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Comprehensive Fecal IncontinenceManagement Program in Critical Care

Deborah P. Gray, BSN, CWOCN, RN

Skyline Medical Center is a 204 bed acute care facility in Nashville,Tennessee that is part of the HCA Tri-Star healthcare system. Thefacility has 22 CCU beds and a 6 bed Neuro ICU unit which providescare for a wide variety of health problems. Incontinence was a commonmanagement concern in the ICUs with 40% of the facilities critical carepatients experiencing some level of incontinence and subsequentperineal dermatitis during their ICU stay. Repeated cleaning withalkaline soaps, coarse washcloths and prolonged exposure to digestiveenzymes were related to development of perineal dermatitis (PD).Although an intensive pressure ulcer prevention program had alreadybeen implemented, with excellent outcomes, management of incontinentCCU patients continued to be a challenge that was being poorlyaddressed by traditional incontinence care (i.e. barrier creams, pastesand standard rectal tubes, etc.). Incontinence management programsthat address only cleaning and single product protection are insufficientto address PD in the presence of persistent incontinence. 1, 2

1. Nix, D. (2004). A Review of Perineal Skin Care Protocols and the Skin Barrier Product Use. Ostomy Wound Management . 50(12).HMP Communications, PA.

2. Vollman, K. M. (2005). The Cycle of Process Improvements: A Workshop on Process Improvement Strategies for Optimizing SkinCare Outcomes in the ICU.

3. Emory University (1997, May). Management of the Patient with Urinary Incontinence. In Continence Module. Sec. 4, pp. 52-83.Emory University W.O.C.N Nursing Program, Atlanta, GA.

4. Gray, M., Jones, D. P. (2003, March). The Effect of Different Formulations of Equivalent Active Ingredients on the Performance ofTwo Topical Wound Treatment Products. Ostomy and Wound Management. 50 (3), pp. 34 (8). HMP Communications.

5. Howe, K., Padmanabhan, A., Stern, M. A., Williams, J. (2005, May/June). Managing Diarrhea and Fecal Incontinence: Results of aProspective Clinical Study in the ICU. Journal of WOCN, 32(38).Supplement 2, Abstract Program, p. Lippincott, Williams & Wilkins.

6. Bliss, D. A., Zehrer, C., Savik, K., Ding, L., Hedblom, E. (2005, May/June). An Economic Evaluation of Skin Damage PreventionRegimes among Nursing Home Residents with Incontinence: Labor Costs. Journal of WOCN. 32 (38). Supplement 2, AbstractProgram, p. S1. Lippincott, Williams & Wilkins.

7. Nix, D. (2000). Wound Care: Factors to Consider When Selecting Cleaning Products. Journal of WOCN. 27, pp. 260-268. Mosby.Retrieved 10/27/05 www.wocn.org/education/articles1.html

8. Cleaver, K., Smith, G., Browser, C, Monroe, K. (2005). Evidence-based prevention: a Study evaluating the efficacy of a uniquelydelivered skin protect ant on Incontinent patients and the formulation of sacral/buttock pressure ulcers. WOCN

2005 Poster Presentation. Las Vegas, NV.9. Bates-Jenson, B. & Sussman, C. (2001). Pressure Ulcers: Pathophysiology and Prevention. In Wound Care, 2nd Ed. Ch. 325-360.

Lippincott, Williams & Wilkins. Philadelphia, PA.10. Convatec (2004). Clinical Evaluation of Flexi-seal Fecal Incontinence Management System. Clinical Trial: CC 198-03-A695.11. Convatec (2004). Flexi-Seal: Directions for Use. E.R. Squibb & Sons, L.L.C. Princeton, N.J12. Hollister (2004). Hollister Drainable Fecal Collector. Hollister Inc., Libertyville, Ill.13. Doughty, D. B. (1991). Management of Urinary Incontinence. In Urinary and Fecal Incontinence: Nursing Management. Ch.4, pp.

95-150. Mosby, St. Louis, MI.14. Hunter, S., Anderson, J., Hanson, D., Thompson, P., Langemo, D., Klug, M. G. (2003, Sept.). Clinical Trial of a Prevention and Treatment Protocol for Skin Breakdown in Two Nursing Homes. Journal of Wound,

Ostomy and Continence Nursing. 30 (5), pp. 250 (8). Mosby.15. Newman, D. K. (1999). Incontinence Products. In T he Urinary Incontinence Sourcebook. Ch.17, pp.230 (18). Lowell House, Los

Angles, CA.16. Nix, D. (2005). An Analysis of 66 Perineal Skin Care Protocols from 32 States: Use of Skin Protectants is Lacking in Protocols and

Application. WOCN 2005 Poster Presentation. Las. Vegas, NV.17. Bohacek, L., Farley, K. (2004). Improved Healthcare Outcomes in Partial Thickness Wounds. Case Studies.18. Doughty, D. (2005, May-June). Comparison of Pressure Ulcer Treatments in Long-term Care Facilit ies. 32(3), pp. 163 (7). Journal

of W.O.C.N. Lippincott, Williams & Wilkins.19. WOCN (1996). Role of the Wound, Ostomy and Continence Nurses in Continence Management. WOCN Position Statement .

www.wocn.org/publications/posstate/role/html Retrieved 10/27/05.20. WOCN (2003). Guideline for Prevention and Management of Pressure Ulcers: Clinical Practice Guidelines. WOCN Society. Glenview,

IL.

Sample size for the Incontinence Management Guideline (IMG)study was small, 20 patients, due to limitations in available data collectionpersonnel. Post-implementation prevalence studies did, however, includeassessment and evaluation of an additional 40 patients increasing validity offindings.

The findings of this study indicate that incontinence related perinealdermatitis can be greatly decreased in the CCU population through acomprehensive management program that promotes consistency in application ofbarrier products, gentle cleansing of the skin, active treatment of compromisedskin, and use of containment products for persistent high-volume incontinence.Single product use was ineffective in addressing all of the needs of the incontinentpatients. By utilizing treatment modalities at multiple levels (i.e. protection,treatment, and containment, etc.) the IMG promotes management of a complexproblem through a more comprehensive clinical approach. The IMG defines andstandardizes incontinence care that allows staff to “flex” patients from one level ofmanagement to another based upon their current condition and clinical need. Theflexibility outlined in the IMG was key to its success, promoting critical thinkingby staff, effective management, and positive clinical outcomes for patientsexperiencing incontinence in the CCU.

To improve clinical outcomes for the incontinent ICU patient, theWOCN proposed to develop comprehensive guidelines for incontinencemanagement based upon current clinical evidence. Development ofguidelines included review of current literature, product trial, guidelinetrial, algorithm development, order-set development, and completion ofthe clinical approval process at Skyline.

Components of the proposed incontinence management guidelineincluded:

1. Promotion of consistent protection of intact skin. 3 , 5

2. Treatment of compromised skin with active ingredients. 4, 17

3. Containment options for intractable fecal incontinence. 6 , 10

4. Non-traumatic cleansing of skin. 7 , 8, 9

Comprehensive management of incontinence reduces the incidence ofperineal dermatitis (PD) and reduces the risk for incontinence relatedpressure ulcers. 1 8

BACKGROUND

PURPOSE AND HYPOTHESIS

MATERIALS AND METHODS

References

AbstractAbstractThe foundation for comprehensive incontinence management guidelines and an algorithm for clinical decisionThe foundation for comprehensive incontinence management guidelines and an algorithm for clinical decision

making include: (a) protection, (b) treatment of compromised skin with active ingredients, and (c) use of containmentmaking include: (a) protection, (b) treatment of compromised skin with active ingredients, and (c) use of containmentdevices for persistent fecal incontinence. An estimated 33% of all hospitalized adults suffer from fecal incontinence devices for persistent fecal incontinence. An estimated 33% of all hospitalized adults suffer from fecal incontinence 11 . .Incontinent patients are at a 22% higher risk for pressure ulcer development and when immobile the risk increases toIncontinent patients are at a 22% higher risk for pressure ulcer development and when immobile the risk increases to30%30% 2 2 . Fecal incontinence reduces skin tolerance, macerates tissue, increases tissue permeability, reduces tissue . Fecal incontinence reduces skin tolerance, macerates tissue, increases tissue permeability, reduces tissuetolerance for friction, exposes skin to bacteria and digestive enzymes, increases pain and removes the protective acid-tolerance for friction, exposes skin to bacteria and digestive enzymes, increases pain and removes the protective acid-mantle of the skin.mantle of the skin.1, 201, 20 Repeated cleaning with alkaline soaps, coarse washcloths and prolonged exposure to Repeated cleaning with alkaline soaps, coarse washcloths and prolonged exposure todigestive enzymes are related to development of perineal dermatitis (PD). PD presents clinically as painful erythemiadigestive enzymes are related to development of perineal dermatitis (PD). PD presents clinically as painful erythemiawith or without vesication, induration, denuding, crusting and scaling of the skin in the perineal and perianalwith or without vesication, induration, denuding, crusting and scaling of the skin in the perineal and perianalregions. regions. 2 0,12 0,1 Incontinence management programs that address only cleaning and single product protection Incontinence management programs that address only cleaning and single product protection 1 ,21 ,2 are areinsufficient to address PD in the presence of persistent incontinence.insufficient to address PD in the presence of persistent incontinence. A review of WOCN Clinical Practice Guidelines, AHRQ Clinical Practice Guidelines, Ovid, Info-Quest, Pro- A review of WOCN Clinical Practice Guidelines, AHRQ Clinical Practice Guidelines, Ovid, Info-Quest, Pro-quest, and Medline databases from 2000-2005 was completed to support Evidence Based Practice (EBP) and bestquest, and Medline databases from 2000-2005 was completed to support Evidence Based Practice (EBP) and bestclinical practice. Key search words included, clinical practice. Key search words included, ““ incontinenceincontinence””, , ““ fecal incontinencefecal incontinence””, and , and ““ perineal perineal dermatitisdermatitis””..Outcome and comparison data was collected by retrospective and post implementation review of CCU medicalOutcome and comparison data was collected by retrospective and post implementation review of CCU medicalrecords. Product selection criteria included: (a) cost effectiveness, (b) ease of use, (c) patient comfort, (d) positiverecords. Product selection criteria included: (a) cost effectiveness, (b) ease of use, (c) patient comfort, (d) positiveclinical outcomes, (e) compliance, and (f) clinical validation of manufactures product claims. Products selectedclinical outcomes, (e) compliance, and (f) clinical validation of manufactures product claims. Products selectedincluded disposable wipes with 3 % dimethicone, a barrier/treatment product with active ingredients (tripsin-bassam-included disposable wipes with 3 % dimethicone, a barrier/treatment product with active ingredients (tripsin-bassam-peru-caster-oil ointment in a safflower oil base) and fecal containment systems (internal and external). Key programperu-caster-oil ointment in a safflower oil base) and fecal containment systems (internal and external). Key programelements include: (a) consistent protection of intact skin, (b) active treatment of compromised skin, (c) non-traumaticelements include: (a) consistent protection of intact skin, (b) active treatment of compromised skin, (c) non-traumaticcleansing, and (d) containment of intractable fecal incontinence.cleansing, and (d) containment of intractable fecal incontinence.

69 Y/O W/F admitted 1/19/06 w/ weakness, SOB, and hypoglycemia secondary to adjustments in oral glycemic69 Y/O W/F admitted 1/19/06 w/ weakness, SOB, and hypoglycemia secondary to adjustments in oral glycemicmanagement 3 days prior to admission. Hx was relevant for DM-II, HTN, severe PVD, CAD, CHF, respiratory failure, hx ofmanagement 3 days prior to admission. Hx was relevant for DM-II, HTN, severe PVD, CAD, CHF, respiratory failure, hx ofseizure, peripheral neuropathy and ischemia to (R) and (L) foot (possible cholesterol emboli post heart catherization theseizure, peripheral neuropathy and ischemia to (R) and (L) foot (possible cholesterol emboli post heart catherization theprevious week). Multi-system failure requiring intubation. NPO until TF started on1/25/06 with fecal incontinence andprevious week). Multi-system failure requiring intubation. NPO until TF started on1/25/06 with fecal incontinence andliquid stool in excess of 500cc/24hr. P revention/protection level of IMG begun on 1/23/06, advanced to treatment level andliquid stool in excess of 500cc/24hr. P revention/protection level of IMG begun on 1/23/06, advanced to treatment level andrectal catheter place on 1/31/06. When condition stabilized, skin improvement rapidly progressed (see photos) using therectal catheter place on 1/31/06. When condition stabilized, skin improvement rapidly progressed (see photos) using theIncontinence Management Guideline.Incontinence Management Guideline.

Pre IMG PD Prevelance=40%

12

8 CCU w/o inc.

CCU pt. w/ Inc &

PD

IMG Study Group PD Prevelance=40%

12

7

1

Inc.w /o PD

Inc w / PD

PD w / PD & ulcers

Post IMG PD Prevelance=2%

11

1

31

Inc. Pt w/o PD

Inc. Pt. w/ PD

Pt. w/o Inc or PD

Average Cost of Inc.Care

80

29

020406080

100

T.C

.

Clo

ths+

Oi

nt+

RC

Daily Cost

CONCLUSIONS