1. AMDA/Pfizer Quality Improvement Award Whitehall of Boca Raton Christine E. Lynn College of Nursing Charles E. Schmidt College of Biomedical Science Florida Atlantic University Improving Continence Management in Post-Acute Skilled Care

2. Whitehall of Boca Raton  Census ~ 155  ~ 2/3 Medicare skilled post- acute care  High quality based on recent surveys  Actively involved medical director  Frequent physician and NP visits

3. 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

4. Not Pictured: Gloria McGann – Director, Wound Care Team Marsha Gordon - Wound Care Nurse Dr. Terri Touhy Dr. Gabriella Engstrom Whitehall Staff

5. Background  All previous studies of continence management have been done in long- stay 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

6. 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. non- responders 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”

7. 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

9. http://interact.geriu.org

10. 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.

11. 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

12. Whitehall Boca Continence History Resident Name:__________________________________Room:______________________ Date of Admission:_______________________________Date:_____________ Sex:___F____MAge:______ Admission diagnoses:_____________________________________ 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_____Other (specify) 2)Was the resident satisfied with treatment? _____No_____Yes_____Unknown 2.Was the resident admitted to Whitehall with a catheter?_____No_____Yes If yes: a) Reason for catheter (check all that apply). _____Monitor output _____Manage incontinence _____Skin protection/pressure ulcer _____Retention _____Uncertain b) Catheter removed?_____No_____Yes(Date:_______) c) Post-void residual?_____ml_____N/A 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

13. 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 _________________________________

14. Day Check # Date Time Condition at Check Response to Prompt to Toilet Results of ToiletingSymptoms 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 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 3 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 Bladder Diary Resident name____________________________Room No______________ Adapted from: Ouslander, JG J Amer Med Dir Assoc 2007; 8: S6 – S11

15. 3 – Day Trial of Prompted Voiding Time 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 Adapted from: Ouslander, JG J Amer Med Dir Assoc 2007; 8: S6 – S11

16. MeasureResult 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 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 Responder 1 :  Continue toileting program: Prompted Voiding Timed Voiding Non-responder 1 :  Manage supportively with individualized check and change schedule  Supportive management based on o Resident/family preference o Unresponsiveness to toileting o Both  Consider drug therapy for urge incontinence  Consider further evaluation  Care plan in place Wound Care Team Evaluation of Response to Toileting Trial Resident Name ________________ Room Number ______Date: __________________ 1 Good response should be based on clinical judgment and resident/family satisfaction with the response. Signature Wound Care Nurse _________________________________________________ Adapted from: Ouslander, JG J Amer Med Dir Assoc 2007; 8: S6 – S11

17. Preliminary Baseline Data ( 4-month period in 2008) 92 records of consecutive admissions reviewed Patient CharacteristicsN = 92 Age83.7 (53 – 97) Sex Female Male 49 (53%) 43 (47%) Short term memory problem69 (73%) Independent in decision making61 (75%) Independent in transfer3 (3%)

18. Preliminary Baseline Data ( 4-month period in 2008) 92 records of consecutive admissions reviewed Patient Characteristics (cont.)N = 92 Length of stay35.9 (1 – 153) Discharge location Home Acute hospital Long stay NH Missing 57 (62%) 27 (29%) 7 (8%) 1 (1%)

19. Preliminary Baseline Data ( 4-month period in 2008) 92 records of consecutive admissions reviewed Continence CharacteristicsN = 92 Independent in toileting3 (3%) Incontinence on admission None Incontinent of urine and/or stool 52 (60%) 27 (26%) Indwelling catheter12 (13%) Missing1 (1%) Number of patients treated with drug therapy 4 (10% of those with UI) Continent at dischargeNot systematically recorded

20. Preliminary Baseline Data ( 4-month period in 2008) 92 records of consecutive admissions reviewed Urinary Tract InfectionsN = 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%) _____________________________________________________________ Clinical criteria included pain (4), fever( 2), AMS (1) 6 were treated based on RBC in urine with no other documentation of symptoms

21. Ouslander, JG J Amer Med Dir Assoc 2007; 8: S6 – S11 Examples of QI Data

22. 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

23. 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

24. 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)

25. 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