Exploration of the Effect of Standardized Skin Care Model on Incontinence Associated Dermatitis of Critically Ill Patients Tao-Fen Shiung, RN, MSN. 1 Ji-Han Chen, RN, MSN. 2 Shin-Shang Chou, RN, MBA, DNS. 3 1 & 2 Intensive Care Unit, Taipei Veterans General Hospital, Taipei, Taiwan 3 Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan

2 Background ﻪIncontinent critical ill patients are at high risk for incontinence-associated dermatitis (IAD). ﻪBecause of IAD, skin may bleed, progress to painful ulceration, finally result in secondary infection. All symptoms cause patients’ discomfort and increase treatment costs. ﻪSkin is the first defense system. It is vital to keep it intact. ﻪIt is a daily challenge for healthcare professionals to maintain a healthy skin in patients with incontinence.

3 Objective ﻪThe purpose of this study was to test an evidence-based skin care model for critically ill patients.

4 Methods Design A quasi-experimental study design Setting 42-bed medical surgical ICU in a medical center in Taiwan. Data collection From May till December 2011

5 Methods-Subjects ﻪThe inclusion criteria were ﻩAged > 18 ﻩIncontinent of urine or/and fecal ﻪThe exclusion criteria were ﻩThe patients admitted with Incontinence Associated Dermatitis (IAD). ﻩPatients with any Dermatologic diagnosis.

6 Methods ﻪPhase 1 (May - August) ﻪControlled group ﻪUsual skin care by the ICU nurses based on their experiences. (cleanser and zinc oxide barrier) ﻪPhase 2 (September - December) ﻪExperimental group ﻪStandardized skin care (no-rinse cleanser and dimethicone barrier)

Methods Data collection Patients’demographic data Assessment :The Perineal Assessment Tool, PAT the type of irritant the duration of contact the condition of the perineal skin the total number of contributing factors Daily checklist of patients’skin and incontinence condition Data collection period ： 1-14 day or transfer to ward 7

Data Collection Period 8 X1: Current Skin Care X2: Standardized Skin Care Model O1：Patients’ Demographic information O2：Perineal Assessment Tool ( PAT) and Daily Checklist of Skin and Incontinence Condition O1+O2 X1 O2 O1+O2 X2 O2 (Day1-14) (Day1-14)

9 Standardized Skin Care ﻪPAT ≦ 6 ﻩPreventive interventions ﻯ Clean skin with no-rinse skin cleanser for non-IAD patients ﻪPAT > 6 or IAD ﻩ Protective interventions ﻯIAD patients with non skin breakdown : No-rinse skin cleanser and skin barrier cream (Dimethicone). ﻯIAD patients with skin breakdown: No-rinse skin cleanser and no sting barrier spray(Hexamethyldisiloxane).

10 Methods Conducting the study Education program for all nursing staff Implement the standardized skin care into daily practice

11 Results

12 Results- Demographic characteristics Experimental N=61 Control N=50 N%N%χ2χ2 p Gender Male 40(65.6)34(68.0) Female 21(34.4)16(32.0) Incontinence Fecal53(86.9)44(88.0) Fecal&Urine8(13.1)6(12.0)

Results- Demographic characteristics 13 Experimental N=61 Control N=50 Mean (SD) Mean (SD) t p Age 65.2(18.0)68.1(18.2) APACHE II21.2(7.7)21.2(6.6) ICU stay8.93(3.4)9.78(3.6) Albumin2.5(0.5)2.3(0.6) PAT score6.98(2.61)6.73(2.59) Chronic disease 1.9(1.2)1.9(1.3).24.81

14 Results- Demographic characteristics Experimental N=541 (day/person) Control N=483 (day/person) N%N%χ2χ2 p Conscious Clear 296(54.7)257(68.0) Unclear 245(45.3)226(32.0) Limb edema No214(39.6)267(55.3) Yes327(60.4)216(44.7)

15 Results- IAD incidence rates Experimental N=61 Control N=50 N%N%χ2χ2 p IAD incidence Yes 19(31.1)26(52.0) No 42(68.9)24(48.0)

16 Results – IAD Severity Experimental N=95 Control N=159 N%N%χ2χ2 p IAD redness Mild92(96.8)121(76.1) Moderate3(3.2)36(22.6) Sever0(0)2(1.3) IAD area <10cm92(96.8)136(85.5) 10-20cm3(3.2)23(14.5)

Subjects Collected at 1-14 Day (Person/Day) 17 Days Total Controlled Group Experimental Group Total

IAD Incidence Rate (Per Day) 18 Days Controlled group Experimental group

variablesRegression coefficient Standard error tp IAD incidence Experimental group Controlled group 0b0b 0.. control(d2/d1) control(d3/d1) control(d4/d1) control(d5/d1) control(d6/d1) control(d7/d1) control(d8/d1) Difference of slopes from day1 to day2 between 2 groups Difference of slopes from day1 to day3 between 2 groups Difference of slopes from day1 to day4 between 2 groups Difference of slopes from day1 to day5 between 2 groups Difference of slopes from day1 to day6 between 2 groups Difference of slopes from day1 to day7 between 2 groups Difference of slopes from day1 to day8 between 2 groups Comparison of intervention effect between the two groups

20 Discussion ﻩ50 patients was received usual skin care by the ICU nurses based on their experiences, 26 patients with IAD, the IAD incidence rate was 52%. ﻩ61 patients was received standardized skin care, 19 patients with IAD, the IAD incidence rate was 31%. ﻩStandardized skin care model can reduce the incidence of IAD.

21 Discussion ﻪIAD did not develop in all patients with fectal incontience, therefore, Zinc Oxide is playing a role for preventing IAD. ﻪWhen choosing skin protection product, ease of use and efficacy should both be taken into account. ﻪNo rinse cleanser, Dimethicone cream and spray may be a better choice.

22 Conclusions This study results provide a strong evidence for clinicians in reducing IAD incidence by application standardized skin care in critically ills.

23 Thanks for your attention