Continence Care
Urinary Continence Program – Case Studies
The following examples are representative of actual patient encounters by On-Sight Senior Care.
ONSIGHT Continence Care Hailed for Dramatic Improvements in QI Report - August 10, 2007
A QI report tracks low risk incontinence in the nursing home and specifically relates information which can trigger surveyors to examine care for deficits. On a national level, QI statistics are trended and, when statistics fall out of the normal ranges, surveyors are alerted.
QI data is compiled regularly and then reported to the state. After five months of evaluation and treatment of Sunbridge of the Triad UI residents by ONSIGHT Continence Care, significant changes in the QI report were noted. Specifically, the QI report reflected a reduction in incontinent residents without a toileting plan form 100% to 62% and a reduction in low risk incontinence from 65% to 60%.
These results reflect the individual evaluations establishment of treatment plans for most of the residents with low risk incontinence. Angie Chevron, DON – Sunbridge of the Triad, shared these results with great admiration for the impact Laura Hardcastle, nurse practitioner with ONSIGHT Continence Care, has had in her facility. These reductions reinforce the positive impact a continence nurse practitioner can have in evaluating and treating residents with UI in long term care.
Mrs. J
- An 82 year-old female who was admitted 2 months ago, transfers with one person assist but is always looking to be taken to the bathroom.
- Resident is frequently incontinent, usually on the way to the bathroom.
- Ms. J has dementia and hypertension but drives the staff crazy with her constant need to toilet.
- She has fallen twice at night trying to go to the bathroom. Her son is convinced it is a behavior of her dementia. A psych consult is pending.
- Upon evaluation she has 60cc post void residual via bladder scan, her vaginal exam is positive for significant vaginal atrophy, her urinalysis is negative.
- Cystometrogram shows a bladder capacity of 190cc and she had several bladder or detrusor spasms.
- Estrogen ring and Oxytrol patch were ordered.
- Outcome: In one month she no longer asks to go to the bathroom constantly and has responded well to a scheduled toileting program.
Mr. S
- Resident is a 78 year- old male who has dementia but is mostly ambulatory.
- He has a “habit” of voiding into trashcans or rubber plants or the nearest corner whenever he has to go.
- Nursing Aides think he is just a “dirty old man.” He is also missing the urinal in his room and his roommate does not want to stay in the room because of the urine odor.
- Exam showed an enlarged prostate and his post void residual via bladder scan showed 345cc. Urinalysis was negative. Kidney function is normal.
- Cystometrogram shows 400cc capacity but a large bladder contraction occurred at that volume, and was uncontrollable. He has no constipation issues at this time.
- He was placed on Flomax and two weeks later his post void was 100cc. He was still having some accidents and so was placed on the Oxytrol patch.
- Outcome: In one month he is mostly continent and does not void in inappropriate places.
Savings Projection - Urinary Continence Service
Introduction: This information is based upon a cost studyconducted by a 300-bed facility that has used URO Health Services for more than twelve months.
- Adult Absorbency Products - diaper usage one year prior to URO Health services and then one-year post.
- Average reduction - $2.34 per day for the residents being treated
- Annual Savings - $854.10 per year/resident.
- Nursing home - Average census of 50 residents treated for Urinary Incontinence.
- Gross Annual Savings - $42,705 projected.
- Facility Compliance - the facility must work closely with ON-Sight Continence Care and our Nurse Practitioners in order to implement cost-savings policies:
- No diapers for continent patients
- Different products for day vs. night
- Adherence to toileting schedules
Additional Expense Reduction Opportunities
- Nursing Staff/Labor Savings
- Decrease need for linen/clothing/diaper changes which could potentially impact staff burnout/turnover; improved productivity
- Decrease man hours spent treating UTI; decreased patient resistance to antibiotics from frequent UTI
- Reduction in Laundry Services/Expenses
- Reduced Risk for Resident Falls
- Reduced fracture risk
- Reductions in Vulvar/Perineal/Sacral Dermatitis which leads to skin breakdown
- Reductions in Decubitis Ulcers leading to decreases in treatments (wound vaccines, dressings, creams, etc)
- Decreased need for Foley catheters which are placed for wound healing and subsequently lead to UTIs
- Reduction in the use of re-usable & disposable absorbency bed-pads
- Reduction in UTI’s which reduces costs of antibiotics/ admission to hospital
* Note: Some nursing assistants are “double diapering” UI patients inorder to reduce daily changes. This practice contributes to Dermatitisand may increase the cost of absorbency products by 25-30%.
Outcome Measurements – Clinical Management of: Urge UrinaryIncontinence Frequency Urinary Tract Infection In Long-term CareResidents
Background:
- Medicare implemented the new F-Tag 315 in June 2005. It states that not only should every resident with UI have an evaluation and plan of care for their incontinence but that every resident with frequent UTI’s should have a plan of care for reduction of UTI’s.
- Recent review of the literature on UI indicates that along with reducing the number of wetting episodes, reduction of UTI in older women can be helped by treating vaginal atrophy. (Kelly 2007).
- Normalizing vaginal mucosal lining with local estrogen normalizes the pH, lubricates the urethra, which helps repel bacteria, and may reduce the receptivity of the detrusor muscle to inappropriate contractions. (Kelly 2007).
- Treating urinary frequency may also reduce the number of falls. Many falls in long-term care residents occur on the way to the bathroom with a strong urge to void.
- Facilities who evaluate resident falls include the evaluation of urinary urgency in the plan for reduction of falls.
- This study describes the treatment of residents with vaginal atrophy with a vaginal estrogen ring. Residents with small bladder capacity and detrusor instability via simple CMG (Cystometrogram) where also treated with an OAB (Overactive Bladder) agent, most often the oxybutinin patch.
- The estrogen ring is the treatment of choice in these residents with vaginal atrophy because it contains the least amount of estrogen as compared to creams and tablets, it requires less nursing time, (every three month changes as opposed to two or three times a week cream or tablet insertions). It is also less cost per month as compared to other products.
- The estrogen from the ring is not systemically absorbed and requires no opposition with progesterone in the case where a uterus is present. The majority of the residents (88%) in this sample have no uterus.
- This is a descriptive retrospective chart survey of 69 residents who were treated for urge urinary incontinence, urinary frequency, and frequent urinary tract infection. The residents that were treated exhibited at least one of these diagnoses, and some had all of them. Detail about what diagnoses are found in the following table:
Reasons for Estrogen
Ring # Patients Total Patients Frequency Only 0 0%
Urge-Incontinence Only 3 4% Urinary Tract Infections Only
1 1%
Frequency + Urge UI
55 80%
Frequency + UTIs
0 0% Urge UI + UTIs
2 3%
Frequency + Urge UI + UTIs
8 12%
- The majority of the residents (80%) had frequency and urge UI.
- 17% or 11 had and additional diagnosis of frequent UTI. (Greater than three UTI’s in six months.) All residents resided in the same facility.
- The oldest is 92 and the youngest was 53. Mean age was 76.
- All were female. This group of 69 is out of 175 residents (39%) who were referred for evaluation and management of their urology symptoms to the continence specialist over a year period of time.
- Results show significant reduction in all symptoms.
- 94% of the residents who were treated for urinary frequency saw a reduction in this symptom.
- Most of these residents reduced their frequency to every 3 hour voids.
- 71% of the residents saw a reduction in Urge UI episodes, with most averaging at least a 50% reduction in wetting episodes. Of the residents who were only seen to reduce UTI’s.
- 91% had no UTI’s in the last 6 months of follow up.
Clinical Outcome Summary:
Total Patients # Patients Total Patients Reduced Frequency 65 94%
Reduced Urge UI 49 71% Reduced UTIs
10 15%
Estrogen Ring Only 14 20%
Total # of Active Patients 175 100% Patients w/ EST Ring 66 39%
Kelly 2007, Estrogen & Its Affects on Vaginal Atrophy inPost-Menopausal Women, Urologic Nursing, Vol. 27, No. 1, pages 40-46.
For additional information on this study please contact:
Lee Nail, C.R.N.P., M.S.N. Senior Clinical Director - Continence Care
lee.nail@onsightseniorcare.com