Differences between Briefs 1

Size: px

Start display at page:

Download "Differences between Briefs 1"

Gwen Chase
6 years ago
Views:

1 Differences between Briefs 1 Comparisons on the Use of Disposable and Reusable Briefs in Long-Term Care: Skin Integrity of Residents and Burden on Staff by Peter Brink, Michael Stones, Wendy Kirkpatrick & Cheryl Everall The article compares skin integrity across homes that used disposable or reusable briefs. Abstract Two studies compared homes that routinely used disposable or reusable briefs. The first study examined effects on skin integrity and the second looked at measures of the burden on staff. The overall findings showed that disposable rather than reusable briefs were associated with a higher frequency of rashes in residents but savings of approximately one-third in the frequency of changes and the time staff spent on changing briefs. The implications are that disposable briefs have both risks and benefits compared with reusable briefs.

2 Introduction Differences between Briefs 2 Urinary incontinence is a problem that affects many residents in long-term care. Previous research showed the condition in approximately two-thirds of residents 1 excluding those who require assistance or reminding, or who have bladder urgency 2 rather than leakage. Excessive skin moisture because of incontinence is a risk factor for decubitus (i.e., skin disorders that include pressure ulcers, stasis ulcers, lesions, and rashes), along with other risks that include advanced age, physical condition (e.g., inactivity, poor circulation), and infrequent washing and turning. 3-6 Procedures to manage urinary incontinence include scheduled toileting plans, bladder retraining program, catheters, pads, and briefs. The two main types of brief are disposable and reusable. The advantages cited for disposable briefs include a higher capacity to absorb moisture than reusable briefs, easier changing of residents, and less need for frequent changes. Their use may lower the gross volume of laundry because there is less leakage that causes cloths and linens to be soiled. A main advantage for reusable briefs is cheapness because of repeated use. Cost is an important consideration particularly in facilities with in-house laundry services because of the existing capital investment in equipment. In a review of the literature on the two types of brief, the present authors were able to locate only two studies that compared the two types of brief with respect to possible effects on skin integrity. These two studies reached opposite conclusions. First, Boulton and Kazemi 7 used nurses' evaluations to determine the relative efficacy of disposable and reusable briefs. Nursing reports indicated that odour was lower and residents were drier with disposable briefs. The majority of nurses believed that disposable briefs were easier to use, that the residents required fewer changes, and that resident care was higher (e.g., resident were checked more frequently, and the perineal area washed more often). The

3 Differences between Briefs 3 authors concluded that disposable briefs were more comfortable than reusable briefs, clean up was easier, and net cost savings were substantial. On the other hand, Haeker 8 found that disposables may contribute to a loss of skin integrity compared with reusable briefs. Although the manufacturer of the disposable briefs blamed the staff's improper application rather than the product Haeker noted that numerous remedial steps were taken to prevent contact between it [the brief] and the skin (p. 347). Some residents participating in this study developed such severe skin problems that they were withdrawn from the trial. Haeker 8 also used nurses' observations in the evaluation. The nurses noted that skin integrity was not maintained and at the end of the study the long-term care facility chose to discontinue the use of disposable briefs. Because both these studies are approximately 20 years old and differed in findings, further comparisons are needed. The purpose of Study 1 was to examine predictors of skin disorder in three nursing homes owned and operated by the same company in the same Ontario city. One home used disposable briefs exclusively; the other two homes used reusable briefs as routine practice with the exception of a small percentage of residents in one home (i.e., less than 5%) whose families provided disposable briefs. The tool used to measure skin disorder and other functions was the Minimum Data Set 2.0 (MDS 2.0). The purpose of Study 2 was to examine the workload associated with changing the two types of brief and the burden perceived by staff. Participants Study 1 Methods The participants were residents of three long-term care facilities in Ontario aged 65 years and older. Homes A and B used reusable briefs as routine practice except for a small minority of

4 Differences between Briefs 4 residents in one home. Home C used only disposable briefs. After exclusion of comatose residents and those using catheters, the total sample consisted of 295 residents (208 women and 87 men, mean age = 81.4). The homes using reusable briefs as routine practice respectively had 101 residents (80 women and 21 men, mean age = 82.34) and 124 residents (83 women and 41 men, mean age = 82.34). The home that used only disposable briefs had 70 residents (45 women and 25 men, mean age = 84.55). Measures The data were from the Minimum Data Set 2.0 (MDS) administered as part of a larger research project. Measures relevant to incontinence include urinary incontinence during the past 14 days (item H1b) ranging from complete control to multiple incontinent episodes per day and whether or not briefs were worn (item H3g). The other MDS 2.0 measures used in this study were as follows: the demographics of age and sex; measures of physical and mental function that included activities of daily living (the ADL short form) and cognitive impairment; 9 measures of skin disorder that consisted of pressure ulcers, stasis ulcers and rashes (from sections M1, M2, M4); remedial measures for skin disorder that included ulcer care (item M5e) and the application of ointments or medication for other than foot care (item M5h). The time period for the skin disorder items was 14 days. Procedure The data were collected by trained assessors as part of a larger Resident Assessment Instrument Health Infomatics Project (RAIHIP) around the turn of the millennium. Preliminary analyses Results There were no significant differences among the three homes with respect to age, sex, or bladder incontinence. The overall rate of any incontinence was 69.2%, which is consistent with

5 Differences between Briefs 5 previous findings 1, with 46.4% of residents having multiple daily episodes. The incontinent residents were older (p<.001), more likely to be female (p<.05), and with more impairment in cognition (p<.001) and activities of daily living (p<.001). Not surprisingly, the probability that a resident used of briefs increased with level of incontinence (Φ=.747, p<.001). However, the use of briefs was also higher in the home with disposable briefs than in the other two homes even after controlling for level of incontinence (i.e., 67.1% versus 41.1%-51.5%; p<.005). The frequencies of skin disorder were 7.8% for any stage of a pressure ulcer, 2.7% for any stage of a stasis ulcer, and 22% for rashes. There were significant correlations between the presence of an ulcer and receipt of ulcer care (Φ=.534, p<.001), and between the presence of a rash and receipt of ointments or medications (Φ=.692, p<.001). Overall, 4.4% of residents received ulcer care and 21.7% received ointments or medication, with these rates being lower than corresponding rates of 11-13% and 32-39% found in complex continuing care facilities. 10 Main analyses The type of analysis used to clarify predictors of ulcers and rashes, respectively, was hierarchical logistic regression. The initial set of predictors were age, sex, cognition, activities of daily living, and the type of brief in routine use at a resident s home. The next predictor to be added was the use of a brief by a resident. Finally, the interaction of type-by-use of brief was added only if it made a further significant contribution to the prediction of skin disorder. The analysis to predict any form of ulcer showed significance only for activities of daily living, with the likelihood of an ulcer increasing with level of impairment (OR=1.116, 95% CI= ). This finding is not surprising because pressure ulcers arise when residents retain the same stationary position for prolonged periods. The significant predictors of rashes from the initial entry were higher levels of bladder incontinence and the routine use of disposable briefs at the home. After inclusion of the

6 Differences between Briefs 6 residents use of briefs, only type of brief remained as a significant predictor. Finally, the interaction of type-by-use of brief significantly predicted rashes even with inclusion of all the other measures and emerged as the only significant predictor (OR=7.296, 95% CI= ). Figure 1 illustrates this interaction with data from each home: rashes are many times more frequent among residents wearing briefs in the home that used disposable briefs than in any other category. Figure 1: Probability of Rash by Use of Brief and Type of Brief in Routine Use % Residents with Rash Home A: Reusable Home B: Reusable 13 Home C: Disposable Use of Brief Not Used Used Home by Type of Brief Discussion The findings of Study 1 show neither demographic differences among the homes nor differences in bladder incontinence. The levels of incontinence were similar to those in other reports, with the frequencies of skin disorder and treatment for skin disorder being somewhat lower than in complex continuing care facilities. 10 Despite an absence of significant differences

7 Differences between Briefs 7 in bladder incontinence, the more frequent use of briefs in Home C suggests that staff may use disposable briefs more readily than reusable briefs. The main finding of Study 1 concern skin disorder. Although there was no evidence to link ulcers with incontinence or use of briefs, such relationships were present with respect to rashes. Incontinence was a significant predictor only before the inclusion of use of briefs and the typeby-use of briefs interaction into the set of predictors. The full prediction model suggests the interaction to be the only significant predictor, with the frequency of rashes being 66% for residents wearing disposable briefs compared with 7-18% in any other condition. It is important to reiterate that the high frequency of rashes among residents in Home C was limited to those wearing briefs (i.e., those without briefs had a frequency similar to the other homes), which suggests that the relationship with rashes is specific to wearing disposable briefs. Participants Study 2 Methods The participants were 42 incontinent residents from the same three facilities used in Study 1, with the data collected approximately 18-month later when two of the homes routinely used disposable briefs. There were 12 males and 32 females with a median date of birth of 1915 (range= ). All 42 residents wore briefs and 95% scored at the highest level of incontinence on the MDS 2.0. Thirty-four residents used disposable briefs and 8 residents used reusable briefs. Materials The materials included an Incontinence Program Log that indexed the number of times a resident was changed during a shift; the minutes spent changing that resident; the frequency of turns, and the frequency of toileting. There were also two items on 7-point Likert scales that

8 Differences between Briefs 8 measured the level of burden associated with the frequency and time spent changing a resident s briefs. Procedure The Log and Likert items were completed by staff on three shifts over a 24-hour period. Results There were no significant differences in the sex or age distributions of residents wearing disposable or reusable briefs, and no differences in the level of incontinence. Data from the Incontinence Program Log were averaged to provide measures of the mean changes per resident during an 8-hour shift and total minutes expended when changing that resident. Analysis of these measures showed that staff made significantly fewer changes and spent significantly less time changing a resident with disposable than reusable briefs (both p<.05). Figure 2 shows the mean values. Figure 3: Frequency of Changes and Time Spent on Changing a Resident per Shift 30 Mean Levels per Shift Measures Frequency of Changes Minutes Spent 0 Disposable Reusable on Changing Type of brief

9 Differences between Briefs 9 Analyses of the other measures failed to find significant differences between type of brief. These measures included frequencies of turns and toileting, and the two subjective ratings of staff burden. The mean levels of perceived burden ranged from on a 7-point scale, where scores higher than the scale midpoint of 4 indicate higher perceptions of burden. Discussion Although Study 2 is limited by its small sample size, residents wearing disposable or reusable briefs were comparable with respect to demographics and incontinence. The findings support claims that the use of disposable briefs results in fewer changes and less time spent on changing compared with reusable briefs. Figure 3 suggests that the savings in both the frequency of changes and time expended are in the region of one-third. The findings do not support claims that the subjective burden by staff differs between the types of brief, with the mean ratings indicating only moderate burden. Conclusions Study 2 showed advantages of disposable over reusable briefs in that both the frequency and total time spent changing residents was approximately one-third lower. However, the findings of Study 1 suggest that the use of disposable briefs had adverse effects on skin integrity. These effects were shown by a higher than expected frequency of rashes only among residents with briefs in the home that routinely used disposable briefs. The finding that residents without briefs in that home did not have excessive rashes suggests that the briefs, rather than the home, contributed to an elevated frequency of rashes. There was no evidence that either type of brief or incontinence contributed to the development of ulcers as suggested by some previous reports. 4,11,12 Because any adverse effects associated with incontinence management are of clinical concern, it is important to reiterate once more limitations and strengths of Study 1. The

10 Differences between Briefs 10 limitations include the use of cross-sectional data that show associations only at a single point in time. Another limitation is that the disposable briefs used in the study were of a specific brand and that the findings obtained may not generalize to other brands produced by the same or different manufacturers. The strengths of the study include a fairly large sample, the use of reliable measures and trained assessors, and a strong association between type-by-use of briefs and rashes. The findings are indeterminate about whether it was the disposable briefs or other factors pertaining to their use that gave rise to the association with rashes in Study 1. In Haeker s 8 study, the manufacturer cited improper application although the nurses concluded otherwise. Improper application may result in undue wetness if the brief was put on incorrectly or the resident left for too long without changing. The findings from Study 2 suggest that changes of disposable briefs occurred with approximately two-thirds the rate for reusable briefs. Given the greater absorbency of disposable briefs, it seems unlikely that their use would result in undue wetness if applied properly. Other interpretations of the findings of Study 1 include the possibility that the structure or composition of the disposable briefs contributed to the development of rashes in ways that are unknown. In conclusion, the findings of Studies 1 and 2 suggest an adverse association between the use of disposable briefs and rashes but beneficial effects on the workload of staff. Clearly more investigation is needed about the effects of briefs on skin integrity. Such investigation should include comparisons between type and brand of product, and also the effects of application. References 1 Steel, J., & Fonda, D. (1995). Minimizing the cost of urinary incontinence in homes. PharmacoEconomics, 7,

11 Differences between Briefs 11 2 Norton, P. (1990). Prevalence and social impact of urinary incontinence in women. Clinical Obstetrics and Gynecology, 33, Hogstel, M. (1983). Skin care for the aged. Journal of Gerontological Nursing, 9, Schnelle, J., Adamson, G., Cruise, P., Al-Samarrai, N., Sarbaugh, F., Uman, G., et al. (1997). Skin disorders and moisture in incontinent home residents: Intervention implications. Journal of the American Geriatrics Society, 45, Bergstrom, N., & Braden, B. (1992). A prospective study of pressure sore risk among institutionalized elderly. Journal of the American Geriatric Society, 40, Cooney, L. (1997). Pressure sores and urinary incontinence. Journal of the American Geriatric Society, 45, Boulton, S., & Kazemi (1984). Evaluation of disposable briefs. American Journal of Nursing, 84, Haeker, S. (1985). Disposable vs. reusable incontinence products. Geriatrics, 40, Lawton, P., Casten, P., Van Haitsma, K., Corn, J., & Kleban, M. (1998). Psychometric characteristics of the minimum Data Set II: Validity. Journal of the American Geriatrics Society, 46, Canadian Institute for Health Information (2004). Complex Continuing Care in Ontario: Resident Demographics and System Characteristics. Ottawa: CIHI 11 Terpenning, M., & Bradley, S. (1991). Why aging leads to increased susceptibility to infection. Geriatrics, 46,

12 Differences between Briefs Berlowitz, D., Brandeis, G., Morris, J., Ash, A., Anderson, J., Kader, B., & Moskowitz. M. (2001). Deriving a risk-adjustment model for pressure ulcer development using the minimum data set. Journal of the American Geriatric Society, 49, Peter Brink is a doctoral student in Health Science and Gerontology at the University of Waterloo. This article is part of his graduate research at Lakehead University. Contact him at pbrink@lakeheadu.ca Michael Stones is professor in the Department of Psychology at Lakehead University. He has conducted research and administered university institutes and programs in gerontology for over thirty years. Contact him at mstones@lakeheadu.ca Wendy Kirkpatrick is an R.N. who has worked thirty years in the long-term care sector. She is administrator of Grandview Lodge Home for the Aged in Thunder Bay. her at wkirkpatrick@city.thunder-bay.on.ca Cheryl Everall is a medical student at McMaster University. Her address is Cheryl.Everall@learnlink.mcmaster.ca

Portable Bladder Ultrasound. OHTAC Recommendation. Portable Bladder Ultrasound

Portable Bladder Ultrasound. OHTAC Recommendation. Portable Bladder Ultrasound OHTAC Recommendation Portable Bladder Ultrasound April 18, 2006 1 The Ontario Health Technology Advisory Committee (OHTAC) met on April 18, 2006 to review the utility of portable bladder ultrasound for