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Incontinence Care Guidelines

The Centers for Medicare & Medicaid Services (CMS) has developed revised guidance for incontinence and catheters. This new guidance includes expanded guidelines for care (summarized below), as well as a new Investigative Protocol and compliance and severity guidance. The comprehensive Surveyor Guidance will be issued to state surveyors with an implementation date of June 27, 2005, and they are preparing to use it in their inspections.

Urinary Incontinence

Regulations require that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible.

The first steps toward ensuring a resident receives appropriate treatment and services to restore as much bladder function as possible or to manage the incontinence are to identify the resident already experiencing some level of incontinence and to complete an accurate, thorough assessment of factors that may predispose the resident to having urinary incontinence.

Assessment

Factors contributing to urinary incontinence may be resolved after a careful examination and review of history. A resident should be evaluated at admission and whenever there is a change in cognition, physical ability, or urinary tract function. This evaluation should include identification of individuals with reversible and irreversible (e.g., bladder tumors and spinal cord disease) causes of incontinence.

It is important that staff, when completing the completing the comprehensive assessment, consider the following:

  • Prior history of urinary incontinence
  • Voiding patterns
  • Medication review
  • Patterns of fluid intake, such as amounts, time of day, and alterations and potential complications, such as decreased or increased urine output
  • Environmental factors and assistive devices that may restrict or facilitate a resident’s ability to access the toilet
  • Other factors that may be relevant

Types of Urinary Incontinence

Identifying the cause of the incontinence is a key aspect of the assessment and helps identify the appropriate program/interventions to address incontinence.

  • Urge Incontinence is characterized by abrupt urgency, frequency, and nocturia (part of the overactive bladder diagnosis).
  • Stress Incontinence is the loss of a small amount of urine with physical activity such as coughing, sneezing, laughing, walking stairs or lifting.
  • Mixed Incontinence is the combination of urge incontinence and stress incontinence
  • Overflow Incontinence occurs when the bladder is distended from urine retention.
  • Functional Incontinence refers to incontinence that is secondary to factors other than inherently abnormal urinary tract function.
  • Transient Incontinence refers to temporary or occasional incontinence that may be related to a variety of causes.

Interventions

The facility must follow the care process (accurate assessment, care planning, consistent implementation and monitoring of the care plan with evaluation of the effectiveness of the interventions, and revision, as appropriate). Recording and evaluating specific information (such as frequency and times of incontinence and toileting and response to specific interventions) is important for determining progress, changes, or decline.

Facility practices that promote achieving the highest practicable level of functioning, may prevent or minimize a decline or lack of improvement in degree of continence. Such as:

  • Managing pain or providing adaptive equipment, or both, to improve function for residents suffering from various conditions.
  • Removing or improving environmental impediments that affect the resident’s level of continence
  • Treating underlying conditions that can negatively impact the degree of continence
  • Possibly adjusting medications affecting continence
  • Implementing a fluid, or bowel management program, or both, to meet the assessed needs.

Types of Interventions

Behavioral Programs

Behavioral program interventions are among the least invasive approaches to address urinary incontinence and have no known adverse complications. Behavior programs involve efforts to modify the resident’s behavior, environment, or both.

Intermittent Catheterization

Sterile insertion and removal of a catheter through the urethra every 3 to 6 hours for bladder drainage may be appropriate for managing acute or chronic urinary retention.

Medication Therapy

Medications are often used to treat specific types of incontinence, including stress incontinence and those categories associated with an overactive bladder.

Pessary

A pessary is an intra-vaginal device used to treat pelvic muscle relaxation or prolapse of pelvic organs.

Absorbent Products, Toileting Devices, and External Collection Devices

Absorbent incontinence products include perineal pads or panty liners for slight leakage, undergarments and protective underwear for moderate to heavy leakage, guards and drip collection pouches for men, and products (called adult briefs) for moderate or heavy loss. Advantages of using absorbent products to manage urinary incontinence include the ability to contain urine (some may wick the urine away from the skin), provide protections for clothing, and preserve the resident's dignity and comfort. Factors contributing to the selection of the type of product to be used should include the severity of incontinence, gender, fit and ease of use.

Catheterization

Regulations require that a resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary. Some residents are admitted to the facility with indwelling catheters that were placed elsewhere (e.g., during a recent acute hospitalization). The facility is responsible for either assessing the resident at risk for urinary catheterization or who currently has a catheter. This is followed by implementation of appropriate individualized interventions and monitoring for the interventions’ effectiveness.

Assessment

A resident may be admitted to the facility with or without an indwelling urinary catheter and may be continent or incontinent or urine. Regardless of the admission status, a comprehensive assessment should address those factors that predispose the resident to the development of urinary incontinence and the use of an indwelling urinary catheter.

Intermittent Catheterization

Intermittent catheterization can often manage overflow incontinence effectively. Residents who have new onset incontinence from a transient, hypotonic/atonic bladder (usually seen following indwelling catheterization in the hospital) may benefit from intermittent bladder catheterization until the bladder tone returns.

Indwelling Catheter Use

The facility's documented assessment and staff's approach to the resident should be based on evidence to support the use of an indwelling catheter. Appropriate indications for continuing use of an indwelling catheter beyond 14 days may include urinary retention that cannot be treated or corrected medically or surgically and for which alternative therapy is not feasible. This is characterized by:

  1. Documented post void residual volumes in a range over 200 milliliters (ml)
  2. Inability to manage the retention/incontinence with intermittent catheterization
  3. Persistent overflow incontinence, symptomatic infections, or renal dysfunction, or all three.
Catheter-Related Complications

An indwelling catheter may be associated with significant complication, including bacteremia, bladder stones, fistula formation, epididymitis, and chronic renal inflammation. In addition, indwelling catheters are prone to blockage. If there is no evidence of blockage, catheters need not be changed routinely as long as monitoring is adequate. Based on the resident’s individualized assessment, the catheter may need to be changed more or less often than every 30 days.

The full copy of this guidance can be found at http://www.cms.hhs.gov/medicaid/survey-cert/sc0523.pdf