1. Do we have an incontinence problem? South Dakota Foundation for Medical Care South Dakotas Quality Improvement Organization (QIO)

2. A thought to ponder…. How does it make me feel? Embarrassed Im not going in there like this! Isolated No way, no how would I go in Sit by myself in the car It really didnt matter how I felt….it was what everyone else was going to think that helped me make the decision to stay in the car!!

3. Percentage of Residents Whose Need for Help with ADLs has Increased National - 16% South Dakota - 16 % Our Nursing Home - _____

4. Percentage of Residents with Low-Risk for Developing a Pressure Sore National - 3% South Dakota - 4% Our Nursing Home - _____

5. Percentage of Low-Risk Residents Who Lose Control of Their Bowels or Bladder National - 46% South Dakota - 46% Our Nursing Home - ____

6. Emotional Stress R/T Incontinence Anxiety Diminished self-esteem social isolation depriving residents of opportunities for personal growth and enjoyment

7. Do we know…. How many of our residents are continent upon admission? How many of our residents become incontinent after admission? How many days it takes our continent residents to become incontinent?

8. Incontinence Puts residents at risk for pressure ulcers urinary tract infections urosepsis perineal rashes falls fractures

9. Incontinence upon Admission What are we doing about residents who come in to our facility suffering from incontinence? Do we accept it as a problem associated with aging? AMDA RAI AHCPR Clinical Guidelines

10. Admission Process Are we identifying not only incontinent residents but those at risk as well? Are we finding the cause behind the incontinence? Do we know how long the resident has experienced incontinence?

11. Become a Detective! Low-Risk vs High-Risk High = residents with a high risk of incontinence Low = residents with a low risk of incontinence Are we finding the cause behind the incontinence?

12. Types of Incontinence Stress Incontinence bladder cant handle the increased compression during exercise, coughing or sneezing Urge Incontinence caused by sudden, involuntary bladder contraction Mixed Incontinence combination of both stress and urge incontinence

13. Types of Incontinence Overflow Incontinence bladder becomes too full because it cant be fully emptied, is rarer and is the result of bladder obstruction or injury

14. Possible Reversible Factors Resident Conditions delirium fecal impaction depression symptomatic urinary tract infection edema

15. Possible Reversible Factors Environmental Conditions impaired mobility lack of access to a toilet restraints restrictive clothing

16. Possible Reversible Factors Excessive Beverage Intake caffeine Disease Parkinsons other neurological diseases effecting motor skills

17. Possible Reversible Factors Medications diuretics drugs that stimulate or block sympathetic nervous system psychoactive medications

18. Contributing Factors Resident Conditions pain excessive or inadequate urine output atrophic vaginitis cancer of the bladder or prostate urethral obstruction disorders of the brain or spinal cord tabes dorsalis

19. Contributing Factors Abnormal Lab Values elevated blood glucose elevated calcium

20. Assessment of Incontinent Residents Identify potentially reversible and contributing factors bladder record or voiding diary targeted physical examination including rectal exam and pelvic in women

21. Assessment of Incontinent Residents Optional tests as appropriate urinalysis urine culture and sensitivity Glucose, calcium Vitamin B-12 Urine cytology Post-void residual determination Urodynamic tests e.g., stress tests filling and voiding cystometry

22. Treatments Trial toileting program 3-5 day trial prompted or timed voiding Residents responding favorably should continue with plan Residents not responding favorably should be referred for other treatment options

23. Other Treatment Options behavioral therapy drug therapy surgical treatment electrical stimulation intravaginal support devices pads and external collection devices intermittent catheterization

24. Drug Therapies Urge Incontinence anticholinergics bladder relaxants Stress Incontinence alpha-adrenergic antagonists estrogen Should be initiated at the smallest recommended dose and slowly titrated upwards based on resident response and tolerance

25. Monitoring Responsiveness to Treatment an objective measure of the severity of UI such as a bladder record resident satisfaction with treatment side effects of treatment

26. Physical and Environmental Barriers Toilet/commode accessibility Grab bars are present if needed Toilet seat is adequate height Lighting is adequate Commodes and urinals are used as supplements as needed Furniture allows easy rise for resident to be able to get up to go to the bathroom Call light is within reach / ability to use Contractures Ambulatory assistive devices needed

27. Physical Limitations Ease of taking garments off and putting on Getting to the toilet Ability to perform hygiene tasks

28. Current Approaches Bladder retraining Prompted voiding Pads/briefs Habit training Prompted voiding with assistance Catheter Ureterostomy Pelvic muscle rehabilitation

29. A Successful Restorative B&B Program Includes: Adequate fluid intake 2000-2500 ml/day Honor preferences Assistance Encouragement Keep fluids readily accessible Offer fluids with each resident contact

30. Different Resident/Same Plan? A scheduled two-hour voiding program will not work for all residents especially those who are receiving diuretics and other medications it takes a good detective to determine when the resident is most likely to use the toilet

31. ?? Would it – Could it work ?? Having the same caregiver care for the resident during the evaluation phase…… Would it – could it assist us to determine the residents bowel and bladder elimination patterns?

32. Resources www.medqic.org Facility Assessment Checklists – Incontinence Quality Measures Manual RAI Manual AMDA Clinical Practice Guidelines www.guideline.gov www.guideline.gov

33. Contact Us Bernadette Nelson, RN, Project Manager Phone (605)336-3505 Extension 263 Email: bnelson@sdqio.sdps.org Rhonda Streff, RN, Assistant Project Manager Phone (605)336-3505 Extension 262 Email: rstreff@sdqio.sdps.org Ryan Sailor, Analyst Phone (605)336-3505 Extension 220 Email: rsailor@sdqio.sdps.org Jane Viereck, Coordinator Phone (605)336-3505 Extension 266 Email: jviereck@sdqio.sdps.org