bladder management in female stroke.pdf

Current IssuesBladder Management in FemaleStroke Survivors: TranslatingResearch into PracticeMichele Cournan, DNP RN CRRN ANP-BC FNP

Aims: Impaired bladder management is common after stroke. By implementing evidence-based interventions, compre-hensive inpatient rehabilitation can assist the stroke survivor in improving bladder management skills. The study goalwas to determine if these interventions could improve bladder function of these stroke survivors.Methods: This research utilization project was implemented in a free-standing inpatient rehabilitation facility, on 35female stroke survivors. Thirty-five patients discharged from the same facility immediately before implementation ofthese interventions were used as the control group.Results: Functional independence measure (FIM) bladder score was used to determine bladder function at admissionand discharge, and to calculate FIM change. ANOVA results indicated that implementation of these interventions didsignificantly increase bladder FIM scores.Conclusions: Consistent implementation of evidence-based interventions by an interdisciplinary rehabilitation teamcan influence bladder management skills in poststroke patients.

In 2006, stroke affected 6.5 million Americans,approximately 3% of the population. The imple-mentation of stroke protocols in emergencydepartments has decreased the stroke death rateto 29.7% from 1995 to 2005 (American HeartAssociation, 2009). This improved treatment haslead to approximately 6,500,000 stroke survivorsalive today; a majority of these are women.Women are more likely to have greater disabilityresulting from their stroke than men and have atwo times greater incidence of urinary inconti-nence poststroke (American Heart Association,2009).

Functional incontinence, or the loss of urinerelated to physical disability or cognitive impair-ment that prevents the individual from reachingthe toilet, is fairly common after stroke. Inconti-nence affects 26%–44% of stroke survivors (Dumou-lin, Korner-Bitensky, & Tannenbaum, 2005).Comprehensive inpatient rehabilitation can assistthe individual to improve functional abilities andminimize disability. There are several evidence-based protocols in the literature focusing on blad-der incontinence. Although these protocols arewidely available and the interventions easy toimplement, in our facility these protocols andinterventions have not been applied systematically.This research utilization project implementedseveral evidence-based interventions with the goalof increasing the stroke survivors’ indepen-dence in bladder management skills as evidencedby increasing bladder Functional Independence

MeasureTM (FIM) change (discharge minus admis-sion score).

Background

Maslow (1943) would consider that meeting theindividual’s most basic needs, including bladdermanagement, would be essential for an individual’srecovery. Loss of ability to manage one’s own blad-der needs affects one’s quality of life and life satis-faction, including participation in social and othermeaningful activities, as individuals fear urine leak-age and odor (Edwards, Hahn, & Dromerick, 2005).Bladder impairment is a major burden on caregiv-ers. Many stroke survivors require some assistanceafter discharge, which is likely to be intermittent.The woman who, after stroke, cannot indepen-dently manage bladder activities requires constantavailability of an assistant due to the unpredictablenature of bladder needs. This need for constantsupervision may therefore increase institutionaliza-tion rates and disability after rehabilitation (Patel,Coshall, Lawrence, Rudd, & Wolfe, 2001) and maybe a financial burden to the individual due to thecost of bladder management products (Chan, 1997).Incontinence can contribute to additional medicalcomplications including skin breakdown, infection,and urosepsis and have a negative impact on theindividual’s social and emotional well-being (Chan,1997).

Bladder impairment may influence rehabilita-tion outcomes (Bates et al., 2005; Massucci et al.,2006). A 2005 study by Edwards, Hahn, and

Rehabilitation NURSING

KEY WORDS

bladder management

outcome measurement

outcomes model

quality health

rehabilitation

stroke

urinary incontinence

220 Rehabilitation Nursing � Vol. 37, No. 5 � September-October 2012

© 2012 Association of Rehabilitation Nurses � DOI: 10.1002/rnj.054

Dromerick reported the functional independence ofa stroke survivor 6 months poststroke was worsefor the individual with incontinence than for thecontinent individual. It is essential for rehabilitationprofessionals to implement individualized, compre-hensive bladder management programs to facilitateindependence and quality of life (Bates et al., 2005;Massucci et al., 2006; Patel et al., 2001).

Inability to manage one’s bladder after stroke isonly partially explained by preexisting urinaryincontinence (Nakayama et al., 1997). Analysis byGelber, Good, Laven and Verhulst (1993) docu-mented the major mechanisms of bladder impair-ment after stroke as the following: (1) disruption ofneuromicturition pathways; (2) stroke-relatedcognitive and language deficits; (3) motor impair-ment; and (4) medication use. The disruption ofneuromicturition pathways can lead to an impairedawareness of the need to void even in thecognitively intact individual (Pettersen, Stien, &Wyller, 2006). These mechanisms can be influencedby the rehabilitation process (Thomas et al., 2005).

Review of Literature

Systematic reviews including Joanna BriggsReview, Cochrane Review and Evidence-BasedPractice Guidelines are considered to be level oneor the strongest evidence (Schmidt & Brown,2009). There were no guidelines addressing blad-der management, incontinence or stroke in theJoanna Briggs Review database. In 2008, Thomaset al., completed a review of the literature for theCochrane Collaboration on the treatment of uri-nary incontinence after stroke in adults. Therewere very few research studies on incontinence instroke survivors. The studies that were conductedtested several interventions including behavioral,pharmacological, physical, and complementary,and very few replicated previous studies. Theoutcomes used in these studies varied, making itimpossible to combine studies. Studies tended tohave small sample sizes and incomplete data,likely introducing bias. This review concludedthat there was very little stroke-specific evidenceto guide practice, but that the limited evidencedoes suggest that the largest impact on inconti-nence occurs in the acute rehabilitation phase.There were several guidelines in the NationalClearing House Guidelines database. Althoughpublished, most of these guidelines do not citestrong randomized controlled-based studies. Sev-eral of the studies cited contain interventions formanaging incontinence, but few studies examinethe effectiveness of these interventions in thestroke population.

In 1992, the Agency for Health Care Policy andResearch (now the Agency for Healthcare Researchand Quality—AHRQ) published the clinicalpractice guideline entitled “Urinary Incontinence inAdults.” This guideline provided recommendationsfor the treatment of incontinence including behav-ioral techniques (bladder training, habit training,prompted voiding, and pelvic floor exercises) andpharmacologic and surgical treatment. Althoughciting the literature, the authors did not determinethe level of evidence to support these interventions.At this time, this guideline is not in use and nolonger available from the AHRQ due to its lack ofevidence.

Since this time, several other guidelines for themanagement of urinary incontinence have beenpublished. Most of these published guidelines aregeared toward stress or urge incontinence, or over-active bladder in women. There are some aspects ofthese guidelines that are applicable to any form ofincontinence including a comprehensive assess-ment, a comprehensive individualized plan forbladder management, and the avoidance ofindwelling catheters (National Stroke Foundationof Australia, 2007; Dowling-Castronovo & Brad-way, 2008; Registered Nurses Association ofOntario, 2005; American College of Obstetriciansand Gynecologists, 2005; American Heart Associa-tion, 2009; Finnish Medical Society Duodecim,2008; Cournan et al., 2007).

In 1998, Brittain, Peet, and Cateleden published“Stroke and Incontinence.” The authors concludedthat evidence demonstrated bladder retrainingprograms and physical therapy (PT) could signifi-cantly improve incontinence, but that these inter-ventions had not been tested in individuals afterstroke. Bladder retraining was not defined in thisarticle. Even though this article concluded thatfurther research was necessary, very little researchhas been conducted in the stroke population todate.

In 2005, the “Management of Adult Stroke Reha-bilitation Care: A Clinical Practice Guideline” waspublished in the American Heart Association jour-nal Stroke (Duncan et al.). The bladder managementrecommendations from this guideline include anassessment of bladder function to include the pres-ence of dysuria; measurement of frequency, vol-ume, and control and the presence of retentionusing a bladder scanner or straight catheterization;removal of indwelling catheters within 48 hours ofthe stroke; the use of silver-coated catheters if anindwelling catheter is necessary; the need for anindividualized bladder training program; and theuse of prompted voiding. There are several

Rehabilitation Nursing � Vol. 37, No. 5 � September-October 2012 221

limitations to this guideline. First, there is no defini-tion of “bladder training program” included in theguidelines, leaving clinicians to guess what they areto implement. Second, authors suggest that theseinterventions may not be generalizable to the strokepopulation as many studies on incontinence have ahigh dementia population and were not specific tothe stroke population. Much of the evidence in thisguideline is fair to poor quality and is not based onrandomized control studies.

“The Specialty Practice of Rehabilitation Nurs-ing: A Core Curriculum” (Cournan et al., 2007)discusses bladder management as part of a compre-hensive rehabilitation program. This core curricu-lum is widely considered to be the basis forrehabilitation nursing practice. The core curriculumincluded the following interventions: the use of thecrede and valsalvamaneuvers; intermittent catheter-ization; and reflex voiding with a condom catheterfor males. As with other guidelines, these are notspecific to the stroke population, and the evidence isbased on quasi experimental studies or expertopinion.

The Heart and Stroke Foundation of Canada(Dumoulin & Korner-Bitensky, 2009), recommendsthe following: timed voiding, prompted voiding,bladder retraining with urge suppression, bladderretraining with urge suppression in combinationwith pelvic floor exercises, and pelvic floor exer-cises. These guidelines were indicated for inconti-nence and are not specific to the stroke populationand the level of evidence is limited.

The removal of an indwelling catheter as soon aspossible to facilitate bladder retraining is includedin multiple guidelines (Duncan et al., 2005;Dowling-Castronovo & Bradway, 2008; NationalStroke Foundation of Australia, 2007). This removaldecreases the risk of urinary tract infections andfacilitates bladder sphincter control. As cathetersare removed (unless medically contradicted) uponadmission to this facility per protocol, this impor-tant intervention was not included in the study. Theuse of bladder scanning and intermittent catheteri-zation are also part of the current protocol for thosewith urinary retention or whose catheter wasrecently removed at this facility. This, too, is sup-ported by the literature (Duncan et al., 2005;Dowling-Castronovo & Bradway, 2008). After anextensive review of the literature, additional inter-ventions were chosen for implementation. The sup-port in the literature for these interventions follows.

Enhanced Bladder History

A comprehensive history regarding bladder con-trol, specifically history of incontinence, diagnostic

work-up, and treatments and strategies used,assists the interdisciplinary team in individualizingthe plan of care (National Stroke Foundation ofAustralia, 2007; Dowling-Castronovo & Bradway,2008; Registered Nurses Association of Ontario,2005; American College of Obstetricians andGynecologists, 2005; American Heart Association,2009; Finnish Medical Society Duodecim, 2008;Cournan et al., 2007). There are no publishedresearch studies that tested the effects of this com-prehensive history on bladder control outcomes;level of evidence is expert opinion.

Timed/Prompted Voiding

Timed voiding is assisting the individual who isnot independent in toileting activities to thebathroom (or transfer to a commode) at fixed timeintervals. Prompted voiding is providing positivereinforcement to the individual when they requestassistance with the need to void. The differencebeing that timed voiding is initiated by the care-giver and prompted voiding is initiated by thestroke survivor (Dumoulin et al., 2005). This is acommonly employed behavior managementtechnique. There are no randomized controlledstudies to measure the effectiveness of this inter-vention. As these are commonly used bladderretraining techniques, rehabilitation professionalsare likely to be basing their interventions on resultsof single, small trials (Thomas et al., 2005).

Bathroom Training

After stroke , individuals are often incontinent forfunctional reasons (Dowling-Castronovo & Brad-way, 2008). In other words, if they were able towalk independently and use both arms to managetheir clothing, they would likely be continent. Forindividuals to be independent in bladder manage-ment they must be able to access the bathroom,manage their clothing, use assistive devices asneeded (grab bars, reachers, pull-ups, etc.), andthen perform hygiene. To be able to perform thesetasks in light of their functional deficits, an individ-ualized comprehensive program must be initiatedto work on each of these tasks. The stronger theindividuals become, the more likely they are to beable to manage their bladder needs. As with manyof the other interventions, there are no researchstudies to demonstrate that improving function willimpact bladder management; level of evidence isexpert opinion.

Pelvic Floor Exercises

Pelvic floor exercises consist of contraction of thepelvic floor muscles to improve strength and/or


Bladder Management in Female Stroke Survivors: TranslatingResearch into Practice

timing of the contraction or to inhibit detrusor con-traction. It is believed that by strengthening the pel-vic floor muscles, the individual will not beincontinent when there is increased intraabdominalpressure. (Dumoulin et al., 2005). Multiple guide-lines include this intervention (Finnish MedicalSociety Duodecim, 2008; American College ofObstetricians and Gynecologists, 2005) and there isstrong evidence with random controlled studies instress and urge incontinence, but no research spe-cific to the stroke population.

These interventions, enhanced history, timed/prompted voiding, bathroom training, and pelvicfloor exercises, were chosen based on severalfactors. They have the strongest evidence of any thatare not currently in use in this facility. They can beinitiated quickly. They are easily incorporated intocurrent therapy sessions with little required staffeducation and documented in the current electronicmedical record (EMR) without significant changes.They will not require any additional time or expenseon the part of the facility, and most importantly,they have no potential to harm the individual.

Theoretical Framework

The Quality Health Outcomes Model was used toframe this study (see Figure 1; Mitchell, Ferketich,& Jennings, 1998). This model is dynamic, withtwo-directional relationships between each of thecomponents: system, outcomes, client, and inter-ventions. Interventions must always act throughthe system and client to affect the outcome. The sys-tem includes the hospital, skill mix, and demo-graphics. For this study, the system is representedby a rehabilitation hospital with a staff mix of regis-tered nurses, licensed practical nurses, nursingassistants, physical therapists, and occupationaltherapists participating in the application of theinterventions. In this model, interventions are bothdirect and indirect and include how they are deliv-ered. Table 1 outlines the interventions, the skillmix responsible for the interventions, and how theinterventions were monitored and measured. Cli-ents are those to whom the interventions are direc-ted. For this study, this would be female strokesurvivors. Some client characteristics may influencetheir ability to benefit from the interventions,including motivation, readiness, anxiety, anddepression. Outcomes are “operationalized in fivecategories: achievement of appropriate self-care,demonstration of health-promoting behaviors,health-related quality of life, perception of beingwell cared for, and symptom management” (p. 45).This study examined the effects of the interventionsproposed on female stroke survivors in an acute

rehabilitation hospital to determine if self-care (FIMbladder management score) and discharge to homewere improved.

The Setting

The setting for this project was a 115-bed acuteinpatient rehabilitation facility (IRF), located in asmall urban community in upstate New York. TheIRF has been admitting individuals after stroke forover 80 years. In this IRF, stroke survivors areadmitted to the neurovascular unit. A nationaldatabase (eRehabData) exists for IRFs to comparecharacteristics of individuals served and outcomes.This database served as the data repository for thisstudy. The stroke survivors admitted to this IRFwere of similar age, race, onset days, comorbidities,and functional abilities upon admission to those inthe region and nation, therefore minimizing threatsto external validity.

At this IRF, the rehabilitation management teamassembles each quarter to review the outcomes ofall of its programs. These outcomes are measuredby the FIM an 18-measure scale which measuresburden of care, or if the task is being performed bythe individual or a caregiver. FIM scores are deter-mined upon admission and discharge. The IRF sub-scribes to a national database (eRehabData) whichallows them to compare their outcomes to those of

Figure 1. Quality Health

OutcomesModel


Table

1.In

terventio

nsandProcesses

Interventions

Processes

Enhancedhistory

Tim

ed/p

romptedvoiding

Bathroom

training

Pelvic

floorexercises

Resp

onsible

discipline

RN

Allclinicalstaff

OT

PT

Required

educa

tion

These

were

addedto

the

electronic

admissiondatabase

currentlyin

use

.No

additionaltrainingwas

required.Staffwasinform

ed

asto

whenthese

questions

were

tobeadded

Individuals

were

offereda

toiletingopportunity

(commode/bathroom)

every

4hours.This

may

occ

urduringatherapy

session.Allstaffwas

educa

tedasto

theneed

forthis

program,the

expectedoutcomes,

andthesp

ecificsc

hedule

(asallindividuals

willnot

betoiletedatthesa

metime).

Thesc

hedule

wasentered

into

theEMRso

thatitwill

appearonthenursing

statusboard

andPCI

(printoutwithsp

ecific

questions)

Skillsare

notnew

forOTs.

Theywere

educa

tedon

theinitiativeand

requiredto

haveatleast

fivebathroom

training

sessionswitheach

individual(unless

determ

inedto

be

independent)during

thestay,reco

gnizing

thatdueto

thevarious

levels

ofdisability,OTs

willuse

clinicaljudgment

asto

whento

inco

rporate

this

into

theprogram

PTwithexpertiseandexperience

ininco

ntinence

clinicsto

train

PTstaffontheproper

instructionofpelvic

floor

exercises.

Nursingwere

taught

toreinforceperform

ance

of

these

exercises.

PTwilluse

clinicaljudgmentasto

when

theindividuals’co

gnitive

abilityallowsthese

tobe

inco

rporatedinto

theirprogram

Adherence

monitor

Completionofquestionsin

admissiondatabase

(EMR)

Increase

dfrequency

of

toiletingdocu

mentation

(EMR)

OTdocu

mentationin

daily

note

(EMR)

PTdocu

mentationin

dailynote

(EMR)

Managementof

intervention

fatigue

Postingofpercentageof

completionofthis

additionaldata

innursing

staffroom

Postingofoutcomesand

compliance

withprotoco

lonunitandin

nursing

staffroom

every

five

disch

arges,

notifica

tion

ofnursingmanagerof

outcomesforreinforcement,

notifica

tionofse

nior

managementfor

reinforcement


compliance

withprotoco

lonunitandin

OToffice

every

fivedisch

arges,

notifica

tionofOTmanager

ofoutcomesforreinforcement,

notifica

tionofse

niormanagement

forreinforcement


compliance

withprotoco

lon

unitandPToffice

every

five

disch

arges,

notifica

tionofPT

managerofoutcomesfor

reinforcement,notifica

tionof

seniormanagementfor

reinforcement

Outcome

100%

history

questions

completed

Decrease

dnumberofinco

ntinent

episodes,

decrease

dnumber

ofbladderaccidents,increase

dnumberoftoiletingepisodes

Increase

dindependence

intoiletingsk

ills

Decrease

dnumberofbladder

acc

idents,decrease

dnumber

ofinco

ntinence

episodes

Measu

reSignifica

ntch

angein

bladder

FIM

score

Significa

ntch

angein

bladder

FIM

score

Significa

ntch

angein

bladder

FIM

Note.EM

R,electronicmedicalrecord;FIM,FunctionalIndependenceMeasure;PT,physicaltherapy;OT,occupationaltherapy.



other subscribers. Program managers are responsi-ble for reviewing outcomes for the quarter, com-paring them to those of the region (New York, NewJersey, Pennsylvania) and nation, and reportingthem to the outcomes committee. In February 2009,the stroke program’s 2008 year-end statistics(n = 338) were reported. The onset days (the aver-age number of days from the date of the stroke tothe individual’s admission to the rehabilitationfacility) were compared to the nation and theregion. The length of stay was on average 3 dayslonger than the nation and 2 days longer than theregion. An average of 3% more of these individualswere discharged home than the national averageand 8% more than the regional average (Table 2).

Recognizing that on average the IRF receivesthe individual within a day of the nation andregion, their length of stay is on average 2–3 dayslonger, and a higher percentage of individuals dis-charged to home, the committee expected the FIMoutcomes to be better than the region and nation.The committee then compared each individualFIM item to those of the region and nation. In2008, 247 individuals were discharged from thefacility, 130, or 53%, were women. In 2008, themean admission bladder FIM score poststroke atthis IRF was, higher than the nation and region,indicating that individuals were admitted with lessbladder impairment than individuals in the regionand nation. The mean discharge bladder FIM scorefor the same population was compared to thenation and region. FIM change per day was alsocompared to the nation and region (Table 2). In2007, 309 stroke individuals were discharged fromthis facility after stroke, 136, or 44%, were women.The mean discharge bladder score for females was4.75 with mean onset days 12.8 (receiving individ-uals sooner), length of stay 16.6 days (dischargingindividuals significantly sooner), and FIM changeper day of 0.11. There were no changes in scoring

or documentation from 2007 to 2008, yet a 19%decrease in the mean discharge bladder FIM scoreoccurred. This was concerning to the facility’s out-comes committee as the facility was due forCommission on Accreditation of RehabilitationFacilities (CARF) recertification for its stroke spe-cialty program, and the outcomes for this programwere trending downward.

There were no additional cost or resource utili-zation expenses to the facility for implementationof this program as individuals are already receiving3 or more therapy hours per day and these inter-ventions were incorporated into these existing ses-sions. This allowed for immediate implementationof the interventions without impact to the facility’scurrent budget. As this is a modification to an exist-ing therapy program and all individuals/familiesparticipate in goal-setting with the interdisciplinaryteam, there was no human subjects review.

Population

The population is a nonrandom sample of femalestroke survivors admitted to the neurovascularunit of the IRF who have impaired bladder man-agement and are discharged during the study timeframe. Bladder management is defined per Centersfor Medicare and Medicaid Services (CMS) guide-lines as complete and intentional control of theurinary bladder and, if necessary, safe use ofequipment or medications for bladder control.Male patients were excluded as the largest declinein bladder management scores was among femaleindividuals. Those female individuals who wereusing intermittent straight catheterization or anindwelling catheter before their stroke wereexcluded from the study as their bladder manage-ment is unlikely to improve from their baselinestatus. Individuals who had receptive aphasiawere also excluded from this study as these indi-viduals had difficulty processing instructions. Indi-viduals must have had a 7-day or longer stay andbe discharged during the study time frame as theFIM scores are collected 24 hours before dischargeper CMS regulations. All individuals who met thecriteria participated in the study through theirscheduled therapy sessions.

Methods

As the facility was not satisfied with the decline inbladder FIM scores and the facility was scheduledfor a CARF survey on its stroke specialty programin January 2010, the executive management teamasked the first author to chair a committee toexamine this issue. The overall goal of this committeewas to research bladder management interventions

Table 2. 2008 Characteristics of

Rehabilitation Stay for Facility,

Region, andNation

Facility Region Nation

Onset DaysM 13.41 12.86 13.5

LOSM 21.25 19.05 18.5

Dischargehome (%)

63.13% 55.19 60.54

Mean BladderD/C FIM score

3.61 3.98 4.11

Bladder FIMchange per day

0.02 1.37 1.4


that were evidence based and appropriate forthe individuals served and to implement the iden-tified interventions with the goal of improvingbladder FIM scores as evidenced by greater FIMchange.

A committee was formed with staff membersfrom PT, occupational therapy (OT), nursing, medi-cal staff (NP—myself), social work, and the Pro-spective Payment System (PPS) coordinator (theindividual responsible for scoring the FIM) toexamine the bladder scoring process and the inter-ventions in use. The group began by examining thescoring of this item. The FIM is scored using theCMS 2002 guidelines. Bladder management isdefined as complete and intentional control of theurinary bladder and, if necessary, the safe use ofequipment or medication for bladder control (CMS,2004). The PPS coordinator is responsible forassigning an FIM score after reading all the docu-mentation from all of the disciplines. This docu-mentation is electronic and was designed by thePPS coordinator and other FIM experts at the facil-ity to capture all the information needed for scor-ing. After reviewing the documentation, scoringpractices, and the CMS guidelines, the committeedetermined that the scoring guidelines were beingfollowed and that scoring was not influencing thechange in bladder FIM scores.

The next step was to review what interventionswere being used for individuals with impairedbladder management. Indwelling catheters werebeing removed consistently upon admission andbladder scanning with straight catheterization wasbeing used for individuals with urinary retention.Other than these two interventions, it appeared thatthere were no standardized interventions to pro-mote independent bladder management. The medi-cal and nursing staff used many different bladderstrategies, and PT and OT seemed not to beinvolved at all in the bladder retraining process.The committee determined that an interdisciplinaryteam approach to this problem using evidence-based recommendations, initiated in a standardizedmanner, would improve bladder managementscores and therefore the individual’s quality of life.After a literature search and review, the interdisci-plinary team implemented the following interven-tions:

1. Enhanced bladder history. The admissiondatabase included the questions: “Inconti-nent?” (with a yes/no response) and “Cathe-ter?” (with a yes/no response). The followingwere added: Did you experience loss of urineprior to your stroke? Were you diagnosedwith incontinence and if so, what type (stress,

urge, functional)? Is your incontinence inter-mittent or continuous?

2. Timed and prompted voiding, which wouldoccur at specific times throughout the day. Ifthis timing were to occur during a therapysession, the therapist would be responsible forassisting the individual to the bathroom.Frequency to be initiated at every 2-hourtoileting, to be gradually increased to every4 hours.

3. Bathroom training programs to include cloth-ing management, device management (briefs/pull-ups), and peritoneal hygiene to be incor-porated into OT sessions and to be reinforcedby nursing.

4. Pelvic floor exercises to be incorporated intoPT sessions and to be reinforced by nursing.

Implementation of Interventions

Implementation was the responsibility of thespecific department with oversight from thecommittee. All involved staff members receivedtraining on the interventions. The enhanced historyquestions were added by a programmer into thecurrent electronic “Admission Database.” It is man-datory that this database be completed within1 hour of admission for every individual. The firstquestion “Did you experience loss of urine prior toyour stroke?” was mandatory, the remaining twoquestions were mandatory only if the answer to thefirst question was yes.

All individuals who had impaired bladder man-agement skills had “timed/prompted voiding q4h”added to the process interventions list of the EMR(this is the work list for the staff, and documenta-tion is attached to each task) by the primary RN.The nursing representative on the committee hadthe responsibility for ensuring that this wascompleted within 8 hours of admission.

The occupational therapists on the unit wereresponsible for initiating the bathroom trainingprogram. This program may not have been imple-mented immediately upon admission, as theindividual might not have been functionally readyto learn to manage these tasks. The OT on thecommittee was responsible for ensuring that thebathroom management program was initiatedwithin 10 days of admission. Pelvic floor exerciseswere the responsibility of the PT department.These exercises were easily incorporated into thecurrent PT program and were initiated on the firstday of therapy. The PT on the committee wasresponsible for ensuring each individual had agoal of being independent with a home pelvicfloor exercise program by discharge. Random



audits and EMR reviews were conducted by eachmember of the committee to ensure that theseinterventions were implemented. Each week atteam rounds, the RN was responsible for reportingon the individual’s bladder management status sothe entire team would know the individual'sprogress to date.

Sample. A comparison group, pretest/posttestdesign was implemented, comparing the admissionand discharge FIM scores of all female stroke survi-vors discharged in the first quarter of 2010 afterimplementation of the guidelines and the admis-sion and discharge FIM scores of an equal numberof female stroke survivors discharged immediatelybefore implementation. Although the comparisongroup received a rehabilitation program includingbladder management strategies, they did notreceive pelvic training exercises and specific bath-room training sessions. The nursing staff didencourage bathroom use, but did not provide forprompted/timed voiding at routinely scheduledtimes.

Data Collection. The FIM contains two bladderquestions. The first question collects ordinal-leveldata on the amount of assistance the individualrequires with bladder management tasks. Bladdermanagement is defined as the complete and inten-tional control of the bladder and is scored 0–7, withhigher scores indicating increasing levels of inde-pendence in the task, 7 being complete indepen-dence without a helper or device (CMS, 2004). Thesecond is based on a separate scale, also ordinal,which determines the number of accidents the indi-vidual has in a 7-day time period. Accidents aredefined as soiling of linen or clothing with urine,including bedpan and urinal spills. This item isscored 1–7 with 7 indicating no accidents and 1indicating five or more accidents in the past 7 days(CMS, 2004). Clinical staff must document answersto these two specific bladder questions using dropdown choices to eliminate extraneous data in theEMR. The most dependent score is used. Occupa-tional and physical therapists were involved in thedata collection along with all three levels of nursingstaff: nursing assistant, LPN, and RN. The staffmember who was working with the individual atthe time of bladder emptying was responsible fordocumenting in the EMR the amount of assistancerequired. Bladder data are collected each time theindividual empties her bladder either voluntarily orinvoluntarily.

Competency in documentation of functionalstatus is validated via annual exams where theclinician must pass a standardized exam created byeRehabData, with a score of 80 or greater and

demonstrate competence in documentation in theEMR. All data documented by the clinicians wereread by the facility's PPS coordinator, who wascharged with assigning the actual FIM score basedon the documentation. This score was then docu-mented in the EMR and uploaded to eRehabData.The PPS coordinator was charged with ensuringthe accuracy of all scores. Demographic data werealso documented in the EMR and uploaded intoeRehabData.

FIM scores were determined based on CMSguidelines—admission (or initial) scores were col-lected over the first 3 days after admission and dis-charge (or outcome) scores were collected 24 hoursbefore discharge. The lowest or most dependentscore was entered into the EMR. To determine effec-tiveness of the interventions, the bladder FIMchange (discharge score minus admission score) ofthe intervention group was compared to those ofthe comparison group.

Reliability. The FIM has been used in rehabilita-tion facilities since 1989 and in 2002 was acquiredby the CMS and incorporated into the IRF PPS.Original studies on the FIM found that it providesfor interrater reliability across different raters withvarying educational levels and professional back-grounds. The median interrater reliability valuewas .95 (Ottenbacher, Hsu, Granger, & Fiedler,1996). FIM is responsive to change in functionalabilities in stroke survivors and is not prone toceiling and floor effects (Dromerick, Edwards, &Diringer, 2003). A 2004 study in stroke survivorsfound that FIM is sensitive enough to captureminimal changes in functional abilities and hasbeen found to be both a valid and reliable mea-sure of Activities of Daily Living functioning inthis population (Kwon, Hartzema, Duncan, &Min-Lai).

Threats to Validity. As all women with impairedbladder management discharged from the IRF par-ticipated in the study, there is no opportunity forrandom selection, which increases the likelihood ofthreats to external validity. Another threat to theexternal validity is the unique setting of the IRF.These facilities have extensive therapy and nursingresources to allow for the intensive therapeutic ses-sions necessary to reinforce bladder managementinterventions. This reinforcement is less likely tooccur in an acute care hospital, subacute rehabilita-tion facility or in-home or outpatient therapy. With-out these resources, replication of results would beunlikely. A third threat to external validity wouldrelate to the population. As the facility already com-pares itself to national data, it is known that strokesurvivors admitted to this facility are similar in age,


onset day (time from stroke to admission to IRF),and comorbidities.

Internal validity was threatened by selectionbias. This was minimized by choosing a compari-son group, which was discharged immediatelybefore the implementation of the new bladder man-agement interventions. This eliminated the poten-tial of other treatment changes impacting thebladder scores. There has been only one significantchange in the characteristics of poststroke individu-als since the initiation of the database in 2002: anincreased number of women, which did not affectthe validity of the results as only women areincluded in this study. A second threat to internalvalidity was the use of multiple staff to implementinterventions and document findings. All clinicianspass a competency exam each year. The documen-tation was computerized and contained dropdowns which do not allow for free text; thereforethe questions can only be answered using FIMlanguage. The actual scoring was completed by thePPS coordinator who is a clinician and has been inthe role for 3 years. The implementation of theinterventions was monitored.

Results

A sample size of 40 was obtained. One individualwas eliminated from the study as she was indepen-dent with bladder management skills upon admis-sion, two became acutely ill and were transferredafter only 2 days, and two became acutely ill anddied. The sample 35 (postintervention group) wascompared to the last 35 women discharged in 2009(preintervention group). PASW version 18 (IBM,2010) was used to analyze the data.

The mean age of the preintervention group was75 years, compared to 70 years for the postinter-vention group, which was not significantlydifferent (p = .21). The onset days, the averagenumber of days from the date of the stroke to theindividual’s admission to the rehabilitation facility,for the preintervention group was 12.72 and for thepostintervention group it was 11.29; indicating thatthose in the postintervention group were admittedto the IRF sooner than those in the preinterventiongroup. The mean admission FIM score preinterven-tion was 1.4 and postintervention was 2.0. Therewas no statistically significant difference betweenthe means.

The mean bladder FIM change (discharge scoreminus admission score) before the implementationof the evidence-based guidelines was compared tothe bladder FIM change postintervention (Table 3)using ANOVA. Square root data transformationimproved the skewness to 0.14, so this variable was

used and the assumption of normality was met.Results (Table 4) were significant, F(67) = 6.87,p = .01, indicating that women who had receivedthe interventions experienced a significantly greatermean FIM change (2.83) in bladder FIM scorethan those who did not receive the interventions(1.57).

Fidelity of the Intervention

Fidelity is the extent to which the interventionsdelivered are “true” to those stated. It has fiveaspects; adherence (the interventions are deliveredas described), exposure (the amount of contentreceived), quality of the delivery, participantresponsiveness (engagement), and program differ-entiation (interventions can be distinguished fromother programs) (Dane & Schneider, 1998). Fidelitywas monitored and tracked on a weekly basisduring interdisciplinary team rounds (Attachment 1).If the intervention was not initiated, rationale for notincluding it was discussed among team membersand it was added if appropriate. Teammembers usedclinical judgment to determine if the individual couldsafely begin the bathroom training. Some individ-uals’ cognitive abilities delayed the implementationof pelvic floor exercises. Once the individual wasreceiving all of the interventions, they were no longertracked on the fidelity tool.

Timeline

An overview of this issue was presented to theNeurovascular team on November 5, 2009. Trainingfor each department occurred during the months ofNovember and December. Changes to the EMR to

Table 3. Preintervention and

Postintervention FIMChange

Preintervention(n = 35)

Postintervention(n = 35)

Mean SD Mean SD

1.6 (2.17) 2.83 (2.23)

Table 4. ANOVA Results: Bladder FIM

Change

Source ofvariance

Sum ofsquares df

Meansquare F p

Betweengroups

6.150 1 6.150 6.872 .011

Withingroups

59.961 67 0.895

Total 66.111 68

Note. Significant at the p < .05 level.



facilitate documentation of the interventions tookplace in December. Implementation began withthose who were inpatients as of January 1, 2010,and discharged after January 15, 2010. Data collec-tion was based on discharges of this cohort andtook place in January–March 2010. Re-education ofthe staff occurred as needed throughout data collec-tion. All data were uploaded to eRehabdata byApril 6, 2010.

Discussion

There were several limitations to this study. Thechanges in FIM gain and discharge destinationcould be influenced by the team’s focus on improv-ing outcomes for this population and not by theinterventions themselves. This study did not con-trol for differences in motivation, anxiety, or depres-sion between the two groups. These factors mayhave been responsible for the changes in bladderscores in the interventions group. With four sepa-rate interventions, it cannot be determined if anyone intervention alone was responsible for improv-ing outcomes or if it was the combination of inter-ventions responsible for the changes. This was asmall research utilization project, and replicationsof these results are necessary. This study onlyincluded female stroke survivors and it is unclear ifthese interventions will produce the same results inmen.

Monitoring fidelity was a time-consuming pro-cess. Nursing assistants play a vital role in thetimed/prompted voiding, and it was essential thatthey not only understand what to do, but why itwas important to do so. The intervention of timed/prompted voiding did place an additional burdenon the evening and night shifts, as there were fewernursing staff to provide the interventions. Inputfrom these staff members did conclude that timed/prompted voiding was easier than incontinencecare (changing linen, skin care). Providing continu-ous feedback and outcomes to staff was an impor-tant staff motivator.

The facility will focus on sustaining the pro-gram by continuing to track the documentation ofthe timed/prompted voiding, bathroom program,and pelvic floor exercises through the second quar-ter. If at this time it is determined that this hasbecome routine, tracking will be done randomly.This tracking will continue to be completed by thetask force. Outcomes will continue to be monitoredby the neurovascular program director andreported at the quarterly outcomes committee.Outcomes for the stroke program are posted quar-terly on the neurovascular unit for staff, visitors,and patients to view.

Conclusion

There are multiple bladder management interven-tions used in the care of stroke survivors, however,many are in use because “we have always done itthis way.” Facilities must examine their currentpractices and modify them to reflect evidence-based practice. There are several evidence-basedguidelines available for the management of inconti-nence that contain interventions that can easily beapplied to the female stroke population. Systematicand consistent implementation of these interven-tions by an interdisciplinary team requires staffeducation and constant monitoring to ensure com-pliance. Although this can be a time-consumingprocess, the efforts can lead to significant improve-ment in bladder management skills for femalestroke survivors.

About the AuthorMichele Cournan,DNP, RN, CRRN, ANP-BC, FNP isDirector of Clinical Operations at Sunnyview Rehabilita-tion Hospital, Schenectady, NewYork, NY. Addresscorrespondence to her at [email protected].

ReferencesAmerican College of Obstetricians and Gynecologists (2005).

Urinary incontinence in women. Obstetrics & Gynecology,105(6), 1533–1545.

American Heart Association (2009). Heart Disease and StrokeStatistics 2009 Update at-a-Glance. Retrieved June 15, 2009,from http://www.americanheart.org/downloadable/heart/1240250946756LS-1982%20Heart%20and%20Stroke%20Update.042009.pdf

Arnott, B., Abbott, R., et al. (2005). Clinical Guidelines for StrokeRehabilitation and Recovery. Melbourne, Australia: NationalStroke Foundation, 31–32.

Bates, B., Choi, J. Y., Duncan, P. W., Glasberg, J. J., Grahm, G.D., Katz, R. C. et al. (2005). Veterans Affairs/Department ofDefense clinical practice guideline for the management ofadult stroke rehabilitation care: Executive summary. Stroke,36, 2049–2056.

Brittain, K. R., Peet, M., & Castleden, C. M. (1998). Stroke andincontinence. Stroke, 29, 524–528.

Chan, H. (1997). Bladder management in acute care of strokepatients: A quality improvement project. Journal of Neuro-science Nursing, 29 (3), 187–190.

Key Practice Points• Incontinence post-stroke is common and can be a barrier to discharge to home.

• Evidence suggests that the largest impact on incontinence occurs in the acute reha-bilitation phase.

• Implementation of evidenced based interventions by an interdisciplinary rehabilita-tion team can influence discharge destination and bladder management skills infemale post-stroke patients.

• Systematic and consistent implementation of evidenced based interventions by aninterdisciplinary team requires staff education and constant monitoring to ensurecompliance.


CMS (2004). The Inpatient Rehabilitation Facility-Patient Assess-ment Instrument (IRF-PAI) Training Manual. Baltimore:CMS.

Cournan, M., Kautz, D. D., & Conrad, B. (2007). Chapter 7:Physical Healthcare Patterns and Nursing Interventions. InK. Mauk (Ed.), The Specialty Practice of Rehabilitation Nurs-ing: A Core Curriculum. (4th ed., pp. 92–123). Glenview, IL:Association of Rehabilitation Nurses.

Dane, A. V., & Schneider, B. H. (1998). Program integrity inprimary and early secondary prevention: Are implementa-tion effects out of control? Clinical Psychology Review, 18,23–45.

Dowling-Castronovo, A., & Bradway, C. (2008). Urinaryincontinence in older adults admitted to acute care. In: E.Capezuti, D. Zwicker, M. Mezey, & T. Fulmer, (Eds.), Evi-dence-based geriatric nursing protocols for best practice (3rded., pp. 309–336). New York: Springer Publishing.

Dromerick, A., Edwards, D., & Diringer, M. (2003). Sensitivityto changes in disability after stroke: A comparison of fourscales useful in clinical trials. Journal of RehabilitationResearch & Development, 40 (1), 1. Retrieved July 29, 2009,from Academic Search Premier database.

Dumoulin, C., & Korner-Bitensky, N. (2009). Urinary Inconti-nence. Retrieved June 10, 2009, from http://www.medicine.mcgill.ca/Strokengine/module_ui_intro-en.html

Dumoulin, C., Korner-Bitensky, N., & Tannenbaum, C. (2005).Urinary incontinence after stroke: does rehabilitation make adifference? A systematic review of the effectiveness of behav-ioral therapy. Topics in Stroke Rehabilitation, 12 (3), 66–76.

Duncan, P. W., Zorowitz, R., Bates, B., Choi, J. Y., Glasberg, J.J., Graham, G. D., et al. (2005). Management of adultstroke rehabilitation care: A clinical practice guideline.Stroke, 36, e100–e143.

Edwards, D. F., Hahn, M., & Dromerick, A. (2005). Post strokeurinary loss, incontinence and life satisfaction: When doespost-stroke urinary loss become incontinence? NeurologicalUrodynamics, 25, 39–45.

Finnish Medical Society Duodecim (2008). Urinary inconti-nence in women. In: EBM Guidelines. Evidence-Based Medi-cine [Internet]. Helsinki, Finland: Wiley Interscience.

Gelber, D. A., Good, D. C., Laven, L. J., & Verhulst, S. J.(1993). Causes of urinary incontinence after hemisphericstroke. Stroke, 24, 378–382.

IBM (2010). PASW. Retrieved January 12, 2010, from http://www-01.ibm.com/software/analytics/spss/products/statis-tics/advanced-statistics/

Kwon, S., Hartzema, A. G., Duncan, P. W., & Min-Lai, S.(2004). Disability measures in stroke: Relationship amongthe Barthel Index, the Functional Independence Measure,and the Modified Rankin Scale. Stroke, 35 (4), 918–923.

Maslow, A. H. (1943). A theory of human motivation.Psychological Review, 50, 370–396.

Massucci, M., Perdon, L., Agosti, M., Celani, M. G., Righetti,E., Recupero, E., et al. (2006). Prognostic factors of activitylimitation and discharge destination after stroke rehabilita-tion. American Journal of Physical Medicine & Rehabilitation,85 (12), 963–970.

Mitchell, P. H., Ferketich, S., & Jennings, B. American Acad-emy of Nursing Expert Panel on Quality Health Care.(1998). Quality of Health Outcomes Model (Image). Journalof Nursing Scholarship, 30(1), 43–36.

Nakayama, H., Jorgensen, H. S., & Pedersen, P. M. (2007).Prevalence and risk factors for incontinence after stroke.The Copenhagen stroke study. Stroke 28, 58–62.

National Stroke Foundation of Australia. (2007). Preventionand Management of Complications. Clinical Guidelines forAcute Stroke Management (39–42). Melbourne, Australia:National Stroke Foundation.

Ottenbacher, K. J., Hsu, Y., Granger, C. V., & Fiedler, R. C.(1996). The reliability of the functional independence mea-sure: A quantitative review. Archives of Physical Medicineand Rehabilitation, 77 (12), 1226–1232.

Patel, M., Coshall, C., Lawrence, E., Rudd, A. G., & Wolfe, C.D. (2001). Recovery from poststroke urinary incontinence:Associated factors and impact on outcome. Journal of theAmerican Geriatrics Society, 49 (9), 1229–1233.

Pettersen, R., Stien, R., & Wyller, T. B. (2006). Post-strokeurinary incontinence with impaired awareness of the needto void: Clinical and urodynamic features. BJU Interna-tional, 99, 1073–1077.

Registered Nurses’ Association of Ontario (RNAO) (2005).Promoting continence using prompted voiding. Toronto:Author.

Schmidt, N., & Brown, J. M. (2009). Evidence-based practice fornurses: appraisal and application of research. Sudbury, MA:Jones and Bartlett Publishers.

Thomas, L. H., Barrett, J., Cross, S., French, B., Leathley, M.,Sutton, C. , Watkins, C. (2005). Prevention and treatmentof urinary incontinence after stroke in adults. CochraneDatabase of Systematic Reviews 2005, Issue 3, Art. No.:CD004462. DOI: 10.1002/14651858.CD004462.pub2.

Thomas, L. H., Cross, S., Barrett, J., French, B., Leathley, M.,Sutton, C. , Watkins, C. (2008). Treatment of urinary incon-tinence after stroke in adults. Cochrane Database of Systema-tic Reviews 2008, Issue 1, Art. No.: CD004462. DOI:10.1002/14651858.CD004462.pub3.

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