Cournan
M. Rehabil
Nurs. 2012 Sep-Oct;37(5):220-30. doi: 10.1002/rnj.054. Epub 2012 Jul 26.
PMID: 22949275
Pelvic Physiotherapy Journal Club - January 8, 2014
Cindy Neville, PT, DPT, WCS, BCB-PMD
Director Women’s Health, Brooks Rehabilitation - Jacksonville, Florida
Aim of the article: To
determine if implementation of multidisciplinary comprehensive evidence based
intervention resulted in improved bladder management in female stroke survivors
in an inpatient rehabilitation setting
Why I picked this article:
§ The
majority of falls (25.4% )at Brooks Rehabilitation Hospital in 2013 were
related to toileting. The majority were on the stroke unit (35%)
§ Urinary
incontinence negatively affects stroke outcomes; increased infections, nephritis,
fungal dermatitis, wounds, falls, depression, DC to SNF
§ Specific
rehabilitation interventions for bladder control are not routinely offered as a
part of inpatient treatment of stroke, but might improve outcomes.
§ Stroke
survivors are not a targeted population for many pelvic PTs practicing in OP
clinics, but they should be. In a telephone interview study of 663 OTs and 656
PTs working in stroke rehabilitation in Canada
§ Brooks Rehabilitation
Hospital (IRF = Inpatient
Rehabilitation Facility)in Jacksonville
Florida
§ A Recent
systematic review ( Dumoulin 2005) found that “only four randomized clinical trials
(RCTs), one cohort study, and recommendations from three clinical practice
guidelines were found. There is limited evidence that bladder retraining with
urge suppression in combination with pelvic floor exercises results in
reduction of UI in male individuals with stroke. Further research is urgently
needed to elucidate clinical recommendations about the efficacy of behavioral
approaches”
§ Real life
clinical practice is different than research studies in scope and ability to
assess outcomes. This article describes a real life clinical program within the
context of research.
Background:
§
In 2006, stroke affected 6.5 million
Americans, approximately 3% of the population. The stroke death rate has
decreased to 29.7% from 1995 to 2005
§
6,500,000 stroke survivors are alive today;
a majority of these are women.
§
Women are more likely to have greater
disability resulting from their stroke than men and have a two times greater
incidence of urinary incontinence post stroke.
§
UI is a strong predictor of functional
recovery.
o
Incontinence in first-time stroke survivors
younger than 75 years was the best single predictor of disability at 3 months, with a
sensitivity of 60% and specificity of 78%.
o
Functional independence of a stroke
survivor 6 months post stroke was worse for the individual with incontinence
than for the continent individual.
§
Major mechanisms of bladder impairment after
stroke as the following: (1) disruption of neuromicturition pathways; (2)
stroke-related cognitive and language deficits; (3) motor impairment; and (4)
medication use.
Impetus
for the study:
The
IRF leadership was not satisfied with decline in bladder FIM (Functional
Independence Measures) scores pending CARF survey. A multidisciplinary team was
assembled to examine FIM scoring process (described below) and bladder
interventions. They found that no standard interventions to promote bladder
independence were being used in the IRF other than the removal of indwelling
catheters upon admission, and bladder scanning with straight catheterization
for individuals with retention.
Study Design: “research utilization
project”; non random prospective interventional design.
Subjects: 35 female stroke survivors admitted to the
neurovascular unit of the IRF who have impaired bladder management and are
discharged during the study time of 3 months. (original sample size of 40)
- Definition of bladder management: (per CMS 2004) complete and intentional control of the urinary bladder and, if necessary, safe use of equipment or medications for bladder control
Exclusion criteria: males,
use of catheter before stroke, receptive aphasia, length of stay < 7 days
Control group: 35 pre test post test
design comparing admission and discharge FIM scores of all female stroke
survivors discharged in first quarter prior to implementation
Outcomes: Mean bladder management score pre and post intervention
- Pre-intervention
bladder management FIM score = lowest score collected over the first 3
days of admission,
- post
intervention FIM score collected 24 hours within discharge.
Bladder management FIM contains 2 questions ; designed to
measure the burden of care and not individual function or quality of life.
1.
complete and intentional control of the urinary bladder scored
0–7, 7 being complete independence without a
helper or device
2.
second is the number of accidents the individual has in a 7-day time period.
Accidents are defined as soiling of linen or clothing with
urine, including bedpan and urinal spills. This item is scored 1–7
with 7 indicating no accidents and 1 indicating five
or more accidents in the past 7 days.
From the IRF-PAI : Inpatient Rehabilitation Facility –Patient Assessment
Instrument
FIM has interrater reliability of .95, responsive to change in stroke
Intervention Evidence based
rehabilitation interventions were agreed upon including
o
“enhanced bladder history” = comprehensive bladder
history including specific screening on admission to diagnose type of UI
o
pfm exercises provided by PT and reinforced
by nursing ( no description of how pfm exercises were taught or performed)
o
behavioral interventions: timed voiding and
prompted voiding starting 2 hours increasing to 4 hours as able
o
functional bathroom activities: provided by
OT reinforced by nursing clothing
management, hygiene, device management
Weekly
audits and EMR reviews conducted to ensure interventions were implemented with
status reports to team. Fidelity (adherence, exposure, quality of the delivery,
responsiveness, and program differentiation) was monitored and tracked on a weekly
basis until an individual was receiving all interventions.
Results
§ Mean Age
70 compared to mean age of 75 of control group , not significant
§ Onset
days from date of stroke: 11.29 vs 12.72- study group were admitted to the IRF
sooner than comparison group
§ Mean
admission FIM scores – not statistically different between groups
§ Mean
bladder FIM change score discharge score minus admission score : 2.283 for the
study group, 1.6 for the control group.
§
Bladder FIM Change: F = 6.87 p=.01
o ANOVA= One-Way Analysis of
Variance is a way to test the equality of three or more means at one time by
using variances. The total variation is
comprised the sum of the squares of the differences of each mean with the grand
mean. The
F test statistic is found by dividing the between group variance by the within
group variance.
Discussion:
§ Threats
to external validity:
o no
opportunity for random selection
increases likelihood of threats to external validity
o participants
receive extensive therapy and nursing care; unlikely to occur in other settings
o study
population already known to be similar to other IRF stroke populations
§ Threats
to internal validity:
o selection
bias was minimized by choosing a comparison group which was discharged
immediately before implementation
o use of
multiple staff to implement interventions
§ Limitations
o Change in
FIM may have been 2 to team’s focus on improved outcomes and not to the
interventions themselves
o Can not
determine if any one intervention was responsible for the improvements
o Only
females were studied
§ Burden of
intervention
o Monitoring
fidelity was time consuming
o Nursing
assistants critical, continuous feedback important for staff motivation
Questions for Group Discussion
§ Where
does urgency frequency without incontinence fit into this picture?
§ How many
of you are actively developing referrals of patients post-stroke with bladder
management problems in your practices?
§ How do
you see this population as being different than your typical outpatient
population
§ Are there
opportunities to partner with local IRFs to encourage rehabilitation based care
in the hospital? Home care? SNF?
Additional References:
Dumoulin C, Korner-Bitensky N, Tannenbaum C .Urinary incontinence after
stroke: identification, assessment, and intervention by rehabilitation
professionals in Canada. Stroke.
2007 Oct;38(10):2745-51. Epub 2007 Sep 6.
Dumoulin C, Korner-Bitensky N, Tannenbaum C. Urinary incontinence after
stroke: does rehabilitation make a difference? A systematic review of the
effectiveness of behavioral therapy. Top
Stroke Rehabil. 2005 Summer;12(3):66-76.
IRF-PAI : Inpatient Rehabilitation Facility –Patient Assessment
Instrument
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