Do we have an incontinence problem?

South Dakota Foundation for Medical CareSouth Dakota’s Quality Improvement Organization (QIO)

A thought to ponder….

How does it make me feel? Embarrassed

“I’m not going in there like this!” Isolated

No way, no how would I go in Sit by myself in the car

It really didn’t matter how I felt….it was what everyone else was going to think that helped me make the decision to stay in the car!!

Percentage of Residents Whose Need for Help with ADLs has Increased

National - 16%South Dakota - 16 %Our Nursing Home - _____

Percentage of Residents with Low-Risk for Developing a Pressure Sore

National - 3%South Dakota - 4%Our Nursing Home - _____

Percentage of Low-Risk Residents Who Lose Control of Their Bowels or Bladder

National - 46%South Dakota - 46%Our Nursing Home - ____

Emotional Stress R/T Incontinence

AnxietyDiminished self-esteem social isolation

depriving residents of opportunities for personal growth and enjoyment

Do we know….

How many of our residents are continent upon admission?How many of our residents become incontinent after admission?How many days it takes our continent residents to become incontinent?

Incontinence

Puts residents at risk for pressure ulcers urinary tract infections urosepsis perineal rashes falls fractures

Incontinence upon Admission

What are we doing about residents who come in to our facility suffering from incontinence? Do we accept it as a problem

associated with aging? AMDA RAI AHCPR Clinical Guidelines

Admission Process

Are we identifying not only incontinent residents but those at risk as well?Are we finding the cause behind the incontinence?Do we know how long the resident has experienced incontinence?

Become a Detective!

Low-Risk vs High-Risk High = residents with a high risk of

incontinence Low = residents with a low risk of

incontinence

Are we finding the cause behind the incontinence?

Types of Incontinence

Stress Incontinence bladder can’t handle the increased compression

during exercise, coughing or sneezing

Urge Incontinence caused by sudden, involuntary bladder

contraction

Mixed Incontinence combination of both stress and urge

incontinence

Types of Incontinence

Overflow Incontinence bladder becomes too full because it

can’t be fully emptied, is rarer and is the result of bladder obstruction or injury

Possible Reversible Factors

Resident Conditions delirium fecal impaction depression symptomatic urinary tract infection edema

Possible Reversible Factors

Environmental Conditions impaired mobility lack of access to a toilet restraints restrictive clothing

Possible Reversible Factors

Excessive Beverage Intake caffeine

Disease Parkinson’s other neurological diseases effecting

motor skills

Possible Reversible Factors

Medications diuretics drugs that stimulate or block

sympathetic nervous system psychoactive medications

Contributing Factors

Resident Conditions pain excessive or inadequate urine output atrophic vaginitis cancer of the bladder or prostate urethral obstruction disorders of the brain or spinal cord tabes dorsalis

Contributing Factors

Abnormal Lab Values elevated blood glucose elevated calcium

Assessment of Incontinent Residents

Identify potentially reversible and contributing factors bladder record or voiding diary targeted physical examination

including rectal exam and pelvic in women

Assessment of Incontinent Residents

Optional tests as appropriate urinalysis urine culture and sensitivity Glucose, calcium Vitamin B-12 Urine cytology Post-void residual determination Urodynamic tests

e.g., stress tests filling and voiding cystometry

Treatments

Trial toileting program 3-5 day trial prompted or timed voiding

Residents responding favorably should continue with planResidents not responding favorably should be referred for other treatment options

Other Treatment Options

behavioral therapydrug therapysurgical treatmentelectrical stimulationintravaginal support devicespads and external collection devicesintermittent catheterization

Drug Therapies

Urge Incontinence anticholinergics bladder relaxants

Stress Incontinence alpha-adrenergic antagonists estrogen

Should be initiated at the smallest recommended dose and slowly titrated upwards based on resident response and tolerance

Monitoring Responsiveness to Treatment

an objective measure of the severity of UI such as a bladder recordresident satisfaction with treatmentside effects of treatment

Physical and Environmental Barriers

Toilet/commode accessibilityGrab bars are present if neededToilet seat is adequate heightLighting is adequateCommodes and urinals are used as supplements as neededFurniture allows easy rise for resident to be able to get up to go to the bathroomCall light is within reach / ability to useContracturesAmbulatory assistive devices needed

Physical Limitations

Ease of taking garments off and putting onGetting to the toiletAbility to perform hygiene tasks

Current Approaches

Bladder retrainingPrompted voidingPads/briefsHabit trainingPrompted voiding with assistanceCatheterUreterostomyPelvic muscle rehabilitation

A Successful Restorative B&B Program Includes:

Adequate fluid intake 2000-2500 ml/day Honor preferences Assistance Encouragement Keep fluids readily accessible Offer fluids with each resident contact

Different Resident/Same Plan?

A scheduled two-hour voiding program will not work for all residents especially those who are receiving

diuretics and other medications it takes a good detective to determine

when the resident is most likely to use the toilet

?? Would it – Could it work ??

Having the same caregiver care for the resident during the evaluation phase……

Would it – could it assist us to determine the resident’s bowel and bladder elimination patterns?

Resources

www.medqic.org Facility Assessment Checklists –

Incontinence

Quality Measures ManualRAI ManualAMDA Clinical Practice Guidelines www.guideline.gov

Contact Us Bernadette Nelson, RN, Project Manager

Phone (605)336-3505 Extension 263 Email: bnelson@sdqio.sdps.org

Rhonda Streff, RN, Assistant Project Manager Phone (605)336-3505 Extension 262 Email: rstreff@sdqio.sdps.org

Ryan Sailor, Analyst Phone (605)336-3505 Extension 220 Email: rsailor@sdqio.sdps.org

Jane Viereck, Coordinator Phone (605)336-3505 Extension 266 Email: jviereck@sdqio.sdps.org