Implementation Science in Nursing Homes: A Case Study of the Integration of Bladder Ultrasound Scanners

Abstract: This report presents qualitative and descriptive findings of a 14-month study of four nursing homes in collaboration with a Midwestern university that implemented the use of bladder ultrasound scanning technology in their facilities. Knowledge and attitudes of nursing home staff and residents about urinary incontinence, as well as the challenges involved with implementing bladder scanning technology into routine practice, were assessed, and feedback about its integration was collected. Within the context of this case study, the authors discuss implementation science alongside four major constructs necessary for the incorporation of new technology and evidence-based research into established practice. The cost impact of new technology integration should be addressed in order to arrive at strategies for optimizing health-related quality-of-life outcomes for residents in the nursing home setting.

Key words: Implementation science, evidence-based research, urinary incontinence, bladder ultrasound scanner, nursing home

Citation: Annals of Long-Term Care: Clinical Care and Aging. 2015;23(6):21-26.
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Bladder dysfunction and urinary incontinence (UI) are a significant occurrence in nursing homes. The prevalence of UI is estimated to be between 45% and 70% for residents of long-term care.¹ Bladder ultrasound scanners can accurately detect urinary volume and retention with lower risk of infection and less discomfort compared with catheterization.^2-6 However, despite evidence-based research demonstrating the benefits of bladder ultrasound scanners, nursing homes have been slow to adopt this technology.

Literature Review
Healthcare integration of evidence-based research leads to improved quality of life. However, the healthcare industry often poorly translates this research into practice.^7,8 As a result, implementation science (IS) in healthcare is gaining attention as a discipline. The Diffusion of Innovation (DOI) theory and the Technology Acceptance Model (TAM) provide the foundation for understanding IS.

The DOI theory sets a standard for studying how new technologies are adopted. The DOI innovation-decision process includes stages of knowledge, persuasion, decision-making, implementation, and confirmation.⁹ The persuasion stage describes how perceptions of innovations can contribute to adoption of new models of care. Rogers identified five significant attributes of an innovation that affect an individual’s perception: relative advantage, compatibility, complexity, trialability, and observability.⁹

The TAM describes how users accept and adopt technology.¹⁰ TAM emphasizes two key principles that determine acceptance of a new technology: perceived usefulness (ie, the extent to which the user believes the technology will improve personal performance) and perceived ease of use (ie, the degree to which the user believes the technology will be effort-free).¹¹ Lee and colleagues¹⁰ constructed a theoretical framework blending key components of the DOI theory and TAM variables and discovered that Rogers’ five attributes were determinants of perceived usefulness and perceived ease of use. Components of DOI and TAM can be used to guide researchers and practitioners in technology implementation in nursing homes.

The Centers for Medicare and Medicaid Services (CMS) instituted F-tag 315, which requires assessment of nursing home residents with UI. Evaluation of post-void residual volume (PVR) is recommended for residents with bladder disorders to detect urinary retention,⁴ a potential cause of UI and urinary tract infection (UTI).¹² Two methods for accurately assessing PVR include catheterization and use of a bladder ultrasound scanner. Evidence-based research has deemed the bladder ultrasound scanner an essential element of PVR assessment and treatment of UI,¹³ just as accurate as catheterization in PVR measurement^2,3,5 and effective in reducing occurrences of catheter-associated UTI (CAUTI).

Although bladder catheterization is considered the “gold standard” for bladder volume assessment and detection of urinary retention,^2,14,15 bladder catheterization can lead to infection and tissue injury.¹⁴ CAUTI is the most common nosocomial infection in the United States and accounts for more than 1 million cases in acute care facilities and nursing homes each year.¹⁶ Urinary catheter use has also been found to have a direct association with morbidity and mortality among elderly residents in nursing homes.¹⁷ Because of the prevalence of CAUTIs and this devastating safety concern, CMS no longer reimburses hospitals for expenses related to preventable CAUTIs.¹⁸

In addition to the negative effects experienced by residents, substantial costs are incurred by the nursing home with each incidence of UTI.¹⁵ One facility attempted to reduce expenses related to unnecessary catheterizations and the resultant CAUTIs by educating staff on UI and implementing a bladder ultrasound program. Their experiment resulted in the avoidance of 1392 catheterizations during the first year.¹³ The number of avoided catheterizations was directly related to the integration of the bladder ultrasound scanner and was associated with a cost savings of $2,784 in catheter supplies. In this study, a first-year cost savings of $45,900 related to prevented UTIs and associated treatment expenditures was also noted.¹³ In a similar study, researchers documented $2,886 in cost savings in catheter supplies over 1 year and concluded that the cost of the bladder ultrasound scanner would be recovered in 2.9 years.¹⁹ These studies support the integration of bladder scanning in evaluation of urinary volume for its potential to reduce the number of invasive catheterizations, resulting in reduced CAUTIs and associated catheter supplies and expenses.

In addition to these key cost outcomes, use of a bladder scanner may reduce costs associated with human resources.¹⁹ Measurement of bladder volume by ultrasound typically requires less than 2 minutes for nursing staff to perform. By contrast, urinary catheterization requires between 7 to 16 minutes.⁵ Additionally, labor costs are calculated differently for each procedure. An ultrasound bladder scan can be performed by a certified nursing assistant (CNA), whereas catheterization requires a licensed practical nurse (LPN) or registered nurse (RN).¹⁴ Finally, it should be noted that the cost of a bladder ultrasound scanner and rolling cart as reported by a leading US distributor of scanners is just above $14,500, with no lease option available (Emily Taylor, BS, email communication, December 2014).

Evidence from the literature supports the use of bladder ultrasound scans for determining PVR urine amounts.^1,4,12,20,21 However, the evidence also demonstrates that access to this technology in nursing homes is limited.^6,15,22

Methods
To examine the benefits, challenges, and costs associated with implementation of bladder ultrasound scanners into the nursing home setting, a Midwestern university collaborated with four nursing homes to integrate this technology into their facilities. The study grant provided bladder ultrasound scanners for each nursing home that took part in the 14-month study. Institutional Review Board approval was attained, as well as informed consent from facility staff, residents, and responsible parties. Codes were assigned to maintain anonymity, and data were collected for aggregate purposes only. Knowledge and attitudes of nursing home staff and residents about UI were assessed through pre- and post-intervention surveys and patient questionnaires.

Results
Integration of Bladder Ultrasound Scanners in Nursing Homes
Nine Bladder Ultrasound Scanner Basics in-service sessions were held in four nursing homes prior to data collection. Employees were first given the Staff Satisfaction and Incontinence Knowledge Survey to complete. Upon completion of the survey, a project overview was provided. Then, an evidence-based education component was shared with the staff related to UI care in a long-term care setting. After discussing when and whom to scan, the mechanics of using the bladder ultrasound scanner were introduced, including demonstration of the equipment. Employees attending this in-service received hands-on scanner training. Members of the project team worked with the nursing home staff to ensure they met the nine competencies for the initial assessment as outlined in Figure 1. The cost of this initial 1-hour in-service session is estimated at just under $800 and includes staff time for 4 RNs, 7 LPNs, and 23 CNAs, plus consultant/trainer fees and supplies. In this particular study, the consulting fees and supplies were grant-funded.

The project team also developed and implemented tools to aid in the continued utilization of the scanner beyond the initial in-service session. These tools included: (1) evidence-based scanner protocol; (2) scan results communication form; (3) laminated instruction card attached to each scanner; (4) pocket reference for nursing home staff including scanning protocol and procedure, as outlined in Figure 2; and (5) educational DVD for the staff.

Midway through the project, staff members attended an interactive refresher in-service session called “Bladder Jeopardy,” similar to the TV game show, Jeopardy, which was designed to reinforce concepts learned in the initial in-service session. A total of eight refresher in-service sessions were held across the four nursing homes.

Feedback from staff and administrators was requested at various time points throughout the study. Customized interventions were developed mid-study in response to feedback regarding barriers to utilization of scanners in the facilities. In response to specific suggestions from staff, cue cards were created to prompt greater utilization of the scanner, and an incentive program was developed to further increase use among employees. Lastly, handouts and posters, including basic facts about UI, were created and displayed in staff break rooms.

Aggregate scanner utilization data were collected 3 times over the course of 39 weeks. An increase was noted in the number of scans performed mid-study in 3 of the 4 nursing homes, which may have been related to initiation of the incentive program. However, after Week 30, utilization data across the four nursing homes were inconsistent.

Staff Knowledge
Nursing home staff completed surveys assessing their knowledge and attitudes about UI at pretest baseline and after 17 weeks post-implementation. The survey consisted of five items related to UI knowledge, including incontinence normalcy, incontinence prevalence, invasiveness of the bladder scanner procedure, indications for scanner use, and the relationship between fluid intake and incontinence.²²

At pretest, Fisher’s Exact Test showed the percentage of correct responses differed significantly (P<.05) by staff position between CNAs (n=33), LPNs (n=58), and RNs (n=16) when answering yes or no to: bladder disorders are a normal part of aging (18%, 50%, and 62.5% respectively), performing a bladder scan is an invasive procedure (67.7%, 90.9%, and 93.8% respectively), decreasing daily fluid intake can prevent episodes of urinary incontinence (67.7%, 94.5%, and 100% respectively). McNemar test results at posttest identified significant (P<.05) increases among all staff (N=46) in knowledge that bladder disorders are not a normal part of aging, knowledge to assess and treat UI, and confidence in helping residents with UI.²²

Patient Perspectives
Of the nursing home residents experiencing UI, 34 completed the validated 40-item Incontinence Stress Questionnaire – Patient (ISQ-P) that was designed for them^23,24 before placement of the bladder ultrasound scanner in the facilities and at approximately 12 weeks post-implementation. No significant change in residents’ perceived health-related quality of life was observed, but residents’ responses reflected an increased willingness to discuss UI. Of the respondents, 71% reported feeling anxious some or all of the time because of their UI. “Disgusted with self,” “helpless,” “irritable,” and “embarrassed” were also reported by 62%, 58%, 58%, and 56% respectively. At pretest, 61% of respondents reported being able to discuss incontinence with others (ie, ability to discuss UI some, half, most, or all of the time). Twelve weeks later, 87% of respondents reported feeling able to discuss incontinence. The psychologically damaging feelings residents reported are consistent with other reports in the literature.^23-29

Researchers also recorded voluntary qualitative responses from residents about their UI experiences. Comments such as “I don’t talk about it much,” “I don’t want to see it or anybody else to see it,” “Not too many people like talking about that,” and “I never had [talked about UI], but [with] you” were recorded. Comments shared by residents in response to the ISQ-P statement, I cry when I think or talk about incontinence, such as “I do it [cry] softly” and “[I cry] inside, while I’m alone,” express the suffering, isolation, and emotional toll resulting from UI.

Qualitative Feedback From Nursing Home Staff and Leadership
Researchers gathered qualitative data regarding barriers to scanner utilization from nursing home staff (n=58) at multiple time points and grouped responses into three categories: (1) “not in job description”; (2) “not trained to use bladder scanner”; and (3) “too little time.” When researchers requested suggestions to improve scanner utilization, 3 categories emerged: (1) continued training and education; (2) access to a scanner at each unit; and (3) continued use of reminders (ie, posters/signs) to use the scanner. Feedback from nursing home administrators (n=8) included concerns about: (1) staff turnover; (2) state visits during implementation; (3) location of scanner; (4) training schedules; (5) delays in post-training implementation; (6) time and staffing; and (7) process once the scan is performed.

Adaptation of Interventions and Innovative Approaches to Improve Quality of Nursing Home Care
Four major constructs are considered when evaluating IS in nursing homes: (1) education; (2) process; (3) culture; and (4) cost. Staff education can be linked to the perceived usefulness of new technology, which is a factor in the innovation-decision process. In this study, varying levels of knowledge based on the credentials of RNs, LPNs, and CNAs were found to have a direct impact on staff attitudes and knowledge related to UI.22 This gap ultimately leads to lack of appropriate recommendations for treatment of residents with UI. Staff may be less likely to pursue UI treatments if they believe bladder disorders are a normal part of aging or if they are not satisfied with or confident in their knowledge of assessing or treating UI. When integrating bladder ultrasound scanners into nursing homes, consideration should be made for the varying levels of education among staff involved in UI care. Additional educational time and training should be provided to CNAs as “first-line managers” of incontinence.^30,31 As a result, staff may feel encouraged by their new UI knowledge and increased mastery of UI evaluation and treatment, resulting in more positive patient outcomes.¹⁵

Comments from administrators indicated location and accessibility of the scanner directly impacted utilization and may have had an effect on a staff member’s perceived ease of use. Complexity correlates negatively with rate of adoption,⁹ and a “keep-it-simple” approach may result in a more successful implementation with greater chance of the intervention being adopted and sustained.³² This study identified success with “keep-it-simple” strategies such as cue cards, incentives, handouts, posters, and quick-reference instruction cards.

Organizational attitude and culture, implementation of evidence-based research,³³ and awareness education are required for staff to recognize the rationale for adopting an intervention.³⁴ Staff who used the bladder ultrasound scanner recognized the relative advantage and perceived usefulness of the technology and felt it had a direct, positive impact on their ability to assess and treat UI. However, whereas researchers identified that some staff believed they could play a part in improving UI in nursing homes, survey data indicated that many staff erroneously believed UI to be a natural part of aging.²² Therefore, the researchers support an assessment of nursing home culture and staff attitude toward UI or any integration of evidence-based research, prior to initiating educational programs and new technology. Nursing home administrators can assist with shifting culture to accept the intervention as an integral part of resident care. Successful IS may be dependent upon the provision of adequate time for educational and related support to promote positive attitudinal shifts in care practices before new technology and evidence-based research are integrated into the practice setting.

Discussion
A review of implementation costs and associated benefits should be conducted prior to integrating bladder ultrasound scanner technology in the nursing home. First, evaluation of the number of yearly catheterizations, number of times a measurement of bladder volume is required, time required for catheterizations, associated labor and supply costs, UTI rates, as well as medication and treatment expenses is recommended. These data should be compared with costs associated with ultrasound, including the number of times a bladder volume assessment is required, scanning time, and related labor costs. Cost savings should then be compared against the cost of purchasing and implementing the scanner into practice.¹⁵

It has been reported that the cost of a bladder ultrasound scanner can be recovered in under 3 years through savings from reduced catheterization supplies.¹⁹ This cost benefit does not take into account prevented CAUTIs, nor does it factor the emotional toll unnecessary catheterizations may have on residents. Based on this case study, the researchers find that in order for a nursing home to experience the cost benefits of integrating a bladder ultrasound scanner, the staff members first need to be educated about UI and accepting of the fact that UI is a dysfunction that is not a normal part of aging.²²

This study uncovered a compelling piece of nursing home culture, the resident voice. Awareness of the resident experience may serve to persuade and drive openness to innovation by nursing home staff. The resident voice also provides grounds for perceived usefulness by staff and administrators,¹⁰ who make decisions about utilization of new technology. Lastly, relative advantage⁹ is enhanced when staff can add an empathic appreciation of why it is necessary and beneficial to enhance residents’ quality of life.

Conclusion
Data gathered from this case study should serve to help researchers and practitioners better understand integration of evidence-based research and technology into nursing homes and begin to fill a gap in the literature as pertains to IS in nursing homes. A focus should be maintained on education, process, culture, and cost when integrating new technology or evidence-based research into nursing home settings, while ensuring that residents are given a greater voice in their care.
 
References
1.    Lekan-Rutledge D. Urinary incontinence strategies for frail elderly women. Urol Nurs. 2004;24(4):281-283, 287-301.

2.    Coombes GM, Millard RJ. The accuracy of portable ultrasound scanning in the measurement of residual urine volume. J Urol. 1994;152(6 Pt 1):2083-2085.

3.    Marks LS, Dorey FJ, Macairan ML, Park C, deKernion, JB. Three-dimensional ultrasound device for rapid determination of bladder volume. Urology. 1997;50(3):341-348.

4.    Newman DK, Gaines T, Snare E. Innovation in bladder assessment: use of technology in extended care. J Gerontol Nurs. 2005;31(12):33-41.

5.    Teng CH, Huang YH, Kuo BJ, Bih LI. Application of portable ultrasound scanners in the measurement of post-void residual urine. J Nurs Res. 2005;13(3):216-224.

6.    Tracey R. Bladder ultrasound reduces catheterizations. Advance for Imaging and Oncology Administrators. 2001;14(10)1-2.

7.    Eccles MP, Mittman BS. Welcome to Implementation Science. Implement Sci. 2006;1:1.

8.    Glasgow RE, Vinson C, Chambers D, Khoury MJ, Kaplan RM, Hunter C. National Institutes of Health approaches to dissemination and implementation science: current and future directions. Am J Public Health. 2012;102(7):1274-1281.

9.    Rogers E. Diffusion of Innovations. 5th Ed. New York, NY: Free Press; 2003.

10.    Lee YH, Hsieh YC, Hsu CN. Adding innovation diffusion theory to the technology acceptance model: supporting employees’ intentions to use e-learning systems. Educ Technol Soc. 2011;14(4):124-137.

11.    Davis FD. Perceived usefulness, perceived ease of use, and user acceptance of information technology. MIS Quarterly. 1989;13(3):319-340.

12.    Sparks A, Boyer D, Gambrel A, et al. The clinical benefits of the bladder scanner: a research synthesis. J Nurs Care Qual. 2004;19(3):188-192.

13.    Phillips J. Integrating bladder ultrasound into a urinary tract infection-reduction project. Am J Nurs. 2000;1:3-15.

14.    Stevens E. Bladder ultrasound: avoiding unnecessary catheterizations. Medsurg Nurs. 2005;14(4):249-253.

15.    Wooldridge L. Ultrasound technology and bladder dysfunction. Am J Nurs. 2000;100(6):3-14.

16.    Tambyah PA, Knasinski V, Maki DG. The direct costs of nosocomial catheter-associated urinary tract infection in the era of managed care. Infect Control Hosp Epidemiol. 2002;23(1):27-31.

17.    Kunin CM, Douthitt S, Dancing J, Anderson J, Moeschberger M. The association between the use of urinary catheters and morbidity and mortality among elderly patients in nursing homes. Am J Epidemiol. 1992;135(3):291-301.

18.    Centers for Medicare and Medicaid Services (CMS). Fact sheets: CMS final rule to improve quality of care during hospital inpatient stays. CMS website. https://www.cms.gov/newsroom/mediareleasedatabase/fact-sheets/2013-fact-sheets-items/2013-08-02-3.html. Published August 2013; accessed May 17, 2015.

19.    Frederickson M, Neitzel JJ, Miller EH, Reuter S, Graner T, Heller J. The implementation of bedside bladder ultrasound technology: effects on patient and cost postoperative outcomes in tertiary care. Orthop Nurs. 2000;19(3):79-87.

20.    Centers for Medicare and Medicaid Services (CMS). CMS Manual System – Pub. 100-07 State Operations Provider Certification. CMS website. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R22SOMA.pdf. Published December 15, 2006; accessed May 17, 2015.

21.    McCliment JK. Non-invasive method overcomes incontinence. Program retrains residents to recognize the urge to void. Contemp Longterm Care. 2002;25(5):15.

22.    Ehlman K, Wilson A, Dugger R, Eggleston B, Coudret N, Mathis S. Nursing home staff members’ attitudes and knowledge about urinary incontinence: the impact of technology and training. Urol Nurs. 2012;32(4):205-213.

23.    Yu LC. Incontinence Stress Index: measuring psychological impact. J Gerontol Nurs. 1987;13(7):18-25.

24.    Yu LC, Kaltreider DL, Hu T, Igou JF, Craighead WE. The ISQ-P tool: measuring stress associated with incontinence. J Gerontol Nurs. 1989;15(2):9-15.

25.    Bradway C. Urinary incontinence among older women. Measurement of the effect on health-related quality of life. J Gerontol Nurs. 2003;29(7):13-19.

26.    Dubeau CE, Simon SE, Morris JN. The effect of urinary incontinence on quality of life in older nursing home residents. J Am Geriatr Soc. 2006;54(9):1325-1333.

27.    Ko Y, Lin SJ, Salmon JW, Bron MS. The impact of urinary incontinence on quality of life of the elderly. Am J Manag Care. 2005;11(4 Suppl):S103-S111.

28.    MacDonald CD, Butler L. Clinical outlook: silent no more: elderly women’s stories of living with urinary incontinence in long-term care. J Gerontol Nurs. 2007;33(1):14-20.

29.    Teunissen D, Van Den Bosch W, Van Weel C, Lagro-Janssen T. “It can always happen”: the impact of urinary incontinence on elderly men and women. Scand J Prim Health Care. 2006;24(3):166-173.

30.    Bowers BJ, Esmond S, Jacobson N. The relationship between staffing and quality in long-term care facilities: exploring the views of nurse aides. J Nurs Care Qual. 2000;14(4):55-64.

31.    Lawhorne LW, Ouslander JG, Parmelee PA, Resnick B, Calabrese B. Urinary incontinence: a neglected geriatric syndrome in nursing facilities. J Am Med Dir Assoc. 2008;9(1):29-35.

32.    Kaasalainen S, Williams J, Hadjistavropoulos T, et al. Creating bridges between researchers and long-term care homes to promote quality of life for residents. Qual Health Res. 2010;20(12):1689-1704.

33.    Gotham HJ. Advancing the implementation of evidence-based practices into clinical practice: How do we get there from here? Prof Psychol Res Pr. 2006;37(6):606-613.

34.    Engst C, Chhokar R, Robinson D, Earthy A, Tate RB, Yassi A. Implementation of a scheduled toileting program in a long term care facility: evaluating the impact on injury risk to caregiving staff. AAOHN J. 2004;52(10):427-435.