In this blog for nurses, Sarah Chapman shares the latest Cochrane evidence on incontinence-associated dermatitis and registered nurses Teresa Chinn and Shannon Deakin consider the challenges of applying evidence to practice.
First, the problems
Incontinence is a common problem in all healthcare settings and in the community too, with prevalence estimated at 10% to 15% for faecal incontinence in community-dwelling adults, while almost half of older, care home residents are incontinent of urine.
The potential miseries associated with incontinence are manifold. One of them is perineal skin breakdown. Incontinence-associated dermatitis (IAD) is skin inflammation, with or without blistering, erosion or loss of the skin’s barrier function, and results from frequent exposure to urine or faecal matter. IAD is sometimes confused with stage I and II pressure ulcers, another misery which incontinence and IAD make more likely.
The approach to prevention and treatment is the same: cleanse, moisturize, protect. There’s good old soap and water for skin cleansing of course. There are ordinary washcloths and super-washcloths, with cleansing, moisturising and protecting properties. Then there are moisturisers and skin protectors, ‘leave-on products’, that may be used alone or together. There are plenty to choose from, creams, pastes, film layers and so on, and the amount used, and the frequency and methods of application, will also vary in practice.
What do we need to know?
Do we know how well they work, if at all? Which ones? Under what circumstances? An intervention might be simple and have a sound theoretical basis; we might have used it for a long time and believe, from what we’ve observed, that it works. But, as discussed recently in another blog, in relation to pressure ulcers, this isn’t enough. Which products and procedures we use have an impact on patients, and on health budgets too.
So what’s the evidence?
A Cochrane review has investigated the effectiveness of products and procedures used to prevent and treat IAD in adults. The main outcomes of interest were the number of people with new IAD; the number with unhealed IAD; and patient satisfaction with treatment.
The review has data from 13 studies with 1295 people. Differences in the study populations, interventions, outcomes and measurement tools used meant that the results couldn’t be combined. Most studies were small and at high risk of bias and provide evidence of very low to moderate quality. So uncertainty remains about the effectiveness of the interventions that were assessed in these studies.
We still don’t know what works best
The evidence suggests that using a no-rinse skin cleanser, or a washcloth with cleansing, moisturising and protecting properties, may be more effective than soap and water. Applying leave-on products, alone or in combination, may be better than not doing so. But that’s about all we can say; none of it with any confidence. We still don’t know what works best – the product or combination of products, how often to use them, how much to put on. None of the trials provide any information on what patients thought of the treatments, nor on harms, which are important things to know. Half the trials included patients with and without IAD at the start, and the relative effectiveness of these interventions for prevention compared with treatment remains as murky as soapy water.
One glimmer of light is that the review authors found two ongoing trials, which they will analyse for the next update of the review. But where does that leave nurses right now, and people caring for themselves at home, when it comes to preventing and treating IAD? Teresa and Shannon are nurses caring for older people, so let’s hear what they think.
Teresa and Shannon: a view from the frontline
Caring for people who are incontinent of urine, faeces or both is not a straight forward issue and whilst on the face of things it seems like there would or should be more evidence to support what we do in this most fundamental aspect of nursing, when you start to think a bit deeper it rather like unraveling knotted wool, in that the more we unravel the more we realize just how complex it is and how many variables there are.
What is our current practice in caring for someone who is incontinent?
Firstly we always try to ascertain any underlying reasons for the incontinence because, as with practically everything, prevention is better than cure. Sometimes it’s something like an underlying urinary tract infection or poor mobility that can lead to incontinence. If it is due to a deterioration in the person’s condition, then often interventions like incontinence pads and appropriate help with personal hygiene is the way forward. Incontinence pads seem to play a huge part in skin integrity and we are often reassured by manufacturers about how the moisture is kept away from the skin … which leads us to one of many questions .. what part do incontinence pads play in IAD prevention?
More questions than evidence currently answers?
We set great stock in washing and drying and even though the evidence around washing is low quality (and doesn’t appear to mention drying) it’s perhaps a dignity issue as well as a skin integrity issue, so has dual purpose. Drying seems particularly important to make sure moisture doesn’t stay on skin and again this begs the question of what is the evidence surrounding this?
Application of moisturizing and barrier creams seems to be universal, though the exact type seems to be prescriber-dependent, and the evidence (again though poor quality) is reassuring that this seems to help. Though whether this is due to a combination of practices, such as incontinence pad technology, skin cleansing and leave on creams, is uncertain and perhaps difficult to isolate. In practice there is also uncertainty on how much cream should be used and how often to apply. Manufacturers instructions help to guide but again there is no evidence to support how this helps in the prevention or treatment of IAD. Could we be applying too much or not enough? Or over or under applying ?
Something that was surprising was the use of no rinse skin cleansers, however we are often told how soaps can dry out the skin so perhaps this makes sense. The Code states that we must “always practice in line with the best available evidence”, so perhaps this is worth considering for some of the people we care for. However no rinse skin cleansers are not freely available in many areas and are more costly than soap and water so a strong case would need to be made … is this evidence a strong enough case?
This review seems to throw up more questions than it resolves. There are so many variables in regard to incontinence and IAD:
- What works well for people who are just incontinent of urine?
- What about people who are incontinent of faeces?
- Does the type of faeces itself make a difference? A type 1 on the Bristol Stool Chart would impact IAD differently to a type 7 wouldn’t it?
- How long was the skin in contact with urine / faeces?
- What about the pre existing skin conditions such as eczema?
- Do incontinence pads help?
- Is it just one thing that helps or a combination of several things?
What can we do when reliable evidence is lacking?
One of the most logical conclusions is to be aware of the evidence, but in the light of poor quality evidence we maybe need to take a person centered approach, critically appraise the evidence and weigh up if its applicable to the person we are caring for at that point in time. If every variable isn’t covered by the research, then we need to bear this in mind when applying it to our practice and the people we care for. Nursing is about using an evidence based approach but also not being static in our views; what works for one person may not work for another.
It will certainly be very interesting to see what the two ongoing trials reveal and whether this will help to answer some questions and there are many of us who will be eager to read these once published. In the meantime we will keep on unraveling that knotted wool!
Sarah Chapman, Teresa Chinn and Shannon Deakin have nothing to disclose.
Interventions for preventing and treating incontinence-associated dermatitis in adults. Cochrane Database of Systematic Reviews 2016, Issue 11. Art. No.: CD011627. DOI: 10.1002/14651858.CD011627.pub2., , , , , , , , , , , , .