October 26, 2021 - CC

QI Spotlight: Reducing Urinary Incontinence to Improve Patient Quality of Life

The October QI Project Spotlight was submitted by Meghan Magill, DO. Dr. Magill is a physician at AMITA Health Rehabilitation in Illinois.

Dr. Magill and her team completed this project to reduce incidents of urinary incontinence in their patient population. About 17 percent of their patient population had frequent urinary incontinence, which affected quality of life, self esteem, and patient satisfaction. Dr. Magill and her team created a personalized toileting program for patients to increase the frequency of patient toileting to prevent incontinence and increase care for this patient population.

Thank you for submitting your project, Dr. Magill!

The QI Project Spotlight (formerly the PIP Spotlight) is a periodic feature on the ABPMR News Center to highlight exemplary Quality Improvement projects submitted by your fellow diplomates (or residents) for continuing certification (CC) credit. Diplomates can use the QI Project Spotlight as a tool to plan their own QIs or as a way to connect with other diplomates doing similar work.

What is the problem you are trying to solve?

Urinary incontinence can lead to poor outcomes and adverse events in hospitalized patients. It also affects quality of life, self esteem, and patient satisfaction. While hospitalized, patients need to ask for help for toileting, but not all of our patients are capable of doing so. In addition, some patients are unaware of bladder incontinence due to sensory impairments. The fear of urinary incontinence can lead some patients to get up and attempt to toilet without assistance, leading to falls and injuries.

We have a large team of people (therapists, patient care technicians, nurses, and doctors) who can all contribute to improving continence in our patient population. I wanted to find how we could put all those people to work and effectively create a program that would improve urinary incontinence among our patient population.

What data (objective measurements) do you have that supports this as a problem?

We have two inpatient rehab units, with average census of 30 per floor. On average, five patients on each floor have frequent urinary incontinence, which is about 17 percent of our patients. Patients attempting to toilet themselves has led to two falls with major adverse events (fracture, head injury) in the past year.

What is your opportunity statement? State the goal you hope to achieve.

Our goal was to use the interdisciplinary team to create a personalized toileting program for patients to improve rates of continence. If we could increase frequency and opportunity to toilet our patients, we would reduce this incidence of bladder incontinence. The outcome of improved continence will lead to better skin care/fewer incidents of skin breakdown from moisture, decreased falls from patients attempting to toilet without help, and improved patient satisfaction (not waiting for help to toilet and improved self esteem). We can achieve this goal in six months.

What is the underlying cause of the performance/quality problem?

Patient toileting is the responsibility of many people on the team, but we don't have a defined process to get patients into a program that everyone is aware of and working together to achieve the goal of continence. Everyone helps with toileting, but the plan needs better definition to produce results.

What change(s) did you implement?

We started a committee with representation from all team members. Nursing, occupational therapy, patient care technician, and physician attended an initial meeting to identify patients in need of assistance with the achievable goal of urinary continence.

The physician entered an order that the patient would be on a toileting protocol (examples: toileting every two hours while awake, or toileting after meals, or offer toileting 4 times per day). The occupational therapy department created a list of those patients with a description of when/where incontinence is noted (before therapy, after meals, overnight, etc.). The list was posted to a drive accessible to all team members. That list would be accessed during nursing huddle (twice per day) and flash rounds with the physician (daily Mon-Fri). We would discuss progress and areas for improvement for the identified patients.

We updated the list with the patient's percent of continent/incontinent voids and any changes in strategies for the toileting program. We also posted a toileting checklist in the room as a visual reminder for all staff members taking part in the toileting protocol. Patient care technician and nursing provided education to patients in the program about toileting goals and the toileting plan.

Did you achieve your goal or target from your opportunity statement? What data do you have to support your conclusion?

Yes. Over the course of six months, 4 out of 5 patients (80 percent) showed improvement on the toileting program, with 80-100 percent continence. We were able to incorporate all team members to the toileting program and work together to prevent incontinence. We increased accountability among team members by using the toileting checklist and increased communication between team members to achieve our goal of improved continence of our patients.

Will you continue with the changes you have implemented?

We will continue to use the program and committee meetings two to three times per year. The toileting checklists remain in at-risk patient's rooms. We continue to use nursing huddle and physician flash rounds to discuss toileting goals and methods to improve continence for patients identified to be at risk.