ࡱ>  Fɀ\pannie Ba==[, 8@"1Arial1Arial1Arial1Arial1Arial1Arial1Arial1Arial1Arial1Arial1Arial1Arial1Arial1Arial"$"#,##0_);\("$"#,##0\)!"$"#,##0_);[Red]\("$"#,##0\)""$"#,##0.00_);\("$"#,##0.00\)'""$"#,##0.00_);[Red]\("$"#,##0.00\)7*2_("$"* #,##0_);_("$"* \(#,##0\);_("$"* "-"_);_(@_).))_(* #,##0_);_(* \(#,##0\);_(* "-"_);_(@_)?,:_("$"* #,##0.00_);_("$"* \(#,##0.00\);_("$"* "-"??_);_(@_)6+1_(* #,##0.00_);_(* \(#,##0.00\);_(* "-"??_);_(@_)"Yes";"Yes";"No""True";"True";"False""On";"On";"Off"],[$ -2]\ #,##0.00_);[Red]\([$ -2]\ #,##0.00\) 0.0000000 0.000000 0.00000 0.0000 0.0000.0                + ) , *              @  D `9 #1-PV Procedure,* #2-Enter Data{#3-Interpret Data#4-Set Warning Limit #5-Checks#6-Motivation Interview #7-PV TrialTH ;=3 A@@   Resident's NameAppropriate Toileting Rate#2 #3 #4#2#3#4 #1 Wetness Rate Warning LimitAvg. Wet Rate All Res.  \ Fɀ   dMbP?_*+%MAuto HP LaserJet 3300 Series PC? odXLetter.HP LaserJet 3300 Series PCL 62xePMkSQs'ic1Q|ţ1"h&Fx [uYC[e&"~d)bܸ?貊[ѵ;}!83sΜ˹L=`@r:$ipdrz:Y@Qc#'46INA>kgmx6b:bю)%Jc ğyW6l @~'K$o#"(4ylsaXSF@\A8o&|2fѺ׼O/Nܯ&nupÁ^.Gts=(ٔ^\Yz7Nn8RYZRu%ZnV*v'MbXzOXnۡêk!O@f^>e"dX??U} $} ;@(  ^B  c $D@-:]`l5ff  c $O A@!#]`OD6 <Day 1, Wet checks 1-4<ff  c $ P A@]` PL7 <Day 2, Wet checks 1-4<ff  c $\P A@]`\P$8 <Day 3, Wet checks 1-4<f^B  c $D@\]`8f^B  c $D@:;]`T9f^B   c $D@9\] `9f^B   c $D@\] `d:f^B  @ c $D@\] `:f^B  c $D@]`t;f^B  c $D@]`;f^B  c $D@]`<f^B  c $D@]` =f^B  c $D@\]`=ff  c $ -<. Welcome! This program will guide you through the steps necessary to identify and implement prompted voiding with responsive incontinent residents. Each step is described in succession on a single Excel sheet, and each sheet is labeled #1 - #5 on the tabs near the bottom of your screen. Also included are two forms called "Motivation Interview" and "PV Trial." You can access these using the arrow keys at the bottom, left-hand corner of your computer screen. Click on either of the right directional arrows (>) to scroll to the right. Use the left directional arrows (<) to scroll left. Right now you are on sheet #1, labeled "PV Procedure." You can skip from sheet to sheet at any time by clicking on the tab for the sheet you want, although you may have to scroll to the right or left to first reveal the tab. You can save your work--and this file--at any time by clicking on the "save" icon near the top of your screen or clicking on "File" at the top of your screen, then clicking on "Save" or "Save As." The first step in the program is a three-day prompted voiding trial, at the end of which you will be able to identify residents responsive to the intervention. Procedures for offering prompted voiding and conducting the trial are presented below. (As a point of order, prompted voiding should be conducted with incontinent residents only after a physician's assessment has determined that there are no transient causes of the person's incontinence. Guidelines for conducting these basic assessments can be found on our website at http://borun.medsch.ucla.edu. Click on "Incontinence Management," then click on "Step 1.") Visit our Website: If at any time you want more detailed information about the prompted voiding intervention, please visit our website at http://borun.medsch.ucla.edu and click on "Incontinence Management." Prompted Voiding Protocol and Trial Start by asking each incontinent resident the questions on our Motivation Interview. Scroll right to worksheet #6. You can also access this form from our website at http://borun.medsch.ucla.edu/modules/Incontinence_management/docs/imformsinterview.pdf. Next, follow these steps, which describe the prompted voiding procedure, for 3 days: Step 1. Contact each incontinent resident every two hours from 8 a.m. to 4 pm (i.e., four times per day). Step 2. Focus the resident's attention on voiding by asking whether he or she is wet or dry. Step 3. Check resident for wetness and give feedback on whether the resident's self-report was correct or incorrect (e.g., "Yes, Mrs. Jones, you are dry.") Step 4. Whether wet or dry, ask the resident if he or she would like to use the toilet (or urinal). a. If yes: 1. Assist him or her with toileting 2. Record the results on the bladder record. 3. Give the resident positive reinforcement by spending an extra minute or two in conversation. b. If no: 1. If the resident has not attempted to void in the last 4 hours, repeat the request to use the toilet once or twice before leaving, and follow step 4(a) if an affirmative response is received. 2. If the resident is wet and declines to use the toilet, change him or her. 3. Inform the resident that you will be back in two hours and request that the resident try to delay voiding until then. Step 5. Record results of each wet check (step 3) and toileting attempt on the Prompted Voiding Trial form--scroll right to worksheet #7. You can also dowload this form from our website at http://borun.medsch.ucla.edu/modules/Incontinence_management/docs/imformspvtrial.pdf. At the end of the 3-day trial, again ask each resident the questions on our Toileting Motivation and Preference Assessment Survey. Data Entry To analyze the data you have collected, click on the tab below for the sheet labeled "#2-Enter Data." < <  "pd { @g  , :* ,1  ( [% 0-  ,& 349 K  Y) *, -f^B  c $D@\\]`$?>@  7 Fɀ $/>JV8afc  dMbP?_*+%MAuto HP LaserJet 3300 Series PC? odXLetter.HP LaserJet 3300 Series PCL 62xePMkSQs'ic1Q|ţ1"h&Fx [uYC[e&"~d)bܸ?貊[ѵ;}!83sΜ˹L=`@r:$ipdrz:Y@Qc#'46INA>kgmx6b:bю)%Jc ğyW6l @~'K$o#"(4ylsaXSF@\A8o&|2fѺ׼O/Nܯ&nupÁ^.Gts=(ٔ^\Yz7Nn8RYZRu%ZnV*v'MbXzOXnۡêk!O@f^>e"dX??U} } m} I} m} } } I} } } m} } } $} }   !"#$%&'()*+,-./0123                       + %  dY@@^ dD   T ?- dY@S U@ dL    Y@   Y@     Y@    Y@      Y@   Y@     Y@   Y@     Y@    Y@ ! !   !Y@ " !  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A A @  AY@@B A  BY@A C C B  CY@BD C  DY@C E E D  EY@DF E  FY@E G G F  GY@FH G  HY@G I I H  IY@HJ I  JY@I K K J  KY@JL K  LY@K M M L  MY@LN M  NY@M O O N  OY@NP O  PY@O Q Q P  QY@PR Q  RY@Q S S R  SY@RD l>b>b>b>b>b>b>b>b>b>b>b>b>b>b>b>TUVWXYZ[\]^_`abcdefghijklmnop q r s T T TY@S U U UU U @- dUY@T V VU VY@U VV@ dL W W WU WY@V VX XU XY@W V Y Y YU YY@X VZ ZU ZY@Y V [ [ [U [Y@Z V\ \U \Y@[ V ] ] ]U ]Y@\ V^ ^U ^Y@] V _ _ _U _Y@^ V` `U `Y@_ V a a aU aY@` Vb bU bY@a V c c cU cY@b Vd dU dY@c Ve eU eY@d Vf fU fY@e Vg gU gY@f Vh hU hY@g Vi iU iY@h Vj jU jY@i Vk kU kY@j Vl lU lY@k Vm mU mY@l Vn nU nY@m Vo oU oY@n Vp pU pY@o Vq qU qY@p Vr rU rY@q Vs sU sY@r VD l>Ub>b>b>b>b>b>b>>>>>>>>>>>>>>>t u v w x y z { | } ~                      t tU tY@s Vu uU uY@t Vv vU vY@u Vw wU wY@v Vx xU xY@w Vy yU yY@x Vz zU zY@y V{ {U {Y@z V| |U |Y@{ V} }U }Y@| V~ ~U ~Y@} V U Y@~ V U Y@ V U Y@ V U Y@ V U Y@ V U Y@ V U Y@ V U Y@ V U Y@ V U Y@ V U Y@ V U Y@ V U Y@ V U Y@ V U Y@ V U Y@ V U Y@ V U Y@ V U Y@ V U Y@ V U Y@ VD@ l>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>      U Y@ V+ %  dY@ V+ %  dY@ dD + %  dY@ dD + %  dY@ dD P>NRR     < (  l  s *f A@FZ]`f|? ll  s *,g A@ t Z]`,g  ll  s *1 A@ F]`1  < <f^B   c $D@<<] `!f^B  c $D@/x]` "ff   c $t# A@Rx] `t#x" -<.Data Entry Step 1. Using the chart below, enter each participating resident's name in the far left column. Hit the "Enter" key to scroll down to the next cell. Step 2. Enter wet check data (see item #1 on the Prompted Voiding Form) for each resident. Enter a "1" in the appropriate cell if the resident was found dry on that check [type 1, then hit the right directional arrow ( -->) on your keyboard to advance to the next cell.] Leave the cell blank if the resident was found wet or soiled on that check. You may enter wet check data all at once, after the three-day trial is completed, or in stages during the prompted voiding trial. If you make a mistake when entering data, just click on the cell with the error, hit the "Delete" button, and enter the correct data. Step 3. The Excel program automatically calculates the "Appropriate Toileting Rate" for each resident in the second-to-the-last column. (The "Wetness Rate," reported in the far-right column, will be used in Step 5.) Interpreting Data: Residents with an appropriate toileting rate above 65% should continue to receive prompted voiding (the procedure described in steps 1-5 on Sheet #1). For more information, click on the tab for Sheet #3, "Interpreting Data".<A  ,Z,DO,V7oIL w, -f^B ! c $D@-3]!`#ff " c $# A@]"`## <Day 1, Wet checks 1-4<ff # c $<$ A@B]#`<$$ <Day 2, Wet checks 1-4<ff $ c $$ A@\ %]$`$% <Day 3, Wet checks 1-4<f^B % c $D@\vU]%`&f^B & c $D@34]&`&f^B ' c $D@2U]'`p'f^B ( c $D@U](`'f^B )@ c $D@  U-])`(f^B * c $D@]*`)f^B + c $D@]+`)f^B , c $D@],`*f^B - c $D@ ]-`*f^B / c $D@ ]/`(+f^B 0 c $D@ ]0`+f^B 1 c $D@]1`8,f^B 2 c $D@  U]2`,f^B 4 c $D@  ]4`H-f^B 6@ c $D@U]6`-f^B 7 c $D@Tc]7`X.f^B 8 c $D@Ud]8` f^B 9@ c $D@ T d]9`f^B : c $D@ U d]:`f^B ;@ c $D@ Td];`f^B < c $D@Td]<`,>@```7 Fɀ |  dMbP?_*+%"??U0(  l  s *0 A@@- "]`0| H<e Interpreting Data Use this chart to guide interpretation of results: Appropriate toileting rate Ability to toilet 76-100% Excellent 66-75% Good 50-65% Fair 0-49% Poor Residents with an appropriate toileting rate above 65% should continue to receive prompted voiding. Residents with appropriate toileting rates below 66% seldom show responsiveness with longer term applications of prompted voiding. Treatment options for these  non-responders should be based on their pre- and post-trial answers to the Toileting Motivation and Preference Assessment Survey questions and their behavior during the trial (see item #3 on the Prompted Voiding Trial form). Non-responsive residents who express a willingness to improve continence should be further evaluated to identify all problems that are potentially treatable by other interventions. As a general rule, any resident who attempts to toilet two times a day (see item #2 on the Prompted Voiding Trial form), even if unsuccessfully, should be considered motivated to stay dry and should thus receive a follow-up evaluation and after that, another prompted voiding trial. About 10%-20% of non-responders will show no willingness to improve continence. In interviews, they express no desire to be either changed or toileted more frequently. In prompted voiding trials, they show or verbalize that toileting assistance is unwanted. These residents should be placed on a check-and-change program. No research findings to date suggest that other treatments will be more successful. <Hk7G V~V  vx >@  7 Fɀ X`j  dMbP?_*+%MAuto HP LaserJet 3300 Series PC? odLetter.HP LaserJet 3300 Series PCL 62xePMkSQs'ic1Q|ţ1"h&Fx [uYC[e&"~d)bܸ?貊[ѵ;}!83sΜ˹L=`@r:$ipdrz:Y@Qc#'46INA>kgmx6b:bю)%Jc ğyW6l @~'K$o#"(4ylsaXSF@\A8o&|2fѺ׼O/Nܯ&nupÁ^.Gts=(ٔ^\Yz7Nn8RYZRu%ZnV*v'MbXzOXnۡêk!O@f^>e"dX??U} m} m } }  } m} X           # %@@B-3OP(%^%@@B D                              DlFf !"#$%&'()*+,-./0123456789:;<=>?  ! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > > ?DJl@ABCDEFGHIJKLMNOPQRSTUVW @ A B C D E F G H I J K L M N O P Q R S T U V W40  @(  l  s *  A@'<]`   h<Monitor the Program For best results and to help sustain staff performance, a supervisory nurse should monitor the program on a weekly basis. Calculate a performance warning limit: The primary method for monitoring prompted voiding programs is to compare expected outcomes to actual outcomes. That is, you should compare the percentage of incontinent residents found wet at a given point in time to the percentage who should be wet if the prompted voiding program is working as expected. If the  actual percentage exceeds the  expected percentage, there s a problem, and it needs further analysis if you want to resolve it. Typical problems stem from changes in a resident s status or break-downs in the prompted voiding work process. Before you can conduct this assessment, you must first establish your program s performance warning limit; that is, you need to determine the highest percentage of residents who should be wet if the program is working well. This calculation is based on data collected during the prompted voiding trial. Only the data for  responsive residents is used; that is, data for residents with appropriate toileting rates greater than 65%. You can find toileting rates for each resident on Sheet #2, in column N. To get to this sheet, click on the tab near the bottom of your screen labeled "#2-Enter Data." Data Entry Follow these steps to determine your program's performance warning limit: 1. Enter each responsive resident's name in column A. Hit the "Enter" key to scroll down to the next cell. 2. For each resident, enter his or her "Wetness Rate" in column B. You can find each resident's wetness rate on Sheet #2 ("Enter Data"), in column "O". 3. The Excel program automatically reports the average wetness rate for all responsive residents in column C. This, in turn, is used to automatically calculate the performance warning limit, reported in column D. (The warning limit is equal to the average wetness rate plus two standard deviations.) The warning limit sets the standard for expected performance. Now you need to gauge the program's actual performance. Click on the tab near the bottom of your screen labeled "#5-Checks" to find out how to conduct weekly control checks.<hy ,HUT  R >@7 Fɀ :  dMbP?_*+%MAuto HP LaserJet 3300 Series PC? odLetter.HP LaserJet 3300 Series PCL 62xePMkSQs'ic1Q|ţ1"h&Fx [uYC[e&"~d)bܸ?貊[ѵ;}!83sΜ˹L=`@r:$ipdrz:Y@Qc#'46INA>kgmx6b:bю)%Jc ğyW6l @~'K$o#"(4ylsaXSF@\A8o&|2fѺ׼O/Nܯ&nupÁ^.Gts=(ٔ^\Yz7Nn8RYZRu%ZnV*v'MbXzOXnۡêk!O@f^>e"dX??UP (   l  s *I A@@-%Z]`I `<  CONDUCT CONTROL CHECKS A supervisory nurse should monitor the prompted voiding program by conducting weekly "wet checks." To do this, the nurse randomly checks at least 10 participating residents for wetness each week. (We estimate that supervisors will spend 15-20 minutes a week conducting these control checks.) The percentage of residents found wet during a check is the "wetness rate." For example, if the nurse finds that 2 of the 10 residents she checks are wet, then the wetness rate for that week is 20%. Guidelines for Scheduling Random Control Checks: Control checks should be unpredictable and should sample the range of times that might be problematic because of staffing issues. We have found in previous work, for example, that late afternoon on Saturday is a time of high wetness rates. COMPARE WETNESS RATES TO THE WARNING LIMIT How well is your program performing? To find out, compare each week's wetness rate to the performance warning limit, reported on Sheet 4, in column D. Again, the warning limit defines acceptable performance. If the wetness rate falls under this limit, then the program is performing as expected. If the wetness rate exceeds the limit, however, the program is considered to be  out of control and further analysis and corrective action are needed to bring it back in line. Consider, for example, whether out-of-control results indicate a change in a resident s status, a breakdown in care during shift changes, or a staffing problem on a particular hallway. All these are common occurrences that can skew program results. Control Chart: It helps to track performance over time by creating a control chart that plots each week's wet-check rate. The control chart lets you see at a glance whether the prompted voiding program is working well or needs improvement. To view a sample control chart, go to this page on our website: http://borun.medsch.ucla.edu/modules/Incontinence_management/step4d.htm. VISIT OUR WEBSITE For more information about the prompted voiding program and to learn about other interventions designed to improve daily care in nursing homes, visit our website at http://borun.medsch.ucla.edu. <`l  A9/[ZC2X@ k j   >@7 Fɀ l  dMbP?_*+%MAuto HP LaserJet 3300 Series PC? odLetter.HP LaserJet 3300 Series PCL 62xePMkSQs'ic1Q|ţ1"h&Fx [uYC[e&"~d)bܸ?貊[ѵ;}!83sΜ˹L=`@r:$ipdrz:Y@Qc#'46INA>kgmx6b:bю)%Jc ğyW6l @~'K$o#"(4ylsaXSF@\A8o&|2fѺ׼O/Nܯ&nupÁ^.Gts=(ٔ^\Yz7Nn8RYZRu%ZnV*v'MbXzOXnۡêk!O@f^>e"dX??U`(  f  c $$( A@K 2]`$(  <TOILETING MOTIVATION AND PREFERENCE ASSESSMENT Instructions: For each resident assessed in the prompted voiding trial, ask the following questions both before and after the trial to assess his or her motivation to use the toilet and to identify preferences for toileting assistance. Our research shows that residents who score two or more on the Minimum Data Set (MDS) recall subscale (see below) are capable of providing reliable and meaningful responses to these interview questions. Residents who fail this cognitive screen should be excluded from interviews but should still undergo the prompted voiding trial. Resident Name:_______________________ Staff Interviewer:_________________________ Date of Interview:____/____/____ mm dd yy Check the best response for the questions below: DK=Don t Know NR=No Response or Nonsense Response REF=Refusal to answer question Interviewer:  I want to ask you some questions about help with using the toilet. 1. Does it bother you to wet in your diaper? ___yes ___no ___ DK/NR/REF 2. Do staff help you to the toilet as much as you would like? ___yes ___no ___ DK/NR/REF 3. Do you want to be helped to the bathroom more often? ___yes ___no ___ DK/NR/REF 3a. If no, ask: Do you want to be helped to the toilet less often? ___yes ___no ___ DK/NR/REF 4. Do you want to be changed more often? ___yes ___no ___ DK/NR/REF 4a. If no, ask: Do you want to be changed less often? ___yes ___no ___ DK/NR/REF After the prompted voiding trial, ask this question as well: 5. Do you like the amount of changing and toileting assistance you have received in the last three (or two) days? ___yes ___no ___ DK/NR/REF Scoring: A high motivation to toilet is indicated if a resident gives the answers in bold italics. A low motivation to toilet seems indicated if a resident responds no to questions 1, 3, 4, 5, and yes to questions 3a, 4a, and yes or no to question 2. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - MDS RECALL SUBSCALE Resident s name:___________________________________________ Check all that the resident was able to accurately recall (in last 7 days): a. Current season: ____ b. Location of own room: ____ c. Staff names and/or faces: ____ d. He/she is in a nursing home: ____ OR e. None of the Above: ____ Resident receives 1 point for each item (a-d) checked. <t/1L>  +  6>CU m+5Vi >@  7 Fɀ   dMbP?_*+%" ??Up(  f  c $t( A@ 7K]`t(C L h<PROMPTED VOIDING TRIAL Instructions: Use this form to record results of wet checks and prompted voiding attempts with one resident for one day of the assessment trial. Each resident should receive prompted voiding every two hours between 8 am and 4 pm, for a total of 4 times on each day of the assessment trial. There is space below to record results for 4 wet checks and prompted voiding attempts. You will need to complete 3 of these forms per resident for a 3-day prompted voiding trial. Resident Name:_____________________ Employee Name:_______________________ Date:______________________________ Day of Trial: ___1st ___2nd ___3rd Time: _____at 1st check ________at 2nd check ________at 3rd check ________at 4th check 1. Resident s condition at check (circle one for each check): 1st check: 2nd check: 3rd check: 4th check: Dry Dry Dry Dry Wet Wet Wet Wet Bowel Bowel Bowel Bowel Wet and bowel Wet and bowel Wet and bowel Wet and bowel 2. Toileting outcome (circle one for each check): 1st check: 2nd check: 3rd check: 4th check: Refused Refused Refused Refused Dry run* Dry run Dry run Dry run Urine Urine Urine Urine Bowel Bowel Bowel Bowel Urine and bowel Urine and bowel Urine and bowel Urine and bowel * A  dry run means that the resident attempted to toilet but failed to void. 3. Resident s reaction to checks and prompts (circle one for each check): 1st check: 2nd check: 3rd check: 4th check: Self-initiates Self-initiates Self-initiates Self-initiates Cooperates-neutral Cooperates-neutral Cooperates-neutral Cooperates-neutral Cooperates-reluctant Cooperates-reluctant Cooperates-reluctant Cooperates-reluctant Uncooperative Uncooperative Uncooperative Uncooperative 4. Level of assistance resident needed to toilet (circle one for each check): 1st check: 2nd check: 3rd check: 4th check: Independent Independent Independent Independent Stand-by asst. Stand-by asst. Stand-by asst. Stand-by asst. Needs help of 1 person Needs help of 1 person Needs help of 1 person Needs help of 1 person Needs help of 2 persons Needs help of 2 persons Needs help of 2 persons Needs help of 2 persons <hL&xB2A   G L >@  7 \pannie [Bb=[, 8@"1Arial1Arial1Arial1Arial1Arial1Arial1Arial1Arial1Arial1Arial1Arial1Arial1Arial1Arial"$"#,##0_);\("$"#,##0\)"$"#,##0_);[Red]\("$"#,##0\) "$"#,##0.00_);\("$"#,##0.00\)%""$"#,##0.00_);[Red]\("$"#,##0.00\)5*2_("$"* #,##0_);_("$"* \(#,##0\);_("$"* "-"_);_(@_),))_(* #,##0_);_(* \(#,##0\);_(* "-"_);_(@_)=,:_("$"* #,##0.00_);_("$"* \(#,##0.00\);_("$"* "-"??_);_(@_)4+1_(* #,##0.00_);_(* \(#,##0.00\);_(* "-"??_);_(@_)"Yes";"Yes";"No""True";"True";"False""On";"On";"Off" 0.0000000 0.000000 0.00000 0.00000.0000.0                + ) , *              @  D 83ffff̙3f3fff3f3f33333f33333W#1-PV Procedure " #2-Enter Datah#3-Interpret Data^p#4-Set Warning Limit #5-Checks#6-Motivation Interview #7-PV Trial  i  dMbP?_*+%MVAuto HP LaserJet 3300 Series PC? odXLetter 0H7^ `.HP LaserJet 3300 Series PCL 62xePMkSQs'ic1Q|ţ1"h&Fx [uYC[e&"~d)bܸ?貊[ѵ;}!83sΜ˹L=`@r:$ipdrz:Y@Qc#'46INA>kgmx6b:bю)%Jc ğyW6l @~'K$o#"(4ylsaXSF@\A8o&|2fѺ׼O/Nܯ&nupÁ^.Gts=(ٔ^\Yz7Nn8RYZRu%ZnV*v'MbXzOXnۡêk!O@f^>e"dX??U} $}  ;@]*-:@]l!# A@^ (.^ Day 1, Wet checks 1-4]l A@^ 8.^ Day 2, Wet checks 1-4]l A@^ .^ Day 3, Wet checks 1-4]*\@]*:;@]* 9\@]* \@]*  \@]* @]* @]* @]* @]*\@] ,xp<< A@-l Welcome! This program will guide you through the steps necessary to identify and implement prompted voiding with responsive incontinent residents. Each step is described in succession on a single Excel sheet, and each sheet is labeled #1 - #5 on the tabs near the bottom of your screen. Also included are two forms called "Motivation Interview" and "PV Trial." You can access these using the arrow keys at the bottom, left-hand corner of your computer screen. Click on either of the right directional arrows (>) to scroll to the right. Use the left directional arrows (<) to scroll left. Right now you are on sheet #1, labeled "PV Procedure." You can skip from sheet to sheet at any time by clicking on the tab for the sheet you want, although you may have to scroll to the right or left to first reveal the tab. You can save your work--and this file--at any time by clicking on the "save" icon near the top of your screen or clicking on "File" at the top of your screen, then clicking on "Save" or "Save As." The first step in the program is a three-day prompted voiding trial, at the end of which you will be able to identify residents responsive to the intervention. Procedures for offering prompted voiding and conducting the trial are presented below. (As a point of order, prompted voiding should be conducted with incontinent residents only after a physician's assessment has determined that there are no transient causes of the person's incontinence. Guidelines for conducting these basic assessments can be found on our website at http://borun.medsch.ucla.edu. Click on "Incontinence Management," then click on "Step 1.") Visit our Website: If at any time you want more detailed information about the prompted voiding intervention, plea <  "pd { @g  , :* ,1  ( [% 0-  ,& 349 K  Y) *, -< se visit our website at http://borun.medsch.ucla.edu and click on "Incontinence Management." Prompted Voiding Protocol and Trial Start by asking each incontinent resident the questions on our Motivation Interview. Scroll right to worksheet #6. You can also access this form from our website at http://borun.medsch.ucla.edu/modules/Incontinence_management/docs/imformsinterview.pdf. Next, follow these steps, which describe the prompted voiding procedure, for 3 days: Step 1. Contact each incontinent resident every two hours from 8 a.m. to 4 pm (i.e., four times per day). Step 2. Focus the resident's attention on voiding by asking whether he or she is wet or dry. Step 3. Check resident for wetness and give feedback on whether the resident's self-report was correct or incorrect (e.g., "Yes, Mrs. Jones, you are dry.") Step 4. Whether wet or dry, ask the resident if he or she would like to use the toilet (or urinal). a. If yes: 1. Assist him or her with toileting 2. Record the results on the bladder record. 3. Give the resident positive reinforcement by spending an extra minute or two in conversation. b. If no: 1. If the resident has not attempted to void in the last 4 hours, repeat the request to use the toilet once or twice before leaving, and follow step 4(a) if an affirmative response is received. 2. If the resident is wet and declines to use the toilet, change him or her. 3. Inform the resident that you will be back in two hours and request that the resident try to delay voiding until then. Step 5. Record results of each wet check (step 3) and toileting attempt on the Prompted Voiding Trial form--scroll right to worksheet #7. You can also dowload this form from our website at http://borun.medsch.ucla.edu/modules/Incontinence_management/docs/imformspvtrial.pdf. At the end of the 3-day trial, again ask each resident the questions on our Toileting Motivation and Preference Assessment Survey. Data Entry To analyze the data you have collected, click on the tab below<+ for the sheet labeled "#2-Enter Data." ]*\\@=[, 8>   "   -'5BqNX[  dMbP?_*+%MVAuto HP LaserJet 3300 Series PC? odXLetter Management." Prompted.HP LaserJet 3300 Series PCL 62xePMkSQs'ic1Q|ţ1"h&Fx [uYC[e&"~d)bܸ?貊[ѵ;}!83sΜ˹L=`@r:$ipdrz:Y@Qc#'46INA>kgmx6b:bю)%Jc ğyW6l @~'K$o#"(4ylsaXSF@\A8o&|2fѺ׼O/Nܯ&nupÁ^.Gts=(ٔ^\Yz7Nn8RYZRu%ZnV*v'MbXzOXnۡêk!O@f^>e"dX??U} } m} I} m} } } I} } } m} } } $} }    !"#$%&'()*+,-./0123Resident's Name #1 #2  #3  #4 #1 #2 #3 #4  #1  #2  #3   #4 " Appropriate Toileting Rate Wetness Rate  ) %  dY@@^dD   T ?- dY@S U@dL    Y@   Y@     Y@    Y@      Y@   Y@     Y@   Y@     Y@    Y@ ! !   !Y@ " !  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Using the chart below, enter each participating resident's name in the far left column. Hit the "Enter" key to scroll down to the next cell. Step 2. Enter wet check data (see item #1 on the Prompted Voiding Form) for each resident. Enter a "1" in the appropriate cell if the resident was found dry on that check [type 1, then hit the right directional arrow ( -->) on your keyboard to advance to the next cell.] Leave the cell blank if the resident was found wet or soiled on that check. You may enter wet check data all at once, after the three-day trial is completed, or in stages during the prompted voiding trial. If you make a mistake when entering data, just click on the cell with the error, hit the "Delete" button, and enter the correct data. Step 3. The Excel program automatically calculates the "Appropriate Toileting Rate" for each resident in the second-to-the-last column. (The "Wetness Rate," reported in the far-right column, will be used in Step 5.) Interpreting Data: Residents with an appropriate toileting rate above 65% should continue to receive prompted voiding (the procedure described in steps 1-5 on Sheet #1). For more information, click on the tab for Sheet #3, "Interpreting Data". A  ,Z,DO,V7oIL w, -]*!-3@]l" A@^ T!^ Day 1, Wet checks 1-4U]l #B A@^ !^ Day 2, Wet checks 1-4U]l $\ % A@^ !^ Day 3, Wet checks 1-4U]* %\vU@]* &34@]* '2U@]*(U@]*)  U-@]**@]*+@]*,@]*- @]*/ @]*0 @]*1@]*2  U@]*4  @]*6U@]*7Tc@]*8Ud@]*9 T d@]*: U d@]*; Td@]*<Td@=[, 8> ```"   h  dMbP?_*+%"??U ]@@- " A@ H< Interpreting Data Use this chart to guide interpretation of results: Appropriate toileting rate Ability to toilet 76-100% Excellent 66-75% Good 50-65% Fair 0-49% Poor Residents with an appropriate toileting rate above 65% should continue to receive prompted voiding. Residents with appropriate toileting rates below 66% seldom show responsiveness with longer term applications of prompted voiding. Treatment options for these non-responders should be based on their pre- and post-trial answers to the Toileting Motivation and Preference Assessment Survey questions and their behavior during the trial (see item #3 on the Prompted Voiding Trial form). Non-responsive residents who express a willingness to improve continence should be further evaluated to identify all problems that are potentially treatable by other interventions. As a general rule, any resident who attempts to toilet two times a day (see item #2 on the Prompted Voiding Trial form), even if unsuccessfully, should be considered motivated to stay dry and should thus receive a follow-up evaluation and after that, another prompted voiding trial. About 10%-20% of non-responders will show no willingness to improve continence. In interviews, they express no desire to be either changed or toileted more frequently. In prompted voiding trials, they show or verbalize that toileting assistance is unwanted. These residents should be placed on a check-and-change program. No research findings to date suggest that other treatments will be more successful. k7G V~V  vx =[, 8>    Xxuz  dMbP?_*+%MVAuto HP LaserJet 3300 Series PC? odLettering Data Use this chart .HP LaserJet 3300 Series PCL 62xePMkSQs'ic1Q|ţ1"h&Fx [uYC[e&"~d)bܸ?貊[ѵ;}!83sΜ˹L=`@r:$ipdrz:Y@Qc#'46INA>kgmx6b:bю)%Jc ğyW6l @~'K$o#"(4ylsaXSF@\A8o&|2fѺ׼O/Nܯ&nupÁ^.Gts=(ٔ^\Yz7Nn8RYZRu%ZnV*v'MbXzOXnۡêk!O@f^>e"dX??U} m} m } }  } m}  X     Resident's Name Wetness RateAvg. Wet Rate All Res. Warning Limit  ! %@B*3OP(%^%@B D                              Dl|a !"#$%&'()*+,-./0123456789:;<=>?  ! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > > ?DKl@ABCDEFGHIJKLMNOPQRSTUVW @ A B C D E F G H I J K L M N O P Q R S T U V W40] '< A@h0Monitor the Program For best results and to help sustain staff performance, a supervisory nurse should monitor the program on a weekly basis. Calculate a performance warning limit: The primary method for monitoring prompted voiding programs is to compare expected outcomes to actual outcomes. That is, you should compare the percentage of incontinent residents found wet at a given point in time to the percentage who should be wet if the prompted voiding program is working as expected. If the actual percentage exceeds the expected percentage, theres a problem, and it needs further analysis if you want to resolve it. Typical problems stem from changes in a residents status or break-downs in the prompted voiding work process. Before you can conduct this assessment, you must first establish your programs performance warning limit; that is, you need to determine the highest percentage of residents who should be wet if the program is working well. This calculation is based on data collected during the prompted voiding trial. Only the data for responsive residents is used; that is, data for residents with appropriate toileting rates greater than 65%. You can find toileting rates for each resident on Sheet #2, in column N. To get to this sheet, click on the tab near the bottom of your screen labeled "#2-Enter Data." Data Entry Follow these steps to determine your program's performance warning limit: 1. Enter each responsive resident's name in column A. Hit the "Enter" key to scroll down to the next cell. 2. For each resident, enter his or her "Wetness Rate" in column B. You can find each resident's wetness rate on Sheet #2 ("Enter Data"), in column "O". 3. The Excel program automatically reports the average wetness rate for all responsive residents in column C. This, in turn, is used to automatically calculate the performance warning limit, reportey ,HUT  R <Ud in column D. (The warning limit is equal to the average wetness rate plus two standard deviations.) The warning limit sets the standard for expected performance. Now you need to gauge the program's actual performance. Click on the tab near the bottom of your screen labeled "#5-Checks" to find out how to conduct weekly control checks.=[, 8> "     dMbP?_*+%MVAuto HP LaserJet 3300 Series PC? odLettero standard deviations.) .HP LaserJet 3300 Series PCL 62xePMkSQs'ic1Q|ţ1"h&Fx [uYC[e&"~d)bܸ?貊[ѵ;}!83sΜ˹L=`@r:$ipdrz:Y@Qc#'46INA>kgmx6b:bю)%Jc ğyW6l @~'K$o#"(4ylsaXSF@\A8o&|2fѺ׼O/Nܯ&nupÁ^.Gts=(ٔ^\Yz7Nn8RYZRu%ZnV*v'MbXzOXnۡêk!O@f^>e"dX??U ] @-%Z A@`pB CONDUCT CONTROL CHECKS A supervisory nurse should monitor the prompted voiding program by conducting weekly "wet checks." To do this, the nurse randomly checks at least 10 participating residents for wetness each week. (We estimate that supervisors will spend 15-20 minutes a week conducting these control checks.) The percentage of residents found wet during a check is the "wetness rate." For example, if the nurse finds that 2 of the 10 residents she checks are wet, then the wetness rate for that week is 20%. Guidelines for Scheduling Random Control Checks: Control checks should be unpredictable and should sample the range of times that might be problematic because of staffing issues. We have found in previous work, for example, that late afternoon on Saturday is a time of high wetness rates. COMPARE WETNESS RATES TO THE WARNING LIMIT How well is your program performing? To find out, compare each week's wetness rate to the performance warning limit, reported on Sheet 4, in column D. Again, the warning limit defines acceptable performance. If the wetness rate falls under this limit, then the program is performing as expected. If the wetness rate exceeds the limit, however, the program is considered to be out of control and further analysis and corrective action are needed to bring it back in line. Consider, for example, whether out-of-control results indicate a change in a residents status, a breakdown in care during shift changes, or a staffing problem on a particular hallway. All these are common occurrences that can skew program results. Control Chart: It helps to track performance over time by creating a control chart that plots each week's wet-check rate. The control chart lets you see at a glance whether the prompted voiding program is working well or needs improvement. To view a sample control chart, go to this page on our website: http://borun.medsch.l  A9/[ZC2X@ k j < ucla.edu/modules/Incontinence_management/step4d.htm. VISIT OUR WEBSITE For more information about the prompted voiding program and to learn about other interventions designed to improve daily care in nursing homes, visit our website at http://borun.medsch.ucla.edu. =[, 8>     dMbP?_*+%MVAuto HP LaserJet 3300 Series PC? odLetterre information about the .HP LaserJet 3300 Series PCL 62xePMkSQs'ic1Q|ţ1"h&Fx [uYC[e&"~d)bܸ?貊[ѵ;}!83sΜ˹L=`@r:$ipdrz:Y@Qc#'46INA>kgmx6b:bю)%Jc ğyW6l @~'K$o#"(4ylsaXSF@\A8o&|2fѺ׼O/Nܯ&nupÁ^.Gts=(ٔ^\Yz7Nn8RYZRu%ZnV*v'MbXzOXnۡêk!O@f^>e"dX??U ] K 2 A@ |VTOILETING MOTIVATION AND PREFERENCE ASSESSMENT Instructions: For each resident assessed in the prompted voiding trial, ask the following questions both before and after the trial to assess his or her motivation to use the toilet and to identify preferences for toileting assistance. Our research shows that residents who score two or more on the Minimum Data Set (MDS) recall subscale (see below) are capable of providing reliable and meaningful responses to these interview questions. Residents who fail this cognitive screen should be excluded from interviews but should still undergo the prompted voiding trial. Resident Name:_______________________ Staff Interviewer:_________________________ Date of Interview:____/____/____ mm dd yy Check the best response for the questions below: DK=Dont Know NR=No Response or Nonsense Response REF=Refusal to answer question Interviewer: I want to ask you some questions about help with using the toilet. 1. Does it bother you to wet in your diaper? ___yes ___no ___ DK/NR/REF 2. Do staff help you to the toilet as much as you would like? ___yes ___no ___ DK/NR/REF 3. Do you want to be helped to the bathroom more often? ___yes ___no ___ DK/NR/REF 3a. If no, ask: Do you want to be helped to the toilet less often? ___yes ___no ___ DK/NR/REF 4. Do you want to be changed more often? ___yes ___no ___ DK/NR/REF 4a. If no, ask: Do you want to be changed less often? ___yes ___no ___ DK/NR/REF After the prompted voiding trial, ask this question as well: 5. Do you like the amount of changing and toileting assistance you have received in the last three (or two) days? ___yes ___no ___ DK/NR/REF Scoring: A high motivation to toilet is indicated if a resident gives the answers in bold italics. A low motivation to toilet t/1L>  +  6>CU m+5Vi <seems indicated if a resident responds no to questions 1, 3, 4, 5, and yes to questions 3a, 4a, and yes or no to question 2. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - MDS RECALL SUBSCALE Residents name:___________________________________________ Check all that the resident was able to accurately recall (in last 7 days): a. Current season: ____ b. Location of own room: ____ c. Staff names and/or faces: ____ d. He/she is in a nursing home: ____ OR e. None of the Above: ____ Resident receives 1 point for each item (a-d) checked. =[, 8>     i  dMbP?_*+%" ??spU ]  7K A@L hoPROMPTED VOIDING TRIAL Instructions: Use this form to record results of wet checks and prompted voiding attempts with one resident for one day of the assessment trial. Each resident should receive prompted voiding every two hours between 8 am and 4 pm, for a total of 4 times on each day of the assessment trial. There is space below to record results for 4 wet checks and prompted voiding attempts. You will need to complete 3 of these forms per resident for a 3-day prompted voiding trial. Resident Name:_____________________ Employee Name:_______________________ Date:______________________________ Day of Trial: ___1st ___2nd ___3rd Time: _____at 1st check ________at 2nd check ________at 3rd check ________at 4th check 1. Residents condition at check (circle one for each check): 1st check: 2nd check: 3rd check: 4th check: Dry Dry Dry Dry Wet Wet Wet Wet Bowel Bowel Bowel Bowel Wet and bowel Wet and bowel Wet and bowel Wet and bowel 2. Toileting outcome (circle one for each check): 1st check: 2nd check: 3rd check: 4th check: Refused Refused Refused Refused Dry run* Dry run Dry run Dry run Urine Urine Urine Urine Bowel Bowel Bowel Bowel Urine and bowel Urine and bowel Urine and bowel Urine and bL&xB2A   G L <owel * A dry run means that the resident attempted to toilet but failed to void. 3. Residents reaction to checks and prompts (circle one for each check): 1st check: 2nd check: 3rd check: 4th check: Self-initiates Self-initiates Self-initiates Self-initiates Cooperates-neutral Cooperates-neutral Cooperates-neutral Cooperates-neutral Cooperates-reluctant Cooperates-reluctant Cooperates-reluctant Cooperates-reluctant Uncooperative Uncooperative Uncooperative Uncooperative 4. Level of assistance resident needed to toilet (circle one for each check): 1st check: 2nd check: 3rd check: 4th check: Independent Independent Independent Independent Stand-by asst. Stand-by asst. Stand-by asst. Stand-by asst. Needs help of 1 person Needs help of 1 person Needs help of 1 person Needs help of 1 person Needs help of 2 persons Needs help of 2 persons Needs help of 2 persons Needs help of 2 persons =[, 8>   Oh+'0HP`p annieannieMicrosoft Excel@e< @ժ=@a e ՜.+,0(8@ \d l AND Properties, LLC #1-PV Procedure#2-Enter Data#3-Interpret Data#4-Set Warning Limit #5-Checks#6-Motivation Interview #7-PV Trial  Worksheets  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root EntryFBook Workbook>SummaryInformation(DocumentSummaryInformation8