Moisture-Associated Skin Damage: Expanding and Updating Practice Based on the Newest ICD-10-CM Codes

Risk Factors for Incontinence-Associated Dermatitis in Critically Ill Patients with Incontinence: A Systematic Review and Meta-analysis

PURPOSE

This systematic review analyzed evidence related to risk factors for Incontinence Associated Dermatitis (IAD) in critically ill incontinent patients.

METHOD

Systematic review and meta-analysis.

SEARCH STRATEGY

Eight databases, including PubMed, Embase, CINAHL, Cochrane Library, and Web of Science, were searched for studies published in the English language. The China National Knowledge Infrastructure, WanFang Data, and Chinese Scientific Journal Database were also searched for studies evaluating risk of IAD in critically ill incontinent patients published in the Chinese language.

FINDINGS

Twenty-four studies with moderate-to-high methodological quality were included. Significant risk factors for developing IAD were being older [odds ratio (OR) = 1.06, 95% confidence interval (CI): 1.02-1.10, P = .007], fever (OR = 2.57, 95% CI: 1.87-3.57, P < .00001), diagnosed with consciousness disorder (OR = 5.70, 95% CI: 2.28-14.22, P = .0002), having higher Acute Physiology and Chronic Health Evaluation (APACHE) II score (OR = 1.71, 95% CI: 1.25-2.35, P = .0009), lower Braden score (OR = 0.73, 95% CI: 0.56-0.96, P = .02), lower oxygen saturation (OR = 2.76, 95% CI: 1.52-5.00, P = .0008), double incontinence (OR = 4.10, 95% CI: 2.34-7.17, P < .00001), liquid stool (OR = 6.55, 95% CI: 4.12-10.41, P < .00001), frequent incontinence (OR = 1.21, 95% CI: 1.03-1.43, P = .02), and higher perineal assessment tool (PAT) score (OR = 3.18, 95% CI: 1.76-5.76, P = .0001).

IMPLICATIONS

Findings of this systematic review and meta-analysis suggest that healthcare providers should consider risk factors such as older age, fever, consciousness disorder, higher APACHE II score, lower Braden score and double incontinence matter when developing strategies for the prevention and management of IAD in critically ill incontinent patients.

Impact of an evidence-based bundle on incontinence-associated dermatitis prevalence in hospital patients: A quasi-experimental translational study

The study aimed to evaluate the effect of an intervention on the prevalence and severity of incontinence-associated dermatitis (IAD) in six hospitals in one state in Australia. This quasi-experimental pre-and post-study, conducted in 18 wards, was part of a larger implementation science study on incontinence-associated dermatitis. Skin and incontinence assessments were conducted on patients during February and March 2020 (pre-intervention) and July and August 2021 (post-intervention). The intervention comprised continence assessment and management, an education brochure for patients, family and caregivers on IAD, the Ghent Global IAD Categorisation Tool (GLOBIAD) and a skin care regime with patient skin protection measures (three-in-one barrier cream cloths, minimisation of bed protection layers, use of appropriate continence aid). A total of 1897 patients were assessed (pre-intervention = 964, post-intervention = 933). A total of 343 (35.6%) pre-intervention patients and 351 (37.6%) post-intervention patients had incontinence. The prevalence of hospital-acquired IAD was 6.71% in the pre-intervention group and 4.27% in the post-intervention group; a reduction of 36.3% (p = 0.159) despite higher patient acuity, prevalence of double incontinence and the COVID-19 pandemic in the post-intervention group compared with the pre-intervention group. Our multisite best practice IAD prevention and treatment intervention was able to reduce the prevalence and severity of hospital-acquired IAD, suggesting enduring effectiveness of the intervention.

Peristomal Moisture-Associated Skin Damage Treatment: Use of Cyanoacrylate Liquid Skin Protectant: A Case Series

BACKGROUND

Despite recent advances in ostomy care, the incidence of stoma and peristomal skin complications including peristomal moisture-associated skin damage (MASD) remains as high as 80% of patients living with ostomies. We evaluated a cyanoacrylate liquid skin protectant (CLSP) for the treatment and healing of peristomal MASD in patients with an ileostomy, ileal conduit, or colostomy.

CASES

Five patients (24-85 years old) with peristomal MASD related to an ileostomy (n = 2), ileal conduit (n = 2), or colostomy (n = 1) were evaluated in this case study. All were treated with a CLSP in an attempt to reduce peristomal MASD caused by effluent leakage, which resulted in painful denudation of the peristomal skin. All patients received 1 to 2 applications of the CLSP prior to replacement of the pouching system. Prior to CLSP application, patients underwent assessment focusing on the causes of ostomy pouching system undermining and leakage. Interventions to prevent recurrent undermining and leakage, usually focused on modifications of the pouching system, were completed when indicated.

CONCLUSIONS

For these 5 patients, complete resolution of peristomal MASD was observed at 2 to 8 days following CLSP treatment. More severe peristomal MASD cases required 7 to 8 days for complete resolution while less severe peristomal MASD resolved within 2 to 3 days. Patients showed less frequent pouching system changes, healing of peristomal skin, and reduced peristomal MASD associated with the CLSP treatment and addressing underlying etiology. On a pain scale of 0 to 10, patients reported less pain with an average of more than 7 out of 10 prior to the CLSP treatment and less than 4 out of 10 after treatment.

Good Things Don't Always Come in Small Packages: Comprehensive Care of Patients With Class 3 Obesity: An Integrative Review

The epidemic of obesity and morbid obesity is straining the American health care system's ability to provide quality patient care. Patients with Class 3 (also referred to as morbid or severe) obesity require specialized equipment, unique approaches in the delivery of care, and understanding of the biopsychosocial pathophysiologic mechanisms underlying their condition. This article defines Class 3 obesity, its pathophysiology, and discusses issues that arise when providing quality care of these individuals including safe patient handling, right-sized equipment, and empathetic interpersonal care. We also discuss skin and wound care issues associated with Class 3 obesity.

Meta-analysis Investigating the Efficacy of Liquid Dressing and Ostomy Powder for the Treatment of Incontinence-Associated Dermatitis

OBJECTIVE

To study the effect of liquid dressing and ostomy powder on the treatment of incontinence-associated dermatitis (IAD).

METHODS

The authors searched PubMed, Web of Science, CNKI (China National Knowledge Internet), and Google Scholar databases for literature through July 28, 2022. After literature screening, two investigators independently extracted data from the included studies and applied the Newcastle-Ottawa Scale to assess the quality of the included studies. The χ2-based Q statistic test and the I2 statistic were used to measure the heterogeneity of the included studies. Publication bias was measured with funnel plots and the Egger test. Sensitivity analysis was conducted by eliminating each study one by one.

RESULTS

Four high-quality studies were included in the meta-analysis, involving a total of 307 participants. The meta-analysis results showed that compared with traditional care, treatment with liquid dressing and ostomy powder significantly improved the effective rate (pooled odds ratio, 21.42; 95% CI, 8.58 to 53.44), shortened the healing time (pooled mean difference, -10.73; 95% CI, -12.92 to -8.54), and reduced the recurrence rate (pooled mean difference, -2.03; 95% CI, -2.30 to -1.77) of IAD. Among the included studies, no publication bias was detected. Sensitivity analysis results confirmed the robustness of the pooled estimates.

CONCLUSIONS

Treatment with liquid dressing and ostomy powder has clinical value for patients with IAD.

Assessment and Identification of Skin Disorders in Skin of Color: An Integrative Review

Skin assessment in patients with dark skin tones (DST) continues to be a challenge for many healthcare providers (HCP) because the visual cues are not always readily identified. For example, identification of early signs of pressure injury when subtle skin color changes are missed has the potential to cause harm and contribute to healthcare disparities. Appropriate wound management can begin only when the wound is correctly identified. For HCPs to identify early signs of skin conditions in DST patients, they must be provided education and effective tools enabling them to identify clinically relevant signs of skin damage in all patients. This article reviews basic anatomy of the skin; it focuses on differences seen in DST and reviews assessment strategies to assist the HCP to identify skin changes and conditions.

Effectiveness of an External Urinary Device for Female Anatomy and Trends in Catheter-Associated Urinary Tract Infections

PURPOSE

The purpose of this study was to examine the effectiveness of an external female urinary management system (external urinary device for female anatomy [EUDFA]) in critically ill women unable to self-toilet and to identify rates of indwelling catheter use, catheter-associated urinary tract infections (CAUTIs), urinary incontinence (UI), and incontinence-associated dermatitis (IAD) before and after the introduction of the EUDFA.

DESIGN

Prospective, observational, and quasi-experimental design.

SUBJECTS AND SETTING

The sample comprised 50 adult female patients in 4 critical/progressive care units using an EUDFA at a large academic hospital in the Midwestern United States. All adult patients in these units were included in the aggregate data.

METHODS

Prospective data collected from the adult female patients over 7 days included urine diverted from the device to a canister and total leakage. Aggregate unit rates of indwelling catheter use, CAUTIs, UI, and IAD were retrospectively examined during 2016, 2018, and 2019. Means and percentages were compared using t tests or chi-square tests.

RESULTS

The EUDFA successfully diverted 85.5% of patients' urine. Indwelling urinary catheter use was significantly lower in 2018 (40.6%) and 2019 (36.6%) compared with 2016 (43.9%) (P < .01). The rate of CAUTIs was lower in 2019 than in 2016, but not significantly (1.34 per 1000 catheter-days vs 0.50, P = .08). The percentage of incontinent patients with IAD was 69.2% in 2016 and 39.5% in 2018-2019 (P = .06).

CONCLUSIONS

The EUDFA was effective in diverting urine from critically ill female incontinent patients and indwelling catheter utilization.

The Influence of Absorbent Products on Skin Integrity: A Scoping Review

PURPOSE

Absorbent products are commonly used to absorb urine and fecal matter and to mitigate potential skin complications such as incontinence-associated dermatitis (IAD). Evidence concerning the effect these products have on skin integrity is limited. This scoping review aimed to explore the evidence/literature on the effect of absorbent containment products on skin integrity.

METHOD

A scoping literature review.

SEARCH STRATEGY

The electronic databases CINAHL, Embase, MEDLINE, and Scopus were searched for published articles between 2014 and 2019. Inclusion criteria were studies that focused on urinary and/or fecal incontinence, use of incontinent absorbent containment products, impact on skin integrity, and published in English. The search identified a total of 441 articles that were identified for the title and abstract review.

FINDINGS

Twelve studies met inclusion criteria and were included in the review. Variability in the study designs did not allow firm conclusions regarding which absorbent products contributed to or prevented IAD. Specifically, we found variations in assessment of IAD, study settings, and types of products used.

IMPLICATIONS

There is insufficient evidence to support the effectiveness of one product category over another for maintaining skin integrity in persons with urinary or fecal incontinence. This paucity of evidence illustrates the need for standardized terminology, a widely used instrument for assessment of IAD, and identification of a standard absorbent product. Additional research using both in vitro and in vivo models, along with real-world clinical studies, is needed to enhance current knowledge and evidence of the impact of absorbent products on skin integrity.

Analgesic effect of structured anal skin care for perianal dermatitis after low anterior resection in the rectal cancer patients: prospective, single-center, open-label, therapeutic confirmatory, randomized clinical trial

Purpose

This prospective, single-center, open-label, therapeutic confirmatory, randomized clinical trial aimed to assess the alleviation of anal pain by applying structured anal skin care including skin protectants in rectal cancer patients with low anterior resection syndrome (LARS) combined with anal pain.

Methods

From December 2017 to May 2020, 42 patients with LARS (scores of ≥21) and anal pain (visual analogue scale [VAS] score of ≥3) were randomly assigned and observed for 4 weeks. The conventional treatment consisted of dietary management, sitz baths, prohibition of anal scrubbing, loperamide, and dioctahedral smectite. In the anal care group, cleanser, barrier cream, and barrier spray were applied to the anal skin after defecation following the conventional treatment. The primary outcome was analgesic effect on anal pain after 2 weeks of structured treatment (anal care group) or conventional (control group). The cutoff for analgesic effect was a decrease in the anal pain score (VAS score of ≥2 or ≥30% reduction).

Results

As a primary outcome, the analgesic effect was significantly higher in the anal care group (P = 0.034). The incontinence-associated dermatitis skin condition score was significantly improved in the anal care group than control group after 4 weeks (P = 0.023). There were no significant differences in LARS scores and quality of life scores between 2 groups.

Conclusion

Structured anal skin care has a significant analgesic effect in reducing anal pain and improving anal skin conditions in patients with LARS after rectal cancer surgery.

Moisture-Associated Skin Damage: Expanding Practice Based on the Newest ICD-10-CM Codes for Irritant Contact Dermatitis Associated With Digestive Secretions and Fecal or Urinary Effluent From an Abdominal Stoma or Enterocutaneous Fistula

Moisture-associated skin damage (MASD) occurs when skin is repeatedly exposed to various sources of bodily secretions or effluents, often leading to irritant contact dermatitis, characterized by inflammation with or without denudation of affected skin. In 2020, the Wound, Ostomy and Continence Nurses Society commissioned an initiative that led to the addition of multiple International Classification of Diseases, Tenth Revision, Clinical Modification codes (ICD-10-CM) for irritant contact dermatitis caused by various forms of MASD for use in the United States. In a recent issue of the Journal of Wound, Ostomy and Continence Nursing, a clinical practice alert identifying the various new codes was published that summarized each of the new codes and provided highlights of the descriptions for each of these codes. This is the second in a series of 2 follow-up articles providing a more detailed description of the MASD conditions to which the newest irritant contact dermatitis ICD-10-CM codes apply. Specifically, this article reviews the clinical manifestations and assessment, pathophysiology, epidemiology, prevention, and management of irritant contact dermatitis associated with digestive secretions from a stoma or fistula, and fecal or urinary effluent from an abdominal stoma or enterocutaneous fistula.