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he correct management of incontinence in the post-acute care environment is very important and, at times, a complex operational and clinical issue. The first step in this process is the proper assessment of and planning for the resident with any level of incontinence. This approach is supported by the new material in the Minimum Data Set (MDS) 2.0 manual, which clearly defines incontinence as the involuntary loss of any amount of urine. With this definitional material driving the MDS database, additional residents in long-term care will be identified as being incontinent. Higher numbers of residents identified as incontinent will stimulate the need for more interventions, scheduled toileting programs, and retraining programs as well as increased scrutiny by regulators of incontinence product types and sizes being utilized. The focus on Federal Tag 315 (Tag F315), which is related to incontinence, increases the survey activity and statistical scrutiny of facilities in this area. The use of a variety of products to assist with the management and care of these residents will be necessary. Successful programs will focus on the types of incontinence and, for some residents, a variety of interventions will be appropriate to include in the care plan.
       This management process combines the skills and knowledge of the clinical staff and management staff. One of the most important components of this process is having a variety of types and sizes of products available for the staff to use with the residents. Many companies that provide products to facilities do not offer adequate varieties of products or sizing options. Therefore, in addition to having quality educational materials to establish effective bladder and bowel training programs, facilities need educational materials for direct care staff relating to the types of products and the correct sizing of the products. Correct sizing and product-type use are important for all levels of staff to understand. The education of the staff begins with an understanding of the issues related to incontinence, the interventions available, and the outcomes possible for a wide variety of clinical situations. Care plans could direct the use of a variety of products at different times of the day for the same resident. Each product necessary for the resident must be sized properly and available to the staff and/or the resident. Care cards or assignments must be specific to the size and type of product and time of day.
       Sizing of products must be related to product type and specific measurements for the resident. General measurements like weight can be helpful, but the specific fit of the product needs to be checked at the beginning of use to confirm that the size is appropriate. Frequently, sizes need to be adjusted because of the size of the abdomen or the thighs when a brief is being used. If a careful assessment of product type and size is done before product use is initiated, the proper product will be acquired for the resident, and the assignment will indicate when it should be used. Educational programs for professionals and direct care staff must include physical assessment, identification of the type of incontinence, measurements of weight and specific body parts, and risk issues unique to the resident’s care plan. Caregivers must get rid of the one-size-fits-all and one-product-for-all mentalities. Incontinence management is a very resident-specific process and frequently requires a variety of interventions for successful outcomes.
       The decision to purchase products to manage incontinence is often made by purchasing departments with minimal input from the clinical staff; as a result, educational programs and multiple product sizes are secondary to price. The most important considerations in this decision should be the construct and efficiency of the product as well as the variety of products and sizes available. In addition to bladder retraining programs and scheduled toileting plans, high-quality incontinence management programs should offer a variety of products and sizes.

The Problem

       In my experience, facilities often purchase a single type of an incontinence product and do not provide directions on the care plan that indicate which size to use and the time of day to use the product. As I look at the body size and weight of many of the residents in post-acute care service units, I see very small people—predominantly females with varying levels of continence and mobility. Some of these residents may benefit from the use of pads or panty liners. Residents with mild levels of stress or postural incontinence could be managed with pads during the day and briefs during the night if the residents’ needs dictate. However, it is usually difficult to find pads for the residents. When I ask about pads or panty liners, I am usually told that the facility uses briefs or nothing. On top of that, when I look for the briefs that are available, I find mostly large- and extra-large-sized products in the storage areas and resident rooms. And the staff wonders why they experience leakage, excoriation, and poor outcomes.
       I will never forget the day I found an exasperated resident standing in the door of her room with her brief around her ankles asking for assistance. I wanted to cry out, “What is happening here? How about dignity? How about risk management? How about quality of care?” In this situation, the staff had used the only product available in the patient’s room, which was an extra- large-sized brief. The resident was very thin, approximately 90 lbs. We looked for a small- or medium-sized product but found none. We found some large-sized products in the utility room, but they were still too large. This resident was ambulatory, but with another risky event like we just witnessed, she could have easily fallen and injured herself.

The Solution

       Product choice and sizing are very important. Clinical staffs leaders need to make their needs (eg, range of products, range of sizes, and the quality or absorbency of the products) known to the purchasing staff. The first consideration in product selection is the ability of the product to absorb urine and protect the skin. Not all products are the same. Look for a product line that has quality absorbency as well as features that will protect the skin. The key words here are wicking, construction, and pH control. Have a variety of product demonstrations and trial products in your facility before you decide on a vendor. The evaluation of the product by your direct care staff is very important, as are the outcomes of the product use. Staff members can evaluate not only the ease of application and removal but also the specific fit for a variety of residents.
       Educational programs to support your clinical program and outcomes tracking are essential parts of the service that the vendor should provide. The educational programs the vendor provides should support clinical activities in the facility related to proper data collection, assessments, and connection to the MDS process definitions and requirements. Direct caregivers need quality educational programs and orientation programs to supplement their knowledge about the types of incontinence, types of products available, and the sizing of these products. The proper documentation of intake and output as well as skin integrity and risk issues are very important for all clinical staff and should be supported by the vendor in concert with the policies and procedures in the facility. A variety of in-service sessions should be conducted to train the staff on sizing techniques as well as periodic quality assurance activities to evaluate that the proper sizes and types of products are being utilized.

Conclusion

       There are many factors to consider when selecting incontinence products and a vendor. The needs of your residents are central to this process as well as cost and the quality of the products. Education for your staff should be a part of the process, not only to promote correct product use (eg, sizing and product selection) but also to build an understanding of the issues related to continence and associated care delivery. Products should keep the residents’ skin dry, maintain a healthy pH of the skin, and not interfere with quality of life or add risk. Additionally, products that protect the residents’ skin through multiple voidings are very helpful at night so that residents can sleep through the night without interruption.
       Correct product use should be the basis for cost analysis. Variety of products available is an increasing focus in purchasing because of the need for these products as we establish care plans focused on the independence of the resident and the growing number of persons identified with issues of incontinence. The cost of the product is important in the decision-making process but not the pivotal point. Product quality and outcomes for the residents should be the primary concern. This requires a combined effort and understanding of the clinical, financial, and administrative staff to find the best product for residents and facility operations.

       Editor’s note: This article was adapted from an article, “The Importance of Properly Sizing Incontinence Products,” published in the March 2004 issue of ECPN.