Incontinence care: managing both patient and cost.

A former director of nursing, Caroline Bercosky understands what her staff goes through when they clean up accidents the residents of South Hill Nursing and Rehabilitation Center might have. Her facility spends more than $48,000 on incontinence products per year.

As executive director, however, she doesn't want her nurses or CNAs concerned with how many disposable briefs or other products they put in service. "I want them to be worried about taking care of the resident," she said. "These are things we don't nickel and dime people over."

Controlling costs while dispensing quality care don't always mix well, and the quality care should come first. South Hill includes incontinence care products in its overhead, Bercosky said. "We don't cost anything out separately." While she can't say it's cheaper, "it's more customer friendly and more co-worker friendly."

The problems of incontinence go beyond the potential embarrassment associated with it. Frequent urge incontinence, for example, leaves women at higher risk of falls and fractures than those who are not urge incontinent. Women are considered more likely to experience bladder control problems for a variety of reasons.

"I've been a nurse for a long time," Bercosky said. "Washing people and keeping them dry is the best thing.... There's a lot of great products out there, but if you don't have the skin washed off and clean to begin with, you're going to see more problems."

There are three essential elements to skin care of the incontinent patient: cleanse, protect, keep dry. Yet residents' bodies don't always cooperate. Maintaining skin integrity and controlling odor are crucial, yet care must also be given to maintain their self-esteem. Whatever perineal cleanser the facility chooses should be formulated to gently remove urine and fecal matter. Even the softest cleansers coupled with wash clothes could tear macerated skin. Consider whether the cleanser must be rinsed off; some are designed for bed bathing and require no rinsing.

Carolyn Dibert, RN, is a regional coordinator for Country Meadows Retirement Communities (CMRC), which is based in Hershey, Pa. Its facilities employ a "bowel and bladder" program residents receive even if they do not yet have a problem. "The point of the program is to avoid incontinence," Dibert said. "Allow them to use the toilet to prevent an embarrassing episode ... be more independent and keep their dignity."

Her colleague Jan Williams, RN, also a CMRC regional coordinator, added, "Incontinence is an embarrassment that governs their lives. By getting them on a schedule ... it really gives them a lot more freedom."

Of course, the residents' medications are also reviewed and they are checked for infections to determine the source of problems.

In more extreme circumstances, CMRC's rehabilitation firm takes residents through a biofeedback treatment in which electrodes are placed on the resident, who relearns how to hold back urine. "It makes them aware of their muscle control," Dibert said. The treatment helps them strengthen pelvic muscles and retain urine.

Len Weiser, executive director of Shipley Manor in Wilmington, Del., said one key way of managing costs has been bundling a daily fee to encompass all incontinence products. "Billing statements are easier to read. There's less room for error," he said. "In just pads and briefs alone, I average about $2,800 in products," per month, Weiser said.

Weiser added that proper training and proper measurement of wearable products helps cut down costs for facilities. "If the provider sends consultants out to show how to provide that tools, the staff are better able to use the products," he said.

Patty Naylor, vice president of sales and marketing, healthcare for GOJO Industries in Akron, Ohio, said having single providers of multi-purpose skin care products and training can save time, cut costs, and improve efficiencies.

Incontinence care industry sales have been growing steadily, with protective disposable underwear showing increases in the area of 30-40 percent annually, according to Amin Setoodeh, Mundelein, Ill.-based Medline's vice president of sales and marketing for personal care division. "It's because protective disposable products promote patient dignity," he said.

They can be problematic for residents who are combative or who suffer from forms of dementia and are easily agitated, he added. They can also be more expensive than adult disposable briefs. "I believe you're going to see the disposable protective underwear concept continue to grow," Setoodeh predicted. "Some changes will be made to make it more affordable" and offer more features.

Setoodeh said incontinence care products could be as much as 40 percent of a facility's medical/surgical budget. But the costs can be brought down with better training. "A lot of patients are using the wrong sizes and wrong types of products," he said. "That has a direct impact financially ... and also has an impact on patient care."

"Long term care currently relies on Medicare and Medicaid as the payor for over 75 percent of its residents," Naylor said. "These budgets are constantly being scrutinized and often reduced. Likewise, staff turnover remains high and caregiver wages continue to rise, while insurance costs increase and litigation claims and rewards have tripled."

Incontinence care is often one of the key reasons families determine a need for long term care. "Incontinence products need to be formulated to meet the challenge of odor protection and skin protection," Naylor said. "These are problems inherent in long term care facilities. Using the right products to help maintain a healthier skin condition will go a long way to lowering infection rates and improving resident care."

RELATED ARTICLE: Clean vs. sterile.

Whether your staff is dealing with incontinence or wound care, keeping the environment clean might seem like an exercise in futility. But no matter how futile it might seem, "This is not an area to cut costs," said Jean Fleming, infection control clinical consultant with Professional Disposables International. "One case of hepatitis B far outweighs the cost of safety."

Considering the increased awareness of nosocomial infections in hospitals and long term care facilities, it's a good idea to review what needs to be as sterile possible and what must be "clean."

A basic rule of thumb is determining whether anything is going to invade the patient's skin. There are both sterile and "clean" gloves. When it comes to choosing which to use, decide "how critical it is that we want to eliminate or reduce the number of pathogenic organisms," she said.

Use sterile when:

[check] Injecting a needle into the skin, drawing blood, starting IV; there's no such thing as "clean" needles.

[check] Withdrawing medication from a multidose valve;

[check] Suctioning a patient, use sterile saline;

[check] Sterile dressings for critical surgical wounds;

[check] Use sterile gloves if any kind of invasive procedure such as central lines at a sophisticated nursing home;

[check] Debriding a wound at bedside, use sterile gloves

[check] Dressings, they may not have to have sterile gloves for trach site, but ...

Clean is acceptable when;

[check] When changing dressings

[check] For personal protection such as avoiding blood or body fluid exposure, or patients with a rash or incontinence.

[check] To keep basic surface infections away from patients. Use thermometer shields.

"It's great to have the individual wipes, but another part of me says you also need to have the wipe that comes out as a Kleenex box," Fleming added. "They're fast to use."--MS

RELATED ARTICLE: Types of incontinence.

Mixed incontinence: it is usually a 60-40 combination of stress incontinence and urge incontinence. Most common in older women and may occur at different times or under different circumstances.

Overflow incontinence: people suffering from this do not feel the urge to urinate. The bladder doesn't empty normally and remains partially full. Small amounts of urine leak on a nearly continuous basis. Weak bladder muscles, caused by nerve damage from diabetes or other diseases, or a blocked urethra can be responsible for overflow incontinence.

Stress incontinence: people can lose urine involuntarily while doing certain physical activities that put pressure on the abdomen. These include: coughing, laughing or sneezing; lifting; walking or other forms of exercise; moving to get up from a chair or out of bed; frequent bathroom use to avoid accidental urination 

Urge Incontinence: people with UI cannot control the sudden urge to urinate and their bladders will contract to squeeze out urine whenever full. A large amount of urine may be released in urge incontinence, as the bladder may empty. UI may occur after a sudden change in position or activity.--MS