incontinence-associated dermatitis and candida …...incontinence-associated dermatitis and candida...
TRANSCRIPT
Incontinence-associated
dermatitis and Candida infection;
Current evidence and practice
Dr Jill Campbell RN
Clinical Nurse, Skin Integrity Service,
Royal Brisbane & Women’s Hospital.
Visiting Fellow, Faculty of Health,
Queensland University of Technology
Royal Brisbane and Women’s Hospital Metro North Health Service District
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• Rapidly ageing population • Increasing complexity of resident health status • Increasing chronic disease burden • Ageing workforce • Staff recruitment & retention challenges • Increasing cost & shrinking financial resources • The requirement for safe and quality care • New aged standards
Dr Jill Campbell
The perfect storm of challenges for 21st century aged care
Perhaps we deliver skin integrity care in silos?
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Do the multiple skin integrity silos have different priorities depending on the most pressing need ?
Or, is there one predominant skin silo that resources are directed to in response to the imperatives of
safety, governance and reputation?
In the context of multiple & competing demands how can we deliver quality, evidence-based skin integrity
care for our residents?
Dr Jill Campbell
However, these approaches may result in…
• Omission
• Duplication
• Fragmentation
• Confusion; for residents and staff
• Conflict & competing interests
• A narrow focus on a single condition can result in a narrow and disconnected solution
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Campbell, Coyer & Osborne (2014)
Dr Jill Campbell
Campbell, Coyer & Osborne (2014)
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Skin Safety Model
Conceptual Framework
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Campbell, Coyer & Osborne (2014)
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Skin Injury; Potential Contributing Factors in RAC
Vulnerable Frail Skin
Situational Stressors
Resident Factors
Systems and
Process Factors
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A closer look at skin injury contributing factors
Resident Factors
• Advanced age
• Multiple chronic conditions
• Medications
• Poor nutrition/hydration
• Impaired cognition
• Impaired mobility
• Altered sensation
• Altered circulation & oxygenation
• Pain
Systems/Processes
• Funding models
• Staff levels & skill mix
• Governance
• Culture
• Safety culture/ procedures
• Handover/clinical communication
• Clinical equipment & resources
• Skin care processes & products
• Continence management
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Contributing factors contd…
Situational stressors
• Acute illness (eg UTI, URTI)
• Acute delirium
• Pain
• Depression
• Psychosocial stressors
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Skin Injury; Exacerbating elements in RAC
Potential Skin Injury
Skin irritants
Perspiration
Urine/faeces
Wound/stoma effluent
Medical adhesives
Pressure
Shear
Friction
Microclimate
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Potential skin injuries may be…
• Pressure Injury
• Skin Tear
• Moisture-associated skin damage;
– IAD
– Intertriginous dermatitis
– Peri-wound/peri-stomal skin damage
– Saliva related injury
• Medical-adhesive related skin injury
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Lived experience of a skin injury
• Pain
• Infection
• Chronic wound
• Disability
• Disfigurement
• Potential adverse impact on functional status
• Depression/distress
• Isolation
• Impaired wellbeing
• Increased cost
• Burden of frequent dressing changes
• Death Augustin et al (2012)
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Reconceptualising how we deliver skin care
• Skin safety approach provides a holistic unifying framework that integrates multiple risk factors
• Different skin injuries can have multiple shared risk factors
• Risk factors interact & can be highly individual
• Risk factors can change over time
• Systems & processes can contribute to injury
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Moving on to look at IAD
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IAD – What it is • A reactive skin response to chronic exposure to urine
& faeces-+
• Could be observed as inflammation, erythema
• +/- erosion
• A threat to skin integrity in incontinent patients (Beeckman et al 2015, Doughty et al 2012, Gray et al, 2007, Gray et al, 2012)
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• Pressure injury
• Skin tear
• Medical-adhesive related skin injury
• Moisture-associated skin damage caused by moisture other than urine and /or faeces.
HOWEVER; all of these skin injuries may occur concurrently with IAD.
Thorough assessment and accurate skin-injury identification is essential for appropriate management
IAD- What it isn’t
Dr Jill Campbell
• Moisture lesions
• Perineal dermatitis
• Incontinence dermatitis
• Contact dermatitis
• Intertrigo
• Heat rash
• Excoriation
• Pressure ulcer
• Nappy rash (Gray et al 2007)
IAD – lots of names
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IAD prevalence in aged care
ranges from
5-30%
Arnold-Long & Reed (2012), Beeckman et al (2012),
Bliss et al (2007), Boronat-Garrido, Kottner, Schmitz
& Lahmann (2016). ,
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Causative factors for IAD
1. Type of incontinence
2. Frequency of incontinent episodes
Beeckman et al (2
Beeckman et al 2015
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IAD Complications • Pain; can be severe & is compared to pain of a
burn Decreased quality of life, loss of
independence, disruption to activities /sleep
• Increased burden and cost of care
• Increased length of hospital stay
IAD predisposes to;
• Pressure injury
• Infection, eg Candida albicans
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If an individual is incontinent they are at risk of IAD
If an individual is continent, any pelvic skin injury is not IAD
Beeckman et al (2015).
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Download from: www.woundsinternational.com Beeckman et al (2015).
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IAD Categorisation Tool
Beeckman et. al, 2015 Dr Jill Campbell 23
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Beeckman et al (2018)
IAD Prevention
2 key interventions cited in literature;
• Manage incontinence
• Implement a structured skin care regimen
– Cleanse
– Protect
– Restore
Beeckman et al 2015
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A severity-based approach to treatment
Beeckman et al 2015
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Candida albicans • Candida albicans is the most common fungal
commensal organism in humans
• Colonises gastrointestinal & genitourinary tract 30-60% healthy individuals
• Can transform from commensal to pathogen
• Candida infection is reported as a frequent complication of IAD (one study found fungal infection in patients with IAD 32%) Campbell et al 2016
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Recognising Candida infection • Mainstay of diagnosis is clinical assessment/ visual
inspection followed by empirical treatment
• Microbiological testing (swabs) often not collected
• Candida infection may present as a central maculopapular rash with characteristic satellite lesions at margins of erythema
• Confluent non-specific rash/erythema
• May be thick, yellowish/white discharge, often in skin folds
• Remember, these presentations are not unique to Candida infections Campbell et al (2016).
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Clinical presentations of Candida infection
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Treating Candida infection
• Thorough skin inspection and clinical assessment
• Topical antifungal medication if clinical presentation of Candida
• Ensure full course of topical medication applied.
• Consider Candida Rx if not responding to best-practice skin care
• Consider topical anti-inflammatory as a pain and symptom management strategy.
• Topical steroid does not treat the fungal infection
• Evaluate response to treatment
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IAD pain; similar to burn pain
Junkin Selekof (2007)
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References
• Arnold-Long, M., Reed, L., Dunning, K., & Ying, J. (2011). Incontinence-associated dermatitis in a long-term acute care facility: Findings from a 12 week prospective study. Journal of Wound Ostomy & Continence Nursing, 38(3S), S7-S7
• Augustin, M., Carville, K., Clark, M., Curran, J., Flour, M., Lindholm, C., … &Young, T. (2012). International
consensus: Optimising wellbeing in people living with a wound. An expert working group review. London: Wounds
International. Retrieved from http://www.woundsinternational.com/media/issues/554/files/content_10309.pdf
• Beeckman D, Campbell J, Campbell K, et al. (2015). Proceedings of the Global IAD expert Panel. Incontinence-associated dermatitis: Moving prevention forward. Wounds International. www.woundsinternational.com accessed 20.9.18
• Beeckman D, Van den Bussche K, et al. (2018). Towards an international language for incontinence-associated dermatitis (IAD): design and evaluation of psychometric properties of the Ghent Global IAD Categorization Tool (GLOBIAD) in 30 countries. British Journal Dermatology. Jun; 178(6):1331-1340
• Campbell, J., Coyer, F., & Osborne, S. (2015). The Skin Safety Model: Reconceptualising skin vulnerability in
older patients. Journal of Nursing Scholarship, 48(1), 14-22.
• Campbell J., Coyer F., Mudge A., Robertson I., & Osborne S. (2016). Candida albicans colonisation, continence
status and incontinence-associated dermatitis in the acute care setting: A pilot study. International Wound Journal,
doi: 10.1111/iwj.12630
• Doughty, D. (2012). Differential assessment of trunk wounds: Pressure ulceration versus incontinence-associated
dermatitis versus intertriginous dermatitis. Ostomy Wound Management, 58(4), 20.
• Gray M, Bliss D, Doughty D, Ermer-Seltun J, Kennedy-Evans K, Palmer M. (2007). Incontinence-associated
dermatitis: A consensus. Journal Wound Ostomy Continence Nursing. 34(1):45-56.
• Gray, M., Beeckman, D., Bliss, D. Z., Fader, M., Logan, S., Junkin, J., . . . & Kurz, P. (2012). Incontinence-
associated dermatitis: A comprehensive review and update. Journal of Wound Ostomy & Continence Nursing,
39(1), 61-74.
• Junkin J, Selekof J. (2007). Prevalence of incontinence and associated skin injury in the acute care inpatient. J
Journal Wound, Ostomy & Continence Nursing. 2007;34(3):260-269.
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