Prevalence, management and clinical challenges associated with acute faecal incontinence in the ICU and critical care settings: the FIRST cross-sectional descriptive survey

Fecal Incontinence after Severe Brain Injury: A Barrier to Discharge after Inpatient Rehabilitation?

BACKGROUND

In this study, we aimed to investigate the incidence of fecal incontinence (FI) after severe acquired brain injuries (sABIs) and to determine whether this symptom can lead to an inability to return home after rehabilitation.

METHODS

This was a retrospective observational cohort study. In total, 521 acute sABI inpatients were enrolled from the Department of Neurorehabilitation at an academic tertiary care hospital. Patients were divided into two groups, with and without FI, at the end of the rehabilitation phase. The primary and secondary endpoints were the incidence of persistent FI and any difference in the discharge destination.

RESULTS

Upon admission, new-onset FI was found in 443 (85%) patients, of which 38% had traumatic sABI. Moreover, 62.7% of all patients had FI upon admission. At discharge, 53.3% (264/495) of patients still had FI. Of these, 75.4% (199/264) had a Rancho Level of Cognitive Functioning Scale (LCFS) ≥3. A statistically significant correlation between FI at discharge and the presence of frontal lesions, autonomic crises, and increased LCFS scores was noted. Among the patients discharged to their homes, the proportion with persistent FI was lower (34% vs. 53.3).

CONCLUSIONS

FI was significantly persistent after sABI, even after recovery from unconsciousness, and must be considered as a consequence of, rather than an independent risk factor for, unfavorable outcomes.

Risk factors of incontinence-associated dermatitis among critically ill patients: A systematic review and meta-analysis

Objectives

Incontinence-associated dermatitis (IAD) is increasingly found among critically ill patients, but the risk factors for IAD in these patients are currently unclear. The purpose of this meta-analysis was to identify the risk factors of IAD in critically ill patients.

Methods

Web of Science, PubMed, EMBASE, and Cochrane Library were systemically searched until July 2022. The studies were selected based on inclusion criteria, and data were independently extracted by two researchers. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of the included studies. Odds ratios (ORs) and their associated 95% confidence intervals (CIs) were used to identify significant differences in the risk factors. The I ² test was used to estimate the heterogeneity of studies, and Egger's test was used to assess the potential publication bias.

Results

A total of 7 studies enrolling 1,238 recipients were included in the meta-analysis. Age ≥ 60 (OR = 2.18, 95% CI: 1.38~3.42), female sex (OR = 1.76, 95% CI: 1.32~2.34), dialysis (OR = 2.67, 95% CI: 1.51~4.73), fever (OR = 1.55, 95% CI: 1.03~2.33), vasoactive agent (OR = 2.35, 95% CI: 1.45~3.80), PAT score ≥ 7 (OR = 5.23, 95% CI: 3.15~8.99), frequency of bowel movement > 3times/d (OR = 5.33, 95% CI: 3.19~8.93), and liquid stool (OR = 2.61, 95% CI: 1.56~4.38) were the risk factors of IAD among critically ill patients.

Conclusions

Many risk factors are related to IAD among critically ill patients. Nursing staff should pay more attention to evaluating the risk of IAD and enhance the care of high-risk groups.

A Structured Skin Care Protocol for Preventing and Treating Incontinence-associated Dermatitis in Critically Ill Patients

OBJECTIVE

To examine the effectiveness of a structured skin care protocol for preventing and treating incontinence-associated dermatitis (IAD) in critically ill patients.

METHODS

Participants were drawn from the ICUs of three teaching hospitals between January 2016 and December 2017. Patients were eligible if they were ≥18 years old, had idiopathic fecal incontinence, had diarrhea but were unable to sense it, and were expected to stay in the ICU for at least 72 hours after developing incontinence. A total of 143 patients were enrolled: 79 in the experimental group and 64 in the control group. In the first phase of the study, routine skin care measures were used; in the second phase, three ICU caregivers were trained to provide a structured skin care protocol. Trained research team members conducted the data collection and analysis. The TREND (Transparent Reporting of Evaluations with Nonrandomized Designs) Statement Checklist was followed in reporting the study results.

RESULTS

Application of the structured skin care protocol reduced the incidence of IAD from 35.9% in the control phase to 17.7% in the intervention phase (χ2 = 6.117, P < .05) and also decreased the severity of IAD (z = -2.023, P < .05). Further, IAD developed later (z = -2.116, P < .05) in the intervention group than in the control group. In addition, the nursing times to prevent or manage IAD did not differ significantly between the groups (t = -0.258, P > .05; t = -1.190, P > .05).

CONCLUSIONS

Use of the developed structured skin care protocol for IAD in critically ill patients lowered the incidence and severity of IAD and delayed IAD development.

MELHORES PRÁTICAS DE ENFERMEIROS NO MANEJO DA INCONTINÊNCIA FECAL EM CONTEXTO HOSPITALAR: REVISÃO INTEGRATIVA

RESUMO Objetivo analisar, na literatura, as melhores práticas de enfermeiros acerca do manejo da Incontinência Fecal em contexto hospitalar. Método trata-se de uma revisão integrativa da literatura com busca realizada em setembro de 2021 nas bases de dados MEDLINE/PubMed, Web of Science e no banco de dados da Biblioteca Virtual em Saúde, que incluiu as bases de dados Literatura Latino-Americana e do Caribe em Ciências da Saúde, Base de Dados de Enfermagem e Índice Bibliográfico Español en Ciencias de la Salud. A análise considerou os métodos descritivos e a elaboração de um corpus textual mediante o software Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires. Resultados foram incluídos 11 estudos (e a análise destes permitiu evidenciar a prevalência do idioma inglês) publicados entre os anos de 1977 e 2021 e que apresentaram, em maior ocorrência, delineamento metodológico observacional com nível de evidência 2C. Os resultados foram agrupados em duas categorias: “Evidências de cuidados para gerenciamento da Incontinência Fecal”, tendo como maior predominância o uso dos sistemas de drenagem fecal, e “Dispositivos de apoio e prevenção de complicações”, apresentando, com maior ocorrência, os dispositivos de contenção. Conclusão identificou-se que as melhores práticas adotadas pelos enfermeiros no contexto hospitalar estão associadas ao uso de sistemas de drenagem e dispositivos de contenção do conteúdo fecal. Evidenciou-se a limitação da equipe de Enfermagem quanto ao uso de outras práticas benéficas ao paciente com Incontinência Fecal.

NURSES' BEST PRACTICES IN THE MANAGEMENT OF FECAL INCONTINENCE IN THE HOSPITAL CONTEXT: AN INTEGRATIVE REVIEW

ABSTRACT Objective to analyze, in the literature, the nurses' best practices towards management of Fecal Incontinence in the hospital context. Method this is an integrative literature review with a search carried out in September 2021 in the MEDLINE/PubMed and Web of Science, as well as in the Biblioteca Virtual em Saúde database, which included the Literatura Latino-Americana e do Caribe em Ciências da Saúde, Base de Dados de Enfermagem and Índice Bibliográfico Español en Ciencias de la Salud databases. The analysis considered the descriptive methods and elaboration of a textual corpus in the Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires software program. Results a total of 11 studies were included (and their analysis allowed evidencing prevalence of the English language) published between 1977 and 2021 and which presented, in a greater proportion, an observational methodological design with level of evidence 2C. The results were grouped into two categories: “Care evidence for the management of Fecal Incontinence”, with greater predominance of the use of fecal drainage systems; and “Support devices and prevention of complications”, presenting, in a greater proportion, the containment devices. Conclusion it was identified that the best practices adopted by nurses in the hospital context are associated with the use of drainage systems and fecal content containment devices. A limitation was evidenced in the nursing team regarding use of other beneficial practices for patients with Fecal Incontinence.

Assessing absorbent products' effectiveness for the prevention and management of incontinence-associated dermatitis caused by urinary, faecal or double adult incontinence: A systematic review

OBJECTIVE

Adults who suffer from incontinence are at substantial risk of developing incontinence-associated dermatitis (IAD). In healthcare settings, several interventions have been implemented to prevent or manage IAD, and several absorbent products have been developed for incontinent patients; however, there is no systematic review that has reported on which absorbent products are effective for the prevention or management of incontinence-associated dermatitis. We conducted a systematic review to investigate the effectiveness of absorbent products in the prevention and management of IAD.

METHODS

MEDLINE (1946-August 31, 2020), CINAHL (1982-August 31, 2020), and Cochrane Library (August 31, 2020) were searched for relevant articles.

RESULTS

Eight studies met the eligibility criteria and were included in this review, including two randomized controlled trials that were designed to evaluate the efficacy of absorbent products on the prevention or management of incontinence-associated dermatitis. Quality of evidence was assessed as low or very low. The findings revealed that some outcomes related to IAD prevention or improvement of IAD can be positively affected by the introduction of a new absorbent product or a difference in the frequency of pad changing, which can control the overhydration of the skin.

CONCLUSIONS

The studies included in this review indicated that the problem of control of overhydration of the skin associated with urine and/or faeces can be controlled by absorbent products and these products may be effective for the prevention or management of incontinence-associated dermatitis. Future research with high-quality studies is required.

Incontinence-associated dermatitis: who is affected?

OBJECTIVE

Intensive care unit (ICU) patients possess multiple risk factors for developing loss of skin integrity, particularly incontinence-associated dermatitis (IAD). IAD is an inflammatory skin condition resulting from repeated and prolonged contact with urine, faeces or both. This study aimed to measure the incidence and clinical characteristics of adult ICU patients with IAD.

METHOD

This was a prospective observational study conducted over three months in an adult ICU. Included patients were ≥18 years who experienced faecal incontinence during their intensive care admission. Patients were excluded if they had an ileostomy or colostomy, had IAD on admission, or were continent of urine and faeces. Skin inspections were performed every second day on all recruited patients by trained research nurses. Other data were collected from patient medical records.

RESULTS

A total of 37 patients took part in the study. Incidence of IAD was 35.1%; 13 patients who had incontinence developed IAD. The mean time to onset of IAD was 3.69 days, median 3 days (SD: 1.8, range: 2-8 days). Of the 13 patients who developed IAD, 12 (92.3%) patients were initially assessed as having category 1 IAD and one (7.7%) patient was initially assessed with category 2 IAD. Of the patients with category 1 IAD, one patient (7.7%) progressed to category 2 IAD severity.

CONCLUSION

A larger sample is recommended to fully explore ICU patient characteristics and IAD development. The incidence of IAD in ICU patients was high at 35%, indicating this condition requires due consideration in ICU patients.

Moisture associated skin damage (MASD) in intensive care patients: A Norwegian point-prevalence study

BACKGROUND

Critically ill patients are at risk of developing moisture associated skin damage and pressure ulcers. These conditions may co-exist and be difficult to distinguish, but a simultaneous investigation may provide a true prevalence.

OBJECTIVES

To investigate the prevalence of moisture associated skin damage and associated factors among Norwegian intensive care patients.

METHODS

A multi-centre one-day point-prevalence study.

RESULTS

Totally, 112 patients participated in the study. Overall, 15 patients (13%, 15/112) had some type of moisture associated skin damage of which six cases (5%, 6/112) were related to faeces and/or urine (incontinence associated dermatitis). Skin breakdown occurred primarily in the pelvic area. Overall, 87% (97/112) had an indwelling urinary catheter. Stools were reported in 42% (47/112) of the patients on the study day, mostly liquid or semi-liquid. Overall, 11% (12/112) had a faecal management system. Only a few care plans for moisture associated skin damage prevention and care existed.

CONCLUSION

Patients in this study were vulnerable to skin breakdown in the pelvic area. Nevertheless, a low prevalence of skin breakdown existed. This may relate to intensive care nurses' qualifications, the 1:1 nurse-patient staffing, the high prevalence of urinary catheters and few patients having stools.

Determining the impact of a bowel management protocol on patients and clinicians' compliance in cardiac intensive care: A mixed-methods approach

BACKGROUND

Bowel management protocols standardise care and, potentially, improve the incidence of diarrhoea and constipation in intensive care. However, little research exists reporting compliance with such protocols in intensive care throughout patients' stay. Furthermore, there is a limited exploration of the barriers and enablers to bowel management protocols following their implementation, an important aspect of improving compliance.

AIM AND OBJECTIVE

To investigate the impact of a bowel management protocol on the incidence of constipation and diarrhoea, levels of compliance, and to explore the enablers and barriers associated with its use in intensive care.

METHODS

A mixed-methods study was conducted in cardiac intensive care using two phases: (a) a retrospective case review of patients' hospital notes, before and after the protocol implementation, establishing the levels of diarrhoea and constipation and levels of compliance; (b) focus groups involving users of the protocol, 6 months following its implementation, exploring the barriers and enablers in practice.

RESULTS AND FINDINGS

Fifty-one patients' notes were reviewed during phase one: 30 pre-implementation and 21 post-implementation. Following the protocol implementation, there was a tendency for a higher incidence of constipation and less severe cases of diarrhoea. Overall compliance with the protocol was low (2.3%). However, there was evidence of behavioural change following protocol implementation, including less variation in aperients given and a shorter, less varied time period between starting enteral feed and administering aperients. Several themes emerged from the focus groups: barriers and enablers to the protocol characteristics and dissemination; barriers to bowel assessment; nurse as a barrier; medical involvement and protocol outcomes.

CONCLUSIONS

The bowel management protocol implementation generated some positive outcomes to bowel care practices. However, compliance was low and until there is improvement, through overcoming the barriers identified, the impact of such protocols in practice will remain largely unknown.

Incidence and risk factors of incontinence-associated dermatitis among patients in the intensive care unit

OBJECTIVE

To investigate the incidence of incontinence-associated dermatitis (IAD) among patients in the intensive care unit (ICU) and to identify potential risk factors to establish a reference for clinical nursing work.

BACKGROUND

Patients in the ICU are susceptible to IAD. IAD is painful, reduces the patient's quality of life and adds to the workload of clinical medical staff. However, risk factors associated with IAD may differ between countries and healthcare settings.

DESIGN

Prospective cohort study METHODS: From November 2016 to November 2017, a prospective cohort study was conducted among109 patients in three Class 3, Grade A hospitals (comprising 9 ICUs in total) in Beijing. The Incontinence-associated Dermatitis and Its Severity (IADS) instrument in Chinese was applied to assess IAD. Univariate and multivariate logistic regression analyses were performed to identify risk factors for IAD.

RESULTS

The study population had 29 community-acquired and 80 nosocomial infections, and 26 (incidence: 23.9%) of these had IAD. On univariate analysis, a significant difference was observed between patients with and without IAD with respect to the following indices: Barthel index, Braden scale score, Nutritional Risk Screening 2002 (NRS2002) score, serum albumin level, occurrence of infection, faecal incontinence, frequency of faecal incontinence, stool property and double (faecal and urinary) incontinence and perineal assessment tool (PAT) score (p < 0.05). Multivariate logistic regression analysis showed that three factors entered the regression equation-that is, the Braden Scale Score, serum albumin level and double incontinence. Of these, the Braden Scale Score and serum albumin level were protective factors for IAD. Thus, the higher the Braden Scale Score, the lower the risk of IAD (OR = 0.678, 95% confidence interval [CI] = 0.494-0.931); a higher level of serum albumin implies a lower risk of IAD, provided it is within the normal range (OR = 0.884, 95%CI = 0.797-0.981). Double incontinence was an independent risk factor for IAD (OR = 10.512, 95% CI = 2.492-44.342).

CONCLUSION

A higher morbidity of IAD is seen in the ICU. Specific preventive and nursing measures are required to maintain the skin integrity of critically ill patients in daily nursing practice to improve patient quality of life and the quality of nursing care.

RELEVANCE TO CLINICAL PRACTICE

Incontinence-associated dermatitis is characterised by inflammation and tissue damage due to prolonged/repeated exposure to urine and/or stool. Not every patient with urine and/or stool incontinence develops IAD. Medical staff can use research-based evidence to identify ICU patients at risk of IAD to reduce morbidity and improve health outcomes.

Incontinence-associated dermatitis in the critically ill patient: an intensive care perspective

BACKGROUND

Incontinence-associated dermatitis is a skin disorder evident as a complication of incontinence. It is characterized by perineal, buttock and groin erythema and skin breakdown. Incontinence-associated dermatitis is a ubiquitous, nosocomial condition commonly present in critically ill patients in the intensive care unit. Critically ill patients, by the nature of their critical illness and therapies used to treat their presenting condition, are commonly predisposed to faecal incontinence and are consequently at high risk of developing incontinence-associated dermatitis. However, this condition is under-explored and under-reported in the intensive care literature.

OBJECTIVE

The aim of this paper is to provide a review of the literature relating to incontinence-associated dermatitis from the critically ill patients in the intensive care setting.

DISCUSSION

There is a paucity of literature addressing this condition in the intensive care context, with only 11 studies identified. This paper will provide an overview of the definitions, prevalence and incidence of incontinence-associated dermatitis. Furthermore, an exposition of incontinence-associated dermatitis from the critically ill patient and intensive care nursing perspectives will be presented through a review of the skin barrier function, clinical presentation, risk factors, clinical assessment and severity categorization, prevention and management of incontinence-associated dermatitis.

CONCLUSION

It is imperative that critical care nurses have an appreciation of incontinence-associated dermatitis as a common, yet preventable condition, and are equipped with knowledge to appropriately prevent and manage this common complication.

Best practice nursing care for ICU patients with incontinence-associated dermatitis and skin complications resulting from faecal incontinence and diarrhoea

AIMS

Incontinence-associated dermatitis (IAD), resulting from diarrhoea and/or faecal incontinence, is a common problem in intensive care, occurring in 7-50% of the patients, with an estimated 10 million dollars spent annually on continence skin care. This project aimed to evaluate and improve the staff knowledge on IAD and also improve practice in the identification, prevention and treatment of IAD in the ICU.

METHODS

A pre/post-audit framework was used to implement the best practice recommendations between August 2013 and March 2014. Nursing staff were surveyed and a chart review was conducted to audit baselines of knowledge and nursing practice regarding IAD. Education and product standardization were used to implement the best practice recommendations and a post-audit was conducted to evaluate changes in knowledge and practice.

RESULTS

Thirty-one (pre-implementation) and 27 (post-implementation) nurses were surveyed to evaluate knowledge on IAD identification, care and documentation practices. No IAD policy or IAD-specific skin assessment tool for use existed in the ICU. After implementation, there was a 40% increase in the ability of the staff to distinguish between IAD and pressure injuries, an increase from 87% to 100% in the use of skin-protectant and an improvement from 25 to 66% in the correct application of skin-protectants. An encouraging 70% of the nurses were using a single standard skin-protectant after implementation as opposed to audit 1, where 100% of the nurses were using multiple products before implementation. There was a 16% increase in the staff surveyed post-audit who said they reported on the perineal skin in patients with IAD. However, IAD documentation in both audit 1 and audit 2, as evidenced by chart review, remained poor.

CONCLUSION

The project had created an awareness of IAD in the ICU. There was clear knowledge improvement and nursing staff were able to differentiate IAD from pressure injuries. The skin cleansing and protection regime is now more clear and consistent, and a single standardized product is being used to prevent and treat IAD. There was a small improvement in consistently documenting the condition of the perineal skin of patients with IAD; however, it was beyond the scope of this project to develop a policy and implement an IAD-specific skin assessment tool in the ICU, as this would have improved documentation of IAD in the ICU.

Prevalence, clinical consequences and management of acute faecal incontinence with diarrhoea in the ICU: The FIRST™ Observational Study

There are limited data on the incidence and management of acute faecal incontinence with diarrhoea in the ICU. The FIRST™ Observational Study was undertaken to obtain data on clinical practices used in the ICU for the management of acute faecal incontinence with diarrhoea in Germany, UK, Spain and Italy. ICU-hospitalised patients ≥18 years of age experiencing a second episode of acute faecal incontinence with diarrhoea in 24 h were recruited, and management practices of acute faecal incontinence with diarrhoea were recorded for up to 15 days. A total of 372 patients had complete data sets; the mean duration of study was 6.8 days. At baseline, 40% of patients experienced mild or moderate-to-severe skin excoriation, which increased to 63% in patients with acute faecal incontinence with diarrhoea lasting >15 days. At baseline, 27% of patients presented with a pressure ulcer, which increased to 37%, 45% and 49% at days 5, 10 and 15, respectively. Traditional methods (pads, sheets and tubes) were more commonly used compared to faecal management systems during days 1-4 (76% vs. 47% faecal management system), while the use of a faecal management system increased to 56% at days 5-9 and 61% at days 10-15. At baseline, only 26% of nurses were satisfied with traditional management methods compared to 69% with faecal management systems. For patients still experiencing acute faecal incontinence with diarrhoea after 15 days, 82% of nurses using a faecal management systems to manage acute faecal incontinence with diarrhoea were satisfied or very satisfied, compared to 37% using traditional methods. These results highlight that acute faecal incontinence with diarrhoea remains an important healthcare challenge in ICUs in Europe; skin breakdown and pressure ulcers remain common complications in patients with acute faecal incontinence with diarrhoea in the ICU.

Expert Recommendations for Managing Acute Faecal Incontinence with Diarrhoea in the Intensive Care Unit

Acute faecal incontinence with diarrhoea (AFId) has been reported to affect up to 40% of patients in the intensive care unit (ICU). The clinical challenges of AFId include the risk of perineal skin breakdown and cross-contamination with nosocomial infections, such as Clostridium difficile. In addition, the management of AFId is a burden on nursing time and hospital resources. Despite these challenges, there is currently no standard way of managing AFId. To address this problem, an international panel of intensive care specialists was convened to discuss AFId management recommendations. The collective knowledge of the specialists combined with literature searches from online medical databases were used to create a set of guidelines together with an accompanying management algorithm to aid healthcare providers in deciding the most appropriate care for patients with AFId in the ICU. These guidelines have been specifically designed to take into account patient severity of illness and comorbidities, which coupled with common AFId-associated clinical complications, can influence management choices. A comprehensive review of current AFId management strategies, taking into account the spectrum of patients and hospital economic limitations, has been included as a reference guide. It is hoped that the wider adoption of these recommendations will be a step forward in improving the current management of AFId in the ICU.