Incontinence products: "cost-effectiveness" means more than just "costs." (nursing homes)

Considerable progress has been made in recent years in the variety and effectiveness of incontinence management products. More than ever before, nursing homes have available products addressing the specific needs of all their incontinent residents, while reducing inconvenience, resident discomfort and threats to skin integrity. Product costs have not been reduced, but cost-effectiveness has increased.

By and large, however, nursing homes are not taking advantage of this.

A case in point: a nursing home stocks a large supply of a popular, but cheap, underpad which must be changed each time it is soiled. Upfront costs are relatively minimal, but the nursing staff uses 10 to 15 of these per bed per day. If they use fewer, residents run the risk of skin breakdown needing treatment. A more expensive underpad is available that can be used throughout the night, without the resident even having to wear absorbent briefs or pads. Which of these two options will prove to be the more cost-effective way to go? The answer seems obvious, but nevertheless and very commonly, "cheap" wins the day.

Similar analysis can be applied to other product selection in this field. Disposables, for example, are still perceived to have a cost advantage over washables, in that adding washables to linens increases laundry costs markedly. That cost advantage is documented, but some recent generations of washables have been chemically treated to reduce bacterial and fungus infections and to neutralize ammonia and its odor. Further, both residents and staff tend to prefer washables for their comfort and convenience (except for residents who are completely bedbound or who are incontinent of urine and feces). Will these advances in washable products add up to increased cost-effectiveness? That bears study, which is preferable to continued reflexive purchase of disposables solely on the basis of cost.

There are other ways in which the "one product only" philosophy can prove wasteful. Do all residents need superabsorbent pads? Of course not. Pads are designed these days for residents ranging from the "slow dribblers" to those "heavy wetters" voiding 300-400 c.c.'s, with the smaller pads being less expensive. Assessing and meeting the individual resident's needs for saturation control and having a variety of products to meet them should therefore prove cost-saving.

External catheters, whatever their cost implications, can offer the more ambulatory residents an occasional relief from pant/pad systems, especially if they prefer not to wear the more obvious pant/pads during outside trips or special events. They are less problematic in men than in women, however -- appropriate fit for a woman's urethral opening is often difficult to achieve and periurethral irritation can result -- and skin must be carefully checked for both sexes (but especially women) if the external catheter is used intermittently.

Another example of the welcome variety of incontinence-related implements these days is the urinal. Mundane though it may be, this device has undergone many design changes in recent years making it more convenient to use for all but the most disabled residents. One recently introduced product channels the urine into a drainage bag that can be hung conveniently at bedside for later reuse. Another is a flat-bottomed urinal that can situate comfortably, and without leakage, on a wheelchair seat. Still another product is a spillproof urinal for use by bedbound men. Also, design of the urinal neck to prevent backflow and of the handles to adapt to arthritic hands are other variable features, and openings have been designed for comfortable utilization by both sexes.

All of which indicates how far manufacturers have come in recent years. Because the rewards can be substantial, they are investing considerable time and money in product improvement and creation. They are very aware of any shortcomings in today's products and are continually attempting to upgrade them. Particularly with the growth of direct sales to consumers, manufacturers are showing a new degree of design awareness and sensitivity to personal concerns.

Oddly enough, sales and marketing are showing more progress on the consumer side than in nursing homes these days. Because of cost constraints, nursing staffs are using, and making the best of, what's purchased for them. In most cases, nurses have little input in purchasing decisions. More involvement by nurses, and more attention to cost-benefit analysis, may yet bring the advantages of today's technology to fruition in the nursing home.

Carol Brink, RN, MPH, is Associate Professor of Clinical Nursing and Chief of Gerontological Nursing at the University of Rochester. She was co-founder of the first continence clinic in the United States, located at the University of Michigan.