Using a nurse-led protocol to reduce infections
Urinary incontinence is a common and potentially disabling condition affecting up to 30% of those aged 65 years and older. Its prevalence in elderly nursing home patients — up to 70%2 are admitted with the condition and some type of accompanying skin breakdown — presents a major cause for concern in light of recent healthcare legislation and directives focusing on quality of care. Additionally, it is notable that this condition is not limited to an elderly population and extends to patients of all ages who are coping with UI as a result of spinal cord injuries, traumatic brain injury and prostate cancer treatments.
In long-term care facilities (LTCFs: nursing homes, skilled nursing facilities and assisted living facilities), UI is associated with substantial morbidity and cost. It can predispose patients to skin irritation, make pressure ulcers difficult to heal, and result in urinary tract infections when the condition is inappropriately managed. The adverse psychological effects for incontinent residents are pain, embarrassment and frustration.
In addition to adversely affecting physical health and psychological well being, urinary incontinence increases healthcare costs. The economic costs of UI in nursing homes have been estimated to be close to $5 billion annually, including the costs of staff time, laundry, and supplies3. Multiple surveys demonstrate that nursing staff generally considers UI to be one of the most time-consuming and difficult conditions they tend to, because it requires spending a disproportionate amount of time on the care of incontinent residents, plus the additional aid required for treating the skin irritation, breakdown, and infection that can accompany UI.
If an evaluation determines that the cause of UI is not treatable, there are several noninvasive management strategies that can greatly improve the symptoms in many patients and lead to improved quality of life for patients and caregivers. Prompted voiding, a simple behavioral intervention, may be effective in managing daytime urinary incontinence, but requires that multiple nursing home staff keep track of individual toileting schedules. Some drug therapies have been successful in restoring controlled bladder functionality. However, when these management strategies don't work and surgery is not an option, treatment is the remaining course of action.
Nurse-led protocols can save lives
Treatment options for urinary incontinence are surprisingly similar today compared to 50 years ago, with the exception of the male external catheter, which has seen notable advancements. LTCFs and the nurses who lead patient care are the first line of defense when it comes to preventing infections. As they hold themselves to the highest standards of care, they evaluate all options and make decisions that affect patients' short- and long-term health. A nurse-led protocol could reduce the incidence of infections when treating urinary incontinence.
Some treatments come with the risk of infection, and for the 4 million Americans who receive care in U.S.-based LTCFs, use of these treatments can be a life-threatening risk — according to the Center for Disease Control, as many as 380,000 residents of LTCFs die every year of infections.
Highly absorbent disposable pads and undergarments are the most common method of managing urinary incontinence in LTCFs, especially at night for residents who are managed by prompted voiding or other interventions during the day and evening. They do exactly what they are meant to — absorb urine and prevent leaks. Although they may keep bedding and clothing cleaner, these products allow urine to be in constant contact with the skin. Over time, the skin breaks down. In as little as five days of continuous use, up to 25% of patients develop Incontinence-Associated Dermatitis4. In addition, continuous use of absorbents is associated with an increased risk of pressure ulcers5.
The risk of infection varies among different types of catheters, with indwelling catheters carrying the highest risk. Studies estimate that as many as 50,000 nursing home residents are using a catheter at any particular time, and catheters are associated with UTIs which can be very dangerous, even fatal. In May 2013, a jury in Colorado found a nursing home in Pueblo liable for $3.7 million for the death of a resident who developed a severe urinary tract infection when nursing home staff failed to monitor her catheter. The risk of developing a CAUTI increases five percent each day a catheter is in place, with a 100 percent infection rate for long-term use7.
External (condom) catheters
Unlike indwelling catheters and absorbent products, which require multiple daily changes, external catheters are designed for a single 24-hour application. The use of condom catheters in cooperative male incontinent patients (especially those with spinal cord injury) has been shown to reduce the risk of CAUTI when compared with indwelling catheters. However, these catheters seal to the shaft of the penis using an aggressive adhesive. As a result, up to 15% of users will experience skin breakdown, and 40% of long-term users will get a UTI8. They can also dislodge and cause additional work for caregivers, as well as patient embarrassment.
Innovation in external catheters for men
A new generation of external male catheters takes into account the rashes, skin sores and UTIs associated with absorbents, as well as the CAUTI that accompanies indwelling and condom catheters. Rather than enveloping the shaft, these “urinary collection devices” are attached to the tip of the penis, resulting in a dry anatomy. This design greatly reduces the risk of skin irritation and CAUTI. In addition, advancements in hydrocolloid manufacturing are resulting in more reliable and comfortable adhesive properties, and less skin irritation and tears.
Gary Damkoehler is Chairman and Chief Executive Officer at BioDerm Inc. To request BioDerm study results, email CAUTIstudy@bioderminc.com.
1 Gibbs CF, Johnson TM, Ouslander JG: Office Management of Geriatric Urinary Incontinence, The American Journal of Medicine 120, 211-220, 2007.
2 Ouslander JG, Kane RL, Abrass IB. Urinary incontinence in elderly nursing home patients, JAMA. 1982; 248:1194-8.
3 Hu TW, The cost impact of urinary incontinence on health-care services. In: AHCPR Clinical Practice Guideline on Urinary Incontinence in Adults. Rockville, Maryland: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research,1994.
4 Shokeir, A., “Squamous cell carcinoma of the bladder: pathyology, diagnosis and treatment,” British Journal of Urology International, 2004; 93: 216-220.
5 Ouslander, J., Greengold, B., Chen, S., “External Condom Catheter Use and Urinary Tract Infections Among Incontinent Male Nursing Home Patients” Journal of the American Geriatrics Society, Vol. 35, 1987; And, Golji, H., “Complications of External Condom Drainage,” Paraplegia (19), 1981.
7 BioDerm estimate, 2005, based on Pajk, Marilyn Pressure Sores. Merck Manual of Geriatrics Section 15, Chapter 124. Internet Edition provided by Medical Services, USMEDSA, USHH. Published by Merck and Co. Inc, 2000.
8 Ouslander, J., Greengold, B., Chen, S.,, “External Condom Catheter Use and Urinary Tract Infections Among Incontinent Male Nursing Home Patients” Journal of the American Geriatrics Society, Vol. 35, 1987.