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Does skin care frequency affect the severity of incontinence-associated dermatitis in critically ill patients?

Conley, Patricia MSN, RN, PCCN; McKinsey, David MD; Ross, Olwyn RN, CWS; Ramsey, Anthony PhD, FNP-C; Feeback, Jennifer CCRP

doi: 10.1097/01.NURSE.0000456382.63520.24
Department: RESEARCH CORNER
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Background: Incontinence-associated dermatitis (IAD) is a potentially serious skin injury that can lead to pressure ulcers (PUs). Multiple studies have indicated the need for evidence to find the most effective skin care protocol to reduce the incidence and severity of IAD in critically ill patients.

Objective: To compare the incidence and severity of IAD in two groups on a progressive care unit (PCU) using a defined skin care protocol: cleaning with a gentle cleanser and moisturizer, then applying a skin protectant/barrier. The control group received the skin care protocol every 12 hours and the interventional group received the protocol every 6 hours; both groups also received it as needed.

Methods: A 9-month randomized prospective study was conducted on 99 patients (N = 55 in the intervention group and N = 44 in the control group) who were incontinent of urine, stool, or both, or had a fecal diversion device or urinary catheter for more than 2 days.

Results: The dermatitis score in the intervention group on discharge was significantly less (7.1%; P ≤ 0.001) in the moderate IAD group than in the control group (10.9%). The dermatitis score means and P values of each group were compared using a paired t test.

Conclusion: The researchers studied a defined skin care protocol using a cleanser with aloe vera and a cleansing lotion, followed by application of either a moisture barrier with silicone or skin protectant with zinc oxide and menthol, undertaken at two different frequencies. Data revealed the incidence of moderate IAD was decreased in the experimental group (receiving the skin protocol every 6 hours and p.r.n.).

Skin care protocols for incontinence-associated dermatitis in critically ill patients

At Research Medical Center in Kansas City, Mo., Patricia Conley is a staff nurse in the PCU, David McKinsey is an infectious diseases physician, Olwyn Ross is a wound care and ostomy nurse, and Jennifer Feeback is the division director of clinical research. Anthony Ramsey is the director at Radford University School of Nursing in Radford, Va.

The authors thank Myra Merritt, BSN, BSEd, RN, clinical manager of the PCU at Research Medical Center and the staff for their support and participation in this study to promote evidence-based best practice; Maithe Enriquez, PhD, RN, FAAN, who helped review the manuscript; and Kitty Serling, MSL, for her assistance with literature searches.

The content in this article has received appropriate institutional review board and/or administrative approval for publication.

Patricia Conley received a scholarship from the research operating committee at Research Medical Center to present the findings from the study.

The authors have disclosed that they have no financial relationships related to this article.

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Background

IAD is an inflammation of the skin in the perineal or perigenital areas, upper/inner thighs, buttocks, and coccyx area from exposure to urine, stool, or both.1-3 IAD can further develop into blisters and denudement of the skin. When the skin becomes macerated and irritated from repeated exposure to urine, stool, or both, the adverse effects of shear and pressure are exacerbated.4

Patients who develop IAD are at risk for experiencing pain, urinary tract infections, and microbial skin infections and for the development of PUs.1,5 Critically ill patients with IAD are especially at risk for developing PUs. Proper nursing assessment of patients at risk for IAD and appropriate treatment are essential for patients with incontinence.2,3

Because IAD and the adverse consequences that can develop into PUs are not well documented, the costs of PUs are used as a point of reference. Treating PUs costs about $11 billion per year; about 60,000 patients die each year in the United States as a direct result of PU complications.6 Medicare and Medicaid Services do not reimburse for the cost of treating hospital-acquired stage III or IV PUs.7,8

Skin injury occurring in hospitalized patients is a quality indicator. Magnet® status recognizes medical centers that promote nursing excellence and provide outstanding patient care; medical centers applying for Magnet status are scrutinized, especially for patients' skin injuries.9

Many risk factors predispose critically ill, hospitalized patients to skin injury:

  • hypoalbuminemia
  • inadequate oxygenation
  • decreased mobility
  • impaired cognitive function
  • fever
  • poor skin condition (due to aging or steroid use).1,10

Studies performed with acutely ill patients have concluded that further research is needed to find a specific skin care protocol that prevents and reduces the severity of IAD.5,11,12 A defined benchmark for IAD incidence in critically ill patients is not available, although Dr. Mikel Gray* (2013, e-mail) states, “Published reviews summarize evidence of prevalence and incidence, but the evidence is limited.”1 Studies have reported a prevalence of up to 42.7%.12

This study would look for evidence of the most effective skin care protocol to reduce the incidence and severity of IAD in critically ill patients.

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Literature review

A review of the literature was conducted using these key words: adult incontinence dermatitis, critical care incontinence dermatitis, incontinence-associated dermatitis critical care, and incontinence-associated dermatitis. The search was limited to English-language studies involving adult patients. PubMed, Google Scholar, CINAHL, and Ovid were searched in 2011, yielding 398 references. The final search yielded 19 articles. Based on Melnyk and Fineout-Overholt's levels of evidence, the articles were categorized as follows:

  • one Level II randomized controlled trial
  • one Level III controlled trial without randomization
  • seven Level IV cohort studies
  • one Level V descriptive study
  • five Level VI descriptive background studies
  • four Level VII consensus opinions from expert committees.13

The evidence reported in the literature reveals a consensus regarding the type of skin products needed to care for patients with urinary and/or bowel incontinence. Experts agree that the protocol should include a gentle cleanser, a moisturizer, and a skin barrier.10-12 These products are most effective in preventing and reducing the severity of IAD when kept in close proximity to the patient and used regularly after each episode of incontinence.14,15 Protocols have included one- and two-step products that have individual or combined pH-balanced cleansers for gentle perineal cleansing, moisturization, and application of a skin protectant or moisture barrier.6,11-13 Various skin protectants are available, including petrolatum-based ointments, dimethicone-based ointments, and zinc oxide creams.14-18 Other researchers said that nurses need to use a reliable skin assessment tool to distinguish IAD from PUs and intertriginous dermatitis, which is inflammation of the skin that results from moisture due to incontinence or perspiration and skin rubbing against skin. Accurate assessment promotes appropriate treatment.17-22

Investigators examined the prevalence of IAD in critically ill patients in ICUs and reported common contributing factors to IAD such as:

  • age older than 50
  • impaired oxygenation
  • poor nutritional status (serum albumin less than 3.5 g/dL)
  • lack of mobility
  • failure in at least one body system (such as heart failure)
  • altered mental status
  • incontinence of urine or stool or both.5,16,20,21,23,24

Patients with fecal incontinence, especially diarrhea, have a higher incidence of IAD compared with patients with urinary incontinence.5,25,26 One study demonstrated decreased IAD with the use of a fecal diversion device in critically ill patients. Further studies are needed to confirm its effectiveness.26

According to researchers, the evidence supporting the most effective skin care products and protocols to prevent and treat IAD has gaps.16,18 Consensus among experts indicates an ongoing need for nursing education focused on properly assessing and managing patients with IAD. Nurses with good assessment skills can identify the risk factors for IAD and prevent PUs.22-25

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Research question

The purpose of this study was to determine the effect of two different frequencies using a defined skin care protocol to prevent or reduce the severity of IAD among critically ill patients in the PCU.

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Methods

Setting and sample. The 9-month randomized prospective study was conducted from June 2012 to February 2013 in a 24-bed PCU at a quaternary care hospital in Kansas City, Mo. To randomize the patients, those enrolled on even-numbered days were put in the intervention group (experimental group), and those enrolled on odd-numbered days were put in the control group (standard protocol). The inclusion criteria consisted of patients age 18 or older who were incontinent of urine and/or stool, surgical patients who had an indwelling urinary catheter for more than 2 days, patients who had a urinary catheter for any other length of time, or patients with a rectal tube in place for liquid stool.26 Patients who came to the PCU from other units, outside facilities, or home were not excluded. Comparative descriptive statistics using the P value were applied to the data collected to measure any significant difference in admission and discharge IAD scores between the intervention and control groups.27 IAD was measured using Brown's grading scale for perineal dermatitis: no erythema, mild erythema, moderate erythema, or severe erythema.27

Procedures. The PCU nursing staff was educated about IAD in a staff meeting and then each nurse was shown five slides illustrating mild, moderate, and severe IAD; denudement (and severe IAD); and IAD with Candida skin infection to test his or her ability to identify these conditions. Each nurse had to score 100% to pass and to ensure interrater reliability. In addition, each nurse on the unit was required to complete the online National Institutes of Health Office of Extramural Research program and submit a copy of the certificate to the unit manager.

The skin care protocol established for the perineal skin for patients enrolled in the study was performed every 12 hours and as needed for the control group and every 6 hours and as needed for the intervention group. The protocol consisted of gently cleaning the skin with a cleanser containing aloe vera mixed with water and a cleansing lotion. After cleaning, the skin was patted dry. If no erythema of the skin was present, a moisture barrier with silicone was applied. If the patient had any erythema, a skin protectant with zinc oxide and menthol was applied to the skin. All four products cost about $10 per patient. Each nurse documented the skin care protocol in the computerized documentation system and on a sheet of paper above the computer in each patient's room that had the protocol written in detail for the patient's assigned treatment group.

During the study, some nurses who cared for the study patients were not in the original group that had received formal instructions. During change-of-shift report, these nurses were informed of the patient's assigned skin care protocol. Specific written instructions were also highlighted in the patient's room above the computer where medications were dispensed.

A signed patient consent form was required for patients to be enrolled in the study. Random assignments were made every other day; assignments were marked on a monthly calendar located in a central location on the unit. Patients were enrolled in the study after arriving at the PCU and then terminated from the study upon transfer to another unit, discharge home, discharge to another facility, or death. On admission and upon leaving the PCU, the skin condition was recorded, as were the serum albumin and total protein levels, Braden score, diet, type of incontinence, previous location of the patient (such as the ICU, home, or a skilled nursing facility), and primary admitting diagnosis.28 Permission was obtained from Brown to use a revised data collection tool to record the data and Braden scores for each patient upon admission and discharge from the study.22,27

Figure

Figure

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Data analysis

All data were entered into Statistical Package for the Social Sciences. Before this study, IAD was underreported on this unit: only two cases were reported in 2011 on the PCU. According to Dr. Gray (2013, e-mail) no benchmark presently exists for IAD in the PCU population, so the best comparison is an estimated range documented from CCUs that range from 27% to 42.7% in reports from the literature.5 Analysis of the descriptive statistics collected from each group and the mean for each item were compared by a paired t test, then assessed for statistical significance.

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Results

The sample size included 99 patients. The average age (in years) for the intervention group (N = 55) was 75 and for the control group (N = 44) was 67. (See Looking at gender and Comparing types of incontinence for further information.) The primary diagnosis for both groups was acute respiratory failure. (See What were the primary diagnoses?) The intervention group had statistically significantly (P < 0.001) more patients receiving enteral nutrition (21.8%) compared with the control group (5.5%). In comparison, the control group had statistically (P < 0.001) more patients on pureed diets (23.6%) compared with the intervention group (3.6%). (See Focusing on diet.) At the conclusion of the 9-month study in the PCU, the intervention group (skin protocol every 6 hours and p.r.n.) had statistically less (P < 0.001) moderate IAD, 7.1%, than the control group (skin protocol every 12 hours and p.r.n.), 10.9%. (See Comparing intervention and control group outcomes and IAD type on admission and discharge from study for specific results.)

Figure. C

Figure. C

Figure

Figure

Variables presenting risks that were present on admission and discharge included hypoalbuminemia and hypoproteinemia, except for the intervention group on admission.26 On admission, the intervention group's mean albumin level was 2.7 g/dL and the control group's mean level was 2.8 g/dL. Scores from the Braden scale assessment when enrolled in the study were on average 15 for the intervention group and 14 for the control group. These scores indicate patients in both groups were at moderate risk for developing a PU according to the Braden scale.

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Discussion and limitations

Minimal controlled clinical trial data about IAD in PCU patients can be found in the literature. Our study did have statistically improved results at time of discharge in the moderate IAD category for the intervention group, but not in the mild or severe categories. This study, comparing two frequencies of a defined skin care protocol in patients at high risk for IAD, indicated no significant difference in the prevalence of mild or severe IAD. Patients who received the intervention four times daily were significantly less likely to develop severe IAD than patients with moderate IAD who were treated twice daily. The findings revealed the intervention groups had 21.8% (P < 0.001) of patients on enteral nutrition (EN)compared with the control group, which had 5.5%. EN is known to contribute to diarrhea or loose stools.10,26 In total, 60% of the patients were transferred from the ICU to the PCU, reinforcing the fact that these patients are critically ill. The cleansing and barrier products used in the study protocol were approved by the hospital's wound care specialist and met the evidence-based criteria from the literature for effectiveness for patients with incontinence and those with IAD.

This study indicates that the frequency of a structured skin care protocol administered every 6 hours and p.r.n. (twice as often as the present standard of care) can be effective in reducing moderate IAD, especially for patients who are at high risk. Educating the nursing staff about how to differentiate the stages of IAD, Candida skin infection, and PUs ensured proper skin care and documentation.

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Conclusions and recommendations

The results of our study corroborate the findings of other investigators; that is, hypoalbuminemia, low serum total protein level, and type of diet have an impact on the risk and development of IAD in patients who are incontinent.20,27 The intervention group had statistically more patients on EN than the control group (P < 0.001), and the mean age was 7 years older. EN predisposes patients to loose and frequent stools. In addition, fecal incontinence is more damaging to the skin than urinary incontinence. Therefore, EN is likely a causative factor that may have impeded the prevention and reduction of all levels of IAD (except moderate, which showed significant reduction) in the intervention group.

Because the three most common primary admitting diagnoses were acute respiratory failure, altered mental status, and pneumonia, obtaining informed consent from these patients was difficult. For patients who could not provide informed consent for themselves, informed consent was obtained using an approved procedure, which included but was not limited to a durable power of attorney (for example, spouse, family member, or significant other). Patients for whom informed consent could not be obtained were excluded from the study.

Figure. F

Figure. F

Table C

Table C

In the literature, impaired oxygenation has been reported to be a factor contributing to IAD.10,21 Altered mental status leads to immobility, which together with urinary and especially loose stool incontinence, puts patients at risk for IAD. Our data reinforced the importance of educating nursing staff so that the inflammation (or erythema) of IAD can be correctly differentiated from PUs because each calls for a different treatment modality.

Table IAD

Table IAD

The skin care protocol frequency remains every 12 hours and as needed, due to lack of statistically supporting data in mild and severe IAD. Further research is needed to determine the most effective frequency of skin care to prevent and reduce the severity of IAD in these high-risk patients. The astronomical cost of hospitalization and healthcare delivery calls for an effective evidence-based skin care intervention for this potentially serious skin condition. Ultimately, the immeasurable benefit to patients who are at risk for IAD or have IAD, is the reduction of suffering, morbidity, and mortality.

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* Mikel Gray, PhD, FNP, PNP, CUNP, CCCN, FAANP, FAAN, professor and NP, Department of Urology and School of Nursing, University of Virginia, Charlottesville.
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Deutschman CS, Ahrens T, Cairns CB, Sessler CN, Parsons PE Critical Care Societies Collaborative/USCIITG Task Force on Critical Care Research. Multisociety task force for critical care research: key issues and recommendations. Am J Crit Care. 2012;21(1):15–23.

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