Bladder Studies for Continence Control.

A new technique, bladder scanning, is giving residents and staff better understanding and control

Picture this: Millie, a cognitively intact but increasingly frail 85-year-old, is starting to get on staff's already overstretched nerves. Every 20 minutes for most of the past three days she has been ringing her call bell seeking assistance to go to the bathroom. When she gets there, she voids but, not surprisingly, only a small amount. She's convinced, though, that she's incontinent, and won't stop ringing that bell.

Or this:

82-year-old Sandra really is incontinent, but the problem started with startling suddenness only two days earlier. She had not changed her diet or started on any new drug therapies and, indeed, she had been known for being free of any sign of incontinence, often requiring toileting only three or four times a day.

Or this:

Isabel has been expressing her advance toward moderately severe dementia by becoming increasingly irritable and even aggressive. She refuses to sit still and screams at anyone who attempts to restrain her. The staff has been taught that even severely demented residents' behavior is an attempt to communicate something. What does 87-year-old Isabel want?

Do these residents sound familiar? Problems with continence control are, of course, commonplace in nursing facilities, and so, too, is the usual response: Apply today's highly engineered incontinence pads or undergarments to protect the resident's skin from voided urine or stool until staff has a chance to change them. This makes, indeed, considerable sense from the standpoint of understaffed and, sometimes, undertrained nursing facilities, where time is a precious commodity.

But what if staff and residents could be trained to stop a continence problem at its source, and without significant added investment in overall staff time? A pioneering nursing home network in eastern Wisconsin, called Wellspring, has been investigating just such an approach. Nursing staff, including RNs, LPNs and CNAs, at all 11 participating facilities have been taught how to apply a new technique that can go a long way toward resolving the situations described above. Using portable bladder ultrasound, it measures bladder volume, gives direct feedback both in data and in pictures, and does so noninvasively, with no catheter ever invading a resident's infection-susceptible urinary tract.

Leslie Saltzstein Wooldridge, RN, MSN, APNP, has been training the Wellspring nursing staffs in use of the bladder-scanning device [*] for the past four years. "We decided, on the basis of a cost/benefit analysis, that this was a technique we should try. We found that the staff time invested up front would save on overall staff time, taking into account the time needed for changing residents or toileting them every 15 or 20 minutes."

The scanner, which has a published accuracy of 90 to 95% for volumes of 50 to 100 mL and 69% for volumes greater than 200 mL, would be employed chiefly with specific subsets of residents: those who require constant attention or, conversely, who are not voiding often enough. It would also be used with cognitively impaired residents exhibiting difficult-to-explain behaviors. In any of these cases, bladder volume might be both the dominating factor and, with proper use of the scanned information, the means of control.

Staff are instructed to listen and watch for any signs of a resident's experiencing a voiding problem. A quick bladder scan determines the next course of action. If urine volume is more than 150 mL, the resident is toileted, using prompted voiding techniques. If the amount is less than 150 mL and the resident is cognitively intact, this prompts the staffer to discuss with the resident the real necessity for voiding and to offer to train him or her to "hold it" long enough to accumulate the requisite 150 mL. The bladder training would entail simply giving the resident bladder volume data and pictorial feedback on the scanner's small screen.

Wooldridge notes it can take some time for a resident to buy into fiddling with the "newfangled contraption," but many do get the point and try to lengthen the period between voiding times, often to up to two or three hours. If a resident's bladder volume and voided amounts are persistently low, on the other hand, this might prompt an effort to increase his or her fluid intake.

Wooldridge says the bladder scans have answered two specific challenges posed by the Wellspring project (about which more will be discussed in a future issue of Nursing Homes/Long Term Care Management): (1) it moves the facilities toward the project's stated goal of eliminating urinary incontinence, a goal that is driven home during an intensive two-day training program for staff, and (2) it empowers the staff to take more responsibility. In being encouraged to engage with residents individually, and to recommend care plan changes based on data that they gather, CNAs and LPNs are afforded a decision-making role.

As for the cognitively impaired resident who is misbehaving, Wooldridge says that the culprit has been found on occasion to be a filled bladder, with post-voiding residuals of 200 mL or more. Not only does this produce intense discomfort, but it also puts the resident at serious risk of urinary tract infection. It raises a flag that this resident's continence needs focused attention. As Wooldridge notes, an every-two-hour toileting schedule is not for everyone--"no one has the time for that"--but the scanner identifies those residents who would benefit from the extra effort.

The upshot of this, says Wooldridge, has been profound: "We believe that we've helped change the culture of the long-term care facility."

Richard L. Peck is editor of Nursing Homes/Long Term Care Management.

(*.) BladderScan, from Diagnostic Ultrasound, Redmond, Washington,