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Improving quality by taking aim at incontinence-associated dermatitis in hospitalized adults.

A practice-improvement project was launched to implement an evidence-based intervention bundle for incontinence-associated dermatitis (IAD) and evaluate its impact on the identification, prevention, and management of IAD in hospitalized adults.

Incontinence-associated dermatitis (IAD) is a condition in which the skin of the perineum, perianal area, buttocks, inner thighs, sacrum, and coccyx becomes erythematous, macerated, denuded, and inflamed following exposure to urine or stool (Beeckman, Verhaeghe, Defloor, Schoonhoven, & Venderwee, 2011; Black et al., 2011; Doughty et al., 2012; Gray et al., 2011; Gray et al., 2012). Current evidence strongly suggests incontinence and IAD are common in acute care settings (Bliss et al., 2011; Campbell, Coyer, & Osborne, 2014; Gray & Bartos, 2013; Park & Kim, 2014). The impact of incontinence and moisture on pressure ulcer formation is recognized in guidelines published by multiple organizations that recommend management of these risk factors (Institute for Clinical Systems Improvement [ICSI], 2014; Minnesota Hospital Association [MHA], 2011; National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance, 2014; Wound, Ostomy and Continence Nurses Society [WOCN], 2010, 2011). Application of evidence-based practices (EBP) for skin care and containment products for incontinence can decrease the incidence of IAD (Beeckman et al., 2011; Denat & Khorshid, 2011). The MHA (2011) identified incontinence skin protection as a component of its Road Map to a Comprehensive Skin Safety program.

Because pressure ulcers can occur on the body in the same locations as IAD, determining if a skin impairment is caused by incontinence or pressure can be challenging (ICSI, 2014; WOCN, 2010). In 2008, the Centers for Medicare & Medicaid Services began to deny reimbursement for medical care of hospital-acquired pressure ulcers (U.S. Department of Health & Human Services, 2008). The financial implications of this practice make correct identification of skin impairment imperative. Furthermore, skin alterations caused by incontinence but misclassified as being caused by pressure inaccurately inflate the pressure ulcer data reported to the National Database of Nursing Quality Indicators and reflect negatively on a health care facility's reputation as a provider of quality care (Mahoney, Rozenboom. Doughty, & Smith, 2011).

The purpose of this practice improvement project was to implement an evidence-based intervention bundle for IAD and evaluate its impact on the identification, prevention, and management of IAD in hospitalized adults.

Literature Review

A comprehensive review of the literature from 1980 through 2012 was completed to identify prevalence of and potential solutions for incontinence and IAD. CINAHL, Ovid/MEDLINE, Pub Med, ProQuest, the Cochrane Library, and National Guideline Clearinghouse databases were searched using the terms incontinence, dermatitis, perineal, incontinence pads, fecal incontinence, urinary incontinence, and pressure ulcers. The following search words were combined: incontinence and dermatitis; perineal and dermatitis; and incontinence pads or fecal incontinence, or urinary incontinence and dermatitis. The number and types of reviewed sources are listed in Table 1. The literature was searched again in January 2015 to identify new evidence and practice guidelines from the past 2 years.

Prevalence of IAD

Although incontinence as a general topic is very well represented in the literature, few sources specifically address the prevalence of incontinence and associated skin damage occurring in acute care. In a prospective epidemiologic study involving 791 patients at 20 acute care facilities, Gray and Bartos (2013) reported an overall incontinence prevalence of 54% (n = 426), with IAD identified in 43% (n = 184) of those incontinent patients. Campbell and colleagues (2014) identified an incontinence prevalence rate of 24% [n = 91) in 376 hospitalized patients. Incontinence-associated dermatitis was present in 42% (n = 38) of the patients with incontinence. Bliss and colleagues (2011) found IAD developed in 16 of 45 patients (36%) with fecal incontinence in three critical care units.

EBP Interventions

Four categories of EBP interventions aimed at addressing the complex issue of IAD were identified in the literature. The bundle of interventions included (a) a defined skin care program, (b) education to help registered nurses (RNs) distinguish IAD from pressure ulcers, (c) evaluation of absorbent products, and (d) documentation enhancements.

A defined skin care program. A well-defined incontinence skin care program incorporates products that cleanse, moisturize, and protect; such a program can be effective in reducing incidence of IAD (Black et al., 2011; Park & Kim, 2014). Skin cleansers with an acidic pH (range 4.9-5.5) are recommended because of their similarity to the pH of healthy skin. For patients with fecal incontinence, products containing zinc oxide provide a more effective barrier than those with petrolatum (Langemo, Hanson, Hunter, Thompson, & Oh, 2011).

IAD differentiation education. Research demonstrates nurses have difficulty distinguishing IAD from pressure ulcers (Beeckman et al., 2010; Mahoney et al., 2011). In a study by Mahoney and colleagues (2011), 100 nurses with wound care expertise were asked to view color photographs and identify the underlying cause of nine wounds on patients' buttocks and in the intergluteal cleft. Disagreement on the primary cause of the lesions was common, with reported agreement being "only 17% better than chance alone" (p. 635).

Beeckman and co-authors (2010) conducted a randomized controlled trial to determine the effects of an educational program on nurses' ability to differentiate pressure ulcers from IAD. At baseline, 1,217 nurses showed 44.5% accuracy in classification of wounds from photographs. The intervention group attended a 1-hour, face-to-face, standardized educational program incorporating lecture, photographs, and video. The control group had a 15-minute review on the classification of pressure ulcer grades. Authors reported statistically significant improvement (p<0.001) in the percentage of correct IAD assessments for the intervention group when compared with the control group (70.7% vs 35.6% accuracy, respectively).

Evaluation of absorbent products. Absorptive products containing polyacrylate polymers effectively pull moisture away from the skin (Beguin et al., 2010). Other key evidence-based recommendations in the literature include limiting the use of disposable briefs and avoiding cloth products (ICSI, 2014; WOCN, 2010, 2011). Fecal enzymes are activated when urine and stool mix together on cloth-containment products, potentially contributing to skin irritation (WOCN, 2011).

Documentation enhancements. The MHA (2011) requires facilities to track and analyze data regarding IAD and to document application of moisture-barrier products for patients who are incontinent. According to Dykes and Collins (2013), electronic medical records are needed to link information about nursing care and patient outcomes in order to describe the impact of nursing on quality of care.

Summary of the Evidence

The clinical problem of IAD is multifactorial, requiring implementation of a bundle of nursing interventions that encompasses identification, prevention, and management. An educational program using photographs can improve nurses' ability to identify IAD (Beeckman et al., 2010). Evidence-based skin barrier and moisture-absorbing products are essential components of a defined skin care program (Doughty et al., 2012). Documentation systems may be used to quantify prevalence of IAD and incontinence, as well as nursing interventions.

Improvement Needs and Group Oversight

Setting Description

This project was conducted at a large Midwestern academic medical center. One of the authors, a clinical nurse specialist (CNS), recognized incontinence as a risk factor for pressure ulcers and developed a doctoral capstone project focusing on IAD. A situational analysis identified care improvement opportunities regarding IAD and availability of data about incontinence prevalence, nurse knowledge level regarding IAD and pressure ulcer differentiation, procedure guideline and incontinence skin care product evidence, and documentation of IAD and related interventions in the electronic medical record (EMR).

Purpose of the EBP Project

The purpose of this project was to implement and evaluate the impact of an evidence-based intervention bundle on the identification, prevention, and management of IAD in hospitalized adults. The intervention bundle included a defined skin care program, an IAD differentiation education program, evaluation of absorbent products, and documentation enhancements.

Oversight Group and Stakeholders

Because managing incontinence and correctly identifying IAD may reduce the incidence of pressure ulcers, this project was supported by nurse leaders. A cost-benefit analysis was conducted (see Table 2). The overall cost of education for all interventions was estimated to be $27,895. If just one case of IAD is not misclassified as a pressure ulcer, an estimated financial loss of $43,180 could be adverted (Berlowitz et al., 2014).

The Inpatient Nursing Clinical Practice Subcommittee (INCPS) provided oversight and approval of the quality improvement project. Individuals and groups having key roles in this IAD project included all inpatient CNSs, clinical RNs who were skin-saver champions on their nursing units, a quality nurse specialist, an informatics nurse specialist, representatives from linen and central services, support service coordinators, and the Nursing Supply Value Analysis Committee (NSVAC). Additional stakeholders included all hospital nursing staff, patient care assistants (PCAs), and patients receiving care at the facility.

Ethical Considerations

Institutional review board (IRB) approval was granted by Minnesota State University Moorhead. Because the intent of this project was to improve local practices surrounding the problem of IAD, IRB approval was not required at the clinical site. The demographic and test forms did not contain any identifiers, and patient records were de-identified. Data were reported in aggregate format to ensure confidentiality.

Continuous Quality Improvement Model

The Multisystem Model of Knowledge Integration and Translation (MKIT) provided the framework for planning, implementing, and evaluating this project (Palmer & Kramlich, 2011). MKIT involves an iterative process of knowledge seeking or generation, integration, implementation, evaluation, and mentoring that begins and ends with reflective inquiry. This cyclic process directed baseline and post-implementation measurement, education, collaborative relationship building, and system changes to sustain programs and further improve outcomes.

An underlying premise of MKIT is that practice can improve when people from different groups share ideas, develop a sense of community, create a shared practice, and pursue joint projects. According to Palmer and Kramlich (2011), diffusion of best practices occurs through partnerships with people at the point of care (microsystem), nurse leaders who support the staff at the bedside (mesosystem), and organizational leaders who ensure the necessary resources are available (macrosystem). The MKIT model guided the inclusion of stakeholders representing various roles and departments.

Quality Indicators and Oata Collection

Baseline data about IAD prevalence revealed an opportunity to improve patient care. In addition to tracking prevalence of IAD, the quality indicators for the intervention bundle were including evidence-based skin care content in a nursing procedure guideline, improving RNs' knowledge regarding differentiating IAD from pressure ulcers, evaluating availability and usage of absorbent products, and incorporating EMR enhancements and analyzing data on the frequency of IAD documentation and related interventions. Project implementation and data collection processes of the quality indicators for each category of intervention are discussed below.

A Defined Skin Care Program

A data collection form developed by the CNS project leader and quality nurse specialist was used for the incontinence and IAD quarterly prevalence audits. Audits were conducted on each nursing unit by an assigned CNS and RN. Completed forms were returned to the CNS project leader for data analysis.

IAD Differentiation Education

The online European Pressure Ulcer Advisory Panel's pressure ulcer classification (PUCLAS) education module (Defloor et al., n.d.) was used to measure RNs' knowledge of IAD identification. Tests were administered before and after IAD differentiation education. Because of variations in the pressure ulcer staging system used in Europe and the United States and the focus on skin alterations in the anatomic skin surfaces likely to be exposed to incontinence, PUCLAS content was modified with permission (D. Beeckman, personal communication, May 14, 2012).

Four CNSs with expertise in skin and wound care evaluated the content validity of the photographs using the four-point scale described by Polit and Beck (2012). Photograph selection and educational content were modified following the first two phases of content review. Ultimately, 100% agreement was achieved among content experts.

The pretest IAD classification education module included 16 slides of skin alterations. Each slide showed a photograph and the following classification choices: (a) blanchable erythema, (b) stage I, (c) stage II, (d) unstageable, (e) incontinence-related, (f) perspiration-related, and (g) combination of pressure and incontinence or perspiration. The posttest module contained the same 16 photographs presented in a different order. The IAD differentiation education contained didactic content and photographs, including those used in the pretest and posttest.

Clinical nurse specialists, unit-based skin-saver RNs, and RNs on units with a higher prevalence of incontinence were invited to participate in the hour-long IAD differentiation education program, which included the pretest, education, posttest, and discussion. Using a written script to ensure each group received exactly the same content, the CNS project leader conducted five classes describing IAD differentiation in the fall of 2012.

Evaluation of Absorbent Products

After a review of the literature, the CNS project leader proposed an evaluation of absorbent pads. In August 2012, the evaluation was conducted at the clinical site by a work group of CNSs and members of the NSVAC. The quality and effectiveness of the incontinence pads were judged by their durability, reliability in preventing leaks, absorbency, and degree of moisture wicking from the skin. Each pad was tested for 1 week on inpatient units and evaluated by the nursing staff. Results of the completed product evaluation forms and costs of current products were reviewed. Recommendations were developed and endorsed by the CNSs and INCPS.

Documentation Enhancements

Quarterly incontinence and IAD prevalence audits were scheduled for September and November 2012. Flow sheet rows were added to the EMR after the September audit to standardize documentation of IAD and interventions related to IAD prevention and management. After the unit-based RNs and CNSs completed patient assessments, the incontinence and IAD prevalence audit forms were provided to the CNS project leader. Every third audit form was selected for chart review by the CNS until 20 were identified. The EMRs of the 20 hospitalized adults served as the source of snapshot data. The Nursing Care Plan Data Collection Instrument, developed by Larrabee and colleagues (2001), was customized and used by the CNS project leader during manual chart review.

Evaluation and Action Plan

A Defined Skin Care Program

The existing IAD procedural guideline was revised on the basis of current evidence to include content on using a defined skin care program. The four CNS skin experts provided feedback on the revised guideline, which then was reviewed and approved by all CNSs and the INCPS. An online best practices education module regarding IAD guideline changes, evidence-based usage of absorbent pads, and documentation enhancements was developed and made available to all nursing staff. Quarterly incontinence and IAD prevalence data will continue to be collected, and trends over time will be shared with unit-based CNSs and INCPS. The standard documentation location for IAD will facilitate electronic data retrieval.

IAD Differentiation Education

After the IAD differentiation education of 73 nurses, JMP statistical software (Statistical Discovery; SAS Institute, Inc) was used to calculate and compare correct responses on pretests and posttests (means 5.68 and 12.68, respectively) and describe nurse demographics (see Table 3). The two-sample f-test for pretest and posttest scores was completed to determine statistical significance. The nurse's knowledge significantly improved (p<0.001) after education. Following the success of this IAD differentiation education, content was added to the facility-wide RN and CNS orientation modules and the IAD procedural guideline.

Evaluation of Absorbent Products

Evidence-based recommendations on usage of absorbent products were incorporated into the IAD procedural guideline. A 2-minute video demonstrating the absorbency of the new polymer product was developed and included in staff education. Incontinence-associated dermatitis best practices education also was provided at the PCA skills fair and added to orientation content. Implementation of the new absorbent product occurred in January 2013. The impact of the product change on absorbent pad usage and costs, cloth pad purchases, distribution, and laundering over the long term will be monitored by the CNS project leader, support service coordinators, and linen and central services supervisors. Cost-benefit analysis has demonstrated savings related to linen usage and purchase costs.

Documentation Enhancements

Enhancements in the EMR to facilitate documentation of IAD and incontinence-related nursing interventions were developed in collaboration with the CNS skin experts and an informatics nurse specialist, approved by the INCPS, and implemented in September 2012. In November 2012, chart review data were analyzed using JMP statistical software (SAS; Cary, NC) to determine differences in frequency of documentation of incontinence-related care plans and nursing interventions. Little difference was found in frequency of observed LAD interventions (see Table 4).

Similarity of results between the two chart audits may have been influenced by the fact the IAD best practices and documentation education modules were not required and may not have been completed before the second audit. Additionally, PCAs did not receive education on the EMR intervention rows until 1 month after data were collected because of the prescheduled annual skills fair. The low percentage of incontinence-related care plans may be related to nurses' perception of incontinence management as a component of basic care that did not require a written plan.

Results and Limitations

Results

The project's purpose was accomplished over 5 months. Additional time is needed for nurses to complete the IAD best practices and documentation education modules and use the new incontinence pads before the impact of the intervention bundle on IAD prevalence can be determined. Strategies were designed to sustain and monitor the impact of the IAD EBP project over time; these included the following: (a) embedding IAD best practices and IAD differentiation education content into CNS, RN, and PCA orientation; (b) biennially reviewing the IAD procedural guideline; (c) scheduling quarterly incontinence and IAD prevalence audits; and (d) monthly monitoring of absorbent and cloth pads usage, as well as their cost through 2014.

Limitations

System issues created some limitations in the orderly implementation of various components of the intervention bundle. Each component required its own set of approvals and plans, making it difficult to follow a defined timeline. For example, the timing of the chart reviews was influenced by the scheduled prevalence audits and the capstone coursework schedule. Thus, the second chart review occurred before full project implementation. Limited information technology resources resulted in delays in implementing enhancements to the EMR. The addition to the incontinence-related nursing diagnosis electronic care plan for cleansing skin and applying skin protectants was delayed until December 2012 because of limited informatics resources. The completion of the IAD best practices education was not mandatory, thus influencing the degree to which bundle elements were performed initially.

Nursing Implications

This project highlighted the importance of conducting a periodic, systematic review of the literature for incontinence care, as well as a situational analysis to determine project feasibility. Systems issues, including documentation and appropriate product availability, need to be addressed to facilitate the delivery of evidence-based care.

Although the results of this project are not generalizable, other health care facilities may consider using photographs in IAD education to help RNs differentiate IAD from pressure ulcers. They also should design EMR documentation to capture IAD frequency and related nursing interventions. Lessons learned during project implementation may be helpful for future efforts related to EBP: (a) align project with institutional priorities, (b] involve multidisciplinary stakeholders, (c) select a leader with an interest in the clinical issue who has dedicated time, and (d) review the institution's process for necessary approvals to reduce delays in implementation.

Conclusion

A bundle of evidence-based interventions to identify, prevent, and manage IAD was implemented successfully. The significant improvement in nurses' post-education IAD classification scores suggests the use of skin and wound photographs may help reduce misclassification of IAD as pressure ulcers. Chart reviews will determine if allowing more time for nursing staff to complete the online education will affect documentation frequency of incontinence-related care plans and interventions. Systems have been developed to facilitate monitoring and identify trends in IAD prevalence and chart review data over time to determine the impact of and adherence to the intervention bundle.

Therese M. Jacobson, DNP, APRN, CNS, CWOCN, is Clinical Nurse Specialist, Mayo Clinic, Rochester, MN.

Tracy Wright, PhD, RN-BC, CNB, is Professor, School of Nursing, Minnesota State University Moorhead, Moorhead, MN.

References

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Reprinted from MEDSURG Nursing, "Improving Quality by Taking Aim at Incontinence-Associated Dermatitis in Hospitalized Adults," Volume 24, Number 3, pp. 151-157. Reprinted with permission of the publisher, Jannetti Publications, Inc., East Holly Avenue/Box 56, Pitman, NJ 08071-0056; Phone: (856) 256-2300; Fax: (856) 589-7463; Email: msjrnl@ajj.com; Website: www.medsurgnursing.net. For a sample copy of the journal, please contact the publisher.
Table 1.
Summary of Reviewed Sources *

                                                           Number
Type of Article or Guideline                            of References

Randomized controlled trial                                   5
Clinical practice guideline                                   4
Quasi-experimental study                                      2
Systematic review and the WOCN Best Practice document         2
Single descriptive study                                     17
Expert opinion                                               15

* This summary represents the sources reviewed before implementation
of the project in 2012.

Table 2.
Cost-Benefit Analysis

Implementation                        Cost

Define skin care      Online IAD Best Practices staff
program and           education, estimated total $11,655
documentation
enhancements.         Product usage and potential
                      increase in use, cost unknown

                      Documentation changes, estimated
                      $940

IAD differentiation   Salary of participants (CNSs, skin
education             savers, and unit practice committee
                      RNs), estimated total $3,375 (a)

                      Printing $51 75

                      Incentives $60.87

Incontinence pad      Costs associated with online staff
evaluation            education on use and cost of pad
                      (estimated total $11,812.50),
                      product evaluation, and program
                      development

                      Cost of new pad, more expensive
                      than current pad

                      Purchase and laundry costs for
                      cloth pads (80% decrease
                      anticipated)

Total estimated       As calculated from above,
education costs       $27,895.12

                      In addition, estimated 160 hours
                      (gratis  DNP student)

                      Clinical and Economic Benefits

Implementation               Patient                 Institution

Define skin care      Decrease                Compliance with MHA safe
program and           prevalence of IAD       skin program and ability
documentation         and associated          to efficiently monitor
enhancements.         pain.                   outcomes

IAD differentiation   Accurate diagnosis      Potential avoidance of
education             and treatment           revenue loss due to IAD
                                              misclassification is
                                              $43,180 (cost of
                                              hospitalization for one
                                              pressure ulcer [Berlowitz
                                              et al., 2014])

Incontinence pad      Improve satisfaction    Long-term cost savings
evaluation            and comfort by          (anticipated) by
                      feeling drier and       eliminating breathable
                      maintaining skin        pads, reducing cloth pad
                      integrity.              use by 75%, and
                                              decreasing frequency of
                                              linen changes

Total estimated       Care is evidence-       Reputation is enhanced
education costs       based and measurable.   through improved quality.

(a) Average nursing salaries were obtained from websites (Average
RNSalary.net, n.d.; Health Informatics Forum, 2011; Indeed.com, 2013).

Table 3.
IAD Education Nurse Demographics (N = 73)

Nurse Characteristics             Number (%)

Age range in years
  23-30                            20 (27.4)
  31-40                            25 (34.2)
  41-50                            13 (17.8)
  51-60                            11 (15.1)
  61-65                             3  (4.0)
  Missing data                      1  (1.4)
Experience as an RN in years
  1-10                             34 (46.6)
  11-20                            18 (24.6)
  21-30                            11 (15.1)
  31-40                             7  (9.6)
  41-43                             3  (4.1)
Current nursing role
  Skin-saver RN                    13 (17.8)
  Unit practice committee RN       17 (23.3)
  Clinical nurse specialist        41 (56.2)
  Other                             2  (2.7)
Sex
  Female                           67 (91.8)
  Male                              6  (8.2)
Race
  Asian                             1  (1.4)
  Black                             2  (2.7)
  White                            70 (95.8)
Ethnicity
  Hispanic/Latino                   0  (0.0)
  Not Hispanic or Latino           56 (76.7)
  Missing data                     17 (23.3)
Education level
  Associate degree in nursing       3  (4.1)
  Bachelor degree in nursing       28 (38.4)
  Master of science in nursing     35 (47.9)
  Doctor of nursing practice        1  (1.4)
  PhD in nursing                    0  (0.0)
  Missing data                      6  (8.2)

Table 4.
Documentation Audit Results (N = 20)

                               September 2012        November 2012
                             Pre-Implementation   Post-Implementation
Chart Review                     Number (%)           Number (%)

Type of incontinence
  Urine                             8 (40)               3 (15)
  Stool                             9 (45)              14 (70)
  Both                              3 (15)               3 (15)
Nursing diagnosis related
  to incontinence                   2 (10)               2 (10)
Incontinence documented
  within 48 hours
  (range 1-16)                     15 (75)              12 (60)
IAD documented as a skin
  alteration within
  48 hours                          2 (10)               2 (10)
Cleanser ordered                     1 (5)               2 (10)
Use of cleanser documented
  within 48 hours                   6 (30)               7 (35)
  (range 1-10)
Protectant ordered                  3 (15)               2 (10)
Use of protectant
  documented within 48              6 (30)              11 (55)
  hours (range 1-12)
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Title Annotation:Quality/Performance Improvement
Author:Jacobson, Therese M.; Wright, Tracy
Publication:Urologic Nursing
Article Type:Report
Date:Nov 1, 2015
Words:4939
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