Today's rules for using incontinence products.

The long term care industry continues to change rapidly and it appears no let up is in store. Staffing continues to be a major challenge and with the current emphasis on shortening hospital stays, the intensity of care required by typical residents also continues to rise.

As an example of that, only a few years ago, the average incidence of incontinence in a long term care facility was estimated at 40-45%. Most recent estimates now place that figure at 55% or even higher. How this incontinence is managed is increasingly a major issue, for a number of reasons.

First, it is estimated that, for a typical long-term care facility, expenditures for managing incontinence are second only to those spent on food. Clearly, the cost-effectiveness with which incontinence is managed can have a substantial impact on a facility's financial position. In addition, because managing incontinence is so time-consuming, a program which is poorly thought through can contribute to staff turn-over and low morale. By the same token, a well-designed incontinence management program can improve a facility's perceived quality of care on the part of families and the community it serves. Most importantly, an excellent incontinence management program will positively impact the resident's own dignity and possible physical health.

Traditional Role of Absorbent Products

Historically, nursing has turned to absorbent products such as adult briefs as one of the primary means of managing incontinence. These products have evolved to where today they provide better quality, help present a more dignified image for the resident and family, and are more effective in managing incontinence. Plus, prices have come down such that disposable products are now more cost-effective than ever before.

Nevertheless, viewing absorbent product as a solution to incontinence can be a negative factor in providing good resident care. An over-reliance on these products can cause staff to become less diligent in urging residents to achieve their own maximum function. Staff can become less attentive in urging individuals back to continence and staying dry through the use of bladder training and toileting programs.

Overuse can also result in higher costs than necessary. Frequently, the high expense associated with overuse is dealt with through seeking less expensive, and many times less functional, products. This can be self-defeating to the extent that it results in further increases in utilization and staff time to compensate for inadequate product performance - more changing of clothes and linens, more cleaning of patients and spills, and more management of skin irritations and breakdown.

A Better Concept

Today, many nurses no longer think of absorbent products as the primary means of managing incontinence, but rather view them as they should be - as a support to good nursing care. Good nursing practices dictate that an individualized care plan be developed for each resident based on a thorough assessment. This assessment-based care plan includes a strategy for managing incontinence and a provision to track the results of the strategy. Once a plan is developed for each resident, disposable absorbent products will support this strategy in a different fashion for different residents.

For severely impaired residents, adult briefs and remain the primary means of protecting linen, clothing, and insuring the best possible skin condition. These products should work with" the residents and staff to help each resident reach his or her maximum functional level. They should also help control costs through reducing linen usage and eliminating product duplication (i.e., where more that one product is used at a time).

In other cases, specific products should be utilized for daytime incontinence management. For example, for alert residents, there are products today which are more dignified and discreet than conventional briefs and allow for more resident involvement in their own self care. There are also products that are specifically designed to make bladder training and prompted toileting an easier process. For some residents, products specifically designed to manage very light incontinence should be used instead of full briefs. Many nurses also feel that an open system using high quality incontinence underpads is preferable bedtime management.

Implementation

Not all facilities are ready to implement a program in which a specific modality is developed for each resident. There must be a reasonable degree of staff stability, so that proper training can in take place and have the desired effect, and there must be a strong desire to continuously improve patient care. Four basic steps are necessary (see table at right).

Goals

The goal of any incontinence management program should be to restore the highest degree of continence and dignity possible while keeping costs in line. The facilities should attempt to move as many residents as possible out of briefs to other kinds of incontinence management products. Where absorbent products do need to be used, it's important that the right one be used. This product should be no more than is necessary to contain the incontinence by itself (with no product duplication), and it should take into account ease of use, resident preference, and patient dignity.

With a properly implemented program, the results should be that product consumption decreases, the cost per use decreases, and the level of resident care increases, as documented by incontinence charts and skin assessments.

* First, a plan must be developed specifying the types of products and modalities to be used for each type or level of incontinence.

* Second, residents should be assessed, and based on that assessment, decisions should be made as to what type of program and products should be utilized for that specific resident.

* Third, experimentation should be encouraged. Each resident is different, and those who are most cognitive and cooperative should be considered first for bladder training and a prompted toileting program. The guiding rule should be to use the smallest, most discreet product possible for each resident.

* Fourth, measurement is important to determine how successful nursing has been in helping residents toward continence and staying dry.