Independent risk factors for the development of incontinence-associated dermatitis (category 2) in critically ill patients with fecal incontinence: A cross-sectional observational study in 48 ICU units

https://doi.org/10.1016/j.ijnurstu.2018.01.014Get rights and content

Abstract

Background

Critically ill patients suffering from fecal incontinence have a major risk of developing incontinence-associated dermatitis (IAD). The presence of moisture and digestive enzymes (lipase, protease) negatively influences skin barrier function. Additional risk factors will make some patients even more vulnerable than others. In order to provide (cost) effective prevention, this specific patient population should be identified timely.

Objectives

To identify independent risk factors for the development of IAD category 2 (skin loss) in critically ill patients with fecal incontinence.

Design

A cross-sectional observational study.

Setting and participants

The study was performed in 48 ICU wards from 27 Belgian hospitals. Patients of 18 years or older, with fecal incontinence at the moment of data collection, were eligible to participate. Patients with persistent skin redness due to incontinence (IAD category 1) were excluded.

Methods

Potential risk factors were carefully determined based on literature and expert consultations. Data were collected over a period of eight months by trained researchers using patient records and observation of skin care practices. At the time a patient was included in the study, all relevant data from the past six days, or since admission at the ICU, were recorded. Simultaneously, direct skin observations were performed and high definition photographs were ratified by an expert IAD researcher. A multiple binary logistic regression model was composed to identify independent risk factors. Variables with P < .25 in single binary logistic regression analyses were added to the multiple model using a forward procedure. A cut-off value of P < .1 was established to retain variables in the final model. Nagelkerke’s R2 and Hosmer-Lemeshow statistic were calculated as measures of model fit.

Results

The sample comprised of 206 patients, of which 95 presented with IAD category 2, and 111 were free of IAD. Seven independent risk factors were identified: liquid stool [odds ratio (OR) 4.69; 95% confidence interval (CI) 2.28–9.62], diabetes (OR 2.89; 95% CI 1.34–6.27), age (OR 1.05; 95% CI 1.02–1.08), smoking (OR 2.67; 95% CI 1.21–5.91), non-use of diapers (OR 2.97; 95% CI 1.39–6.33), fever (OR 2.60; 95% CI 1.23–5.53), and low oxygen saturation (OR 2.15; 95% CI 1.03–4.48). Nagelkerke’s R2 was 0.377. The Hosmer-Lemeshow statistic indicated no significant difference between the observed and expected values (p = .301).

Conclusions

Liquid stool, diabetes, age, smoking, non-use of diapers, fever, and low oxygen saturation were independently associated with IAD category 2 in critically ill patients with fecal incontinence.

Section snippets

What is already known about the topic?

  • •

    Critically ill patients with fecal incontinence are at high risk for incontinence-associated dermatitis (IAD) due to the presence of intestinal enzymes, and bacterial flora.

  • •

    Timely application of a structured skin care regimen, consisting of incontinence management, gently cleansing, and application of a leave-on product, are recommended to prevent IAD development.

  • •

    Additional risk factors contribute to a higher vulnerability and, the need for more specific interventions.

What this paper adds

  • •

    Independent risk factors were identified in a sample of 206 critically ill patients with fecal incontinence from 48 ICU units in 27 Belgian hospitals, by composing a multiple binary logistic regression model.

  • •

    Liquid stool, diabetes, age, smoking, not using adult diapers, fever, and frequent low oxygen saturation were factors increasing the risk of IAD category 2 (skin loss).

  • •

    The risk factors identified may contribute to timely identification of high risk patients, and the development of specific

Study design

A cross-sectional observational study was designed. Direct skin observations were performed at one point in time and, simultaneously, potential IAD risk factors were measured. Patients with IAD category 2 were compared with patients without IAD to identify significant differences in the prevalence of potential IAD risk factors.

Settings and participants

The study was conducted at the intensive care unit (ICU), including cardiac/coronary care units (CCU), of a convenience sample of Belgian hospitals. All hospitals in the

Characteristics of the participants

The study sample consisted of 206 participants of which 138 (67.0%) were male. Mean age of the participants was 65.1 years [standard deviation (SD) 14.9] and mean APACHE II score was 23.20 (SD 7.5). The median length of stay was 14 days (interquartile range 8–26, range 1–82). Of all participants, 199 (96.6%) had indwelling urinary catheters at the time of data collection and were defined as not urinary incontinent. The most common primary diagnoses at admission were cardiopulmonary conditions

Discussion

This study aimed to identify independent risk factors for the development of IAD category 2 in critically ill adults with fecal incontinence. Liquid stool, diabetes, age, smoking, non-use of diapers, fever, and low oxygen saturation appeared to be independently associated with the outcome of our study. Our findings deliver necessary knowledge to support a more accurate IAD risk assessment which promotes early identification of high risk patients.

The risk factors identified were theoretically

Conclusions

Liquid stool, diabetes, age, smoking, non-use of diapers, fever, and low oxygen saturation were independently associated with IAD category 2 in critically ill patients with fecal incontinence. These risk factors are theoretically plausible and provide important guidance to identify high risk ICU patients in need for specific IAD prevention strategies. The use of a skin care protocol, including gentle skin cleansing, and the application of leave-on products to maintain or restore skin barrier

Funding

This investigator initiated study received a research grant from 3 M Deutschland GmbH. The funder had no role in the design of this study, data collection, analyses, interpretation of the data, or the development and submission of the manuscript.

Conflicts of interest

Prof. dr. Dimitri Beeckman serves as an academic on the scientific advisory boards of companies developing products and procedures to prevent and treat the condition under study. The other authors have no conflicts of interest to declare.

Acknowledgements

The authors would like to offer special thanks to Lisan Deolet, Eline Geukens, Heini Kanervo, and Nanou Winter for their contribution to the data collection. We would also express great appreciation to the management and the nurses of all participating hospitals for their support and collaboration.

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