Ingenuity encounters incontinence.

CAREGIVERS' CREATIVITY MAY BE THE KEY TO PRESERVING RESIDENTS' DIGNITY AND SAFETY

In the Saul Alzheimer's Unit at the 816-bed Bronx Division of the Jewish Home & Hospital, aide Daphne Bartley knew firsthand the repetitive behavior of a resident who removed her protective incontinence brief before getting out of bed every day. Because accidental urination would bring about a dangerous situation--a wet, slippery floor--Bartley knew that, in a restraint-free environment, her antidote to such behavior would need to be creative.

Bartley, an avid and talented seamstress, fashioned a sweatsuit into a one-piece garment that zipped up the back and brought it in for the resident to wear. What began as an effort to solve one problem has now become a hospital-wide care plan solution in similar cases.

"We encourage staff to really understand [each resident's problems]," explains Kenneth Sherman, senior vice president/administrator of Jewish Home's Bronx Division. Bartley understood her charges so well that she recently was awarded "Nurse Aide of the Year" by the United Hospital Fund of New York for her work in creatively dealing with an incontinent resident and avoiding a potentially hazardous incident. "The resident behavior really changed, and we showed the empowerment of the staff," says Sherman.

Individualized treatments needed

"We try everything," Roslyn Edwards, vice president of nursing, explains of Jewish Home & Hospital's efforts to maintain or influence continence among residents. Edwards estimates 75 percent of residents are to some degree incontinent. "The important issue is to aggressively go after incontinence, to spend dollars upfront trying to prevent the negative outcome and spend the time on education upfront," she says.

Prompted voiding. Bladder retraining. It's likely your care facility has tried the familiar answers to incontinence problems--sometimes successfully, sometimes not. Incontinence, widely known as the second most common reason for nursing home admission (right behind dementia), may affect 60 percent or more of nursing home residents, according to industry statistics.

Incontinence is, by some reports, a $10 billion long term care problem and a $20 billion problem nationwide all told. Even beyond its pricetag for extra staff hours, briefs, pads, and maintenance products, incontinence takes a huge toll on dignity and mobility among long term care residents. What's more, the extraordinarily expensive problems associated with skin breakdown due to urine exposure can be so difficult to treat that they can lead to a decline in general health.

Caregiving for incontinent residents is, however, not a problem without creative solutions for some cases--Daphne Bartley's being among the more original we've encountered. The secret is finding the treatable among them and reversing the problem or curbing incontinent episodes. "A routine staff training approach doesn't work. It is unrealistic to go into a facility and say, 'Here's the magic bullet: you go around and make sure staff members are doing this,'" explains Gwen Uman, founding partner of Vital Research in Los Angeles, an organization that studies the problems of the aging. "It's too demoralizing if you're doing stuff that doesn't work."

What's increasingly clear, as indicated by Daphne Bartley's ingenuity, is that correctly training and empowering line staff may mean the difference between improvements and status quo. At Good Shepherd Services Ltd. in Seymour, Wis., a senior care community that includes a 96-bed nursing home, using a line-staff empowerment model solution to deal with incontinence has brought a calculated savings of $1 million in nurse aide time and slashed linen usage by 1 ton monthly.

The dramatic savings underscore the vast potential for improving care standards when dealing with incontinence issues. At Good Shepherd Services, that incredible outcome results from an umbrella program that began six years prior. "It was a matter of survival--literally, corporate survival," explains Mary Ann Kehoe, executive director of Good Shepherd Services and Wellspring Innovative Solutions for Integrated Health Services. The latter, an independent organization of 11 not-for-profit care communities, forged the programs and management restructuring that give Good Shepherd an edge in curbing incontinence.

The usual first step: staff training

Incorporating line staff in all departments, the Wellspring Program model is built on intensive training and follow-up on clinical best practices in seven modules, including elimination. Good Shepherd sent a care team--nurse aides, nurses, and dietary staff--to a retreat center for two days and an overnight stay to learn from clinical experts and prepare to train colleagues. "They bond with each other as a team in a train-the-trainer model," says Kehoe. Far from routine training, the model relies on networking, sharing clinical expertise, and keeping team players accountable and supportive. "We don't let it slide," Kehoe says of responsibility for care. "We have changed the mainstream management paradigm."

For issues surrounding continence, learning centered on appropriate assessment ("What type of incontinence are we dealing with?"), resident rights, documentation, privacy, infection control, and resident personality types ("How can we encourage continence? We can't even get her to cooperate!"). Teams have six months to implement a plan and get residents and staff on a standardized program, with two years to gather data and complete statistical analyses of each care area.

Staff members collected data on 1,100 residents, noting incontinent episodes. Six years ago, when Good Shepherd began the program, it tracked 50 percent of residents as incontinent with an average of five episodes per resident per day. By contrast, in 1999-2000, total incontinent episodes numbered 256,000, statistically less than one per day per resident.

What, exactly, brought about such stunning results? According to Kehoe, "Staff is taught how to identify stress incontinence and environmental and urge incontinence." They learn how to implement appropriate care for each resident need, including corrective behavioral techniques, and identify positive interventions. Staff members also trained to use technology such as diagnostic ultrasound bladder scanners for accuracy in determining bladder contents. Caregivers also log detailed records for tracking residents' bladder function and incontinent episodes.

"For our biggest issue in long term care, forever we've determined treatment as toileting every two to four hours," says Kehoe. "It's just not doable." A diagnosis or determination regarding the type of incontinence a resident experiences can help direct intervention.

Researcher Gwen Uman agrees. She points to training and empowerment of staff as essential tools, alongside abiding by the wishes of the resident for drug-therapy options, briefs, or pads. "One of the things missing," says Uman, "is residents' input: what they would like and what they want." First, Uman advises, find the cause of the incontinent episodes. (See "An international view of incontinence," page 14.)

Solutions come in all Sizes

By recognizing "very simple things," says Kehoe, staff can head off incontinent episodes. Staff is cued to watch for warning signs: constipation, decreased fluid intake, and weakened pelvic muscles, for example. And they encourage learned techniques among residents for complete emptying of the bladder, including double voiding and pressing on the bladder. "We always prioritize residents by who we can keep dry," says Kehoe. And answering call lights quickly becomes critical to getting residents to the loo in time.

At Good Shepherd, technology becomes an essential tool for biofeedback. A nurse aide can detect a resident's urine level to within 5 cc, and understand what action becomes necessary. Maybe there's an urge to void, but no content; or maybe there's a full bladder but an inability to void. Line staff is taught to recognize the situation, and call a nurse for further assessment, even catheterization to relieve discomfort.

Such enterprising line staff diagnostics take less time, according to Kehoe, than unnecessarily toileting a resident based on predetermined scheduling, or changing a resident following an incontinent episode. "It takes eight minutes for toileting of a wheelchair-bound resident, and think how long it takes to change clothes--to undress and redress a person," she says. On Good Shepherd's monthly laundry load--now one ton lighter thanks to the intensive staff training and action on incontinence--Kehoe stresses the peripheral savings in wear and tear on clothing and linen.

At Jewish Home & Hospital, which includes multiple locations in the New York metro area, a three-day assessment of residents upon admission provides for monitoring fluid intake and urine output--and categorizes a range of need. According to Edwards, a resident's bladder function will categorize him or her in one of four categories:

* Continent. Able to toilet independently; requiring only observation and monitoring for change in behavior, function, or mobility.

* Assisted toileting schedule. Resident requires help with frequent toileting to stay comfortable, clean, and dry.

* Bladder retraining program. Incontinent upon admission, resident may have a physical disability or other abnormality that may be rectified, leading to the continence.

* Incontinent. Resident cannot be toileted.

For example, all at-risk cases (based on medical conditions such as the ability to swallow and mental status) are part of the center's hydration program, designed to encourage consumption of 2,000 cc of fluid every 24 hours. Residents in the program get a yellow dot on their ID band to alert staff. And toileting follows fluid intake within an hour.

It is a stringent program that requires diligent monitoring by staff. "If a resident is not drinking, you're not getting a true picture," explains Edwards. "And if you're not aware when family and friends give fluids, it alters the assessment of intake and output."

In the fight to keep residents continent, plenty of bathrooms and reduced environmental barriers may make a difference in some cases. "We hide bathrooms," says Uman. "You have to know where one is to get to it."

At Jewish Home & Hospital's Bronx division, changing health related facilities to skilled nursing included adding bathroom facilities on corridors, not just in each resident room.

To care for residents unable to toilet, Jewish Home & Hospital sets rigorous infection-control standards for changing and handling wet or soiled pads and briefs. Industry practice includes bagging or double-bagging of used incontinence products and immediate, proper disposal by gloved staff members, with a change of gloves required before clean protective garments are handled. Hygienic standards for hand-washing must be followed.

Labor intensive 

Absorptive powers of high-quality protective undergarments continue to improve, with moisture-wicking action a plus for keeping skin dry. "The product is not the substitute for care," cautions Edwards. "It's a very labor-intensive issue." Consider Jewish Home & Hospital's standard practice as case in point: following a pad- or brief-change schedule, staff members reposition incontinent residents every two hours, with regular changes every two to four hours--including soap-and-water washing, drying, and applying barrier cream.

Good Shepherd's team has equally high standards for residents it cannot improve in continence. Says Kehoe, "Once we [identify] a case as palliative, we look to keep skin intact and odor-free." In many incontinence cases, there are no other solutions.

Tampa, Fla.-based freelancer Rachel Long is a regular contributor to CLTC.

AN INTERNATIONAL VIEW OF INCONTINENCE

The worldwide scientific community involved in continence issues seeks answers and solutions to a range of questions and problems that affect the caregiving community. To understand global strides in preventing incontinence, and to check out what's new product-wise for dealing with it, we talked with U.K.-based researcher Alan Cottenden, senior lecturer in Medical Physics at University College London and head of the Continence Technology Group, a multi-disciplinary research team and joint venture of the university's Department of Medical Physics and Bioengineering and its Department of Medicine.

CLTC: What promising new therapies or products may ease the problems of incontinence among the elderly?

Cottenden: We don't see any major new therapies or products coming along soon that will radically alter treatment and management of elderly incontinent people. Perhaps the biggest impact could be made if there were less acceptance of incontinence as an inevitable consequence of old age, which would lead to a more energetic search for a cure--or at least an alleviation of symptoms--wherever possible. However, over the past 10 years or so there has been a steady improvement in products, especially absorbent pads. In general, they leak less and are more comfortable.

CLTC: How are leading-edge caregivers best dealing with, or creatively approaching, the huge problem of incontinence in group care settings?

Cottenden: In the U.K. there are about 400,000 nursing home beds and about half of the residents are incontinent of urine. One of the notable features of such settings is the great variety in strategies for dealing with incontinence. One of the main problems is the paucity of research aimed at identifying optimum strategies in terms of quality of life (for incontinent people and also their caregivers) and cost-effectiveness. It is currently impossible to devise a strategy based on solid research findings.

One of the differences between United States and U.K. nursing homes is in size. U.K. homes frequently have fewer than 30 residents, which may make it easier to focus on individualized care than in the larger United States facilities. Incidentally, although there is little published research relating to these settings, most of what there is from United States work. An important move in the U.K. at present is increasing pressure from the Nursing Home Inspectorate for nursing homes to be able to demonstrate good policies for the treatment and management of incontinence.

CLTC: What are your findings in evaluating products for incontinence?

Cottenden: We are funded by the U.K. Medical Devices Agency to run large, multi-center, clinical evaluations of incontinence products to help buyers make informed choices. Recent studies have looked at washable absorbent pants with an integral pad for lightly incontinent women, hydrogel-coated catheters for intermittent self-catheterization, and hand-held urinals for women. A current study is addressing small disposable pads for lightly incontinent women.

It is usual to find significant differences in performance among products. Interestingly, it is often the case that price varies a lot--as well as performance -- and it is not always the case that more expensive products perform better than less expensive ones.

CLTC: What are your latest efforts in product design and development?

Cottenden: Over the years we have worked on various new product designs. Our most successful product has been Kylie Pants, washable absorbent pants available in various forms for men, women, and children. They are available in around 15 countries now, I think.

For the past 15 years or so, I have sat on the International Standards Organization committee for absorbent incontinence products. In recent years this has generated a couple of laboratory methods for estimating the absorption capacity/leakage performance of incontinence pads. We have done quite a lot of work to try to reach a better understanding of how absorbent materials work to assist with designing better products. We have recently starting collaborating with a mathematician to create mathematical models for the spread of fluids in absorbent structures, which we expect to help us in our understanding.

CLTC: What related issues affect your research?

Cottenden: We are interested in learning more about the impact of incontinence--especially in those who use absorbent pads--on skin health and sleep quality. For example, does changing pads more or less frequently during the night help or hinder skin health and sleep quality? We are trying to understand these matters better as a basis for devising evidence-based strategies for optimal management of incontinence.