The Prevalence of Incontinence and Its Association With Urinary Tract Infections, Dermatitis, Slips and Falls, and Behavioral Disturbances Among Older Adults in Medicare Fee-for-Service

PURPOSE

The purpose of this study was to examine the prevalence of urinary (UI), fecal (FI), and dual incontinence (DI) in older adults and their association with urinary tract infections, dermatitis, slips and falls, and behavioral disturbances based on Medicare fee-for-service (FFS) claims data.

DESIGN

Retrospective analysis.

SUBJECTS AND SETTINGS

Data from administrative claims from the CMS Medicare Limited Data Set (5% sample) for all months in 2018 were reviewed. The analysis was limited to FFS Medicare beneficiaries, with minimum of 3-month enrollment in Parts A and B who were at least 65 years old. This cohort included 1.2 million beneficiaries in the United States.

METHODS

We used diagnosis codes to identify members with incontinence and grouped these members into 3 categories (UI only, FI only, and DI). We also divided claims based on 4 sites of care (nursing home, skilled nursing facility, home health, and self- or family care). We then determined the prevalence of (1) urinary tract infections (UTIs), (2) dermatitis, (3) slips and falls, and (4) behavioral disturbances for each type of incontinence.

RESULTS

We found that 11.2% of Medicare members had a claims-based diagnosis of incontinence in 2018. On average, those diagnosed with incontinence experienced 5 times more UTIs, 2 times as many dermatitis events, more than twice as many slips and falls, and 2.8 times more behavior disturbances compared to those without an incontinence diagnosis. For those with DI, the prevalence of the 4 outcomes was significantly higher (between 22% and 185%) compared to those with UI only.

CONCLUSIONS

Findings show that Medicare beneficiaries diagnosed as incontinent experience a much higher prevalence of UTIs, dermatitis, slips and falls, and behavioral disturbances compared to those without a diagnosis of incontinence. Our results suggest that incontinence may be an important indicator diagnosis for multiple other conditions and, if not well-managed, may challenge the desire for those who are incontinent to age at home.

The effectiveness of faecal collection devices in preventing moderate to severe incontinence-associated dermatitis: A systematic review and network meta-analysis

BACKGROUND

Incontinence-associated dermatitis (IAD) is a common problem among critically ill patients with faecal incontinence (FI). However, there are few studies comparing the effects of different faecal collection devices impact the prevention of moderate to severe IAD in this patient population.

AIM

This review aims to compare the effectiveness of various devices for collecting faecal matter in preventing moderate to severe IAD in critically ill patients suffering from FI through a network meta-analysis.

STUDY DESIGN

We conducted a systematic search of PubMed, Embase, ProQuest, CENTRAL, CINAHL Plus with Full Text, China National Knowledge Infrastructure (CNKI), Wan fang, Wei Pu, and China Biomedicine (CBM) from their inception until May 4, 2023. The selected studies were randomized controlled trials (RCTs). Two researchers independently performed study selection and data extraction. We assessed the risk of bias using the Cochrane risk of bias tool Version 2.0. RevMan 5.4 was utilized for conventional pairwise meta-analysis of direct comparisons, while Stata16.0 was employed for network meta-analysis.

RESULTS

A total of 14 studies, involving 1345 patients, were included in the analysis. Pairwise meta-analysis showed that an anal bag[odds ratio(OR): 0.07(0.03, 0.20)], a balloon catheter[(OR:0.30(0.15, 0.62)], and an anal bag connected to negative pressure and flushing [(OR: 0.09(0.01,0.68)] all reduced the incidence of moderate to severe IAD in critically ill patients compared with usual care measures, respectively. The cumulative rank probabilities indicated that moderate to severe IAD prevention was more effective when employing balloon catheters connected to negative pressure [surface under the cumulative ranking curve(SUCRA): 20.8%] and anal bags connected to negative pressure (SUCRA: 27.0%) among critically ill patients with FI.

CONCLUSION

FI is a common problem among severely ill patients, and the reduction of moderate and severe IAD incidence is deemed essential. In this review, it is suggested that both balloon catheters connected to negative pressure and anal bags connected to negative pressure are associated with a higher effectiveness in preventing moderate and severe IAD.

RELEVANCE TO CLINICAL PRACTICE

The findings of this review can assist healthcare professionals in the selection of suitable stool management devices for the prevention of moderate to severe IAD in critically ill patients with FI.

Knowledge and Visual Differentiation Ability of the Pressure Injury Classification System and Incontinence-Associated Dermatitis among Hospital Nurses: A Descriptive Study

This study investigated clinical nurses' knowledge and visual differentiation ability of the pressure injury classification system (PICS) and incontinence-associated dermatitis (IAD), additionally analyzing possible influencing factors. A convenience sample of 248 nurses took the PICS and IAD knowledge test (KT) and completed the visual differentiation ability test (VDAT), consisting of 21 photographs with clinical information. The overall mean score for correct answers was 12.65 ± 2.90 points in PICS and IAD KT and 11.43 ± 4.57 points in VDAT. Incorrect responses were most common for statements related to stage II, III, IAD for PICS and IAD KT, and deep tissue pressure injury (DTPI), unstageable, and stage III for VDAT. Significant correlations were found between PICS and IAD KT and VDAT (r = 0.252, p < 0.001). Factors affecting scores for VDAT were the scores of PICS and IAD KT, debridement experience in nursing patients with PI, and the management frequency of PI and IAD. Results indicate that nurses have an overall understanding of PICS and IAD, but low visual differentiation ability regarding stage III, DTPI, and unstageable PI. Continuing education is needed to further improve knowledge and visual differentiation ability for PICS and IAD.

Incontinence-Associated Dermatitis in Older Intensive Care Patients: A Review and Case Report

Background

Incontinence-Associated Dermatitis is a serious skin injury causing suffering, secondary infection, and inducing almost six times more pressure sore than normal skin patients. This moisture and chemical skin irritation is a concern, especially for intensive care unit nurses. This study aimed to review the effective nursing strategy for preventing and caring for incontinence-associated dermatitis in older intensive care unit patients and pilot its feasibility.

Methods

The five databases, including PubMed, Google Scholar, CINAHL Complete, WanFang, and CNKI, were searched, and articles were screened and extracted. The strategies and details of prevention and care for incontinence-associated dermatitis were reviewed and summarized. Finally, selected strategies were applied to five intensive care unit patients with various health conditions and levels of Incontinence-Associated Dermatitis severity.

Results

The literature review found that there is a standardized nursing process for incontinence-associated dermatitis. The prevention and care strategies for incontinence-associated dermatitis include assessment, risk factor management, skin cleaning, skin protection, and health education and training. In actual clinical application, personalized nursing measures can positively impact patients. Five case studies from our pilot confirmed this finding.

Conclusion

Personalized nursing measures can positively impact patients in actual clinical applications. Our five case studies implementing the strategies from the review confirmed this finding. In clinical work, it is recommended to develop personalized nursing programs for specific risk factors of older intensive care unit patients.

Protocol Registration

TCTR20230808004.

Development of prone positioning and skin damage prevention digital education: the PRONEtect project

OBJECTIVE

The incidence of skin/tissue damage, such as pressure ulcers, remains high in mechanically ventilated patients in the prone position. According to guidelines, critically ill patients with acute respiratory distress syndrome (ARDS) should be prone for at least 12-16 hours to improve oxygenation and decrease mortality. Therefore, educating clinicians on how to reposition and manage the patient safely in a prone position plays a vital role in preventing adverse events. This project aimed to develop accessible online educational content to assist clinicians in safely executing the prone manoeuvre and minimise skin/tissue damage.

METHOD

The development of the educational content was based on: a gap analysis and comprehensive review of available educational resources; evidence-based scientific literature; advice from international experts; and a qualitative study exploring the learning needs of 20 clinicians in Belgium and Sweden between February-August 2022.

RESULTS

Volunteer clinicians assisted with the creation of eight simulation videos which were professionally filmed and edited. The interactive videos included the supine-to-prone and prone-to-supine manoeuvres, endotracheal and nasogastric tube securement, eye care, stoma care, protecting high-risk areas from pressure damage, and incontinence-associated dermatitis prevention. A prone positioning protocol, a checklist summarising the key aspects of the protocol, and teaching aids (slide deck for didactic lecturing) were developed and validated by a review of the relevant evidence-based literature and the international expert panel. A website was designed to host the content, with free user access, at www.pronetection.com.

CONCLUSION

Education is one strategy towards prevention of complications of prone positioning. Accessible education could assist clinicians unfamiliar with prone positioning or current clinicians requiring refresher training to safely manage patients in this position.

Measurement instruments to evaluate diaper dermatitis in children: Systematic review of measurement properties

AIM

The aim of this study was to summarize and evaluate the empirical evidence on the measurement properties of diaper dermatitis (DD) measurement instruments in children.

DESIGN

Systematic review.

METHODS

MEDLINE, CINAHL and EMBASE were systematically searched until 14 June 2021. Citation searching was conducted in Scopus. The risk of bias, the reported measurement properties and the quality of evidence were evaluated using the COSMIN framework. The reporting follows the PRISMA 2020 statement.

RESULTS

We identified 1200 records in the databases and 108 records during citation searching and included four studies describing three measurement instruments for DD in children and their measurement properties. We considered the content validity inconsistent for all three instruments. The study authors reported internal consistency, reliability and construct validity for one instrument. We rated the quality of evidence from very low to moderate.

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.

Humidity-Sensing Mattress for Long-Term Bedridden Patients with Incontinence-Associated Dermatitis

Designing new medical devices with advanced humidity sensors is of great significance for patients with incontinence-associated dermatitis (IAD). The primary goal of this study is to test the humidity-sensing mattress system for patients with IAD in clinical settings. The design of the mattress is set at 203 cm, with 10 × 3 sensors, dimensions of 19 × 32 cm, and a weighted bearing of 200 kg. The main sensors consist of a humidity-sensing film, a thin-film electrode (6 × 0.1 mm), and a glass substrate (500 nm). The sensitivity of the test mattress system showed that the resistance-humidity sensor was at a temperature of 35 °C (V0 = 30 V, V0 = 350 mV), with slope at 1.13 V/fF, f = 1 MHz, 20-90% RH, and a response time of 20 s at 2 μm. In addition, the humidity sensor reached 90% RH, with a response time of less than 10 s, a magnitude of 107-104 Ω, 1 mol%, CrO1.5, and FO1.5, respectively. This design is not only a simple, low-cost medical sensing device, but also opens a new pathway for developing humidity-sensing mattresses in the field of flexible sensors, wearable medical diagnostic devices, and health detection.

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.

Risk factors of incontinence-associated dermatitis among critically ill patients: A systematic review and meta-analysis

Objectives

Incontinence-associated dermatitis (IAD) is increasingly found among critically ill patients, but the risk factors for IAD in these patients are currently unclear. The purpose of this meta-analysis was to identify the risk factors of IAD in critically ill patients.

Methods

Web of Science, PubMed, EMBASE, and Cochrane Library were systemically searched until July 2022. The studies were selected based on inclusion criteria, and data were independently extracted by two researchers. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of the included studies. Odds ratios (ORs) and their associated 95% confidence intervals (CIs) were used to identify significant differences in the risk factors. The I ² test was used to estimate the heterogeneity of studies, and Egger's test was used to assess the potential publication bias.

Results

A total of 7 studies enrolling 1,238 recipients were included in the meta-analysis. Age ≥ 60 (OR = 2.18, 95% CI: 1.38~3.42), female sex (OR = 1.76, 95% CI: 1.32~2.34), dialysis (OR = 2.67, 95% CI: 1.51~4.73), fever (OR = 1.55, 95% CI: 1.03~2.33), vasoactive agent (OR = 2.35, 95% CI: 1.45~3.80), PAT score ≥ 7 (OR = 5.23, 95% CI: 3.15~8.99), frequency of bowel movement > 3times/d (OR = 5.33, 95% CI: 3.19~8.93), and liquid stool (OR = 2.61, 95% CI: 1.56~4.38) were the risk factors of IAD among critically ill patients.

Conclusions

Many risk factors are related to IAD among critically ill patients. Nursing staff should pay more attention to evaluating the risk of IAD and enhance the care of high-risk groups.

The ability of critical care nurses to identify pressure injury and incontinence-associated dermatitis: A multicentre cross-sectional survey

AIM

To investigate the ability of critical care nurses to identify pressure injury and incontinence-associated dermatitis and analyse the possible influencing factors.

DESIGN

Cross-sectional survey.

METHODS

This study was conducted at 24 hospitals across 12 provinces in China. A self-made electronic questionnaire was used. Nurses identified and judged injuries according to the information provided.

RESULTS

The average identification score for pressure injury and incontinence-associated dermatitis was 9.00 ± 3.51 points, and only 2.16% of nurses scored ≥16 points. The average correct identification rate for pressure injury and incontinence-associated dermatitis was 45%. The correct identification rate for stage 1 pressure injury was the highest, while those for stage 3, stage 4, deep tissue pressure injury and unstageable pressure injury were all lower than 50%; incontinence-associated dermatitis was also easily misjudged. Nurses' educational backgrounds, professional titles, job positions, hospital levels and learning frequency were the factors that affected their ability to identify pressure injury and incontinence-associated dermatitis.

Bacterial invasion into the epidermis of rats with sodium lauryl sulphate-irritated skin increases damage and induces incontinence-associated dermatitis

Incontinence-associated dermatitis (IAD) is caused by prolonged exposure to urine/liquid stool. It is a common and often painful skin condition in older incontinent adults because of poor prevention. Patients with urinary infections are at risk of developing IAD, and to guide the development of novel prevention strategies, we aimed to develop an animal model of IAD by urine and bacteria. First, contralateral sites on the dorsal skin of Sprague-Dawley rats were compromised by sodium lauryl sulphate (SLS), simulating frequent cleansing with soap/water. Filter discs were then placed inside ring-shaped chambers on foam dressings, inoculated with or without Pseudomonas aeruginosa, covered with agarose gels immersed in cultured filtrated urine, and secured in place with an occlusive dressing for 3 days. Untreated and SLS-compromised sites served as controls. The IAD was developed at bacteria-inoculated sites, characterised by severe IAD-like redness that persisted for up to 3 days post-exposure and higher disruption of the skin barrier function compared with non-inoculated sites. Pathological changes included epidermal thickening, partial skin loss, inflammatory cell infiltration, accumulation of red blood cells, and invasion of bacteria into the epidermis. This novel, clinically relevant IAD rat model can serve for future prevention developments.

Quality and clinical applicability of recommendations for incontinence-associated dermatitis: A systematic review of guidelines and consensus statements

AIMS AND OBJECTIVES

The aim of this study was to assess methodological quality of all currently available guidelines and consensus statements for IAD using the Appraisal of Guidelines, Research and Evaluation (AGREE) II and the AGREE Recommendation Excellence (AGREE-REX) instruments.

BACKGROUND

Globally, incontinence-associated dermatitis (IAD) is a significant health challenge. IAD is a complex healthcare problem that reduces quality of life of patients, increases healthcare costs and prolongs hospital stays. Several guidelines and consensus statements are available for IAD. However, the quality of these guidelines and consensus statements remains unclear.

DESIGN

A systematic review of guidelines and consensus statements.

METHODS

Our study was undertaken using PRISMA guidelines. We searched seven electronic databases. Guidelines and consensus statements had to be published in English, Chinese or German languages. Five independent reviewers assessed the methodological quality of guidelines and consensus statements using the AGREE II and AGREE-REX instruments. Mean with standard deviation (SD) and median with interquartile range (IQR) were calculated for descriptive analyses. We generated bubble plots to describe the assessment results of each domain of each guideline and consensus statement.

RESULTS

We included ten guidelines and consensus statements. The NICE guidelines, obtained the highest scores, fulfilled 86.11%-98.61% of criteria in AGREE II and 76.67%-91.11% for AGREE-REX. In the domains 'Stakeholder Involvement' (4.39 ± 1.64), 'Rigor of Development' (3.38 ± 1.86), 'Applicability' (3.62 ± 1.64), 'Editorial Independence' (3.91 ± 2.56) and 'Values and Preferences' (2.98 ± 1.41), the remaining guidelines and consensus statements showed deficiencies.

CONCLUSIONS

Altogether, this study demonstrated that the currently available guidelines and consensus statements for IAD have room for methodological improvement. NICE guidelines on faecal incontinence and urinary incontinence have better quality. Remaining guidelines and consensus statements showed substantial methodological weaknesses, especially the domains of 'Stakeholder Involvement', 'Rigor of Development', 'Applicability', 'Editorial independence' and 'Values and Preferences'. This study was registered on INPLASY. (Registration number: INPLASY202190078).

RELEVANCE TO CLINICAL PRACTICE

The currently available guidelines and consensus statements on IAD have room for methodological improvement.

Prevention and Care for Incontinence-Associated Dermatitis Among Older Adults: A Systematic Review

Background

The prevalent rate of incontinence-associated dermatitis (IAD) trends upward in older populations. Skin breakdown from IAD impacts the quality of life of older adults and reflects the quality of care in hospitals and long-term care facilities. Specific and appropriate interventions for prevention and care are needed. This systematic review aims to review optimal strategies for prevention and care for older adults with IAD.

Methods

PubMed, CINAHL, SCOPUS, Medline, ProQuest, ThaiLIS, ThaiJo, and E-Thesis were searched for articles published between January 2010 and December 2020. Only articles focusing on older adults were included for the review.

Results

Eleven articles met the inclusion/exclusion criteria. Interventions for the prevention and care of IAD among older adults were categorized as assessment, incontinence management/causative factors management, cleansing, application of medical products for both skin moisturizing and skin barrier, body positioning, nutrition promotion, health education and training, and outcome evaluation. Specific prevention and care strategies for older adults with IAD included using specific assessment tools, applying skin cleansing pH from 4.0 to 6.8, body positioning, and promoting food with high protein. Other strategies were similar to those reported for adult patients.

Conclusion

The systematic review extracted current and specific prevention and care strategies for IAD in older adults. The prevention and care strategies from this systematic review should be applied in clinical practice. However, more rigorous research methodology is recommended in future studies, especially in examining intervention outcomes. Nurses and other health professionals should be educated and trained to understand the causes of IAD in older adults and the specific prevention and care strategies for this population. Because older adults are prone to skin damage, and this type of skin breakdown differs from pressure ulcers, the tools for assessment and evaluation, and the strategies for prevention and care require special attention.

Prospero Registration Number

CRD42021251711.

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Incontinence and Incontinence-Associated Dermatitis in Acute Care: A Retrospective Analysis of Total Cost of Care and Patient Outcomes From the Premier Healthcare Database

PURPOSE

To evaluate the prevalence of incontinence and treatment of incontinence-associated dermatitis (IAD) and associations with outcomes including total cost of care, length of stay (LOS), 30-day readmission, sacral area pressure injuries present on admission and hospital acquired pressure injuries, and progression of all sacral area pressure injuries to a higher stage.

DESIGN

Retrospective analysis.

SUBJECTS AND SETTINGS

Data were retrieved from the Premier Healthcare Database and comprised more than 15 million unique adult patient admissions from 937 hospitals. Patients were 18 years or older and admitted to a participating hospital between January 1, 2016, and December 31, 2019.

METHODS

Given the absence of an IAD International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code, we categorized patients treated for IAD by selecting patients with a documented incontinence ICD-10-CM code and a documented charge for dermatology products used to treat IAD. The t test and χ2 tests determined whether incontinence and treatment for IAD were associated with outcomes.

RESULTS

Incontinence prevalence was 1.5% for the entire sample; prevalence rate for IAD among incontinent patients was 0.7%. As compared to continent patients, incontinent patients had longer LOS (6.4 days versus 4.4 days), were 1.4 times more likely to be readmitted, 4.7 times more likely to have a sacral pressure injury upon admission pressure injury, 5.1 times more likely to have a sacral hospital-acquired pressure injury, and 5.8 times more likely to have a sacral pressure injury progress to a severe stage. As compared to incontinent patients without IAD treatment, those with IAD treatment had longer LOS (9.7 days versus 6.4 days), were 1.3 times more likely to be readmitted, and were 2.0 times more likely to have a sacral hospital-acquired pressure injury. Total index hospital costs were 1.2 times higher for incontinent patients and 1.3 times higher for patients with IAD treatment.

CONCLUSIONS

Incontinence and IAD prevalence are substantially lower than past research due to underreporting of incontinence. The lack of an ICD-10-CM code for IAD further exacerbates the underreporting of IAD. Despite low prevalence numbers, our results show higher health care costs and worse outcomes for incontinent patients and patients with IAD treatment.

Promoting effect of acylated homoserine lactone on the healing of tissue damage in model rats with incontinence-associated dermatitis

OBJECTIVE

One of the most common complications in patients with incontinence is incontinence-associated dermatitis (IAD). This study was conducted to determine the pathophysiology of the healing process of IAD and to develop an effective therapeutic approach according to its pathophysiology.

METHOD

IAD was reproduced on a dorsal rat skin by applying agarose gel containing water and enzymes, and inoculating it with bacteria. Examination of the IAD healing process suggested that the promotion of keratinocyte migration and improvement of basement membrane enhance keratinocyte layer elongations, which contribute to IAD healing. A therapeutic approach using N-(3-oxotetradecanoyl)-L-homoserine lactone, which is one of the acylated homoserine lactones (AHLs) and can promote keratinocyte migration in vitro, was applied on the IAD area in rats.

RESULTS

AHL treatment after IAD development resulted in an earlier tipping point for recovery than the vehicle treatment. Histological and immunohistological analyses revealed that the tissue surface was already covered by the epidermis, indicating the results of elongation of the keratinocyte layer from hair follicles. The characteristics of the alignment of basal keratinocytes, the existence of stratum corneum, and the membrane-like distribution of the components of basement membrane were similar to those of a normal epidermis.

CONCLUSION

These results suggested that AHL application possibly contributed to earlier IAD healing before progressing to a severe state. Although elongation of the keratinocyte layer was observed in both the AHL and vehicle groups, the possibility that AHL application promotes IAD healing was suggested. The new concept of the enhancement of keratinocyte migration as a therapeutic approach for IAD would change the skin care strategy for IAD in the healthcare setting.

Establishment of incontinence-associated dermatitis rat models and assessment of the therapeutic effects of zinc oxide, painless skin protective film and silicone dressing

The aim of the present study was to construct incontinence-associated dermatitis (IAD) rat models and observe the therapeutic effects of zinc oxide, painless skin protective film and silicone dressing on IAD. A total of 54 rats were randomly divided into nine groups: i) Control group; ii) trypsin model group; iii) model + zinc oxide group; iv) model + painless skin protective film group; v) model + silicon dressing group; vi) synthetic urine combined with trypsin model group (joint model group); vii) joint model + zinc oxide group; viii) joint model + painless skin protective film group; and ix) joint model + silicone dressing group. A total of 4 days after applying the zinc oxide, protective film or silicon dressing intervention, IAD scores and pH values in skin tissues were examined. Skin tissues and blood samples were collected. Hematoxylin and eosin staining, immunohistochemical staining of major histocompatibility complex class II (MHC-II) and western blot analysis of MHC-II, NF-κB/p65, phosphorylated (p)-NF-κB/p65, STAT1 and p-STAT1 were carried out in skin tissue. Serum IFN-γ, IL-1β, IL-2 and TNF-α levels were determined using ELISA. The results demonstrated that IAD scores and pH values were both higher in the model groups than the control, which were significantly ameliorated by silicone dressing. The skin tissue structure of IAD rats both in trypsin model group and joint model group was severely damaged, the wounds were not covered by epidermis, and numerous inflammatory cell infiltrations were observed. After treatment, dermatitis was improved. Skin tissue from the trypsin and joint IAD models had higher MHC-II, NF-κB p65, p-NF-κB p65, STAT1 and p-STAT1 expression than controls, which was decreased by protective film and silicon dressing. Zinc oxide reduced NF-κB p65, p-NF-κB p65, STAT1 and p-STAT1 expression. However, no significant differences were observed in NF-κB/p-NF-κB ratio and STAT1/p-STAT1 ratio among groups. Furthermore, serum IFN-γ, IL-1β, IL-2 and TNF-α levels were significantly elevated in trypsin and joint IAD rats. The upregulation of these cytokines was significantly inhibited after all three treatments. Among the three treatment methods, silicone dressing had the best therapeutic effect. Thus, these findings revealed that zinc oxide, painless skin protective film and silicone dressing could ameliorate the severity of IAD rat models, and that silicone dressing possessed the best therapeutic effect.

Management of incontinence-associated dermatitis with topical antibiotics and antifungal medication

OBJECTIVE

The primary goals of managing incontinence-associated dermatitis (IAD) are to control the incontinence and to stop the progress of dermatitis. This study evaluated the effectiveness of using a combination of topical antibiotic and topical antifungal medication to manage IAD.

METHOD

Patients with grade 2 IAD treated with a combination of topical antibiotic Biomycin (CBC Biotechnological and Pharmaceutical, Taiwan) and antifungal clotrimazole (Sinphar Group, Taiwan) between January 2017 and January 2019 were included in this retrospective study. Data collected included patients' age, sex, diagnosis, body mass index, comorbidities and surface area involved. Patients were reviewed fortnightly until the wounds had healed, the patient was discharged or had died.

RESULTS

A total of 76 patients were included. There were 39 men and 37 women with a mean age of 74 years. In 58 (76%) patients, the surface area involved was >50cm², in 13 (17%) patients the involved area was 20-50cm² and in five (7%) patients the area involved was <20cm². The mean number of days treated was 10.3 (range: 1-53). A total of 46 (61%) patients showed total healing of their IAD, 17 (22%) patients showed improvement of >50% of the involved area, seven (9%) patients showed improvement of 0-50%, five (7%) patients showed no improvement and one (1%) patient showed an increase in the area involved.

CONCLUSION

This combination of treatment was effective in the management of IAD. It was cheap, easy to apply, easy to remove and easily accessible. It could be used efficiently by the hospital staff and the patient's family.

Incontinence-associated dermatitis: who is affected?

OBJECTIVE

Intensive care unit (ICU) patients possess multiple risk factors for developing loss of skin integrity, particularly incontinence-associated dermatitis (IAD). IAD is an inflammatory skin condition resulting from repeated and prolonged contact with urine, faeces or both. This study aimed to measure the incidence and clinical characteristics of adult ICU patients with IAD.

METHOD

This was a prospective observational study conducted over three months in an adult ICU. Included patients were ≥18 years who experienced faecal incontinence during their intensive care admission. Patients were excluded if they had an ileostomy or colostomy, had IAD on admission, or were continent of urine and faeces. Skin inspections were performed every second day on all recruited patients by trained research nurses. Other data were collected from patient medical records.

RESULTS

A total of 37 patients took part in the study. Incidence of IAD was 35.1%; 13 patients who had incontinence developed IAD. The mean time to onset of IAD was 3.69 days, median 3 days (SD: 1.8, range: 2-8 days). Of the 13 patients who developed IAD, 12 (92.3%) patients were initially assessed as having category 1 IAD and one (7.7%) patient was initially assessed with category 2 IAD. Of the patients with category 1 IAD, one patient (7.7%) progressed to category 2 IAD severity.

CONCLUSION

A larger sample is recommended to fully explore ICU patient characteristics and IAD development. The incidence of IAD in ICU patients was high at 35%, indicating this condition requires due consideration in ICU patients.

Effectiveness of skin cleanser and protectant regimen on incontinence-associated dermatitis outcomes in acute care patients: A cluster randomised trial

Skin cleansers and protectants protect skin from incontinent matter to reduce the risk of incontinence-associated dermatitis (IAD), but their effectiveness treating established IAD in the tropics is unknown. We conducted an open-label cluster randomised trial to compare the effectiveness of a combined regimen of (1) specialised skin cleansers with disposable body wipes and (2) either an acrylic terpolymer (T1) or zinc oxide (T2) skin protectant against disposable body wipes and zinc oxide protectant (control) in promoting IAD healing and reducing the risk of deterioration. Eighty-four patients were recruited in a tertiary hospital in Singapore between April 2019 and January 2020 (T1: n = 23; T2: n = 37; Control: n = 24). Although not statistically significant, patients treated with T1 and T2 were 1.5 times as likely to experience IAD healing within seven days compared with the control (P = .66). Healing was more pronounced in participants with skin loss treated with T1 or T2. No treatment was superior in preventing IAD deterioration, the prevalence of which remained small (8%-14%). While skin cleaning and protectants reduced the overall risk of skin deterioration, the addition of skin cleansers enhanced IAD healing within a short period, an important consideration for future research examining IAD treatment in acute care.

Management of incontinence-associated dermatitis: A systematic review of monetary data

The objective was to systematically review monetary data related to management of incontinence‐associated dermatitis (IAD) in an adult population. Six electronic databases were searched: MEDLINE, CINAHL, Web of Science, EMBASE, The Cochrane Library and EconLit. The search string combined index terms and text words related to IAD and monetary data. The quality of the articles was assessed using the consensus on Health Economic Criteria. Results were synthesised narratively because of methodological heterogeneity. Nine studies were included. Only direct medical costs were reported. The product cost per application for prevention ranged between $0.05 and $0.52, and for treatment between $0.20 and $0.35. The product cost per patient/day for prevention ranged between $0.23 and $20.17. The product cost of IAD prevention and treatment per patient/day ranged between $0.57 and $1.08. The cost to treat IAD did not consider the treatment of secondary infection. The calculation of labour cost and total cost differed considerably between studies. Summarising monetary data is a challenge because of heterogeneity in currencies, settings, samples, time horizons, health‐ and cost outcome valuation, IAD definition and measurements, and included costs. Procedures for health economic evaluations are to be clarified to guarantee valid interpretation and comparison with other studies.

Combination of urease inhibitor and antiseptic inhibits urea decomposition-induced ammonia production by Proteus mirabilis

The decomposition of urea into ammonia by urease-producing bacterium shows an elevation in the pH level, which can lead to incontinence-associated dermatitis (IAD). This study aimed to examine the efficacy of a combination of antiseptic and urease inhibitor in inhibiting the decomposition of urea by the urease-producing bacterium Proteus mirabilis. We performed in vitro assays to compare the effects of a combination of antiseptic and urease inhibitor, antiseptic only, urease inhibitor only, and an untreated control with the effects of a urea-containing solution. Cultured P. mirabilis was mixed with urea-containing solution, followed by the addition of antiseptic and/or urease inhibitor. The main outcome used to assess the efficacy of the different treatments was ammonia concentration at 4-hours post-treatment initiation, and multiple comparison analysis was performed using Dunnett's test to compare the results between groups. Ammonia concentrations in samples treated with either antiseptic or urease inhibitor were lower than those in the untreated control, while the combination of antiseptic and urease inhibitor resulted in decreased ammonia concentrations compared with either treatment alone. Therefore, the application of both urease inhibitor and antiseptic is more effective for the inhibition of urea decomposition by urease-producing bacteria. Novel preventive strategies using these reagents may be effective for preventing IAD.

Prospective trial for the clinical efficacy of anogenital skin care with miconazole nitrate-containing soap for diaper candidiasis

Anogenital skin care for the elderly remains an umbrella term concerning protective and non-interventional regimens, particularly for ordinary diaper users. Our recent investigation has demonstrated the preventive effect of daily anogenital washing with miconazole nitrate-containing soap to the development of diaper candidiasis. We extended this work to cover our hypothesis as to whether the miconazole soap has a therapeutic benefit in genital candidiasis. The study outline includes: (i) the enrollment of 21 bedridden inpatients (84 ± 9 years; eight men and 13 women) who were diagnosed clinically and mycologically with genital candidiasis, and who had never received topical and/or systemic antifungal agents; (ii) administration of anogenital washing with 0.75% miconazole-containing soap once daily for 4 weeks; and (iii) assessment of clinical symptoms and detection of Candida materials by culture and microscopic examination. As assessed by clinical symptom scoring for incontinence-associated dermatitis (IAD), the ratio of patients with severe to moderate symptoms dramatically decreased by 2 weeks and 10 of 21 patients became symptom-free at 4 weeks. The IAD clinical severity score was significantly decreased at 4 weeks. Compared with the baseline positivity, both microscopic and cultured Candida-positive rates were significantly decreased at 4 weeks after washing. All culture-detected fungi were Candida albicans. Severe adverse events did not occur in all participants. Individual medical and risk factors had no significant correlation with clinical severity and duration of candidiasis on variance analysis. In conclusion, topical washing with miconazole soap is a safe and reliable non-medical approach for soothing diaper-associated genital candidiasis in bedridden inpatients in whom it is difficult to perform prompt medical examination.

[Using Teamwork to Reduce the Incidence of Incontinence-Associated Dermatitis]

BACKGROUND & PROBLEMS

Dermatitis associated with incontinence was the cause of 55% of the total of 386 skin lesion cases in our unit between July and December 2016 and 40.3% of the skin lesion cases in our unit during March and April 2017, indicating the importance of this issue. Our survey showed that the nurses in our unit scored an average of 78.9% on knowledge related to the prevention of incontinence-associated dermatitis and only 58.2% on knowledge related to incontinence-associated dermatitis care. The main reasons for the high incidence of incontinence-associated dermatitis included: incorrect implementation of care, no discussion with the medical team, no incontinence care standards, no continue education, lack of related equipment for preventing incontinence-associated dermatitis, unit patient characteristics, and drugs used.

PURPOSE

To reduce the incidence of incontinence-associated dermatitis from 40.3% to 32.0%.

RESOLUTION

A care-bundle in treating incontinence-associated dermatitis was implemented by designing an assessment flow chart for evaluating incontinence-associated dermatitis, by setting standard guidelines for incontinence-associated dermatitis care, by distributing reminder cards, special toolboxes, and by changing how the little diapers were wrapped. In-service education lessons, inter-professional collaborative practice, and regular internal audit were also executed.

RESULTS

After project implementation, the knowledge score of nurses increased from 78.9% to 95.7%; the correctness of care score, as retested in November 2017, increased from 58.2% to 91.5%; and the incidence of incontinence-associated dermatitis dropped to 18.5%. These improvements achieved the goals of this project. Furthermore, the sustained effect of the project measures was confirmed, with the incidence of incontinence-associated dermatitis determined as 17.9% at three months after completion of the project.

CONCLUSIONS

Formulating care procedures and cooperating with medical team personnel to provide creative care measures were shown to effectively decrease the incidence of incontinence-associated dermatitis and improve overall quality of care. The findings of this project support the revision by hospitals of regulations and procedures related to adult incontinence-associated dermatitis to provide caregivers with basis-of-care standards and uniform care procedures and standards in support of effective patient skin care regimens.

Outcome measurement instruments for erythema associated with incontinence-associated dermatitis: Systematic review

AIM

To: (a) examine which outcome measurement instruments for erythema associated with incontinence-associated dermatitis (IAD) with supporting evidence about measurement properties are available; (b) evaluate the methodological quality of the studies and the quality of the measurement properties; and (c) identify eligible instruments to measure erythema in incontinence-associated dermatitis research.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, EMBASE, CINAHL and CENTRAL were systematically searched until July 2018 (update December 2018). Additional input was gathered from 151 incontinence-associated dermatitis experts. Cited and citing references of included studies were screened.

REVIEW METHODS

The COSMIN Risk of Bias checklist was applied to evaluate the methodological quality of the studies. Reported measurement properties were rated against criteria for good measurement properties.

RESULTS

Fourteen studies, describing 10 measurement instruments, were included. In five instruments, erythema was captured as a separate concept, two studies provided empirical evidence about the measurement properties. The most studied measurement properties were reliability (9 studies), measurement error (4 studies) and criterion validity (4 studies). In one study, internal consistency was examined.

CONCLUSION

No instrument measuring exclusively erythema associated with incontinence-associated dermatitis exists. There is no single composite incontinence-associated dermatitis measurement instrument that outperforms others. Development or adaption of an instrument to measure erythema associated with incontinence-associated dermatitis is one option to solve this challenge.

IMPACT

The evidence about measurement properties of instruments measuring erythema associated with incontinence-associated dermatitis has not been summarized to date. The lack of an instrument should trigger activities to measure this domain accurately in future clinical trials.

Design and psychometric testing of the attitude towards the prevention of incontinence-associated dermatitis instrument (APrIAD)

Despite the availability of a range of skin care products for the prevention of incontinence-associated dermatitis (IAD), prevalence remains high. Nurses' attitude is an important determinant to take into account in quality improvement projects. This study aimed to design a psychometrically test the attitude towards the prevention of incontinence-associated dermatitis instrument (APrIAD). A prospective psychometric instrument validation study was performed in a convenience sample of 217 Belgian nurses. Construct validity and reliability (internal consistency, stability) were tested. The exploratory factor analysis demonstrated a model consisting of four factors and 14 items: (a) beliefs about the impact of IAD on patients, (b) beliefs about team responsibility to prevent IAD, (c) beliefs about personal responsibility to prevent IAD, and (d) beliefs about the effectiveness of IAD prevention products and procedures. Cronbach's α was 0.72 for factor 1, 0.65 for factor 2, 0.63 for factor 3, and 0.47 for factor 4. The intra-class correlation coefficient was 0.689 (95% confidence interval [CI] 0.477-0.825) for the total instrument, 0.591 (95% CI 0.388-0.764) for factor 1, 0.387 (95% CI 0.080-0.626) for factor 2, 0.640 (95% CI 0.406-0.795) for factor 3, and 0.768 (95% CI 0.597-0.872) for factor 4. Psychometric testing of the APrIAD demonstrated adequate validity and reliability measures.

An experimental study of friction between volar forearm skin and nonwoven fabrics used in disposable absorbent products for incontinence

Incontinence-associated dermatitis is common among wearers of absorbent incontinence products and friction between product materials and skin is thought to be a contributing factor, but the details of its role are unclear. In this study, friction was measured between the dry volar forearm of 19 women (20-95 years) and five nonwovens typical of those in commercial disposable products. Euler's model/Amontons' law held to high precision for all person-fabric pairs for both static and dynamic friction, despite substantial variations in forearm size, soft tissue compliance and skin smoothness between subjects, sometimes substantial lateral contraction in fabric strips, and skin rucking beneath them. For a given subject, the highest coefficients of friction among the fabrics exceeded the lowest by ∼30% to 75%, while - for a given fabric - the highest coefficients of friction among the subjects exceeded the lowest by ∼55% to 85%. The order of coefficient of friction values across fabrics was similar for each subject, and across subjects for each fabric. There was no systematic variation with subject age. The data were well modelled by estimating the coefficients of friction for a given person-fabric combination as the product of the mean coefficient of friction across all fabrics for that person, and the mean coefficient of friction across all persons for that fabric, normalised to the mean coefficient of friction across all person-fabric combinations. Predicted values were within 10% of measured figures for ∼97% of person-fabric combinations. Stick-and-slip behaviour was observed with seven person-fabric combinations, but especially strongly for two subjects with each of two fabrics. It is not clear why and further investigation is merited. Comparison of the data with results from earlier work with the same fabrics and a skin surrogate (Lorica Soft) suggests that measurements with Lorica Soft may be helpful to screen, evaluate and compare candidate materials preparatory to human studies.

Incidence and risk factors of incontinence-associated dermatitis among patients in the intensive care unit

OBJECTIVE

To investigate the incidence of incontinence-associated dermatitis (IAD) among patients in the intensive care unit (ICU) and to identify potential risk factors to establish a reference for clinical nursing work.

BACKGROUND

Patients in the ICU are susceptible to IAD. IAD is painful, reduces the patient's quality of life and adds to the workload of clinical medical staff. However, risk factors associated with IAD may differ between countries and healthcare settings.

DESIGN

Prospective cohort study METHODS: From November 2016 to November 2017, a prospective cohort study was conducted among109 patients in three Class 3, Grade A hospitals (comprising 9 ICUs in total) in Beijing. The Incontinence-associated Dermatitis and Its Severity (IADS) instrument in Chinese was applied to assess IAD. Univariate and multivariate logistic regression analyses were performed to identify risk factors for IAD.

RESULTS

The study population had 29 community-acquired and 80 nosocomial infections, and 26 (incidence: 23.9%) of these had IAD. On univariate analysis, a significant difference was observed between patients with and without IAD with respect to the following indices: Barthel index, Braden scale score, Nutritional Risk Screening 2002 (NRS2002) score, serum albumin level, occurrence of infection, faecal incontinence, frequency of faecal incontinence, stool property and double (faecal and urinary) incontinence and perineal assessment tool (PAT) score (p < 0.05). Multivariate logistic regression analysis showed that three factors entered the regression equation-that is, the Braden Scale Score, serum albumin level and double incontinence. Of these, the Braden Scale Score and serum albumin level were protective factors for IAD. Thus, the higher the Braden Scale Score, the lower the risk of IAD (OR = 0.678, 95% confidence interval [CI] = 0.494-0.931); a higher level of serum albumin implies a lower risk of IAD, provided it is within the normal range (OR = 0.884, 95%CI = 0.797-0.981). Double incontinence was an independent risk factor for IAD (OR = 10.512, 95% CI = 2.492-44.342).

CONCLUSION

A higher morbidity of IAD is seen in the ICU. Specific preventive and nursing measures are required to maintain the skin integrity of critically ill patients in daily nursing practice to improve patient quality of life and the quality of nursing care.

RELEVANCE TO CLINICAL PRACTICE

Incontinence-associated dermatitis is characterised by inflammation and tissue damage due to prolonged/repeated exposure to urine and/or stool. Not every patient with urine and/or stool incontinence develops IAD. Medical staff can use research-based evidence to identify ICU patients at risk of IAD to reduce morbidity and improve health outcomes.

Influence of digestive enzymes on development of incontinence-associated dermatitis: Inner tissue damage and skin barrier impairment caused by lipidolytic enzymes and proteases in rat macerated skin

One of the most common complications in patients with incontinence is incontinence-associated dermatitis. This study aimed to examine the influences of lipidolytic enzymes and/or proteases on skin barrier and tissue structure on the development of incontinence-associated dermatitis. Two animal experiments, ex vivo and in vivo, were performed using rats to examine the influences of 3 factors (maceration, proteases, and lipidolytic enzymes) alone or in various combinations on the barrier function and histology of the skin. As a result, skin treatments, including both of the skin maceration and proteases application, caused erythrocyte leakage from the blood vessels in the dermis. The erythrocyte leakage was observed in a larger area in the skin treated with proteases and lipidolytic enzymes with maceration than in the skin treated with proteases with maceration, that is, the addition of lipidolytic enzymes to skin maceration with proteases enhanced erythrocyte leakage. Lipidolytic enzymes in macerated skin are factors that accelerate tissue damage via skin barrier impairment, and proteases are the factors that trigger the development of incontinence-associated dermatitis via tissue damage. Advanced nursing care of perineal skin in patients with faecal incontinence is required because of the deleterious influence of lipidolytic enzymes and proteases.

The Ghent Global IAD Monitoring Tool (GLOBIAD-M) to monitor the healing of incontinence-associated dermatitis (IAD): Design and reliability study

The aim of this study was to design and evaluate the reliability of the Ghent Global incontinence-associated dermatitis (IAD) Monitoring Tool (GLOBIAD-M). The tool was designed based on the internationally validated Ghent Global IAD Categorisation Tool (GLOBIAD). After designing and validation by experts, one trained researcher carried out 36 observations of 9 patients affected with IAD. Photographs of the IAD lesions were independently assessed by a second trained researcher. Measures for inter-rater agreement (p_o ) and reliability [Cohen's Kappa (ĸ) and intra-class correlation coefficients (ICC)] were analysed. The p_o ranged between 0.86 for the item 'maceration' and 0.97 for the item 'clinical signs of infection'. The ĸ for the item 'GLOBIAD classification' was 0.61 [95% confidence interval (CI) 0.28-0.95] and 0.72 (95% CI 0.50-0.95) for 'maceration'. The lowest ĸ was found for the item 'oedema' (0.27; 95% CI -0.24-0.79). The ICC of the item 'redness' was 0.83 (95% CI 0.69-0.91) and 0.87 (95% CI 0.76-0.93) for 'skin loss'. The inter-rater agreement and reliability of the GLOBIAD-M appears to be good for the assessment of photographs by experts. This tool could support clinical decision-making for IAD treatment. Further validation with clinicians is, however, needed.

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.

Skin Protectants Made of Curable Polymers: Effect of Application on Local Skin Temperature

Objective: To measure the skin temperature after application of a new skin protectant intended for incontinence-associated dermatitis (IAD), compared with a commercial product with an analogous cyanoacrylate-based chemistry.

Approach: Twelve healthy human volunteers received an application of the new product on one thigh and of the comparator on the other thigh. An infrared camera using ThermaCAM™ software imaged the skin and measured the temperature at the skin surface over time to characterize the thermal cure profile induced by the products on the skin.

Results: The new product led to a drop in skin surface temperature (endothermic reaction), whereas the commercial product displayed an exotherm and a slight rise in skin surface temperature.

Innovation: Cyanoacrylate-based chemistries come in various formulations, differing in the side chains and additives used. They are liquid monomers that polymerize after application, and this polymerization is accompanied by an exothermic reaction that can be perceived as an unpleasant warming sensation, especially on compromised skin. A new formulation was designed to mitigate this rise in temperature.

Conclusion: The new skin protectant may potentially be more comfortable for IAD patients, since it causes a drop in skin surface temperature instead of a rise during the curing process that follows application.

Effect on Microbial Growth of a New Skin Protectant Formulation

Objective: Evaluate the effect of a new investigational skin protectant formulation on the growth of various microorganisms in vitro. Approach: An in vitro laboratory assay with various species of gram-positive bacteria, gram-negative bacteria, and yeast grown on agar plates was used to verify that a new investigational product used for the management of incontinence-associated dermatitis (IAD) does not support microbial growth. Results: The investigational product did not support the growth of all organisms tested for 48 h in these assays. The results demonstrate the barrier properties of this investigational formulation against bacteria and yeast that are relevant to incontinent patients. Innovation: IAD accompanied by skin damage is difficult to manage with currently available products. A new skin protectant that can be applied as a liquid and polymerizes into a breathable film in situ even in the presence of exudate (as shown previously) has been developed and tested to ensure that it does not support microbial growth. Conclusion: This work verifies that this new product does not support microbial growth in vitro using organisms relevant for the intended application.

[Local barrier creams for skin care in newborns, infants and toddlers with incontinence-associated dermatitis (IAD) – Narrative Review]

Background: The incontinence-associated dermatitis (IAD) is a common condition in newborns, infants and toddlers. For the therapy nurses and parents have the choice between numerous barrier creams based on zinc oxide, Dexpanthenol or Vaseline in various combinations of active agents and with additional ingredients. Research question: Which combination of active ingredients in local barrier creams reduce pain, severity of or duration of healing in IAD in neonates, infants and young children? Method: MEDLINE and CINAHL was systematically search for randomized controlled trials on the effect of barrier creams in pediatric patients with IAD. These were evaluated on validity and applicability. Results: 15 RCTs were found, of which six were included in the systematic review. The methodological quality of these trials ranges from good to poor, partially high bias risk were recognizable. Barrier creams containing the active ingredients zinc oxide / lanolin, zinc oxide / cod liver oil, zinc oxide / Dexpanthenol, paraffin / beeswax / Dexpanthenol show effects. They reduce the IAD-associated symptoms. Conclusions: The investigated barrier creams can be used in the pediatric nursing for the treatment of IAD. Because of limitations it cannot be ruled out that further studies will change the results.

PROTECT - trial: a multicentre prospective pragmatic RCT and health economic analysis of the effect of tailored repositioning to prevent pressure ulcers - study protocol

AIM

The aims of this trial were as follows: (1) to compare the (cost-) effectiveness of a turning and repositioning system and an algorithm for a tailored repositioning vs. usual care to improve reposition frequency in patients at risk; and (2) to compare the (cost-) effectiveness of standardized incontinence care vs. usual care.

BACKGROUND

Pressure ulcers are a serious and common problem for hospitalized patients. In many countries, pressure ulcers are recognized as a national health issue and governments designate pressure ulcers as one of the most important sentinel events for health care. International guidelines recommend the use of pressure redistributing support surfaces, systematic patient repositioning and preventive skin care to prevent pressure ulcers. Interventions should be patient-tailored and based on a thorough assessment of both the patient and contextual risk factors. There is a lack of rigorous research addressing the effectiveness of a turning and repositioning system and it is unclear how to tailor the frequency and posture to specific patient needs.

DESIGN

Multicentre, cluster, three-arm, randomized, controlled pragmatic trial and a cost-effectiveness analysis. The ward is the unit of randomization.

METHODS

Tailored repositioning, the use of a device to facilitate patient repositioning and an optimal procedure for incontinence care will be combined. Participating wards will be intensive care units, geriatric and rehabilitation wards. A sample size calculation was performed (80% power, α = 0·05). This study is approved by the Ethics Committee (February 2016).

DISCUSSION

Data collection is currently ongoing. The results are expected to be obtained in March 2017.

Candida albicans colonisation, continence status and incontinence-associated dermatitis in the acute care setting: a pilot study

Candida albicans is the most prevalent human fungal commensal organism and is reported to be the most frequent aetiological organism responsible for infection associated with incontinence-associated dermatitis. However, it remains unclear whether incontinence predisposes a patient to increased Candida colonisation or whether incontinence acts as a trigger for Candida infection in those already colonised. The purpose of this observational cross-sectional study was to estimate colonisation rates of C. albicans in continent, compared to incontinent patients, and patients with incontinence-associated dermatitis. Data were collected on 81 inpatients of a major Australian hospital and included a pelvic skin inspection and microbiological specimens to detect C. Albicans at hospital admission. The mean age of the sample was 76 years (SD = 12.22) with 53% being male. Incontinent participants (n = 53) had a non-significant trend towards greater Candida colonisation rates at the perianal site (43% versus 28%) χ² (1, N = 81) = 4·453, p = ·638 and the inguinal site (24% versus 14%) χ² (1, N = 81) = 6·868, p = ·258 compared to continent patients (n = 28). The incontinent subgroup with incontinence-associated dermatitis (n = 22) showed no difference in colonisation rates compared to those without incontinence-associated dermatitis. Understanding the epidemiology of colonisation may have implications for the prevention of Candida infection in these patients.

An Approach to Urinary Incontinence for Dermatologists

Incontinence-associated dermatitis (IAD) is a condition often encountered by dermatologists. IAD is an inflammatory skin condition secondary to prolonged urine exposure-it is a dermatologic sequela of urinary incontinence. Incontinence should not be dismissed simply as an age-related disorder; rather, it is due to a number of pathologic conditions that can be either reversible or manageable. It is thus critical to identify and treat the underlying causes of urinary incontinence. Clinical management of this common medical issue restores normality to patients' lives while also preventing future dermatologic complications. In this article, we aim to provide dermatologists with an overview of IAD and an approach to the diagnosis and initial management of urinary incontinence.

Barrier products in the treatment of incontinence-associated dermatitis

This article reviews contemporary primary research studies to establish the evidence supporting the use of barrier products and evaluate practice regarding their use in the acute hospital setting. Six primary research studies investigating the use of barrier products for preventing and managing incontinence-associated dermatitis were reviewed. The aim was to identify the most effective treatments for incontinence-associated dermatitis to enhance the quality of life of patients. The studies identified that there is no significant difference in efficacy between petrolatum, zinc oxide oil and a polymer-based barrier film, and that a polymer-based barrier film is more cost-effective than petrolatum or zinc oxide. However, further robust research studies are required to inform practice. The efficacy and cost-effectiveness of barrier products can be enhanced by providing education in clinical practice on consistent skin care regimens and effective use of barrier products.

A systematic review and meta-analysis of incontinence-associated dermatitis, incontinence, and moisture as risk factors for pressure ulcer development

The aim of this analysis was to identify the association between incontinence-associated dermatitis (IAD), its most important etiologic factors (incontinence and moisture), and pressure ulcers (PUs). A systematic review and meta-analysis were performed. We searched Medline, Embase, CINAHL, Web of Science, and the Cochrane Library for relevant papers dating through March 15, 2013. Fifty-eight studies were included. Measures of relative effect at the univariate level were meta-analyzed. In most studies (86%), a significant association between variables of interest was found, with pooled odds ratios of PUs in univariate models between 1.92 (95% CI 1.54-2.38) for urinary incontinence and 4.99 (95% CI 2.62-9.50) for double incontinence (p < .05). This evidence indicates an association between IAD, its most important etiological factors, and PUs. Methodological issues should be considered when interpreting the results of this review.