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well-structured and easy-to-implement program for preventing skin damage due to incontinence, or incontinence dermatitis (ID), is vital not only to your residents’ health but also to the financial health of your facility. More than 50% of institutionalized elder Americans are estimated to be incontinent.¹ Incontinent residents are at risk for developing ID, which predisposes them to pressure ulcers.^2,3 Given that a single pressure ulcer can cost as much as $30,000 to treat and potentially put your facility at risk for citation, implementing a sound ID prevention program is well worth the effort.⁴
       Surprisingly, almost no research has been done on the mechanism(s) involved in the development of ID. However, development of a very similar disorder, infant diaper dermatitis (IDD), is well described in the literature.^5,6 It is assumed that ID and IDD share similar etiologies with the caveat that ID is further complicated by the fragility of elder skin. Development of ID is not just a single event but rather a cascade of interacting events that weaken the skin, making it vulnerable to further breakdown from friction, shear, pressure, and infection (see Figure 1).

Figure 1

       Excessive moisture is thought to be the primary factor in the development of ID. Exposure of the skin to moisture increases skin’s permeability to chemical irritants, boosts risk of infection, and makes skin more vulnerable to friction, shear, and pressure.^3,5,6 When fecal contaminants are present, enzymes in the stool convert urea (from urine) to ammonia, which increases the pH of the skin and perineal environment. This increased pH has 3 detrimental effects on the skin: reactivating digestive enzymes in the stool that are normally inactive; further increasing permeability of the skin to chemical irritants; and, combined with body heat and moisture, providing an ideal environment for microbial growth.^5,6

Preventing Skin Damage

       Programs to prevent skin damage have become a standard of care in many long-term care facilities. Breaking the cycle of events by preventing skin exposure to excessive moisture, chemical irritants, and the detrimental effects of stool enzymes reduces treatment costs. Ideally, behavioral and medical interventions should be implemented to prevent incontinence from occurring in the first place. However, this is not always possible. Typically, residents are placed in extended-care facilities because of diminished cognitive or physical functions that prevent them from learning or implementing toileting practices.⁷ Therefore, effective and proper use of skin barrier products is paramount to preventing occurrence of ID.
       Skin barrier products vary greatly in formulation and technology. The oldest, most commonly used technology is petrolatum. Petrolatum ointments are inexpensive and effective when used as indicated. However, because petrolatum ointments easily wash off the skin and transfer to clothing, linens, and briefs, proper use dictates reapplication after every incontinent episode clean up.⁸ Frequent application adds significant product and labor costs to this seemingly inexpensive technology. It also adds burden to the already overworked caregiver, which may increase caregiver burnout and noncompliance of protocol.
       Compared to petrolatum-based ointments, polymer-based barrier film is a relatively new incontinence skin care technology. Barrier films have much longer durability than petrolatum ointments and are highly effective at treating ID.^8–10 In order to better understand the clinical utility and cost implications of using polymer-based barrier films in an ID prevention program, the incontinence barrier film product, 3M™ Cavilon™ No Sting Barrier Film (3M Health Care, St. Paul, Minn), was recently studied in a once-daily and 3-times-weekly prevention protocol in an extended-care facility.

Methods

       All residents enrolled in this study were incontinent, had intact perineal skin at the start of the study, and had no history of sensitivities to skin care products. At the start of the study, caregivers attended an in-service on proper incontinence skin care and were informed of the study objectives and design. Demographic data for participating residents were extracted from the most recent Minimum Data Set (MDS) in such a way as to de-identify the residents. 3M Cavilon No Sting Barrier Film was used once daily for 6 weeks. All residents were then switched to 3-times-weekly application for the remaining 6 weeks.
       Efficacy was tracked for the entire 12 weeks. Time-motion measurements were collected from a convenience sample of residents and caregivers over a 24-hour period during the first half of the study. This included the amount (grams) of barrier product applied per episode, time to apply the barrier, and time to clean up an incontinent episode. For 2 consecutive days during the study, nursing assistants (all certified) documented frequency of incontinence episodes throughout the day on all available residents.

Results

       Seventy-eight residents were enrolled in this study. Most of them (76.9%) were female, and all were Caucasian. Median age was between 81 and 90 years old, and more than 33% were above the age of 90. Seventy-two percent were reported to be frequently to totally incontinent of urine, and approximately 23% were frequently to totally incontinent of stool. About one-third of the residents required extensive assistance to complete daily personal care functions (see Table 1).

Table 1

       After in-service training on incontinence skin care, an adaptation period, and removal of existing barrier products from residents’ rooms, caregivers participating in this study easily adapted to the new skin care protocols and remained compliant throughout the study. Occurrence of ID was low throughout the study. There were 3 new cases of ID reported, which represents 3.9% of study residents. Of the 3 cases, 2 occurred with the once-daily application protocol, the other with the 3-times-weekly protocol.
       Data from this nursing home and 3 others participating in a larger cost-effectiveness study were pooled into an economic analysis comparing the barrier film protocols to 2 commonly used petrolatum ointments.¹¹ Results of the economic analysis indicate that when frequency of application is taken into account, cost per day of the seemingly inexpensive petrolatum products is approximately double that of the barrier film once-daily application protocol—and more than 4 times that of the 3-times-weekly application protocol (see Figure 2). When labor to apply the barrier is factored into the cost, it further favors the barrier film. However, even without the labor component, the barrier film was less expensive to use than ointments for prevention of ID.

Figure 2

Conclusion

       In switching from ointments to 3M Cavilon No Sting Barrier Film in an ID prevention protocol, a typical extended-care facility is likely to save 47–78% annually in barrier product cost. When labor to apply the product is included in the analysis, the projected cost savings increase by as much as 81%. For a typical 150-bed facility, barrier cost savings are projected to be between $9,000-$16,000; with labor added into the calculations, projected savings are $21,000-$31,000.
       These results indicate that 3M Cavilon No Sting Barrier Film can be successfully incorporated into ID prevention programs using reapplication protocols tailored to meet facility needs. Although this study is limited in size, there appears to be no clinically significant difference in efficacy between the once-daily and 3-times-weekly reapplication protocols.
       The full version of the study can be found in the December 2004 issue of Ostomy/Wound Management.