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Keywords:

  • bladder;
  • brain injury;
  • family issues

Abstract

  1. Top of page
  2. Abstract
  3. Literature Review
  4. Design
  5. Implementation
  6. Analysis
  7. Discussion
  8. Conclusions
  9. References
  10. Biography

Purpose

The purpose of this study is to examine the impact of an evidence-based training program on patient outcomes of continence, falls, and discharge disposition in the rehab population.

Methods

Criteria for inclusion required new onset of two or more episodes of urinary incontinence. Sixty-six subjects were enrolled with 33 subjects receiving evidence-based interventions.

Results

The intervention group showed improvement in continence (p = .020), with no difference between groups on discharge disposition (p = .744). Results showed an unexpected higher occurrence of falls in the treatment group (p = .000).

Discussion and Clinical Relevance

This study supports existing literature indicating that continence is not an independent predictor of nursing home admission and offers new evidence that use of an evidence-based intervention bundle can significantly improve patient continence including those patients with mild to moderate cognitive impairment.

Urinary incontinence is defined as “involuntary loss of urine” (Hoeman, 2002) with an estimated 13 million individuals experiencing some type of incontinence (Ward-Smith, 2009). Urinary incontinence can profoundly impact quality of life once the condition can no longer be concealed from others and has been linked to job loss, social isolation, falls, skin breakdown, and loss of independence. Prevalence rates of incontinence vary between 19%–55% of women and 2%–34% of men experiencing urinary incontinence, whereas others report a prevalence of 30%–50% of incontinence in community dwelling women over the age of 65, additional studies report that 85% of the 13 million individuals experiencing incontinence are women. (Brown et al., 2000; Holroyd-Leduc, Mehta, & Covinsky, 2004; Milne, 2004; National Association for Continence, 2008; Shamliyan, Kane, Wyman, & Wilt, 2008; Ward-Smith, 2009).

There is ample literature demonstrating that as age increases so does the incidence of falls. Falls are responsible for 70% of accidental deaths in persons 75 years of age or older although the rate of injury is highest among those individuals 85 years or older (Fuller, 2000). About one third of community dwelling elderly individuals fall each year. Comparably the incidence of falls for hospitalized patients report rates of 2% to 17% of patients experiencing a fall during hospitalization or between 2.9 and 13 falls per 1000 bed days (Ackerman et al., 2010; Hayes, 2004). Although most falls do not lead to death or injury, individuals who experience a fall frequently become apprehensive of falling again as they fear injury or loss of independence and as a result limit their mobility in turn contributing to social isolation.

In a study by Miu, Lau and Szeto (2009) the most frequently reported quality of life impairments reported were feeling frustrated, emotional health and participation in social activities outside one's home. Although this study was specifically focused on community dwelling individuals with dementia, the presence of urinary incontinence in any individual may cause embarrassment and anxiety leading to social isolation as they fear not having access to a toilet while in public. This withdrawal and social isolation can contribute to the global reduction in quality of life indicators.

The purpose of this study is to examine the impact of an evidence-based continence training program on patient outcomes of continence, falls, and discharge disposition by comparing outcomes between pre and post intervention groups.

These researchers hypothesize that achieving continence will reduce falls and increase discharge disposition to go home.

Literature Review

  1. Top of page
  2. Abstract
  3. Literature Review
  4. Design
  5. Implementation
  6. Analysis
  7. Discussion
  8. Conclusions
  9. References
  10. Biography

In a meta-analysis conducted by Chiarelli, Mackenzie and Osmotherly (2009), it was reported there is a clear association between falls and urinary incontinence in the community dwelling population. Specifically, overactive bladder or urge incontinence rather than stress incontinence is linked to falls. The link between urinary incontinence and falls is most likely related to the need to rush to the bathroom caused by the sudden urge to void. This may be compounded by the need to manage multiple tasks such as walking, controlling the flow of urine, and negotiating obstacles while rushing to the bathroom. In a study by Brown et al. (2000) with more than 6,000 community dwelling women, weekly or more frequent urge incontinence was independently associated with risk of falling. Stress incontinence was not independently associated with falls or fractures. There are limited studies examining the relationship between urinary incontinence and patient placement in nursing homes and what literature exists presents conflicting information. A study conducted with two cohorts of patients within the Kaiser Foundation Health Plan of Northern California found that urinary incontinence was a predictor of nursing home admission (Thom, Haan & Van Den Eeden, 1997). In a large prospective cohort study (Holroyd-Leduc et al., 2004) of community dwelling individuals it was demonstrated that urinary incontinence was not an independent predictor of nursing home placement. This study did find a relationship between subgroups of patients and nursing home admissions, specifically BMI, vision, ADL status, and smoking.

Design

  1. Top of page
  2. Abstract
  3. Literature Review
  4. Design
  5. Implementation
  6. Analysis
  7. Discussion
  8. Conclusions
  9. References
  10. Biography

The setting for this study was a 54-bed acute inpatient rehabilitation department within a community hospital in the Midwest. Primary admitting diagnoses for this department are stroke and traumatic brain injury. The traumatic brain injury population is housed separately from the acute population and was excluded from this study. Baseline data regarding patient outcomes of falls, discharge disposition, and incontinence status were gathered before implementation of the evidence-based interventions. Data were gathered utilizing computerized information system, quality data reporting system, and chart review. Sampling occurred by convenience method with the first group of 30 subjects that met criteria chosen in the time period immediately before implementation of the evidence-based practice intervention. The second group of patients were chosen when they were admitted to the department and it was determined that they met criteria. Criteria for inclusion required new onset of two or more episodes of urinary incontinence within 72 hours before admission to rehab or two or more episodes of documented urinary incontinence after admission to rehab. Patient identification for participation in the study was gathered through use of an information systems report that gathered incidence of urinary incontinence. Patients excluded from the study included patients with urinary tract infection (UTI), neurogenic bladder, spinal cord injury patients, urinary retention greater than 300 mL or history of long standing incontinence not related to current reason for rehab stay. Incontinence was defined as any episode of loss of urine and did not differentiate between stresses and urge incontinence. Falls were defined as any unplanned descent to the floor whether assisted or unassisted, observed or unobserved. Discharge to home included home without additional services, home with outpatient services, or home with home health services. In addition, if the patient was discharged to an assisted living facility, this was considered a discharge to home. Protection of subjects was ensured through approval of the study by the organizations Institutional Review Board before study implementation.

Implementation

  1. Top of page
  2. Abstract
  3. Literature Review
  4. Design
  5. Implementation
  6. Analysis
  7. Discussion
  8. Conclusions
  9. References
  10. Biography

Before implementation of the evidence-based interventions the clinical nurse specialist (CNS) and wound ostomy continence nurse (WOCN) created a bladder training policy as practice previously was fragmented and lacked coherent methodology for implementation of interventions for urinary incontinence. Staff education was completed and included details of the new bladder policy, types of incontinence, explanation of the rationale, use of the interventions, and included a posttest. A pass rate of 80% was expected on the posttest. Interventions included assessment by CWOCN, urinalysis, post void residual via bladder scan 1–3 times, voiding diary, dietary restrictions, review of medications that contribute to incontinence, timed voiding schedule, and encouragement of fluid intake up to 2,000 mL until 6 pm followed by restriction of fluid intake.

Interventions were chosen based on review of the literature for best practice evidence. Urinalysis was conducted as evidence shows an UTI can exacerbate or even cause urinary incontinence. For patients with positive UTI findings, treatment was initiated to determine if the incontinence would resolve with correction of the infection. Patient fluid intake was encouraged up to 2 L/day as literature review reveals that adequate fluid intake reduces UTI (Gray, 2005) and frequently patients with incontinence self restrict intake to reduce incidence of incontinence. Although, overall fluid intake was encouraged, fluid intake was restricted in the evening and nighttime hours to reduce nocturnal voiding needs. In consultation with the hospital dietician the following foods were restricted: caffeine, chocolate, citrus juices, aspartame, tomato-based products as these can contribute to urinary frequency and urgency (Gray, 2005). Voiding diaries are used to detect patterns of urinary incontinence, frequency, and associations with fluid intake and incontinence patterns (Gray, 2005). Responsibility for completion of the voiding diary rested with the patient as cognitive and physical abilities allowed with staff serving as an alternative when the patients were unable to participate. Post void residual was conducted to rule out bladder retention that could lead to exclusion. In consultation with pharmacy medications that can cause or exacerbate urinary incontinence were identified so that physician consultation regarding alternative medication use could be explored for patients in the study. Timed voiding is differentiated from prompted voiding as fixed or scheduled toileting. For our study this meant, we took patients to the bathroom every 2 hours and sat them on the toilet during waking hours and woke them up every 4 hours at night and sat them on the toilet. Timed voiding was chosen for this population because it has been recommended for management of urinary incontinence in patients who are physically impaired, dependent upon caregivers, or cognitively impaired. The results of one systematic review and one metastudy review report timed voiding for these patient populations (Ostaszkiewicz, Roe, & Johnston, 2005; Roe, Ostaszkiewicz, Milne, & Wallace, 2006) successfully reduced the incidence of incontinence. It is important to note that timed voiding represented only one component of the interventions in these reviews and was only one component in this study.

Analysis

  1. Top of page
  2. Abstract
  3. Literature Review
  4. Design
  5. Implementation
  6. Analysis
  7. Discussion
  8. Conclusions
  9. References
  10. Biography

Descriptive statistics of between group comparisons included: age, gender, and length of stay. Using an Independent Samples test, no statistical difference was seen between the groups in relation to age (F = .204, p = .653) or length of stay (F = .022, p = .882). A chi-square goodness of fit test was calculated comparing the frequency of occurrence of continence on discharge. It was hypothesized that the two groups without intervention would have equal episodes of incontinence/continence on discharge. A significant deviation from hypothesized values was found (p = .020). The individuals in the treatment group were less likely to be incontinent on discharge when compared to the baseline group (Table 1). ANOVA was used to calculate discharge disposition as it was hypothesized that the two groups without intervention would have equal discharge disposition home. The hypothesis was supported as there was no significant difference between groups (p = .744). Using chi-square falls were significantly higher in the intervention group than the comparison group (p = .000) (Table 2). Further ANOVA analysis indicated that there was significant difference in Morse scores between the two groups with the intervention group remaining at higher risk for falls than the control group (p = .018) (Table 3).

Table 1. Test Statistics
 Study GroupContinent at DC
  1. a

    Study group showed significant improvement in continence at discharge.

  2. b

    Significant difference in continence at discharge; p = 0.012.

Chi-square0.410a6.333b
df11
Asymp. Sig..522.012
Table 2. Test Statistics
 Study GroupFalls
  1. a

    Study group showed significantly higher rate of falls compared to control group.

  2. Significant difference in falls; p = .000.

Chi-square0.410a27.557a
df11
Asymp. Sig..522.000
Table 3. ANOVA
 Sum of SquaresdfMean SquareFSig.
  1. The Morse scores on the study group patients were significantly higher at discharge.

Morse Score on Admission
Between Groups1,080.79711,080.7972.368.129
Within Groups26,928.22059456.411  
Total28,009.01660   
Morse Score Mid-Stay
Between Groups904.4711904.4712.815.099
Within Groups18,954.54559321.263  
Total19,859.01660   
Morse Score at Discharge
Between Groups2,046.47612,046.4765.960.018
Within Groups20,258.44259343.363  
Total22,304.91860   

Discussion

  1. Top of page
  2. Abstract
  3. Literature Review
  4. Design
  5. Implementation
  6. Analysis
  7. Discussion
  8. Conclusions
  9. References
  10. Biography

Implementation of these evidence-based interventions did not support the original hypothesis on all outcomes. There was a significant reduction or elimination of urinary incontinence; however, there was no significant reduction achieved regarding discharge disposition. This finding supports existing literature that reports urinary incontinence is not an independent predictor of nursing home admission. Factors that may have influenced this result include the patient's cognitive and physical status at discharge or changes in the family support system from their admission status. More importantly in this study the intervention group had a significantly higher incidence of falls, this is in contrast to existing literature. It is hypothesized that this is due to the intervention group having higher fall risk scores on the Morse Scale throughout their stay with a statistical significance reported at discharge. This may indicate the intervention group admitting diagnoses and/or co-morbidities had a higher severity of illness/morbidity ranking than the comparison group. In addition, it may indicate that the intervention group did not realize the same functional improvements as an end outcome of their rehab therapy in relation to the comparison group. The significant results of this study on the reduction of urinary incontinence support the use of evidence-based practice interventions for management of urinary incontinence. In this time of restricted budgets, it is also important to note that this study supports the use of these interventions on populations other than ambulatory, cognitively intact individuals as participants with mild to moderate cognitive barriers were included in the study. The operational definition for cognitive impairment used to determine exclusion concerned the participant's ability to follow directions and patients who were so severely impaired that they were unable to follow directions.

Conclusions

  1. Top of page
  2. Abstract
  3. Literature Review
  4. Design
  5. Implementation
  6. Analysis
  7. Discussion
  8. Conclusions
  9. References
  10. Biography

Limitations for this study include the small sample size and convenience sampling methodology. In addition, no control over fall risk rating between groups was completed which may account for the higher incidence of falls in the intervention group especially as there was a statistical difference between groups fall risk rating at discharge in the treatment group. This limitation has significance for future research efforts as controlling the fall risk rating between groups could reveal a relationship between continence and likelihood of falling. It is important to note, however, that the treatment group was at higher risk for falls throughout their stay, which could indicate a higher acuity of this population. It is unknown whether this assumption is correct and if so, if it is due to changes in cognitive, physical, or medical conditions between groups. Regardless of the cause, the treatment group did benefit from the evidence-based intervention bundle in terms of incontinence. This lends support to the need for use of these interventions on both cognitively intact and cognitively impaired individuals and points to future research implications.

Key Practice Points
  • Evidence based nursing intervention bundles are supported for management of urinary incontinence.
  • Urinary incontinence is not an independent predictor of nursing home admissions.
  • Evidenced based nursing intervention bundles for urinary incontinence have an impact with both the cognitively intact and cognitively impaired patient populations.
  • Patients with higher Morse fall risk scores and incontinence were at higher risk of falling during this study.
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References

  1. Top of page
  2. Abstract
  3. Literature Review
  4. Design
  5. Implementation
  6. Analysis
  7. Discussion
  8. Conclusions
  9. References
  10. Biography
  • Ackerman, D. B., Trousdale, R. T., Bieber, P., Henley, J., Pagnano, M. W., & Berry, D. J. (2010). Postoperative patient falls on an orthopedic inpatient unit. The Journal of Arthoplasty, 25(1), 1014.
  • Brown, J., Vittinghoff, E., Wyman, J., Stone, K., Nevitt, M., Ensrud, K. et al. (2000). Urinary incontinence: Does it increase risk for falls and fractures. Journal of the American Geriatrics Society, 48(7), 721725.
  • Chiarelli, P. E., Mackenzie, L. A., & Osmotherly, P. G. (2009). Urinary incontinence is associated with an increase in falls: A systematic review. Australian Journal of Physiotherapy, 55, 8995.
  • Fuller, G. F. (2000). Falls in the elderly. American Family Physician, 61(7), 21592167.
  • Gray, M. (2005). Assessment and management of urinary incontinence. The Nurse Practitioner, 30(7), 3343.
  • Hayes, N. (2004). Prevention of falls among older patients in the hospital environment. British Journal of Nursing, 13(15), 896901.
  • Hoeman, S. P. (2002). Rehabilitation Nursing: Process, Applications and Outcomes (3rd ed.). St. Louis, MO: Mosby.
  • Holroyd-Leduc, J. M., Mehta, K. M., & Covinsky, K. E. (2004). Urinary incontinence and its association with death, nursing home admission, and functional decline. Journal of the American Geriatric Society, 52, 712718.
  • Milne, J. L. (2004). Behavioral therapies and the primary care level: The current state of knowledge. Journal of Wound Ostomy Continence Nursing, 31(6), 367376.
  • Miu, D., Lau, S., & Szeto, S. (2009). Etiology and predictors of urinary incontinence and its effect on quality of life. Geriatrics and Gerontology, 10, 177182.
  • National Association for Continence (2008). Facts and statistics. Retrieved November 17, 2009, from www.nafc.org/media/media-kit/facts-statistics
  • Ostaszkiewicz, J., Roe, B., & Johnston, L. (2005). Effects of timed voiding for the management of urinary Incontinence in adult: Systematic review. Journal of Advanced Nursing, 52(4), 420431.
  • Roe, B., Ostaszkiewicz, J., Milne, J., & Wallace, S. (2006). Systematic reviews of bladder training and voiding programmes in adults: A synopsis of findings from data analysis and outcomes using metastudy techniques. Journal of Advanced Nursing, 57(1), 1531.
  • Shamliyan, T. A., Kane, R. L., Wyman, J., & Wilt, T. J. (2008). Systematic review: Randomized, controlled trials of nonsurgical treatments for urinary incontinence in women. Annals of Internal Medicine, 148(6), 459474.
  • Thom, D. H., Haan, M. N., & Van Den Eeden, S. K. (1997). Medically recognized urinary incontinence and risks of hospitalization nursing home admission and mortality. Age & Ageing, 26:367374.
  • Ward-Smith, P. (2009). The cost of urinary incontinence. Urologic Nursing, 29(3), 188190, 194.

Biography

  1. Top of page
  2. Abstract
  3. Literature Review
  4. Design
  5. Implementation
  6. Analysis
  7. Discussion
  8. Conclusions
  9. References
  10. Biography
  • Marcia Grandstaff, RN MSN CRRN CWCN, is Clinical Nurse Specialist at Advanced Practice Nursing, Community Health Network, Indianapolis, IN. Address correspondence to mgrandstaff@ecommunity.com. Deborah Lyons, MSN RN NE-BC, is Network Executive Director, Disease Management, Community Health Network, Indianapolis, IN.