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FEATURES: ORIGINAL INVESTIGATIONS

Skin Care Protocols for Pressure Ulcers and Incontinence in Long-Term Care: A Quasi-Experimental Study

Thompson, Patricia MS, RN; Langemo, Diane PhD, RN, FAAN; Anderson, Julie PhD, RN, CCRC; Hanson, Darlene MS, RN; Hunter, Susan MSN, RN

Author Information
Advances in Skin & Wound Care: October 2005 - Volume 18 - Issue 8 - p 422-429

Pressure ulcers (PrUs) and incontinence are significant health issues, particularly among the aging population. Two factors compound the problem: almost half of PrUs develop on the sacrum or ischium,1 and fecal incontinence leads to skin irritation and/or breakdown. Fecal incontinence, in fact, has been found to hasten the development of PrUs.2 It is not surprising, then, that an individual with fecal incontinence is 22 times more likely to develop a PrU than an individual without this condition.2

Over the next few decades, PrUs and incontinence are likely to become even greater problems as the US population rapidly ages. The percentage of Americans over age 65 is expected to increase from 12.8% in 1996 to 20% in 2030.3 Therefore, scientific study that links preventive interventions to effective clinical evaluation of PrUs4 and incontinence5 is essential. Practitioners and researchers have made significant strides in understanding the etiology, prevention, and treatment of PrUs; however, work remains to be accomplished to attain the Healthy People 2010 goal of reducing the prevalence of PrUs in residents of long-term-care (LTC) facilities by 50%.6

The increased financial burden must be considered as well. With age comes a greater need for health care services, which places more demand on state and federal budgets. A publication from the Agency for Healthcare Research and Quality7 (formerly the Agency for Health Care Policy and Research [AHCPR]) reported in 2001 that more than 1.5 million older adults were institutionalized in the United States. In 1997, residents of LTC facilities utilized 35.8% of Medicaid spending, or approximately $32 billion.8 Unless policymakers allocate resources more cost effectively, LTC facilities will be limited in the dollars they have available to spend on prevention and treatment of PrUs and fecal incontinence.

PRESSURE ULCERS

A PrU is a type of wound that results in visible changes in blood supply to dermal and supporting tissue, usually from compression over a bony prominence. The damage can vary from nonblanchable erythema of intact skin to a crater into the muscle and, at times, exposure of the bone.9,10 About 95% of PrUs occur in the lower portion of the body. The sacrum isthe most frequent site of PrUs, followed by the heels; the remaining PrUs occur over a variety of areas.10 Reported PrU incidence in LTC ranges from 2.2% to 23.9%; reported prevalence ranges from 2.3% to 28%.11 Overall PrU incidence and prevalence rates have remained between 8% and 15% in the last decade.12 Care that focuses on prevention, early intervention, and treatment of skin breakdown is advocated by the AHCPR. Although implementation of protocols based on the AHCPR's PrU prevention and treatment guidelines13,14 can consume large amounts of health care providers' time and resources, studies have shown that in most settings, PrU incidence decreases when these recommendations are implemented.15-17

A study with a random sample of 834 residents in 35 Veteran's Administration LTC facilities assessed the rates of adherence to PrU prevention guidelines in the facilities.18 The results varied significantly, from 29% to 51% adherence to all 15 recommended guidelines (P < .001). Standardized assessment of PrU risk was identified as one of the most important recommendations; however, only 61% of patients for whom it was indicated had a risk assessment done.18

The time to heal a PrU is variable and largely depends on the stage of the PrU and the individual's physiologic condition. The longer the time to heal, the greater the costs incurred. In 1990, Brandeis et al19 studied 19,889 older adults in 51 nursing homes and found that 75% of Stage II PrUs and 17% of Stage III or IV PrUs healed in 8 weeks. Most improvement in healing time took place in the first 3 months of the person's nursing home stay. Although Stage II PrUs were significantly more likely to heal than higher-staged PrUs, up to 23% of Stage II PrUs and 48% of Stage IV PrUs had not healed after 1 year.

Another study evaluated healing in 40 older adults (aged 65 to 102) who were residents of LTC facilities. These residents had chronic wounds and had been treated under the same protocol.20 The protocol consisted of topical therapies, growth factors, and cellular therapy. Healing was defined as 100% epithelialization without drainage. Approximately 73% of the chronic wounds healed, suggesting that healing can occur in older adults with pressure or chronic ulcers when early treatment protocols are implemented.20

INCONTINENCE AND PERINEAL DERMATITIS

Incontinence is defined in the Minimum Data Set (MDS 2.0) as2 or more episodes of bladder or bowel incontinence in 1 week.21 Urinary and fecal incontinence are significant risk factors for PrUs because both result in excess moisture,22,23 one of the major PrU risk factors, and because both can irritate the skin due to the chemical properties of urine and feces. Incontinence combined with friction and/or shear compounds the problem. In addition, removal of stool adds a mechanical irritation to the skin.

Another problem often caused by urinary and fecal incontinence is perineal dermatitis,22,23 an inflammation of the perineum precipitated by irritation, usually due to moisture in combination with chemical and/or mechanical irritation. Use of incontinence briefs can worsen the problem.22 The prevalence of perineal dermatitis in older adults reportedly varies from 23% to 41%.24

Left untreated, perineal dermatitis can progress to ulceration and secondary infection. The clinical practice guideline on PrUs from the Wound, Ostomy and Continence Nurses Society25 notes that as many as 33% of hospitalized adults develop perineal skin injury. Frantz et al5 reported that approximately half of the 1.5 million residents of LTC facilities in the United States are incontinent, and that without a protocol for incontinence management, PrU rates increase. In 1 study,26 16 participants with incontinence developed 26 Stage I and Stage II PrUs before an incontinence protocol was implemented. After implementation, 3 participants developed 5 PrUs over a 6-month period.26

INCONTINENCE INTERVENTIONS

The AHCPR PrU prevention guideline13 calls for the use of underpads or briefs that absorb moisture and wick it away from the skin of incontinent individuals, as well as skin barriers to help protect the skin. A 2002 study27 reported that although the total annual spending on skin protectants in the United States was nearly $33 million, the average spending per patient was only 10 cents per day. In a study that analyzed perineal skin protocols in 32 states,28 researchers reported that 85% of perineal skin protocols included the use of skin protectants; however, the authors noted that the skin protectant appeared to be underutilized.28

A recent study in LTC followed 63 residents for 6 months and evaluated the effectiveness of an incontinence management protocol based on the AHCPR clinical guidelines.5 Total daily cost of incontinence care was $573, or $9.09 (±$10.52) per participant, per day. Three elements were included in the cost analysis: direct nursing care, indirect nursing care, and supplies. For the 6-month study period, facility costs were $86,436, with 46% of the total attributed to labor expenses. Incontinence interventions, including toileting, barrier cream, disposable briefs, and/or bed pads, were used for approximately one third of residents in the study.5

Incontinence and pressure, particularly in the sacral and perineal areas, occur simultaneously in many instances. Nursing protocols generally focus on skin care as the foundation of PrU prevention. This is particularly true when patients are incontinent; it is essential to reduce their exposure to moisture and the chemically irritating properties of urine and feces. Gentle cleansing and use of appropriate products will minimize mechanical irritation and trauma to the perineal/perianal areas.

Lyder24 reported that the use of moisture repellents can help keep skin free from direct contact with irritants. Another study of incontinent female LTC residents23 found that a no-rinse cleanser used with a moisture barrier cream was less likely to harm skin integrity than soap and water used alone as a cleanser. Three studies that used moisture barriers29-31 did not result in statistical significance for evidence-based practice, leading to the need for further study to evaluate such protocols.

The purpose of the present quasi-experimental clinical study was to assess the effectiveness of incorporating a body wash and a skin protectant into existing skin care protocols based on the AHCPR PrU guidelines.13,14 The research questions were (1) What is the difference in the occurrence of Stage I and Stage II PrUs before and after the introduction of skin care protocols including a body wash and a skin protectant for LTC residents? (2) What is the difference in healing time of Stage I and Stage II PrUs before and after the introduction of skin care protocols incorporating a body wash and a skin protectant on Stage I and Stage II PrUs? (3) What is the occurrence rate of urinary and fecal incontinence in 2 LTC facilities? (4) What is the relationship between incontinence and PrU development in residents of LTC facilities?

METHODS

Setting and subjects

The authors conducted a secondary analysis of their data from a larger quasi-experimental study on the clinical effectiveness of skin care protocols on skin breakdown in 2 rural skilled LTC facilities located in the north central United States.32 Agency A had 45 beds and Agency B had 67 beds. Approval to conduct the study was obtained through the local university Institutional Review Board and the medical director and administrator of both agencies. Agency administrators sent an informational letter about the study to adult residents or their guardians and requested them to respond in writing if they wished to be excluded. Two residents declined participation in the study. All consenting residents were included in the convenience sample.

The sample consisted of 136 adult residents, with 53 at Agency A and 83 at Agency B. The majority of residents were in both samples (preintervention and postintervention periods). Females comprised approximately 70% and males approximately 30% of the sample.

Interventions

During a 3-month preintervention period, the researchers documented skin assessment data and information on PrU development, treatment, healing time, and incontinence. Following the preintervention period, an educational session was conducted for all nursing staff. The education included how to assess Stage I and Stage II PrUs, the physiology of aging skin, and the introduction of a body wash and a skin protectant into skin care protocols designed to prevent and treat skin breakdown. A total of 84% of licensed staff and 72% of unlicensed staff in both agencies attended the in-service educational sessions. Components of the skin care protocols included skin assessment techniques, prevention and treatment for dry skin, identification of Stage I and Stage II PrUs, and skin protection and early intervention for incontinence. Nursing staff were instructed to cleanse the skin with the body wash after each incontinent episode and to apply the skin protectant to the perineal/perianal area after each cleansing. They were told to check each incontinent resident's skin every 2 hours for soiling; they were to cleanse the skin with the body wash and reapply the skin protectant as needed.

Before implementation of the experimental intervention that included a body wash and a skin protectant, each agency was following skin care protocols based on AHCPR guidelines.13,14 The experimental intervention included the addition of a body wash and a skin protectant to routine care for prevention and treatment of skin breakdown. This was the only protocol change from preintervention to postintervention.

The body wash used in the study was a nonirritating, pH-balanced, no-rinse cleanser/deodorizer (Lantiseptic All Body Wash; Summit Industries, Inc, Marietta, GA). The lanolin moisturizer component is intended to prevent dry skin. The skin protectant used in the study was a fine-grain emulsion consisting of 50% lanolin with beeswax and petrolatum additives33 (Lantiseptic Skin Protectant, Summit Industries, Marietta, GA).

Instruments and data collection

Following a thorough literature search, a data collection form was designed by the authors. Content validity of the data form was established by an expert review panel. Study data included demographics (age and gender); scores on the Braden Scale for Predicting Pressure Sore Risk34; occurrence of Stage I and Stage II PrUs, date of occurrence, and location of the PrU; presence of urinary and fecal incontinence; whether a PrU was present on admission to the study; and the use of the body wash and the skin protectant for prevention and/or treatment of Stage I and Stage II PrUs. Nurses who had experience with research-based PrU and incontinence protocols collected the data from each agency on an ongoing basis. Researchers met weekly with the nurse data collectors to clarify the information on the data collection forms.

Definition of terms

Pressure ulcers are usually located over bony prominences (eg, sacrum, coccyx, hips, or heels) and staged according to the extent of observable tissue damage.9 For the present study, Stage I and Stage II PrUs were staged according to the National Pressure Ulcer Advisory Panel (NPUAP) definitions, as follows:

  • Stage I-an observable pressure-related alteration of intact skin whose indicators as compared to the adjacent or oppositeareas on the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel), and/or sensation (pain or itching). The ulcer appears as a defined area of persistent redness in light skin, whereas in darker skin, the ulcer may appear with persistent red, blue, or purple hues35 (Figure 1).
  • Figure 1
    Figure 1:
    STAGE I PRESSURE ULCER
  • Stage II-a partial-thickness skin loss involving the loss ofepidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater9 (Figure 2).
  • Figure 2
    Figure 2:
    STAGE II PRESSURE ULCERS

As mentioned earlier, incontinence was defined according to the Minimum Data Set (MDS 2.0) as 2 or more episodes of bladder or bowel incontinence in 1 week.21

Point prevalence was defined as a cross-sectional count of the number of cases at a specific point in time (a snap shot of the phenomena), or the number of persons with PrUs whoexist in a population at a given point in time. Incidence was defined as the number of persons initially ulcer-free who developed a PrU within a particular period in a particular population.11

Data analysis

Data were summarized and analyzed using the Statistical Package for Social Sciences 11.0 (SPSS, Inc, Chicago, IL). Chi-square (χ2) and t tests were used to test for statistical significance, with t tests used on interval and ratio data and chi-square used on nominal and ordinal data.

RESULTS

Of the 136 participants, 28 developed 1 or more Stage I or II PrUs during the study, 7 females and 3 males from Agency A and 14 females and 4 males from Agency B. The total number of Stage I and Stage II PrUs significantly decreased from 35 preintervention to 14 postintervention (t = 19.48, df = 47, P = .05). The prevalence of Stage I and Stage II PrUs in the preintervention period was 11.3%, compared with 4.8% postintervention (t = 2.47, df = 1.0, P = .244). Pressure ulcer incidence was 32.7% preintervention and 8.9% postintervention(t = 8.48, df = 2.0, P = .01). The decrease in incidence was statistically significant.

The most common location of PrUs during the preintervention period was the sacrum (25.7%), followed by the ischium (22.9%), and the heel (14.3%); the most common location postintervention was the ischium (28.6%), followed by the sacrum and toe (both 21.4%) (Table 1). The mean age of the residents at Agency A (M = 81.7 ± 10.6 years) was slightly older than the mean age of residents at Agency B (M = 79.9 ± 9.1 years). The mean Braden Scale score was slightly higher in Agency B than in Agency A (B = 16.0 ± 3.0, 11-22; A = 15.4 ± 2.03, 12-23), indicating an overall higher risk of PrU among residents of Agency A. (A higher Braden Scale score indicates lower PrU risk.) Overall, Agency A had a higher mean age of residents and a lower mean Braden Scale score, indicating a higher risk for skin breakdown. The differences between the 2 agencies were not statistically significant, however.

Table 1
Table 1:
NUMBER AND PERCENTAGE OF STAGE I AND STAGE II PRESSURE ULCERS BY LOCATION PREINTERVENTION AND POSTINTERVENTION

The presence of urinary and/or fecal incontinence was assessed because they have been associated with a higher risk of PrU development.5 More than half of the residents in this study who had a PrU also had urinary incontinence (61.2%) and more than one-third (45.9%) had fecal incontinence. Of the 10 residents with a PrU in Agency A, 80% also had urinary incontinence and 70% had fecal incontinence. Of the 18 residents in Agency B with a PrU, 61.9% had urinary incontinence and 44.4% had fecal incontinence. The presence of urinary and fecal incontinence was significantly associated with the development of Stage I or II PrUs in the entire sample (χ2 = 44.8, P = .000).

Pressure ulcer healing times decreased from the preintervention period to the postintervention period. Overall PrU healing time ranged from 4 to 70 days preintervention (M=22.7 ± 18.3 days) to 6 to 49 days postintervention (M = 16.0 ± 12.9 days). The average healing time in Agency A decreased from preintervention (range, 4-54 days; M = 17.5 ± 17.4 days) to postintervention (range, 7-20 days; M = 13.0 ± 6.9 days). Similar reductions were found in Agency B (preintervention range, 7-70 days; M = 26.9 ± 17.8 days; postintervention range, 6-49 days; M = 18.0 ± 16.1 days). Healing times (days) were placed into categories due to the small sample and widely varying ranges (1-23 = short, 24-48 = moderate, and >48 = long). Overall, the decrease in PrU healing time from preintervention to postintervention was statistically significant (χ2 = 14.9, P = .001).

A variety of treatments were used for PrUs in this study. The most common treatment was an occlusive dressing, followed by a skin protectant and pressure reduction. During the preintervention phase, the most common treatment for a Stage I or Stage II PrU was an occlusive dressing. Postintervention, the 2 most common treatments were occlusive dressings and a skin protectant.

DISCUSSION

In this study, the prevalence of PrUs was 11.3% preintervention and 4.8% postintervention; incidence was 32.7% preintervention and 8.9% postintervention. Prior studies have reported incidence rates ranging from 2.2% to 23% and prevalence rates ranging from 2.3% to 28%.11 The higher incidence numbers in the present study are likely a result of including Stage I and Stage II PrUs in the statistical analysis; previous studies have not consistently included Stage I PrUs.

Overall, the incidence of Stage I and Stage II PrUs in the present study decreased significantly when a body wash and a skin protectant were incorporated into routine skin care prevention and early intervention protocols based on AHCPR guidelines. It is likely that the use of a body wash and a skin protectant coupled with the existing skin care protocols prevented the development of some PrUs and contributed to a decline in the occurrence of Stage I and Stage II PrUs. This is further supported by the significant decrease in incidence from preintervention to postintervention. Because it was not possible to control all resident or process variables in the analysis, the determination of a cause-and-effect relationship could not be made. The nursing staff had prior knowledge of components of the skin care protocols, such as ongoing risk assessment using the Braden Scale, nutrition/hydration monitoring, bowel and bladder training, and daily skin assessments. This likely enhanced their commitment to the investigative protocols, and thus, contributed to the study results.

It has been previously reported that the number of incident PrUs in a LTC facility was reduced from 16 residents developing 26 new ulcers during a 6-month preintervention period to 3 residents developing 5 PrUs postimplementation.26 Another LTC study documented a statistically significant reduction in the prevalence of Stage I to Stage IV PrUs over a 14-month period (P = .01).36 Other studies have concluded that a skin cleanser and a skin protectant were effective on skin breakdown; these studies were unable to establish statistical significance, however.23,29-31 The present study did establish significance for a decreased rate of PrUs, yet it must be interpreted with caution because products other than the body wash and the skin protectant were occasionally used.

Pressure ulcer healing outcomes have not been extensively studied in the literature. Findings in the present study demonstrate that healing times significantly decreased for Stage I and Stage II PrUs, from a mean of nearly 23 days preintervention to 16 days postintervention, primarily through the use ofskin care protocols based on AHCPR guidelines13,14 and treatment with semiocclusive dressings and/or a skin protectant. These findings are supported by Brem et al,20 who documented that chronic wounds in older adults heal with early treatment. Long-term-care residents with a PrU have a higher mortality, but with the use of standardized protocols and follow-up, the majority of PrUs can be expected to heal in 1 year.19 Decreasing the healing time results in a direct savings in health care costs and, more importantly, results in better quality outcomes for residents.

Urinary and fecal incontinence were statistically significant factors in the development of Stage I and Stage II PrUs in this study. Overall, 63.3% of the residents in the study had urinary incontinence and 36.7% had fecal incontinence; Agency A had approximately 15% more residents with urinary and fecal incontinence than Agency B. The results are fairly consistent with reports from the AHCPR13 and Frantz et al5 that half of residents of LTC facilities are incontinent. Maceration can occur with urinary and fecal incontinence. The use of a body wash decreases the surface tension on the skin to ease cleansing, and the skin protectant provides a barrier to protect the skin.33 For residents with incontinence, it means that overall PrU care should include strict adherence to the AHCPR guidelines,13,14 including the use of a body wash and a skin protectant.

It is believed that, in this study, education on the use of a body wash and a skin protectant and the incorporation of these products into existing skin care protocols resulted in more frequent and consistent utilization of study products. The use of the body wash and the skin protectant provided a consistent approach to care for nursing staff for preventing and treating Stage I and Stage II PrUs and incontinence. In addition, the directors and assistant directors of nursing monitored and reinforced protocol compliance on an ongoing basis. Had the educational in-service session been mandatory, with 100% attendance, perhaps the decrease in occurrence would have been greater.

Limitations

This study demonstrated a reduction in Stage I and Stage II PrUs between the preintervention period and the postintervention period. However, this reduction needs to be measured over a longer period to evaluate if the results can be maintained. In addition, the present study demonstrated an association between a decreasing incidence of Stage I and Stage II PrUs and incorporation of the use of a body wash and a skin protectant into skin care protocols based on AHCPR guidelines.13,14 However, this study did not review the body wash, skin protectant, and AHCPR guidelines separately in the analysis, which might have produced different results.

Nursing staff independently assessed residents and initiated interventions when they recognized unrelieved erythema or a break in the skin. Although the body wash and the skin protectant were incorporated into existing skin care protocols, nursing staff were allowed to determine when to use these products. One of the challenges in interpreting PrU study results is in determining whether the effects of the treatment method itself or the effect of increased staff vigilance was the primary contributing factor.37 The findings of the present study were also limited to the accurate documentation of the resident skin assessments and treatments as outlined in the study protocols.

Adherence to the experimental study protocols likely varied between the 2 agencies. Both agencies had weekly discussion meetings with the research assistants on PrU skin assessment and findings, as well as information indicative of adherence to treatment and prevention protocols for Stage I and Stage II PrUs and incontinence. Agency A held more informal meetings; Agency B held formal interdisciplinary team meetings each week. The amount of administrative reinforcement of the skin care protocols in each agency may have affected the results.

CONCLUSIONS

This study documented a decrease in Stage I and Stage II PrUs through prevention and early intervention protocols that included the use of a body wash and a skin protectant consistent with best practices and a team approach. If appropriate prevention strategies and early treatment are provided to older adults with chronic wounds and incontinence, many PrUs could be prevented. This could likely decrease the number of PrUs that progress to Stage III or IV. In this way, complications of infection, pain, and escalating health care costs would be avoided and greater patient comfort and quality of life would be realized.

Essential care for older adults should include scientific studies that evaluate prevention and treatment interventions for skin care. Given all the demands resulting from shrinking health care resources, it is incumbent upon LTC facilities to improve measurement and outcome strategies for PrU prevention and treatment. Future studies should focus on PrU prevention and early intervention protocols, which should consistently incorporate a body wash and a skin protectant, in decreasing the occurrence of PrUs. The present study supports the AHCPR guideline recommendations for the use of a skin protectant for skin with prolonged exposure to moisture from fecal or urinary incontinence. Research focused on care variations in PrU prevention, treatment, and incontinence among rural LTC facilities would be helpful. Because 75% of Stage II PrUs heal in 8 weeks,19 a study to evaluate only the use of a body wash and a skin protectant on Stage I and Stage II PrUs for 8 weeks would be in order.

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