Urinary Incontinence Guideline:
Real World Examples of Use

The first urinary incontinence guideline sponsored by the Agency for Health Care Policy and Research (AHCPR) was released in March 1992. In the four years since then, AHCPR has disseminated over 1.2 million copies of the guideline and quick reference guide for clinicians—an abbreviated form of the guideline—and an equal number of patient guides.

The biggest users are nursing homes, home health agencies, hospitals, and other providers, including managed care organizations. But nursing schools, specialized health services, government agencies, businesses, and consumer groups also are using them.

The guideline has wide application and is being used to reduce the number of incontinent patients, save health care dollars by avoiding tests and surgery, and improve quality.

Health Facilities and Services

• Use of the urinary incontinence guideline helped the Heritage Manor Nursing Home in Chattanooga, TN, cut the number of incontinent residents by 65 percent in just 14 months. During the same period (September 1992 to November 1993), the facility was able to more than double its number of normally dry patients (those fully dry or continent with assistance). This included six individuals previously considered untreatable.
• AHCPR's urinary incontinence guideline has saved hundreds of people from surgery, according to Michael I. Williams, chief executive officer of Advantage Medical Services, a Bradenton, FL health provider that uses behavior-based treatment built on the AHCPR guideline. Ninety percent of its patients, which it receives on referral from local primary care doctors, improve within three weeks. The treatment method has also reduced costs by eliminating unnecessary testing. Advantage Medical Services can begin treating patients after completing tests that cost no more than $100, according to Mr. Williams, who said that the test costs of incontinent patients referred to urologists typically run between $400 and $2,000.
• Noble Horizons, a nursing home in Salisbury, CT, used AHCPR's urinary incontinence guideline to develop a continence management program. By March 1995—six months after initiating the program—half the residents who underwent prompted voiding training, which is recommended by the guideline, had improved their continence status.
• Using the AHCPR guideline as the basis for its behavior-based treatment program, New Beginnings Continence Clinic in Sioux Falls, SD, has helped many patients regain continence without surgery. In a random study of patient outcomes at the clinic, 72 percent of the patients improved their continence status, and 26 percent of these became fully continent.
• The Kansas Foundation for Medical Care, Inc., the Medicare peer review organization for Kansas, relies heavily on the urinary incontinence guideline and AHCPR guidelines for other conditions as sources for identifying quality indicators to measure quality of care and help providers improve services.
• At the Visiting Nurses Association of Health Midwest, a home health services organization in Kansas City, MO, employing more than 2,000 nurses, therapists and other allied health workers, nurses have increased their competency in handling incontinent homebound patients thanks to the guideline. According to Shirley Harland, RN, CETN, a certified enterostomal therapist, the nurses have found the guideline extremely helpful in standardizing treatment.
• Nurses at Central Mississippi Health Care At Home—a home health service agency in Jackson—no longer consider urinary incontinence a normal part of aging because of the AHCPR guideline, according to Bonnie Carminati, RNC, CETN, CDE. Ms. Carminati said the guideline has improved the ability of staff nurses and home health aides to identify and assess continence problems.
• By using behavioral methods recommended in the guideline, Marilyn-Lu Webb, RN, CNP, CRRN, PhD, director of incontinence management at the Linder Quann Medical Group in Fresno, CA, has been able to cure or improve the incontinence problems of 98 percent of her patients. Ms. Webb said she is able to spare most patients the necessity of referral to urologists and the expense and discomfort of unnecessary surgery.
• The guideline has also helped reduce costs at Ralston-Penn Center, a nurse-managed treatment facility in Philadelphia. According to Christine Bradway, RN, MSN, director of its continence program, AHCPR's guideline influenced a change in their clinical practices, and helped reduce initial patient testing.

State Agencies

• In Texas, state long-term care facility surveyors use AHCPR's urinary incontinence and pressure ulcer guidelines to help identify and correct problems in 2,378 Medicare/Medicaid nursing homes, personal care homes, and facilities serving persons with mental retardation.
• Maryland State policy has designated AHCPR's urinary incontinence guideline as a standard for state and private-sector health care organizations to follow. This policy of Maryland's Health Resources Planning Commission, in effect since 1992, is designed to promote use of the guideline as a model for facilities to develop their own protocols, as a standard for licensing nursing homes, and as a potential basis for nursing home reimbursement.
• Urinary incontinence and other AHCPR guidelines serve as models of care for nurses with Delaware's Division of Services for Aging and Adults with Physical Disabilities when handling Medicaid waiver cases to assess whether the State should allow Medicaid funds to support home care as an alternative to nursing home care. In these cases, the nurses often use the AHCPR guidelines as guides for setting up and monitoring nursing home plans for patients. Division staff also use AHCPR guidelines as models of care when investigating allegations of abuse, neglect or exploitation of elderly persons by family members or others. The Division is a part of Delaware's Department of Health and Human Services.
• The State of Florida has required that the AHCPR urinary incontinence guideline be made available to all hospitals and health professionals throughout the state, with the state's formal endorsement, in order to reduce unwarranted variation in the delivery of medical equipment, improve the quality of medical care, and promote the appropriate utilization of health care services.

Nursing Education

• AHCPR's urinary incontinence guideline is now the standard resource for nursing students of Petersburg Junior College in Pinellas Park, FL. According to Dr. Jodi Parks, director of nursing, students previously relied on various textbooks—which she said were usually outdated—to learn how to treat bladder problems. Dr. Parks said nursing instructors can now offer their students a more consistent approach to treating patients by using AHCPR's guideline as a standard of care.
• At the Ohio State University College of Nursing, the urinary incontinence and three other AHCPR guidelines are required reading for graduate students of Dr. Linda Bernhard. She uses the guidelines to teach her students how to make clinical diagnoses preparatory to their undergoing clinical experience.

March 1996

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