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Incontinence associated dermatitis and pressure injury

Know the difference between incontinence associated dermatitis and pressure injury to improve consumer health outcomes

20 October 2022

Key points:

  • Clinical staff should be made aware of the differences between incontinence associated dermatitis (IAD) and pressure injury (PI).
  • IAD and PIs are commonly confused.
  • If the consumer is not incontinent, it is not IAD.
  • IAD and PI can coexist.
  • Both conditions must be adequately assessed and monitored, including photographic monitoring where appropriate.
  • If either condition continues to progress, specialist advice should be sought.

The Aged Care Quality and Safety Commission is seeing concerning issues in relation to incontinence associated dermatitis (IAD) and confusion with pressure injury (PI). This includes clinical staff failing to recognise IAD.

It is important for residential and home care providers to have systems in place to identify risk factors associated with IAD and PI. The Commission will want to see how you, as a provider, understand and manage the risks of IAD and PI development for each consumer.

Aged care providers must ensure the clinical staff managing these issues know how to distinguish between IAD and PIs. This is important as the causes and management of IAD and PI are different.

Care staff should be educated to notify clinical staff when they notice any changes in the skin such as redness or excoriation. This will enable clinical staff to undertake further assessment and implement timely strategies to reduce further damage to the skin.

The requirements to report PIs through the National Aged Care Mandatory Quality Indicator Program (QI Program) must not be used as a reason to mislabel PI as IAD.

If a consumer is not incontinent, then it is not IAD.

Where PI and IAD co-exist, both must be recognised, managed and monitored.

Photographic monitoring to assess status and progression or resolution of these conditions is important. Photos should be of sufficient quality and stored for review purposes.

If the conditions are progressing despite intervention and management strategies, this should be identified and escalated within the service. Review and advice from a GP or wound expert should be sought in a timely manner.

The following can increase the risk of developing PI:

  • history of previous PI
  • development of IAD
  • failure to identify PI risk on admission to the service or after a change in health status
  • failure to conduct skin assessment for individuals at risk of PI soon after admission or transfer from a health service
  • failure to detect a change in a consumer’s condition which may impact their skin i.e. reduced ability to self-reposition or mobilise
  • not detecting and responding to over sedation
  • failing to facilitate normal levels of mobility, for example when people are kept in bed or chair or confined to a room for infection control purposes
  • overreliance on pressure mattresses or pressure chairs and cushions, with under-use of repositioning
  • failure to reposition consumers at risk of PIs on an individualised schedule
  • failure to use opportunities such as toileting, showering, dressing, continence aid change to monitor the skin for IAD and PI
  • failure to monitor pressure on areas other than the sacrum e.g. heels under socks, both in bed and when sitting out of bed with legs out straight; hips, knees or ankles for people on their side; and wherever body parts are resting on equipment e.g. bedrails or chair parts.

The following can increase the risk of developing IAD: 

  • keeping people urinating in pads when they can self-toilet – either independently or with regular regimes, prompting and assistance
  • failure to protect the skin by not changing pads frequently enough and removing irritants, debris and microorganisms from the skin
  • ineffective choice and use of a continence product, cleansing agent or barrier cream
  • failure to use good hygiene measures, such as appropriate washing and properly drying skin
  • limited understanding of the IAD process, with overreliance on creams, such as Clonea, as both prevention and treatment.

Case example

The Commission saw an example at an assessment visit last year where Quality Assessors became aware of a female resident with a severe wound over the sacral region which was deep, down to bone and causing severe pain.

This wound had been present for several weeks, initially recognised as IAD, when it was described as a red rash in the groin in the setting of use of continence pads and with no skin breakdown. The management had not been reviewed or changed despite significant worsening.

As it deepened and enlarged there was clearly a progressing PI, however it had not been identified. There had been no increased attention to pressure care or to address the increasing pain of the resident. There was no escalation to GP review or to a wound care specialist. It had not been included in the QI data reporting and had not been considered as a case of neglect for SIRS reporting.

This information contributed to evidence of failure to meet the requirements of the Aged Care Quality Standards and a finding of immediate and severe risk to an identified individual was made. The Commission took regulatory action in relation to clinical care and clinical governance.

Please share this alert with management and relevant staff within your service.

Dr Melanie Wroth MB BS, FRACP

Chief Clinical Advisor

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