Development of a Risk Assessment Tool for Incontinence-associated Dermatitis (IAD): a Cohort Study on the Predictive Performance of Risk Factors for IAD

Problem Statement:

Incontinence-Associated Dermatitis (IAD) is a type of irritant contact dermatitis caused by prolonged skin exposure to urine and/or feces. It commonly affects individuals with incontinence. IAD is associated with decreased quality of life, increased care burden, loss of independence, and higher susceptibility to secondary infections and pressure ulcers. These complications lead to prolonged hospital stays and increased healthcare costs.

Despite its clinical relevance, there is insufficient consensus regarding the most critical risk factors for IAD. Existing literature points to a wide range of potential contributors including patient demographics, comorbidities, hygiene practices, and care protocols. A comprehensive prospective study is needed to investigate these risk factors within a hospitalized population in order to inform effective prevention and management strategies.

Methodology:

A prospective cohort design will be conducted across multiple hospital settings in Sweden and Belgium. The study targets adult patients, aged 18 years or older, who suffer from urinary, fecal, or double incontinence upon admission to the hospital and are free of IAD at enrollment.

The primary goal of this prospective cohort study is to collect data on specific factors, including age, sex, stool consistency, etc. and assess their association with the development of IAD. Through the compilation of this data, the study aims to determine whether the identified factors are indeed risk factors for the occurrence of IAD.

Data Collection:

Data collection will be managed through an electronic case report form (eCRF) using the RedCap® platform. Nurses will conduct daily inspections of the perianal skin area for each patient, recording observations and, when signs of IAD were identified, capture photographic evidence. These images will be reviewed by a blinded expert panel from the SCENTR team at Örebro University to confirm the diagnosis.

Collected variables include demographic data such as age, sex, and body weight, as well as clinical and care-related factors. These encompass comorbidities (e.g., diabetes, dermatological conditions, Clostridioides difficile infection), cognitive status, smoking habits, nutritional support (including enteral and parenteral nutrition), sedative and vasopressor use, and antibiotic therapy. Care-related variables include the frequency and type of incontinence, the number of absorbent product changes, skin cleansing and barrier product usage, and whether patients are mechanically ventilated. Additionally, functional assessments based on selected Braden Scale subscales-moisture, friction/shear, self-care ability, and mobility-will be recorded. Stool consistency will be classified using the Bristol Stool Chart, with a particular focus on types 6 and 7 (loose and watery stools), which have been previously identified as potential contributors to skin breakdown.

Data Analysis:

Statistical analysis, conducted using SPSS statistical package version 28.0 or later, will involve presenting summary statistics for demographics and clinical characteristics. Univariate analyses will explore associations between potential risk factors and IAD development, employing appropriate tests. Variables with p ≤ 0.2 significance in bivariate analysis will undergo multivariate logistic regression. Beforehand, multicollinearity will be assessed using multiple linear regression, and variables will be removed via the backwards method with P = 0.1 cut-off. Model fit will be evaluated using Nagelkerke R2 and Hosmer-Lemeshow statistic, with significance set at α = 0.05.

Inclusion criteria

• The patient or their legally authorized representative signed informed consent.
• The patient is aged 18 years or older.
• The patient suffers from incontinence* (urinary, faecal, double incontinence).
• The patient is free of IAD at inclusion. *Incontinence is defined as involuntary loss of urine and/or stool.

Exclusion criteria

• Patients admitted to emergency departments, paediatric units, maternity units, psychiatric units, and palliative care units.
• Patients who are receiving end-of-life care.