nix gray iad wocn final (10-20-2015) - sage products · 10/20/2015 1 from hygienic task to...

10/20/2015

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From Hygienic Task to Preventive Intervention: Preventing and

Managing Incontinence Associated Dermatitis in the Critical Care Unit

Presented by:

Denise Nix, MS, RN, CWOCN

Mikel Gray, PhD, FNP, PNP, CUNP, CCCN, FAANP, FAAN

October 21, 2015

1 pm EDT

Objectives

• Review etiology and epidemiology of IAD in the critical care unit.

• Discuss the natural history of IAD in the acute and critical care settings and its relationship to pressure ulcer risk.

• Identify strategies to prevent IAD in the critical care unit, and its incorporation into preventive care bundles for hospital acquired pressure ulcers and catheter associated urinary tract infection.

• Outline strategies for managing IAD in the critical are unit, including strategies for containing urinary and fecal incontinence.

Definition: Incontinence Associated Dermatitis (IAD)

• Irritation and inflammation associated with

exposure to stool or urine

• Often accompanied by erosion of the skin

• Sometimes accompanied by secondary cutaneous

infection (candidiasis)

Gray M, et al. J Wound Ostomy Continence Nurs. 2012;39(1):61-74.

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Etiology

• Two etiologic factors– Fecal incontinence

– Urinary incontinence

• Multiple possible risk

(associated) factors– Nutrition

– Acuity of illness

– Immobility

IAD: Etiologic Factors

• Stool: fecal enzymes– Proteases and lipases are pH sensitive

– Both destroy down principal elements of skin’s

moisture barrier (proteins and fats)1,2

– In vivo evidence shows that exposure to digestive

enzymes in human skin leads to3

• ↑ TEWL

• ↑ pH

– Damage is exacerbated with liquid stool (diarrhea)

1. Atherton DJ. Eur Academy Dermatology Venerology. 2001;15(Supp1):1.

2. Gray M. J Wound Ostomy Continence Nurs. 2004;31(1 Suppl):S2-9.

3. Anderson PH, et al. Contact Dermatitis. 1994;30(3):152.

IAD: Etiologic Factors

• Urine: hyperhydration, pH, mechanical effects– ↓ skin hardness, rendering it more susceptible to

friction, shear and erosion1-3

– Hyperhydration also ↑ pH of skin4

• ↑ permeability to pathogenic species

• ↑ activates/supports activity of lipases and proteases

– Effects exacerbated by saturated occlusive device such

as warp around incontinence brief

1. Berg W, et al. Pediatric Dermatology. 1986;3:102.

2. Leyden JJ, et al. Archives of Dermatology. 1977;113:1678.

3. Gray M. J Wound Ostomy Continence Nurs. 2004;31(1 Suppl):S2-9.

4. Zimmerer RE, et al. Pediatric Dermatology. 1986;3:95.

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• Junkin and Selekof: 22%-27% in multisite study of

three acute care facilities1

• National QI database with 3,884 patient

observations involving 424 acute care facilities – 1,716 were incontinent of urine or stool

• 57% had double incontinence (UI and FI)

• 27% had FI alone

• 15% had UI alone

– Prevalence of IAD: 24%

1. Gray M, et al. J Wound Ostomy Continence Nurs. 2012;39(1):61-74.

Epidemiology of IAD: Prevalence in Acute Care (includes critical care units)

Epidemiology of IAD: Prevalence in Acute Care (includes critical care units)

• National QI database (3,884 patient observations;

424 acute care facilities) – 60% of IAD ranked as mild

– 27% of IAD ranked as moderate

– 5% of IAD ranked as severe

• 74.7% of IAD was facility acquired

• Patients with double UI and FI were more likely to

develop UI than patients with FI or UI alone

(p<0.001)

Table from: Gray M, et al. J Wound Ostomy Continence Nurs. 2012;39(1):61-74.

Epidemiology of IAD: Incidence in Critical Care

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IAD and Pressure Ulcer Risk

• Association between these conditions is extremely

strong but precise nature of the relationship is not

entirely understood

• IAD vs. Stage II PU especially problematic1

• FI and double incontinence strongly associated

with PU risk, mixed evidence concerning UI alone2-6

1. Bates-Jensen BB. J Wound Ostomy Continence Nurs. 2009;36(3):277-84.

2. Maklebust J, Magnan MA. Advances in Wound Care. 1994;7(6):25.

3. Gunninberg L. Journal of Wound Care. 2004;13(7):286.

4. Fader M, et al. Journal of Clinical Nursing. 2003;12(3):374.

5. Berlowitz DR, et al. Journal of the American Geriatrics Society. 2001;49(7):866-

71.

6. Narayan S, et al. J Wound Ostomy Continence Nurs. 2005;32(3):163.

IAD and PU Risk: Multisite National Database Analysis


424 acute care facilities) – Relationship of IAD to all sacral pressure ulcers (Stage

II-IV, unstageable), based on modeling using logistic

regression• Incontinence was not associated with PU occurrences

• Persons with IAD were more likely to develop PU than those

without IAD and immobility (OR=4.56; 95% CI 3.68-5.65)

• IAD was associated with greater likelihood of developing any

PU, even when analysis adjusted for immobility (35.4% vs.

12.4%, p<0.001)

IAD and PU Risk: Multisite National Database Analysis


424 acute care facilities) – Relationship of IAD to full thickness pressure ulcers

(Stage III-IV, unstageable), based on modeling using

logistic regression• Persons with IAD were more likely to develop a full thickness

sacral pressure ulcer (OR=2.65, 95% CI 1.74-4.03)

• Persons with IAD were more likely to develop a full thickness

PU than were persons without IAD, even when controlling for

immobility (6.9% vs. 3.3%, p<0.001)

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IAD: Diagnosis

• Diagnosis primarily based on visual inspection – Inflammation (bright red) in

persons with lighter skin tones – Located in skin fold or

underneath containment device

– Borders are poorly demarcated and irregular

– Surface of skin may “glisten” owing to serous exudate

IAD: Diagnosis in persons with Darker Skin Tones• Inflammation not readily

apparent (i.e., not bright red when confined to epidermal layer); often seen as areas of hyperpigmentation or variable red tones

• Hypopigmented areas with chronic inflammation

• Pattern of skin damage does not vary

IAD: Diagnosis

• Inspect Skin Folds – Opposing skin surfaces trap

and harbor moisture

– Warm moist environment

encourages bacterial and

fungal colonization,

overgrowth and infection

– Friction occurs as skin folds

rub against one another

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IAD: Diagnosis

• Assess for skin erosion– Partial thickness

erosion occurs with IAD

– Necrotic tissue: eschar

or slough, full thickness

damage indicates

pressure ulceration

IAD: Diagnosis

• Look for secondary cutaneous infection, especially candidiasis– Opportunistic infection

with candida albicans

– Thrives in warm, moist environment and damages stratum corneum

– Seen in 18% of one group of 976 acute care inpatients1

1. Junkin J, Selekof J. J Wound Ostomy Continence Nurs. 2007;34(3):260-9.

Black JM, et al. J Wound Ostomy Continence Nurs. 2011;38(4):359-70.

IAD: Diagnosis

• Suspect PU when

wound– Lies over bony

prominence

– Has distinctive borders

– Full thickness

– Necrotic tissue (black

eschar) is present

– Skin is dark to purplish

red

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IAD Diagnosis: History is Essential

• Emerging evidence

reminds us that

isolated photographs

do not reflect clinical

reality

• The biggest aid in this

case is a thorough

history

Differential Diagnosis: IAD vs. PU

Black JM, et al. J Wound Ostomy Continence Nurs. 2011;38(4):359-70.

Borchert K, et al. J Wound Ostomy Continence Nurs. 2010;37(5):527.

IAD and its Severity Instrument

• Designed and validated by WOC nurses and their faculty

• Two WOC nurses established initial face validity• Content and criterion validity via 9 WOC nurses in

North Central Region of the WOCN Society• Interrater reliability via 247 WOC nurses attending

2007 National Conference • Descriptive, ranks severity allowing longitudinal

assessment; responsiveness has not yet been tested

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Does Technology Play a Role?

• Three technologies have been proposed to

enhance diagnosis at the bedside

• All attempt to aid clinician to differentiate “bottom

up” damage from “top down” damage such as

exposure to urine/stool– High Resolution Ultrasonography

– Subepidermal moisture detection

– Thermal imaging

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1. Quintavalle PR, et al. Advances in Skin & Wound Care. 2006;19(9):498.

High Resolution Ultrasound

• Study using high resolution ultrasound showed

differences in appearance of normal volunteers

and NH residents with Braden scores ≤ 18

Sub-Epidermal Moisture Measurement• Employs small wand that measures

SEM when attached to the skin for several seconds

• Generates a number called DPU (dermal phase unit) ranges from 0-999; no standard unit attached

• Differentiated Stage I PU vs. erythema in 31 residents in 2 NH1

• ↑ SEM associated with 8.5-15 fold increase in Stage I and Stage II PU in 66 subjects with darker skin tone2

1. Bates-Jensen BM, et al. Wound Repair & Regeneration. 2008;16:189.

2. Bates-Jensen BM. J Wound Ostomy Continence Nurs. 2009;36(3):277-84.

1. Andersen ES, Karlsmark T. Skin Research & Technology. 2008;14(3):270-6.

Thermography

• Thermography evaluates local tissue circulation by visualizing temperature of targeted tissue1

• Sparse evidence suggests it does not characterize severity but may differentiate PU from MASD, and may be useful for prediction of SDIT progression

• Imaging system recently approved for use by United States FDA (early 2015); device weighs about 2 pounds; attached to laptop computer

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IAD Prevention and Management

• Identify/treat reversible causes of

incontinence

• Structured skin care regimen– Cleanse and protect

– Restore (moisturize) as indicated

– Contain as indicated

• Education and collaboration– Overlapping bundles:

– CAUTI (C), HAPU (P), and Falls (F)

Address Reversible Causes of Incontinence!

• Restricted mobility or dexterity (F, P, C)

• Psychological conditions/delirium (F, P, C)

• Stool impaction or constipation (F, P, C)

• Urinary retention (C, P)

• Pharmaceuticals (F, P, C)

• Infection (F, P, C)

Willson M, et al. Executive summary: a quick reference guide for managing FI. J

Wound Ostomy Continence Nurs. 2014;41(1): 61-9.

• Scheduled assistance with urinal, bedpan, or

commode

• As normal of a position as possible– Commode preferable to bedpan

– Toilet preferable to commode

– Male and female urinals

Restricted Mobility/Dexterity

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Diarrhea in Critical Care

• Incidence 14-15%1,2

• Linked to– increased LOS1

– significant mortality and morbidity1,2

• Several Types/causes– osmotic– secretory– exudative– motility disorders– infections

1. Marcon A, et al. Nosocomial diarrhea in the intensive care unit. Braz J Infect

Dis. 2006;10(6)6:384-389.

2. Thibault R, et al. Diarrhoea in the intensive care unit: respective contribution

of feeding and antibiotics. Crit Care. 2013;17(4):153.

Infection Induced Diarrhea

• C. difficile = most common HA diarrhea1,2

• 20-40% of hospitalized patients1

• 5-30% suffer relapse1

• Early identification/culture1,2

• Prevent transmission!1,2

1. Willson M, et al. Executive summary: a quick reference guide for managing FI.

J Wound Ostomy Continence Nurs. 2014;41(1):61-9

2. http://www.msnbc.msn.com/id/27633551/ns/health-health_care/t/nasty-

intestinal-bug-spikes-us-hospitals/

Antibiotics

Medication Induced Diarrhea

Willson M, et al. Executive summary: a quick reference guide for managing FI. J

Wound Ostomy Continence Nurs. 2014;41(1):61-9.

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• Incidence of constipation in ICU up to 70-83%1,2

• Linked to failure to wean, increased LOS, and

delayed enteral feeding1,2

• Evaluate history and symptoms� Continuous leaking of stool � Continuous urge to defecate� Restlessness and agitation � Hydration� Medications (opioids, diuretics, CA channel blocker,

CNS depressants)� Rectal exam

Stool Impaction/Constipation

1. Nassar AP, et al. Constipation in intensive care unit: incidence and risk

factors. J Crit Care. 2009 Dec;24(4):630

2. Mostafa SM, et al. Constipation and its implications in the critically ill patient.

Br J Anaesth. 2003;91(6):815–819.

ICU Bowel Management Protocols

• Ferris & East (2007) 13% � diarrhea, 8% � ICU

days1

• McPeake, et al. (2011) 20.7% �constipation,

15.2%� diarrhea2

• Knowles, et al. (2014) no change in practice

despite education sessions, printed facts sheets

and reminders3

1. Ferris S, East V. Managing diarrhoea in intensive care. Aust Crit Care.

2007;20(1):7-13.

2. McPeake J, et al. The implementation of a bowel management protocol in an

adult intensive care unit. Nurs Crit Care. 2011;16(5):235-42.

3. Knowles S, et al. Evaluation of the implementation of a bowel management

protocol in intensive care: effect on clinician practices and patient outcomes. J

Clin Nurs. 2014;23(5-6):716-30.

ICU Bowel Management Protocol

Pittman J, Beeson T, Carter B, Terry C. Implementation of a bowel management

program in critical care. J Wound Ostomy Continence Nurs. 2015;42(4):389-394.

• Effectiveness of education

• 6 critical care units and 230 nurses – web-based module

– unit based skills session/competency

– Self efficacy scores

• Significant (P<.001) improvement in knowledge

and self efficacy scores

• Enhanced collaboration with the WOC nurses/CNS

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Skin Care

• Cleanse

• Restore (if indicated)

• Treat infection (if indicated)

• Protect

• Contain (if indicated)

Safe and Gentle Cleansing (P, C)

• Specifically indicated for continence care

• Low dermatitis potential (hypoallergenic)

• pH alkaline similar to normal skin

• No-rinse skin cleanser; liquid or wipe

• Minimal friction, rubbing

• Soft, disposable non-woven cloth

• Dry skin if needed after cleansing

Beekman D, et al. Wounds International. 2015. www.woundsinternational.com

Doughty D, et al. J Wound Ostomy Continence Nurs. 2012;39(3):303-15.

Avoid

• Bar Soap– Bacteria, pH

• Basins– Bacteria

• Fragrance– Sensitivities

• Regular Washcloths – Friction

• Antibacterials– Normal flora, pH, sensitivities



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Antibacterials and CAUTI

• CDC and CAUTI1

– Use routine hygiene while catheter in place– Routine antimicrobial prophylaxis NOT

recommended– Cleaning periurethral area with antiseptics NOT

recommended

• Dedicated meatal cleansing? – One option to prevent cross contamination– Choose products that are pH balanced and without

antiseptics

1. http://www.cdc.gov/hicpac/cauti/001_cauti.html

Moisturize/Restore as Needed

• Prevents TEWL and dryness

• Not indicated for overhydrated or maceration skin

• No need for another product IF cleanser or barrier

contains moisturizer ingredient– Emollients smooth and soften skin (e.g., oils and

synthetics)

– Humectants draw and hold water in the stratum

corneum (e.g., urea and glycerine)

– Lipids (e.g., ceramides)



Skin Protectants/Moisture Barriers

• Knowing about a protectant ingredient is useful (e.g., Petrolatum, Dimethicone, Zinc Oxide)

• Total formulation MORE important– Creams/ointments (oils/lipid + water)

– Pastes (ointment + absorbent powder adheres to wet,

weepy skin)

– Films (liquid + polymer dissolved in a solvent applied

with wand or spray)



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Protectant Ingredients

• Petrolatum– Occlusive, transparent, increases skin hydration, may impair fluid

uptake of absorbent pads/briefs, often found in combination with

Zinc or Dimethicone

• Dimethicone silicone (siloxane)– Non-occlusive, transparent

• Zinc oxide– Opaque/white, requires remove for skin inspection

• Acrylate terpolymer film– Liquid transparent film, dissolved in solvent for delivery then

dries, does not moisturize, fewer applications if compatible skin

cleanser used



Protectant Ingredients

• Hoggarth, et al. 2005

• Dimethecone hydrates > petrolatum

• Petrolatum macerates > dimethecone

• Zinc associated with more irritation than others

• Interpret with caution!– Applied under occlusive tape

– On healthy forearms

Hoggarth A, et al. A controlled, three-part trial to investigate the barrier function

and skin hydration properties of six skin protectants. Ostomy Wound Manage.

2005;51(12):30-42.

Ideal* Skin Protectant/Moisture Barrier

� Waterproof to protect repel moisture/irritants� Stays in place on the skin� Long lasting, durable� Breathable to prevent maceration� Easy to apply/remove or no removal required � Comfortable, no sting� Able to observe skin through the barrier

* If not ideal, how will you compensate?



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Treat Candidiasis When Present

• Do not treat prophylactically

• Clotrimizole/Miconizole common choices in

absence of lab test (broad spectrum and low cost)

• Available in powders, sprays, ointments, creams or

antifungals/moisture barriers combined

• If not combined; apply antifungal followed by

moisture barrier

• Occasional need for systemic antifungals

Nix D, Haugen V. Prevention and management of incontinence-associated

dermatitis. Drugs Aging. 2010;27(6):491-96.

IAD Skin Care

Intact no redness

Prevention with _________

(e.g., 3 and 1 product)

Moderate to severe nonintact

weepy, denuded _________

(e.g., Paste, Spray Film,

Containment device)

Candidiasis erythema satellite

lesions _________

(e.g., antifungal followed by

skin protectant)

Intact mild red OR anticipated

diarrhea- add additional

protection _________

(e.g., ointment)

Reassessment

• Expect improvement in 2-3 days

• If no improvement:– Ensure plan of care is in place

• If compliance is an issue, don’t ask what’s wrong with the

patient or staff before asking “what’s wrong with the plan?”

– Re-evaluate differential diagnosis

– Adjust plan of care

– Keep it simple, save time



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Save Time, Improve Compliance

• No rinse cleansers• Moisturizing cleanser and skin protectant

incorporated into a spray• Cleanser, moisturizers, and skin protectant

incorporated into a disposable cloth• Antifungal and skin protectant combined into an

ointment or cream• Products that require fewer applications• Containment devices (external pouches and FDA

approved indwelling devices)



External Pouches

• Pouches with attached adherent solid skin barrier

• Clamp or attach to drainage

• Skin under adhesive must be moisture and and an

and emollient free

• As needed – cut larger opening, dust denuded

weepy areas with ostomy powder and add ostomy

paste for better seal and/or add barrier film to

protect exposed skin, LET IT DRY)

Beitz JM. Fecal incontinence in acutely and critically ill patients: options in

management. Ostomy Wound Manage. 2006;52(12):56-8, 60, 62-6.

FDA Approved Indwelling Fecal Devices• Inserts into rectum

• Closed system diverts stool away from skin

• Saves time, skin, and spread of C-diff

• Use with moisture barrier in case of leakage

• Critical to know indications and

contraindications for safety

• Complications include mucosal injury, lower GI

bleeding, temporary anal sphincter atony

• Complication rate correlates with length of

time used

Beitz JM. Fecal incontinence in acutely and critically ill patients: options in

management. Ostomy Wound Manage. 2006;52(12):56-8, 60, 62-6.

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Absorptive Pads/Briefs: Complaints

• Traps moisture

• Increases perspiration

• Increases pH

• May impair pressure redistribution capacity of

some products

• Product clogged/less effective due to moisture

barrier ointments

• Look alike pads not intended for incontinence use

Langemo D, et al. Adv Skin Wound Care. 2011;24(3):126-40.

Gray M, et al. J Wound Ostomy Continence Nurs. 2012;39(1):61-74.

Zimmerer, et al. Pediatric Dermatol. 1986; 3:95-101.

Fader M, et al. Cochrane DataBase Syst Rev. 2008.

• High absorbent polymers “wick”

moisture off skin1

• Maintain acidity of skin pH2

• More sizes for better fit and less leakage2

• Breathable/air permeable materials1,2

• Microclimate Disposable Body Pad

Absorptive Pads/Briefs: Improving

1. Palese A, Carniel G. The effects of a multi-intervention incontinence care program on

clinical, economic, and environmental outcomes. J Wound Ostomy Continence Nurs.

2011;8(2):177-83.

2. Beguin AM, et al. Improving diaper design to address incontinence associated

dermatitis. BMC Geriatrics. 2010;10:86.

Special Populations

• Bariatric– Assist to lift panniculus/pannus for urinal

placement

– Commode with size and weight specifications

for safety

– Elbow length gloves

• Neonatal– Sensitivities

– Transcutaneous absorption

Gallagher S. Skin Care Needs of the Obese, Nix, et al. Skin Care Needs of the

Neonatal and Pediatric patient, Bryant R, Nix D. Coeditors: Acute and Chronic

Wounds: Current Management Concepts, 5th Edition. St. Louis, Mosby, 2015 In

Print.

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Education (F, P, C)

• Leaders, KOL, and IT for overlapping bundles– Infection control, Falls committee, CAUTI Champions

• Materials Management– Quality and accessibility of products

• Patients and Family

• Clinical Staff AND Administrators

• Build your case!

THANK YOU!

nix gray iad wocn final (10-20-2015) - sage products · 10/20/2015 1 from hygienic task to...

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