This article appears in the September/October issue of PSQH.
By Debra Thayer, MS, RN, CWOCN
Incontinence-associated dermatitis (IAD) is seen in all healthcare settings. As a form of healthcare-acquired skin injury, it is now recognized as both avoidable and preventable. Exposure to stool and/or urine is causative for skin damage. Injury occurs primarily through epidermal changes induced by moisture and inflammation, often in combination with friction.
Why is IAD a patient safety and quality of care issue?
Several negative clinical outcomes, including pain, discomfort, depression, and poor quality of life, are associated with IAD (Beeckman et al., 2015; Junkin & Selekof, 2008; Guillemin et al., 2015). IAD has been identified as an independent risk factor for pressure injury/ulcer development (Demarre et al., 2015), and occurrence of pressure injuries is positively correlated to IAD severity (Park, 2014). Additionally, patients with IAD are considered to be at increased risk for development of cutaneous fungal infections (Campbell, Coyer, & Osborne, 2016).
All patients with incontinence are at risk for developing IAD. The key risk factor affecting the severity and progression of IAD is type of incontinence. Exposure to liquid stool or mixed urine and feces is considered to put individuals at the highest risk for skin breakdown and is more likely to result in severe presentations of damage (Beeckman et al., 2015).
In healthcare settings, and especially in critical care, acute fecal incontinence with diarrhea (Heidegger et al., 2016) is a significant problem with a reported prevalence of up to 38% (Tirlapur et al., 2016). Efforts to prevent catheter-associated urinary tract infection have resulted in reduced use of indwelling urinary catheters. With this practice, mixed urinary and fecal incontinence has become more common, with an attendant potential increase in risk for skin breakdown. Unfortunately, risk for skin damage is not always considered when planning care. Use of IAD-specific risk assessment tools is uncommon, and while the Braden Scale is commonly used in clinical settings, it is not predictive of IAD.
Clinical assessment of IAD is foundational for effective prevention and management, yet it remains a challenge for bedside staff. With Category 1 IAD (Beeckman et al., 2015), erythema will be observed but can vary in color and intensity. When Category 2 IAD (Beeckman et al., 2015) (moderate to severe skin injury) is present, epidermal damage accompanies erythema. This may involve patchy erosion (commonly but inaccurately referred to as “excoriation”) or more extensive skin injury (i.e., denudation of the epidermis). The latter is typically associated with exposure to more damaging irritants such as liquid stool or mixed urine and stool. Affected areas reflect patterns of exposure.
In individuals incontinent only of urine, the external genitalia, groin folds, and pubic area are primarily affected. With fecal incontinence, skin damage can be expected in the peri-anal region, extending to the buttocks or even the posterior thighs (Friers & Thayer, 2000). Skin damage can also reflect changes specific to the presence of secondary fungal or bacterial infection.
Why should we think differently about IAD prevention?
Prevention and management of IAD involves two essential interventions (Beeckman et al., 2015). First, whenever possible, management of incontinence should be attempted to reduce or eliminate exposure to moisture and irritants. Second, a structured skin care regimen should be implemented.
IAD incidence of 43% has been reported in the acute care setting with Category 2 IAD present in 35% of patients (Gray & Bartos, 2013). In a study of critical care patients, 81% had IAD at the time of discharge (Bliss et al., 2011). This data would suggest that common skin care interventions for IAD prevention are often ineffective, especially in high-risk populations.
A 2016 Cochrane review concluded: “Little evidence of very low to moderate quality exists on the interventions for preventing and treating IAD in adults.” And while application of products “seems to be more effective” than no products, “performance of products depends on formulation and usage” (Beeckman et al., 2016).
For prevention and treatment of Category 2 IAD, clinicians will typically use a semi-solid moisture barrier product. These formulations contain traditional ingredients such as zinc oxide and petrolatum. Severe skin damage presents a special challenge, as the denuded surface is typically wet and weeps serous fluid. In this situation, a clinical protocol will commonly call for use of a paste.
Pastes are a specific type of semi-solid moisture barrier, formulated with 15%–30% zinc oxide as the primary ingredient. Corn starch, gums, or carboxymethylcellulose are then added to thicken the mixture and presumably enhance the ability of the product to adhere to the wet, damaged surface. While commonly used, limitations for these products can be significant:
Pastes do not always create a protective coating sufficient to repel corrosive irritants such as enzyme-rich liquid stool. Lack of durability and inability to remain in place can leave skin unprotected and necessitate frequent reapplication.
The gritty texture of most pastes makes application (and wear) at best uncomfortable and at worst painful. Once on the skin, these products can dehydrate. The resultant clumping and caking makes removal challenging as well as time-consuming for the nurse (Heidegger et al., 2016; Bayón-García et al., 2012), not to mention potentially miserable for the patient. To avoid this situation, many clinicians advocate removing only the soiled “surface” layer of paste. The feasibility and success of this approach is questionable. In actual practice, stool easily embeds into the paste, necessitating thorough cleansing.
The stickiness of pastes will increase friction at the skin surface and could heighten the risk for damage from shearing forces over the sacro-coccygeal area and buttocks.
Pastes are occlusive and opaque. Lack of breathability can increase the risk of trapped wetness and maceration. Inability to observe the skin necessitates complete cleansing (with the attendant risk of disrupting underlying tissue) in order to perform an accurate skin assessment.
Pastes are provided in multi-use tubes. During routine use, contamination can occur, and pathogens may be spread inadvertently within the patient room and beyond. When infections such as C. difficile or norovirus are present, this presents a special concern for the infection preventionist.
Are there alternatives to traditional semi-solid moisture barriers?
Early in 2017, a novel polymer-based liquid moisture barrier was introduced. This high-endurance skin protectant creates a long-lasting protective coating. The exceptional durability occurs as a result of the polymer’s ability to elongate during wear. This elastomeric property provides protection even when the skin is exposed to caustic fluids such as diarrhea stools and gastric fluid, and allows for extended effectiveness; only two to three applications per week are needed. As discussed above, the majority of semi-solid moisture barrier pastes and ointments cannot reliably attach to an underlying surface that is wet; they are mobile and transfer off the affected area in between applications. To enable attachment to a moist surface, this new skin protectant incorporates an ingredient with wet adhesion properties, termed a cyanoacrylate. Once on the skin, this breathable protective coating creates an environment that supports healing and has been shown to reduce pain associated with IAD and IAD care (Brennan, Milne, Agrell-Kann, & Ekholm, 2017).
Ideal for management of Category 2 IAD, this novel product can also be used to help prevent skin damage in high-risk patients (i.e., those with existing or anticipated diarrhea). The product can protect skin in other challenging clinical situations where moderate to severe damage is present or risk of breakdown is significant, such as problematic stomas, fistulas, and leaking feeding tubes.
IAD is an avoidable and preventable healthcare-associated skin injury that requires understanding of etiology, attention to risk assessment, and awareness of effective strategies for prevention and management. Healthcare organizations need to understand their incidence of IAD and the impact it has on quality of care and the patient experience. A novel, practice-changing technology can help facilities move beyond traditional approaches and toward improved clinical outcomes for patients, while making IAD care more manageable for caregivers.
Debra Thayer, MS, RN, CWOCN, has over 25 years’ experience specializing in wound care. Prior to joining 3M, Thayer worked as a clinical specialist in hospitals and postacute settings providing wound, ostomy, and continence care. In her current role, she works on product and program development and has lectured globally on skin- and wound-related topics. Thayer has contributed to clinical research and has published, with her most recent byline as lead author for the chapter “ ‘Top Down’ Injuries: Moisture-Associated Skin Damage, Medical Adhesive-Related Skin Injury and Skin Tears” in the recently published WOC Nurse Core Curriculum wound care textbook. Incontinence-associated dermatitis (IAD) and medical adhesive-related skin injuries (MARSI) are areas of special interest.
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