Preventing Incontinence-Associated Dermatitis (IAD)

Incontinence is a leading risk factor for skin breakdown, known as Incontinence Associated Dermatitis (IAD).1 IAD is defined as “an inflammation of the skin that occurs when urine or stool comes into contact with perineal or perigenital skin.”2

Not only does IAD cause skin irritation and discomfort, but it also is a major risk factor for pressure injuries.1 IAD is often grouped with pressure injuries, but they are not one and the same—IAD works from the outside in, while pressure injuries work from the inside out. Since they are different conditions, they should be treated differently.

Applying a barrier after each incontinence episode can help eliminate IAD. One comprehensive pressure injury prevention program—including a uniquely delivered skin protectant for incontinence care—reduced the incidence of sacral/buttock pressure injuries by 89%.3 The barrier is a simple way to prevent a costly condition, yet it is often overlooked. A study of 76 protocols found barriers should cost 23.5 cents for each application, but facilities actually spend only 10 cents per day per incontinent patient.4

Using the basin to clean patients after an incontinence episode puts them at risk for nosocomial infection. Basin sampling has proven that the basin is a reservoir for bacteria, including S. aureus and the multi-drug resistant organisms (MDROs) methicillin-resistant S. aureus (MRSA) and vancomycin-resistant enterococci (VRE).5, 6

This education section will help you bolster your IAD prevention program with evidence-based incontinence care. The IAD Assessment will help your facility track outcomes from your incontinence care protocol.

These unique tools will help you assess current clinical practice, educate staff, customize and implement evidence-based protocols, complete a performance improvement plan, and track progress, from pressure injury rates, to staff compliance, to costs.

REFERENCE: 1. Maklebust J, Magnan MA, Adv Wound Care. Nov 1994;7(6):25,27-8,31-4 passim. 2. Gray M, et al., J Wound Ostomy Continence Nurse. 2007 Jan-Feb;34(1):45-54. 3. Clever K, et al., Ost Wound Mgmt. Dec 2002;48(12):60-7. 4. Gray M, Lerner-Selekof J, Junkin J, CE symposium in conjunction with 2006 WOCN Conference, Minneapolis, MN, 2006 June. 5. Marchaim D, et al., Hospital bath basins are frequently contaminated with multi-drug resistant human pathogens. Poster presented at SHEA 21st Annual Scientific Meeting, April 2011. 6. Johnson D, Lineweaver, Maze L, Patients’ bath basins as potential sources of infection: a multicenter sampling study, AJCC, Vol 18, No 1, Jan 2009.

Incontinence-Associated Dermatitis, Characteristics and Relationship to Pressure Injury – A Multisite Epidemiologic Analysis
Mikel Gray, PhD, RN, FNP, PNP, CUNP, CCCN, FAAN, FAANP; and Karen K. Giuliano, PhD, RN, FAAN
J Wound Ostomy Continence Nurs. 2018 Jan; 45(1): 63–67.
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A Prospective, Descriptive, Quality Improvement Study to Decrease Incontinence-Associated Dermatitis and Hospital-Acquired Pressure Ulcers
Kimberly D. Hall, DNP, RN, GCNS-BC, CWCN-AP; and Rebecca C. Clark, PhD, RN
Ostomy Wound Management 2015;61(7):26–30
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Incontinence-Associated Dermatitis: Consensus Statements, Evidence-Based Guidelines for Prevention and Treatment, and Current Challenges
Doughty D
JWOCN
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A 3-in-1 Perineal Care Washcloth Impregnated With Dimethicone 3% Versus Water and pH Neutral Soap to Prevent and Treat Incontinence-Associated Dermatitis
Beeckman D
JWOCN
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Incontinence-associated dermatitis: a consensus
Gray M, Bliss D, Doughty D, Ermer-Seltun J, Kennedy-Evans K, Palmer M
Journal of Wound, Ostomy and Continence Nursing 2007 Jan/Feb;34(1):45-54.
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Risk factors associated with having a pressure ulcer: a secondary data analysis
Maklebust J
Advances in Wound Care. Nov 1994;7(6):25,27-8,31-4 passim.
View abstract

Location, Location, Location: Incontinence care supplies at the bedside
Schmitz T
Nursing Management
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Perineal Dermatitis in Critical Care Patients
Driver D
Crit Care Nurse 2007 Aug; 27(4): 42-46
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Evaluating the efficacy of a uniquely delivered skin protectant and its effect on the formation of sacral/buttock pressure ulcers
Clever K
Long-Term Care Unit, Fulton County Medical Center, McConnellsburg, PA
Ostomy/Wound Management. Dec 2002;48(12):60-7.
View abstract
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A review of perineal skin care protocols and skin barrier product use
Nix D
Ostomy/Wound Management. Dec 2004;50(12):59-67.
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Save our skin: initiative cuts pressure ulcer incidence in half
Courtney BA
Nursing Management. Apr 2006;37(4):36-45.
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A comprehensive program to prevent pressure ulcers in long-term care: exploring costs and outcomes
Lyder CH
Ostomy/Wound Management. Apr 2002;48(4):52-62.
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The Challenges of an Incontinence-Associated Dermatitis Reduction Project in the Time of a Global Pandemic The Challenges of an Incontinence-Associated Dermatitis Reduction Project in the Time of a Global Pandemic
Zello M, MSN, FNP-C, CWON
Banner Health, Phoenix, AZ
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An Incontinence Associated Dermatitis Reduction Project and the Challenges Faced Due to a Global Pandemic An Incontinence Associated Dermatitis Reduction Project and the Challenges Faced Due to a Global Pandemic
Zello M, MSN, FNP-C, CWON, RN
Banner Health, Phoenix, AZ
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Barrier Cream Cloth Efficacy and Prevention of Transepidermal Water Loss-An Important Consideration in Product Selection
West D
Presented at the WOCN 49th Annual Conference May 19-23, 2017, Salt Lake City, UT
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Incontinence Cleansing Protocol Results in 75% Decrease in IAD and 20% Decrease in Facility-Acquired Pressure Ulcers
Sullivan R, PhD, RN, CWON, LNCC
Presented at Mayo Clinic, Jacksonville, FL
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Implementing Nurse-Driven Interventions to Improve Incontinence Associated Dermatitis and Hospital-Acquired Pressure Ulcers
Hall K
The Clinical Symposium on Advances in Skin & Wound Care; September 9-12, 2011
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Consistency the key for treating severe perineal dermatitis due to incontinence
Sluser
Sturgeon Community Hospital and Health Centre
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Quality Improvement Initiative Decreases Incontinence-Associated Dermatitis 92%
Bohnenkamp S
Poster presented at the 26th Annual Symposium on Advanced Wound Care (SAWC); May 1-5, 2013
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Comparison of Skin Barrier Effectiveness for Products Containing Dimethicone
West D
Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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What we don’t know can hurt us: pilot prevalence survey of incontinence and related perineal skin injury in acute care
Junkin J
Poster presented at the Clinical Symposium on Advances in Skin and Wound Care, Las Vegas, NV, Oct 2005.
Download poster (PDF)
Download handout (PDF)
It’s Easy: Preventing Incontinence-Associated Dermatitis and Early Stage Pressure Injury
Wolfman A
Poster presented at Capital Health’s Best Practice Conference Wound Care: Champions for Change: October 6-8, 2008
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Incontinence Associated Dermatitis in the Acute Care Setting: A Prospective Multi-site Epidemiologic Study
Gray
Presented at the 23rd Annual Meeting of the Wound Healing Society; SAWC Spring/WHS Joint Meeting: Denver, Colorado, May 1 – 5, 2013
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Protecting Patients Skin With The Reduction Of Incontinence-Associated Dermatitis
Morrow H17th Annual Wound Care Conference November 3-6, 2011
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Comparative Effectiveness Study of 3% Dimethicone Barrier Cloths v. Standard of Care Products in Incontinence Care in Austria
Kurz
Poster presented at the WOCN conference, New Orleans, LA, June 2011
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Comparing efforts on 3 Continents to Improve Clinical Practice for the Prevention and Treatment of Incontinence-Associated Dermatitis
Junkin J
Poster presented at the WOCN conference, New Orleans, LA, June 2011
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Implementing a Three-Pronged Incontinence-Associated Dermatitis Prevention Strategy to Promote a Positive Patient Experience
Mac Pherson
Poster presented at the 24th Annual Symposium on Advanced Wound Care and Wound Healing Society (SAWC/WHS); April 14-17, 2011
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Improved Access to Incontinence Care Products Leads to a Reduction in Facility Acquired Pressure Ulcers
Krapfl
Poster presented at the 42nd Annual WOCN Conference, June 12-16, 2010
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Educating Staff on the Accurate Location and Etiology of Buttock Ulcers
Junkin J
Poster presented at the 42nd Annual WOCN Conference, June 12-16, 2010
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Use of Barrier-Impregnated Cloths to Treat Severe Incontinence-Associated Dermatitis: A Case Study
Lake L
Poster presented at the 42nd Annual WOCN Conference, June 12-16, 2010
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Bedside Cleanup Stations Eliminate Incontinence-Associated Dermatitis
Schmitz T
Poster presented at Capital Health’s Best Practice Conference Wound Care: Champions for Change: October 6-8, 2008
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The efforts of a skin protection task force significantly decreases the number of hospital-acquired pressure ulcers
Davis-Zeek
Poster presented at WOCN 40th Annual Conference: June 21-25, 2008
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Targeting incontinence-associated dermatitis; ­a leading risk factor for pressure ulcers US hospitals no longer paid for pressure ulcers ­ fecal incontinence increases pressure ulcer risk by 22X
Junkin J
Poster presented at 3rd Congress of the World Union of Wound Healing Societies: June 4-8, 2008 Toronto, Canada
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Location, location, location: Getting your incontinence care process bedside yields reduction in skin injury
Schmitz T
Poster Presented at Institute for Healthcare Improvement (IHI), Orlando, FL, December 2007.
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Cost-effective, quality care for the patient with incontinence
Dieter L
Research poster abstract presented at WOCN Society Annual Conference, Minneapolis, MN, Jun 2006.
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Prevention of perineal skin injury in a high risk patient
Schroeder K
Midwestern Regional Medical Center, Cancer Treatment Centers of America, Zion, IL.
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What the Experts Say – Incontinence Care & Pressure Ulcer Prevention
Excerpts from various studies/articles, 1994-2008.
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What the experts say about the financial implications of pressure ulcers
Excerpts from various studies/articles, 1996-2003.
Download (PDF)

IHI Protecting 5 Million Lives From Harm Campaign targets pressure ulcer prevention
The 5 Million Lives Campaign is an initiative to protect patients from five million incidents of medical harm.
(December 2006 – December 2008).

IHI “Prevent Pressure Ulcers” How-to Guide1,2
4.Manage Moisture: Keep the Patient Dry and Moisturize Skin
Cleanse skin at time of soiling and at routine intervals with “gentle use of a mild cleansing agent that minimizes irritation and dryness of the skin.”
“Minimize exposure of the skin to moisture due to incontinence, perspiration, or wound drainage.”
“Use topical agents that act as moisture barriers and moisturize the skin.”
“Provide supplies at the bedside of each at-risk patient who is incontinent. This provides the staff with the supplies they need to immediately clean, dry, and protect the patient’s skin after each episode of incontinence.”
“Provide premoistened, disposable barrier wipes to help cleanse, moisturize, deodorize, and protect patients from perineal dermatitis due to incontinence.”

Download “Prevent Pressure Ulcers” How-to Guide
Download “Prevent Pressure Ulcers” Annotated Bibliography
View campaign materials for pressure ulcer prevention (and all 12 campaign interventions)
View campaign highlights

Pressure ulcer prevention points
The National Pressure Ulcer Advisory Panel (NPUAP), Reston, VA.Summary of the AHCPR Clinical Practice Guideline, Pressure Ulcers in Adults: Prediction and Prevention (AHCPR Publication No. 92-0047. Rockville, MD: May 1992).
Download NPUAP Summary

Prevalence of incontinence and associated skin injury in the acute care inpatient
Junkin J
J Wound Ostomy Continence Nurs. 2007 May-Jun;34(3):260-9.
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21-day Cumulative Irritancy Patch Test: Comfort Shield® Perineal Care Washcloths
West
Northwestern University Department of Dermatology, Chicago IL, Jul/Aug 1999.
Download study (PDF)

Best-practice protocols: Reducing harm from pressure ulcers 
Griffin B
Nursing Management Sep 2007; 38(9): 29-32
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Protecting patients from harm: Preventing pressure ulcers in hospital patients
Ayello
Nursing 2007 Oct 2007; 37(10): 36-40
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Nursing opinion poll reveals pressure ulcer prevention not seen as a top priority
ICT Online
Poll conducted at the Wound Ostomy Continence Nurse Society 2004 annual conference by Sage Products Inc, Jun 2004.
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Risk factors for pressure ulcers
Wounds1.com, WOUND NEWS: Wound Technology, Jan 22, 2002.
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My scope of practice: one-step care yields big results
Zeiger B
Ostomy/Wound Management. Dec 2005;51(12):18-20.
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Comfort Shield® and Bedside Barrier Station Comparison (PDF)
3 Day Clinical Template (doc)
Product Evaluation Form

IAD Assessment Tool

Download (PDF)

Patient Education Card

Download (PDF)

Lanyard Request Form

Order Lanyards

Customizable Protocol

Comfort Shield® Product #7996 (doc)
Comfort Shield® Product #7502 (doc)

Sample Performance Improvement Plan
Track the impact of Perineal Cleansing and Moisture Barrier application on incontinent patients at your facility with this customizable template.
Customize (doc)View/print only (PDF)
Sample Process Improvement Plan
Assess staff knowledge and opinions about incontinence care practices in your facility. This template includes a section to list your facility’s desired objectives, your protocol, and an area to record results from the Clinical Evaluation Form.
Step 1. Establish your facility’s objectives for incontinence care. Then enter them into the left hand column of the Process Improvement Plan template.
Process Improvement Plan TemplateCustomize (doc)View/print only (PDF)
Step 2.Customize a Clinical Evaluation Form to measure and record staff opinions about incontinence care and the effectiveness of new practices.
Step 3. Analyze your completed Clinical Evaluation Form to determine the best incontinence care tools to achieve protocol compliance and meet documented objectives. Record your results in the right hand column of the Process Improvement Plan template.