You’d think the largest organ in the human body — 21 square feet of it, all of it wholly accessible — would be an easy thing to maintain and keep free of disease.
But its role as a temperature regulator, pathogen barrier, and sheer complexity as the placeholder for more than 11 miles of blood vessels, makes skin one of the most challenging parts of the human body to keep whole. The process of aging complicates it even more as years of immobility, poor diet and exposure to sun and medications take a heavy toll.
Long-term caregivers still struggle with the most basic tasks of keeping an incontinent woman’s skin intact or an elderly man’s stubborn diabetic ulcer from worsening. Wound care resources are often thin and cost-containment pressures can be oppressive. In addition, chronic workforce issues can lead to costly shortcuts.
No magic pill exists to fix all of the problems with skin care. Instead, clinical specialists and other experts extol the virtues of common sense and vigilance as the best remedies available, and they hope for better advances in skin care.
What’s holding caregivers back from even the fundamentals?
A lay person would be stunned to learn of one major culprit, as Amin Setoodeh, RN, senior vice president of skin health and clinical services for Medline, explains:
“As the population of aging individuals continues to increase in the next few decades, care providers will continue to face the daunting task of preventing and treating skin injuries in the community or in the institutional settings,” he says. “I believe there is a false sense of security when it comes to the basics of skin care.”
Infection preventionists and epidemiologists may preach about it until their faces turn blue, but here are two other givens:
“The number one culprit is handwashing,” says Ellen Thompson, RN, wound and product specialist for Gentell. “The lack of proper handwashing is responsible for the spread of countless infections of the skin.”
Poor diet and skipping simple moisturizers cause problems.
“Residents of nursing homes are at risk for skin issues due to pre-existing factors such as diabetes, immobility, autoimmune disorders, dehydration and nutritional compromise,” Thompson adds. “Providing the needed nutritional support is paramount in preventing skin disorders. Offering fluids to maintain hydration is key. Providing moisturizing lotions is necessary to maintain the health of aging skin.”
But even the basics are wasted on non-compliant patients, according to nursing expert Amy Stewart, MSN.
“Nursing home staff do indeed know the basics of skin care but there are circumstances that are out of the control of staff,” says Stewart, who serves as vice president of curriculum development for the American Association of Post-Acute Care Nursing.
For example, a resident may refuse some or all types of skin care and that puts them at an increased risk for skin breakdown. This might include refusal to eat, including supplements that provide much needed protein, or refusals to be turned and repositioned, or participate in a toileting plan.
Another major impediment is a woeful lack of resources, such as too little staff with not enough expertise, or who can perform proper assessments. Setoodeh says many skilled facilities are affected by deficits of all three.
“The biggest issue today in our industry is a lack of required resources for us to provide appropriate skin care for complex patients,” says Setoodeh, who spends a lot of time visiting facilities around the nation, with quality ratings ranging from one to five stars.
“Care providers try to do their best with what they have, but clinical bias in practice and lack of focus on evidence-based practice impacts progress,” he notes.
Medline’s own internal studies have shown Setoodeh and others that facilities with higher star ratings invest heavily on prevention rather than taking a reactive focus on treatment of skin injuries.
A lack of appropriate products is another culprit.
In many cases, poor quality incontinence products are used and staff shortages hinder the ability to change dressings as frequently as they should, according to Mihaela Grigore, chief operating officer of TZMO USA. Even if inadequate products are changed more frequently, residents are deprived of restorative sleep from all the interruptions, she adds.
Incontinence-damaged skin typically requires special low alkaline pH cleansers, but many facilities opt for the cheaper “water and soap” approach, which “often results in drier, more vulnerable skin,” Grigore adds. In some facilities, caregivers have been known to skip using any incontinence products at all — a practice referred to as “airing.”
Grigore and others say cost containment pressures are at the heart of so many poor product decisions.
“Skin and wound care management should be individualized based on each specific patient’s needs, rather than just focusing on the CMS allowable to cover supply cost,” says Setoodeh.
Adds Grigore, “From our experience, unfortunately, priority for many nursing home clients is the unit cost per item and not the overall expense with incontinence products. Using poor quality products with low performance generates problems with the skin. We need to look differently at the cost of care and focus on prevention more.”
Being restricted to certain products doesn’t help.
“Skin care products are developed daily and many nurses want to try these new innovative products, but they may be hindered by the fact that their facility has a formulary that allows them to only use certain approved products,” Stewart adds.
Wound care experts are unified in promoting a multidisciplinary approach to geriatric skin care.
Setoodeh’s assertion, meanwhile, leaves no doubt: “Critical thinking and the ability to make important decisions is crucial,” he says. “The biggest culprit for mismanagement of skin health is a lack of a cohesive team approach for holistic skin health management.”
Setoodeh offers the following four red flags that would correctly trigger a team-based assessment:
1) Daily wound care dressing changes without supported clinical evidence — something that could increase cost and staff workload burden.
2) Lack of access to an updated evidence-based guideline with a focus on skin health prevention, intervention and treatment. Programs that don’t reflect changes in clinical practice lead to poor skin care practices.
3) Inconsistent assessments of the patient’s environment such as seating, support surfaces and off-loading, which could lead to poor outcomes.
4) Sporadic training on skin health management.
Caregivers should take solace in knowing that skin care course corrections, while challenging, pay significant dividends down the road.
A successful skin care program begins with “strong leadership defining what the facility’s approach to skin care will look like. From there, a commitment to building a foundation of proactive skin care,” Setoodeh says.
Staff education and training must be consistent and ongoing.
It’s not enough to educate. There must be validation that staff understand what they’ve learned, says Stewart, who discourages a “cookie-cutter” approach to interventions.
Show caregivers what to do with combatant, non-compliant residents, and how to enlist family to reverse the behavior. Thompson urges all facilities to also include good nutrition and hydration as a vital skin care tool.
Proper skin care inside a skilled facility can be challenged by cost pressures, but Grigore recommends managers take the long view on spending.
“Evaluate the incontinence care cost as an overall cost and not by looking at the price per unit only for the main product,” she says. Remember to include all additional expenses associated with incontinence — from gloves and wipes to laundry and staff time needed in dressings and briefs changes.
Finally, experts agree a back-to-basics approach to skin care is always a good idea.
“A holistic approach of total care, which combines care plans to address all these issues along with the proper choice of incontinence products, proper skin cleansing and caring routines, is the best way to achieve better skin health,” says Tony Forsberg, RN, national clinical director for ESSITY HMS North America. “Prevention is always better than a cure.”