My name is Kathleen Vollman. I'm a critical care clinical nurse specialist, and I've been a nurse for 44 years, 10 directly at the bedside and critical care, and then 13 at the bedside as a clinical nurse specialist for the medical ICUs at Henry Ford Hospital in Detroit. And that's where my journey started in pressure injury prevention, because we had a challenge, which we were able to overcome, I'm very proud to say. And in 2003, I launched my own company. It's called Advancing Nursing, which is focused on creating empowered work environments for nurses through knowledge, skill, and process improvement. My goal is really, and the focus is, the right tools and knowledge to prevent harm to our patients, driven by nursing and the multidisciplinary team. I am on the board of the National Pressure Injury Advisory panel, and I'm currently the president of the World Federation of Critical Care Nurses. 

Microclimate actually was defined a couple of times in the literature, and the official definition that the National Pressure Injury Advisory panel uses is that it involves the skin temperature, it involves humidity, and it involves airflow, those 3 components. And then if a patient is lying down, it interfaces with the surface that they're on. 

Basically, if we don't clean the skin correctly with a pH-balanced soap, no-rinse, we can dry the skin out, which sets it up for injury specifically by moisture. If we don't contain urine correctly, whether we use internal or external based on the indications for the patient, the appropriate indications for the patient or appropriate toileting mechanisms. Part of another component, and I don't know if your audience is aware of this data, there have been 3 studies looking at what is called incontinence-associated dermatitis. So literally skin injury related to moisture. And on average in acute care, the incontinence rate ranges between 42% and 55%. Half the patients in a hospital or in an acute care environment have some form of incontinence, whether it's urine and stool. So we know both of those have enzymes and caustic material that impacts and damages the skin. So it's not just the moisture itself, which can happen by sweating and inappropriate temperature control. It's the caustic material that the skin is then exposed to and the stratum corneum gets weakened and it starts to break down. 

As a part of that, what I'd like to recommend your audience to look at is called the SPIPP. It is for free on the National Pressure Injury Advisory Panel website. And what they did is they took all the various ingredients of pressure injury prevention from the international guidelines and they put it in one sheet of paper, and there is a section on moisture in there. And I already talked to you about appropriate bathing. I would not recommend tap water bathing and use of washcloth because the washcloth is very rough. I would not use wash cloth in cleaning stool either because of the roughness. It impacts the transepidermal water loss, drying the skin out, again, making it susceptible to injury. 

The second is the surface that they're on and a lot of paying attention to the airflow if the patient has excessive moisture, looking at surfaces that have good microclimates. And if we look at the guidelines now, they're the S3 guidelines for creating a surface. It needs to have appropriate microclimate, immersion, and envelopment. Those are the 3 factors. So you're looking for that microclimate factor as a part of it. 

Second, or third I think we're at, is the actual wick-away pad that you put underneath the patient. You want to make sure that it is good enough to truly wick away the moisture. And what I always talk with my clinician colleagues about is thinking about the Pampers diaper for swimming, and they literally have the entire pool in the diaper when they leave the pool. You're looking for that level of wick-away. So I ask them to take their pads, pour 150 ccs of warm water on the pad, and wait 3 to 5 minutes, put their hand in, and make sure it's dry. Then they have a good wick-away pad. There is no reusable incontinence pad that works, that wicks away moisture. So if those are anywhere in your world, it's game over. They're sitting in a puddle. Doesn't matter what barrier you put on, when they're in that much moisture, they're going to break down. 

And then we get to what to put on the patient. And so we need to clean with a pH-balanced substance that helps, especially if it's stool. We need to moisturize, and we need to protect. And the IHI, as well as a couple of other organizations, recommend this concept of putting all of those together in a single cloth to make sure none of the steps are missed. Because one of my colleagues, Denise Nix, did a study where they looked at the number of urinary incontinent episodes and they compared it to how much barrier was used, because you're supposed to clean, moisturize, and protect. And these patients, based on the number of incontinent episodes, should have had a $1.39 a day of moisture barrier use. They had less than 10 cents. It's not because the science doesn't work, because all of those products have been tested. Well, it's the system setup. In a very busy day, I always have what I need to clean. The barrier may be in a bucket or on the counter, and so I forget it. So, I always work on making it easy for the frontline clinician to do the right thing. 

So those are pretty much the steps you want to focus on. And then containment of the urine or stool, and there are multiple devices on the market now that help with both of those. So that, and if we are able to do that ,because the skin breaks 4 times greater in the presence of moisture, if we are able to do that, then we don't start the process of weakening the skin so that pressure and shear can play a role in it continuing to break down. 

I would like to add to individuals, if they are on a skin team and it's called “pressure injury prevention team,” change the name, because it's about the whole skin.

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