Improving Skin Assessments in Darkly Pigmented Skin and Incontinence-Associated Dermatitis in the Acute Care Setting: A Quality Improvement Project

Background: Detecting erythema and compromised skin integrity is challenging in darkly pigmented skin. Current literature states skin assessment and treatment education are tailored toward white patients. It is vital nurses are trained to identify breakdown and treat compromised skin integrity in all skin tones. Local Problem: Most nurses lack the training to identify early skin breakdown in darkly pigmented skin. Skin assessments depend on visual cues to identify skin changes that are easily observed in white skin but are more challenging in darker skin. Patients with darker skin are more likely to develop unrecognized skin breakdown and suffer more negative outcomes related to skin integrity. Methods: This quality improvement project was developed to assess bedside nurses current knowledge, tailor an education intervention to address knowledge gaps, and assess change in identification, treatment, and documentation of skin integrity in darkly pigmented skin. A pre- intervention questionnaire was used to assessed nurses' baseline knowledge of skin assessments and treatment after an incontinent episode. A skin assessment tool was developed to aid in recognizing erythema on patients with darkly pigmented skin. Nurses participated in an education session during their mandatory staff meeting. A post-intervention questionnaire evaluated the knowledge change and a pre- and post-intervention questionnaire assessed the nurses change in documenting incontinence-associated dermatitis (IAD). Interventions: Nurses participated in an education-session based on pre-intervention questionnaire responses highlighting variations in skin assessment across all skin tones, recognition of IAD versus pressure ulcers, and the various methods for prevention and treatment after an incontinent episode. Badge reference cards provided visual distinctions of erythema in various skin tones and provided different clinical presentations and mechanisms of action for IAD and pressure ulcers. Printed educational materials with content from the education session were also displayed at the nurses' station and unit supply rooms. Results: Post-intervention questionnaire results demonstrated that bedside nurses had an increased awareness of how to recognize and treat incontinence and IAD across all skin tones. Nursing staff stated they felt satisfied with the education session and printed resources and will continue to use their gained knowledge in their nursing practice. Incontinence-associated dermatitis documentation rates doubled after the delivery of the intervention. Conclusion: Many bedside nurses are unaware of differences in skin assessments in darkly pigmented skin. Although much work in needed to improve bedside nurse's documentation of skin assessments, this project illustrates the potential to highlight challenges to skin integrity as a comorbidity and not just a hygienic challenge.