1. Hydration Practices and Urinary Incontinence Care Planning
National Content Webinar Series
September 17, 2015
Welcome to today’s content webinar on Hydration Practices and Urinary Incontinence Care Planning for the residents and families we serve. This webinar is part of the Agency for Healthcare Research and Quality’s (or AHRQ’s) Safety Program for Long-Term Care that addresses Healthcare-Associated Infections (or HAIs) and Catheter Associated Urinary Tract Infections (or CAUTI).
This education session was designed specifically for any staff member who works in a long-term care facility. Every team member is important in helping make your long-term care facility a safe place to live and work!

2. Objectives
Upon completion of this training, participants will be able to:
Identify evidence-based practices (EBP) relative to resident hydration and incontinence care planning;
Demonstrate how resident hydration and incontinence care planning practices can reduce indwelling urinary catheter use and CAUTI; and
Demonstrate communication strategies to engagement resident and family members with hydration practice and incontinence care planning.
Upon completion of today’s training, participants will be able to:
Identify evidence-based practices (EBP) relative to resident hydration and incontinence care planning;
Demonstrate how resident hydration and incontinence care planning practices can reduce indwelling urinary catheter use and CAUTI; and
Demonstrate strategies to engage residents and family members with hydration practice and incontinence care planning.
Topic

3. What is Urinary Incontinence (UI)?
Involuntary loss of bladder control
Urinary leakage
Nursing home facilities
Short-term residents: 36.7% report urinary leakage
Long-term residents: 79.3% report urinary leakage
Both women and men can become incontinent from localized tumor/cancer, diabetes, neurological disorders and physical changes associated with aging
Urinary incontinence (UI), also known as 'loss of bladder control' or 'urinary leakage,‘ is the involuntary loss of bladder control. UI can range from a mild bladder leak to uncontrollable wetting.
In a healthy individual, muscles in the walls of the bladder contract, or squeeze, to force urine out through the urethra. At the same time, the muscles around the urethra opening relax to let the urine pass out of the body. When an individual is incontinent the bladder muscles may contract uncontrollably or the muscles around the opening of the urethra may not be strong enough to block the urethra opening.
Urinary incontinence is very common in nursing homes and long-term care facilities. A survey of nursing homes conducted in 2009 found that 36.7% of short-term residents had some level of urinary incontinence and 79.3% of long-term residents had UI.
But both women and men can become incontinent from brain injury, stroke, diabetes, tumors or cancers, multiple sclerosis, and/or physical changes associated with aging. UI is about twice as common in women as in men due to changes that occur as a result of pregnancy, childbirth and menopause.
Images source National Kidney and Urologic Disease Information Clearinghouse, accessed on 9/16/2015.
Gornia et al. June Prevalence of Incontinence Among Older Americans. Vital and Health Statistics. CDC.

4. How Does UI Impact Emotional Well-being?
Reduces social engagement
Lowers participation in other activities
Increases risk of reduced sensory stimulation
Lowers quality of life
Lowers levels of personal care
Urinary incontinence can have a tremendous negative impact on residents’ emotional well being. Research shows that residents with unmanaged urinary incontinence may limit their social engagement and participation in activities and may experience a lower quality of life. Residents with UI may also be at risk for lower levels of personal care and reduced sensory stimulation.
Common urinary incontinence care challenges:
Lack of staff training/education
Lack of staff
CNA retention
Which products to use
Resident and Staff noncompliance
Staff lack enough time incontinence care requires
Cost
Fluid intake
Time for urinary training
Keeping staff up to speed on best practices in the course of their busy day
Initiation of timed voiding schedules to prevent the incontinence
Lack of understanding that it can be prevented
Resident dementia
Establishing proper timing schedules when working with multiple residents at the same time
Assessing and changing absorbent pads frequently enough
Timeliness in catching incontinence
Complications with resident skin rashes and infections
Current policies are impractical in practice
Documentation
Communication of who needs assistance with toileting between shifts
Knowledge and skills of staff regarding proper perenial care

5. Medical Indications for Catheter Insertion
Inappropriate Catheter Use
Urinary incontinence
Immobility
Appropriate Catheter Use
Urinary retention
Bladder outlet obstruction
To assist in healing perineal /sacral wounds
Prolonged immobilization
End of life comfort
Accurate output measurement in the critically ill
Perioperative for selected surgical procedures of the genitourinary tract or long procedures
Unmanaged urinary incontinence can also increase a resident’s risk of getting a catheter-associated urinary tract infection (or CAUTI) because many people mistakenly use catheters to treat urinary incontinence.
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It is important when determining a resident's individual care plan to make sure that they only have a catheter when medically necessary.
Catheters are considered medically necessary if a resident meets one of the following criteria:
Urinary retention
Bladder outlet obstruction
To assist in healing perineal /sacral wounds
Prolonged immobilization
End of life comfort
Accurate output measurement in the critically ill
Perioperative: selected surgical procedures of the genitourinary tract or long procedures
Remember, if a resident does not have a catheter they cannot get at CAUTI.
If you are ever unsure if a resident needs a urinary catheter, talk with a nurse manager or physician to review the resident’s care needs.
Faikh MG et al. AJIC 2014;S223-S229.
Clinical indicators for Catheters (2009):

6. Best Research Evidence
Habit Training Catheter Alternatives for UI: Evidence-based Practice (EBP)
Target group
All
Procedure
Identify resident’s natural voiding pattern
Create an individualized toileting schedule
Outcome
Number of incontinent episodes
Pad change due to incontinence in 24 hours
Comments
Requires early planning, staff buy-in and consistent adherence
Best Research Evidence
Patient Values
Clinical Expertise
EBP
There are many evidence-based strategies for managing urinary incontinence without using an indwelling urinary catheter.
One method is habit training. Habit training is based on a resident’s usual pattern of voiding. This method can be used with any resident struggling with UI. Long-term care facility staff determine a resident's natural voiding habits and record this pattern. Then an individualized toileting schedule is developed based on this information.
Habit training requires early planning efforts, staff buy-in and consistent staff adherence to the voiding care plan. This method requires teamwork and a commitment to supporting the resident’s preferences.
Image concept from Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312:71-72
CMS Manual System. June Department of Health and Human Services (DHHS), Centers for Medicare & Medicaid Services (CMS)

7. Prompted vs. Timed Voiding Catheter Alternatives for UI: Evidence-based Practice (EBP)
Prompted Voiding
Timed Voiding
Target group
Cognitively and/or physically impaired
Procedure
Verbal prompt to ask the residents if they are wet or dry & if they need toilet assistance
Physical assistance to reach the bathroom
Positive reinforcement
Outcome
Self-initiated requests
Number of incontinent episodes
Comments
Labor intensive, requires staff buy-in and consistent adherence
Target group
Residents not capable of independent toileting; usually cognitively impaired
Procedure
Fixed intervals between toileting assistance
Outcome
Number of incontinent episodes
Pad change due to incontinence in 24 hours
Maintenance of skin integrity
Comments
Consider passive toileting assistance programs; requires staff adherence
Prompted voiding is another evidence-based strategy that can be used to help resident’s manage their urinary incontinence (UI). The two essential features of prompted voiding are:
prompting residents to toilet, and
providing positive encouragement when residents request assistance to go to the bathroom and/or void while on the toilet.
Prompted voiding works well with cognitively or physically impaired residents, but it is labor intensive.
Timed voiding is also known as scheduled toileting. Timed voiding works well with residents who are not capable of independent toileting. Timed voiding is based on a pre-determined schedule of voiding, such as voiding every three to four hours. Timed voiding is probably the most frequently used behavioral technique to help residents managed their UI.
Additional Facilitator’s notes
Take a few moments to review the content on this slide. Ask staff to share examples of how each of these methods have been used to support resident’s UI. Identify what works well and any challenges your facility might have with each method.
CMS Manual System. June Department of Health and Human Services (DHHS), Centers for Medicare & Medicaid Services (CMS)

8. Other Catheter Alternatives for UI Evidence-based Practice (EBP)
Treatment Medications
Absorbent Pads
Oxybutynin
Tolterodine
Trospium
Darifenacin
Solifenacin
Fesoterodine
Mainstay for UI containment
Should be based on resident’s needs and preferences
F-tag 315: Should only occur after an appropriate evaluation and after alternatives are considered
Another alternative to using catheters to address UI is medication. Medications, such as the ones listed on this slide, can help residents with urinary incontinence, but also have side effects that could potentially worsen incontinence episodes.
Absorbent pads are a valuable and frequently used method for managing urinary incontinence in LTC settings. There are many products for both men and women, including pads for moderate to heavy leakage and guards for drips. Pads provide protection for clothing and preserve the resident’s dignity and comfort. It is important to remember that every absorbent pad product has its saturation point.
Absorbent pads can also have their disadvantages. Some residents may find absorbent products undignified. Pads can also cause skin breakdown and irritation, be very costly and require a lot of time to check and change them.
It is important when selecting an absorbent pad for a resident to consider the severity of the incontinence, the resident’s gender, how the pad should fit, and ease of use. Remember: The use of absorbent pads should be based on the resident’s needs and preferences, and the use of pads should only occur after an evaluation of other alternatives.
Additional Facilitator’s Notes
Adverse Events caused by UI medications:
Chronic use increases the risk of caries and tooth loss; residents need regular dental care
Class effect: Cognitive impairment (Evidence is insufficient that any agent is “safer” than another for all residents or those with dementia; it is not established that the cognitive risk outweighs the potential treatment benefit).
Do not combine with cholinesterase inhibitors because of lack of efficacy, risk of increased functional impairment.
Long term us of absorbent products: Although many residents have used absorbent products prior to admission to the LTC facility and the use of absorbent products may be appropriate, absorbent products should not be used as the primary long term approach to continence management until the resident has been appropriately evaluated and other alternative approaches have been considered.

9. Urinary incontinence can be significantly impacted by a resident’s hydration status. Too much fluid can put additional pressure on the resident’s bladder, while dehydration can cause bladder irritation, worsening urinary incontinence. So let’s discuss hydration practices that can prevent these issues.
Hydration Practices

10. Dehydration Definition, Causes and Risks
Dehydration = Abnormal depletion of body fluids
Causes
Increased fluid loss due to acute illness, medication, environment
Decreased fluid intake as a result of decreased thirst perception, difficulty swallowing, intentional decrease in intake to prevent incontinence
Residents At Risk for Dehydration
Dehydration is the abnormal depletion of body fluids. Dehydration can either be caused by increasing fluid loss in the body or decreasing fluid intake. Acute illness, resident medications or environmental factors, such as heat, may increase a resident’s fluid loss. Fluid intake may decrease because of decreased sense of thirst, difficulty swallowing or an intentional decrease in intake in order to prevent urinary incontinence.
Many factors can increase a resident’s risk of becoming dehydrated. Some of these risks include, medications a resident may be taking, or functional impairment such as dementia. It is important to pay extra close attention to residents that may experience these risk factors so you can take action to prevent dehydration.
Additional Facilitators Notes
Conditions associated with dehydration include:
Urinary tract infections (UTI)
Pneumonia
Pressure ulcers
Hypotension
Constipation
Depression
Confusion/Disorientation
Functional Decline
Falls
Gastroenteritis
End-stage diseases
Medications
Dysphagia
Restricted diets, enteral nutrition, thick liquids
Communication problems
Medications
Functional impairment (unable to feed self)
Cognitive impairment/Dementia
Chronic diseases (kidney, diabetes, cardiovascular)
Depression
Fever/infection
Vomiting/Diarrhea

11. Signs and Symptoms of Dehydration
Decreased urine output
Hypotension
Constipation
Change in mental status
Tachycardia
Thirsty
Dry, sticky mouth
Tired, feeling weak
There are many common signs and symptoms associated with dehydration. Common signs of dehydration include:
Decreased urine output
Hypotension
Constipation
Change in mental status
Tachycardia
Some common symptoms of dehydration include:
Thirst
Dry-mouth or a sticky mouth, and
A tired or weak feeling
Remember, a change in mental status is also a sign of a CAUTI, but only if this sign is in addition to leukocytosis, or a high level of white blood cells in the urine (i.e., >14,000 cells/mm3 or Left shift (> 6% or 1,500 bands/mm3)). White cells present in the urine cannot rule in a CAUTI; their absence can only help to rule out a CAUTI. It is important that you refer to the signs and symptoms of CAUTI to determine whether or not the change in mental status may be related to another cause.
Change in mental status
Dry Mouth
Hypotension and/or Tachycardia
Constipation and/or Decreased urine output
Tired and/or Feeling weak

12. How to Prevent Dehydration
Involve the dietary and nutrition teams
Provide foods high in water content
Provide liquids before and with meals
Provide liquids between meals and with medication passes
Encourage each resident to drink fluids and offer fluid preferences
Develop targeted care plans to prevent dehydration/re-hydrate
Ensure good mouth care
Track and review fluid intake
There are many simply activities that all facility staff can use to help residents avoid dehydration. Many of these activities involve the management of resident intake of food and water, so involve the dietary and nutrition staff as soon as possible when developing a resident’s care plan. These staff members can provide additional suggestions to help keep residents hydrated, such as serving foods that are high in water content. Some examples of water rich food include:
Lettuce, celery, dill pickles, sauerkraut, watermelon or strawberries (all > 90% water)
Other foods include: Cream of Wheat-87%, canned pears-86%, cottage cheese-79% , and red kidney beans-67%
Staff can make sure that residents have liquids available before, during and after meals, including during medication passes. If residents are struggling to stay hydrated, provide the resident with emotional support and encouragement and make sure you have fluids available that they actually enjoy drinking. Finally, develop individual, targeted care plans to prevent dehydration and help rehydrate residents.
Additional Facilitator's Notes
USDA National Nutrient Database:
American Dietetic Association:

13. Strategies to Improve UI and Hydration Management at Your Facility
Assess residents at risk for dehydration and urinary incontinence
Include hydration as a topic in safety discussions
Engage residents, families and volunteers to support hydration and incontinence care planning and activities
Celebrate often and serve refreshments to residents!
Hydration management depends on good communication and teamwork among all staff. Think about how you can support each other – and the resident – by sharing information to assess which residents may be at risk for dehydration and UI. It is especially important to share information during handoffs at shift change and team huddles so everyone on the team is aware of the opportunities to help residents stay hydrated or remain on their individualized incontinence plan.
During safety huddles or meetings, make hydration and UI planning a safety topic. Remember, your efforts as a team to prevent dehydration and to safely manage UI can help prevent UTIs and other problems. If you are concerned about a resident who may be dehydrated or whose UI plan may not being followed, use the TeamSTEPPS CUS or Two-Challenge Rule. These strategies help you communicate to other team members that you are concerned there may be a resident safety issue surrounding the resident’s UI or fluid management.
Engage residents and their family members in all activities designed to manage UI and prevent dehydration. The resident and family are part of the team so share information and encourage them to be active members in the plan of care.
An easy way to increase hydration is to celebrate and serve refreshments. Social interaction can be a great time to encourage fluid intake and recognize the efforts of all team members.
Additional Facilitators Notes
Additional Urinary Incontinence and Hydration Care Strategies
Incontinence Care Management Strategies:
Trial Voiding Program
Some facilities have implemented a watch that has alarms at specific intervals to prompt residents to toilet
One facility has used music and movement therapy. Residents are trained to do Kegel muscle exercise while listening to music. In some instances residents have converted from incontinence to continence.
Hydration Care Practices
Activities during the day with different fluids
Resident/family education about dehydration
Educate staff about the importance of hydration
Hydration stations and/or hydration carts
Snack carts
Include juices and a variety of drinks
Make them brightly colored
Flavored water
Water by bedside
Water passes during each shift and with med pass
Serve watermelon, smoothies, popsicles and sno cones
Smoothie parties
Happy hour
Passing snacks and drinks
Water dispenser in all day room
Multiple areas where fluids are provided
Daily "Juice for the Spirit" for all residents
For residents that prefer other beverages, keep extras in their room/refrigerator
Kitchen provides thickened liquids to each unit for residents who require thickened liquids to promote hydration
Encourage increased water intake during the day
Encourage staff to pass fluids in a timely matter
Ensure staff go into the rooms and offer fluids on a regular basis for residents who cannot get out of bed
Have a sunshine aide that passes a cart with different drinks throughout the facility
Both
Have family help with offering hydration and voiding while they are visiting
Encourages families to bring in beverages
Document hydration and incontinence care as part of daily rounding activities
Use data and evidence to help engage administration and leadership
Make hydration and incontinence care a part of each resident's individual care plan
During shift changes communicate about residents’ hydration and incontinence status
Share residents’ hydration and incontinence status during team/unit huddles
Make it a point to toilet residents prior to activities or visiting with families
Use intentional rounding; consider using a checklist

14. Stay Updated with Useful Resources
Learn From Defects Tool
National Content Webinar: Training LTC Facility Staff on Catheter Insertion & Maintenance to Prevent CAUTIs
Bowel and Bladder Elimination Toolkit – Mountain-Pacific Quality Health
As we wrap up today’s discussion, I’d like to thank you for participating in this education session. We need everyone’s help to reduce HAIs and CAUTIs in long-term care facilities. The following resources are available to you as participants in the AHRQ Safety Program for Long-term Care: HAIs/CAUTI project. We hope these resources will help you support your facility’s goals to reduce CAUTIs and HAIs and improve your culture of safety.
Thank you and have a great day.
Additional Facilitator Notes
Resources:
The first resource is a link to the AHRQ Safety Program for Long-term Care: HAIs/CAUTI project website. On the website you will find a variety of tools to help you prevent CAUTIs and improve your facility’s culture of safety.
The second resource is a link to the TeamSTEPPS for Long-term Care web page. TeamSTEPPS is a communication and teamwork system that offers solutions to improving collaboration and communication within health care facilities. The resources on this page are specifically designed for the long-term care environment.
The third resource is a link to the Learn From Defects Tool.
The fourth resource is a link to the June National Content Webinar on Catheter Care and Maintenance.
The final resources is a link to the Bowel and Bladder Elimination Toolkit developed by Mountain Pacific Quality Health.

15. References
Centers for Disease Control and Prevention. Healthcare Infection Control Practices Advisory Committee (HICPAC) approved guidelines for the Prevention of catheter-associated urinary tract infections, Available at Centers for Disease Control and Prevention. Identifying Healthcare-associated Infections (HAI) for NHSN Surveillance (online). Accessible at: Clinical indicators for Catheters (2009): Faikh MG et al. AJIC 2014;S223-S229 Gornia et al. June Prevalence of Incontinence Among Older Americans. Vital and Health Statistics. CDC. National Healthcare Safety Network (NHSN). Long-term Care Facility (LTCF) Component Healthcare Associated Infection Surveillance Module: UTI Event Reporting [online]. Prompted Voiding for Management of Urinary Incontinence Among Older Adults. Annals of Long-Term Care. Ouslander JG, Schnelle JF, Uman G, et al. Predictors of successful prompted voiding among incontinent nursing home residents. JAMA. 1995;273:1366–137. Stone ND, Ashraf MS, Calder J. Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria. Infect Control Hosp Epidemiol 2012;33(10):