforma. A written skin care policy for preterm neonates was formulated and circulated among all healthcare providers. Baseline data were collected regarding the number of MARSI events per 1000 adhesive application days. Interactive sessions were regularly organised for sensitisation of MARSI identification and prevention strategies.
Implementation phase
Three PDSA cycles were planned based on the major risk factors identified formerly. During the first cycle, skin risk stratification was done at admission using the skin risk assessment and management tool (SRAMT) score, a widely accepted and validated tool in preterm neonates. It consists of three sections: risk assessment, care protocol and salient points on further management.6 The SRAMT score stratifies neonates into various risk categories based on eight variables (namely, gestation, sensory perception, activity/mobility, moisture, respiratory support, skin integrity, frequency of blood collection and nutrition).6 The frequency of preventive skin scoring assessment for a particular neonate was governed by this score determined at admission. For example, a neonate with a risk score of 9–16 was categorised as ‘moderate risk’, requiring repositioning and reassessment of skin integrity every 6–8th hours. Similarly, risk scores 17–24 and 25–32 were categorised as ‘high risk’ and extreme risk’, respectively. Repositioning the neonate/external equipment device and reassessing and documenting skin integrity were planned every 4–6 hours in ‘high-risk’ neonates and 2–4 hours in neonates at ‘extreme risk’ of developing skin injury. In the event of a skin injury, the management was based on the guidelines outlined in this tool. All nurses were trained for score administration daily. Nursing-in-charges supervised the implementation and documentation during rounds. This cycle aimed to perform skin risk assessment in >90% of eligible neonates at admission. The frequency of preventive skin assessment checks was determined based on the skin risk assessment tool. The skin risk assessment at admission was further extended to skin condition assessment on a daily basis by streamlining the use of neonatal skin condition score (NSCS) during the second PDSA cycle. Duty nurses were trained regarding the administration of NSCS and identification of the MARSI type, the frequency of which was based on the assessed skin risk stratification. The proportion of neonates/day with NSCS documentation was noted. This cycle targeted performing and documenting skin scoring in >90% eligible neonates/day. Prior to the start of this study, various evidence-based skincare practices were followed in our unit. However, the practice was not uniform. A skincare protocol was formulated for addressing skin condition in very/extremely preterm neonates. It included delivery room practices, care of the umbilical cord, diaper area, skin preparation prior to placement of central lines, emollient application, suitable medical adhesive selection, adhesive product application and cautious adhesive product removal. The final PDSA cycle was based on the reinforcement of the MARSI prevention bundle, especially barrier spray over the underlying skin, prior to adhesive application. For objective assessment, the proportion of procedure/day with barrier spray application before adhesive was documented. The goal of this cycle was to apply barrier spray application prior to >90% adhesives applied per day. IEC activities generating awareness regarding skin care bundles were planned throughout the implementation phase. The study team meticulously monitored the MARSI rate throughout the implementation phase. Data were collected using a prestructured proforma. The primary and secondary outcomes were plotted with a graphical time series representation via Microsoft Excel in separate run charts. Various changes (trend, shift), if any, were annotated.
Sustenance phase
After achieving the desired aim, data collection continued during the sustenance phase. During the implementation phase, a collective meeting of team members with stakeholders and nursing staff was organised weekly to analyse results from the previous week with run charts display and formulate strategies for the subsequent week. These meetings were conducted monthly for result analysis and constructive bidirectional feedback in the sustenance phase. The sustenance phase was planned for 6 months.
Results
The median MARSI rate was 30 events per 1000 adhesive application days in the baseline period (6 weeks). PDSA cycles were initiated based on apriori risk factor assessment, and their compliance rates were monitored (figure 4). A total of 391 adhesive application sites were assessed for the evidence of MARSI. In our study, as per SRAMT assessment at admission, the percentages of neonates with ‘extreme risk’, ‘high risk’, ‘moderate risk’ and ‘low risk’ for skin injury were 52%, 49%, 3% and 0, respectively. The balancing outcome was assessed with the ease of performance using a Likert scale. Most nurses (92%) rated the ease of skin risk stratification, skin condition assessment and inclusion of the MARSI bundle (application of barrier spray) in routine care as easily achievable (figure 4). No accidental displacements of the tubes or lines were reported during the study period. At the end of the first PDSA cycle, the median MARSI rate dropped to 21.2 events per 1000 adhesive application days. It dropped further to 9.1 events per 1000 adhesive application days at the end of the second cycle (figure 4). No MARSI events were reported following the last PDSA cycle (figure 5). These results were sustained in the postimplementation phase over 6 months owing to continuous training, result satisfaction and adherence to the unit protocol.
(A) Run chart demonstrating process indicators and (B) Pie charts displaying ease of performance percentage as the balancing indicators across the planned Plan—Do—Study—Act (PDSA) cycles during the study period. NSCS, neonatal skin condition score; SRAMT, skin risk assessment and management tool.
Run chart demonstrating the medical adhesive-related skin injury (MARSI) event rate across the study period. PDSA, Plan—Do—Study—Act.
Discussion
We demonstrated a reduction in the incidence of MARSI rate from 30 events per 1000 adhesive applications (during baseline assessment) to around zero events over 5 months. The results were sustained in the postimplementation phase owing to continuing staff education and motivation along with the established standard operative protocols for skin care and MARSI prevention in preterm neonates. Neonates, especially preterm neonates, are incredibly susceptible to MARSI owing to an immature integumentary system with a thin stratum corneum and weak dermoepidermal junction.7 Despite numerous practice innovations in neonatal care over the last two decades, the risks and incidence of MARSI remain unchanged.8 The lack of adhesive component awareness, paucity of evidence-based guidelines related to neonatal MARSI prevention and management, periodic need for multiple device securements to newborn skin and impact of prematurity make the prevention of MARSI challenging.
Over time, the focus of MARSI management has transitioned from treating injury when noticed to its prevention by periodic skin assessment.2 Regular skin surveillance is crucial in decreasing the risk of iatrogenic skin injuries during NICU stay.9 Of the several skin risk assessment tools validated in neonates, the SRAMT remains the most commonly used risk stratification tool.6 With the introduction of this skin risk assessment tool, the focus shifted from skin injury and management to its prevention. In a study by Broom et al, the predictive ability of the SRAMT was higher than the Neonatal Braden Q score and observational skills of experienced nursing staff.10 We used NSCS for assessment. The NSCS was initially introduced by Lung et al in their Association of Women’s Health, Obstetric and Neonatal Nurses/ National Association of Neonatal Nurses (AWHONN/NANN) skincare evidence-based practice project.11 It is a simple scoring tool using skin dryness, erythema and breakdown for skin condition scoring and assessment of skin injury with the best score of 3 and worst score of 9. It is reliable when used by single and multiple raters to assess neonatal skin condition, across various weight bands and racial groups.11 12 With basic training, the nurses could easily reassess skin condition based on the predetermined frequency. The implementation of change ideas during the study period carried the risk of overburdening the nurses with existing routine work, thus, acting as a potential barrier towards a positive practice change. The existing knowledge about skin-friendly practices in preterm neonates among the nurses and resident physicians turned out to be useful. By the end of first PDSA cycles, majority of the nurses were convinced that MARSI is largely preventable by careful monitoring. As MARSI became a routine term during handovers and team discussions, the parents were now paying attention to the same and desired being a part of the initiative as well. The most significant impact was brought about by the display of run charts with precipitous fall in the MARSI event rate following successive PDSA cycles. The results of the previous cycle served as a momentum for the forthcoming change idea. Withstanding the practice change beyond the study period was the most challenging part. The enthusiasm among staff and standardised skin assessment approach stood out in the sustenance phase.
The knowledge of neonatal skin physiology and maturity based on the MARSI prevention bundle consists of skin preparation, suitable medical adhesive selection, adhesive product application and cautious adhesive product removal. Skin barrier application is recommended for individuals at risk of developing MARSI.13 An alcohol-free, non-sting silicon-based aerosol barrier spray leaves a protective interface between the skin surface and the adhesive surface of the dressing, thereby acting as a mechanical barrier and decreasing skin damage.14 We employed these evidence-based practices in routine care while attempting to reduce the existing MARSI rates in our unit.
According to existing literature, 16%–27% of hospitalised neonates are predisposed to developing at least one MARSI event during the routine application of adhesives to secure medical devices during hospital stay.1 8 About 10%–15% of these injuries leave behind a scar, while approximately 5% are associated with functional and cosmetic damage.2 Lund et al demonstrated significantly improved skin condition in NICU babies by application of AWHONN/NANN neonatal skin care research-based guidelines in routine practice. The clinical practice guidelines included use of neutral pH cleansers and only water (if birthweight <1000 g) during bathing, emollients like aquaphor in the first 2–4 weeks of life in very preterm neonates, judicious use of adhesives and disinfectants, practices to reduce transepidermal water loss and cord care.11 In a case-control study adressing MARSI events around PICC insertion site in oncological patients, Zhao et al showed a significant reduction in MARSI incidence rate in the MARSI nursing care management group versus conventional group. The intervention group adhered to skin risk prevention, identification and management by dedicated team.15 To the best of our knowledge, in our study, we attempted to reduce the incidence of neonatal MARSI in a resource-limited setting with modest interventions. The parents and caregivers were considered a vital part of the team and were encouraged to contribute actively in team meetings. This helped us strengthen the good practices related to skincare and MARSI prevention bundles in very preterm neonates. The overall generalisability is high. It is feasible, low cost and has potential for high benefit. However, the positive trend following a practice change may be context specific. Although we defined MARSI prior to the start of the study, there may have been a few chances when a MARSI event would have been inadvertently missed or included due to interobserver variation.
Conclusion
We demonstrated the feasibility and sustainability of a modest-quality improvement approach in reducing the incidence of MARSI in very preterm neonates while employing existing resources. Implementing the quality improvement initiative to reinforce the MARSI bundle for evidence-based skin care significantly reduced iatrogenic cutaneous injury events in very preterm neonates. The nursing staff rated the ease of performance for including MARSI prevention bundle in routine care as easily achievable.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by Institutional Ethics committee, AIIMS Bhubaneswar, India (Ref: T/IM-NF/Neonat/23/117).
Acknowledgments
We acknowledge all the members of our quality improvement team, our nursing team and ever cooperative parents for their valuable support and contributions to our quality improvement project.
Footnotes
X @UshaDevi_Neo
Contributors Study planning: SKar and UD. Study conduct: SKar, UD, SJ, SA, TKS, PKM, TS and JPS. Data collection: SKar, VL and SKarmakar. Data analysis: SKar and UD. Manuscript writing: SKar, UD, TKS, PKM, TS and JPS. Guarantor: UD.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Publication of this article is made Open Access with funding from the Nationwide Quality of Care Network.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.