Change in care hours, cost, and functional independence following continence and assistive technology intervention in an acquired brain injury population

PURPOSE

After acquired brain injury (ABI) dependence on intervention for continence management is common. This preliminary investigation aimed to (i) quantify toileting care hours and costs in a community-based ABI rehabilitation and disability setting, and (ii) measure change in care needs, costs, and functional independence after intervention with assistive technologies (ATs).

METHOD

Pragmatic pre-post intervention pilot study of 14 adults with ABI and toileting disability accessing community-based neurorehabilitation or disability support in Western Australia. Toileting and functional independence were assessed monthly from baseline (T₀) to 3-month follow-up (T₃). Basic and nursing care hours (Northwick Park Dependency Score), cost of care estimates (Northwick Park Care Needs Assessment), functional independence (Functional Independence and Assessment Measure), and cost of consumables were examined pre- and post-intervention with ATs. Multilevel mixed-effects models with bootstrap estimation were conducted.

RESULTS

Cost of consumables significantly declined (AU$69/week), and functional independence significantly improved following intervention (+23.5 points). There was a non-significant reduction in care needs for toileting (4 h/week) and in the cost of toileting care (AU$633/week).

CONCLUSION

Toileting disability substantially impacts care hours and costs. This study provides preliminary evidence that comprehensive continence management is beneficial in reducing costs and supporting people with an ABI to increase their independence.IMPLICATIONS FOR REHABILITATIONA comprehensive continence assessment and management plan reduces the number of care hours, cost of care, and cost of continence products in a neurorehabilitation and disability support sample for people with acquired brain injury (ABI).Assistive technologies for continence management are beneficial in supporting people with ABI to increase independence, and reduce costs.Providing comprehensive continence assessment and management plan reduces reliance on staff for continence care, and improves functional independence.

Toileting Resistance Among Preschool-Age Children with and Without Autism Spectrum Disorder

OBJECTIVE

Children with autism spectrum disorder (ASD) may achieve continence later than other children. Little is known about factors associated with toileting resistance in children with ASD and other developmental delays/disabilities (DD). We sought to describe toileting resistance in children with ASD and DD and those from the general population (POP) and identify factors associated with toileting resistance in children with ASD and DD.

METHOD

Families and children aged 24 to 68 months were enrolled in the Study to Explore Early Development, a multisite case-control study on ASD. Children with ASD (N = 743) and DD (N = 766) and those from the POP (N = 693) who were 48 months or older were included in this study. Parents reported toileting resistance, gastrointestinal issues, behavior problems, and ASD symptoms in their children. Children completed an in-person evaluation to determine ASD status and developmental level.

RESULTS

Toileting resistance was more common among children with ASD (49.1%) than children with DD (23.6%) and those from the POP (8.0%). Diarrhea and deficits in social awareness were significantly associated with toileting resistance in children with ASD and DD. Constipation, expressive language delays, and low social motivation were significantly associated with toileting resistance only in children with ASD; very low visual reception skills and oppositional behaviors were significantly associated with toileting resistance in only children with DD (all p ≤ 0.05).

CONCLUSION

Evaluating gastrointestinal issues, developmental delays, and social deficits before toileting training may help identify children with atypical development who are likely to present with toileting resistance. These evaluations can be incorporated into health supervision visits.

Association between toileting independence and higher brain functions in post-stroke inpatients: A cross-sectional study

OBJECTIVES

We aimed to cross-sectionally examine and clarify the types of higher brain functions associated with toileting independence in post-stroke inpatients.

MATERIALS AND METHODS

From November 2017 to October 2020, 51 participants were selected from a database of post-stroke inpatients in a Japanese hospital; the selected participants had missing data. The objective variable was the independence of toileting and toilet transfer in the Functional Independence Measure; independence was set at 6 points or more. The covariates were age, sex, and Berg balance scale score; the explanatory variables were higher brain functions of four items (forward digit span, visual cancelation task [VCT] correctness rate, symbol digit modalities test score, and Kohs block design test score). Logistic regression analysis was performed using multiple imputation and Bayesian modeling.

RESULTS

VCT correctness rate was significantly associated with toileting independence in the best model selected (odds ratio 1.16; 95% credible interval 1.02, 1.49).

CONCLUSION

Selective attention (assessed by VCT correctness rate) may be associated with, and predict, toileting independence in post-stroke inpatients.

Art of connectedness: Value-creating care for older persons provided with toileting assistance and containment strategies-A critical interpretive synthesis

AIMS AND OBJECTIVES

The aim was to conduct a synthesis of the literature on value-creating care for older persons with incontinence provided with toileting assistance and containment strategies, from the perspectives of older persons and healthcare professionals.

BACKGROUND

Incontinence is a health problem for many persons worldwide and the problem will increase as the global population ages. It can have a profound impact on a person's wellbeing, and assistance with toileting and containment strategies is common in home care settings and nursing homes.

DESIGN

The design was a literature review with an iterative, reflexive and critical approach.

METHODS

A critical interpretive synthesis was conducted. Ten papers published between 2011 and 2019 were analysed. The PRISMA -ScR Checklist was used in this review.

RESULTS

Based on the findings, the conceptual construct 'The art of connectedness' was developed, built on co-created care, personalised care and reflective care between the older person and healthcare professionals. Co-created care is based on establishing a relationship, building trust and respecting preferences. Personalised care consists of meeting the person's needs, promoting comfort and maintaining self-determination. Reflective care entails showing empathy, upholding the person's dignity and developing professional competence.

CONCLUSIONS

Value-creating care consists conceptually of a connectedness that starts with co-creating the care together with the older person in a close relationship. Assistance is given and received based on the older person's individual needs and is highly valued by the older person as it helps them maintain self-determination. Reflective care is of importance for healthcare professionals.

RELEVANCE FOR PRACTICE

The findings are hoped to enhance healthcare professionals' understanding of how to improve the clinical encounter in nursing when providing assistance. They may also stimulate critical reflection among healthcare professionals on how to improve assistance to meet the older person's values.

Managing Falls: Implementation of a Three-Intervention Initiative to Improve Quality of Care for Patients With Cancer

BACKGROUND

All healthcare institutions prioritize falls as a major safety issue. Falls are of particular concern on inpatient oncology units where patients are substantially at risk for injury related to falls.

OBJECTIVES

This article describes a multifaceted fall-prevention initiative that can be implemented on oncology units using evidence-based interventions in the key areas of communication, toileting, and hourly rounding. The Visual Rounding Tool for communication around hourly rounding and proactive toileting is also introduced.

METHODS

Based on a root cause analysis and literature review, the inpatient oncology unit-based committee launched a three-intervention initiative, carried out during three consecutive months, to address patient falls.

FINDINGS

Fall rates decreased using the three- intervention initiative. Systematic improvement in processes enabled an increased occurrence of communication between nurses and assistive personnel, increased use of the Visual Rounding Tool for proactive toileting and hourly rounding, and a significant but short-lived decrease in call light use.

Toileting ability of patients after primary reverse total shoulder arthroplasty

Background

This study aimed to determine the toileting ability (TA) of patients undergoing primary reverse total shoulder arthroplasty (RTSA) and identify factors associated with TA postoperatively.

Methods

A questionnaire regarding toileting was administered to 119 patients who underwent primary RTSA with a minimum 1-year follow-up. Patients were separated into 2 groups based on whether the arm that underwent RTSA was the one used for toileting (study group, n = 74) or not (control group, n = 45). Patient-reported TA was calculated both before and after RTSA. Multivariate analysis was performed to identify factors associated with TA postoperatively.

Results

Impairment in TA before RTSA was higher in the study group and affected almost three-quarters of the patients (72%). In the study group, primary RTSA resulted in a statistically significant improvement in TA (P < .001), and no difference in TA was found between groups after RTSA (P = .076). Postoperatively, 92% of the patients in the study group were able to manage toileting with the involved extremity (54% without difficulty and 38% with some degree of difficulty). Only 1 patient (1.3%) was totally unable to manage toileting with either arm postoperatively. The patients at risk of toileting difficulties postoperatively were those who had preoperative toileting difficulties and lower postoperative internal rotation range of motion.

Conclusions

Over 90% of patients can manage toileting after primary RTSA, and total toileting inability is rare after the procedure (1.3%). Patients should be counseled that after primary RTSA, they have a high probability of being able to manage toileting with independence even if it is with some difficulty.

Supporting parents of children aged 2-13 with toileting difficulties: Group-based workshops versus individual appointments

INTRODUCTION

Toileting is a key activity of daily living and an important milestone in children's development. Difficulties with this process can cause stress to both child and parents and negatively affect their wellbeing. This study compared the perceived parental competence and child wellbeing of families attending a group-based workshop on toileting issues with families attending an individual appointment at a continence clinic.

METHODS

All parents attending the workshops and attending the clinic between July 2016 and December 2017 were invited to participate in the study. The children were aged between 2 and 13 years. Three measures were used: 1) Parenting Sense of Competence Scale; (2) the Revised Quality of Life Questionnaire for Children (KINDLR) and (3) Parent self-assessment of information and support needs. Participants completed all measures at three points: prior to intervention, 1 week and 1 month post-intervention.

RESULTS

Data were collected from 89 parents attending the workshops and 46 parents attending the clinic. Children were not assessed. Non-parametric tests were used to examine between group differences. Within group changes overtime were examined using Friedman's two-way analysis of variance. Parents who attended the workshop showed significant increases in parenting sense of competence and perceived child quality of life post-intervention. Although there were significant differences between and pre- and post-measures for workshop attendees, there were no significant differences found between the two groups indicating that both forms of intervention had beneficial results.

CONCLUSION

These results suggest that group-based workshops can positively impact parents' perceived competence in managing their child's toileting issues and wellbeing. Further research is recommended to explore the relationship between parenting competence and child wellbeing and to determine which aspects of the workshops were most beneficial.

Toileting-related falls at night in hospitalised patients: The role of nocturia

OBJECTIVE

The purpose of this study was to describe the prevalence and characteristics of toileting-related falls in hospitalised older people.

METHODS

Retrospective analysis of falls related to night-time toileting in patients 60 years or over in a tertiary hospital during a one-year period.

RESULTS

Overall 34% of falls were related to toileting with at least 44% of these falls occurring during the night. Toilet-related falls peaked between 11 pm and 1 am, a period that coincides with maximum supine-induced diuresis. Almost half of night falls occurred at the bedside. In 80% of night toileting-related falls, patients were mobilising without the recommended level of assistance. Half of all patients had no strategies for toileting documented in their care plan.

CONCLUSION

Findings support screening for nocturia in older inpatients and implementation of strategies to reduce both the need for toileting at night and risk factors for falling.

Towards Smart Adaptive Care Toilets

Standard toilets in Western countries often do not meet the needs of elderly and disabled people with physical limitations. While the existing concept of barrier-free toilets and the emerging "changing places" concept offer more space and support, the fixed height of the toilet seat still imposes a major problem during all phases of toilet use and can limit the users' autonomy by requiring personal assistance. Thus, in the EU project iToilet an innovative ICT-based modular height adjustable toilet system was designed to support the autonomy, dignity and safety of older people living at home by digital technology enhancements adapting the toilet to their needs and preferences. The main requirements were: double foldable handrails, height and tilt adjustment, emergency detection and call, and ease of use. The ICT component in this approach serves a double purpose of enhancing usability of the base assistive technology while at the same time providing safety for independent use. A field test of a prototype system in real environments of a day care center and a rehabilitation clinic has been successfully finished. The application of the iToilet concept also in semi-public settings is currently studied in the Toilet4me project.

A closer look at the health of cats showing urinary house-soiling (periuria): a case-control study

OBJECTIVES

The aim of this study was to perform a case-control medical evaluation of cats from multi-cat households presenting with inappropriate latrining and spraying behavior.

METHODS

Owners of 18 'spraying' and 23 'latrining' cats with normal control subjects available from the same households were recruited for a case-control study. Otherwise overtly healthy dyads (each dyad consisting of a case cat and a control cat) were brought together to the veterinary hospital of the University of São Paulo for a medical work-up (ie, physical examination, complete blood count, biochemical profile, urinalysis and urine culture, abdominal ultrasound of the urinary system and in females, where possible, cystoscopy).

RESULTS

Medical problems were identified with similar frequency in the 'sprayers' (38.9%), 'latriners' (39.1%) and controls of the latrining group (26.1%), but not the controls of the spraying group (5.5%). The difference between 'cases' and 'controls' from spraying households was significant. Common potential health-related changes include renal insufficiency, cystitis and bladder lithiasis. Renal calculi, higher creatinine levels (within normal reference interval) and 'glomerulations' (detected during cystoscopy) were also found in the remaining sprayers and latriners that were considered clinically healthy. Post-cystoscopy, a new form of periuria occurred in two cats (one sprayer and one latriner).

CONCLUSIONS AND RELEVANCE

These results indicate that spraying or latrining behavior in the home, as well as living with a cat that is not using the litter box as a latrine, are all associated with a higher level of urinary tract abnormalities; living with a cat that is spraying, however, does not have this association. The findings also suggest that both forms of periuria might be associated with interstitial cystitis. We therefore conclude that all cats with periuria need to be carefully evaluated medically and that treatment of latrine-related problems should consider all cats in the house, whereas spraying may be more focused on the individual displaying the problem.

Common Risk Factors for Urinary House Soiling (Periuria) in Cats and Its Differentiation: The Sensitivity and Specificity of Common Diagnostic Signs

Urinary house soiling (periuria) in the home is a common but serious behaviour problem in cats. Although many specific risk factors and triggers have been postulated, their importance is largely unknown. This study assessed: (1) the significance of purported risk factors for periuria as well as specifically marking and latrine behaviour in the home; (2) the specificity and sensitivity of signs commonly used to differentiate latrine and marking behaviour. Owner responses to an internet survey (n = 245) were classified into three groups: control, marking and latrine behaviour, along with 41 potential risk factors and 15 predictors used to diagnose marking and latrine problems. Univariate statistical analyses and non-parametric tests of association were used to determine simple associations. In addition the sensitivity and specificity of four cardinal signs (posture to urinate, attempt to cover soiled area, surface chosen and volume of urine deposited) were calculated. Significant potential risk factors were: age (marking cats were older than the other two groups); multi-cat household (increased risk of marking and latrine behaviours); free outside access and cat flaps in the house (higher frequency of marking); outside access in general (lower prevalence of latrine behaviour); defecation outside the litter box (higher frequency of latrine behaviour); a heavy dependence by the cat on its owner (lower frequency of latrine behaviour) and a relaxed personality (lower risk of marking behaviour). Litterbox attributes and disease related factors were not significant. Individual cardinal signs were generally not good predictors of diagnosis. This study challenges the poor quality of evidence that has underpinned some of the hypotheses concerning the causes of periuria in cats. The results, in particular, highlight the general importance of the social environment, with the presence of other cats in the household, the cat-owner bond and personality related factors, alongside factors like the use of a cat flap which might also alter the social environment, all implicated as significant risk factors. While the physical environment may be important in specific cases, it seems this is less important as a general risk factor. The findings quantify the risk of misdiagnosis if a single sign is considered sufficient for diagnosis.

Impairment in toileting behavior after a stroke

AIM

Dependence for toileting is the most problematic aspect for patients after a stroke. However, the relative difficulty of each component of toileting and the predictors for independent performance of these activities are unknown. We investigated these issues in stroke patients using Boltzmann sigmoid and generalized linear modeling.

METHODS

We carried out a cross-sectional correlation study, including 107 adult inpatients, hospitalized for a stroke. We assessed the activity components of toileting, as well as evaluated physical impairment using the Fugl-Meyer Assessment, impairments in balance using the Berg Balance Scale, cognitive impairments using the Mini-Mental State Examination and the presence or absence of unilateral spatial neglect or aphasia.

RESULTS

Boltzmann sigmoid modeling showed that the total scores required to obtain a response at 50% of the maximal value for the required components of toileting ranged between 2.691 and 34.962 points, for the components of "wearing pants" and "cutting the toilet paper," respectively. A generalized linear model showed that the Berg Balance Scale score was a significant predictor for independent performance on most component activities of toileting.

CONCLUSIONS

The component of toileting that was easiest to carry out was cutting the toilet paper, and the most difficult was wearing pants. Balance impairment was an independent predictor of independent toileting after stroke. This detailed toileting assessment enabled us to document the most difficult components of toileting, and to assess the motor and process skills required for independent toileting. Geriatr Gerontol Int 2018; 18: 1166-1172.

Care Challenges in the Bathroom: The Views of Professional Care Providers Working in Clients' Homes

In home care, bathroom activities-particularly bathing and toileting-present a unique set of challenges. In this focus group study, professional home care providers identified factors that increase the danger and difficulty of assisting their clients with bathing and toileting. These included small restrictive spaces, a poor fit between available equipment and the environment, a reliance on manual handling techniques (but insufficient space to use optimal body mechanics), attempts to maintain normalcy, and caring for unsteady and unpredictable clients. Specific elements of each activity that care providers found difficult included multitasking to support client stability while performing care below the waist (dressing/undressing, providing perineal care) and helping clients to lift their legs in and out of a bathtub. Participants did not feel that available assistive devices provided enough assistance to reduce the danger and difficulty of these activities.

"Bursting" to Go and Other Experiences

Children's use of the toilet at school, although rarely explored, is an important facet of school experience with consequences for physical and psychological health. A mixed methods study investigated views of 25 children (4-5 years) regarding potential stressors in the first school year, including views of toileting, in Dublin, Ireland. Despite very positive responses to school, most responses to toileting (15 of 25) were mixed or negative. Although some liked to go, or noted the toilets were clean, most indicated delayed toilet use ("bursting" to go) and ambivalent or negative experiences such as fear of not identifying the right toilet, fear of being alone, lack of privacy, and potential bullying. Many children did not expect to receive help from the teacher. As delaying toilet use can have lasting health consequences, teacher-nurse collaboration could be used to develop whole-school policies to support children's early adjustment in this sensitive area of functioning.