Equity, Diversity and Inclusion (EDI) Informed Skin Assessments

Several PI cases during fiscal year 21-22 were identified in patients with darker skin tones. Retrospective review of these cases showed progression to stage 3 due to late identification of PI. Noted cases did not have significant comorbidities and would not flag on existing skin assessment scale.
Images showing normal and abnormal skin in medical textbooks and online overwhelmingly feature pale skin. When health care providers only learn to recognize problems in lighter skin tones, we are unknowingly providing biased care that puts our patients with darker skin tones at risk. Patients with darker skin are at similar risk for PIs as people with lighter skin tone, but their injuries are usually only found at a later stage, leading to deeper wounds and worse patient outcomes. To address this disparity we developed the 4T’s skin assessment tool.
4T’s:
Tone: Use Munsell chart to compare areas and document changes. Colour changes can range from dark brown to blue/grey, comparable with a red to reddish-blue colour associated with erythema in lighter skin tones. Patients with darkly pigmented skin have no visible blanching.
Texture: Shiny, hardened, boggy. May feel either firmer or softer than the surrounding areas.
Temperature: Palpate to detect subtle changes in temperature from surrounding skin (cooler or warmer). Changes usually occur before any alterations in skin colour
Warmth occurs because of inflammation. Cool temperature can be indicative of tissue death (no perfusion).
Twinge: Assess for pain. Pain often precedes changes in skin colour.