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Guest Editorial: Guidance on Urinary Incontinence
It is most appropriate and timely that the theme of this issue of Ostomy/Wound Management is urinary incontinence. This field continues to grow and expand, creating more opportunities for nurses who specialize in both incontinence and wound care.
At the same time, UI is the subject of further regulatory emphasis in the long-term care setting - the Centers for Medicaid and Medicare (CMS) is changing its instructions to nursing home surveyors on how to evaluate incontinence care. The CMS has completed its long awaited “guidance to surveyors” on UI and the use of indwelling catheters. The purpose of this 4-year project was to provide more structured guidance for determining severity and scope of deficient practices in nursing homes and to increase the consistency with which states apply federal standards for determining severity and scope of facility deficiency practices. According to CMS’s Guidance to Surveyors: Urinary Incontinence and Catheters, key components of incontinence care in nursing homes is assessment of the problem and a multidisciplinary approach to its treatment and management.
Current CMS regulations in relation to UI and the use of indwelling catheters are as follows:
• Urinary incontinence requires that residents who are incontinent of bladder receive appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible.
• Urinary incontinence requires that a resident who enters the facility without an indwelling catheter should not be catheterized unless the resident’s clinical condition demonstrates that catheterization was necessary.
The CMS further notes that in the course of addressing UI (ie, developing and implementing care plan interventions for treatment and services related to achieving the highest practicable level of urinary continence, preventing and treating urinary tract infections, and avoiding the use of indwelling catheters without medical justification), it is important to involve the resident and/or his/her surrogate in care decisions and to consider whether the resident has an advance directive in place.
The guidance document stresses the importance of a facility’s having systems/procedures in place to ensure that 1) UI assessments are timely and appropriate; 2) interventions are defined, implemented, monitored, and revised as appropriate in accordance with current standards of practice; and 3) changes in bladder condition such as UI and urinary retention are recognized, evaluated, reported, and addressed. The medical director, nurse practitioner, or specialist and the quality assessment and assurance committee may help the facility evaluate existing strategies for identifying and managing incontinence, catheter use, and UTIs and ensure that facility policies and procedures are consistent with current standards of practice. Areas identified in the guidance document as areas of deficiencies include:
• Use of indwelling catheters with no medical necessity
• Poor hygiene and perineal care
• Poor catheter care
• Repeated UTIs
• Lack of toileting programs
• No rehabilitation programs (eg, bladder retraining, pelvic muscle exercises)
To complement the guidance document, the CMS conducted a webcast that included a panel of experts (Joe Ouslander, MD; Mary Palmer, RNC, PhD; Mikel Gray, RNC, PhD; and myself). The webcast is informative and specific to the components of continence care in the long-term care setting and is available at www.cms.internetstreaming.com.
The guidance document is currently undergoing final CMS review with expected release by the end of the year. It was primarily developed to assist state surveyors in the review process but will have wide application to nursing home staff. This presents a golden opportunity for nurses who are experts in the area of UI and wound care to offer their unique services - nursing homes will need experts to assist them in understanding the key components to UI assessment and care plan development.
