Guest Editorial: Challenge to Change: CMS Interpretive Guidance — Urinary Incontinence and Indwelling Catheters

    This issue of Ostomy Wound Management includes articles on bladder and bowel clinical practice. Offered are a study on the barrier function/skin hydration capabilities of skin protectants, a study of barrier properties that may compromise diaper use, a review of the emotional impact of urinary diversions, a discussion of a new technology for containment (the anal bag), and a case study of a surgical approach to chronic constipation.

Much of this information is especially timely because of the impact of the Centers for Medicare and Medicaid Services’ (CMS) new Investigative Guidance Tag F-315 for nursing homes, which addresses urinary incontinence (UI) and indwelling urinary catheters.

    For the past several years, the CMS has been updating information on various guidance documents used by state surveyors. The objective was to provide more structured guidance for determining the extent and increasing the consistency with which states apply federal standards regarding the severity and scope of facility deficiency practices. The former F-315 document stated that if a resident entered a facility without a catheter, the facility should do everything in its power to ensure that resident is never catheterized and if a resident entered a facility with a catheter, the facility should do everything possible to successfully remove the catheter. The former F-316 document stated that a facility must note whether a resident with incontinence entered a facility and create a care plan to eliminate, reduce, or manage the incontinence — essentially, to restore as much bladder function as possible in any individual resident.

    The F-315 and F-316 documents have been combined under one Tag to become F-315. The new F-315 document essentially covers the areas addressed in the former F-315 and F-316 documents but goes into much greater detail regarding definitions, assessment, and plan of care. Since the release of the new F-315 in June, nursing home surveyors from state health departments have developed plans for determining deficiencies based on the new F-315 guidance.

    Among several major changes in the F 315 document is that UI is now defined as any wetness on the skin. In the past, most facilities had considered incontinence to be a complete void (urinary evacuation). This new definition may increase the incidence of incontinence in facilities. The overall intent of the F-315 guidance is to ensure that:
  • Residents with incontinence are identified, assessed, and provided appropriate treatment to maintain as much normal urinary function as possible
  • Indwelling catheters are not used without medical justification; if not justified, they must be removed as soon as clinically warranted
   • Residents receive the appropriate care to prevent urinary tract infections (UTIs).

    If a resident enters a facility and is determined to be incontinent, the facility must do a complete assessment to determine the type of incontinence (see Table 1). The treatment for UI depends on the type and causes of incontinence and the capabilities and motivation of the resident. Options for managing UI in nursing home residents primarily include behavioral programs and medication therapy. Other measures and supportive devices used in the management of UI and/or urinary retention may include intermittent catheterization; pelvic organ support devices (pessary); use of incontinence products, garments, and external collection systems (men); and environmental accommodation and/or modification.

    Urinary tract infections are the most common infections in nursing homes. As such, F-315 includes a section specifically addressing UTIs and their diagnosis. Criteria needed to diagnose UTI for those residents with catheters and those residents without catheters are as follows.
    1. Residents with catheters should have at least two of the following signs/symptoms:
  • Fever or chills
  • New flank pain or suprapubic pain
  • Change in character of urine
  • Worsening of mental or functional status.

    2. Residents without catheters should have at least three of the following signs/symptoms:
  • Fever
  • New or increased burning pain in urination
  • New flank or suprapubic pain
  • Change in charter of urine
  • Worsening of mental or functional status.

    The old and new F-315 are similar in that catheters should be avoided at all times unless clinically necessary. The new F-315 defines utilization of two specific types of catheters. Intermittent catheters or straight catheterizations may be used on an as-needed basis to manage overflow incontinence. Indwelling urinary catheters (urethral or suprapubic catheters or long-term catheters) should be used in the following circumstances:
• Urinary retention cannot be treated or corrected medically or surgically, alternative therapy is not feasible, and retention is characterized by documented post void residual (PVR) volumes >200 mL
• Retention/incontinence cannot be managed with intermittent catheterization
• Persistent overflow incontinence, symptomatic infections, and/or renal dysfunction are present
• Contamination of a Stage III or Stage IV pressure ulcer with urine has impeded healing, despite appropriate personal care for incontinence
• Terminal illness or severe impairment makes positioning or clothing changes uncomfortable or is associated with intractable pain.

    The F-315 guidance document is a wealth of information about how to assess and manage a resident with UI and provides resources for staff. In order to meet the requirements of the F-315 guidance, nursing homes will rely on the expertise of nurses who understand incontinence, opening opportunities in an area of practice that desperately needs qualified nurses. Meanwhile, nurses working in long-term care should become familiar with and adept at incorporating the new guidance criteria into incontinence care protocols. Hopefully, this issue of OWM will shed light on several commonly encountered incontinence concerns.

1. American Medical Directors Association. Clinical practice guideline: urinary incontinence. Columbia, Md: 2005.

2. Centers for Medicare and Medicaid Services (CMS). State operations provider certification (Publication No. 100-07). Baltimore, Md.: 2005.

3. CMS Webcast. Available at: www.cms.internetstreaming.com. Accessed August 15, 2005.

4. Newman DK. Urinary incontinence and indwelling catheters: CMS guidance for long-term care. ECPN. 2005;June101(5):50–56.