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Outcomes:

Patients' Embarrassment Can Lead To Poor Agency Outcomes

Published on Fri Feb 20, 2004

It's up to you to break the silence.

Don't underestimate bowel incontinence problems - or your outcomes will suffer.

Improvement in bowel incontinence is one of the outcome based quality improvement measures, so agencies should aim for accuracy and consistency in assessing this problem. The improvement in bowel incontinence outcome measure depends on your answers to M0540 (Bowel Incontinence Frequency) at start of care, resumption of care and discharge.

The problem: If you miss bowel incontinence problems on admission, but your colleagues identify them on recert or discharge, the patient's condition appears to decline during the episode, even if that patient actually has improved, says con-sultant Marion Donahue with Hamden, CT-based Simione Consultants.

When answering M0540, remember that bowel incontinence includes any loss of bowel control "regardless of reason" and "episodes of incontinence despite bowel regimen," instruct the experts from the 3M National OASIS Integrity Project in their report released in November 2003. It does not include a patient's ostomy.

Unlike the all-or-nothing approach of M0530 (Urinary Incontinence), M0540 allows for a range of answers, says OASIS expert Linda Krulish with Redmond, WA-based Home Therapy Services. The responses are on a continuum, so the patient who very rarely or never has bowel incontinence would be "0" while one to three times a week would be a "2." The highest number choice is "5," for bowel incontinence more often than once daily.

What to do: Bowel incontinence -- like urinary incontinence - is an area many people find difficult to discuss, Krulish says. To discover a problem, you'll need to specifically address the issue, she advises.

  • Ask clearly. Don't just ask, "Are you having any trouble with anything?" Krulish instructs. Instead, ask "Do you ever leak stool or not make it to the bathroom in time?" If the patient says "Yes," then ask, "How often?"

  • Use your senses. Observe as well as ask. Do you smell the odor of stool? Do you see stained undergarments in the bathroom or when assessing the patient's skin condition? Does the caregiver mention that the patient has trouble making it to the bathroom in time?

  • Don't stop with yes. Keep asking questions that help you pinpoint the source of the incontinence. If a patient does have bowel incontinence, "you want to try to figure out the cause," Krulish says. Is it acute or chronic? Is it related to Alzheimer's, dementia or neurological problems? Do you need to address it in the treatment plan? Is it related to changes in diet or mobility? Or is this a new problem that hasn't yet been identified or addressed?

  • Focus on the present. M0540 doesn't address the treatment of bowel problems, advised the Centers for Medicare & Medicaid Services at the April 2003 New Orleans OASIS Educator's Conference. If a patient is on a bowel training program, answer based on the current situation, CMS said. Even if the patient had bowel incontinence in the past, if the program effectively controls the incontinence, you can answer "0" (very rarely or never has bowel incontinence).

  • Document in detail. M0540 is an area often underdocumented, Donahue reports. Part of the reason for the assessment is to develop the plan of care, Krulish emphasizes. So document not only your assessment findings, but also details of any bowel training program the patient may be on.

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