Hospital-acquired pressure injury: our seven years of experience

OBJECTIVE

A pressure injury (PI) happens on the skin and in deeper tissues. Generally, it occurs due to prolonged compression over bony structures. A PI, when occurring during a hospital stay, is regarded as a hospital-acquired pressure injury (HAPI), and is considered as a marker for patient care quality. It might cause medical, legal or economic problems, and could be a burden on health systems. In this study we evaluate the factors contributing to HAPI formation.

METHOD

Between June 2014-June 2021, we retrospectively investigated the files of patients who were hospitalised with different medical conditions in Bayindir Sögütözü Hospital, Ankara, Turkey, for patients' age, sex, Waterlow scale score, mobilisation status, application of zinc-containing and/or barrier creams (ZnBC), airbed usage, hospitalisation period, and the day of wound opening.

RESULTS

The study cohort comprised 2327 hospitalised patients: 303 (13%) developed Stage 2 and deeper PIs; 2024 patients were hospitalised and discharged without wound opening. We found an increased risk in male patients and a lack of efficacy of ZnBC in protection from HAPI in our study population. However, we observed that ZnBC helped to delay wound opening and that the most protective treatment was the use of airbeds.

CONCLUSION

Health professionals should be more aware of HAPI formation with prolonged hospitalisation periods. Only the use of an airbed for a patient hospitalised for a long period appears to be protective against PI formation. On the other hand, use of ZnBC delays wound opening. However, further research is needed to demonstrate the protective effect of ZnBC, due to the lack of randomisation in our study and the lack of some nursing records.

Developing a clinical care pathway to reduce and treat enteric feeding tube site skin excoriation: a quality-improvement pilot study

Skin excoriation is a common complication of enteral tube feeding; however, universal guidelines for treatment do not exist. A quality improvement pilot study to inform the development of a local clinical care pathway was conducted. The enteral nutrition team identified products and assessed patient preference, ease of use, availability, and clinical outcomes for inclusion. This pathway includes gentle site cleansing followed by skin protectant application. For mild skin excoriation (<5 mm), acrylate terpolymer barrier film (3M Cavilon No Sting Barrier Film) was applied once every seven days. Moderate skin excoriation (5-20 mm) received acrylate terpolymer barrier film twice a day for seven days. Severe skin excoriation (>20 mm) received advanced elastomeric skin protectant (3M Cavilon Advanced Skin Protectant) applied once every 3-4 days for 2-4 weeks. Ten patients were included, three were selected for discussion. Adoption of this local clinical care pathway resulted in skin healing and improved patient comfort.

The costs, health outcomes and cost-effectiveness of interventions for the prevention and treatment of incontinence-associated dermatitis: A systematic review

BACKGROUND

Incontinence-associated dermatitis is a common, under-recognized painful skin condition associated with poorer quality of life, increased nurse workloads, and costs.

OBJECTIVE

To systematically review economic evidence for the prevention and treatment of incontinence-associated dermatitis.

DESIGN

Systematic review of quantitative research.

DATA SOURCES

PubMed, MEDLINE, EMBASE, Cochrane Library, York Centre for Reviews and Dissemination database, Econlit, Tufts' Cost-Effectiveness Analysis Registry, and Web of Science.

REVIEW METHODS

A comprehensive search for studies on resource use (costs), health outcomes, and cost-effectiveness of interventions for incontinence-associated dermatitis was conducted. Screening, data extraction, and initial quality assessment were conducted independently by two reviewers, with disagreements/queries regarding quality settled through consensus with the larger team. Quality evaluated using the Consolidated Health Economic Evaluation Reporting Standards checklist and results narratively arranged.

FINDINGS

Seventeen studies (10 for prevention, one for treatment and six for both prevention and treatment) included. All studies measured resource use from a healthcare provider perspective; 14 quantified resources in monetary terms. Considerable variation existed in the resource use data primarily due to differences in the type of resources counted, selected time horizons, valuation methods, and reporting approaches. Ten studies provided evidence of their intervention to be cost saving (or at least cost avoiding). Five studies on barrier products provided evidence to be cost saving: three for prevention, one for treatment, and one for both prevention and treatment. Two studies of cleanser and barrier products provided evidence to be cost saving for the prevention and treatment of incontinence-associated dermatitis. One study found a cleanser to be a cost saving preventative intervention. One bowel management system was found to be cost saving over time only, and one nurse education intervention was found to be cost saving for preventing and treating incontinence-associated dermatitis. One barrier product was found to be cost-effective for preventing and treating the condition. Finally, one study found a cleanser and barrier product was time saving for prevention. None of the studies incorporated a multi-attribute quality of life measure; however, two studies included person-reported outcome measures for pain. A narrow range of resources (mainly products) were considered, and there was limited information on how they were counted and valued. Analyses relating to heterogeneity among patients/hospital wards or health facilities and uncertainty were lacking.

CONCLUSIONS

Barrier products are possibly a more cost-effective treatment than others; however, this evidence lacks certainty. Structured health economic evaluations are required for a reliable evidence-base on the interventions for incontinence-associated dermatitis.

TWEETABLE ABSTRACT

Most incontinence-associated dermatitis studies lack person-reported outcomes, costs beyond product/staff time, and economic evaluation.

Development and Characterization of Xanthan Gum and Alginate Based Bioadhesive Film for Pycnogenol Topical Use in Wound Treatment

Pycnogenol (PYC) is a concentrate of phenolic compounds derived from French maritime pine; its biological activity as antioxidant, anti-inflammatory and antibacterial suggests its use in the treatment of open wounds. A bioadhesive film, loaded with PYC, was prepared by casting, starting with a combination of two biopolymer acqueous solutions: xanthan gum (1% wt/wt) and sodium alginate (1.5% wt/wt), in a 2.5/7.5 (wt/wt) ratio. In both solutions, glycerol (10% wt/wt) was added as plasticizing agent. The film resulted in an adhesive capable to absorb a simulated wound fluid (~ 65% wt/wt within 1 h), therefore suitable for exuding wounds. The mechanical characterization showed that the film is deformable (elastic modulus E = 3.070 ± 0.044 MPa), suggesting adaptability to any type of surface and resistance to mechanical solicitations. PYC is released within 24 h by a sustained mechanism, achieving a maximum concentration of ~0.2 mg/mL, that is safe for keratinocytes, as shown by cytotoxicity studies. A concentration of 0.015 mg/mL is reached in the first 5 min after application, at which point PYC stimulates keratinocyte growth. These preliminary results suggest the use of PYC in formulations designed for topical use.

Prevention and Management of Incontinence-Associated Dermatitis in the Pediatric Population: An Integrative Review

An integrative review was conducted to synthesize evidence on prevention and management of incontinence-associated dermatitis (IAD) in the pediatric population. A 5-step integrative process was used to guide the review. Articles published from January 2000 to April 6, 2017, were identified and retrieved from CINAHL, PubMed, ProQuest (MEDLINE), and Scopus; key terms were associated with IAD, pediatric, prevention, and management. Supplemental and manual searches were carried out to identify other relevant studies. The studies' findings were extracted and summarized in a table of evidence, with their quality evaluated using the Joanna Briggs Institute's Critical Appraisal Checklist. Sixteen articles were included in the review. Articles explored prevention and management strategies including skin cleansing technique, diaper selection, and the application of topical skin care products. Inconsistent and limited evidence was found regarding the benefits of using disposable wipes in preference to water-moistened washcloths in the cleansing process and on the use of superabsorbent polymer diapers with breathable outer lining in IAD prevention. Findings were inconclusive with regard to the best topical skin care product for IAD care. However, the application of skin protectants was encouraged by the authors, as well as promoted in various clinical guidelines. The development of a structured skin care regimen supplemented by a comprehensive patient education program was advised to enhance the prevention and management of IAD.

Clinical Evaluation of a Skin Protectant for the Management of Incontinence-Associated Dermatitis: An Open-Label, Nonrandomized, Prospective Study

PURPOSE:

The purpose of this study was to evaluate the efficacy of an investigational skin protectant product at managing severe skin breakdown associated with incontinence.

DESIGN:

Open-label, nonrandomized, prospective study.

SUBJECTS AND SETTING:

The sample comprised 16 patients; inclusion criteria were: patients older than 18 years, cared for in the intensive care unit of a level I trauma center hospital or in long-term care facilities in the northeast region of the United States, and had incontinence-associated dermatitis (IAD). Twelve of the patients had epidermal skin loss and 4 had severe redness.

METHODS:

The investigational product is a formulation based on acrylate chemistry. The skin protectant application schedule was twice weekly for up to 3 weeks for a maximum of 6 applications during the study period. The skin was evaluated via a skin assessment instrument specifically designed for use in this study; this instrument has not undergone validation studies. The main outcome measure was changes in the instrument score over time. In addition, complete reepithelialization was recorded when observed, and pain scores (associated with IAD) were noted in participants who were able to report pain.

RESULTS:

The IAD score improved in 13 of 16 patients, remained unchanged in 1 patient, and deteriorated in 2 patients. The median percent improvement in the skin assessment instrument was 96% (P = .013). Four of the patients with epidermal skin loss had complete reepithelialization of the skin surface with 4 to 6 applications of the skin protectant, and 5 had substantial improvement. The 4 patients with severe red skin returned to healthy normal skin with 2 to 4 skin protectant applications. Substantial pain reduction was reported by all 9 patients who reported pain at enrollment. No adverse events associated with the skin protectant application were reported during data collection.

CONCLUSION:

Results of this study suggest that an acrylate-based product, evaluated here for the first time in patients, may be effective as a protective barrier in the presence of continued incontinence. Additional research is needed to confirm these findings.

No Sting Barrier Film to Protect Skin in Adult Patients: Findings From a Scoping Review With Implications for Evidence-Based Practice

BACKGROUND

In the industrialized world, approximately 1-1.5% of the population has received treatments for skin lesions. In the 1990s, a polymeric barrier film called the No Sting Barrier Film (NSBF) was developed as an alternative to petrolatum-based ointments and zinc oxide formulas. To date, few studies have explored the effectiveness of NSBF in protecting skin integrity.

AIMS

To map the methods, fields and outcomes used to produce evidence on NSBF effectiveness.

METHODS

A scoping review was performed in 2015. A search strategy for identifying relevant studies was designed and performed. Systematic reviews, meta-analyses, randomized controlled trials, controlled clinical trials, and comparative studies for all types of interventions were included; research conducted in any clinical context was eligible for inclusion. Studies were selected by two reviewers; data extraction and analysis also was performed by two reviewers and disagreements were discussed.

RESULTS

Six studies were included. NSBF's potential as a skin protector was investigated with respect to (a) chronic wounds (pressure ulcers or vascular leg ulcers); (b) urinary or fecal incontinence; and (c) post-mastectomy irradiation. The principal clinical outcomes investigated were, respectively: (a) wound healing, wound exudates and erythema control; (b) incidence of incontinence-associated dermatitis and skin reactions; and (c) intensity of pruritus and skin reactions. Pain and comfort were measured in all clinical applications. The main process outcomes investigated were: (a) ease of application, (b) application and removal time, and (c) costs. Zinc oxide and petroleum formulations were the most common comparison interventions in research on chronic ulcers and incontinence; sorbolene cream and topical corticosteroids were the most frequent comparisons in the context of post-mastectomy irradiation.

LINKING EVIDENCE TO ACTION

NBSF may be used for peri-wound skin protection in patients with chronic wounds, with urinary or fecal incontinence and for women undergoing post-mastectomy irradiation. However, more robust experimental studies are needed in all clinical fields where NBSF is applied.

Best practice nursing care for ICU patients with incontinence-associated dermatitis and skin complications resulting from faecal incontinence and diarrhoea

AIMS

Incontinence-associated dermatitis (IAD), resulting from diarrhoea and/or faecal incontinence, is a common problem in intensive care, occurring in 7-50% of the patients, with an estimated 10 million dollars spent annually on continence skin care. This project aimed to evaluate and improve the staff knowledge on IAD and also improve practice in the identification, prevention and treatment of IAD in the ICU.

METHODS

A pre/post-audit framework was used to implement the best practice recommendations between August 2013 and March 2014. Nursing staff were surveyed and a chart review was conducted to audit baselines of knowledge and nursing practice regarding IAD. Education and product standardization were used to implement the best practice recommendations and a post-audit was conducted to evaluate changes in knowledge and practice.

RESULTS

Thirty-one (pre-implementation) and 27 (post-implementation) nurses were surveyed to evaluate knowledge on IAD identification, care and documentation practices. No IAD policy or IAD-specific skin assessment tool for use existed in the ICU. After implementation, there was a 40% increase in the ability of the staff to distinguish between IAD and pressure injuries, an increase from 87% to 100% in the use of skin-protectant and an improvement from 25 to 66% in the correct application of skin-protectants. An encouraging 70% of the nurses were using a single standard skin-protectant after implementation as opposed to audit 1, where 100% of the nurses were using multiple products before implementation. There was a 16% increase in the staff surveyed post-audit who said they reported on the perineal skin in patients with IAD. However, IAD documentation in both audit 1 and audit 2, as evidenced by chart review, remained poor.

CONCLUSION

The project had created an awareness of IAD in the ICU. There was clear knowledge improvement and nursing staff were able to differentiate IAD from pressure injuries. The skin cleansing and protection regime is now more clear and consistent, and a single standardized product is being used to prevent and treat IAD. There was a small improvement in consistently documenting the condition of the perineal skin of patients with IAD; however, it was beyond the scope of this project to develop a policy and implement an IAD-specific skin assessment tool in the ICU, as this would have improved documentation of IAD in the ICU.

Effectively managing wound exudate

The management of wound exudate remains a clinical challenge despite technological advances in products with better exudate-handling capacities. This clinical challenge is occasionally encountered when thick exudate (viscous exudate) is present, and when most modern dressings do not possess the capabilities to manage the viscosity while enabling exudate absorption. Maceration to the peri-wound area poses another challenge, irrespective of the number of topical barrier application products on the market and the innovation of dressing products that lock exudate away or those that encourage vertical wicking. In addition to all the above, in clinical practice, the assessment and documentation of wound exudate remains sporadic, leading to the challenges of effective wound exudate dressing selection and cost-effective dressings.

Evaluation of a skin barrier cream for managing IAD in elderly patients using high-frequency ultrasound

Incontinence-associated dermatitis (IAD) is a defined pathological entity and presents a significant burden for patients and health-care systems. The main objective of this evaluation was to test the efficacy and safety of a skin barrier cream in the management of uncomplicated IAD in elderly patients. Ten incontinent patients with mobility problems that presented with signs of IAD were included in the evaluation. The evaluation took place during a 2-week period. The product's efficacy was objectively evaluated in each patient with high-frequency ultrasound scans taken from the irritated skin compared with an ultrasound scan taken from normal adjacent (control) skin. Data analysis showed a statistical significance in favour of the capacity of the product to help reduce inflammatory signs. Photographic follow-up allowed correlation of ultrasound findings and clinical signs. The product was effective in treating the skin irritation and preventing further skin breakdown. There were no adverse events during the evaluation.

Protecting the radiation-damaged skin from friction: a mini review

Radiation-induced skin reactions are an unavoidable side effect of external beam radiation therapy, particularly in areas prone to friction and excess moisture such as the axilla, head and neck region, perineum and skin folds. Clinical studies investigating interventions for preventing or managing these reactions have largely focussed on formulations with moisturising, anti-inflammatory, anti-microbial and wound healing properties. However, none of these interventions has emerged as a consistent candidate for best practice. Much less emphasis has been placed on evaluating ways to protect the radiation-damaged skin from friction and excess moisture. This mini review analyses the clinical evidence for barrier products that form a protective layer by adhering very closely to the skin folds and do not cause further trauma to the radiation-damaged skin upon removal. A database search identified only two types of barrier products that fitted these criteria and these were tested in two case series and six controlled clinical trials. Friction protection was most effective when the interventions were used from the start of treatment and continued for several weeks after completion of treatment. Soft silicone dressings (Mepilex Lite and Mepitel Film) and Cavilon No Sting Barrier Film, but not Cavilon Moisturizing Barrier Cream, decreased skin reaction severity, most likely due to differences in formulation and skin build-up properties. It seems that prophylactic use of friction protection of areas at risk could be a worthwhile addition to routine care of radiation-damaged skin.

The role of barrier protection ain pressure ulcer prevention

This article considers the anatomy and physiology of the skin, the natural protection the skin provides in relation to barrier protection and the importance of barrier protection in pressure ulcer prevention. The current national pressure ulcer agenda including high impact actions and the SSKIN care bundle, along with their implementation within one NHS Health Care Trust are discussed.

Evaluation of clinical and financial outcomes of a new no-sting barrier film and barrier cream in a large UK primary care organisation

The study involves 95 subjects within a UK Primary Care Organisation and was undertaken in two arms. The objective was to determine the clinical outcomes and clinical acceptability of a newly available range of no-sting barrier film and no-sting barrier cream products offering significant financial benefits. The importance of undertaking this study is underpinned by evidence in the literature relating to the use of no-sting barrier preparations within clinical practice. The first part of the study (arm 1) involved extensive evaluation of either the film or cream barrier in 36 patients and was compared to existing standardised barrier protection care within the organisation. The results indicated that the new product range met all the criteria for formulary inclusion and following this the barrier range was further evaluated in arm 2, 33 patients with barrier cream and 26 patients with barrier film. The entire study was conducted over a 3-month period with patient treatment lasting a minimum of 2 days to a maximum 4-week period adhering to the agreed evaluation protocol as approved by clinical governance. In arm 1 (n = 36), the clinical expectation of the product was met in 32 cases relating to ease of use, conformability, no-sting, quick drying, ease of absorption, compatibility with devices, frequency of application, prevention and management including visual skin improvement resulting in a recommendation for formulary listing in 31 of 36 cases. In arm 2 (n = 59), barrier film and barrier cream performance was consistently rated same as, better than or much better than the existing barrier used. A formulary listing recommendation was made in 51 of 59 cases.

Incontinence-associated dermatitis: consensus statements, evidence-based guidelines for prevention and treatment, and current challenges

In 2010, an international consensus conference was held to review current evidence regarding the pathology, prevention, and management of incontinence-associated dermatitis (IAD). The results of this literature review were published in a previous issue of this Journal. This article summarizes key consensus statements agreed upon by the panelists, evidence-based guidelines for prevention and management of IAD, and a discussion of the major challenges currently faced by clinicians caring for these patients. The panelists concur that IAD is clinically and pathologically distinct from pressure ulcers and intertriginous dermatitis, and that a consistently applied, structured, or defined skin care program is effective for prevention and management of IAD. They also agreed that differential assessment of IAD versus pressure ulceration versus intertriginous dermatitis remains a major challenge. Panel members also concur that evidence is lacking concerning which products and protocols provide the best outcomes for IAD prevention and treatment in individual patients. Issues related to differential assessment, product labeling and utilization, staff education, and cost of care are the primary focus of this article.