September 2012 Issue 3 Volume 3Practice The dangers of faecal incontinence in the at-risk patient

The dangers of faecal incontinence in the at-risk patient

01/09/12 | Complex wounds, Skin integrity, Wellbeing and concordance | Janice Bianchi, Teresa Segovia-Gómez

The dangers of faecal incontinence in the at-risk patient Faecal incontinence can have serious consequences for a patient's skin, quality of life and dignity. Clinicians and support workers need to be aware of the impact faecal incontinence can have on individual patients. This article identifies the negative effects of faecal incontinence in relation to morbidity, quality of life and health economics.

Introduction
When faecal incontinence occurs tissue can deteriorate rapidly. Bliss et al[1] reported onset of incontinence-associated dermatitis (IAD) at between six and 42 days after onset (median 13 days).  

All clinicians and support workers need to be aware of the impact faecal incontinence can have on individual patients. Early recognition of at-risk patients, prevention strategies and treatment may prevent tissue breakdown. It is, therefore, important for clinicians to be aware of the possible causes of faecal incontinence and to understand the physiological changes that may occur.  

Clostridium difficile is the most significant cause of hospital-acquired diarrhoea and is responsible for considerable morbidity and mortality. Patients with C. difficile-associated diarrhoea may also experience faecal incontinence[2]. Other important causes of faecal incontinence are outlined in Table 1

Who is at risk
Faecal incontinence is a common and debilitating condition with prevalence varying between care settings. The reported prevalence of faecal incontinence is 18% to 37% in patients in acute/critical care settings[3,4]. In long-term care hospitals a prevalence of 46% was reported[5] with prevalence of between 40% and 79% in residential and nursing homes[1,6]. Faecal incontinence can occur as an acute episode, eg after commencing antibiotic therapy or during an exacerbation of inflammatory bowel disease, or as part of a chronic condition, eg in the presence of anal sphincter damage or a neurological condition. It affects all age groups but is most commonly seen in the elderly population[7] and in patients managed in critical care settings[8]

The consequences of faecal incontinence
The physiological changes that occur due to faecal incontinence are thought to be a result of an increase in the pH of the skin. The normal pH of the skin varies from person to person but, in the normal state, the skin is acidic with a mean pH of 5.5-5.9. Changes in the external pH of the skin affect the fatty acid content of the skin and impair the barrier formed by the skin cells[9,10]

Normal stool is alkaline, with a typical pH of 7.0-7.5. Exposure to faeces contributes to an abnormally high skin pH. In addition to damaging the barrier function of the skin cells, an increased pH encourages bacterial colonisation, most often by Candida albicans and Staphylococcus from the perineal skin and the gastrointestinal tract[11]. Overgrowth of these or other microorganisms can lead to skin irritation or infection, which can further weaken the skin's defence mechanisms.

The excess moisture also makes the skin susceptible to mechanical damage, friction and shearing forces[9]. In liquid stool, lipidolytic and proteolytic enzymes also damage the skin by breaking down the epidermis[11].

In addition to the local damage caused by faecal incontinence, there is an increased risk of systemic infection such as urinary tract infection and microbial skin infection[12].

Pressure ulcer development is associated with increased morbidity and mortality. Other consequences include a higher risk of nosocomial infections and other hospital complications, and increased length of stay[13]

Moisture lesions, moisture ulcers, perineal dermatitis, diaper dermatitis and IAD all refer to skin damage caused by excessive moisture[14] and are potential consequences of faecal incontinence. 

Nix[7] suggested that IAD develops in one-third of patients who are faecally incontinent - this correlates with a study carried out by Bliss et al[1] who found that, in a study population of elderly residents in nursing homes, all of the patients who developed IAD also had faecal incontinence. Bliss et al[1] defined the different levels of IAD as:

  • Mild: light redness, intact skin, slight discomfort
  • Moderate: medium redness, presence of skin peeling or flaking, small areas of shallow broken skin or small blisters
  • Severe: dark or intense redness, presence of rash, deeper skin peeling or erosion, large blisters or weeping skin and pain.

Table 2 describes the different types of lesions that can occur as a consequence of faecal incontinence.

 

 

FAECAL INCONTINENCE AND QUALITY OF LIFE 
The psychological impact of both faecal incontinence and the resultant skin damage should not be underestimated and can negatively impact patients' dignity, causing embarrassment and stigma[15]. Lack of bowel control and subsequent odour can also impact on both social and physical functioning. Additionally, skin excoriation caused by faecal incontinence is an extremely debilitating and often very painful condition[16] and as such can significantly impact on the patient's quality of life. 

Financial cost
In addition to the physical and psychological impact of faecal incontinence, there are significant cost implications in terms of increased length of hospital stay and the subsequent effect on employment. In these times of limited economic resources, all clinicians must be aware of safe and effective methods of reducing healthcare costs.

Gray et al[17] suggest that pressure ulcer treatment data should include costs associated with skin injury caused by incontinence. Any financial analysis also has to account for the cost of linen changes, including clinicians' and carers' time and laundry costs, as well as other factors such as aprons, gloves, skin cleansers and disposing of soiled items.

Economic considerations for healthcare providers, in terms of staff and consumables, were studied by Bale et al[6]. The researchers found the introduction of a structured skin care protocol, along with an educational programme, resulted in a significant reduction in the number of patients developing grade 1 pressure ulcers (p=0.042) and incontinence-related dermatitis (p=0.021), as well as a time reduction in patient care associated with incontinence-related skin damage (p<0.001; mean reduction - 4 minutes 2 seconds per patient). In addition to a reduction in the amount of consumables used prior to implementation, this resulted in cost savings of £8.85 for qualified staff and £3.43 for unqualified staff. The researchers also noted patients' skin condition was maintained or improved following implementation.

Similarly, Durnal et al[18] evaluated a faecal management system in a hospital intensive care unit and demonstrated a 45% reduction in costs compared to traditional methods (absorbent briefs, skin cleansers, moisturisers). The cost savings identified were mainly due to a reduction in nursing time, which was substantially reduced by using a faecal management system.

Evaluating moisture-related skin damage
When skin damage has occurred, accurate skin assessment is essential. Clinicians should use a recognised assessment tool to aid grading and decision making for treatment of tissue damage. Table 3 describes the tools available.

Despite the availability of these tools, which are specifically designed to assess IAD, the most common instruments used to assess moisture-related skin damage are pressure ulcer staging systems[17]. 

Early identification of skin damage using a recognised tool, as well as timely intervention, can prevent an area of excoriation developing in to a pressure ulcer. Reduction in pressure ulcer incidence is a priority in many healthcare settings in the UK now, with services setting targets to eliminate all avoidable category 3 and 4 pressure ulcers and other regions attempting to prevent all category 2,3 and 4 pressure ulcers[19]. In addition, the declaration of Rio provides further evidence of the global recognition of the need to dramatically reduce the prevalence and incidence of pressure ulcers[20]. The Declaration of Rio set out the rights of people not to experience pressure ulcers. In addition it suggests steps to implement and help protect patients.

Guide to managing faecal incontinence 
It is essential to identify the underlying cause of faecal incontinence and, where possible, take measures to correct it. An inter-professional approach is required. This may mean changing the drug regimen, for example, or working with continence advisors to re-establish normal bowel habits - possibly even corrective surgery. With some causes of faecal incontinence, restoring normal function may not be possible, for example, where there is anal sphincter damage or in neurological conditions. In all cases measures should be taken to minimise the risk of tissue breakdown.  

If skin damage has occurred , early intervention using a structured approach is required to minimise the damage. Gray et al[17] recommend using a structured skin care programme with active treatment for IAD, including the following measures for patients with mild to moderate IAD: 

  • Routinely cleanse and moisturise the skin - avoid the use of soap and water and use perineal skin cleansers, which combine detergents and surfactants to loosen and remove dirt and irritants. Many are pH-balanced and contain moisturising agents 
  • Routinely apply a skin protectant - these include acrylate polymer-based liquid film; petroleum ointment; zinc oxide in 1% dimethicone; and petroleum ointment 
  • Treat cutaneous candadiasis when present - this will present as a bright red rash with outlying satellite papules or pustules. The skin will be sore rather than itchy
  • Apply moisturiser after each episode of incontinence. If candidiasis is present, apply a moisture-barrier combination product with anti-fungal agent, eg azole or allylamine
  • Educate carers to use a structured regimen, assessing skin frequently for resolution or progression of IAD, especially after each episode of incontinence
  • Evaluate or begin management programme for underlying incontinence.

 

Faecal management systems
Several products are available to clinicians for the containment of faecal matter. Anal bags may be used, however, the skin will require protection by other means if there is a chance of leakage around the device. Body worn pads are also useful but should be changed promptly after each episode of faecal incontinence to avoid or minimise skin damage. 

However, where diarrhoea is severe and high volume, IAD and widespread skin breakdown can occur very rapidly. In this instance it is appropriate to consider the use of a faecal management system[15]

In addition to cost savings described by Durnal et al[18], one study found that, in patients with faecal incontinence and diarrhoea in a surgical intensive care unit, the use of faecal management systems reduced incidence of skin damage from 43% to 12.5%[21]

Beldon[22] identified that faecal management systems provide a 'closed system', which is useful if the patient has infective diarrhoea, containing infectious waste and helping to control infections like C. difficile from spreading[23]. Closed systems also enable the monitoring of fluid balance, and help in maintaining skin integrity and preserving the patient's dignity. 

Any FMS should be used in accordance with manufacturers' instructions to ensure proper use of the device and on appropriate patients.

The case study presented above demonstrates the effective use of a faecal management system in reducing skin damage.

Conclusion
Faecal incontinence can have a seriously deleterious affect on patients' wellbeing if not addressed, contributing to moisture lesions, pressure ulcers and combined lesions. If diarrhoea is caused by infectious bacteria such as C. difficile, the risk of cross infection may be high. Increased costs in terms of nursing time, consumables, and for some patients, increased length of stay may be also be significant.

Prevention is paramount but if this is not possible, or if the patient is being seen at a late stage, adequate measures must be put in place to control faecal incontinence and minimise its effect on the skin of the patient. 

 

Author details
Janice Bianchi is a Medical Education Specialist at JB Med Ed Ltd and Honorary Lecturer at University of Glasgow, Scotland

This article was produced with an educational grant from ConvaTec.