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Addressing incontinence: Outcomes improve 24%
Education, better assessments help agency, patients
With "improvement in urinary incontinence" identified as one of the pay-for-performance measures for the upcoming Centers for Medicare & Medicaid Services' demonstration project, it is essential that hospice managers take a closer look at how they identify and treat incontinence.
"Incontinence is an important issue for home health patients because it can lead to other problems," says Theresa Gates, PT, director of rehabilitation services at Home Care Advantage in Jacksonville, FL. Incontinence can lead to skin integrity issues and can be a cause of falls in the home, she explains. Proper assessment of incontinence and identification of the type of incontinence the patient is experiencing is necessary to provide the right treatment, she adds.
"A lot of patients don't want to talk about incontinence," says Diane Tiberg, RN, CHCE, director of nurses at Keweenaw Home Nursing and Hospice in Calumet, MI. "We even have staff members who are not comfortable asking patients about incontinence or did not know how to ask without embarrassing the patient," she says.
In 2002, when Tiberg's agency first addressed incontinence, the agency's rate of "improvement in incontinence" jumped to 62.3% from 37.7% in 2001. "The national reference in 2002 was 52.4% so we were not only able to improve our own rate, but we reached a level above the national average," says Tiberg. The rates have continued to stay above the national reference rate but they have fluctuated between 64% and 54%, she says. "Some of the change is due to new staff and a need to re-educate existing staff to remind everyone that although we're focused on other performance improvement areas, incontinence is still important," she adds.
The first step to improving success with incontinence was a comprehensive education program, says Tiberg. "We invited an urologist to talk about how to recognize symptoms of incontinence, how to assess the cause of incontinence, and different techniques to treat incontinence," she says. An assessment card with questions to ask and clues to notice in the home helped nurses better identify the patient's incontinence at the start of care, she says.
"One of the reasons for a low improvement rate for incontinence is recognition of the problem later in the patient's care rather than earlier," points out Tiberg. When patients' incontinence is identified after care has started or at or near discharge, the agency has no time to improve the patient's condition, she says. "If nurses identify the problem early, we can document more accurately and we have time to address the issue," she adds.
Because incontinence is almost never the primary reason for a patient's admission, patients don't think it is important because they don't realize that incontinence can lead to other problems related to skin integrity and falls, says Gates. "When a patient is going to the bathroom four or five times every night, there is a real risk for falls," she explains. "We need to address incontinence to make sure that we improve outcomes in all categories," she adds.
Word questions carefully
When asking patients about incontinence, it is best not to use the word "incontinence," suggests Gates. "Many patients don't understand the word or they don't want to admit to another medical condition," she says. When asking a patient about incontinence, Gates suggests asking, "Are there any times when you can't make it to the bathroom in time?" This question is not threatening and it is specific and simple to answer, she says. If you get a positive response to this question, you can continue with other specific questions about accidents during the night, accidents during the day, and more details about what the patient is doing when the accidents occur, she adds.
Even if the patient does not admit to a problem, nurses need to be aware of any signs, says Tiberg. Odor, a package of pads in the bathroom, or the patient's defensive reaction to questions related to incontinence are all reasons to follow up with other questions, she says. Point out that many of your patients have told you about problems and that usually it is very simple to find ways to address the problem, she adds.
There are two types of incontinence, says Gates. "Urge incontinence can be treated with a variety of urge-suppression techniques and exercises to strengthen pelvic floor muscles," she points out. "We can also teach the patient to be proactive and use a voiding schedule so that the patient can urinate before the urge is so strong that it cannot be controlled."
Stress incontinence requires more assessment to determine the trigger, says Gates. "Does the patient lose control when sitting down or standing from a sitting position, or is the loss of control related to coughing or laughing?" she asks. Once you've identified the cause, you can teach patients to use their pelvic floor muscles to prevent accidents, she says.
Gates' agency has a group of physical and occupational therapists who have undergone extra training to address incontinence. In addition to the advanced clinical training for rehabilitation staff, agency nurses received four hours of general education to help identify incontinence upon admission or early in the patient's care and to distinguish between stress and urge incontinence, says Gates.
In addition to teaching Kegel exercises to patients to strengthen their pelvic floor muscles, Gates' therapists use behavior modification techniques that include biofeedback, electrical stimulation, and voiding schedules to help patients learn to control their incontinence. "Because fluid intake can affect a patient's ability to control their bladder, we have patients keep a three-day diary to measure their fluid intake, their voiding schedule, and the occurrence of leaks," she says.
After reviewing the diary, the therapist will suggest changes in behavior, she explains. "For example, a patient who is going to the bathroom frequently during the night might routinely drink a 24-ounce Pepsi at 8 p.m. every night." Eliminating drinks that stimulate the bladder, reducing amounts of fluid taken just before bedtime, and changing the time that larger amounts of fluid are drunk can reduce the number of trips to the bathroom, she adds.
The multidisciplinary approach with nurses identifying incontinence and therapists offering different treatments geared toward the patient's needs has resulted in some wonderful outcomes, says Gates. "We have some patients who have gone from using five pads per day to only one per day, and we have patients who would have 10 leaks per day improving to one leak per day," she says.
Even if your nurses and therapists accurately diagnose incontinence, your efforts won't be successful unless the patient wants to address the issue, warns Gates. She explains, "Even though you know you can help, some patients are quite comfortable wearing pads and they don't consider their incontinence a quality-of-life issue. In these cases, you let them know you can help when they are ready and you respect their decision."
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