Incontinence-associated dermatitis and Candida infection; Current evidence and practice

Transcription

1 Incontinence-associated dermatitis and Candida infection; Current evidence and practice 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

2 The perfect storm of challenges for 21 st century aged care 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 2

3 In the context of multiple & competing demands how can we deliver quality, evidence-based skin integrity care for our residents? Perhaps we deliver skin integrity care in silos? 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? 3

4 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 Campbell, Coyer & Osborne (2014) 4

5 Campbell, Coyer & Osborne (2014) 5

6 Conceptual Framework Skin Safety Model Campbell, Coyer & Osborne (2014) 6

7 Skin Injury; Potential Contributing Factors in RAC Resident Factors Systems and Process Factors Situational Stressors Vulnerable Frail Skin 7

8 Resident Factors Advanced age A closer look at skin injury Multiple chronic conditions Medications Poor nutrition/hydration Impaired cognition Impaired mobility Altered sensation Altered circulation & oxygenation Pain contributing factors 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 8

9 Contributing factors contd Situational stressors Acute illness (eg UTI, URTI) Acute delirium Pain Depression Psychosocial stressors 9

10 Skin Injury; Exacerbating elements in RAC Pressure Shear Skin irritants Perspiration Urine/faeces Wound/stoma effluent Medical adhesives Friction Microclimate Potential Skin Injury 10

11 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 11

12 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) 12

13 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 13

14 Moving on to look at IAD 14

15 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) 15

16 Pressure injury Skin tear IAD- What it isn t 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 16

17 IAD lots of names Moisture lesions Perineal dermatitis Incontinence dermatitis Contact dermatitis Intertrigo Heat rash Excoriation Pressure ulcer Nappy rash (Gray et al 2007) 17

18 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)., 18

19 Causative factors for IAD 1. Type of incontinence 2. Frequency of incontinent episodes Beeckman et al (2 Beeckman et al

20 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 20

21 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). 21

22 Download from: Beeckman et al (2015). 22

23 IAD Categorisation Tool Beeckman et. al,

24 24 Beeckman et al (2018)

25 IAD Prevention 2 key interventions cited in literature; Manage incontinence Implement a structured skin care regimen Cleanse Protect Restore Beeckman et al

26 A severity-based approach to treatment 26 Beeckman et al 2015

27 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

28 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). 28

29 Clinical presentations of Candida infection 29

30 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 bestpractice 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 30

31 IAD pain; similar to burn pain Junkin Selekof (2007) 31

32 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 Beeckman D, Campbell J, Campbell K, et al. (2015). Proceedings of the Global IAD expert Panel. Incontinence-associated dermatitis: Moving prevention forward. Wounds International. accessed 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): Campbell, J., Coyer, F., & Osborne, S. (2015). The Skin Safety Model: Reconceptualising skin vulnerability in older patients. Journal of Nursing Scholarship, 48(1), 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: /iwj 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): Gray, M., Beeckman, D., Bliss, D. Z., Fader, M., Logan, S., Junkin, J.,... & Kurz, P. (2012). Incontinenceassociated dermatitis: A comprehensive review and update. Journal of Wound Ostomy & Continence Nursing, 39(1), 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):