Patient Safety —The Role of Medical Adhesives

Birmingham Area WOC Nurses Association

April 21st 2016 Workshop

Margaret Cameron Spain Auditorium-UAB Hospital

Janet M. Davis MSN RN GNP CWOCN

2

Disclosure Statement

Janet M. Davis

is employed by 3M Health Care

Critical & Chronic Care Solutions Division

3

At the end of this program, clinicians will be able to:

• Identify patients at risk for Medical Adhesive-Related Skin

Injuries (MARSI)

• Choose medical adhesives based on patient characteristics and

adhesive technology

• Identify the common causes of impaired skin integrity under

medical adhesives

• Articulate interventions to ensure patient safety and maintain

skin integrity when using medical adhesives

Objectives

4

Adhesive Use is a Patient Safety Concern

MacerationIrritant Contact DermatitisAllergic Dermatitis Folliculitis

Tension Injury or BlisterSkin Stripping Skin Tear

5

• This is just what happens with adhesives!

• Remove adhesives quickly

• Remove adhesives slowly

• Adhesives are a necessary evil and skin

injury the “cost of doing business”

• Nothing can be done

Attitudes Among Care Providers

6

Twenty-three (23) multidisciplinary

Key Opinion Leaders with

specialized expertise were invited

to establish consensus statements

regarding the assessment,

prevention and treatment of

Medical Adhesive-Related Skin

Injury (MARSI).

Medical Adhesives and Patient Safety: Results from a U.S.-based Consensus Conference

7

Skin injury is occurring more often than you think

Konya C, Sanada H, Sugama J, et al. Skin injuries caused by medical adhesive tape in older people and associated factors. J Clin Nurs. 2010; 19:1236-1242.Malone ML, Rozario N, Gavinski M, Goodwin J. The epidemiology of skin tears in the institutionalized elderly. J. Am. Geratr Soc 1991;39(6):591-595.

15.5

3

1.5

8

Adhesive injury is the most common source of skin breakdown in infants in the NICU.

Kuller-McManus J. Skin breakdown: Risk factors, prevention and treatment. Newborn and Infant Reviews. 2001; 1: 35-42.

9

“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.”

Consensus panel definitions:

10

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.

Consensus panel definitions:

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. Journal of Wound, Ostomy & Continence Nursing 2013;40(4):365-380.

11

What is it?

• Mechanical injury caused by adhesives

• Epidermis detaches from itself or dermis

• Can involve few or many or all layers ofepidermal cells

• Skin-adhesive attachment > skin-skin attachment

What is the cause?

• Too aggressive tape

• Frequent re-taping same area

• Use of tackifier on fragile skin

• Incorrect removal technique

Types of Skin Trauma: Skin Stripping

Shiny skin is a classic “look” of skin stripping

12

How to prevent/treat?

• Use gentler tape — silicone if possible

• Apply alcohol-free skin barrier film

• Tape on intact skin

• Consider a taping platform

• Use self-adherent non-adhesive wrap

Types of Skin Trauma: Skin Stripping

Shiny skin is a classic “look” of skin stripping

13

What is it?

• Mechanical injury caused by shear force from strapping tape over wound or swelling occurring under non-stretchy tape

• Epidermis pulls apart

• Skin-adhesive attachment > skin-skin-attachment

What is the cause?

• Strapping tape over skin; strapping does not increase adhesion. Tape resists stretch and returns to its original shape.

• Edema, hematoma formation or distention occurring under an unyielding, non-stretch tape

Types of Skin Trauma: Tension Blisters

Blisters at edge of tape is classic “look” of tension blisters

14

How to prevent/treat?

• Use tape with stretch if swelling,

movement anticipated

• Stretch tape over gauze only, not skin

• Use an alcohol free skin barrier film on

fragile skin or when re-taping

• If distention is observed, loosen

and reposition or replace tape

Types of Skin Trauma: Tension Blisters

Blisters at edge of tape is classic “look” of tension blisters

15

What is it?

• Irritation: redness, swelling, blistering usually in

area exposed to adhesive

• Can look similar to allergic dermatitis

What is the cause?

• Chemical irritants or skin preps trapped between

adhesive and skin

• Common caused when skin preps are not

allowed to dry before tape is applied

Types of Skin Trauma: Irritant Contact Dermatitis

Non-allergic dermatitis

16

How to prevent/treat?

• Assure skin is clean and dry before applying tape

• Protect with alcohol-free skin barrier film and

allow to dry completely before applying tape

• If possible, avoid using tackifiers

Types of Skin Trauma: Irritant Contact Dermatitis

Non-allergic dermatitis

17

What is it?

• Cell-mediated immunological response to a

particular component of tape adhesive or backing

• Erythema, edema, itching, wheals, vesicles

• Similar appearance to non-allergic dermatitis

What is the cause?

• A true allergic reaction occurs in sensitized

individuals who come in contact with a substance

to which they have previously been sensitized

Types of Skin Trauma: Allergic Dermatitis

Allergic dermatitis is rare (occurs in 3–5% of the

population)

18

How to prevent/treat?

• Consider consultation with a dermatologist or

allergist to confirm

• Avoid the allergen. If reaction is caused by an

acrylate tape, consider using silicone tape

• Contact manufacturer for assistance

Types of Skin Trauma: Allergic Dermatitis

Allergic dermatitis is rare (occurs in 3–5% of the

population)

19

Risk Factors

20

• Underlying illness

• Extremes of age

• Immuno-suppression

• Skin changes as with sun exposure

• Treatment of medical conditions

Key Risk Factors for MARSI

21

Skin injury results when the

skin to adhesive attachment

is stronger than the skin to

skin attachment.

How do medical adhesives cause skin injury?

22

Inadequate/improper

• Skin preparation

• Adhesive product selection

• Adhesive product application

• Adhesive product removal

What are the preventable causes of MARSI?

23

Understanding Medical Tape Technology

24

Combination of adhesive

technology and backing technology

determines tape performance

Medical Adhesive Tape/Dressing/Device Composition

Who knew?

25

Medical Adhesives — Not just tape, but same principles

26

Adhesives Used in Medical Tape

Natural Rubber Latex Adhesives Introduced

Silicone Adhesives Introduced

Acrylate Adhesives Introduced

1900s 1960s 1990s

27

Silicone vs. Acrylates

Three Primary Differences Between Silicone and Acrylate Adhesives

Adhesive profile over time

Surface Tension

Silicone Adhesive

Skin cell removal visualization

Silicone adhesive Acrylate adhesive

Acrylate Adhesive

28

Backings used in medical tapes

29

Preventing and Reducing MARSI

Based on Consensus Panel Recommendations

30

Part of the body

• Contoured vs. flat

• Potential for skin to stretch: edema, distention, movement

Skin condition

• Dry vs. moist or oily

• Intact vs. “at-risk” vs. damaged

• Age-related

Length of wear

• Short time

• Longer wear time

Selection

31

Ask: What level of securement is needed?

Sports TapingHeavy Tubinge.g., ET, NGT

Immobilizing Body Parts

Lightweight Tubes/Device

Securing Medical Devices

Anchoring Dressings

Gentle To Skin Strong Adhesion Multi-Purpose

Light Tubing, Low to Medium Adhesion

Critical Securement and Heavy Tubing

32

Preparation

• Remove excess hair

• Be sure skin is clean and dry

• Apply protective alcohol-free barrier film

• Use gentlest tape that can do the job

• Alcohol-free barrier film optional with silicone tape

• Avoid routine use of tackifiers

“Allow preps to dry completely”

33

• Apply sufficient pressure to activate

pressure-sensitive adhesives

• Cover adequate surface area

• Obtain full contact between the tape

and skin or tubing so moisture cannot

penetrate and loosen the tape

Application

Consensus Statement 12, 13, 17

Application Tips:

• Clip hair, if needed

• Minimize touching

adhesive

• Allow preps to dry

• Apply to clean, dry skin

• Do not stretch or strap

over skin

34

Application

Consensus Statements 17

Use sufficient pressure Cover adequate surface area

Obtain full contact

35

StretchHow to apply soft cloth tape

to secure a surgical dressing

Consensus Statement 12, 13

Stretch of tape

Proper Tape Application

Inc

isio

n

Pro

pe

r T

ap

e A

pp

lica

tio

n

Transverse Incision

(Hip to Hip)

Str

etc

h o

f ta

pe

Vertical Incision

(Head to Toe)

Incision

36

Removal

L-O-W and S-L-O-W

37

Removal

Tape methodStretch method

38

Infection Prevention

21. Store and use adhesive-containing

products in a manner that prevents

contamination.

22. Single-patient-use adhesive

products are preferred.

Consensus Statements

39

Single patient use rolls can help

balance infection prevention

goals and managing costs by

reducing waste.

Consensus Statements 21, 22

Single Patient Use Rolls

“Dedicate non-disposable items that cannot be cleaned and disinfected (e.g. adhesive tape) between patients for use only on the patient” 1

1. Federal Register. Vol. 72, No. 73. Rules and regulations (73 FR 20373 4/15/2008).2. Redelmeier DA and Livesley NJ. Adhesive tape and intravascular catheter-associated infections. J Gen Internal Med. 1999; 14:373-5. 3. Hageman JC, Patel JB, Carey RC, Tenover FC, McDonald LC. Investigation and control of vancomycin-intermediate and resistant Staphylococcus aureus: A guide for health departments and infection prevention personnel. CDC. Atlanta, GA. 2006.4.3M Market Research Data on File (2010/2011).5. Love KL. Single-Patient Rolls of Medical Tapes Reduce Cross-Contamination Risk. Infection Control Today. 2013; 17 (1).

40

Selection

• Based on clinical need and patient characteristics

• Use tape with stretch when needed

• Consider silicone adhesive for at-risk skin

Tips to Take with You

41

Preparation

• Skin is clean and dry

• Use alcohol-free protective barrier/skin prep

• Allow preps to dry completely

Tips to Take with You

42

Application and Removal

• Cover adequate surface area

• Obtain full contact

• Apply sufficient pressure

• Remove low and slow

Tips to Take with You

43

MARSI Prevention

• Build MARSI surveillance into Pressure Ulcer P&I surveys

• Educate your organization

Tips to Take with You

Tape affects the experience of every patient every day. Use your knowledge to make their experience better and

share what you have learned with your colleagues.

44

Tape with Care

Your patient’s skin depends on it.

45

For more information:

McNichol L, Lund C, Rosen T, Gray M. Medical Adhesives and Patient

Safety: State of the Science. Journal Wound Ostomy Continence

Nursing. 2013; 40(4): 365-380.

Thank you for your attention!