A Hospital Wide Toolkit for Preventing and Managing MASD

C. Tod Brindle, MSN, RN, ET, CWOCN 2014 Recipient of the American Hospital Association’s McKesson Quest for Quality Prize

Virginia Commonwealth University Medical Center Richmond, VA

Study # LIT038WC

Presented at the Wounds UK Conference in Harrogate, England, November 2014

This study was sponsored by:

The clinical education division of

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A Hospital Wide Toolkit for Preventing and Managing MASD

PROBLEMMoisture associated skin damage (MASD) describes skin conditions caused by the impact of moisture, friction and microorganisms on skin integrity. MASD includes: Incontinence-associated dermatitis (IAD), Intertriginous dermatitis (ITD), Peristomal moisture-associated dermatitis and Periwound moisture-associated dermatitis. The risk and severity of these conditions is determined by many factors including the source of moisture, the frequency and duration of exposure, type and virulence of associated organisms and the patient’s body habitus.

SIGNIFICANCETo describe the benefits of a skin care toolkit utilized by a large academic university medical center demonstrating improved patient outcomes and cost effective solutions for the prevention and treatment of various forms of MASD.

IMPLEMENTATIONA retrospective descriptive analysis showing the implementation of a skin moisturizer, protective barrier cream, moisture wicking incontinence pad and cyanoacrylate liquid skin protectant in the prevention and treatment of various forms of MASD including peristomal dermatitis, incontinence associated dermatitis and periwound dermatitis.

EDUCATION Staff should be taught proper assessment techniques and assessment pearls to help differentiate MASD from a pressure ulcer. Staff should have competencies and resources available to assist in proper description and documentation. Challenging scenarios should be validated by a pressure ulcer expert such as a WOCN or CWS practitioner. Our tools focus on the use of an adequate patient history, anatomical location, skin presentation, and a variety of visual and tactile clues to guide appropriate diagnosis. Clinicians should be careful not to overlook the fact that mixed etiology lesions as well as cutaneous manifestations not related to pressure and moisture may also occur in these areas.

CONCLUSIONThe introduction of a barrier cream with white petrolatum allowed our facility to reduce the number of barrier cream products from 4 to 1, via the ability of the product to be used on all patients. This demonstrated an immediate cost savings of over $41,000 dollars annually. Additionally, the use of cyanoacrylate liquid skin protectants in the management of IAD, peristomal skin damage and periwound dermatitis associated with fistulas provided cost savings, and improved wear time for ostomy and fistula appliances. Moving away from washable under pads to high volume moisture wicking under pads improved incontinence management.

REFERENCES: 1. Brindle CT, Woo, K. The Sweet Death of

Crusting: Improving the Care of Ostomates and Those with MASD. J Wound Ostomy Continence Nurs 2014; (in press).

2. Brindle CT. Chapter 16- Enterocutaneous Fistulas: Current Concepts in Management. In: Losken A, Janis J. (Eds). 2012. Advances in Abdominal Wall Reconstruction; Quality Medical Publishing, Inc., St. Louis, MO.

3. Shigeta Y, Nakagami G, Sanada H, Konya C, Sugama J: Factors influencing intact skin in women with incontinence using absorbent products, results of a cross-sectional, comparative study. Ostomy Wound Manage 2010, 56(12):26–28,30–33.

4. Gray M, Black J, Baharestani M, Bliss D, et al. Moisture –Associated Skin Damage. JWOCN. 2011; 38 (3): 233-241.

5. Black J, Gray M, Bliss D, Kennedy-Evans K, et al. MASD Part 2: Incontinence-Associated Dermatitis and Intertiginous Dermatitis. JWOCN. 2011; 38 (4): 359-370.

6. Colwell J, Ratliff C, Goldberg M, Baherestani M, et al. MASD Part 3: Peristomal Moisture Associated Dermatitis and Periwound Moisture-Associated Dermatitis. JWOCN. 2011; 38 (5): 541-553.

An example of one of the wall posters that is used throughout the facility to help staff differential between IAD and a pressure ulcer.

Periwound Moisture Associated Dermatitis2

Intertriginous Dermititis5

Peristomal and Periwound dermatitis developing around an enterocutaneous fistula and flush ostomy site, causing pain, chemical denudation and inability to adhere a pouching system. Cyanoacrylate liquid skin protectant provided pain relief, resolution of the MASD and immediate dry pouchable surface with extended wear barrier rings and a wound pouch.

Intertirginous dermatitis (ITD) is related to moisture and friction between the skin folds and is susceptible to opportunistic bacteria. ITD is prevented in our facility using dry antimicrobial fabric. However, in situations where a fabric or dressing is not practical, such as the gluteal fold, cyanoacrylate liquid skin protectant is used. The patient on the left had ITD in the gluteal cleft that was inappropriately managed with barrier cream, which was ineffective. Cyanoacrylate liquid skin protectant was applied twice weekly until resolution.

Fistula pouching systems are effective but expensive. Periwound dermatitis occurs secondary to the large volumes of caustic, bacteria laden effluent. Traditional crusting techniques are unreliable, and provide an uneven surface for pouching which leads to frequent leaking. The ability to treat and prevent periwound dermatitis, while allowing for an immediate dry pouching surface which is compatible with a variety of manufacturer’s extended wear barriers saves time and resources. This 42 y/o obese male presented with severe, painful periwound MASD which was treated with cyanoacrylate liquid skin protectant, extended wear rings and a fistula pouch.

Peristomal Dermatitis1

Caring for the indigent ostomate with peristomal dermatitis is a challenge due to frequent leaking, inability to apply a pouch, access to supplies and cost. Traditional crusting methods are inadequate and too laborious with high output stomas. Cyanoacrylate liquid skin protectant is preferred in these situations as it provides a smooth, dry, pouchable surface in one step. This patient had a emergent ileostomy created after trauma and was changing pouches 4 times daily at home. The patient was given 2 ampules of cyanoacrylate liquid skin protectant in clinic and applied every 72 hours. MASD resolved in 6 days (2 pouch changes).

Incontinence Associated Dermatitis1,3-5

A patient in cardiac surgery ICU with a left ventricular access device (LVAD) developed Clostridium difficile and developed severe MASD with candidiasis due to voluminous stools with inability to use fecal management system. The patient was managed with M-W-F application of cyanoacrylate liquid skin protectant and prn application of barrier cream after each bowel movement.

The hospital had 3 barrier creams in stock before conversion: 1) Zn-menthol based barrier 2) A 100% Zn barrier and 3) A dimethicone barrier. The 100% Zn barrier was the only product used in neonates and pediatrics due to staff concern over hypersensitivity reactions. The WOC team worked with value analysis by replacing these three products with Zn-white petrolatum barrier, producing a savings of $41,129 (54% reduction) without a reduction in quality.

Cost Breakdown of barrier products

Product Annual Spend (1-1-12 to 12-31-12)

Annual volume Estimated Annual Spend on new product

Estimated savings (54%)

Zn – Menthol $71,630 13,603Dimethicone $497 84100% Zinc $4,218 1,110

$76,345 14,797Zn-White Petrolatum $35,216 $41,129

WHY USE AN ADVANCED MOISTURE WICKING UNDERPAD INSTEAD OF STANDARD PADS OR LINENS?• Under pads without wicking technology found to hold urine against the skin• pH of the under pad correlated to the pH of the stratum corneum in women studied.• Damage to the skin occurs due to urine being held against skin.• Urine in absorbent pad breaks down to NH3, results in alkaline contact surface.• Causes skin irritation and inflammation. RECOMMENDATIONS:• Limit the total number of linens: (1 sheet and1 underpad only; 1 anti-shear repositioning sheet if patient is immobile)• NO ADULT BRIEFS: unless patient going off unit for procedure or ambulating with PT/OT• Do NOT use baby powder or corn starch derivatives• Check patient with known incontinence at least every 2 hours and offer toileting assistance• Determine the etiology of the incontinence, discuss with MD and refer patients for evaluation if necessary.