Transcript Improving the Management of Urinary Incontinence in

AMDA/Pfizer Quality
Improvement Award
Improving Continence Management in
Post-Acute Skilled Care
Whitehall of Boca Raton
Christine E. Lynn College of Nursing
Charles E. Schmidt College of Biomedical Science
Florida Atlantic University
Whitehall of Boca Raton
 Census ~ 155
 ~ 2/3 Medicare skilled postacute care
 High quality based on recent
surveys
 Actively involved medical
director
 Frequent physician and NP
visits
Key Staff
Gilda Osborne – Administrator
Debra Milbut – DON/Project Champion
Gloria McGann – Director, Wound Care Team
Marsha Gordon - Wound Care Nurse
Judith Lango - Resident Assessment Coordinator
Terri Touhy – Professor of Nursing
Ruth Tappen – Professor of Nursing
Gabriella Engstrom – Visiting Professor of Nursing
Darc-Pucelle Nicolas - GNP student
Joseph Ouslander – Professor of Clinical Biomedical Science
Whitehall Staff
Dr. Gabriella
Engstrom
Dr. Terri Touhy
Not Pictured:
– Director, Wound Care Team
Gloria McGann
Marsha Gordon - Wound Care Nurse
Background
 All previous studies of continence
management have been done in longstay or mixed skilled and long-stay
populations
 Post-acute skilled patients have more
active rehabilitation and changes in
functional status
 Optimal continence management is
critical during this time period to
facilitate discharge home
Objectives
 Improve the process and outcomes of continence
care in a post-acute care unit
 Minimize catheter use and complications
 Document continence assessments and toileting trials
 Identify responders to continue toileting program vs. nonresponders for supportive care
 Identify residents appropriate for a therapeutic trial of drug therapy
 Ongoing monitoring and quality improvement
 Reduce the number of antibiotic courses for “UTI’s”
Project Steps
 Leadership buy-in
 Review of existing guidelines and
resources
 AMDA
 F-Tag 315 and surveyor guidance
 Relevant literature review
 Review and revision of Whitehall policies,
procedures, forms
 Baseline data collection
 Staff education
 Implementation
 Ongoing data collection and review
http://interact.geriu.org
Whitehall Boca
AMDA 2009 Project UI and UTI
Objectives: To improve the management of urinary incontinence (UI) and prevent symptomatic urinary tract
infections (UTI) among residents admitted for post-acute care in a Medicare skilled nursing facility (SNF).
Procedure for Urinary Continence History, Wound Care Evaluation, 3 Day Trial of
Prompted Voiding on Savoy Unit
1) Nursing Urinary Continence History for Skilled Care Residents completed by Admission Nurse and placed on
chart in nursing notes section
2) Wound Care Team reviews continence history and other pertinent resident information and places resident on
3 Day Trial of Prompted Voiding or supportive management, check and change programs
3) Wound Care Team notifies Charge Nurse of residents placed on 3 Day Trial of Prompted Voiding.
4) Charge Nurse informs Unit Coordinator of the names of residents to be placed on a 3 Day Trial of Prompted
Voiding.
5) Unit Secretary places copies of the 3 Day Prompted Voiding Trial documentation forms with resident’s name
in the unit notebook for continence management
6) Unit Secretary places name of resident on 3 Day Trial of Prompted Voiding on the pocket care plan for the
nursing assistants
7) Nursing assistants complete the 3 Day Trial of Prompted Voiding and chart results each day on the resident’s
form in the unit notebook for continence management
8) Completed 3 Day Trial of Prompted Voiding documentation forms are filed on resident’s chart in nursing notes
section
9) Wound Care Team evaluates the results of the 3 Day Trial of Prompted Voiding using Wound Care Evaluation
form. Depending on evaluation, Wound Care Team places resident on an on-going prompted voiding program, a
supportive check and change program, or refers the resident for further evaluation.
10) Wound Care Evaluation form in filed on the resident’s chart in the nursing notes section.
Responsibilities
Admission Nurse
• Complete the Nursing Continence History on all new residents of Savoy Unit.
•File completed continence history in nursing notes section of the resident’s chart
•Please complete total continence history even if resident is continent
Wound Care Team
•Review Nursing Urinary Continence History and other data and place resident on 3 Day Trial of Prompted Voiding if
appropriate
•Notify Charge Nurse of the resident’s to be placed on 3 Day Prompted Voiding Trial
•Evaluate results of 3 Day Prompted Voiding Trial using Wound Care Evaluation Form. Refer resident to ongoing
prompted voiding program, supportive program, or further referral for further evaluation
•Place completed Wound Care Evaluation Form on resident’s chart in nursing note section
Charge Nurse
•Notify Unit Secretary of resident’s to be placed on 3 Day Trial of Prompted Voiding
•Provide oversight of prompted voiding trials
Unit Secretary
•Put name and room number of resident on 3 Day Prompted Voiding Trial on 3 copies of 3 Day Prompted Voiding Trial
documentation forms and file in unit continence program notebook
•Place resident’s name on the nursing assistant’s pocket care plans
•File completed records of 3 Day Prompted Voiding Trial on resident’s chart in nursing note section
Nursing Assistant
•Complete 3 Day Prompted Voiding Trial for resident
•Document results each of the three days on the 3 Day Trial of Prompted Voiding form in the unit continence program
notebook
•Inform Charge Nurse and Wound Care Team of any concerns about the Day Prompted Voiding Trial program
Nurse Educator
•Collaborate with project staff to provide education on incontinence and UTIs
•Collaborate with staff on implementation of new policies and procedures
•Collaborate with the team to monitor and evaluate project outcomes
Whitehall Boca
Continence History
Resident Name:__________________________________
Date of Admission:_______________________________
Sex:___F
____M
Admission diagnoses:_____________________________________
Room:______________________
Date:_____________
Age:______
History
•Incontinent before qualifying hospitalization?
____No
____Yes
_____Unknown _____N/A
•If yes, was incontinence being treated?
_____No
_____Yes
_____Unknown
1.If yes, check all that apply:
_____Behavioral _____
Drug (specify)
_____
Pads_____
2) Was the resident satisfied with treatment?
_____No
_____Yes
_____Unknown
2. Was the resident admitted to Whitehall with a catheter?
_____No
If yes:
a) Reason for catheter (check all that apply).
_____Monitor output
_____Manage incontinence
_____Skin protection/pressure ulcer
_____Retention
_____Uncertain
b) Catheter removed?
_____No
c) Post-void residual?
_____ml
•Does the resident have symptoms of (check all that apply)?
_____Urgency/urge incontinence
_____Stress incontinence
_____Urine loss with no warning
_____Difficulty urinating and/or incomplete bladder emptying
_____Nighttime incontinence
_____Burning or painful urination
4. How much does the urinary incontinence (or catheter) bother the resident?
_____Not at all
_____Some
_____A lot
_____Uncertain
5. Stool incontinence?
_____No
_____Yes
6. Constipation?
_____No
_____Yes
Medication Review (Refer to Table)
•Is the resident on one or more medications that can cause or worsen incontinence?
_____No
_____Yes (specify)
•Does the resident drink one or more caffeinated beverages per day?
_____No
_____Yes
Other (specify)
_____Yes
_____Yes
_____N/A
(Date:_______)
Clinical Review
•Cognitive impairment may contribute to urinary incontinence?
_____No
_____Yes
_____Uncertain
•Mobility impairment may contribute to urinary incontinence?
_____No
_____Yes
_____Uncertain
•Suprapubic fullness or tenderness?
_____No _____Yes
_____N/A
•Large amount of stool in rectum.
_____No _____Yes
_____N/A
•Perineal skin.
_____Normal
_____Irritated
•External vagina/labia/urethra.
_____Normal
_____Evidence of irritation/vaginitis
_____Prolapse through the introitus
_____N/A
Summary
•Based on this history the most likely type of urinary incontinence is:
_____Urge
_____Stress _____Mixed
_____Functional
_____Incontinence related to reversible factors (specify)
_____N/A (catheter still in place)
_____Uncertain
•Management (check all that apply)
_____Start/continue toileting trial
_____Remove catheter and start bladder training
_____Address constipation
_____Attempt to reduce caffeine intake
_____Check and change due to severe cognitive and/or mobility impairment
_____Contact primary MD/NP re:
_____Medications that could be contributing
_____Evaluate for UTI
_____Evaluate for urinary retention
_____Consider drug treatment for incontinence
_____Other
Signature of nurse completing form _________________________________
Bladder Diary
Resident name____________________________
Day
Check #
Date
Time
Response to Prompt
to Toilet
Results of Toileting
Symptoms
Day 1
Check 1
Date________
Time________
Dry
Wet
Bowel
Wet/Bowel
Yes
No
Continent Void
Continent Bowel
Continent
Void/Bowel
Dry Run
Not Toileting
Urge
Stress
Incontinence
without warning
Other
Unable to assess
Day 1
Check 2
Dry
Wet
Bowel
Wet/Bowel
Yes
No
Continent Void
Continent Bowel
Continent
Void/Bowel
Dry Run
Not Toileting
Urge
Stress
Incontinence
without warning
Other
Unable to assess
Dry
Wet
Bowel
Wet/Bowel
Yes
No
Continent Void
Continent Bowel
Continent
Void/Bowel
Dry Run
Not Toileting
Urge
Stress
Incontinence
without warning
Other
Unable to assess
Date________
Time________
Day 1
Check 3
Date_________
Time________
Adapted from:
Ouslander, JG
J Amer Med Dir Assoc
2007; 8: S6 – S11
Condition at Check
Room No______________
3 – Day Trial of Prompted Voiding
Time
Adapted from:
Ouslander, JG
J Amer Med Dir Assoc
2007; 8: S6 – S11
The patient was………..
at check
Did the patient go to the
bathroom?
Results at the bathroom?
Time________
Dry
Wet
Bowel
Wet and Bowel
Yes
No
Void
Bowel
Void and Bowel
Nothing
Time________
Dry
Wet
Bowel
Wet and Bowel
Yes
No
Void
Bowel
Void and Bowel
Nothing
Time________
Dry
Wet
Bowel
Wet and Bowel
Yes
No
Void
Bowel
Void and Bowel
Nothing
Time________
Dry
Wet
Bowel
Wet and Bowel
Yes
No
Void
Bowel
Void and Bowel
Nothing
Time________
Dry
Wet
Bowel
Wet and Bowel
Yes
No
Void
Bowel
Void and Bowel
Nothing
Time________
Dry
Wet
Bowel
Wet and Bowel
Yes
No
Void
Bowel
Void and Bowel
Nothing
Time________
Dry
Wet
Bowel
Wet and Bowel
Yes
No
Void
Bowel
Void and Bowel
Nothing
Wound Care Team
Evaluation of Response to Toileting Trial
Resident Name ________________ Room Number ______Date: __________________
Measure
Number of days trial implemented
Total number of checks
Attempts to toilet

Number documented

% of checks
Continent voids

Number documented

% of checks
Incontinent voids

Number documented

% of checks
Continent bowel movements

Number documented

% of checks



o
o
o



Result
Responsive to toileting; e.g., < 1 incontinence episode during daytime hours and
resident satisfied with treatment
Wound Care Team Decision Based on Results After Collaboration with
Continence Promotion Team
Responder1:
Continue toileting program:
Prompted Voiding
Timed Voiding
Non-responder1:
Manage supportively with individualized check and change schedule
Supportive management based on
Resident/family preference
Unresponsiveness to toileting
Both
Consider drug therapy for urge incontinence
Consider further evaluation
Care plan in place
Adapted from:
1 Good response should be based on clinical judgment and resident/family satisfaction with the response.
Ouslander, JG
Signature Wound Care Nurse _________________________________________________
J Amer Med Dir Assoc
2007; 8: S6 – S11
Preliminary Baseline Data
(4-month period in 2008)
92 records of consecutive admissions reviewed
Patient Characteristics
N = 92
83.7 (53 – 97)
Age
Sex
Female
Male
49 (53%)
43 (47%)
Short term memory problem
69 (73%)
Independent in decision making
61 (75%)
Independent in transfer
3 (3%)
Preliminary Baseline Data
(4-month period in 2008)
92 records of consecutive admissions reviewed
Patient Characteristics (cont.)
Length of stay
Discharge location
Home
Acute hospital
Long stay NH
Missing
N = 92
35.9 (1 – 153)
57 (62%)
27 (29%)
7 (8%)
1 (1%)
Preliminary Baseline Data
(4-month period in 2008)
92 records of consecutive admissions reviewed
Continence Characteristics
Independent in toileting
N = 92
3 (3%)
Incontinence on admission
None
Incontinent of urine and/or stool
52 (60%)
27 (26%)
Indwelling catheter
12 (13%)
Missing
Number of patients treated with drug
therapy
Continent at discharge
1 (1%)
4 (10% of those
with UI)
Not systematically
recorded
Preliminary Baseline Data
(4-month period in 2008)
92 records of consecutive admissions reviewed
Urinary Tract Infections
N = 92
Urinary Tract Infection
(noted on Infection Control Report)
16 (17%)
# of UTI Treated
With clinical criteria documented
Without clinical criteria
12 (13%)
6 (50%)
6 (50%)
_____________________________________________________________
Clinical criteria included pain (4), fever( 2), AMS (1)
6 were treated based on RBC in urine with no other documentation of symptoms
Examples of
QI Data
Ouslander, JG
J Amer Med Dir Assoc
2007; 8: S6 – S11
QI Data Being Collected
(4-month period in 2009)
Continence Characteristics
Incontinence on admission
None
Occasional
Usual or total
Missing
Incontinence on discharge
None
Occasional
Usual or total
Missing
Indwelling catheter use on admission
Indwelling catheter use on discharge
QI Data Being Collected
(4-month period in 2009)
Continence Characteristics
Documentation and results of nursing
continence assessments
Documentation and results of toileting trials
Number of patients maintained on a toileting
program
Number of patients treated with drug therapy
Urinary Tract Infection (noted on MDS)
# of UTI Treated
With clinical criteria met
Without clinical criteria met
Challenges
 Collaborators on the QI initiative external to the organization
 Even a willing facility with good staff has many priorities, and can be
distracted from QI initiatives (surveys, filling beds, etc.)
 Even good facilities have turnover – the DON/project champion left
in late 2009
 Champion was not a “hands-on” care provider
 Communication between nurses and CNAs was not optimal
 LTC staff are often stuck in their ways: new approaches are often
considered time consuming and too much paperwork
 Data collection for major QI initiatives takes a lot of time which is
usually not budgeted
 Facility wanted data collected by facility staff (which posed
challenges but is appropriate for QI)
Successes
 Creation of a facility team to develop new policies and procedures – staff
enjoyed having their expertise and experience recognized
 Enhanced education and increased awareness of staff on evidence-based
practices for UI and UTI management - particularly adequate assessment
and prompted voiding protocol
 Improved evidence-based procedures and processes to assess UI, make
decisions related to UI management, and document interventions
 Identification of areas for improvement in UTI management, particularly in
residents admitted with UTIs or catheters
 Statistics on incidence of UTIs during project are higher than those
found in prior Infection Control Reports
 Increased awareness of medications appropriate to treat UI
 Use of such medications was low and may indicate the need for more
engagement of primary care providers in continence management