Enacting Evidence-Based Incontinence Care in the Inpatient Rehabilitation Setting

Background: The majority of patients with incontinence after suffering a stroke or brain injury are not optimally managed in the inpatient setting. An incontinence order set with a Timed Toileting option is in use in the Stroke and Brain Injury unit. However, given the average patient's robust rehabilitation schedule resulting in extensive time spent away from the unit, the execution of these orders is not an accurate representation of evidence-recommended Timed Toileting. Methods: A quality improvement project was developed to increase the likelihood that Timed Toileting would occur by increasing interdisciplinary awareness, communication, and facilitating documentation. A Timed Toileting initiative was launched with corresponding in-person education. This initiative was geared toward the Stroke and Brain Injury Unit's multidisciplinary staff and sought to improve team communication and collaboration while enhancing knowledge and ease of documentation in the Electronic Health Record (EHR). Pre and Post surveys were utilized to determine the Timed Toileting initiative's impact and assess the staff's perceptions regarding using Timed Toileting in vulnerable populations such as patients with cognitive impairment, visual impairment, auditory impairment, or elevated BMI. The EHR was also utilized to assess initiative use and ascertain any changes in the documentation of Timed Toileting after implementation. A Wilcoxon signed-rank test was utilized to determine the change between pre and post-initiative survey responses and to determine if Timed Toileting documentation had increased among the interdisciplinary staff in the EHR. Results: Twenty-seven interdisciplinary staff members responded to the pre and post-surveys. No statistically significant differences were detected in participants' perceptions of initiative use or changes in documentation pre and post-survey, likely due to the small sample size and short overall project duration. Similarly, no statistically significant differences were noted in the EHR documentation of voiding, likely due to the small sample size (N=9 patients). Staff expressed confidence in implementing the Timed Toileting initiative in vulnerable patients. A robust 81% (N = 9) of staff indicated that they either "always" (18%) (N = 2) or "most of the time" (63%) (N = 7) were able to easily assist vulnerable patients with Timed Toileting. Pervasive themes gleaned from the qualitative data in both surveys encompassed the following: improved communication, improved team collaboration, and struggles with staffing or increased patient acuity that made accomplishing Timed Toileting the most problematic. Conclusions: The staff perceived this initiative as valuable for facilitating communication, teamwork, and standardizing documentation. Continued efforts moving forward include easing documentation challenges by allowing therapies the same access to the Intake and Output Flowsheets in the EHR as nursing and healthcare assistants while encouraging ongoing communication and improved patient handoffs between the teams.