Skin tears and pressure injuries on NEMT rides: transfers, cushions, and long trips

Why thin skin tears

The International Skin Tear Advisory Panel defines a skin tear as a traumatic wound caused by mechanical forces, including the removal of adhesives, that does not go through the fat layer under the skin. Its tool kit names the forces as shear, friction, and blunt force that separate the layers of the skin. A tear can lift only the top layer or go through the full thickness of the skin, and it often leaves a loose flap. The panel says skin tears are painful, carry a high risk of becoming complex chronic wounds, and have been reported as often as pressure ulcers or more.

Skin tears are common in older adults, the panel notes, and the National Institute on Aging explains why: the outer layer of skin gets thinner and less elastic with age, and more fragile blood vessels make older adults bruise more easily. Conditions common in older riders, such as diabetes, kidney disease, and heart disease, also affect the skin.

The panel’s risk pathway sorts the warning signs into three groups:

• General health. Chronic or critical illness, many medications, and impaired thinking, sight, hearing, or nutrition.
• Mobility. A history of falls, limited mobility, needing help with daily activities, and mechanical trauma.
• Skin. Very old or very young age, fragile skin, and earlier skin tears.

It treats impaired vision, limited mobility, needing help with daily activities, the extremes of age, and a previous skin tear as high risk. Its data sheet also lists steroid use, blood thinners and antiplatelet drugs, chemotherapy, swelling, and being unable to change position without help among the causes. Many regular NEMT riders tick several of those boxes, which is why “do you bruise or tear easily?” belongs in the booking questions.

Where tears happen during a ride

A 2018 review of incident reports from six Pennsylvania long-term care facilities gives a useful picture. About 9% of residents had a reported skin tear in the two months reviewed, 93% of them had limited mobility, and forearm tears were nearly twice as common as lower-leg tears. Falls caused the most tears, and residents moving themselves in a wheelchair came next. The panel’s own data sheet adds knocks, help with daily activities, removing adhesive tape, and agitation or resisting care as causes.

Each of those has a match in a NEMT trip:

• A hand on the forearm. Steadying a rider by the forearm or wrist presses and pulls on exactly the skin that tears most.
• Armrests, door frames, and buckles. Forearms brush past them during every transfer and every belt fastening.
• Footplates, lift edges, and the van step. Shins take the knocks, especially when a rider is moved quickly or a footplate swings back.
• Tie-down hooks and straps. Fingers and lower legs sit close to the hardware while a chair is being secured.
• Sliding across a seat or board. Shear is exactly the force that separates skin layers.
• An upset rider. A rider who pulls away or resists can tear skin against whatever is close. Our guide to riders with dementia covers calming techniques.

Transfers that leave skin intact

Transfers are when hands, edges, and skin meet. The general method is in our transfer guide. For riders with fragile skin, add these habits:

1. Ask before you touch. A rider who has torn before is at high risk of tearing again, and they can tell you which spots worry them.
2. Hold a belt, not an arm. A gait belt fastened over clothing gives the driver a grip that does not press on bare skin.
3. Lift clear, never drag. Clearing obstacles instead of rubbing past them avoids shear, according to the Model Systems Knowledge Translation Center, which also suggests putting a towel or pad on a transfer board where bare skin will touch it.
4. Clear the path. Swing the armrest away, fold back the footplate, and move the belt buckle before the rider moves, rather than working around them.
5. Slow down. Rushed transfers are where knocks happen. A late pickup is better than a wound.

If a skin tear happens

A driver’s part is first aid and a clean handoff. The panel’s treatment algorithm starts with controlling bleeding, and the cleaning, flap work, and dressing choices belong to a nurse or clinic.

1. Stop and settle the rider. Get them seated and stable before looking at the wound.
2. Control the bleeding. Gentle, steady pressure with clean gauze.
3. Leave the flap where it is. Do not pull off or trim loose skin. The panel says the loose flap can usually be put back in place.
4. Cover it without tape. Use a clean non-stick dressing from the first aid kit if your training allows. The panel lists removing adhesive as a cause of skin tears and cautions against dressings with adhesive borders on this skin.
5. Get it seen. Tell the receiving nurse, facility, or caregiver, and let them take it from there.

Knowing the panel’s three types helps the driver describe what they saw. Type 1 is a flap that can be laid back over the wound with no skin missing. Type 2 has part of the flap missing. Type 3 has lost the whole flap, leaving the wound bed exposed. Bleeding that does not slow with steady pressure is an emergency. The first aid and CPR rules for drivers are in our CPR and first aid guide.

Say what happened before you drive away

Telling the receiving staff changes how the injury is handled. CMS guidance to nursing home surveyors in Appendix PP of the State Operations Manual defines an injury of unknown source as one nobody saw happen, the resident cannot explain, and that looks suspicious because of its extent, location, number, or pattern. Its examples of injuries that must be reported include unexplained skin tears in places other than the arms or legs, and in patterns such as matching tears on both arms. Injuries that staff saw happen, with no sign of abuse or neglect, are among the examples that do not have to be reported.

A tear the driver saw and explains at the door is a known injury with a known cause. The same tear discovered hours later with no explanation can set off a report and an investigation at the facility. Write it down while it is fresh:

• The time and place, such as “pickup, 9:14, transfer from wheelchair to van seat.”
• How it happened and which part of the body.
• The approximate size and whether skin was missing.
• The first aid given.
• The name of the person you told at the destination.

File the same facts on your incident report form and follow your broker’s incident rules. The reporting duty cuts both ways. The National Institute on Aging notes that bruises in older adults can also be a sign of elder abuse, so marks a driver notices at pickup belong in a report too. Our guide to preventing rider abuse covers what to do with them.

Pressure injuries build while the rider sits still

A pressure injury is slower and quieter than a tear. CMS defines it as localized damage to the skin or the tissue underneath, usually over a bony spot or under a medical device, caused by intense or prolonged pressure, or pressure combined with shear. The earliest stage is redness on unbroken skin that does not fade when pressed. In darker skin it may show as persistent red, blue, or purple tones, and changes in feeling, warmth, or firmness can come first.

AHRQ’s hospital prevention toolkit says prolonged time on a hard surface or in one position raises the risk of skin breakdown, and it names transporting a patient among the times that happens. It flags procedures longer than four hours as particularly high risk, and a long-distance stretcher trip can last that long. The toolkit also names higher-risk groups that NEMT companies carry every day: people with spinal cord injuries, diabetes, or poor circulation in the legs (which puts the heels at risk), and people at the end of life.

The Model Systems Knowledge Translation Center lists the places where bone sits close to the surface, which makes the skin over them the most at risk: the lower back and tailbone, the seat bones, the hips, the heels, the elbows, the knees, the ankles, and the back of the head. A rider lying on a stretcher rests on the tailbone, heels, and back of the head. A seated rider rests on the seat bones.

Cushions, positions, and stops on long trips

Riders who travel in their own wheelchair should keep their own cushion under them. Model Systems guidance on power chairs says research evidence suggests a well-fitted pressure-reducing cushion protects against pressure sores better than low-cost foam. A few more habits cost nothing:

• Check what the rider is sitting on. The Model Systems prevention factsheet warns against thick seams, rivets, and bulky pockets, and against carrying anything in a back pocket.
• Plan position changes. Wheelchair users with spinal cord injuries are told to shift their weight every 15 to 30 minutes, including in a car. Riders who cannot shift alone depend on someone else to move them, so long trips need stops and an escort or crew who can help. Our spinal cord injury guide covers tilt chairs on the road.
• Plan for moisture. The same factsheet calls for washing and drying skin right after any leakage, and the skin tear panel lists incontinence among its causes. Restroom stops on long trips protect skin as well as dignity. Our long-distance trip guide covers planning stops and position changes on rides of several hours.
• Pass on what you hear. Drivers do not undress riders to check skin. If a rider or escort mentions pain over a bony spot, a wet seat, or a red area, tell the receiving staff.

When someone asks what happened on the trip

If a facility or family asks about a skin tear days later, the HealthRide trip record shows the pickup and drop-off times and the signatures captured on screen in the driver app. The trip log can be exported as a CSV or PDF for the incident file, alongside the driver’s written account.