Incontinence-associated dermatitis (IAD) is a frequent complication of urinary and fecal incontinence that is defined as “inflammation of the skin that occurs when urine or stool comes into contact with perineal or perigenital skin.”1 In a survey of acute care patients, the overall prevalence of incontinence was 19.7% and of the patients suffering from incontinence, 42.5% suffered from skin injury.2 Skin injury results from chronic exposure to urine or stool which erodes the protective barrier provided by healthy skin3 and increases a patient’s risk for infection and the development of pressure ulcers (PUs).2,4,5 The Institute for Healthcare Improvement (IHI) recommends an all-in-one system that incorporates cleansing solutions with emollients and skin protectants be available for use at the bedside, which can help prevent IAD.6 Implementation of an effective skin care program reduces the incidence of IAD7-9 and hospital-acquired pressure ulcers (HAPUs).10

A nurse-driven initiative was undertaken at Carilion Clinic in Roanoke, Virginia to investigate the prevalence of incontinence in a high-risk patient population, determine the relationship between IAD and the development of HAPUs, and evaluate the effectiveness of an all-in-one premoistened barrier clotha in comparison to current standard of care.

The Clinical Symposium on Advances in Skin & Wound Care; September 9-12, 2011

References1. Gray M, Bliss DZ, Doughty DB, Ermer-Seltun J, Kennedy-Evans KL, Palmer MH. Incontinence-associated dermatitis: a consensus. J

Wound Ostomy Continence Nurs. 2007;34(1):45-54.

2. Junkin J, Selekof JL. Prevalence of incontinence and associated skin injury in the acute care inpatient. J Wound Ostomy Continence Nurs. 2007;34(3):260-269.

3. Gray M. Preventing and managing perineal dermatitis: a shared goal for wound and continence care. J Wound Ostomy Continence Nurs. 2004;31(1 suppl):S2-S9.

4. Junkin J, Selekof JL. Beyond “diaper rash”: Incontinence-associated dermatitis: does it have you seeing red? Nursing. 2008;38(11 Suppl):56hn1-10.

5. Maklebust J, Magnan MA. Risk factors associated with having a pressure ulcer: a secondary data analysis. Adv Wound Care. 1994;7(6):25, 27-28, 31-34 passim.

6. 5 Million Lives Campaign. Getting Started Kit: Prevent Pressure Ulcers How-to Guide. Cambridge, MA: Institute for Healthcare Improvement; 2008. (Available at www.ihi.org)

7. Schmitz T. Location, location, location: Incontinence care supplies at the bedside. Nurs Manage. 2010;41(12):44-9; quiz 49-50.

8. Cooper P, Gray D. Comparison of two skin care regimes for incontinence. Adv Wound Care. 1994;7(6):25, 27-8, 31-4 passim.

9. Driver DS. Perineal dermatitis in critical care patients. Crit Care Nurse. 2007; 27(4):42-46.

10. Clever K, Smith G, Bowser C, Monroe K. Evaluating the efficacy of a uniquely delivered skin protectant and its effect on the formation of sacral/buttock pressure ulcers. Ostomy/Wound Manage. 2002;48(12):60-67.

a Comfort Shield® Barrier Cream Cloths, Sage Products Inc, Cary, IL

Kimberly D. Hall, MSN, RN, GCNS-BC, CWCN-AP; Rebecca C. Clark, PhD, RN; Krista D. Henderson, MSN, RN, CPHQ

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Implementing Nurse-Driven Interventions to Improve Incontinence Associated Dermatitis and Hospital-Acquired Pressure Ulcers

Patient Cohort A total of 200 patients (pts) were enrolled in the entire study (Phase 1: n=100; Phase 2 n=100).

Phase 1: n=17 pts neurotrauma ICU; n=23 pts neurotrauma PCU; n=60 pts neuro step-down unit (control)

Phase 2: n=15 pts neurotrauma ICU (intervention unit); n=31 pts neurotrauma PCU (intervention unit); n=54 pts neuro step-down unit (control unit)

Incontinence Prevalence Survey ResultsThe prevalence of incontinence of all patients (N=200) was 39% (78 pts) (Figure 1).

Phase 1: Of 100 patients, 29% (29 pts) were incontinent of either urine or stool (1 urine only; 19 stool only; 9 both urine and stool).

Phase 2: Of 100 patients, 49% (49 pts) were incontinent of either urine or stool. o Control Group (neuro step-down): 24 incontinent (5 urine only; 12

stool only; 7 both)

o Intervention Group (neurotrauma ICU + neurotrauma PCU): 25 incontinent (2 urine only; 15 stool only; 8 both)– Neurotrauma ICU: 11 incontinent (0 urine only; 10 stool only; 1 both)– Neurotrauma PCU: 14 incontinent (2 urine only; 5 stool only; 7 both)

Incidence of IAD Phase 1: Of 29 patients who were incontinent, 38% (11 pts) developed IAD.

Phase 2 Control Group: Of 24 patients who were incontinent, 25% (6 pts) developed IAD (Figure 2).

Phase 2 Intervention Group: Of 25 patients who were incontinent, no patients receiving the intervention the entire study period developed IAD or a HAPU (Figure 2).

Development of HAPU Phase 1: Of 11 patients who developed IAD, 82% (9 pts) developed a HAPU.

Phase 2 Control Group: Of 6 patients who developed IAD, 83% (5 pts) developed HAPU.

Phase 2 Intervention Group: No patients developed IAD or a HAPU.

RESULTSDesign/Clinical Setting A prospective 2-phase evaluation was conducted in a high-risk patient population within 3 units: 1) neurotrauma intensive care unit (ICU), 2) neurotrauma progressive care unit (PCU), 3) and neuro step-down unit.

Definitions The Control Group received standard of care. Standard of care was defined as incontinence cleanup measures currently in place (non-standardized use of multiple products including foam cleanser, washcloths, and hospital grade moisturizers and zinc-based barrier creams at caregiver discretion). The Intervention Group received standard of care defined as standardized use of a disposable 1-step cleansing, moisturizing, and barrier application cloth during incontinence cleanup.

Phase descriptions Phase 1 was initiated on 02/01/11 and all patients were followed until discharge or up to 14 days following admission. During Phase 1, patients on all units received standard of care. Surveys were conducted to determine the prevalence of incontinence in the high-risk patient population – identifying patients incontinent of urine, stool, or both. Patients were followed to determine incidence of IAD and incidence of HAPU in the patient population. No additional caregiver education was provided during Phase 1.

Phase 2 was initiated on 03/01/11 and all patients were followed until discharge or up to 14 days following admission. During Phase 2, units were separated into “control” and “intervention” units. The control unit (neuro step-down) received standard of care and intervention units (neurotrauma ICU and neurotrauma PCU) received the intervention. Caregiver education consisted of facility-based online education about IAD for both licensed and unlicensed staff. Education about IAD included risk factors, etiology, proper identification, assessment, differentiation of IAD and PUs, documentation, best practice for prevention and treatment, proper techniques for incontinence cleaning, and compatible/incompatible skin care products during the intervention phase. During the intervention phase, signs were placed outside of all patient rooms to remind staff that standard of care was replaced with the 1-step barrier cloths.

METHODSHigh-risk patients with incontinence are at significant risk for developing IAD and HAPUs. Patients who received an intervention that standardized incontinence cleanup with a barrier-impregnated cloth following each incontinence episode experienced a lower incidence of IAD (0% Intervention Group vs 25% Control Group) and HAPU (0% Intervention Group vs 83% Control Group) compared with control patients who received the standard of care. This small patient population prevents definitive conclusions from being drawn; however, additional research is warranted.

Chronic exposure to urine and/or fecal material compromises the integrity of a patient’s skin, increasing a patient’s risk for infection and the development of PUs.2-5 Early risk assessment combined with prevention strategies are important in the prevention of IAD and the development of HAPUs.4 This small study in a high-risk patient population provides insight into the prevalence of incontinence in this patient population, concurs with prior research2 demonstrating the propensity for patients who develop IAD to experience pressure-related skin breakdown, and further supports the importance of standardizing incontinence cleanup and ensuring effective IAD prevention efforts.

CONCLUSION

CLINICAL PRACTICE IMPLICATIONS

BACKGROUND

FIGURE 2. Development of IAD and HAPU in Phase 2

FIGURE 1. Prevalence of incontinence (N = 200)

No incontinence(n = 122)

Urine only (n = 7)

Stool only (n = 46)

Urine and stool (n = 25)

0%

5%

10%

15%

20%

25%

30%

Control group Intervention group

Developed IAD

Developed HAPU

Patie

nts w

ho d

evel

oped

IAD

and

HAPU

0/256/24

Control Group Intervention Group

5/24 0/25

Support for this study was provided by Sage Products, Inc., in the form of study product, poster development, and conference attendance.