Nearly 43% of provider-reported adverse events are skin-integrity related and its prevalence exceeds medication events by 20 percentage points. Skin integrity is a comorbidity that includes: HAPU (hospital acquired pressure ulcers), MARSI (medical adhesive-related skin injuries), skin tears, blistering, and epidermal stripping. Tissue trauma caused by the removal of adhesive tape is known to increase the size of wounds, exacerbate wound pain and delay healing, impacting at least 1.5 million patients annually in the U.S. Approximately 42% of skin-integrity events occur in surgical patients. Documented evidence for intraoperative acquired pressure ulcers range from as low as 3.5% to as high as 66% of patients and increase the mortality by 7.23%. The problem remains paramount as the number of hospital patients who develop HAPUs rose 63% between 1999 and 2009. The Joint Commission estimates treatment of each HAPU costs between $14,000 and $40,000. Hospital acquired pressure ulcers now have graver implications for healthcare since the Centers for Medicare & Medicaid Services (CMS) no longer pay for HAPUs. The incidence of tape-induced skin damage affects an additional 7.1% to 15.5% of patients with treatment costs averaging between $110 and $150. Spinal surgery and abdominal incisions represent up to 36% of Stage I and Stage II HAPUs. Additional shear and load are frequently placed on the patients’ shoulders during spinal surgery. Likewise, the added weight of the abdominal pannus is responsible for skin-integrity issues in obese patients. Even a BMI > 25 kg/m2 results in a three-fold increase in skin-integrity events as compared to non-obese patients.

Introduction

Blistering associated with surgical positioning has been a known hospital related complication for decades. Specifically, the use of taping for surgical dressings, and intraoperative positioning has been documented to create a high incidence of skin breakdown. This risk is exaggerated in the elderly, obese, malnourished or diabetic. As hospital populations become older, frailer and our population as a whole more obese, the incidence of this problem can only increase. In addition, CMS has begun the process of identifying complications that occur in the hospital and were not pre-existing as “zero event occurrences”. In other words, they presume for better or worse, the correct incidence of these complications is zero, and therefore will not reimburse hospitals for the cost of treating these complications. Since complications such as UTI, surgical infections or skin blistering occur even with the best of hospital care, these occurrences must be eliminated in order to prevent additional strain from over taxed budgets.

Current Taping Method Issues

Successful surgical procedures require stable positioning of patients. Many procedures require positioning in inherently unstable positions, requiring the use of supplemental taping to keep the operative field stable and accessible. Body shapes occasionally require that abdominal pannus, breasts, shoulders or necks be held back away from the surgical field to allow adequate exposure. Traditionally, this has been performed with the use of wide silk or adhesive tape, augmented by application of additional adhesives such as Benzoin. Even with the best technique, this has often lead to blistering and skin breakdown. Studies have suggested that blistering is directly proportional to the degree of shear stress at the dermal, epidermal interface. This shear stress is a product of the force applied, the area over which it is applied, and the inherent flexibility of the material adjacent to the skin. Koval, Egol et al from the Hospital for Joint Diseases New York have shown that more flexible tape such as perforated cloth tape minimized but did not prevent blistering over more common silk tape: 10% (5/50 patients) for perforated cloth vs. 41% (20/49 patients) for silk tape. Unfortunately, the use of flexible cloth tape is impractical for intraoperative positioning as its flexibility in stretch prevents it from holding tissues in place. They also showed that factors such as age, gender, co-morbidities, smoking history, nutritional status or the type of surgery performed did not predict the development of skin breakdown. This suggests that all patients on whom adhesives are used for intraoperative positioning independent of their demographics, co-morbidities or scheduled surgery are at risk. Hahn et al compared tape to a circumferential ace wrap to hold dressings in place, showing a 15% incidence of blistering with tape vs. 1% for circumferential Ace wrap, again supporting adhesive taping as a risk for this hospital acquired complication. Milne, et al prospectively studied hip dressings, applying tape directly to skin (34% incidence of blisters), tape to a hydrocolloid barrier (duoderm) (14% blisters), and tape to a nonhydrocolloid barrier (stoma adhesive) (no blisters). Only through the application of a relatively thick adhesive pad that widely distributed the shear loads (nonhydrocolloidal barrier) was blistering prevented completely. As CMS beings to withhold funding for in-house complications, it becomes ever more critical to identify and prevent those complications that are preventable. Intraoperative blistering from positioning tape is such a complication. The Pannus Retention System with its extensive loading distribution pads is similar in effect to the nonhydrocolloidal barrier system noted in Milne’s study. In over 1,500 applications in orthopedic, neurosurgical, obstetrical, and gynecological surgical cases, the TZ Medical PRS System has had no reported adverse events or blistering.