Incontinence-associated dermatitis (IAD) is a “form of irritant dermatitis that develops from chronic exposure to urine or liquid stool.”1,2 Incontinence-associated dermatitis is one of four types of moisture-associated skin damage (MASD) that has been reported in the literature; MASD has been defined as “inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, or saliva.”1,3 The other three etiologies of MASD are perspiration (intertriginous dermatitis), wound exudate (periwound MASD [maceration]), and skin damage from ostomy output (peristomal MASD).1–4 This article will focus only on IAD.
Identifying the correct cause of and differentiating IAD from other skin conditions are imperative to guide prevention and treatment. In their classic work, Sackett et al5 stated that “evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” They proposed that three components—a professional’s clinical experience, patient preference, and the best external evidence—should be considered when developing a plan of care. Therefore, in this article, the authors have included not only a review of the literature, but also reflections on their clinical experiences in implementing change. This will form the foundation for recommendations and a framework for evidence-based clinical action using the ACT mnemonic (Assess, Cleanse, and Treat; Table 1).
Overview of the Problem
To address a worldwide healthcare concern such as IAD, the extent of the problem needs to be identified. Unfortunately, IAD is underreported as a healthcare condition. A 2003 study of an initial sample of 20,028 American adults with 30 acute and chronic conditions did not report any findings regarding incontinence or its impact on skin such as IAD.6
Incontinence is a major concern for patients and caregivers. A European team7 conducted a survey of 355 patients and found that the most frequent care problem (15.8%) was urinary incontinence. Next was fecal incontinence, at 14.6%.7 Although patient preference is an important component of evidence-based care,5 the voice of the patients and their family caregiver at home is not always reported in the literature.
One exception is the recent report by AARP regarding unmet caregiver needs after implementation of the Caregiver Advise, Record, Enable Act in the United States.8,9 Those survey results indicate that of the seven categories of possible medical/nursing tasks performed by caregivers, 35% comprised ostomy or wound care, and caregivers found these tasks more difficult than others. Respondents stated this care impinged on familial and social norms because it required an intimate level of personal care for someone with whom the family caregiver has had a long-standing relationship.8,9
The authors of this article agree with the recommendations by Reinhard et al8 and Reinhard and Ryan9 that professional organizations should take the lead and support clinicians in communicating best practices and training family caregivers. Some organizations have already begun this process, but much more needs to be done. Succinct guidance and information on IAD are needed, both for professional caregivers and lay people to improve the care delivery for this condition.8,9
In an attempt to provide this guidance, the authors will review prevalence, incidence, and risk factors for IAD, along with some pathophysiology and information about IAD in specific populations. The authors also will introduce the ACT mnemonic for IAD skin care needs. Ultimately, synthesis and awareness of the current literature are not enough; clinicians and caregivers must act to prevent and treat IAD.
A university health sciences librarian in conjunction with the authors devised the search strategies for cinahl and PubMed using a combination of subject terms and keywords to ensure a comprehensive search. Filters applied were: research, English language, and publication date 2002 to present chosen because the application of and research can take up to 17 years).10,11
The total article yield from cinahl was 24 and 306 from PubMed. In addition, the Scopus database was used to locate citing articles from the most relevant records obtained from the initial search results. The librarian performed the initial screening for relevance based on criteria established by the authors. Inclusion criteria were: articles in English, research findings in accordance with manufacturer instructions for product usage, studies, consensus documents, and expert opinions that were relevant to the topic and matched the key terms. Exclusion criteria were duplicate publications of the same data and advertorials. The search was supplemented by the authors’ personal files of IAD articles/publications. A total of 105 articles were identified and included in this review.1–105
Prevalence and Incidence
In order to begin to address a problem, it is helpful to know the extent of the phenomenon of interest, in this case, IAD. Several studies in a variety of care settings have provided an initial understanding of IAD as a health concern. The authors will describe these data by age, care setting, and association with pressure injury development.
Infants and Children. Ward examined 272,841 encounters on the National Ambulatory Medical Care Survey (1990–1997) in which IAD (formerly known as “diaper dermatitis”) was diagnosed.12 The prevalence in infants was estimated to be 7% to 35%, with the peak occurring between 9 and 12 months.12 In the acute care setting, Heimall et al13 reported a 24% prevalence, whereas Noonan et al14 reported a prevalence of 17%.
Long-term Care and Long-term Acute Care. Long et al15 reported a 7.6% incidence of IAD in a long-term acute care facility in the United States. They identified that one of the reasons for this high rate was that soap, water, and washcloths were routinely used to care for persons with IAD.
The Centers for Medicare & Medicaid Services (CMS) has designated MASD as a reportable condition on the resident assessment instrument Section M1040H in long-term care (LTC). While MASD trails the national data for pressure injuries (4.00% to 6.63% versus 8.20% to 7.48% from 2012 to 2017), it is certainly a skin condition that warrants consideration for persons in LTC.16 In fact, CMS data reveal that the frequency of MASD has steadily risen since it was first reported on the MDS 3.0 in LTC in 2012 and is now approaching pressure injury percentages.16 The percentage of only IAD as a type of MASD as reported in M1040H (MASD) on the Minimum Data Set 3.0 in LTC is unknown because CMS includes all causes of MASD in this item.17 These CMS data reported above are consistent with LTC IAD prevalence data of 5.7% reported by Bliss et al from 2006 prior to IAD from MASD being reported on the MDS 3.018 and 5.5% incidence after IAD/MASD was captured on the MDS.19
Acute Care. The prevalence of IAD in the critically ill ranges from approximately 7.0% to 50.0%, and IAD occurs in 50% of those patients with diarrhea in the intensive care unit (ICU).20 In two studies with small patient enrollment in hospitals in the US, IAD prevalence was reported to be 27% (n = 976) and 20% (n = 608), respectively.21 In an Australian hospital, prevalence of urinary or fecal incontinence was 24% (91/376), with 42% (38/91) of those who had incontinence developing IAD.22 A large sample of 5,342 adults in American hospitals reports that 46.6% (n = 2,492) were incontinent of urine, stool, or both, with 1,140 or 21.3% of the total sample having IAD.23 Of those with incontinence (1,140/2,492), just under half (45.7%) had IAD.23
Pressure Injuries. The literature also supports an association between IAD and pressure injuries.1–3,20,24–27 Since 2008, CMS reimburses US hospitals only for stage 3 or 4 pressure injuries that are documented on admission. Long-term-care facilities risk civil penalty monies if residents develop pressure injuries. Therefore, preventing IAD to decrease pressure injuries is even more important.
The importance of addressing IAD is underscored by Lachenbruch et al,24 who have provided evidence of higher facility-acquired pressure injury rates (acute care, long-term acute care, LTC, and rehabilitation settings) in persons who were incontinent (6.0%) compared with those who were continent (1.6%). Other analyses from Europe support an association between IAD and the development of pressure injuries.25–27 A more recent study of acute care facilities in the US reveals that among those with incontinence, sacral full-thickness pressure injury prevalence was 3.8% (95/2,492).23
Pathophysiology of IAD
The skin is an amazing multilayered self-renewing organ that deserves clinical attention to preserve its barrier protection function as well as its other important functions of immune surveillance, thermoregulation/insulation, sensation, heat production and control of evaporation, storage, adequate water content/moisture balance, and synthesis such as vitamin D.28–30 The stratum corneum, which is the outer layer of the skin, is composed of keratinized epithelium.28 The stratum corneum has an “acid” mantle that favors the synthesis of ceramides by β-glucocerebrosidase in an optimum pH of 5.6.31 While normal healthy skin provides a protective barrier by its “mortar” (lipids) and “brick” (corneocytes [cells]) structure, the mechanisms by which IAD disrupts the barrier structure is believed to be multifactorial, with the two major factors being pH changes (Figure 1) and wetness.
The skin has a normal flora of organisms that are kept in check when skin pH remains within the usual acid mantle range. When skin pH moves into the alkaline range, pathogenic bacteria counts rise.31,32 Repeated exposure to urine and/or feces can lead to changes in skin pH from the normal acidic pH of 4 to 6 to an alkaline pH (>7). Using alkaline soaps can also increase the skin’s pH. Once the skin pH is raised into the alkaline range, the skin lipids are altered, leaving the skin vulnerable to damage. This is because enzymes such as alkaline ceramidase have increased activity at alkaline pH levels.31,33 Higher activity of alkaline ceramidase has been found in older adult skin31,33,34 and may explain why older adult skin is more vulnerable to damage from incontinence.
A study by Larner et al35 reported that repeated application of alkaline urine on the arms of normal volunteers resulted in skin irritation. No irritation was seen on skin exposed to water, leading the researchers to hypothesize that the pH change from repeated application of urine, rather than hydration, was the causative factor. They also hypothesized that when skin is repeatedly exposed to alkaline urine it does not have time to recover and return to its normal pH.35
Another external threat that can cause damage to wet skin is aggressive cleansing accompanied by excessive friction. Wet skin may also have a higher frictional coefficient than dry skin.31 Wet skin may be more susceptible to damage from mechanical trauma31 such as from friction during cleansing, repositioning, or transferring. Sopher and Gefen36 reported from their animal stratum corneum research that compression and shear in the presence of wetness produced the highest skin surface loads compared with compression in a dry environment. Compression with shear in a dry environment also was a factor in skin damage. Thus, managing incontinence to prevent skin wetness helps avoid skin lesions such as pressure injuries.36
When developing policies and protocols, clinicians need to be aware of the risk factors for different age populations. Prevention measures and treatments to reduce the incidence and severity of IAD are critical for all settings. Standardized prevention and treatment algorithms have proven to be useful for nursing staff in decreasing IAD. For example, Noonan et al14 found that consistently implementing prevention strategies resulted in 16% prevalence (n = 24) from the 60% of patients (n = 148) who were incontinent of urine and/or stool. This was lower than the 25% prevalence that Ward et al12 found in the general pediatric population wearing diapers (Figure 2).
Shaked and Gefen37 used a biomechanical computational laboratory model to explore the effects of stresses on wet skin (such as from incontinence) during repositioning. They concluded that the “rise in stresses for a wet interface became more prominent when the skin tissue was stiffer, which represented aging or diabetes. This important finding demonstrates how the aged/diabetic skin is more fragile than young adult skin when repositioning in a moist environment.”37
Infant and Child Skin. Infant skin is not mature at birth and differs from adult skin in several ways. Their stratum corneum is thinner, the microvasculature in the skin is not as organized, and there is a lower concentration of melanin than in adults.38 Infant skin pH levels range from 6.34 to 7.5, depending on location, which is higher than adult skin.38
The epidermal barrier is formed during the third trimester and increases during maturity. The stratum corneum in term infants is 10 to 20 layers, but only 2 to 3 layers in infants younger than 30 weeks’ gestation, and is almost absent at 24 weeks’ gestation.39 These premature infants are at risk of increased transepidermal water loss, experience increased absorption of topical agents, and have increased susceptibility to chemical and mechanical injury.38,39 Careful attention must be paid to the type of product used with this population.38,39
Several factors then predispose this population to increased risk of skin damage in the diaper region, including overhydration, exposure to urine and stool, increased pH, and diet, along with the depth of the stratum corneum. It is possible for IAD to have multiple causes, but is often thought to be the result of reaction to the irritants in the diaper area such as friction, occlusion, moisture, urine, feces, or chemicals.
Barrier products containing zinc oxide, petrolatum, or dimethicone can provide a physical barrier to irritants and moisture. Topical antifungals and/or corticosteroids may need to be used depending on the cause of the dermatitis.12 Heimall et al13 developed algorithms incorporating first- and second-line products to be used for prevention and treatment and reserving the third-line products for refractory cases. Heimall et al13 were able to reduce the initial prevalence of diaper dermatitis from 24% to 11% over a 2-year span after implementing the new standards.
Older Adult Skin. As the “baby boomer” generation has aged, the proportion of the US population that can potentially have skin needs because of IAD may increase. As skin ages, skin function as described previously deteriorates.28–34 Older adult skin has a higher activity level of alkaline ceramidase,31,33,34 which can lead to vulnerability in the structure of the skin. In an animal study by Sopher and Gefen,36 skin with deeper wrinkles as well as older skin had a higher risk (six times greater) than younger skin for potential stress damage. Aging skin also has a 20% loss in dermal thickness (“paper-thin” skin). Other changes in aging skin include a flattening of the dermal-epidermal junction and surface pH that is less acidic.30
Critically Ill Patients. Bliss et al40 report that in critically ill patients with decreased cognition and fecal incontinence the skin does not quickly recover to a normal healthy state. In these populations, clinicians need to promote healthy skin and IAD prevention with well-defined and consistently implemented skin regimens.
Peart and Richardson41 address the subject of inadequate assessment of patients at risk of developing IAD and skin damage related to fecal incontinence. Increased education is necessary to provide quality patient care and prevention of IAD.41 Park and Kim42 discuss that for ICU patients using the defined skin care regimen of a no-rinse skin cleanser, application of a skin protectant, and an indwelling fecal drainage system when indicated will decrease IAD.
Providing education to ICU staff can improve IAD outcomes and prevention. Pather and Hines20 surveyed the baseline knowledge of 31 nurses in preventing IAD. Following the survey and providing education and product standardization, there was a 40% increase in the ability of staff to distinguish between IAD and pressure injuries.20 This may support the theory that the consistent use of interventions and education can reduce the rates of IAD and nursing time in the treatment of IAD. Although these were studies based on the critical care population, these baseline theories may be applicable to all patient populations.
There are many consensus statements from expert panels, best practice statements from individuals, and care protocols in the literature.* The authors believe that there is a need for clinicians to have a concise way to translate this knowledge into everyday practice. For years, care bundles and mnemonics have enabled clinicians to remember key components of care interventions. A quick and easy-to-remember mnemonic such as ACT can be readily used by the healthcare provider or caregiver. The A stands for assess; C for cleanse skin, correct cause, and contain incontinence; and T for treat vulnerable and/or damaged skin and avoid traumatic skin injury.
Assessment is an important first step in providing appropriate care. Several skin assessment instruments have been described in the literature.43–48 Some tools have included consideration of color changes in persons with darker skin tones such as the Incontinence-Associated Dermatitis and its Severity Instrument.48 Another is the modification of the Kennedy Skin Condition Assessment Tool with a photo guide for persons with brown skin.29 Some IAD assessment tools require multiple factors to be evaluated and can be time consuming for clinicians to complete. These tools may be more suitable for research studies than everyday clinical practice.47
Three factors are most critical to consider in skin assessment for IAD: cause, color, and condition.
Cause. The cause of IAD is incontinence of urine, stool, or both. Although research supports that higher prevalence rates are reported in individuals with fecal incontinence23,24,27,49 or both urinary and fecal incontinence,23 urinary incontinence alone still has a significantly high prevalence rate that warrants clinical attention.
Differentiate that the cause is from IAD rather than a pressure injury. Consensus from the literature is that, compared with pressure injury, IAD is diffuse, inflammatory skin injury from incontinence of urine, feces, or a combination of both. Houwing et al50 report that histopathologic biopsy of IAD reveals inflammation, whereas pressure injuries have evidence of ischemia. Other IAD characteristics that clinicians can assess include edges that are not distinct and superficial (partial-thickness skin loss)1–3 involvement without necrotic tissue.
Color. Because IAD is believed to be an inflammatory condition of the skin, visible color changes may assist in assessment. Color changes may present differently, depending on the category of a person’s skin color according to Fitzpatrick’s scale.29 The Fitzpatrick scale, commonly used in dermatology, numerically classifies non–IAD-damaged skin color on a scale from 1 to 6 from pale white to deeply pigmented based on the skin’s color description and reaction to UV light.29 Erythema may appear bright red in individuals with lighter skin tones (Figure 3) or present as more subtle skin discoloration in those with darker skin tones (Figure 4).
Condition. Determine whether the skin is open or closed. Open skin should be described as an erosion. Erosion has been defined as “a loss of epidermis with a dermal base.”28,29 Erosion is intraepidermal. Skin breakdown in IAD also can be categorized as an erosion (Figure 5).
Assess for the presence of fungal infection and yeast. The literature often clumps together true dermatophyte fungus and yeast as fungus, but clinically they are distinct. True fungus (dermatophytes) has a red active margin, and yeast (Candida) is associated with satellite papules and pustules. For Candida, look for an area with a confluent red center and the presence of satellite lesions (Figure 4). Research indicates that fungus occurs in persons with IAD. Campbell et al22 report fungal presence in 32% (12/38) of patients with IAD, whereas Gray and Giulano23 report that 14.8% (169/1,140) of patients with IAD had a fungal rash.
The maintenance of clean, dry skin is a fundamental principle in skin care. There is wide acceptance for recommendations in the literature supporting the move from cleansing the skin with soap and water51 and phasing out wash basins that present an infection control hazard.52 Surfactants lower the surface tension and act as detergents to remove debris from the skin. Skin should be cleansed with a pH-balanced cleanser1 to maintain the acid mantle. A pH-balanced cleanser reduces skin irritation and dryness, reducing the risk of impaired skin integrity.1,2 Despite expert opinion, many laypersons and professionals alike are unfamiliar with this practice recommendation and rationale. Consequently, those with urinary and fecal incontinence (as well as those caring for them) routinely endorse skin care that is tradition and assumption based rather than evidence based, that is, washing with harsh, deodorant soaps in an attempt to kill bacteria and rid the skin of odors. This practice is known to elevate the pH of the skin, making it more susceptible to bacterial and fungal overgrowth.
One of the patient-centered concerns is odor from IAD. This might be one of the reasons that patients and their caregivers use deodorant alkaline soaps that promise skin odor reduction. In a laboratory study, researchers attempted to evaluate odor reduction by placing synthetic urine in the perineal crotch portion of disposable absorbent incontinence products. Bacteria growth and ammonia formed by bacteria were then measured. Changing the pH of the product inhibited bacterial growth. Although ammonia is not the only reason for odor from incontinence, the continued development of incontinence products that address this issue may be helpful for practice.53
Soaps and cleansers with numerous ingredients, such as preservatives, fragrances, and dyes, increase the potential for skin sensitivities and reactions. Selecting products with fewer ingredients may improve skin integrity for vulnerable populations.
Correct the Cause. Incontinence should be corrected if possible. That said, discussion of behavioral methods to correct incontinence is beyond the scope of this article. If correction of incontinence is not possible, containment of the urine or stool will help reduce exposure of the skin to the wetness and pH changes associated with urinary and/or fecal incontinence and thus help prevent IAD. Remember to treat the whole person: if a person has incontinence, consider pressure off-loading and redistribution, as research23,24,27 indicates the risk of pressure injury is higher in persons with incontinence.
Contain Incontinence. The authors agree that noninvasive methods for managing urinary incontinence are preferred over indwelling urinary catheters whenever possible to decrease the likelihood of catheter-associated urinary tract infections. For males, noninvasive urinary incontinence containment has historically been achieved using external catheters (condom style) or the occasional propped and padded urinal. For females, urinary incontinence containment has been challenging. There are now management options such as female urinary collection devices. Research by Sugama et al54 in Japan found that hospitalized female patients 65 years or older who had IAD healed faster (43.3%, n = 13) when a test absorbent pad was used compared with the four patients (13.3%) in the group who used the usual absorbent pad (P = .009). No significant difference was found in the moisture content of the stratum corneum (P = .823) or skin pH (P = .761) between the two groups.54
For fecal incontinence, indwelling bowel management systems may be a temporary management option. When using external urinary and/or bowel management systems, attention to prevent medical device–related pressure injuries is needed.
Newer body-worn absorbent products that improve moisture management by keeping wetness away from the skin or that lower the pH of the skin in the presence of incontinence may also be considered.51,55,56 Bliss et al57 tested the reaction of the skin on the thighs and forearms of older adults when an alkaline solution was applied between two groups. Skin pH was significantly lower (more acidic) when an incontinence brief with a spiral-shaped fiber was worn compared with a wet standard brief (P < .001).57 The mean skin pH on the wet thigh with a spiral-shaped fiber was 5.7 compared with 6.4 with a standard brief. Incontinence briefs containing a spiral-shaped fiber significantly acidify the pH of the skin exposed to an alkaline solution, whereas industry-standard briefs do not.57 Because alkaline skin pH is a risk factor for IAD, results suggest that briefs with spiral-shaped fiber may help prevent IAD.57 Findings encourage further research.
Fortunately, advancements in technology continue to be translated into newer products that are available for patient use “Older” body-worn products intended to contain urinary or fecal incontinence are not the same as the new products that are now available. With advances in science, clinicians may need to unlearn previous beliefs about absorbent products.55
Skin assessments and characteristics should provide guidance and help clinicians when determining the care plan for prevention and healing of IAD-damaged skin. There are three basic components to the plan of care: cleansing (described previously), moisturizing, and protecting the skin. Products needed to achieve this care may consist of these three components individually or as products that combine two or three of these components in one product. Products with fewer ingredients (dyes, fragrances, preservatives) may be an option to avoid allergies. Therefore, it is imperative that clinicians know the composition of the products they use for skin care. Some studies support a single-step intervention (where cleanser, moisturizer, and skin protectants are incorporated into a single product such as a soft washcloth) for efficiency and staff adherence to the skin care regimen.56,58
Moisturizing. This is the second component of skin care. Moisturizers are used to repair the barrier function of the epidermis, promote retention of water content, and prevent transepidermal water loss. Moisturizers have varying formulas but will contain either emollients, humectants, or occlusives. Emollients smooth the skin surface with the addition of lipids. Humectants attract water to the stratum corneum. Occlusives provide a barrier to the skin from exposure to stool and/or urine. A study by Wickett and Damjanovic59 reports that “products with high levels of glycerin may provide 24-hour moisturization on healthy subjects with moderately dry skin.” Many products combine moisturizing and skin protection and may be a part of a defined skin regimen.58,60,61
Protecting Skin. The final part of a defined skin care regimen for prevention and treatment of IAD is skin protection. Skin protectants (also called moisture barriers) should provide a barrier to the stratum corneum from irritants such as urine, stool, and excess moisture. There are various types of skin protectants, including products with petrolatum, zinc, dimethicone, and liquid acrylates. These products may be formulated as creams, lotions, ointments, pastes, or films. These products provide varying degrees of protection, and it can be challenging to decide which is the best product to use in individual patient circumstances because of a general lack of evidence. The performance of an individual product is determined by the total formulation and not only the skin-protecting ingredient. Kon et al62 found that the addition of a skin barrier cream to skin care protocol resulted in increased hydration of the stratum corneum, decreased skin pH, and decreased the magnitude of erythema in persons in a long-term-care facility in Japan. Razor et al63 used a zinc oxide cream, which resulted in better treatment of IAD in adult hospitalized patients in the Philippines.
Although the evidence on which product or products to use for IAD is inconclusive, one must look at the ingredients in the products to determine product selection for a specific patient’s condition. Most of the skin barrier products used for both prevention and treatment contain one or more of the following ingredients: petrolatum, zinc oxide, dimethicone, and acrylate terpolymer. Petrolatum (petroleum jelly) is a common base for many ointments. Petrolatum is transparent, forms an occlusive layer, and improves skin hydration. Zinc oxide is an opaque or clear cream or paste. Some preparations have added ingredients that also relieve itch. Dimethicone, a silicone-based product, is transparent, nonocclusive, and moisturizing. Acrylate terpolymer is a liquid film-forming acrylate and does not require removal or reapplication with each episode of incontinence.61
There is little to guide the care provider in terms of frequency of application for incontinence care products; most manufactures direct the caregiver to reapply products following each episode of incontinence. Newer, long-lasting barriers such as those in the cyanoacrylate class are believed to maintain their barrier function after repeated contact with urine, feces, and dual incontinence and the subsequent cleansing of the skin for several days.64
Trauma. Cleansing with higher-pH soaps and cleansers, when coupled with cleansing techniques that involve rough scrubbing with terry cloth, loofa, and other materials, can cause injury to the skin. In addition, these methods disrupt and deplete the lipid layer of protection in the skin’s make-up, allowing portals of entry for bacteria between cells. Beeckman et al58 suggest that massage and vigorous rubbing of the skin with a harsh washcloth are more likely to contribute to skin/cellular damage and tissue inflammation than to promote beneficial outcomes associated with massage (such as increased tissue blood flow).2 Consequently, it is recommended that incontinence cleansing be performed using soft cloths to reduce the potential for trauma, particularly in fragile and vulnerable areas such as the perineum.58
Barriers to Treatment. While most would consider limited access to products an obvious barrier to care, in the authors’ clinical experience, there can be agency and institutional reports of incidences in which administrators have restricted access to incontinence cleansers, moisturizers, moisture barriers, and soft bathing cloths during “off” shifts and weekends in an effort to control overuse and contain costs. Community care agencies do not routinely provide these products in the US, leaving family members to rely on non–medical-grade products. Failure to have the necessary supplies at the bedside, in the bathroom, or on the nightstand of the person with incontinence means a substitution will be made, whether that be in favor of an abrasive cloth, an alkaline soap, an inadequate moisture barrier, or the omission of an evidence-based step. Direct care providers require easy access to products with demonstrated efficacy. Guidance from professional organizations is needed to direct consumers toward efficacious product ingredients to deliver predictable results.
More study is needed in this area, but if the claims can be substantiated, some of the burden of caregiving would be alleviated. There is evidence to support that adherence to a structured skin care regimen using products that cleanse, moisturize, and protect in combination with timely incontinence care using soft cloths reduces the incidence of IAD.20
Jacobson and Wright65 explored the results of a bundled care approach to prevention of IAD in a large academic medical center. The bundled care approach included a defined skin care program, educational modules on IAD, use of absorbent pads, enhanced standardized changes to IAD documentation, and quarterly monitoring of IAD prevalence data. Although nurses’ knowledge statistically improved (P < .001), there was little difference in frequency of observed IAD interventions.64 The authors felt that not requiring the education could account for their results.65
KNOWLEDGE TRANSLATION AND CASE STUDY
Knowledge translation (KT) may be an unfamiliar concept to some practitioners, but it can be a powerful model to use in clinical decision making. Therefore, a summary of KT with its barriers and possible solutions has been included (Table 2) so that clinicians have a succinct guide available to them to help close the gap between the literature and the implementation of science into practice. Using the KT concept as well as the Rogers’ Diffusion of Innovation Theory,66 clinicians can provide guidance for IAD practice change. Further, clinical examples of KT may be helpful to illustrate this concept and the literature as summarized. The following case study describes how one medical center implemented practice change regarding IAD care using many of these KT principles.
In late 2008, a large Midwest academic medical center initiated a newly defined skin care regimen. The purpose was to standardize incontinence and skin care throughout the hospital for adult and pediatric populations. This initiative involved several new products that were introduced simultaneously to aid in the prevention of IAD, but this case study will focus only on skin care; the other products are beyond the scope of this article.
The program included transitioning to a standardized one-step product that cleansed, moisturized, and protected the skin. Prior to this defined skin regimen, traditional soap and water and a one-step spray cleanser were available for staff to use to cleanse patients with incontinence. After introduction of the new product, there continued to be variability in skin cleansing technique and product use. Some staff continued to use soap and water, whereas others would use the prepackaged moistened cloths meant for bathing. It became apparent that a defined, standardized skin regimen was necessary to improve patient care.
As the defined regimen was standardized, the product manufacturer representatives provided education to all shifts. This education was provided over a 3- to 4-day period in an effort to roll out the new program and standard of practice to all staff simultaneously.
A clearly defined algorithm for treatment and prevention was developed for IAD care. Consistent use of the term “incontinence-associated dermatitis” was adopted and included within the nursing department standards and practice for the institution. Education for the new product and the term IAD were discussed within the shared governance skin care committee. Unit-based skin champions were then directed to share this information with other nursing staff at both unit meetings and at the bedside. All new nursing staff received education on IAD and the standard of practice at the institution-wide orientation.
As with the introduction of any new product or process, there were some barriers to change that required repeated education to all nursing staff, including nursing assistants. Skin care champions were an integral part of maintaining the change in practice at the forefront of daily care. A “Save Our Skin” education program was offered twice a year for both nurses and nursing assistants. Informational flyers were distributed frequently to the units. Information about the skin care products was included in the unit’s tool kits for easy access. The same information is available on the skin care committee’s intranet site. Most recently, online competency presentations on skin care have been developed and implemented for annual review by all inpatient nursing staff.
As the defined skin care regimen was being initiated, a new electronic medical record was launched. The wound, ostomy, and continence nursing team worked with the information technology department to develop documentation on IAD prevention and treatment. This documentation comprised a portion of the safety interventions that were linked to the Braden subscale scores. If the patient was identified as at risk within the moisture subscale, the IAD documentation was automatically populated as a visual cue to initiate prevention strategies. Currently, the electronic medical record is undergoing optimization to more effectively document MASD and IAD. Further, the wound, ostomy, and continence nurses developed flowsheet documentation within the electronic medical record called a navigator that enables them to quantify the number of patients they assess and treat with IAD.
Incontinence-associated dermatitis remains an important practice concern. Information and guidelines about IAD exist in the literature, but getting time-constrained clinicians to adopt them into their routine practice is a challenge. Further, given the increasing numbers of patients in the US who are “home alone” and being cared for by family members, training in proper skin care to prevent and treat IAD is essential.
Care for IAD requires a combination of process and products that are consistently used. Simplified decision-making tools and algorithms are necessary to assist providers in assessing for IAD and implementing prevention and treatment options. This review of the literature supports using various products designed to protect skin, cleansing the skin soon after an incontinence episode, and using newer absorptive products that wick wetness away from the skin to decrease skin damage from IAD. The ACT mnemonic has been introduced as a simple reminder to professionals or caregivers to deliver evidence-based care to patients with IAD. Consistent adherence to a mutually agreed-upon IAD care plan is needed by all involved.
1. Black JM, Gray M, Bliss DZ, et al. MASD part 2: incontinence-associated dermatitis and intertriginous dermatitis: a consensus. J Wound Ostomy Continence Nurs 2011;38(4):359-70.
2. 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.
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