Efficacy of Incontinence-Associated Dermatitis Intervention for Patients in Intensive Care: An Open-Label Pilot Randomized Controlled Trial.

OBJECTIVE: To determine the feasibility of an adequately powered trial testing a long-acting cyanoacrylate skin protectant to prevent incontinence-associated dermatitis in critically ill patients. METHODS: This open-label pilot randomized controlled feasibility study was conducted in the adult ICU of an Australian quaternary referral hospital. Patients were allocated to either an intervention group or a control group (usual care). The intervention was the application of a skin protectant (a durable, ultra-thin, transparent, waterproof, no-removal barrier film). Data collected by trained research nurses included demographic and clinical variables, skin assessment, and incontinence-associated dermatitis presence and severity. Data were analyzed using descriptive and inferential statistics. RESULTS: Of the 799 patients screened, 85% were eliminated because of a short ICU stay or other exclusion criteria. The mean proportion of patients not meeting any of the exclusion criteria was 22% on each screening day. Protocol fidelity was followed for 90% of intervention participant study days. Retention of participants was 86% (31 participants out of 36), 15 in the intervention group and 16 in the control group. Enrolled patients had a mean age of 59 years, 50% were obese, 67% were male, and 36% were smokers. Two patients (11%) in the intervention group developed incontinence-associated dermatitis, compared with three (17%) in the control group. CONCLUSIONS: This study reports no significant findings between the two groups. Difficulty in recruitment and feasibility issues might be overcome with changes to inclusion criteria and study design.

Moisture-associated skin damage: an overview of its diagnosis and management.

This educational article introduces an explores moisture-associated skin damage (MASD) and the four forms it manifests as, namely, incontinence-associated dermatitis; intertriginous dermatitis; peristomal moisture-associated dermatitis; and peri-wound moisture-associated dermatitis. The aetiology and predisposing factors of each form are critically discussed, in addition to the treatments and interventions that can be used by nurses to support patient recovery. Nurses and other health professionals working with patients who are at risk of skin damage or who already require wound care, must be knowledgeable about all aspects of MASD. Fortunately, a plethora of evidence-based literature exists to support health professionals in their practice, although validated assessment and recording tools for incontinence-associated dermatitis are limited.

How to manage incontinence-associated dermatitis in older adults.

An estimated 14 million adults experience incontinence in England alone, and this population is at a very high risk of developing incontinence-associated dermatitis (IAD). The risk associated with developing IAD is further increased among older adults, due to the effects of the ageing process, which leave the skin thinner and more fragile. Understanding the causative factors of IAD in addition to understanding the impact of IAD on the skin enable the clinician to make informed choices regarding treatment, management and prevention. Additionally, understanding the association between IAD and pressure ulcers is a critical component of IAD management, as IAD and pressure ulcers often coexist or develop alongside each other.

Peristomal Moisture-Associated Skin Damage and Independence in Pouching System Changes in Persons With New Fecal Ostomies.

PURPOSE: The purpose of this study was to evaluate factors related to peristomal moisture-associated skin damage (MASD) in patients who underwent ostomy surgery because of colorectal cancer, and their independence in pouching system changes. Findings were used to determine pre- and postsurgical care for these patients. DESIGN: Retrospective review of medical records. SUBJECTS AND SETTING: The study setting was an 800-bed hospital in metropolitan Tokyo, Japan. The sample comprised 89 patients (median age: 65 years; male vs female: 58 vs 31) who visited a stoma clinic within 8 weeks of ostomy surgery. Fifty-two subjects had ileostomies and 37 had colostomies; data were collected between January 2008 and July 2014. METHODS: Data were collected from outpatient and inpatient records. Potential relationships between MASD and independence in pouching system changes were evaluated via univariate tests to identify possible associations, followed by logistic regression analysis. RESULTS: Patients living with an ileostomy were more likely to experience peristomal MASD than were patients living with a colostomy (odds ratio [OR] = 3.782; 95% confidence interval [CI]: 1.34-10.64; P = .012). Analysis also found that patients with postsurgical chemotherapy were more than 2.5 times more likely to experience peristomal MASD than patients who did not require postoperative chemotherapy (OR = 2.702; 95% CI: 1.02-7.18; P = .046). We also found that patients 65 years or older were significantly more likely to have difficulty in changing their pouching system than were younger patients (OR = 7.193; 95% CI: 2.21-23.41; P = .001), as were those with diabetes mellitus (OR = 11.842; 95% CI: 2.56-54.77; P = .002). CONCLUSIONS: Patients undergoing ileostomy and those receiving postoperative chemotherapy are more likely to experience peristomal MASD. Older patients (>65 years) and those with diabetes mellitus are less likely to achieve independence. These findings influenced our management of persons undergoing ostomy surgery for management of colorectal cancer in our clinic. We recommend additional research using a larger and more diverse sample to confirm our findings.

[Avoiding peristomal skin problems]. / Éviter les problèmes cutanés péristomiaux.

Peristomal irritation is one of the most common complications in patients with a stoma. In many cases, prevention is limited to the care provided during the post-operative period. However, it can start before the operation by improving the physical condition of the patient. It continues during the perioperative period with the surgical technique. Prevention advice can be given during these three key stages of the patient's treatment.

North America Wound, Ostomy, and Continence and Enterostomal Therapy Nurses Current Ostomy Care Practice Related to Peristomal Skin Issues.

PURPOSE: The purpose of this study was to describe the practice of 796 ostomy nurses in North America in 2014 related to peristomal skin issues. DESIGN: Descriptive study. SUBJECTS AND SETTING: Participants were 796 wound, ostomy, and continence (WOC) and enterostomal therapy (ET) nurses currently practicing in the United States or Canada and caring for patients with ostomies. The collection of data occurred in conjunction with an educational program on peristomal skin complications and practice issues and solicited the participant's perception on the incidence and frequency of peristomal skin issues as well as on practice patterns. METHODS: Participants attended an educational program. They were also asked to anonymously respond to multiple-choice questions on ostomy care management via an audience response system followed by discussion of each item and their responses. This descriptive study reports on the answers to the questions as well as the pertinent discussion points. RESULTS: Participants estimated that approximately 77.70% of their patients developed peristomal skin issues. The most commonly encountered problem was irritant contact dermatitis (peristomal moisture-associated skin damage). Contributing factors were inappropriate use of a pouching system owing to lack of follow-up after hospital discharge. Reported interventions for the prevention and management of peristomal skin issues included preoperative stoma site marking, use of a convex pouching system, and barrier rings. However, subsequent discussion revealed that the frequency of use of these products varied considerably. Participants identified shortened hospital stays, absence of preoperative stoma marking, and limited outpatient follow-up as contributing to development of peristomal skin problems. CONCLUSION: WOC and ET nurses estimate that more than three-quarters of persons living with an ostomy develop peristomal skin problems. Multiple interventions for managing these problems were identified, but some variability in management approaches emerged.

An interventional skin care protocol (InSPiRE) to reduce incontinence-associated dermatitis in critically ill patients in the intensive care unit: A before and after study.

AIM: This study aimed to test the effectiveness of a bundle combining best available evidence to reduce the incidence of incontinence-associated dermatitis occurrences in critically ill patients. METHODS: The study used a before and after design and was conducted in an adult intensive care unit of an Australian quartenary referral hospital. Data, collected by trained research nurses, included demographic and clinical variables, skin assessment, incontinence-associated dermatitis presence and severity. Data were analysed using descriptive and inferential statistics. RESULTS: Of the 207 patients enrolled, 146 patients were mechanically ventilated and incontinent thus eligible for analysis, 80 with 768days of observation in the after/intervention group and 66 with 733days of observation in the before group. Most patients were men, mean age 53 years. Groups were similar on demographic variables. Incontinence-associated dermatitis incidence was lower in the intervention group (15%; 12/80) compared to the control group (32%; 21/66) (p=0.016). Incontinence-associated dermatitis events developed later in the intensive care unit stay in the intervention group (Logrank=5.2, p=<0.022). CONCLUSION: This study demonstrated that the use of a bundle combining best available evidence reduced the incidence and delayed the development of incontinence-associated dermatitis occurrences in critically ill patients. Systematic ongoing patient assessments, combined with tailored prevention measures are central to preventing incontinence-associated dermatitis in this vulnerable patient group.

Management of irritant contact dermatitis and peripherally inserted central catheters.

Cutaneous skin changes are common in patients undergoing treatment for cancer. However, changes in central line care, maintenance practices, and chemotherapy protocols in the early 2000s may have led to the development of a common problem of irritant contact dermatitis (ICD) at peripherally inserted central catheter (PICC) insertion sites. Repeated exposure to chlorhexidine gluconate topical antiseptic solution, used in the general dressing care and maintenance with PICCs, may be the leading contributor to the development of ICD at the insertion site. A number of additional factors theoretically contribute to the development of ICD at the PICC insertion site in patients receiving chemotherapy. In this article, ICD will be defined, incidence and potential risk factors will be identified, and diagnostic framework will be explored; in addition, pathophysiology, onset, presentation, evaluation, and differential diagnosis of ICD at PICC sites will be analyzed. Finally, a synopsis of three different treatment approaches from healthcare facilities in Canada as well as implications for nursing practice and research will be presented.

MASD part 2: incontinence-associated dermatitis and intertriginous dermatitis: a consensus.

A consensus panel was convened to review current knowledge of moisture-associated skin damage (MASD) and to provide recommendations for prevention and management. This article provides a summary of the discussion and the recommendations in regards to 2 types of MASD: incontinence-associated dermatitis (IAD) and intertriginous dermatitis (ITD). A focused history and physical assessment are essential for diagnosing IAD or ITD and distinguishing these forms of skin damage from other types of skin damage. Panel members recommend cleansing, moisturizing, and applying a skin protectant to skin affected by IAD and to the perineal skin of persons with urinary or fecal incontinence deemed at risk for IAD. Prevention and treatment of ITD includes measures to ensure that skin folds are dry and free from friction; however, panel members do not recommend use of bed linens, paper towels, or dressings for separating skin folds. Individuals with ITD are at risk for fungal and bacterial infections and these infections should be treated appropriately; for example, candidal infections should be treated with antifungal therapies.

Incontinence-associated dermatitis in critically ill adults: time to development, severity, and risk factors.

PURPOSE: The purpose of this study was to determine the time to development, severity, and risk factors of incontinence-associated dermatitis (IAD) among critically ill patients with fecal incontinence. SUBJECTS AND SETTING: Forty-five patients with a mean age of 49.4 ± 18.5 years (mean ± SD) in the surgical/trauma critical care unit (ICU) of 1 of 3 urban hospitals who were free of any perineal skin damage at study start participated in the study. The majority (76%) were male. METHODS: Surveillance of skin for IAD and chart review of data initially and daily. RESULTS: Incontinence-associated dermatitis developed in 36% of patients. The median time to onset of IAD was 4 days (range, 1-6). Eighty-one percent of patients still had IAD at discharge from the ICU and at the end of their surveillance (median time = 7 days, range, 1-19 days). The severity of erythema associated with IAD was mild, moderate, or severe for 13%, 11%, or 4% (means) of the time patients were observed. Denudement occurred 9% of the observed time. Frequent incontinence of loose or liquid stools and diminished cognitive awareness were significant independent risk factors for development of IAD sooner. CONCLUSION: Incontinence-associated dermatitis develops in critically ill patients with fecal incontinence relatively quickly and does not resolve in most before their discharge from the ICU. Early monitoring and prevention of IAD, especially in patients with diminished cognition or with frequent leakage of loose or liquid feces, are recommended to promote skin health.

Early Peristomal Skin Complications Reported by WOC Nurses.

PURPOSE: The range of peristomal skin complications reported in the literature varies from 10% to 70%. Inconsistent terminology as well as a lack of a standardized tracking tool may account for this variability. The purpose of this study was to describe peristomal skin complications seen by WOC nurses over a 1-year period using a standardized data collection tool and using the peristomal terminology developed by the WOCN Society. METHODS: A prospective research design was used to describe peristomal skin complications of ostomy patients seen within the first 2 months of ostomy surgery by WOC Central Virginia Affiliate nurses. The WOC nurses completed a peristomal skin complication form on each ostomy patient that was seen within 2 months of the original ostomy surgery regardless of whether or not he or she had a peristomal complication. Descriptive statistics were used to summarize data. SUBJECTS AND SETTING: Twelve WOC nurses saw a total of 89 patients over a 12-month period. Subjects had a median age of 61 years (range, 1-91 years). The sample included 46 females and 43 males. All patients were seen in the central Virginia area. Thirty-two patients were seen in hospital, 31 were seen in a home health setting, and 26 were seen in outpatient clinic. RESULTS: Forty-two patients (47%) had peristomal complications. The types of ostomies seen were 37 colostomies, 33 ileostomies, and 15 urinary conduits. Thirty-one patients had chemical damage to the peristomal skin (irritant dermatitis), 5 had mechanical injury, and 4 had Candida infections, 1 had an allergic reaction, and another had pyoderma gangrenosum. CONCLUSIONS: Research studies that describe peristomal skin complications over time and over multiple settings are limited. A central data repository using a standardized tool may be one way to monitor them and then begin to look at standardized evidence-based peristomal skin care.

The incontinence-associated dermatitis and its severity instrument: development and validation.

PURPOSE: To develop and test the validity and interrater reliability of the Incontinence-Associated Dermatitis and its Severity Instrument, a novel tool describing incontinence-associated dermatitis and its severity. METHODS: Investigators consulted 2 certified WOC nurse experts to determine face validity of the instrument. Seven additional certified WOC nurses evaluated the tool for content validity. The instrument was tested for interrater reliability by attendees at the 2007 WOCN Society National Conference and employees at a health care system in Minnesota. Criterion validity was determined by comparing IAD severity scores of testers with those of the 2 WOC experts and PI. RESULTS: Consultants determined that the instrument had face and content validity. Two hundred forty-seven attendees at the WOCN Society's National Conference (mean nursing experience 25±9 years [mean±SD]), 100 nursing staff in Minnesota: 84 staff nurses (mean nursing experience 17±12 years), and 16 nursing assistants (mean nursing experience 7±7 years) determined that the instrument has content validity. There were no significant differences in scores of IAD severity for the 4 cases among the 3 types of testers (P>.05). Overall agreement between the 347 raters and the experts using intraclass correlation was 0.98 (P=.006). CONCLUSION: The Incontinence-Associated Dermatitis and its Severity Instrument demonstrated good validity and interrater reliability and its development fulfills an unmet need in both research and clinical practice settings.