More to incontinence management than meets the eye. (Feature Article).

Managing incontinence is an ongoing challenge for long-term care facilities, both in terms of quality of care and expense. Some costs are directly attributable to the use of garments and other absorbent products for incontinent residents, but other costs are not so apparent. Managing Editor Linda Ziun sought the expert advice of Toni Moodie, RN, BSN, an experienced nurse who spent 7 years as a director of nursing. She now serves as a director of account management for SCA Incontinence Care.

Zinn: What are the most common mistakes you see nursing homes make in managing their incontinence programs?

Moodie: Organizations often don't realize the importance of an incontinence manager or focus person to oversee the total program. When implementing a new incontinence program or reviewing an existing one, facilities need to be certain there is one person who oversees ongoing issues and does problem solving along the way. In other words, that person needs to oversee ordering, supplying units, ensuring proper sizing of incontinence products (and resizing, if necessary) and proper assessment of residents, educating staff (both existing and new), reviewing the budget and bringing issues to administration as needed.

Another common shortcoming I see is in the assessment of clinical goals--both in making sure they are being set and that they are being achieved. Using assessment tools and using the appropriate product for each resident is essential to individualized, high-quality care.

Finally, too often the roles and importance of CNAs/hands-on caregivers are underestimated in the decision-making process for incontinence programs. They are the ones who are familiar with the residents and responsible for product usage, and they should be aware of the issues involved.

Zinn: What are the options for solving these problems?

Moodie: Up front, prior to setting up an incontinence program, you need to designate an incontinence program manager who has education regarding all aspects of the program and implementation plans. This person could be anyone in the facility the administration chooses, as long as there is a method in place for the incontinence manager to review his/her findings with administration to solve problems.

When instituting the program, this manager should use assessment guides to evaluate individual residents for clinical goals, such as toileting programs, and review the criteria for the use of briefs vs pads/pants vs pull-up type products, to ensure the highest quality care, maintain residents' dignity and keep them at their highest levels of functioning and mobility.

Another important point is that the caregivers should be involved early on, to help decide on key elements of the incontinence program. They know the residents and what the staffing issues are. Involving them up front ensures good information and helps when new elements of the program are introduced to the whole staff, because they know they had a hand in the decision making.

Zinn: What are the most common questions nursing homes ask your support staff regarding managing incontinence, and what do you tell them?

Moodie: They want to know what will make managing incontinence easier for their staff and request the tools available for training and retraining, such as sizing kits and instructional videos.

They also want to know if there are any products for keeping residents dry. Many products are, in fact, available for helping people stay dry, such as a daylight pad for stress incontinence, an incontinence pouch for men who dribble urine because of prostrate problems, a pad/pant system for residents who are on bowel/bladder training and pull-ups for people with Alzheimer's.

Our clients also want to know what kind of clinical support we offer. In our company, each account is assigned an account manager. Our account managers are businesspeople with a clinical background. They work with the incontinence manager and the staff to ensure quality clinical outcomes; at the same time, they work with administration to conduct business reviews and ensure cost containment.

Another frequent question is how we initiate a new incontinence program. In our organization, the account manager and the district sales rep and distributor work in partnership to make sure all aspects of the program--from working with staff to getting product into the building--are efficient and effective.

Zinn: In addition to potential for resident discomfort, why is improper sizing a problem?

Moodie: Improper sizing leads to waste of products. It is typical in nursing homes for a high percentage of residents who should be wearing medium briefs to be wearing large briefs. This is a costly mistake, amounting to as much as $150 to 180 per resident per year, depending on the type and grade of products used. A hidden cost associated with improper sizing is the potential for skin problems, which then equates to dollars in staff time and use of extra skin care products to alleviate them.

Inappropriate sizing also can lead to leakage onto linens, which increases the need for staff time to keep the resident dry and increases laundry costs because of more frequent bed changes. Often CNAs resort to padding the beds with cloth or disposable underpads, which are costly to launder or purchase. This can contribute to skin breakdown because of wrinkling and extra layers under the residents' bodies, and can nullify the pressure-relief features of specialty beds and mattresses. Leakage also causes odors on residents' clothes. These are serious quality-of-care, dignity and customer-satisfaction issues.

Disposable products are also wasted when they have to be removed for toileting. And nurses might also need to unfasten disposable garments to give suppositories or do dressing changes, such as for a gastric tube. Each time the tape tab is removed, unless there is a refastenable tape zone, the product has to be removed and a new brief applied.

Another potential area for waste is when staff change products too often. The national average change rate for a high-quality, multivoid product is 3.5 to 4.5 changes every 24 hours, which is possible because of state-of-the-art superabsorbent polymer technology that protects skin integrity. This material wicks urine away from the skin and turns it from liquid to a gel. I want to emphasize that low-quality products cannot be used in this way.

Zinn: In SCA Incontinence Care's new TENA[R] OnTrack program which helps facilities manage incontinence, what measures are in place to ensure quality of care?

Moodie: The account managers are consultants with many years of nursing experience who are educated and trained in long-term care and, specifically, incontinence. They work together with each facility to ensure good outcomes.

There are many toots and processes that the account manager can use in collaboration with the incontinence manager to help the facility implement its program and to assist with staff development. For example, we provide installation kits with videos, product reviews, product application posters, staff handouts and tape measures. We use a "train the trainer" method to teach frontline staff to use sizing kits, so that the facility can be self-sufficient.

We provide individualized care forms and staff training in resident assessment, and we help the facility decide what its clinical goals are and help them choose the best products to support those goals. There is also a business review, to show the facility the cost savings associated with proper sizing, and the improved outcomes that result from correcting sizing errors.

In addition to TENA OnTrack, we've developed the Mastercare series, which includes a video and facilitator guide, staff development tools, program announcements and training evaluations, all in one binder. Topics range from managing nighttime incontinence to nurses' roles in bowel and bladder training to CNAs' roles in bowel and bladder programs.

Zinn: How would you summarize the importance of having a well-planned and carefully maintained incontinence program?

Moodie: There is more to an incontinence program than products used. A good program touches almost every part of the facility, including housekeeping, central supply, nursing, laundry, administration, activities and social work. And the issue of incontinence affects resident comfort and satisfaction in many ways: odor, dignity, skin integrity, urinary tract infections, mobility, ambulation, assistive devices, toileting and many more.

This is why including all departments when putting a program together is ideal, so that all players are involved and agree to the same goals. In the end the residents' comfort and dignity are the most important issues.

Moodie, RN, BSN, has 30 years' nursing experince, 7 of which she served as a director of nursing in Large and small nursing homes in Vermont and Virginia. She is a director of account management for SCA Incontinence Care, Eastern Region. For more information, call [phone].