AMDA/Pfizer Quality Improvement Award

1. Improving Continence Management in Post-Acute Skilled Care 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

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

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 ____M Age:______ • Admission diagnoses:_____________________________________ • History • Incontinent before qualifying hospitalization? • ____No ____Yes _____Unknown _____N/A • If yes, was incontinence being treated? • _____No _____Yes _____Unknown • 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. 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 Adapted from: Ouslander, JG J Amer Med Dir Assoc 2007; 8: S6 – S11

16. Wound Care Team Evaluation of Response to Toileting Trial Resident Name ________________ Room Number ______Date: __________________ Adapted from: Ouslander, JG J Amer Med Dir Assoc 2007; 8: S6 – S11 1Good response should be based on clinical judgment and resident/family satisfaction with the response. Signature Wound Care Nurse _________________________________________________

17. Preliminary Baseline Data(4-month period in 2008) • 92 records of consecutive admissions reviewed

18. Preliminary Baseline Data(4-month period in 2008) • 92 records of consecutive admissions reviewed

19. Preliminary Baseline Data(4-month period in 2008) • 92 records of consecutive admissions reviewed

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

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

22. QI Data Being Collected(4-month period in 2009)

23. QI Data Being Collected(4-month period in 2009)

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