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Abstract: Diaper dermatitis (DD), an acute inflammatory reaction of skin in the perineal area, is an extremely common pediatric condition. Nurses' practice of preventing and treating DD is inconsistent and often not evidence-based. In addition, a 2008 Skin Injury Prevalence Study at our hospital revealed that 24% of inpatients had DD. The authors developed a project to determine a consistent and evidence-based approach to DD prevention and treatment including the availability of products. A complete literature review was conducted in addition to benchmarking with other pediatric hospitals, consultation with topic experts, and evaluation of current nursing practice prior to revising the existing perineal skin care nursing standard. The evidence supports frequent diaper changes, use of super absorbent diapers, and protection of perineal skin with a product containing petrolatum and/or zinc oxide. As supported by the literature, we revised the standard to include improvements in practice as well as product updates for prevention and treatment. Hospital-wide implementation of the revised standard included training "Skin Care Champions" to educate staff and support practice improvements. Ongoing education and monitoring by the Skin Care Champions is necessary to further improve the prevention and treatment of DD for our patients.
Diaper dermatitis (DD), an acute inflammatory reaction of skin in the perineal area, is an extremely common pediatric condition. The etiology of DD is multifactorial and includes moisture, warmth, friction, urine, and feces. Skin contact with urine and feces plays an integral role as moisture trapped against the skin causes increased permeability and susceptibility to damage from friction (Berg, Milligan, & Sarbaugh, 1994). The skin therefore loses its ability to provide an effective barrier against irritants and microbes. Urine contact with diapered skin causes an increase in skin pH thus increasing skin permeability and activating fecal enzymes, known irritants that can cause skin destruction. As the stratum corneum becomes damaged, microbes are more likely to cause inflammation and can lead to the development of a secondary infection (Shin, 2005). The signs and symptoms of DD range from generalized erythema to skin breakdown leading to an open wound. Above all, DD causes discomfort for the child as well as significant caregiver distress.
Age and health status influence DD risk. DD can occur in diapered and/or incontinent patients of varying ages. Neonates, specifically premature neonates, are at increased risk (Lund et al., 2001), as well as patients between 9 and 12 months of age (Jordan, Lawson, Berg, Franxman, & Marrer, 1986). DD commonly affects healthy children; however, acutely and chronically ill children may be at higher risk due to factors including medications that can cause diarrhea, underlying diagnoses such as cancer, gastrointestinal anomalies, neurological disorders, genetic syndromes, and malnutrition. In a point prevalence study, Noonan, Quigley, and Curley (2006) found 60% of hospitalized children less than 18 years of age incontinent of urine and/or stool with 16% of these patients having hospital-acquired DD. McLane, Bookout, McCord, McCain, and Jefferson (2004) found excoriation/DD as the most common type of skin breakdown (42%) in their prevalence study of hospitalized children aged birth to 17 years old.
The DD frequency cited in the literature, the suspicion that our hospital's rate was high, and observed practice variations encouraged us to look at our own prevalence rates and prevention and treatment tactics. We utilized the Iowa Model of Evidence-Based Practice (EBP) as the framework for our project (Titler et al., 2001). Problem-focused triggers included nursing and physician requests for barrier products not carried by the hospital and frequent changes to the treatment plan from shift to shift. Nurses, physicians, and pharmacists, as well as families, expressed dissatisfaction with the lack of zinc-based product availability. Additionally, medical care teams frequently ordered individual pharmaceutical ingredients that nurses mixed together at the bedside to create their own concoctions. The Nursing Practice department viewed these bedside concoctions as a patient safety issue and, therefore, a priority for the hospital to address. In addition, a 1-day Skin Injury Prevalence Study conducted in our hospital reported 24% of inpatients had DD (unpublished data). This information supports our hospital's inconsistent approach toward prevention and treatment of this commonly occurring problem.
To address this issue, we formed an interdisciplinary team comprised of a wound ostomy continence nurse, nurse researcher, pharmacist, and clinical nurse specialists (CNSs) from surgery, oncology, complex chronic/integrated care, and neonatal intensive care. With a team formed and problem areas identified, we extensively reviewed the literature to determine the best evidence for DD prevention and treatment.
The team conducted a broad literature search through CINAHL and Ovid, with no age or date limitations. Search terms included diaper rash, diaper dermatitis, nappy rash, irritant contact dermatitis, perineal skin breakdown, oncology, neonatology, surgery, petrolatum, zinc oxide, cholestyramine, baby powder, and cornstarch. Incontinence-associated dermatitis (IAD), a term used for DD symptoms in older pediatric and adult patients, was not included in this search (Gray et al., 2007). A review of article reference lists provided additional sources. We also reviewed national neonatal skin care guidelines. In addition to the literature, we searched for additional evidence by querying pharmacy and nursing listserves, consulting with topic experts in our hospital, and benchmarking with other pediatric hospitals for their DD prevention and treatment practices.
The literature search yielded 96 articles dating from 1962 to 2011 of which we evaluated 82 that specifically addressed DD prevention and treatment. We used the rating scale as described by Melnyk and Fineout-Overholt (2011) to level the evidence. Less than 12% of the articles were systematic reviews or randomized controlled trials (Levels I & II) and the remaining articles were nonrandomized trials, single descriptive studies, literature reviews, or expert opinions (Levels III-VII). See Table 1 for a summary of select recommendations from the literature.
Although the literature supports that DD is a common condition in the hospitalized child, definitive Levels I and II evidence supporting the most effective prevention and treatment options is not available (Rowe, McCall, & Kent, 2008). However, there is some consensus of lower levels of evidence around effective barriers. The literature supports that petrolatum and/or zinc oxide provide effective barriers against potential perineal skin irritants and maceration (Association of Women's Health, Obstetric and Neonatal Nurses [AWHONN], 2007; Hoggarth, Waring, Alexander, Greenwood, & Callaghan, 2005; Lund, Kuller, Lane, Lott, & Raines, 1999; Nield & Kamat, 2007). Baldwin et al. (2001) studied disposable diapers that delivered a continuous zinc oxide- and petrolatum-based formulation to the skin. Infants wearing these diapers had reduced DD and skin erythema compared to the control group wearing regular diapers. Baldwin also found that an increased concentration of zinc oxide in an impregnated diaper led to an increased transfer of zinc oxide to the skin. Hoggarth et al. (2005) found petrolatum to be an effective barrier against skin breakdown.
Other factors to consider include the type of diaper and frequency of diaper changes. A Cochrane Review did not find definitive evidence to support or refute the use and type of disposable diapers for prevention of DD (Baer, Davies, & Easterbrook, 2006). However, multiple descriptive and expert opinion articles recommend using super absorbent diapers containing gelling materials, which keep moisture away from skin (Davis, Leyden, Grove, & Raynor, 1989; Lund et al., 1999; Nield & Kamat, 2007; Scheinfeld, 2005). Caregivers should change diapers frequently, as often as every 2 hours or sooner if the diaper is wet and/or soiled (AWHONN, 2007; Atherton, 2004; Borkowski, 2004; Nield & Kamat; Visscher, 2009).
The literature supports certain processes for cleansing the diaper area and subsequent application of diaper area products. Some authors encourage the use of soft cloths and water for cleansing the diaper area due to preservatives in baby wipes that have the potential to cause skin irritation (AWHONN, 2007; Borkowski, 2004). However, many authors continue to support the use of baby wipes due to advances in manufacturing that have decreased the number of additives that they contain (AWHONN, 2007; Atherton, 2004; Ehretsmann, Schaefer, & Adam, 2001; Nield & Kamat, 2007; Odio, Streicher-Scott, & Hansen, 2001). Appropriate application of prevention and treatment products is also an important factor to consider. Several experts (Lund et al., 1999, 2001; Taquino, 2000) advise caregivers to apply barrier products thickly and refrain from rubbing off completely during diaper changes to prevent further skin damage. Covering barrier products with a thin layer of petrolatum may help prevent the diaper from sticking to the product (Borkowski, 2004). When a fungal infection is present, caregivers should apply the antifungal first with the barrier product layered on top. Antifungal powder can also be layered with skin protectant/sealant, referred to as "crusting" (Gray, 2007).
In conjunction with searching for evidence, our team developed a survey to collect baseline data prior to any practice changes (Titler et al., 2001). This survey included data regarding diapered status, DD products at the bedside, and presence and type of DD as described by Noonan et al. (2006). The survey included 195 patients from six inpatient units specifically chosen due to their high risk of DD as shown in our hospital's previous Skin Injury Prevalence Study. Results filtered for only diapered and incontinent patients showed that 16% had DD, of which 76% were Type I and a variety of products existed at the bedsides (Figure 1, January 2010 data).
Changing practice to reflect the current evidence is not without challenge. Cullen and Titler (2004) state that initiating a project and effectively changing practice can take 18 to 24 months. This is especially true regarding the prevention and treatment of DD because many clinicians have set ideas based on past experience-both as clinicians and as parents. In addition, caregivers have opinions on how to prevent and treat DD for their child. EBP models do account for these patient and family preferences along with clinical expertise and research evidence (Melnyk & Fineout-Overholt, 2011). Despite these challenges, nursing practice needs to reflect the evidence. Therefore, our team forged ahead with updating our perineal skin care standard based on the current evidence.
After a comprehensive review of the evidence, we revised our nursing standard. The new perineal skin care standard focuses on prevention and the importance of clearly identifying patients at risk for DD in order to employ prevention strategies early in the hospitalization. For patients with DD, a clear time frame was developed to discourage constant changing of products and allow one particular product time to exhibit effectiveness. In order to improve user-friendliness, we added a single-page, step-by-step algorithm (Figure 2) with photos and product application instructions. Detailed instructions elaborating on the algorithm and routine diaper care are included in the body of the standard.
Prior to implementation, we sought feedback from frontline staff as end users regarding use of the current standard as well as information on format, understandability, and ease of use for the revised standard (Titler et al., 2001). To gather this information, we conducted focus groups with key stakeholders. Forty-three nurses and one advanced practice nurse across six units frequently caring for diapered patients participated in the discussions. We drafted a standard script to guide the discussion. Questions included:
1. Were you aware of the current Perineal Skin Care Standard?
2. How do you use the current standard?
3. What are the obstacles to using the current standard?
4. What do you like/dislike about the revised standard?
5. What would make the revised standard more adaptable to practice? More user-friendly? More helpful or accessible?
Based on the feedback, many nurses were unaware of our current standard or had read it once during orientation and had not accessed it again. Primary obstacles were inaccessibility, including difficulty searching the nursing intranet or having no direct links to the standard. Regarding feedback on the revised standard, nurses commented positively about the inclusion of photos of DD, as well as the algorithm for prevention and treatment. The nurses offered many ideas to improve the revised standard, chiefly surrounding clarification of product application and removal.
Using the evidence, we moved forward to update our current products. We consulted our hospital allergy, dermatology, and infection control experts regarding common additives and "tubs" versus "tubes" for product containers. Following the EBP process, we also considered caregiver preferences and availability of products in the community so treatment could be continued at home (Melnyk & Fineout-Overholt, 2011). Next, we obtained approval from the hospital product evaluation committee and collaborated with materials distribution to plan product availability, location, and switch-out. Titler et al. (2001) recommends piloting an EBP change in a small sample, such as a single unit; however, this was not feasible with our hospital's system for changing products house wide. The hospital stocked petrolatum (Vaseline), but did not designate it as a DD product. Petrolatum, the first-line product for prevention, is now available on each unit's open supply cart. We replaced our second-line product with a 40% zinc-based product (Desitin Maximum Strength Original Paste), which is available in each unit's Pyxis MedStation. In addition to being evidence-based, this change saves the hospital approximately $8,000 per year. Nurses order products in the third line of prevention and treatment (Triple Paste, etc.) from materials distribution for individual patients. Our algorithm encourages the use of first- and second-line products and reserves the use of third-line products for when frontline products fail or as determined by patient needs.
Once we finalized revisions to the standard, we devised a hospital-wide rollout plan. This plan included presentations to the hospital CNS group, nursing department shared governance councils, and approximately 60 unit-based Skin Care Champions who are responsible for skin care education on their units. The team presented the entire EBP project during Nurses' Week as both a poster and oral presentation. All nursing units received a tip sheet highlighting the major changes to the standard, color posters of the algorithm to post, and cameras to document DD visually and see improvements with healing over time.
Although DD is a common condition in the hospitalized child, definitive optimal prevention and treatment strategies are still debatable as there is a lack of randomized controlled trials. This lack of high-level evidence makes recommendations more difficult. Additionally, much of the evidence available is dated; therefore, more studies are needed to identify the best options available.
The implementation of EBP changes proved to be a challenge in such a large pediatric hospital. Thousands of staff required education and training that spanned multiple disciplines. The risk of staff information overload was ever present as there were many competing priorities throughout the hospital at the time we disseminated the new standard. Buy-in from staff and consistency in practice were essential for the implementation of practice changes and important for patients and families to have consistent, evidence-based care.
Clinicians often have preferences for DD prevention and treatment based on clinical and personal experience. Straying from those preferences, especially when believed to be the best method or product, can be difficult. Additionally, caregivers may also have personal preferences for their child and may want to continue with their own prevention or treatment strategies. While acknowledging clinician and caregiver preferences, we sought to educate through the evidence-based revision of the standard and patient/family education materials.
As part of the EBP implementation process, Titler et al. (2001) recommend reevaluation after implementation of practice changes. In light of our initial finding of 24% prevalence of DD, we reassessed our high-risk units prior to implementing our revised standard and found a 16% prevalence rate. These rates from high-risk units closely mirror hospital-wide data. Following implementation of the revised standard, our prevalence rate was 15% at 3 months, 18% at 6 months, and 11% at 9 months. Therefore, over a 2-year period, the prevalence rate for high-risk units dropped from 24% to 11%. Preimplementation, prevalence assessments of Type IV DD were 11% and 5%. In the 9 months following implementation, the prevalence of Type IV DD decreased to 0% (see Figure 1). To capture compliance with the standard, we collected information regarding products at the bedside. Prior to implementation of the revised standard, 14% of high-risk patients had "other" products at the bedside not currently identified in the standard. Postimplementation, data revealed a decrease of "other" products to 6% potentially reflecting increased compliance with the revised standard.
The hospital Skin Care Champions were integral in bringing DD prevention and treatment to the forefront of nursing care. They will continue with this work as nursing staff needs frequent reminders of the importance of perineal skin care within the busy demands of bedside care. Routine collection of skin condition data serves as a reminder and offers another opportunity for Skin Care Champions to discuss perineal skin care with nurses. Utilizing multiple avenues for information dissemination helps ensure that the message is heard.
DD continues to affect hospitalized children and should remain a priority for nurses caring for diapered and incontinent patients. DD is often a preventable condition if appropriate attention and care are provided. Most importantly, nurses have the opportunity to influence DD rates through preventative evidence-based care. Our hospital demonstrated improvement in the prevalence of DD and the severity of cases, but there is always room for additional improvement.
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