Development of screening and assessment tools for
continence management in residential aged care
Research team
Professor Bev O’Connell
A/Professor David Fonda
Ms Keren Day
Ms Joan Ostaszkiewicz
Dr Mary Hawkins
Dr Cadeyrn Gaskin
Dr Jaya Pinikahana
Prepared for the Department of Health and Ageing
November 2006
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Development of screening and assessment tools for continence management in
residential aged care
© Deakin University 2006
Published by Deakin University, Geelong, Victoria 3217, Australia
This project was funded by the Department of Health and Ageing as part of the
National Continence Management Strategy
Disclaimer:
As an independent consultancy report, this document does not necessarily reflect the
views of the Australian Government, but has been published to encourage further
discussion on this important issue.
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Acknowledgements
The project team would like to acknowledge and express our sincere gratitude to a
number of people for their contributions.
Members of the key stakeholder advisory group:
Ms Rowan Cockerell, Director Residential Services, Malvern Elderly Citizens
Welfare Association Community Care, East Malvern
Mr Craig Clarke, Consultant Geriatrician, Eastern Health, The Peter James Centre,
Forest Hills
Ms Susan McCarthy, Coordinator, Continence Foundation of Australia (Victorian
Branch), Victorian Continence Resource Centre
Ms Annie Truscot, RN, Edward Street Nursing Home, Eastern Health, Upper Ferntree
Gully
Ms Anne Robinson, Director Residential Services, Australian Nurses for Continence
The Continence Outcomes Measurement Experts:
Ms Jan Sansoni, Centre for Health Service Development, University of Wollongong
Mr Nicholas Marosszeky, Centre for Health Service Development, University of
Wollongong.
We would also like to acknowledge Kate Macdonald and Jacinta Miller for their
editorial comments and research assistance
This project was funded by the Department of Health and Ageing as part of the
National Continence Management Strategy
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Contents
EXECUTIVE SUMMARY ......................................................................................... 5
INTRODUCTION ........................................................................................................ 7
METHOD ..................................................................................................................... 9
1. UPDATE THE DATABASE OF CONTINENCE SCREENING AND ASSESSMENT TOOLS ................................................................................................................ 9
2. UPDATE THE TOOL EVALUATION CHECKLIST .................................................. 10 3. EVALUATE THE SCREENING AND ASSESSMENT TOOLS .................................... 11 4. DRAFT STANDARD TOOLS ................................................................................ 11 5. CONSULTATION WITH KEY STAKEHOLDERS..................................................... 12
OUTCOMES AND DELIVERABLES .................................................................... 14
AN UPDATED DATABASE OF CONTINENCE SCREENING AND ASSESSMENT TOOLS ... 14 AN UPDATED EVALUATION CHECKLIST ................................................................... 15 EVALUATION AND RANKING OF CONTINENCE SCREENING AND ASSESSMENT
TOOLS .............................................................................................................. 15 EARLY VERSIONS OF DRAFT STANDARD TOOLS AND CONSULTATION WITH KEY
STAKEHOLDERS ............................................................................................... 15 A FINAL SET OF DRAFT STANDARD TOOLS FOR THE SCREENING AND
ASSESSMENT OF INCONTINENCE ...................................................................... 16 1. Initial Standard Continence Screening Form for Residential Aged Care ........ 16 2. Standard Bladder Chart for Residential Aged Care ......................................... 17 3. Standard Bowel Chart for Residential Aged Care ........................................... 17 4. Standard Continence Assessment and Care Plan Form for Residential Aged Care ...................................................................................................................... 17 Continence Care Flow Chart for Residential Aged Care ..................................... 18
RECOMMENDATIONS ................................................................................................ 18
REFERENCES ........................................................................................................... 19
APPENDIX A: UPDATED EVALUATION CHECKLIST ................................................... 22 APPENDIX B: INITIAL STANDARD CONTINENCE SCREENING FORM FOR RAC .......... 23 APPENDIX C: STANDARD BLADDER CHART FOR RAC ............................................. 24 APPENDIX D: STANDARD BOWEL CHART FOR RAC ................................................ 25 APPENDIX E: STANDARD CONTINENCE ASSESSMENT AND CARE PLAN FOR RAC ... 26 APPENDIX F: STANDARD CONTINENCE FLOW CHART FOR RAC .............................. 32
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Executive Summary
More than 159,000 elderly people live in residential aged care (RAC) facilities in
Australia (Australian Institue of Health and Welfare [AIHW], 2006a) and most of
these residents require assistance with toileting (68%) and their bladder (68%), and
bowel (83%) management (AIHW, 2006b). The use of best practice assessment and
management protocols for continence care is of fundamental importance to the
delivery of care for the elderly. The purpose of this project, commissioned by the
Department of Health and Ageing, was to develop screening and assessment tools for
continence management in RAC.
To develop the continence screening and assessment tools, the database of screening
and assessment tools, developed by O’Connell et al. (2005), was used as a basis for
the project. A review of recent literature and a search of websites of peak continence
bodies and companies that sell continence products revealed that no new tools were
available for evaluation. To evaluate the tools in the database, the O’Connell et al.
Continence Resource Evaluation Checklist was updated with information from the
International Consultation on Continence (Fonda et al., 2005), Residential Care
Manual (Department of Health and Ageing, 2005), Minimum Data Sets (Centers for
Medicare and Medicaid Services, 2002), and advice from a key stakeholder advisory
group.
The top ten assessment and management tools listed in the O’Connell et al. (2005)
report and selected items from the Continence Outcomes Management Suite of
instruments (Thomas et al., 2006) were used to inform the development of the
continence screening and assessment tools. Care was taken to ensure using language
that was appropriate to the education and experience of the different levels of RAC
staff. The draft tools went through several revisions following consultation with
members of a key stakeholder advisory group, outcomes measurement experts, and
staff of the Department of Health and Ageing, before the final version was produced.
This suite of tools comprised the following forms:
Initial Standard Continence Screening Form for Residential Aged Care.
Standard Bladder Chart for Residential Aged Care.
Standard Bowel Chart for Residential Aged Care.
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Standard Continence Assessment and Care Plan Form for Residential Aged
Care.
In addition, a Continence Care Flow Chart for Residential Aged Care was developed
to assist in providing directions for the use of these standard tools.
The following recommendations are made to ensure that the standard tools are
appropriate and acceptable for use in RAC settings:
1. The draft standard tools should be trialled and evaluated to ensure that they
assist staff with different levels of knowledge and expertise to make
appropriate clinical decisions about the continence care of residents.
2. Implementing the draft standard tools should be underpinned by a national
coordinated education program for the assessment, management, and
promotion of continence in RAC. This program should incorporate current
education resources and ensure all RAC facilities have access to those
materials and programs.
During the consultative process the key stakeholder advisory group made the
following recommendations:
1. The draft standard tools should be recommended for use as a matter of
routine in RAC settings.
2. The draft standard tools should be made available to RAC facilities in
electronic form.
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Introduction
Incontinence is a common and costly health issue that residential aged care (RAC)
facilities in Australia are required to manage. In 2005, there were 2,933 mainstream
RAC facilities in this country providing accommodation and care for 159,532
residents (AIHW, 2006a). Analysis of 2003 data from the Australian Bureau of
Statistics, indicated that 68% of permanent residents required assistance with
toileting, 68% needed support with bladder management, and 83% required support
with bowel management (AIHW, 2006b). Data on the cost of delivering incontinence
care in Australian RAC facilities are not readily available; however, the estimated cost
in a sub-acute setting is $49 per person per day (Morris et al., 2005).
Among frail, elderly people, incontinence coexists with physical, cognitive,
functional, and social issues (Fonda et al., 2005). The presence of comorbidities
complicates the assessment of incontinence in RAC. The three main objectives to the
basic assessment of frail elderly patients with incontinence are
To identify potentially reversible causes and contributing factors
To determine the need for further investigation
To develop a management plan (Ouslander, 2000).
There are a number of resources that have been developed to facilitate the assessment
of continence in RAC facilities. O’Connell et al. (2005) evaluated 76 such resources
against criteria from the International Continence Society (ICS) and World Health
Organisation (WHO) for the assessment of incontinence in the frail elderly (Fonda et
al., 2002). The evaluation criteria used by O’Connell et al consisted of 28 clinical
symptoms and 15 factors that contribute to incontinence. The project found that
Most tools did not have sufficient items to meet the criteria for assessing
voiding patterns and symptoms
Some tools did not include bowel charts and bladder charts
Most tools did not provide cues to guide the diagnosis, management, and
evaluation of incontinence
Tools with strengths in some aspects of incontinence assessment typically had
weaknesses in other areas
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The levels of expertise of staff (e.g., registered nurse and personal care
assistant) for whom the resources were designed were not identified in most
of the tools.
Despite shortcomings in many of the tools reviewed, most did contain sufficient
criteria to form the basis for developing standardised continence assessment tools.
From these findings, O’Connell et al. (2005) recommended that standard tools be
developed for the assessment, planning, and evaluation of incontinence in RAC.
The objective of this project is to develop a draft set of user-friendly standard tools to
screen and assess the continence care of residents in residential aged care facilities.
This report outlines the development of such screening and assessment tools for
continence management in RAC and contains copies of the tools. In producing these
screening and assessment tools, the following tasks were performed:
1. The database of continence assessment and management tools that was
developed during the O’Connell et al. (2005) project was updated to
incorporate tools published since the conclusion of the project, including those
identified in the Continence Outcomes Measurement Suite Project (Thomas et
al., 2006).
2. The continence tool evaluation checklist developed by O’Connell et al. was
updated.
3. The newly developed tools, and those from the Continence Outcomes
Measurement Suite Project (Thomas et al.), were evaluated using the checklist.
Tools evaluated in the O’Connell et al. project were further evaluated with the
additional criteria in the checklist.
4. Components or parts of highly ranked tools were used to develop the standard
tools.
5. Stakeholders were consulted and involved in the ongoing development of the
standard tools.
6. A final set of standard tools was produced.
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Method
The project objectives were addressed through undertaking five tasks described in the
following section.
1. Update the Database of Continence Screening and Assessment
Tools
The database of assessment and management tools developed during the O’Connell et
al. (2005) study was updated and used as the basis for developing screening and
assessment tools, with cues for management. This database contained 76 tools for the
assessment and management of continence in RAC facilities. To update this database,
a search of the academic and grey literature was undertaken.
To update the previous review of literature by O’Connell et al. (2005), a search of
health literature databases (Medline, Pubmed, CINAHL, PsycINFO, Cochrane
Library) was conducted using the terms “continence”, “incontinence”, “tools”,
“instruments”, “residential aged care”, “elderly”, and “assessment guidelines”
separately and in combination. Parameters for the search was the period from January
2003 to June 2006. Publications were selected that represented guidelines, primary
research or systematic reviews of primary research specifically addressing the
assessment and management incontinence in frail older adults. A contemporary text
on incontinence produced by an international consultation on incontinence was
reviewed with particular attention to recommendations for continence assessment and
management in frail older adults (Abrams, Andersson, Brubaker, Cardozo, Cottenden,
Denis, et al., 2005). Tools relevant to this project were also identified from those
recommended for use in the Continence Outcomes Measurement Suite (Thomas et al.,
2006).
A search of the websites of several personal hygiene companies (Hygiene Australasia,
Tyco, Sutherland Medical, Kimberly Clark, Australian Pacific Paper Products, and
Coloplast) was undertaken to establish whether those companies had produced, and
made freely available, any continence assessment tools.
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The websites of 19 prominent national and international peak bodies with expertise in
continence or urology (e.g., American Urological Association, Canadian Continence
Foundation, Continence Foundation [UK]) were searched to attempt to locate
screening and assessment tools.
2. Update the Tool Evaluation Checklist
To facilitate the development of standard screening and assessment tools to meet best
practice continence care of the frail elderly person and the requirements of the
Department of Health and Ageing, the continence tool evaluation checklist, as
proposed by O’Connell et al. (2005), was updated. Criteria for the updated evaluation
checklist were developed from
The International Consultation on Incontinence’s (ICI) recommendations on
continence assessment and management for the care of the frail elderly (Fonda
et al., 2005). These recommendations were an updated version of those
previously published by Fonda et al. (2002). This report informed the
development of the O’Connell et al. (2005) tool evaluation checklist.
The continence assessment and management standards published in the
Residential Care Manual (Department of Health and Ageing, 2005). This
manual is a guide to the operation and financial support of Australian
Government-funded RAC facilities. These standards are important because
they adhere to the legislative requirements of the Aged Care Act 1997 and the
Aged Care (Consequential Provisions) Act 1997.
The Minimum Data Sets (MDS) – Version 2.0. The MDS was designed by the
Centers for Medicare and Medicaid Services (CMS) in the USA for nursing
home resident assessment and care screening (CMS, 2002).
Advice from the key stakeholder advisory group that resident preferences
should be considered in the development of continence management
strategies. This advice reflects the continence management guidelines of the
American Medical Directors Association (AMDA, 2006), in which seeking
patient preferences is recommended in the development of care plans.
The updated evaluation checklist included questions pertaining to both urinary and
faecal incontinence, cues for treatment and management options linked to diagnoses,
and cues for the evaluation of treatment and management plans.
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3. Evaluate the Screening and Assessment Tools
The top 10 tools from the O’Connell et al (2005) report were further evaluated in the
current study using the updated checklist. These 10 tools were chosen because they
were the highest ranking tools using the O’Connell et al. checklist (incorporating four
broad areas of criteria: assessment of urinary and faecal incontinence symptoms,
assessment of factors contributing to incontinence, urinary and faecal incontinence
management, design quality), which included criteria similar to that of the updated
checklist. Additionally, the outcomes measurement experts identified questions from
the instruments in the Continence Outcomes Measurement Suite (Thomas et al., 2006)
that best complied with items on the updated evaluation checklist.
4. Draft Standard Tools
Draft standard tools were developed through the inclusion or adaptation of questions
from the highest ranked existing tools. Questions were selected for the screening and
assessment of both urinary and faecal incontinence. Selected questions included those
with cues for treatment and management options linked to diagnoses and cues for the
evaluation of treatment and management plans. The Aged Care Funding Instrument
(ACFI; Department of Health and Ageing, 2006) was examined to identify items that
would be assessed as part of the usual process when a person is admitted to a RAC, to
prevent duplication of assessment questions.
The draft standard tools were directly linked to the evaluation checklist criteria and, as
such, incorporated questions designed to assess levels of urinary and faecal
incontinence; assess factors contributing to incontinence in frail, elderly people (such
as mobility, mental status, diet, medications, and environmental barriers); provide
cues to health care workers alerting them to the treatment and management options
linked to diagnoses; and provide cues to health care workers to evaluate treatment and
develop management plans (outcome measures). Attention was given to the design of
the draft standard tools and, in particular, the language used in the tools and the levels
of education and experience health care workers would need to use them effectively.
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5. Consultation with Key Stakeholders
The consultative process involved key stakeholders from three groups:
1. Key stakeholder advisory group. This group included staff from RAC facilities,
health professionals with expertise in the area of incontinence (geriatricians and
continence advisors), and representatives from peak bodies that specialise in
continence promotion. Members of the key stakeholder advisory group are
outlined in the Table 1.
Table 1
Members of the Key Stakeholder Advisory Group
Name Position title Affiliation
Ms Rowan Cockerell Director Residential
Services
MECWA – Malvern Elderly Citizens
Welfare Association
Dr Craig Clarke Consultant Geriatrician
Ms Susan McCarthy Coordinator Continence Foundation of Australia
(Vic Branch) Victorian Continence
Resource Centre
Ms Annie Truscott Registered Nurse (Div 1) Eastern Health, Edward Street Nursing
Home
Ms Anne Robinson Director Residential
Services
Australian Nurses for Continence
The key stakeholder advisory group was established at the outset of the project to
assist the project team to judge the appropriateness of the content to be included in the
standard tools. The key stakeholder advisory group met on two occasions and
additional advice and comment on versions of the draft standard tools was obtained
from them via email.
2. Outcomes measurement experts. The project team consulted two outcomes
measurement experts: Jan Sansoni and Nick Marosszeky from the Centre for Health
Service Development, University of Wollongong. These experts were members of the
team that produced the Continence Outcomes Measurement Suite (Thomas et al.,
2006). The project team regularly sought the advice of the outcomes measurement
experts via teleconferences and email.
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3. Department of Health and Ageing. Staff from the Department of Health and Ageing
were provided with copies of the draft tools. Their comments on the tools were
included in later versions of the drafts.
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Outcomes and Deliverables
An Updated Database of Continence Screening and Assessment Tools
A search of the academic literature found no new tools for the screening, assessment,
and management of incontinence in RAC. A search of the internet websites of peak
bodies that provide continence services and companies that sell continence products
did not reveal any new tools.
The outcomes measurement experts identified five instruments with items suitable for
inclusion in the standard tools. The instruments and their constituent items that were
adapted for use during development of the standard tools for RAC were
1. Wexner Faecal Incontinence Symptom Scoring System (Jorge & Wexner,
1993):
• Does the resident leak, have accidents or lose control with solid stool/
bowel motion?
• Does the resident leak, have accidents or lose control with liquid stool/
bowel motion?
2. Bristol Female Lower Urinary Tract Symptom Questionnaire (Jackson et al.,
1996):
• If the resident is experiencing a bladder problem, how much of a problem
is this for them?
• If the resident is experiencing a bowel problem, how much of a problem is
this for them?
3. King’s Health Questionnaire (Kelleher, Cardozo, Khullar, & Salvatore, 1997):
• Does the incontinence and/or need to pass urine disturb the resident’s
sleep?
4. Incontinence Severity Index (Sandvik et al., 1993):
• How often is urine loss experienced?
• How much urine is lost each time?
5. Urogenital Distress Inventory (Shumaker et al., 1994):
• Do you experience urine loss related to the feeling of urgency?
• If yes, how much are you bothered by it?
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Because the original items from the above mentioned instruments were modified for
use in the development of the RAC draft standard tools, the psychometric properties
of these tools need to be established.
An Updated Evaluation Checklist
The updated evaluation checklist contains all of the 43 items from the O’Connell et al.
(2005) checklist, with two additional items. The first item was from the MDS (CMS,
2002) and referred to change in urinary continence. The second item was from the
AMDA (2006) and referred to patient preferences. The evaluation checklist covered
symptoms of urinary and faecal incontinence, factors that contribute to incontinence,
cues for treatment and management options linked to diagnoses, and design quality
criteria. The final updated evaluation checklist is shown in Appendix A.
Evaluation and Ranking of Continence Screening and Assessment
Tools
Because no new continence screening and assessment tools were identified from the
recent academic and grey literature, only the top 10 tools from the O’Connell et al.
(2005) report and those items identified by the outcomes measurement experts were
evaluated against the updated checklist criteria. None of the tools met all of the
updated evaluation checklist criteria. Items could be drawn, however, from the 10
highest ranking continence tools (O’Connell et al.) and the selection of continence
outcome measurement items to cover all the updated checklist criteria.
Early Versions of Draft Standard Tools and Consultation with Key
Stakeholders
Several iterations of the tools were developed by the project team in consultation with
the key stakeholder advisory group and the Outcomes Measurement Experts group.
This consultation process took into account the context of RAC, the nature and
functionality of frail elderly residents, and a need to incorporate some valid and
reliable outcome measures. Some difficulties were experienced identifying valid and
reliable outcome measures for this group of elderly people, hence, some measures
were adapted to accommodate this population.
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A Final Set of Draft Standard Tools for the Screening and
Assessment of Incontinence
The final set of draft standard tools contains items that address 44 of the 45 updated
evaluation checklist criteria (as shown in Appendix A). The item on the updated
evaluation checklist criteria relating to the assessment of post-void residual was not
included in the standard tools because of limitations associated with currently
available methods for conducting this assessment. These methods include bladder
scanning and urinary in-out catheterisation. The limitations associated with bladder
scanning are that most RAC facilities do not have access to the appropriate equipment
or staff with the level of expertise to perform the scan and interpret the results.
Performing in-out catheterisation on the frail elderly is unnecessarily invasive and
may expose these patients to the risk of urinary tract infection.
The final set of draft standard tools contain items that assess levels of urinary and
faecal incontinence symptoms and the factors that contribute to incontinence in the
frail elderly (e.g., mobility, mental status, diet, medications, environmental barriers).
The items also provide cues to health care workers for the treatment of incontinence
and management options linked to diagnoses and the evaluation of treatment and
management plans (outcome measures). Four draft standard tools for continence
screening and assessment in RAC were developed.
1 Initial Standard Continence Screening Form for Residential Aged Care
(Appendix B)
2 Standard Bladder Chart for Residential Aged Care (Appendix C)
3 Standard Bowel Chart for Residential Aged Care (Appendix D)
4 Standard Continence Assessment and Care Plan Form for Residential Aged
Care (Appendix E).
A Continence Care Flow Chart for Residential Aged Care (Appendix F) was
developed to accompany the draft standard tools.
1. Initial Standard Continence Screening Form for Residential Aged Care
The Initial Standard Continence Screening Form was designed to establish whether
the resident has bladder problems, bowel problems, or both. The screening form
indicates whether the incontinence needs to be further assessed, but is not used to
16
investigate the severity or the frequency of incontinence. This tool is designed to be
completed within 48 hours of admission to a RAC facility. If a resident is unable to
answer questions, the tool can be completed by documenting observations or by
asking a family member or other staff member. The response format was chosen to
simplify the decision-making process. The time required for the completion of this
initial screening tool is estimated to be less than 5 minutes.
2. Standard Bladder Chart for Residential Aged Care
The Standard Bladder Chart should be completed for three whole days as a
component of the continence assessment. This tool prompts the health care worker to
document the resident’s bladder voiding at six times throughout each 24-hour period.
There is provision on the chart to make additional relevant comments, for example, to
note that the resident was unable to find a toilet.
3. Standard Bowel Chart for Residential Aged Care
The Standard Bowel Chart should be completed for seven whole days as a component
of the continence assessment. This tool prompts the health care worker to document
the resident’s bowel voiding at six times throughout each 24-hour period. Included is
an allowance to describe the type of bowel movements with reference to the Bristol
Stool Form Scale and to make additional relevant comments. Permission was obtained
to use the Bristol Stool Form Scale from the copyright holder, Norgine Limited.
4. Standard Continence Assessment and Care Plan Form for Residential Aged
Care
The Standard Continence Assessment and Care Plan Form should be completed
within 28 days of admission. The Standard Continence Assessment and Care Plan
Form contains items relating to urinary and faecal continence issues, factors that
influence continence, and continence-related quality of life issues. This form is to be
completed in conjunction with the standard bladder and bowel charts. Some of the
information collected as part of the continence assessment overlaps with items in the
ACFI (Department of Health and Ageing, 2006). Where this occurs, the information
from the ACFI can be used to complete the assessment and care plan. Specifically, the
ACFI items 1 to 9 can provide information relevant to items 1 to 25 of the Standard
Continence Assessment and Care Plan Form and ACFI items 11 to 14 can provide
information relevant to item 26 of the Standard Continence Assessment and Care Plan
17
Form. The Standard Continence Assessment and Care Plan Form provides numerous
continence care options that can be used to form management plans for residents.
Continence Care Flow Chart for Residential Aged Care
The Continence Care Flow Chart is designed to accompany the standard tools and
provide a simple path for care staff of all levels to follow. The flow chart takes into
account the health status of residents on admission and also allows for changes in the
health status of residents during their stay in the RAC facility.
Recommendations
The following recommendations are made to ensure that the standard tools are
appropriate and acceptable for use in RAC settings:
1. The draft standard tools should be trialled and evaluated to ensure that they assist
staff with different levels of knowledge and expertise to make appropriate clinical
decisions about the continence care of residents.
2. Implementing the draft standard tools should be underpinned by a national
coordinated education program for the assessment, management, and promotion of
continence in RAC. This program should incorporate current education resources
and ensure all RAC facilities have access to those materials and programs.
During the consultative process the key stakeholder advisory group made the
following recommendations:
1 The draft standard tools should be recommended for use as a matter of routine in
RAC settings.
2 The draft standard tools should be made available to RAC facilities in electronic
form.
18
References
Abrams, P., Andersson, K.E., Brubaker, L., Cardozo, L., Cottenden, A., Denis, L.,
Donovan, J. et al. (Eds.). (2005). 3rd International consultation on
incontinence: Recommendations of the International Scientific Committee.
Plymouth, UK: Plymouth Distributors Ltd.
American Medical Directors Association. (2006). Urinary incontinence: Clinical
practice guidelines. Columbia, MD: AMDA.
Australian Institute of Health and Welfare. (2006a). Residential aged care in
Australia 2004-2005: A statistical overview (AIHW cat. no. AGE 45).
Canberra, Australia. AIHW. (Aged Care Statistics Series no. 22).
Australian Institute of Health and Welfare. (2006b). Australian incontinence data
analysis and development (AIHW cat. no. DIS 44). Canberra, Australia.
AIHW.
Centers for Medicare and Medicaid Services. (2002). Minimum data set – Version
2.0: For nursing home resident assessment and care screening. Retrieved
September 5, 2006 from
http://www.cms.hhs.gov/NursingHomeQualityInits/Downloads/MDS20MDS
AllForms.pdf
Department of Health and Ageing. (2005). Residential care manual. Canberra,
Australia: Department of Health and Ageing.
Department of Health and Ageing. (2006). Aged Care Funding Instrument. Canberra,
Australia: Department of Health and Ageing. Retrieved October 17, 2006 from
http://www.health.gov.au/internet/wcms/publishing.nsf/Content/F59750625F7
F267ACA256F190010121D/$File/acfiassesstools.pdf
Fonda, D., Benvenuti, F., Cottenden, A., DuBeau, C., Kirshner-Hermans, R., Miller,
K. et al. (2002). Urinary incontinence and bladder dysfunction in older
persons. In P. Abrams, K. E. Andersson, W. Artibani, L. Brubaker, L.
Cardoza, D. Castro, et al. (Eds.). 2nd International consultation on
incontinence: Recommendations of the International Scientific Committee (pp.
625–695). Plymouth, UK: Plymouth Distributors Ltd.
Fonda, D., DuBeau, C. E., Harari, D., Ouslander, J. G., Palmer, M., & Roe, B. (2005).
Incontinence in the frail elderly. In P. Abrams, K. E. Andersson, L. Brubaker,
L. Cardozo, A. Cottenden, L. Denis, J. Donovan, et al. (Eds.). 3rd International
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consultation on incontinence: Recommendations of the International Scientific
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Jackson, S., Donovan, J., Brookes, S., Eckford, S., Swithinbank, L., & Abrams, P.
(1996). The Bristol Female Lower Urinary Tract Symptoms Questionnaire:
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812.
Jorge, J., & Wexner, S. (1993). Etiology and management of faecal incontinence.
Diseases of the Colon and Rectum, 36, 77-97.
Kelleher, C. J., Cardozo, L., Khullar, V., & Salvatore, S. (1997). A new questionnaire
to assess the quality of life of urinary incontinent women. British Journal of
Obstetrics and Gynaecology, 104, 1374-1379.
Morris, A. R., Ho, M. T., Lapsley, H. L., Walsh, J., Gonski, P., & Moore, K. H.
(2005). Costs of managing urinary and faecal incontinence in a sub-acute care
facility: A “bottom-up” approach. Neurourology and Urodynamics, 24, 56-62.
O’Connell, B., Day, K., Hunt, S., Jennings, H., Ostaszkiewicz, J., & Hawkins, M.
(2005). Evaluation of resources for the promotion of continence in residential
aged care: A national consultative approach. Melbourne, Australia: Deakin
University.
Ouslander, J. G. (2000). Intractable incontinence in the elderly. British Journal of
Urology International, 85, 72-78.
Sandvik, H., Hunskaar, S., Seim A., Hermstad, R., Vanvik, A., & Bratt, H. (1993).
Validation of a severity index in female urinary incontinence and its
implementation in an epidemiological survey. Journal of Epidemiology and
Community Health, 47, 497-499.
Shumaker, S. A., Wyman, J. F., Ubersax, J. S., McClish, D., & Fantl, J. A. (1994).
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The Incontinence Impact Questionnaire and the Urogenital Distress Inventory.
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Appendix A: Updated evaluation Checklist
ICI Criteria for Continence Assessment1
Clinical Symptoms Features of the
New Tools Voiding patterns and symptoms? (Bladder Chart) and Assessment tool Bowel patterns and symptoms? (Bowel Chart) and Assessment tool
Bladder Chart Bladder chart for minimum of 3 days? Times of voiding and/or incontinence? Voided volumes? (small, medium, large) Estimate of degree of leakage (incontinence)? Number of pads/clothing changes? Assessment of urgency? Description of associated circumstances? Times resident goes to bed and rises? (In bladder and bowel chart) Fluid intake? Clear instructions for charting? Change in urinary incontinence (referred to in the flow chart)2
Bowel Chart Bowel chart for 3 to 7 days? Times of bowel motions and/or incontinence? Size/amount of bowel motion/incontinence? Type of faecal incontinence (solid/liquid/gas)? Number of pad/clothing changes? Assessment of faecal urgency? Description of associated circumstances? Description of effects on QOL? Clear instructions for charting?
Bother and QOL issues (including impact on ADLs)? Aids and appliances used? Physical examination conducted by appropriately trained staff (prompts to refer
prompts to assess skin) Urinalysis/MSU investigations Post-void residual investigations (Sites do not have appropriate equipment or
level of expertise to perform the scan and interpret the results) x
Factors that Contribute to Incontinence Low fluid intake? Low dietary fibre intake? Impaired mobility? Impaired dexterity? Impaired cognition? UTI-current/recurrent? Constipation and/or faecal loading? Prolapse and atrophic vaginitis? Enlarged prostate? General pain? Sleep disturbance? Other co-morbid conditions and past surgical history of relevance (e.g., arthritis,
diabetes, abdominal or pelvic surgery)? Relevant medicines in use? Skin condition? Toilet access and environmental barriers? Patient Preferences Preferences considered?2
1Fonda, et al. (2002) 2Items that are additional to those in the O’Connell et al. (2005) checklist
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Appendix B: Initial Standard Continence Screening Form for RAC
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Appendix C: Standard Bladder Chart for RAC
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Appendix D: Standard Bowel Chart for RAC
Appendix E: Standard Continence Assessment and Care Plan for
RAC
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Appendix F: Standard Continence Flow Chart for RAC
