Learning to live with F315 incontinence management: clinical consultant Diane A. Smith, MSN, CRNP, offers advice for making the most of the new federal guidelines.

Although incontinence has always been an area of regulatory scrutiny since other quality indicators have been held to stricter guideline compliance standards and penalties, incontinence management has been largely ignored--reduced to a weak, rarely enforced blip on surveyors' radars. But not anymore. Last June, CMS issued its revamped F315, Urinary Incontinence and Catheters. Now it is a whole new endeavor.

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Not that the new F315, a combination of the old F315 and F316, changed what nursing staff were always expected to do. Nursing staff have always been required to do a Resident Assessment Protocol (RAP) on episodes of incontinence, followed by an individualized plan of care. But since January 2006, surveyors are taking a closer look at urinary incontinence (UI), and they have the power to impose financial consequences for noncompliance in detail.

First, though, what is meant by the term "urinary incontinence," or UI? As defined by the International Continence Society, UI is "involuntary loss of urine which is objectively demonstrable and a social or hygienic problem." It is not a disease, but rather a symptom that corresponds to various social and pathophysiological factors. It is not an inevitable part of aging and is often curable and always manageable.

Urinary Assessment and Management

Every resident who experiences incontinence is categorized as either high- or low-risk. Although it would seem that high-risk residents would be of primary concern, the opposite is true. Low-risk residents benefit most from incontinence assessment and treatment. The new F-tag notes that these are the residents who should be evaluated and given an individualized care plan, which may include medications, toileting schedules, bowel regimen, and so on. Moreover, there must be a diagnosis related to the type of incontinence, not just a mention of the resident's incontinence--i.e., transient, stress, urge, overflow, functional, or mixed incontinence. Practitioners are expected to develop specific plans of care.

Perhaps a resident's assessment suggests primary urge incontinence. In such a case, I would first order a cystometrogram to determine the bladder's capacity and stability. One case I consulted on involved an 84-year-old cognitively alert woman with diabetes and Parkinson's disease. She took nearly 20 different medications a day and complained that she "leaks all the time." To investigate the possible cause, a post-void residual was taken that measured nearly 400 cc--a sign of incomplete bladder emptying. If she had just been put on a bladder control drug, she would've gotten worse, not better. Unfortunately, these symptoms also manifest in a distal colon packed with stool, requiring an obviously different treatment. In that case, once the stool is removed, pressure on the bladder is relieved and normal function resumes. This illustrates the ultimate goal of F315: to guarantee that people with incontinence are accurately evaluated and treated.

Indwelling Catheters

In addition to general incontinence issues, the new F-tag calls for every resident with a Foley (indwelling) catheter to be evaluated regularly to see if the catheter can be removed. The previous tag implied that if a doctor wrote that a patient was diagnosed with a neurogenic bladder, the facility could "get away" with keeping the catheter in place. We know, however, that neurogenic bladder is a very nebulous and nonspecific diagnosis. Surveyors today are looking for documentation verifying a trial of catheter removal and, if the catheter was reinserted, ensuring that this was done for due cause. For example, if a catheter is removed and the patient cannot urinate independently, the catheter should not just be reinserted without trying other interventions first. Intermittent catheterization should be attempted once a shift, for example. Since the 1970s, it's been accepted that intermittent rather than indwelling catheterization is preferable because of the lower risk of infection and/or stone formation, and it spares the urethra. Tag F315 requires nursing to fully document that removal was attempted or that keeping the catheter in place was a resident preference (and this would have to be explained at survey time). In general, the F-tag is aimed at eliminating the use of indwelling catheters in older people.

Urinary Tract Infections

One reason incontinence costs Medicare a lot of money is that people with untreated incontinence are prone to urinary tract infections (UTIs). Nursing homes are federally mandated to track the types of UTIs present and how often they occur. To illustrate: In reviewing a case, it was discovered that a particular resident had experienced a UTI every month for a year. What was going on? The new F-tag requires that residents with frequent UTIs be assessed and a medical plan of care initiated. One helpful treatment for older women with UTIs is replacing the vaginal estrogen lost during aging. As estrogen levels decrease, the lining of the vagina and urethra becomes thin and friable, resulting in frequency of urination, frequent getting up at night to void, and unintended loss of urine--all symptoms of vaginal atrophy. In addition, vaginal pH changes during aging and becomes less acidic. This allows bacteria from the colon to grow in the bladder.

Maintaining normal pH and normal discharge actually helps to prevent UTIs. One recommendation is to restore the vaginal lining by giving the patient vaginal estrogen in cream or ring application form. Chronic antibiotic treatment should be avoided because of the risk of antibiotic resistance developing.

Sometimes the care plan isn't medically complex. It may be as simple as recognizing that a patient has chronic constipation. The resulting laxative treatment could produce diarrhea, with the frail resident remaining unclean for a significant period and bacteria gaining easy access to the bladder. Cases like these are the basis for the F-tag's insistence on a focused assessment.

In executing a RAP for incontinence, the most important things to do are to take a post-void residual and monitor for UTI. Nursing needs to start the resident on a trial toileting program--in other words, a restorative program for incontinence. A restorative program is not just keeping records. It's keeping bladder records for a few days, and then reviewing them to see if the resident is still incontinent. If so, the nurse must go back to see if everything medically involved has been addressed. Is the post-void normal? Is there chronic constipation? Does the resident have a chronic UTI? If all those answers are negative, the resident could possibly benefit from a trial on a mild agent controlling an overactive bladder.

If the post-void is normal, perhaps a simple toileting program can address the problem. Not all residents need to be medicated. Bladders work 24 hours a day, and most people over age 75 go to the bathroom twice a night. This means that a toileting program, to be successful, needs to be in effect on all shifts. This doesn't mean that that a resident should be awakened at night. But if the resident is awake at midnight, he or she should be offered a bedpan or commode. The same should occur at 5 a.m. if the resident is awake.

Staffing for Success

It's important to address how nurses manage incontinence. Disposable products are terrific--they help to prevent UTI because they wick moisture away from the skin, and they eliminate a big cleanup mess when the resident can't make it to the bathroom. Unfortunately, though, many staff members use them as a crutch, and this can lead to iatrogenic incontinence. Disposables are not paper toilets; they are a therapeutic nursing intervention to aid the resident, not the aide. And the decision to use absorbent products must be made by a nurse, not a nursing assistant. The resulting assessment should show that the decision was necessary.

Conclusion

The new F315 provides a prescription for managing incontinence and commands a price to pay for ignoring it. Studies have shown that within three months of admission to a long-term care facility, 90% of residents became incontinent. Some of that is a result of our "teaching" it to them, and we can't do that anymore. Since we didn't recognize this and change voluntarily, government guidelines have been set for us. Now we have to change care and how we think about incontinence, how we address it, and how we rank it among our priorities. Good care and deficiency-free surveys should result.

Diane A. Smith, MSN, CRNP, is a geriatric nurse practitioner with 20 years of experience in managing incontinence. She has a private practice that includes consultation to nursing homes to implement incontinence programs. For further information, call [phone]. To send your comments to the author and editors, please send e-mail to [e-mail].