Prompted voiding enters the computer age: report on a work in progress.
A comprehensive, computer program designed to assist nursing homes in implementing prompted voiding programs is now under going final study. It is proving useful in selecting appropriate candidates for the intervention, encouraging staff involvement, and maintaining and evaluating the program's efficacy. The program is expected to be available to nursing homes by December, 1994.
Often nursing home staff automatically toilet residents without first asking them if they need to toilet. This approach is not only demeaning to the resident, but also decreases the opportunity for patient-staff communication and produces a large number of "dry runs." These take their toll in terms of staff time and indignity to the resident.
Prompted voiding is a toileting schedule with a communication protocol. To help focus attention on bodily function, the resident is asked if he or she is wet or dry every 2 hours. If residents indicate that they are wet, they are then asked if they desire toileting assistance. When actual voiding corresponds appropriately with the resident's request for toileting assistance, positive reinforcement is given. The prompted voiding approach does not require computerization, but an appropriately designed computer program can help in solving many problems in implementation.
Secrets to Success
The first secret to a successful prompted voiding program is patient selection. Trying to implement such a program for patients who are unable to toilet is a common and costly mistake. Residents with stress incontinence, for example, are not appropriate candidates for prompted voiding.
It is important to first identify and remove transient factors that can exacerbate incontinence, such as bowel impaction. Secondly, the residents who can store urine in their bladders for two-hour periods and who can voluntarily initiate voiding must he identified. To that end, our computer program's patient selection capability helps to identify the 30 to 40% of incontinent residents who stand to benefit from prompted voiding.
The implementation of the program in the nursing home begins by training nursing assistants to use the computer system. Afterwards, the nursing assistants conduct a 5-day trial run, entering residents' voiding frequency and volume data in to the computer. At the end of the trial period, the data are automatically analyzed, indicating the residents who are viable candidates for prompted voiding.
The continued success of any program depends upon the supervisor's ability to monitor its efficacy and to oversee the degree to which the program is being carried out by staff members. The software meets this need by providing standards of dryness and anticipated variabilities. In short, it shows the staff how dry residents should he when prompted voiding is applied appropriately. The sample control chart in Figure 1 displays the average and variability of wetness levels that can be expected when prompted voiding is implemented. The control chart illustrates graphically a patient's actual wetness status every 2 hours and calculates the average and standard deviation for all patients in the prompted voiding program. A warning limit is set two standard deviations above the average and is used to identify unexpected wetness levels.
The software's troubleshooting capabilities eliminates guesswork by not only detecting excess wetness among the nursing home population, but also by pinpointing problems as they may occur with a particular shift, unit, or even a specific staff member. An example of this capability is illustrated in Figure 2.
The computer program also helps to encourage participation from the staff. At the end of their shift, the nursing assistants enter their data on a personal computer at the nurses' station. Far more rewarding and enjoyable than recording information in a chart that no one is expected to read, the data are displayed with graphics that provide instantaneous feedback. This system also allows for random audits by the superintendent or charge nurse who can also enter data and see it displayed graphically.
Preliminary data on the software are being collected in nine nursing homes in California, Iowa, Alaska and Washington with funding from a National Institute on Aging grant. Final data will be available for analysis within the year.
John F. Schnelle, Ph.D. is Professor in the Department of Medicine and Director of the Borun Center for Gerontological Research, University of California, Los Angeles, UCLA School of Medicine. Patrick McNees, PhD, Director of North Rim Systems in Issaquah, WA, developed the computer program.
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|Title Annotation:||computer program for nursing home management|
|Author:||Schnelle, John F.|
|Date:||Mar 1, 1993|
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