Incontinence as an Independent Risk Factor for Pressure Injury Development and the Role of Technology in Timely Incontinence Care

Managing incontinence is important to protect patients’ skin, thus positively affecting their quality of life. In addition, being responsive to and properly managing this common condition allows caregivers to prioritize care and optimize treatment. This article is the first in a new series for Wound Management & Prevention that addresses the management of incontinence and moisture.

INCONTINENCE AND PRESSURE INJURIES

In the world of pressure injury prevention, pressure and shear are frequent topics of conversation. In the quest to keep patients’ skin safe, health care providers are well-aware of and regularly discuss the impact that a surface or turning and positioning can have on skin health. We implement turning protocols and do our best to account for moisture by utilizing high-tech surfaces, such as microclimate management surfaces, on patient beds. However, one regular moisture source is often regarded as an unavoidable constant: incontinence.

The burden of incontinence in hospitalized patients is significant, with consequences ranging from inefficient clinical workflow to patient dissatisfaction and hospital-acquired pressure injuries (HAPIs). In a multisite epidemiologic analysis conducted by Gray et al,¹ it was found that 47% of patients in the hospital setting were incontinent.

Caregivers are always looking for more effective ways to treat patients and manage chronic conditions. However, practices surrounding incontinence care have remained relatively unchanged for many years. Nurses often only become aware of incontinence events through hourly rounding. Despite advances in barrier creams, skin protectants, collection devices, and moisture-wicking breathable underpads, incontinence-associated dermatitis (IAD) is a persistent challenge. Gray et al¹ also found that in hospitalized patients with incontinence, 45% have or develop IAD during their stay.

In addition to presenting challenges to patient care, comfort, and satisfaction, IAD can place patients at risk of pressure injuries. Although incontinence and IAD may not be etiologic factors for pressure injuries, they do increase the risk of developing a pressure injury in hospitalized patients. Gray et al¹ examined IAD as an independent risk factor for pressure injury and found that it increased the risk of a sacral pressure injury from 6.3% to 32%. A number of those patients were immobile, but adjusting for immobility as a confounding factor still left a 3.56 times higher likelihood of developing a sacral pressure injury.¹ This shows a direct risk of HAPI development in one-third of hospitalized patients due to the development of IAD during their hospital stay.¹ Therefore, health care providers must be aware that incontinence alone can be considered to be an independent risk factor for pressure injury development.

To better understand how incontinence damages the skin, one must start at the cellular level. The cellular structure of the skin can be likened to a brick-and-mortar structure. The bricks are the cells, and the mortar consists of the lipids in between those cells that hold it together. Proteins make up much of the structural elements of the cell and hold cells together as well. On top of all that, a slight acidity on the surface of the skin acts as protection against the invasion of bacteria. Exposure to incontinence insults all these protections. The incontinence itself can raise the pH, removing the protective acidic barrier. Liquid fecal incontinence comes with proteases and lipases, breaking down those proteins and lipids in the brick-and-mortar structure. These biochemical effects can explain how incontinence increases the risk in sacral pressure injuries discussed above.²

Studies have been conducted to prospectively evaluate the impact of incontinence on the skin. These studies were completed with healthy subjects. In a study by Phipps et al,³ 30 healthy subjects were asked to lay on an industry-standard, moisture-wicking underpad that many facilities use for patients with incontinence. The underpad was soaked in synthetic urine, and the impact on the skin was measured over time. Within 15 minutes, changes to skin pH, moisture content of the skin, and clinical measurements (eg, erythema) were found. It was also found that within 15 minutes, protective and structural barriers inherent to healthy skin began to breakdown. In this timeframe, there also was a significant increase in participant-reported discomfort.³ These findings show that even perfect adherence to hourly rounding is not enough to protect patients’ skin from the potential development of IAD and pressure injuries (Figure 1).

The 2019 NPIAP Guidelines for the Prevention and Treatment of Pressure Ulcers/Injuries state that clinicians should implement a skin care regimen that includes cleansing the skin promptly after episodes of incontinence, ideally as close as possible to the inception of the actual incontinence event.⁵ As stated above, increased exposure time to incontinence can increase the risk of skin breakdown and HAPI development. The challenge is that care teams have no way of knowing when these incontinence events are occurring. Although nurses do their best to implement hourly rounding, workflows can be interrupted due to staffing ratios, high-acuity patients, and other incidences. In a blinded study conducted at Dartmouth-Hitchcock, the average exposure time to incontinence was identified as being 123 minutes.⁴ This is evidence that the WatchCare Incontinence Management System by Hillrom is a key innovation for the med-surg space.

This incontinence management system uses sensor technology installed under the surface of a hospital bed (Figure 2). The sensors communicate wirelessly with a smartpad. The smartpad has all the necessary functionality of a breathable, high-absorbency, moisture-wicking underpad but with the added benefit of embedded moisture-detecting technology. Once the smartpad detects the presence of an incontinence event, it communicates back to the sensors in the bed. The bed initiates a discrete visual alert to the care team by lighting up at the foot of the bed and through the nurse call system. These alerts allow the caregiver to be aware of when an incontinence event has occurred and address it through prioritized care as quickly as possible.

The system also enables a caregiver to be prepared for incontinence care before entering the patient room, thereby avoiding the lengthy back and forth to linen carts or supply areas. After implementing this technology, Darthmouth-Hitchcock experienced a reduction in exposure time from 123 minutes to 18.9 minutes, an overall 86% reduction in exposure time.⁴ Utilization of this technology helps health care providers get closer to achieving the NPIAP guidance by enabling care teams to address incontinence in a timely manner and prevent loss of skin integrity. Access to patient information in real time through the WatchCare Incontinence Management System can help caregivers advance connected care and provide better outcomes for patients.

References

1. Gray M, Giuliano KK. Incontinence-associated dermatitis, characteristics and relationship to pressure injury: a multisite epidemiologic analysis. J Wound Ostomy Continence Nurs. 2018;45(1):63–67. doi:10.1097/WON.0000000000000390

2. Parnham A, Copson D, Loban T. Moisture-associated skin damage: causes and an overview of assessment, classification and management. Br J Nurs. 2020;29(12):S30–S37. doi:10.12968/bjon.2020.29.12.S30

3. Phipps L, Gray M, Call E. Time of onset to changes in skin condition during exposure to synthetic urine: a prospective study. J Wound Ostomy Continence Nurs. 2019;46(4):315–320. doi:10.1097/WON.0000000000000549

4. Abbott CL, Chin SG, Pollard MH, Stavseth M, Usher C. Incontinence management system use significantly reduces incontinence exposure time. Poster presented at: Meeting of the American College of Wound Healing and Tissue Repair; October 11-12, 2019; Chicago, IL. 

5. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide. Haesler E, ed. EPUAP/NPIAP/PPIA; 2019.

Innovative Moisture Management was made possible through the support of Hillrom (https://www.hillrom.com). The opinions and statements of the clinicians providing Continence Care are specific to the respective authors and not necessarily those of Hillrom, Wound Management & Prevention, or HMP Global. This article was not subject to the Wound Management & Prevention peer-review process.