A Prospective, Observational Study to Assess the Use of Thermography to Predict Progression of Discolored Intact Skin to Necrosis Among Patients in Skilled Nursing Facilities.

Abstract

Skin temperature may help prospectively determine whether an area of skin discoloration will evolve into necrosis. A prospective, observational study was conducted in 7 skilled nursing facilities to determine if skin temperature measured using infrared thermography could predict the progression of discolored intact skin (blanchable erythema, Stage 1 pressure ulcer, or sus- pected deep tissue injury [sDTI]) to necrosis and to evaluate if nurses could effectively integrate thermography into the clinical setting. Patients residing in or presenting to the facility between October 2014 and August 2015 with a pressure-related area of discolored skin determined to be blanchable erythema, a Stage 1 pressure ulcer, or sDTI and anticipated length of stay >6 days were assessed at initial presentation of the discolored area and after 7 and 14 days by facility nurses trained on camera operation and study protocol. Variables included patient demographic and clinical data, data related to the discolored area (eg, size, date of initial discovery), and temperature and appearance differences between discolored and adjacent intact skin. Skin temperatures at the discolored and adjacent areas were measured during the initial assessment. All facility pressure ulcer prevention and treatment protocols derived from evidence-based clinical practice guidelines remained in use during the study time period. Participating nurses completed a 2-part, pencil/paper survey to examine the feasibility of incorporating thermography for skin assessment into practice. Data analyses were performed using descriptive statistics (frequency analyses) and bivariate analysis (t-tests and chi-squared tests); logistic regression was used to assess associations among patient and pressure ulcer variables. Of the 67 patients studied, the overall mean age was 85 years (SD 10); 52 were women; 63 were Caucasian; and the top 3 diagnoses, accounting for 60% of the study sample, included neurologic (ie, cardiovascular acci- dent/dementia [14, 21%]), cardiac-related (14, 21%), and orthopedic (13, 19%) conditions. Twenty-eight (28) participants were long-term care patients, and 39 were admitted as short-stay patients. The most frequently reported location of discolored intact skin on presentation was the heel (27, 40%). The mean temperature at the site of the discolored skin was 33.6 ̊ C (SD 3) and at the adjacent skin was 33.5 ̊ C (SD 2.5). The mean size of the areas of discoloration was 11 cm2 (SD 21). Capillary refill of the discolored area was absent on initial presentation in 49 patients (72%), and demarcation of the discolored borders was evident for 45 (66%). Of the 67 patients, 30 (45%) experienced complete resolution of the discolored area. At day 7, 8 (16%) of the remaining 50 patients in the sample exhibited skin necrosis and at day 14, a total of 12 patients of the remaining 37 (32%) exhibited skin necrosis. At day 7, skin necrosis was significantly associated with admission to a subacute unit (P = 0.01) and at day 14 to negative capillary refill at initial presentation (P = 0.02). Regardless of skin temperature, negative capillary refill at presentation was significantly associated with skin necrosis at day 7 (P = 0.04). A dichotomous variable was constructed to examine patients with cooler temperatures at the site as compared to their adjacent skin and persons with warmer skin temperatures at the center of the discolored skin for the presence of skin necrosis at both day 7 and day 14. In multivariate analysis, patients with cooler rather than warmer skin temperatures at the center of the discolored area as compared to the adjacent skin were more likely to develop necrosis by day 7 (OR 18.8; P = 0.05; CI: 104-342.44). Participating nurses were uncertain about the feasibility of integrating thermography into practice. Larger prospective studies with more heterogeneous samples are needed to determine the validity of skin temperature measurement as a predictor of skin necrosis and the utility of implementing thermography into clinical practice.