Keeping watch by night

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One facility found moving the daytime nursing shift up by more than an hour results in fewer problems with morning wetness among residents. However, residents who are night owls should be offered a la
One facility found moving the daytime nursing shift up by more than an hour results in fewer problems with morning wetness among residents. However, residents who are night owls should be offered a la

At Lorien Bel Air, Director of Nursing Cheryl Bayne is responsible for 45 long-term care residents and another two dozen patients recovering from surgical procedures.

She estimates 80% of them have incontinence issues, and she's using a relatively new tool to help them stay clean and safe.

An hour north of Baltimore, the facility was the first in the U.S. to test Simavita's Smart Incontinence Management System, or SIM. When new residents arrive — and quarterly after that — Bayne's staff dresses them in briefs specially equipped to monitor wetness and soil. A pager-size pack at the waistband collects data and sends it wirelessly to staff so they can determine each resident's voiding patterns.

The technology has changed the way Lorien tailors toileting plans, and it's one of many options available to skilled nursing homes and other caregivers looking to improve quality of life and avoid major health risks among residents who can no longer control their bladders.

Overnight incontinence presents ongoing challenges for even the best of nursing homes: Episodes place increased demands on staff; prevention requires careful planning and, often, investment; and doing too little can damage both the body and spirit of vulnerable residents.

“Put yourself in these residents' places,” says Amanda Kistler, RN, recording secretary for NADONA's board of directors. “It's really not about what's best for us. It's about what's best for each individual resident.”   

By recognizing personal preferences, selecting high-quality materials and encouraging resident participation, facilities can help restore dignity. Such efforts also pay dividends because they ultimately create staff efficiencies, cut into laundry costs and lower the risk of falls and skin breakdown.

Thirty minutes of urine touching the skin is enough to waterlog the epidermal layer and start the kind of swelling that can lead to a wound, says adult clinical nurse specialist Alex Kahn.

“Research has shown that prevention can save you big bucks,” explains Kahn, who treats internal medicine and wound care clients for Pro Healthcare. “But some people still don't understand the severity of the threat.”

Sleep timers

Better overnight care doesn't necessarily require new products, but a more realistic mindset can go a long way.

“Typically, the overnight shifts are staffed by less personnel, number-wise, working with the assumption that residents sleep at night,” says Mary Madison, RN, a long-term care, senior care and assisted living consultant for Briggs Healthcare. “Just because it's dark outside and the lights inside are dimmed doesn't mean that every resident is tucked into bed for the duration of the night.”

Madison believes that many residents actually need more help between 8 p.m. and 8 a.m., especially when it comes to toileting.

Instead of the check-and-change policy standard in many skilled nursing settings, Madison and other experts contacted by McKnight's advocate a scheduled toileting plan or shifting toileting opportunities to match an individual's needs.

In one facility where Kahn worked, moving the start of the daytime nursing shift up by 90 minutes resulted in fewer problems with a.m. wetness. Many residents who once had episodes while waiting for staff to arrive at 7:30 a.m. could stay dry between a late-night check and 6 a.m.

The impact was clear, providing a more pleasant start to the day for employees and residents.

If residents are night owls, it's important to recognize that. Don't rush patients to bed right after dinner, and consider offering a late toileting prompt for residents still awake at 10 p.m.

Kistler, director of nursing at Salemtowne Retirement Community in North Carolina, is considering that option at her facility, which is about to add a memory unit as part of a $42 million expansion. 

“We have to look at what their routine sleep patterns are,” she says. “We might have somebody who worked third shift their entire life. We'll have to adjust our schedules to what's normal for them.”

Wetness guards

Beyond matching their timing, experts say facilities should be placing residents in undergarments (and selecting bedding materials) suited to their level of need.

Jeannette Podlogar, clinical support manager for McKesson, says today's products — made to wick wetness away from the skin — are superior even to air-drying. But she says some long-time caregiving staff still put incontinent patients to bed without underwear or briefs.

“Things have changed over the last 10 years,” she says. “The products have become more absorbent and the design has changed in a couple of ways.”

One important innovation? Pull-up-like adult diapers with stretch panels offer improved comfort, meaning patients are willing to wear them longer. That brings down costs if you judge by per-use instead of per-piece, Podlogar says.

Issuing size- and gender-appropriate briefs or pull-ups is a critical step for helping newly incontinent residents. Some may opt to wear them only at night, a fine option if it makes them less likely to make a shaky sprint for the bathroom.

“As soon as the resident gets the urge to get up and go to the toilet during the night, there is an immediate increase in the risk of a fall,” says Michelle Christiansen, vice president of clinical services and marketing for Medline's personal care division.

Instead of waiting for a patient's need to present itself, Madison prefers active, preventive toileting offered at set times through the night. That includes cases where two staff members might be needed to move a resident to an upright seated position on a toilet or bedside bowl.

“Staff often spend more time changing sheets and cleansing residents after incontinence episodes than they (would) getting the resident to a bedside commode or onto the toilet,” she points out.

Even for fully dependent residents, a full check every two hours isn't necessarily wise; patients need sleep as much as they do protection and comfort. 

But staff should be trained in ways to look for wetness in the least obtrusive manor possible, including with soft voice and dim lights that allow the resident to fall back asleep, says Kistler.

As an alternative to a gloved check for wetness, Christiansen also recommends using overnight products with wetness indicators. She urges facilities to provide ongoing education around sleep and incontinence practices, either through online courses or a management system. Medline, for example, designed a way to help employees pick the right products and moisture management levels.

Nursing staff also can explore other options that might help reduce residents' need to go in the middle of the night.

Limit fluid intake in the late afternoon and evening, which could decrease urine production overnight, suggests Christiansen. But be careful that residents asked to sip less at night get plenty of opportunity to drink and eat earlier in the day.

Consider the role medications, especially diuretics, play. Kahn says Lasix often can be given at a higher dose once daily, versus a twice-daily dose that contributes to incontinence.

Hi-tech toileting

Technological help for incontinence used to mean a wetness alarm that alerted caregivers to a urine or bowel episode.

But few experts still consider them part of quality overnight facility care.

“We have too many alarms going off now in a given facility,” Madison says. “Such devices can indeed produce anxiety for the individual, whether or not they're able to understand what's happening. They can also wreak havoc on sleep quality.” 

The alarms, often marketed to parents of children who wet the bed, are designed to train someone to improve bladder control — an impossibility for many long-term care patients.

But other high-tech monitors offer a dignity-delivering solution for facilities willing to invest.

Bayne piloted SIM at her company's urging, but signed on to continue using it after the test period. She calls the cost a “no-brainer” because of the benefits it affords.

After using the sensor-equipped briefs to assess an elderly patient with dementia and a history of stroke, staff at Lorien started her on a custom toileting program. Bayne says her fall or near-fall rate went from a maximum of twice a night to once per month. A second, non-communicative resident who often cried out or seemed agitated at night reduced those behaviors after a bathroom schedule adjustment.

Building-wide, the reduced impact on linens was so obvious, her own residents told her she'd be saving money. 

Podlogar says benefits of such systems — McKesson offers Identify by SCA — are that they offer residents discretion while producing a paper trail for providers. Identify and SIM feed precise information into a EMR and can be incorporated into a care plan. Podlogar says some providers use Identify as a way to meet the 72-hour voiding assessment required by CMS upon admission.

“They can be very good and very effective,” Podlogar says. “They are expensive, so for best use, you want to pick residents who have some potential for rehab.”

Because of the loss of self-esteem associated with bedwetting, staff members need to be attuned to changes in condition. Training and guidance is needed for staff to broach the topic carefully with residents and family members, and include a simple explanation on how incontinence can create skin problems. 

There should also be easy, routine ways to share toileting needs and schedules with fellow staff members, whether through the EMR or a paper folder tucked discreetly into a bathroom cubby (used at Salemtowne).

Nocturnal incontinence “is accepted and staff rarely explore the consequences of incontinence during these hours,” Madison says. “With proper observation and data collection, ADL scores would no doubt accurately reflect what's going on. Restorative programs should result (and) Quality Measure scores should improve. Most importantly, the quality of life for residents should improve.”