Objective: The purpose of this study was to assess the extent to which the 1996 AHCPR Clinical Practice Guideline on Urinary Incontinence (UI) was used in nursing homes.
Design: Cases were assessed using retrospective record review. Since the majority of Guideline standards require an order, physical examination or tests, record review was judged as a reasonable way to assess Guideline application.
Setting/Population: The study took place in 52 nursing homes (7,458 beds) in Upstate NY. In order to assess the use of the Guideline, criteria were developed to ensure that these cases truly warranted UI evaluation/treatment. The cases assessed (n=201) met the following criteria. First, UI had to be newly occurring or present upon admission, (2) had to occur at a frequency of least two times per week, (3) UI had to last for at least four weeks, (4) the resident had to not be imminently terminally or comatose; (5) the resident had to stay in the nursing home at least 12 weeks following onset of new UI. Cases of new UI were identified by interviewing each resident's primary certified nursing assistant every four weeks. New cases meeting these criteria occurred at a rate of 4.3 cases per 100 beds per 12 weeks.
Findings: Overall, 31% of the most important Guideline standards (77) were met (0% to 65%) considering only those standards that applied to each individual case. Physical examinations were generally limited with some exceptions. Most had examinations for lower extremity edema (86%), check of the abdomen (88%), as well as neurological exams when warranted (67%) but only 29% had rectal examinations (29%), 14% of men had digital examinations and 4% of women had pelvic examinations. None who were able had a stress cough test. Only 7% of all cases who were able had a post-void residual test (PVR). Slightly more than half (56%) had a urinalysis and two thirds of those who had signs and symptoms of a urinary tract infection (UTI) or had a positive urinalysis had a timely urine for culture and sensitivity.
Treatment of reversible causes of UI was also less than optimal. Only 23% (27/116) of those with reversible causes present at the time of new UI onset had all of them treated in a timely manner. All instances of delirium (n=10), excess fluid intake (n=2), diabetes insipidus (n=1) and caffeine intake (n=1) were treated promptly. Other potential causes that were often treated promptly were new or exacerbated/ increased transfer (97%) or mobility limitations (96%), UTIs (90%), impactions (86%), CHF (77%), environmental barriers to the toilet (71%), physical restraints (56%), anticholinergics (54%), narcotic analgesics (53%) and antipsychotics (50%). Potential causes receiving less attention were were hyperglycemia (42%), venous insufficiency with edema (31%), and a number of potentially precipitating medications including diuretics and antidepressants.
The Guideline suggests that if the type of UI is able to be presumed, PVR is normal and there is no other need for further evaluation, then treatment can be initiated based on the presumed type (stress, urge or mixed UI). The criteria of (1) having a presumed type of UI based on the presence or absence of both stress and urge UI symptoms was rarely met (2%); and (2) having a known normal PVR was also rarely known (3%); resulting in no cases meeting both these criteria. Nonetheless, some new UI treatments were initiated (3%). These treatments were anticholingerics (Ditropan) (2%) and pelvic muscle exercise (0.5%) among those who qualified for these treatments and were not already receiving them. Treatments not utilized were tricyclic antidepressants, estrogen replacement, fluid management, and surgery.
Achievement of continence after the initiation of new treatment/management of UI occurred in only 12 residents (6%) twelve weeks following UI onset. Four percent were due to treatment of reversible causes; 2% were due to a toileting program (scheduled/habit training); and 0.5% were due to urethral dilation.
Conclusions: Overall evaluation/treatment of UI is not evidence-based. Areas of concern are medical providers' low awareness of new UI, attention to reversible causes, rectal/prostate examinations, PVR testing and lack of UI treatment. Barriers to Guideline use include lack of knowledge, awareness and familiarity with the Guideline as well as a lack of resources. Cost of implementing the Guideline appears to be much less than the potential cost savings.
Implications: Improvements in evaluation and treatment of UI in nursing homes are needed. Current research is underway to see if this savings and improved UI outcomes are possible using a focused approach by nurse practitioners to implement the Guideline in nursing homes.
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