Bathing systems.

As a service to readers, NURSING HOMES has initiated an occasional department, "Ask The Vendors." It offers the views of top executives of major nursing home product vendors on questions of interest to their potential customers. The questions will relate to product categories, rather than specific products, with the aim of helping administrators become enlightened purchasers.

For this issue, NURSING HOMES asked manufacturers of bathing systems:

"With so many high-tech bathing systems available these days, how can I decide which is the best approach for me to take?"

"What are safety considerations that must be met in considering my bathing system?"

"These systems look expensive -how do they |pay for themselves?'"

Ray Nass, President, The Apollo Corporation: "First, it is very important to analyze and quantify the resident population in terms of acuity and condition, as well as size. Next, objectives should be established for resident bath frequency - for example, how many baths per resident per week. It is also adviseable to evaluate how each system addresses matters related to OBRA, as well as resident and staff safety.

"The answers to these questions should drive an intelligent equipment decision because they force objective information. For example, if a facility has, as its goal, to provide a maximum number of baths for most residents, it may have to determine how to handle the usually small percentage that represents |worst case' residents. Residents' sizes are important because there are some big residents out there and some bath units with extremely small interior dimensions.

"As for safety, resident transfer should be a major concern. What sort of lift equipment or transfer components are required for each system and how will they affect resident or staff safety? Another issue not often recognized is the need for range-of-motion as a preventative measure for residents at-risk for thromboembolic events. Again, product size is important, because some units are cramped even for smaller people.

"How do systems pay for themselves? Let's take two facilities that I visited recently. One had a supine system that had provided 7,000 baths in seven years; the other had one of our door-at-the-end-of-the-tub seated models that provided 40,000 baths in five years. That's a big difference in productivity and return on investment. Increased productivity also means that staffers can be freed up to perform other duties, including reimbursable activities, which is especially attractive in states with |case mix' reimbursement formulas. Depending upon state codes governing the number of bathing areas per bed, an extremely productive system could reduce the number of bathing systems purchased.

"Finally, flexibility is important to payback. A system that can provide other therapeutic services besides bathing, especially reimbursable services, can sometimes eliminate the necessity of purchasing a single-purpose type of equipment."

James Vanderheiden, National Sales Manager, Sanitas Healthcare Products: "A major consideration is how well established the manufacturer is and what the turnover rate is on sales, distribution and service personnel. Continuity is very important in these matters. If there is a lot of turnover, this lends to poor service and poor in-service training of personnel, which results in the equipment not being used properly, or not being used at all - and there are facilities in that situation.

"Other considerations are that the product should be user-friendly, efficient, versatile, and easy to disinfect. You really should listen to the people who use these systems to get their ideas on this. You would also want to know how easy it is to retrofit new equipment to existing equipment in operation. This eliminates having to replace a complete system.

"Safety has a lot to do with the lift hardware. How secure is it, and what sort of safety switches are used to stop the system from operating if conditions aren't right? How frequently does the lift hardware have to be adjusted for safe operation? Frequent adjustments are time-consuming and frustrating.

"What sort of mixing valves are used to adjust water temperature and prevent scalding? The mixing valves that are supplied to the industry are mechanical and electronic. In our opinion, the mechanical mixing valves are more reliable.

A system can pay for itself in several ways. Prevention of decubiti and dry skin obviously leads to savings in staff time and effort. Also, the system has to be geared toward your resident population. Sitting position systems will, for the most part, handle most of your residents, and are far less expensive than recumbent systems. We produce them both, but we make no secret of the major operation cost difference between the two systems."

James Novotne, Vice-president of Marketing, Arjo-Century, Inc.: "Aside from the usual process of talking to other facilities that already use a system, it is important to pay attention to the standards by which the system was manufactured. Does it meet Underwriters Laboratory (UL) standards or the standards of the National Association of Homebuilders (NAHB), which govern such things as fire safety, durability and other qualities of fiberglass construction? If the system is used therapeutically, as in hydrotherapy, can the manufacturer document meeting FDA's Good Manufacturing Practices?

"Also, does die company provide good support following the sale, with readily available parts and service? Is the documentation accompanying the product - operator's manual, maintenance manual, etc. - useful and easy to understand?

"All of this reflects on product safety issues, too. If these important standards are met and the various manuals provide the ongoing assistance you need you have some reassurance that the system will function safely.

"These systems pay for themselves in many ways. There's an improvement in the overall hygienic climate of the facility because easier, more frequent bathing is possible. The staff can perform not only more efficiently, but more safely. The prevention of one back injury by using a bathing system that includes an integrated lift transfer device could very well pay for the system itself."

John Kraft, President, Silcraft Corp.: "There is a lot of high-tech equipment out there. You should make sure that it is not too high-tech for your facility's needs of capabilities. Too much computer control and digital display may not be compatible with your facility's human environment or the skill levels of the operators. You should also make sure that the system is not beyond the capability of the maintenance staff to service and repair. You have to make sure that you can get parts on a timely basis.

"You also have to make sure that the |high-tech' you do purchase is relevant to your real needs. For example, there is the trend toward height-adjustable tubs. You really only need these when you are bathing residents who must be physically held at all stages of the bath - people with severe contractures, for example, or who are particularly combative. For the typical geriatric resident, though, height-adjustable tubs are not way necessary.

"There are two major safety concerns. The first is the safety and strength of the lifting and transfer system. A system that is lightweight and apparently easy to use may not be the safest for your residents. The second is the effectiveness of the disinfecting system as a protection to both residents and staff. You have to look at the disinfecting capability not only for the tub and whirlpool system, but for the lifting and transfer system. Are there nooks and crannies that are difficult to reach and clean? Is the whirlpool plumbing fully accessable to the disinfecting solution?

"DONs and/or administrators should also make a point of learning about infection control from a knowledgable source - an infection control person in a local hospital, for example - if they feel inadequately briefed in this area. This is a very important consideration in looking at safety, and cannot be overemphasized.

"As for the system |paying for itself,' the real payback is in the improved hygienic status of the residents. There are also some marketing advantages; obviously good hygiene is very reassuring to people contemplating placing a relative in your nursing home."

Gordon Shields, Senior Marketing Manager, Ferno Healthcare, Inc.: "The initial problem in deciding on a system is to audit for the types of residents you have in the facility - ages, medical problems, logistical difficulties in moving about - and particularly focus on those with severe problems and what their product needs might be. Your analysis of the actual utilization of bathing facilities by your particular resident mix will help guide what system to buy and in what quantity.

"You should also |audit' your staff, finding out what their problems and needs are, and if they've worked at other facilities, what their experiences there were with the bathing equipment.

"You should also, of course, study the product literature that's available to you, contact the companies that interest you, look at the equipment on display at trade shows, and talk to peers about what their experiences have been.

"Safety considerations involve both residents and staff. In this age of workman's compensation, back injuries are a major consideration, and ease of transfer is very important. You can also check with the FDA on customer complaints, using the Freedom of Information Act; all of this is public record with bathing systems that are used therapeutically. And, again, checking with those who have actually used the equipment can be very revealing.

"Your first consideration in terms of |payback' is your ability to meet your responsibilities for good-quality care. You also want to provide efficient care, and the right system can save time and, in some cases, staff. Another possible consideration is that, in some areas of the country with water shortages, water usage is a major cost factor; a tub that uses 40 gallons for a full-immersion bath can provide a major cost advantage over one that requires over 100 gallons. And finally, concerning back injuries, which have been frequent, prevention of these alone can provide major savings."

Rolf Borneby, Senior Product Manager, Lumex, Inc.: "The basic question in deciding on an appropriate system is, who are the patients? Are there a significant number of bedridden patients needing transfer equipment? Are their needs mostly in the area of bathing or is hydrotherapy important for skin and wound care? Are there enough mobile patients to justify a height-adjustable system? If hydrotherapy is an important need, should you use a whirlpool system, which has one jet and a hand-held washer, or a hydrotherapy system with six jets and requiring less staff involvement for effective debridement?

"The issue of safety relates most significantly to the question of transfers. This is where the greatest risks lie. Whether it is chairlifts, stretcher lifts, hydraulic-operated shower trolleys, these devices must be effective and safe for both resident and caregiver.

"As for a system's paying for itself, there is a consideration that most purchasers, and possibly even vendors, may not be aware of. For severe pressure sores, especially Stage 4, hydrotherapy is almost always part of the physician's treatment prescription. If hydrotherapy is prescribed by a physician, it is reimbursable as an ancillary PT service by Medicare Part A. We have found that if you use a state-of-the-art hydrotherapy system, one resident receiving treatment can, on average, pay for the entire system in six to nine months. You will find residents in every nursing home who need special attention relating to skin and wound care. An effective hydrotherapy system is a good investment in quality of care."