REVIEW

Prevention of Incontinence-Associated Dermatitis in Nursing Home Residents: Page 3 of 3

May 16, 2012

Gap Analysis

A limited number of quality clinical studies have explored the prevention of IAD in nursing home residents. Almost half of the articles in this literature review were systematic reviews of the literature or reviews of expert opinions rather than clinical research. Some experts have written several articles over the years and continue to investigate IAD; 33% of the articles reviewed were written within the past 3 years, which attests to the importance and timeliness of this topic. However, the lack of high-quality studies makes it difficult to evaluate the effectiveness of the reported prevention protocols.

In general, there is a consensus in the literature that a skin care protocol is important for preventing IAD, but the wide range of products used in the reported studies and the use of the broad term skin protectant make it difficult to compare evidence-based outcomes. It would be beneficial if several studies had compared specific skin protectants (eg, zinc oxide with petrolatum) or different types of disposable briefs for reducing IAD.

 The gap in the variance of the prevalence of IAD reported ranged from 5.7% to more than 50%. Some studies included residents with either urinary or fecal incontinence and some included residents with both. In addition, methods used to identify IAD were inconsistent, leading to varied prevalence rates. The use of validated risk-assessment tools would be helpful in establishing an accurate prevalence rate.

Finally, as mentioned previously, various terms are used in the literature to describe IAD, including perineal dermatitis and the newer term moisture–maceration injury. Consistent terminology would make it easier to research the topic and improve the education of healthcare providers, as clear definitions are important for identifying the type of skin injury and implementing the correct interventions.

Future Research Suggestions

Clinical studies of IAD prevention, rather than only systematic reviews, are needed. These should include the evaluation of prevention protocols, staff education, and types of products used. Comparing traditional soap, water, and washcloth cleansing with one-step products would also be useful. For example, a study by Al-Samarrai and colleagues24 found that using a one-step incontinence cleansing system resulted in greater cleansing frequency and decreased the time spent on incontinence care. Several products have been shown to decrease cost, but they have not been thoroughly evaluated for efficacy or for their ability to decrease the prevalence of IAD.

Evaluations of various types of adult briefs and comparing briefs with underpads are other areas of research that would be useful for making practice decisions. Beguin and colleagues25 designed an adult brief that creates an acidic pH on the surface and airflow at the side panels to avoid maceration of the skin and decrease the occurrence of IAD. The authors evaluated the efficacy of these optimized briefs in 12 patients with preexisting IAD. Of these patients, eight had healed within 21 days of being switched to the optimized briefs. Fader and associates26 studied the effect on the skin of less frequent changes of adult briefs. The authors reported that although superabsorbent briefs are designed to keep residents drier, they can increase skin wetness if left on for an extended period. Although the findings did not reach statistical significance, the authors found that five of 81 individuals developed a stage II pressure ulcer during the less frequent pad-changing regimen. This finding warrants further research.

Use of validated measurement tools to evaluate the patient for IAD versus subjective data of the researcher is another area for improvement in clinical study design. Zimmaro Bliss and colleagues27 studied a large group of nursing home residents with IAD and educated the staff before the residents’ IAD was assessed, but they used subjective findings to characterize IAD severity, such as broken skin, small or large blisters, intense redness, or rash.

Gray and associates1 identified three instruments created specifically to evaluate IAD: (1) the PAT; (2) the Skin Condition Assessment Tool; and (3) the Perineal Dermatitis Grading Scale, but these tools are rarely used, likely because of a lack of awareness of their existence. The PAT evaluates IAD risk by irritant (stool or urine), exposure time, skin condition, and contributing factors.1 The Skin Condition Assessment Tool focuses more on how red and eroded the skin is, whereas the Perineal Dermatitis Grading Scale evaluates the severity of the skin injury and measures changes following specific nursing interventions.1 Most facilities use the NPUAP Staging System to define the IAD injury; however, this system was designed for staging pressure-related injuries and should not be used to evaluate IAD. Further research is needed comparing all of the available skin assessment tools in clinical practice, so that more objective data on their efficacy is provided.

Conclusion

The problem of IAD in nursing home residents is widely acknowledged. A review of the literature supports a structured skin care protocol for IAD prevention that includes gentle cleansing, moisturizing, and use of skin protectants. A number of systematic reviews were found, but few studies examined the economical outcomes of specific products or compared their efficacy in a head-to-head manner. More high-quality studies are needed to measure the clinical efficacy of all suggested prevention measures. In addition, staff education on IAD risk factors, prevention measures, and terminology, and on differentiating between types of IAD and pressure ulcers are important for improving patient care and clinical outcomes. The increased risk of pressure ulcers in residents with incontinence is well reported. Preventing IAD will help decrease pressure ulcer incidence, patient discomfort, morbidity, and the cost of care for this common disorder, while also improving patients’ quality of life.

 

References

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2.     Gray M. Incontinence-related skin damage: essential knowledge. Ostomy Wound Manage. 2007;53(12):28-32.
3.     Nix D, Haugen V. Prevention and management of incontinence-associated dermatitis. Drugs Aging. 2010;27(6):491-496.
4.     Gray M, Black J, Baharestani MM, et al. Moisture-associated skin damage: overview and pathophysiology. J Wound Ostomy Continence Nurs. 2011;38(3):233-241.
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