
==== Front
BMJ Open
BMJ Open
bmjopen
bmjopen
BMJ Open
2044-6055
BMJ Publishing Group BMA House, Tavistock Square, London, WC1H 9JR

39284690
10.1136/bmjopen-2023-080106
bmjopen-2023-080106
Protocol
Nursing
1715
1506
Risk factors of skin tear in older persons: a protocol for systematic review and meta-analysis
http://orcid.org/0000-0003-4580-948X
Chen Lijuan 12*0xmetchenlijuan@163.com

http://orcid.org/0009-0009-4981-8747
Zheng Nengtong 203396202829@qq.com

Jiang Hongzhan 2jhongzhan@foxmail.com

http://orcid.org/0009-0004-2185-1338
Fan Siyue 21172794385@qq.com

Shen Jiali 22898337166@qq.com

Lin Huihui 21093220256@qq.com

Yang Liping 21107518352@qq.com

Yu Doudou 22661182657@qq.com

1 Department of General Surgery, Zhongshan Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
2 Nursing College, Fujian University of Traditional Chinese Medicine, Fuzhou, China
DrLijuanChen; xmetchenlijuan@163.com
None declared.

LC and NZ contributed equally.

2024
16 9 2024
14 9 e08010621 9 2023
19 7 2024
Copyright © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
2024
https://creativecommons.org/licenses/by-nc/4.0/ 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/.

ABSTRACT

Introduction

Skin tear (ST) will prolong the hospitalisation time of an older person, increase the cost of medical expenses and the difficulty in care for nursing staff, and seriously affect the quality of life of the older person. Early identification and intervention of the elderly at risk of ST are key factors in preventing the occurrence of ST in older persons. At present, risk factors for ST in older persons have not been systematically evaluated, let alone summarised to analyse risk factors for ST in older persons. Therefore, this systematic review and meta-analysis aims to synthesise existing research on risk factors for ST in older populations.

Methods and analysis

The protocol is being reported by the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols statement. On 17 September 2023, we will start literature search in PubMed, Embase, Web of Science, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Medline, Chinese Scientific Journal Database, Wan Fang Data Knowledge Service Platform, China National Knowledge Infrastructure, and Chinese Biomedical Literature Database. The language of the included literature is Chinese or English. Using RevMan V.5.4 software, we will perform a systematic review and meta-analysis of the final set of included studies to synthesise the data and draw meaningful conclusions. The Newcastle-Ottawa Quality Assessment Scale and the Agency for Healthcare Research and Quality will be used to assess the quality of the literature. The I2 test will be used to test heterogeneity.

Ethics and dissemination

Ethical approval is not needed for this systematic review, as the study will not directly use information from human participants, and the data we use will be extracted from original studies. This systematic review and meta-analysis has been registered at the International Prospective Register of Systematic Reviews (PROSPERO). Once the systematic review and meta-analysis have been completed, we will publish our study in an academic journal.

PROSPERO registration number

CRD42023460810.

Meta-Analysis
Aged
WOUND MANAGEMENT
Xiamen Municipal Science and Technology Project 3502Z20244ZD1078 Zhongshan Hospital affiliated to Xiamen University 2023zsyyhlky-002
==== Body
pmcSTRENGTHS AND LIMITATIONS OF THIS STUDY

This study will synthesise the risk factors for skin tear (ST) in older persons and will draw more reliable conclusions through systematic review and meta-analysis.

The included studies will be derived from global studies on risk factors for ST in older persons from various countries, and therefore the results obtained can be used for worldwide reference.

This study will also evaluate some new and controversial risk factors. Although relatively little research has been done on these risk factors, they may give clues to the prevention of skin lacerations in older people.

This systematic review and meta-analysis will only include studies in English and Chinese, and will not include studies published in other languages.

Introduction

The International Skin Tear Advisory Panel (ISTAP) updated the definition of a skin tear (ST) to ‘a traumatic wound caused by mechanical force, including the removal of a sticky dressing or tape, the severity of which varies by depth, but not the subcutaneous tissue’ in 2020.1 Studies have found that infants, young children, older persons, critically ill patients or patients with chronic diseases are commonly susceptible to ST.2 3 In studying the epidemiological characteristics of ST in older persons, different countries and regions have different conclusions. A cross-sectional study of 314 elderly people in 17 long-term care facilities in Germany showed that the prevalence of ST was 10.5%.4 A cross-sectional study of 678 elderly people in four long-term care institutions in Canada showed that the prevalence of ST was 14.7%.3 A study of 410 older people in a long-term medical institution in Japan showed that the prevalence of ST was 3.9%.5 ST is one of the most common skin problems in older persons. We should pay more attention to ST in older persons.4

ST prolongs the hospitalisation time, increases the cost of medical expenses, adds to the difficulty of the nursing staff in caring for patients, and seriously affects the quality of life of older persons.6 Therefore, early identification of risk factors that can lead to ST in older persons is crucial. At present, studies have found that the inducing factors of ST in older persons include ecchymosis, senile purpura, haematoma, history of ST, malnutrition, skin oedema and changes in self-care ability.7 8 Although Serra et al8 systematically evaluated the risk factors of ST, there is no systematic evaluation of the risk factors of ST in older persons. To address the lack of research in this area, we will carry out a systematic review of the risk factors for ST in older persons.

Objectives

The purpose of this systematic review is to systematically collect the literature related to the risk factors of ST in older persons, comprehensively and systematically evaluate the risk factors related to ST in older persons, and provide an evidence-based basis for early identification and prevention of ST in older persons in clinical practice.

Methods

The protocol is being reported by the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols statement. The protocol has been registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42023460810).

Condition

The main variable of this study is ST. With the ISTAP classification system, ST can be classified into no skin/flap loss, partial skin/flap loss, and total skin/flap loss according to its characteristics and severity.1 Many studies have shown that ST mainly occurs in the limbs.1 9

Types of studies

We will include all observational studies (registries, cohorts, etc), experimental and epidemiological study designs, including case-control and cohort studies. However, We will exclude research related to animal testing. Full-text accessible studies from around the globe will be accepted. All included studies will be published in either Chinese or English.

Study population

This systematic review and meta-analysis will primarily focus on older persons with ST. According to the WHO and the United Nations reports, the definition of the elderly refers to people ≥60 years of age.10 We directly identified the age of the study population as >60 years.

Exposure

Exposure will include all the risk factors mentioned in the studies that are associated with ST in older persons.

Outcomes

The outcomes of our systematic review and meta-analysis are mainly the risk factors for ST in older persons. Information on the finally included studies and the results of quality assessment of the studies will be presented in tabular form. Data on risk factors for ST in older persons will be extracted and analysed using RevMan V.5.4 software and presented in graphical and textual forms.

Search strategy

After a consensual exploration by the team members, we set up a corresponding search method to identify these contents as accurately as possible: ‘skin tear* /skin laceration*’ ‘relevant factor* / influencing factor* / risk factor* / predictor* / related factor* / associated factor* / relative factor* / determinant*’ . We will also set a standard that the retrieved literature should be full-text literature. The initial stage of the search plan that will be applied to the PubMed database is shown in table 1.

Table 1 Search strategy for PubMed

Search #	Search term	
1	‘Risk Factors’(Mesh) OR risk factor*(Title/Abstract)OR influencing factor*(Title/Abstract)OR relevant factor*(Title/Abstract)OR predictor*(Title/Abstract)OR related factor*(Title/Abstract)OR associated factor*(Title/Abstract)OR relative factor*(Title/Abstract)OR determinant*(Title/Abstract)	
2	‘Skin Tear’(Mesh) OR skin tear*(Title/Abstract)OR skin laceration*(Title/Abstract)	
3	1 AND 2	

First, a search will be conducted in the designated database, and then a preliminary search will be conducted in PubMed to evaluate the effectiveness of the search terms, strategies and selection criteria in identifying all applicable articles. Modifications will be made based on the results obtained. Computers will be used to search PubMed, Embase, Web of Science, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Medline, Chinese Scientific Journal Database, Wan Fang Data Knowledge Service Platform, China National Knowledge Infrastructure, and Chinese Biomedical Literature Database.

Inclusion criteria

The object of study in the literature should be an older person (age ≥60 years) diagnosed with ST.

This literature includes studies on the risk factors for ST in older persons.

Research is about observational (registries, cohorts, etc), experimental and epidemiological study designs, including case-control and cohort studies.

The language of publication is Chinese or English.

Exclusion criteria

The full text is not available.

Repeatedly published studies.

The data in the literature are incomplete or the author cannot be contacted to obtain the data.

The methodological quality evaluation score of the literature is low (Newcastle-Ottawa Quality Assessment Scale (NOS) Score＜4, Agency for Healthcare Research and Quality (AHRQ) Scale Score 0–3).

We will import the literature retrieved from each database into the Endnote V.X9 program for preliminary screening of the literature. Two independent researchers (NZ and HJ) will remove any repetitive literature, read the title and abstract of the literature in detail, and remove the literature that does not meet the inclusion criteria. If at least one researcher believes that the literature meets the inclusion criteria, it will be included, and if the two researchers disagree, a third researcher (SF) will be involved in the discussion. During the screening process of this literature, the reasons for the removal of the paper will be recorded in detail in Excel. The number of retrieved articles, the number of excluded articles and the number of papers finally included will be displayed in the form of a flow chart (figure 1).

Figure 1 Preferred Reporting Items for Systematic Reviews and Meta-Analysis flow diagram of the identification, screening and eligibility of included articles.

Data extraction

The two researchers (JS and HL) will use the following criteria to collect data from related studies during the data extraction process: (1) Author information; (2) Date of publication; (3) Study design; (4) Research country or continent; (4) Data sources used; (6) Demographics and inclusion criteria of the study participants; (7) ‘Older person’ defined; (8) 'STs' diagnostic standards stated; (9) Main results; (10) Risk factors; (11) ORs and 95% CIs for the risk factors (multivariate regression analysis data are recommended).

Risk of bias and quality assessment

The two researchers (LC and NZ) will use the NOS to independently assess the risk of bias in cohort studies and case-control studies. NOS includes three parts: selection of the study population, comparability between groups and exposure/outcome evaluation. There are eight items in NOS with a total score of 9 points. When NOS is used to evaluate the literature，except for the component of comparability, which can be rated up to 2 points, the other components can only be rated up to 1 point. The higher the NOS Score, the higher the quality of the literature. An NOS Score ≥6 is high-quality literature.11 We employ the appraisal criteria suggested by the AHRQ in USA for evaluating the quality of cross-sectional studies. These criteria consist of 11 items, each assigned scores based on ‘Yes’, ‘No’ or ‘Unclear’ answers. Studies receiving scores between 0 and 3 are deemed poor quality, those earning 4–7 points are moderately good, while scores of 8 and higher indicate excellent quality.12

Strategy for data synthesis

We will use RevMan V.5.4 statistical software for data analysis. Binary variable data will be expressed as OR. Mean difference will used for measurement data. Each effect will be expressed as a 95% CI. In order to judge the rationality of the combined analysis of each test, the χ2 test will used to test the heterogeneity between the tests. If there is no heterogeneity (I2≤50%, p>0.10), the fixed-effects model will be used for meta-analysis; if there is heterogeneity (p≤0.10 or I2≥50%), a random-effects model will be used for meta-analysis. Funnel plot and Egger’s test will be used for analysis of publication bias.

Subgroup analysis

If necessary, subgroup analysis will be performed on gender, ethnicity, country, etc.

Patient and public involvement

Patients will not be involved in this study.

Ethics and dissemination

No ethical approbation is necessary for this investigation since it does not entail the utilisation of personal details from participating individuals. The outcomes shall be divulged via peer-evaluated periodicals or conferences. Important protocol revisions will be documented and updated on PROSPERO.

Conclusion

The goal of our systematic review and meta-analysis will be to provide an evidence-based basis for preventing ST in the elderly. We will evaluate and analyse the finally included studies, summarise the risk factors for ST in the elderly and fully discuss the results. We will carry out this study in strict accordance with the content developed in this protocol and report the results obtained as a paper.

Review Process File
16 09 2024

Funding: This study was supported by the Xiamen Municipal Science and Technology Project (No. 3502Z20244ZD1078), the nursing research project of Zhongshan Hospital affiliated to Xiamen University (No. 2023zsyyhlky-002).

Prepublication history for this paper is available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2023-080106).

Patient consent for publication: Not applicable.

Provenance and peer review: Not commissioned; externally peer reviewed.

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.
==== Refs
References

1 Van Tiggelen H LeBlanc K Campbell K et al Standardizing the classification of skin tears: validity and reliability testing of the international skin tear advisory panelclassification system in 44 countries Br J Dermatol 2020 183 146 54 10.1111/bjd.18604 31605618
2 LeBlanc K Campbell KE Wood E et al Best practice recommendations for prevention and management of skin tears in aged skin J Wound Ostomy Continence Nurs 2018 45 540 2 10.1097/WON.0000000000000481 30395131
3 Woo K LeBlanc K Prevalence of skin tears among frail older adults living in canadian long-term care facilities Int J Palliat Nurs 2018 24 288 94 10.12968/ijpn.2018.24.6.288 29932832
4 Völzer B El Genedy-Kalyoncu M Fastner A et al Prevalence and associations of xerosis cutis, incontinence-associated dermatitis, skin tears, pressure ulcers, and intertrigo in aged nursing home residents: a representative prevalence study Int J Nurs Stud 2023 141 104472 10.1016/j.ijnurstu.2023.104472 36898269
5 Koyano Y Nakagami G Iizaka S et al Exploring the prevalence of skin tears and skin properties related to skin tears in elderly patients at a long-term medical facility in Japan Int Wound J 2016 13 189 97 10.1111/iwj.12251 24674027
6 Baranoski S Meeting the challenge of skin tears Adv Skin Wound Care 2005 18 74 5 10.1097/00129334-200503000-00009 15788910
7 Lewin GF Newall N Alan JJ et al Identification of risk factors associated with the development of skin tears in hospitalised older persons: a case-control study Int Wound J 2016 13 1246 51 10.1111/iwj.12490 26400842
8 Serra R Ielapi N Barbetta A et al Skin tears and risk factors assessment: a systematic review on evidence-based medicine Int Wound J 2018 15 38 42 10.1111/iwj.12815 29045078
9 Bermark S Wahlers B Gerber AL et al Prevalence of skin tears in the extremities in inpatients at a hospital in denmark Int Wound J 2018 15 212 7 10.1111/iwj.12847 29464916
10 Bautmans I Knoop V Amuthavalli Thiyagarajan J et al WHO working definition of vitality capacity for healthy longevity monitoring Lancet Healthy Longev 2022 3 e789 96 10.1016/S2666-7568(22)00200-8 36356628
11 Stang A Critical evaluation of the newcastle-ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses Eur J Epidemiol 2010 25 603 5 10.1007/s10654-010-9491-z 20652370
12 Zeng X Zhang Y Kwong JSW et al The methodological quality assessment tools for preclinical and clinical studies, systematic review and meta-analysis, and clinical practice guideline: a systematic review J Evid Based Med 2015 8 2 10 10.1111/jebm.12141 25594108
