Using Innovative Incontinence Detection Systems to Enhance Catheter-Associated Urinary Tract Infection Prevention Practices

Patient safety while in the hospital has moved up on the list of priorities since the release of the 1999 report To Err Is Human,¹ which provided a high-level view of how organizations could improve patient care.² This effort aligns well with the nursing principle of nonmaleficence: to ensure interventions are helping the patient to heal and not causing further damage. The Centers for Medicare and Medicaid Services defines “never events” as preventable, serious, and indicative of a problem in a facility.³ These events include catheter-associated urinary tract infections (CAUTIs) and hospital-acquired pressure injuries (HAPIs) because they are considered preventable complications.³ The goal for caregivers and hospitals is to eliminate the incidence of never events to improve the quality of patient care.

The definitive way to prevent CAUTIs is to avoid using a urinary catheter, but this leaves the nurse with the challenge of managing urinary incontinence. The urinary catheter is replaced with an absorbent underpad designed to wick moisture away from the skin. However, removing the catheter increases the risk of moisture-associated skin damage due to urinary incontinence.⁴ A study by Lachenbruch et al⁵ determined that 53% of hospitalized patients were incontinent, leaving a large portion of hospitalized patients at risk of moisture exposure. Another study by Gray et al⁶ found that approximately 21% of patients who are incontinent of stool and/or urine have incontinence-associated dermatitis (IAD), with a pressure injury prevalence of 17.1%. Numerous studies have shown a direct correlation between incontinence and HAPI development. A systematic review conducted by Beeckman et al⁷ reviewed 58 research studies on the correlation between moisture, IAD, and HAPI development. The review supported that IAD is an independent risk factor of HAPI development and could be preventable if the skin exposure time to moisture is reduced.

The skin changes that lead to IAD happen in as a little as 15 minutes, and Phipps et al,⁸ showed how exposure to a urine-soaked pad leads to clinically significant skin changes. The skin is an essential barrier to preventing bacteria from entering the body; as soon as the barrier has any weakness, the opportunistic infections set in and weaken the ability of the sacral tissue to stay intact. Studies support nursing rounds to help prevent some hospital-acquired conditions such as HAPI. With moisture exposure causing changes to the skin rapidly, catching the incontinence incident with hourly rounds could leave the patient exposed to moisture for as long as an hour.⁸ However, it is essential to understand that nursing shortages and patient care demands make it challenging to round on the hour. Nursing rounds are designed to check on the patient at a minimum at least every hour to ensure the patient has met the four P’s: pain, potty, position, and possessions in reach.⁹ The rounding procedure was developed around increasing patient satisfaction and not necessarily patient outcomes. In addition, hourly rounding has been shown through a systematic review by Mitchell et al⁹ to place a considerable strain on nursing resources.

The problem of IAD leading to HAPI is now widely recognized. A task force assembled by the Wound, Ostomy, and Continence Care society reviewed the literature for best practices around bowel and bladder management after removing a urinary catheter.⁴ A consensus panel of 20 clinicians examined the literature and provided guidance on how to manage absorbent pads that leave a patient’s skin exposed to moisture. Pads are utilized by nursing staff as a barrier between the patient and the bed, and the consensus panel recognized that this was the first line of defense for incontinent patients. For reasons previously mentioned, pads must be changed as soon as possible after the incontinence event to prevent prolonged exposure to moisture. The panel unanimously endorsed that clinicians should consider using pads with embedded technology to alert providers when there is an episode of incontinence for patients who are unable or unwilling to notify staff.⁴

The Hillrom WatchCare System (Figure) has an absorbent pad with an embedded sensor that detects when a patient has moisture in contact with the skin. This pad is integrated into an alert system in the bed that activates an alert to the nurse call system. Once the smartpad detects the presence of an incontinence event, the pad will communicate with the sensor in the bed. The bed sends a notification through the nurse call system to aid the nurse in prioritizing that patient’s care. In addition, there is a visual alert (an illuminated light at the foot of the bed) to notify the care team. With this technology, hospital systems can improve overall moisture exposure times by alerting the care team. A team at Dartmouth-Hitchcock studied the use of the pads and found that after the technology was implemented, the WatchCare system decreased moisture exposure time from 123 minutes to 18.9 minutes.¹⁰ The feedback from the nursing staff was positive as they believed patient care could be provided with the best practice of incontinent care.¹⁰

Innovative Moisture Management was made possible through the support of Hillrom (https://www.hillrom.com). The opinions and statements of the clinicians are specific to the respective authors and not necessarily those of Hillrom, Wound Management & Prevention, or HMP Global. This article was not subject to the Wound Management & Prevention peer-review process.

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