The minimum data set urinary incontinence quality indicators: do they reflect differences in care processes related to incontinence?

PURPOSE: To determine if nursing homes that score in the lower 25th percentile (low prevalence) versus the upper 75th percentile (high prevalence) on each of two Minimum Data Set (MDS) incontinence quality indicators provide different incontinence care processes DESIGN: Cross-sectional. SUBJECTS: 347 long-term residents in 14 skilled nursing facilities for the MDS "prevalence of incontinence" indicator and 432 residents in 16 skilled nursing facilities for the MDS "prevalence of incontinence without a toileting plan" indicator. MEASURES: Nine care processes related to incontinence were defined and operationalized into clinical indicators. Research staff assessed implementation of each care process on 3 consecutive 12-hour days (7 am to 7 pm ). The assessment included resident interviews, physical performance evaluations, and chart abstraction using standardized protocols. RESULTS: Homes with lower prevalence rates on both MDS incontinence quality indicators (good outcomes) had a significantly higher proportion of participants with chart documentation of two relevant care processes: 1 an evaluation of the resident's incontinence history and 2 toileting assistance rendered by staff. However, interviews with incontinent residents capable of accurately reporting care activity occurrence showed no difference in toileting assistance frequency between homes in the upper and lower quartiles for either MDS incontinence indicator. Participants reported an average of 1.8 toileting assists per day across all homes with a narrow average frequency range between homes (1.6-2.0). These frequencies of toileting assistance are not sufficient to improve urinary incontinence. There was also no difference in the frequency of toileting assistance received by incontinent participants rated on the MDS as receiving scheduled toileting (n = 75, mean = 1.9 +/- 1.24) compared to incontinent residents rated on the MDS as not receiving scheduled toileting (n = 131, mean = 1.8 +/- 1.22). None of the homes provided chart documentation that supported staff decisions to place or not place a resident on a scheduled toileting program. CONCLUSIONS: The quality of incontinence assessment and treatment as documented by scheduled toileting interventions was poor across all homes, and the MDS incontinence quality indicators were not associated with clinically important differences in related care processes. Chart documentation that a resident was on a scheduled toileting program or received toileting assistance was not related to resident reports of the frequency of received assistance.     

Right to Know: Reducing Risks of Fecal Pathogen Exposure for ED Patients and Staff

Introduction

The purpose of this article is to review the literature regarding the multiple challenges that contribute to ED bedside toileting and examine best practices that will reduce fecal exposure, cross-contamination among patients, and employee splash injuries.

Methods

We searched the Cumulative Index to Nursing and Allied Health Literature, MEDLINE, and Cochrane database for information about the multiple challenges involved in bedside toileting, using the following search terms: bedside toileting, gastroenteritis, macerator, sluice machine, fecal pathogen exposure, and splash injury. In addition, costs and benefits of reusable versus disposable bedside toileting equipment were compared and contrasted.

Discussion

Emergency departments have a higher exposure rate to fecal pathogens with current methods of bedside toileting. Short incubation periods may not allow the proper lead time needed for patients to access primary care providers. As a result, emergency departments and urgent care centers become a likely point of entry into the health care system. Although most inpatient rooms have built-in bathrooms, most emergency departments and outpatient examination rooms do not. Although many patients are ambulatory, restrictive monitoring equipment is required. For safety reasons, staff must bring toileting equipment to the bedsides of both ambulatory and non-ambulatory patients. Hopper dependence creates longer walking distances and delays. These delays may lead to incontinence events, skin breakdown, more frequent bed changes, and higher linen and labor costs. Reusable bedside toileting equipment is associated with at-risk behaviors. Examples are procrastination and sanitization shortcuts. These behaviors risk cross-contamination of patients especially when urgent situations require equipment to be reused in the interim. ED patients and staff are 5 times more likely to undergo fecal exposure. The 5 phases of ED bedside toileting at which risks occur are as follows: equipment setup, transport of human waste to drainage areas, transfer of waste, pre-cleaning, and equipment disinfection. Therefore it is imperative that ED staff have a full understanding of hazardous materials involved, know safer bedside toileting practices, and have safer equipment available to protect all involved. Upgrading our knowledge, equipment, and practices must become a higher priority for ED leadership.

Biases/Disclosures

The East Bank Emergency Department of the University of Minnesota Medical Center, Fairview, will be moving toward 100% disposable bedside commode pails in addition to disposable bedpans, currently in use. On the basis of a literature review to understand best-practice ED bedside toileting, the following article was created. As a result of our learning, the University of Minnesota Medical Center emergency staff has designed, patented, and developed a landfill-compliant disposable commode pail that absorbs waste while reducing splashes and spills. Disposable commode pails (bags) are conveniently wall mounted for quick availability, and “at-risk behavior” is reduced. Advantages are all point-of-care. Both setup and waste treatment and disposal start and end at the bedside. The advantages are faster response times, reduction of soiled linens and bed changes, prevention of incontinence and skin breakdown events, and reduced splash injuries or pathogen transmission. Patient satisfaction improves with shorter bedside toileting delays. Employee satisfaction increases with reduced human waste handling. The cost of each unit is comparable to an adult overnight diaper. Bariatric commode pails or bags are in the planning phase, and a “green” disposable commode pail, made from biodegradable corn byproducts, will be made available at a higher cost.     

Implementation of a scheduled toileting program in a long term care facility: evaluating the impact on injury risk to caregiving staff.

This study evaluated the impact of a scheduled toileting program on the risk of injury to caregivers and on resident agitation or aggressive behaviors. Injury data, ergonomic assessments, staff questionnaires, and resident agitation checklists were used to evaluate the program in a 75 bed unit, with a similar unit acting as a comparison. The program resulted in an increased percentage of residents toileted regularly in the intervention unit, while aggressive incidents declined in both groups. Staff in the intervention unit reported a significantly lower perceived risk of injury to the head and neck than the comparison group. Although the program resulted in increased workload to manage multitasking, monitor an additional aspect of scheduled care, and perform more toileting transfers, overall risk of physical injury was reduced. The toileting program, a shift toward resident focused care, and enhanced agitation awareness combined to reduce resident handling injuries and resident agitation expressed as verbal behaviors or emotional upset, but not as physical behaviors. Clear communication, mentoring, and monitoring were important for successfully changing care practices.     

Helping hands: CNAs in elder care

One facility's functional model of care for hospitalized elders focuses on improving nutrition, toileting, and promoting mobility.     

Bladder management in adult care homes. Review of a program in North Carolina

In North Carolina there are approximately 34,000 residents in adult care homes (ACHs). Approximately 40% of these residents have urinary incontinence, and others require assistance with toileting. High prevalence of cognitive impairment, few licensed staff, and low staff-to-resident ratios in ACHs make behavioral techniques used in community-dwelling populations and toileting programs used in nursing homes inappropriate for these residents. This program was implemented using a two-level approach (facility and individual resident) and uses an education consultation approach for implementation.     

Satisfaction and retention of CNAs working within a functional model of elder care

With a functional model of care for hospitalized elders focused on improving nutrition and toileting and promoting mobility, certified nurse assistants' satisfaction was improved and turnover was reduced.     

Prospective study of fall risk assessment among institutionalized elderly in Japan

Abstract The purpose of the present study was to identify risk factors for falls among institutionalized elderly, using the standardized risk assessment tool developed by Izumi. We examined 746 patients from three types of facilities: rehabilitation wards in four general hospitals, three long-term care facilities, and three nursing homes, for up to three months. The incidence of falls within all facilities was 12.5%. Patterns of relative risks of falling differed among types of facilities. The highest relative risk of fall in long-term care facilities and nursing homes was nurses' prediction, followed by history of fall and altered mentation. In contrast, that in general hospitals was mobility. In long-term care facilities, history of falls (odds 3.68, 95CI: 1.47–9.23) and interaction (history of falls and assistance with toileting) (odds 3.13, 95CI: 1.48–6.64) showed significance on adjusted-odds ratios for fall. History of falls, altered mentation, and assistance with toileting may be used to screen patients at a high risk for fall at admission.     

Using simulation to prepare neophyte nursing students to deliver intimate patient care

BackgroundPreparing neophyte nursing students to deal with the intimate aspects of patient care including nudity and body excretions is challenging. Traditional simulation approaches that have been used to teach these skills require examination in the context of considering more realistic ways. Mask-Ed™ is a high fidelity modality of simulation that enables the educator to transform into a patient by donning silicone props such as masks and body torsos inclusive of genitalia. The hidden educator is able to coach and direct the learner throughout the simulation.AimThe aim of this study was to identify if Mask-Ed™ simulation enhanced students learning in the context of providing intimate patient care when undertaking the skills of showering and toileting.MethodsFirst year undergraduate nursing students were tasked with showering and toileting a Mask-Ed™ patient in a simulated learning situation within a laboratory context. Following the simulation students were invited to participate in focus groups. Data was recorded, transcribed and analysed using an inductive thematic analysis approach.FindingsFrom class preparation to debrief, participants experienced a safe journey of discovery enabling them to provide intimate care. The realism of the learning environment combined with the confidence students had in their educator, allowed students to overcome their nervousness and anxiety, discover the vulnerable person at the centre of their care, gain confidence and find comrades.DiscussionSimulations that provide neophyte nursing students with an opportunity to face real to life intimate care experiences should be apparent in all undergraduate nursing programs. Nursing students need not only to be prepared to implement skills around safe practice when showering and toileting patients but they also need to feel safe and confident to practice themselves.ConclusionMask-Ed™ is an effective and efficient simulation modality to teach neophyte nursing students about intimate human care.     

Effects of an education program on toileting behaviors and bladder symptoms in overactive bladder patients with type 2 diabetes: A randomized clinical trial

BackgroundOveractive bladder is more common in patients with type 2 diabetes than in those without diabetes. Many patients with diabetes adopt unhealthy toileting behaviors to empty their bladder that may contribute to the onset or worsening of overactive bladder.ObjectiveTo investigate whether an education program targeting toileting behaviors is effective for helping overactive bladder patients with type 2 diabetes in terms of adopting healthy toileting behaviors, improving bladder symptoms, and enhancing quality of life.DesignThe study was a parallel, pragmatic, open-label randomized trial.SettingsThe trial was conducted in a hospital-based endocrinology outpatient department in Jinan, China.ParticipantsA total of 104 patients were randomly assigned to a 6-week education program or a control group.MethodsPrimary outcomes included toileting behaviors and bladder symptoms, including dry/wet overactive bladder and severity of urgency. Secondary outcomes were overactive bladder-specific and general quality of life. The patients were reassessed on the outcome variables at the end of the intervention and at 3 months and 6 months following the intervention. The analysis followed the intent-to-treat principle. To account for the longitudinal data with repeated measures, group comparisons for continuous outcomes were evaluated using linear mixed models. Group differences in binary outcomes were examined using mixed-effects logit models.ResultsCompared with the control group, the education program group showed significant changes in three unhealthy toileting behaviors: premature voiding (−0.7, p < 0.001), place preference for voiding (−0.5, p = 0.007), and delayed voiding (−0.2, p = 0.011). The program significantly relieved the bladder symptoms (−2.2, p < 0.001) and decreased the probability of having wet overactive bladder (−0.3, p < 0.001) and the severity of urgency (−0.4, p < 0.001). It also significantly improved the overactive bladder-specific quality of life by 10.8 points (p = 0.001). Regarding patients’ general quality of life, the physical aspect was enhanced by 3.0 points (p = 0.049); however, no effect on the mental well-being aspect was observed.ConclusionsAmong overactive bladder patients with type 2 diabetes, the 6-week education program targeting toileting behaviors resulted in the adoption of healthy toileting behaviors, relief of bladder symptoms and improvement in quality of life in the 6 months following the intervention compared with routine care alone. The education program was highly successful and may represent an effective, acceptable, feasible, and safe intervention for improving bladder health and quality of life during diabetes care, given that the toileting behavioral changes were maintained during the 6-month follow-up period.     

Listening to carers talking about the subjects of continence and toileting

Toilets and continence play critical roles in the lives of people who care for a relative at home. Issues around toileting are central to the relationship between the carer and the person being cared for, with the bathroom often becoming the most important place in the house.     

Parents' experiences of general hospital admission for adults with learning disabilities

General hospital care for people with learning disabilities is strongly emphasized in recent health policy. Ten sets of parents were interviewed about their experiences of general hospital inpatient care for their adult sons and daughters with learning disabilities. Findings in the areas of placement, occupation, basic nursing care, feeding, toileting, nursing attitudes, staffing and procedures are presented. Recommendations are made for changes to reported nursing practice to improve the quality of general hospital care for people with learning disabilities.     

Toileting Problems in Children and Adolescents with Parent-Reported Diagnoses of Autism Spectrum Disorder

The current study investigated toileting problems in one hundred and twenty-seven children and adolescents with parent-reported diagnoses of autism spectrum disorder. Toileting refers to the accomplishment of various unprompted behaviors, including recognising the need to go to the toilet, and waiting before eliminating. The relationship between toileting problems and age, gender, intellectual disability, gastrointestinal symptoms, sleep problems, comorbid psychopathology, quality of life, and adaptive functioning were examined using parent-report questionnaires. The most common toileting problems were, “Does not independently perform most self-help tasks”, “Has toilet accidents during the day”, and “Parent/caregiver notices smears in underwear”. Gender, presence of intellectual disability, gastrointestinal symptoms, and comorbid psychopathology were significant predictors of toileting problems in this study. The gastrointestinal symptoms of constipation and bloating were found to be significant predictors of toileting difficulties. Specifically, constipation predicted accidents and physical problems associated with toileting, and bloating predicted social/emotional factors and physical problems. A small negative correlation was observed between total toileting problems and total health related quality of life. An increase in physical toileting difficulties was associated with lower quality of life.     

女性护士排尿行为信念及其与排尿行为的关系

目的调查女性护士排尿行为信念现状,并分析其与排尿行为之间的关系。方法采用国际尿失禁咨询委员会女性下尿路症状问卷中文版、女性排尿行为量表、女性排尿行为信念量表对济南市3所综合性三级甲等医院401名女性护士进行调查,对排尿行为信念现状进行描述性分析,采用Pearson相关分析及分层多元线性回归分析研究排尿行为信念与排尿行为的关系。结果女性护士健康排尿行为益处的感知和下尿路症状易感性的感知水平较低,得分分别为(2.86±0.71)分和(3.18±0.67)分。排尿行为信念中健康排尿行为障碍的感知进入回归方程后,调整R2增加了8.3%。结论女性护士排尿行为信念存在严重问题,应对其进行排尿行为信念的干预,重点使其了解健康排尿行为及其益处,同时强化下尿路症状的易感性,增强健康排尿行为的自我效能。医院管理人员应设法改善如厕条件,减少护士健康排尿行为的障碍。     

Continence for adults with urinary dysfunction

Urinary incontinence is a common condition in the UK. A working group in Scotland constructed a best practice statement focusing on: promoting continence awareness; access to toileting facilities; assessment of urinary dysfunction; and continence care planning. Response to the statement has been positive, but the challenge will be to translate this into sustained practice development.     

Technology solutions for high-risk tasks in critical care

There are several high-risk nursing tasks in the critical care environment discussed in this article. These tasks include lateral transfers, repositioning patients up or side to side in bed, bed-to-chair or -wheelchair transfers, pericare of bariatric patients, toileting in bed, sustained limb holding for dressing wounds, and patient transport. Although many, if not all, of these tasks currently are performed manually, there are technological solutions available that undoubtedly can reduce the risks for caregiver and patient injuries. These solutions should be implemented in critical care to promote the safety of all involved in patient care.     

女性护士膀胱过度活动症患病现状及其与排尿行为的关系

目的调查女性护士的膀胱过度活动症(overactive bladder,OAB)患病现状,并探讨OAB与排尿行为的关系。方法采用多阶段整群抽样法,于2012年5-11月对济南市3所三级甲等医院的636名护士进行问卷调查,调查工具包括一般资料及健康状况问卷、国际尿失禁咨询委员会女性下尿路症状问卷(international consultation on incontinence female lower urinary tract symptoms questionnaire,ICIQ-FLUTS)中文版及排尿行为量表,先后进行单因素分析及多元Logistic回归分析,筛选出影响OAB的不良排尿行为。结果 19.2%的护士患有OAB,其中尿急和夜尿是护士OAB最常见的两种症状。单因素分析显示,月经状况和个人尿路感染史及不良排尿行为中的憋尿、排尿地点选择倾向、无尿意排尿、用力排尿对OAB的影响有统计学意义(均P0.05)。Logistic回归分析显示,不良排尿行为中的憋尿和无尿意排尿是OAB的独立影响因素(均P0.01)。结论护士的OAB发病率高于普通女性群体,护士的不良排尿行为(尤其是憋尿和无尿意排尿)可能是OAB的危险因素,应向护士群体普及OAB和正确排尿行为的相关知识,以加强其重视维护自身膀胱健康。     

Toileting behaviours and lower urinary tract symptoms among female nurses: A cross-sectional questionnaire survey

BackgroundUnhealthy toileting behaviours exist among women, and lower urinary tract symptoms have a high prevalence and significant effects on quality of life. However, the relationship between toileting behaviours and lower urinary tract symptoms is unclear.ObjectivesThis study aimed to investigate the prevalence of lower urinary tract symptoms among female nurses, and the association between toileting behaviours and lower urinary tract symptoms.DesignA cross-sectional stratified cluster sampling study.ParticipantsA total of 636 female clinical nurses from tertiary hospitals in Jinan (the capital city of Shandong Province, China).MethodsThe Toileting Behaviour-Women’s Elimination Behaviours and the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms scales were used to assess the participants’ toileting behaviours and lower urinary tract symptoms, respectively. Multiple linear regression analysis was used to evaluate the association between toileting behaviours and lower urinary tract symptoms.ResultsUnhealthy toileting behaviours were common among the female nurses, with delayed voiding being the unhealthiest toileting behaviour, which was followed by place and position preference for voiding. Nearly 68% of the female nurses had at least one lower urinary tract symptom, nearly 50% had incontinence symptoms, 40% had filling symptoms, and 18% had voiding symptoms. Unhealthy toileting behaviours (premature voiding, delayed voiding, and straining to void) were positively associated with lower urinary tract symptoms. However, lower urinary tract symptoms were not significantly associated with voiding place or position preference. Among the control variables, being married or having a history of a urinary tract infection was associated with lower urinary tract symptoms. Having a higher income and regular menstrual period were negatively associated with lower urinary tract symptoms. Compared with vaginal delivery, caesarean delivery had a protective association with lower urinary tract symptoms.ConclusionLower urinary tract symptoms among female nurses should not be overlooked, because their prevalence among female clinical nurses exceeded that among the general population of women. These findings highlight the importance of avoiding unhealthy toileting behaviours (especially premature voiding, delayed voiding, and straining to void), as these unhealthy toileting behaviours were significantly associated with susceptibility to lower urinary tract symptoms.     

Can technology-assisted toilets improve hygiene and independence in geriatric rehabilitation? A cohort study

Purpose: To investigate whether technology-assisted toilets (TATs) could be used to improve toileting hygiene and independence for geriatric rehabilitation patients. TATs are commercially available toilet seats that use a stream of warm water to clean the user, have a fan for drying and are operated by a remote control.

Materials and methods: Twenty-five geriatric rehabilitation in-patients were recruited, six completed the study, and seven partially completed the study. Each participant had two trial bowel movements. One trial involved cleaning themselves with toilet paper; the other involved cleaning themselves with the TAT functions. After each trial, participants received a visual inspection for cleanliness and answered the Psychosocial Impact of Assistive Devices Scale (PIADS), a validated scale, to assess their sense of competence, adaptability and self-esteem in the bathroom. A toileting cleanliness scale, designed for this study, was completed by a nurse after TAT usage. Participants received a score from 1 (completely clean) to 4 (completely soiled) based on a visual inspection after cleaning.

Results: TAT and toileting cleanliness scores were similar. PIADS scores showed a trend towards higher scores when using the TAT, but results were not statistically significant.

Conclusions: TATs cleaned as well as standard toileting in geriatric rehabilitation inpatients. Participants indicated that TATs improved their sense of competence, adaptability and self-esteem. Geriatricians and rehabilitation professionals should consider prescribing TATs in their practice as an assistive device in order to promote patient independence and dignity and reduce the burden of care for patients requiring toileting assistance.

• Implications for rehabilitation

• Technology-assisted toilets (TATs) are commercially-available toilet seats that could be used to allow rehabilitation patients to clean themselves more independently in the bathroom.

• Improved toileting independence can reduce burden of care of geriatric rehabilitation and reduce the impact of toileting assistance on patient dignity and self-esteem.

• Physiatrists should consider recommending TATs to their patients but should take into account whether a patient’s particular set of disabilities will allow them to use a TAT effectively.

     

Urinary incontinence and use of pads--clinical features and need for help in home care at 11 sites in Europe

Aim:  The aim of this study was to obtain evidenced-based knowledge about older persons in home care; we conducted a population-based study at 11 sites in Europe (2001/2002). This article focuses on urinary incontinence and need for help in home care.
Methods:  A sample of 4010 respondents 65 years or older were assessed by the Resident Assessment Instrument for Home Care. Urinary incontinence was defined as leakage once a week or more including use of catheters.
Results:  A total of 1478 individuals had urinary incontinence, 45% men and 47% women. The use of pads ran from 29% to 52% between the sites. The associates of urinary incontinence were: moderate or severe cognitive impairment, dependency in toileting and other activities of daily living compared with less impaired; urinary infections, obesity and faecal incontinence. Caregivers to persons with urinary incontinence reported burden or stress more often then carers to nonurinary incontinence individuals (OR = 2.2, 95% CI 1.8–2.7).
Conclusions:  To enable older people with incontinence to stay at home with a better quality of life, they need caring assistance during toileting on a regular basis.     

Mothers' descriptions of the toilet-training process: a phenomenologic study

Mastery of independent toileting is a major developmental milestone for both children and parents, yet little research has been done on the topic since the early 1960s. Since little empirical data exists on the topic, a phenomenologic approach was used to identify components of the toileting process from the mother's perspective and to identify concepts germane to the toileting process to be studied in future research. Based upon analysis of tape-recorded, open-ended interviews, five recurring themes were identified: timing, trajectories of successes and failures, strategies, mother influencers, and child traits and skills. The recurring themes suggested a commonality of experiences, even though individual stories of the transition from diapers to underpants were unique for each child.