Prevention of Incontinence-Associated Dermatitis in Nursing Home Residents
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Lambert D. Prevention of incontinence-associated dermatitis in nursing home residents. Annals of Long-Term Care: Clinical Care and Aging. 2012;20(5):25-29.
Della Lambert, BSN, RN, CWOCN
Ms. Lambert is in the FNP Program, School of Nursing, University of Cincinnati, OH.
Core Prevention Measures
Minimizing exposure time to urine and feces and implementing a structured skin care regimen are core IAD prevention measures found repeatedly throughout the literature.15 Beeckman and colleagues16 recommended using a pH-balanced skin cleanser, skin moisturizer, and moisture-repellent skin barrier for all residents at risk of IAD, noting that perineal skin cleansers or no-rinse foams are preferable to cleansing with traditional washcloths, soap, and water. Gray12 echoed these recommendations, adding that the cleansing product should not compromise the skin’s moisture barrier. Voegeli17 found that soap and water are most commonly recommended for general skin cleansing, but warned that they can be damaging to a patient with or at risk for IAD. Hodgkinson and colleagues15 performed a systematic review of the literature, and their conclusions support a structured skin care regimen using a no-rinse cleanser. They also concluded that some types of disposable briefs might prevent worsening of skin irritation.
Hunter and colleagues18 performed a quasi-experimental study to assess the effectiveness of skin care protocols on skin breakdown in two nursing homes. The study involved a 3-month preintervention assessment of skin breakdown, followed by a staff education program on using new skin care products (a no-rinse body wash and skin protectant), and then another 3-month assessment of skin breakdown after use of these products. Although both nursing homes reported a reduction in skin breakdown upon using the new skin care regimen, neither noted a significant enough reduction to reach statistical significance. This study included pressure ulcers, perineal dermatitis, cracks and fissures, skin tears, and blisters in the skin breakdown descriptions. When examining perineal dermatitis alone, there was a reduction in this condition from 15 residents before the intervention to eight residents afterward. Clinical guidelines issued by the National Pressure Ulcer Advisory Panel (NPUAP) and the Wound, Ostomy, and Continence Nurses Society suggest that a skin care program that includes cleansing and protecting the skin from incontinence is best for preventing pressure ulcers.19,20 Table 2 lists the prevention measures identified in this review and the number of articles recommending each intervention.
Patient Comfort, Quality of Care and Costs
Prevention of IAD has many practice implications for improving patient comfort and quality of care while reducing pressure ulcer development and costs. Facility-acquired pressure ulcers are considered to be a main quality indicator by regulatory agencies, such as CMS and The Joint Commission (formerly the Joint Commission Accreditation of Healthcare Organizations).3 IAD is usually a partial thickness injury that exposes the nerves in the dermis, causing burn-like pain. Frequent cleansing of the skin after incontinent episodes may also cause pain and can result in further injury if not performed carefully. Pain has been shown to increase morbidity and length of stay in the long-term care and acute care settings.13 Skin care protocols to prevent IAD may also reduce costs. Bliss and colleagues21 performed a multisite quasiexperimental study of four different skin care protocols in 981 nursing home residents to determine the cost and efficacy of these protocols. There was no significant difference in the protocols or the number of cases of IAD that developed. Cost savings were found with the use of an alcohol-free barrier film applied three times weekly. Guest and associates22 reviewed the literature on using a transparent barrier film dressing in IAD and found that it was more cost-effective than traditional daily applications of topical creams and ointments. In 2011, Palese and Carniel23 reported on the effects of an incontinence care program that included 63 nursing home residents. This program implemented the use of new products, educated staff on the proper use of these
products, and provided staff with access to a certified continence nurse. The authors acknowledged the limitation that the study’s sponsor had supplied the products. They reported that the program resulted in a decrease in risk factors for IAD and in direct costs. These findings reinforce the importance of providing staff education on preventing IAD.
Determining the etiology of skin breakdown by distinguishing between lesions caused by moisture, incontinence, pressure, shear, or friction aids in choosing the appropriate treatment and improves the quality of care and outcomes. Further, incorrectly diagnosing the cause of patients’ skin injuries can affect reimbursement, research, and mandatory reporting to regulatory agencies; thus, it is key to educate
staff about risk factors, prevention measures, use and cost of products, risk-assessment tools, and how to differentiate between types of skin injury.13 Recent risk-assessment tools, such as the Perineal Assessment Tool (PAT), have been developed to help prevent IAD by identifying residents at risk and beginning early intervention.14