I was pleased to be a runner-up in the BJN Awards 2020 for my work on a local campaign aiming to raise awareness and reduce the incidence of moisture-associated skin damage (MASD). Positive outcomes have been achieved, which include a clear recording and reporting process to assist continuous quality improvement, a new clinical pathway, a reduction in incidents and raised awareness among staff.
MASD is an umbrella term that covers a range of types of skin damage caused by moisture (Gray et al, 2011). It develops where urine, faeces, stoma output and/or perspiration is in continuous contact with intact skin (eg around the perineum, perianal area, buttocks, groin, inner thighs or natal cleft) and in skin folds where skin is in contact with other skin, such as under breasts, under arms and between buttocks (Voegeli, 2012). In June 2018, NHS Improvement (2018a) recommended that incidences of MASD should be monitored in the same way as pressure ulcers.
MINIMISE Moisture™ was developed, primarily as an education and awareness campaign, to reduce local incidence of MASD. It also provided an opportunity to review resources and skin-care products used in practice and the development of a new clinical pathway. The acronym ‘MINIMISE’ was developed after conducting a literature review of the current evidence relating to MASD. It highlights key areas for consideration, from identifying at-risk patients to implementing effective prevention strategies (see Figure 1).
What does ‘MINIMISE’ stand for?
M = management of incontinence
Incontinence is a recognised risk factor in the development of pressure ulcers, highlighted in the pressure ulcer prevention SSKIN framework (NHS Improvement, 2018b). Following assessment, it is important to make the right choice to manage incontinence at the earliest opportunity; this could include using effective incontinence products (eg pads) or temporary insertion of a urinary catheter or a faecal management system may be advised (Beeckman, 2015).
I = inspect the skin
Close inspection of skin folds and all areas that can be affected by urine, faeces, stoma output and/or perspiration is required. Moisture can often be trapped between skin folds and creases. Include the perianal area, natal cleft, between thighs, in the groin and under the breasts. If the patient is incontinent, more frequent skin inspections are often needed due to their higher risk of MASD/incontinence-associated dermatitis (IAD).
N = nutrition and hydration
It is important to optimise nutrition and hydration. The nutritional status of a patient plays an important role in the maintenance of healthy skin.
I = implement care plan for the prevention or management of MASD for at-risk patients
Prevention is always better than cure. All patients with incontinence are at risk of IAD (Beeckman, 2015).
M = more moves
Immobile patients are at risk of MASD as moisture builds up on the skin
I = identify MASD correctly
Anatomical sites and appearance of pressure and moisture damage can be similar, but treatment will be different (Yates, 2020).
S = skin care
A structured skin-care regimen is recommended for patients at risk of MASD (Beeckman, 2015). This includes cleansing the skin to remove irritants and protecting the skin with a barrier product to reduce exposure to urine and/or faeces, or sweat, and of course, friction. A skin cleanser with a pH similar to the skin's pH is recommended, and a no-rinse cleanser or pre-moistened wipe for patients who are incontinent (Beeckman, 2015). After cleansing, it is important to protect the skin to prevent MASD. Barrier products are used to provide a barrier between the skin and the moisture and irritants that the skin is exposed to (Voegeli, 2012).
E = educate
Educating staff and patients is important. Staff should be able to identify different types of MASD and differentiate from other skin conditions/aetiologies. They should understand the impact MASD can have on patients and be aware of actions that can be taken to prevent MASD or to treat it if it has developed. It is also important that patients understand effective prevention measures to help prevent future occurrences of MASD and, if it does develop, how best to treat it.
Raising awareness
MINIMISE Moisture aimed to raise awareness of the key considerations around the prevention and management of MASD. It aimed to ensure that staff have up-to-date evidence-based resources and tools to support their practice and access to products that will optimise patients' skin integrity and thereby reduce the incidence of MASD, reduce the pain and suffering that it can cause to patients and the associated costs of treatment to the organisation. A unique character was developed, the MINIMISE Moisture logo (see Figure 1), and a trademark was approved in March 2020.
The challenge to reduce MASD is a national one, very much like the challenge to reduce pressure ulcer incidence. As tissue viability nurses, pressure ulcer prevention is always at the forefront of our minds, and it will always continue to be in the future, such is the pain and suffering they can cause to patients. However, MASD can also result in patient harm. The pain and suffering caused by MASD, often through incontinence (such as IAD) has been observed in practice and can, at times, be severe.
There is also a close link between the occurrence of moisture damage and an increased risk of pressure ulcers. After a short audit of practice in the author's Trust, it was evident that a number of different products and practices were being used, and although our incidence may not have been considered to be particularly high, there was no clear guidance for staff and no standardised practice based on best evidence.
Feedback from patients was sought at the planning, implementation and evaluation stages. Staff were also asked about their knowledge of MASD and it became evident that it was varied, often limited, and a variety of different skin products were being used at different times. The campaign formally ran from March to December 2019. In addition, a new clinical pathway was developed, using a small number of products, with clear guidance for staff on when to use them. Staff have reported that it is easy to adhere to, making the delivery of effective care more likely.
One of the challenges, however, was reaching all key staff and sustaining changes in practice. A number of communication channels were utilised including displaying posters in all wards and clinical areas, rotating pull-up banners between wards/clinical areas, using screensavers with key information, and corporate communications.
It has been promoted at all study days, training events and other forums.
A MINIMISE Moisture promotional video was created (available at https://www.youtube.com/watch?v=76bWWcT9ML0). Additional training was provided, empowering staff to promote best practice and challenge others where practice could be improved. Tissue viability nurses were visible on the wards and engaged with staff.
Summary
There has been a range of national campaigns used to raise awareness of pressure ulcer prevention over the past decade, including the Stop the Pressure Day, React to Red, Your Turn, Zero Pressure campaigns and the introduction of a range of care bundles including SSKIN (NHS Improvement, 2017). These have resulted in a heightened awareness and understanding of the prevention, management and treatment of pressure damage that has successfully reduced incidence.
So far, MINIMISE Moisture is a local campaign that highlights key areas to consider in preventing MASD and promotes best practice based on the current available literature (Beeckman, 2015). However, it is a campaign that could be replicated in any care setting. A toolkit for implementation is currently being developed that will provide theoretical and practical guidance on how to implement MINIMISE Moisture in other organisations, with links to resources and promotional merchandise that were used to support our local implementation.