Improved Hygiene Care and Toileting

A Therapists Perspective

Hygiene care—particularly horizontal diapering—for people with severe disabilities can be time-consuming and taxing for the caregiver especially if it involves the traditional changing-table transfers. While changing tables are commonly used for young children and seldom pose problems, as children grow older (and heavier) the process becomes increasingly demanding. As therapists well know, the most frequently cited mechanism of work-related injury in our profession is from lifting and transferring patients.¹ Although mechanical lifts can be used to perform the changing table transfer and ease the work of the caregivers, we must also consider the dignity of the patient. We’ve all seen how humiliating it can be for an adult to submit to a diaper change with limited privacy. So it’s small wonder that many therapists working with people with severe disabilities dread the thought of toileting.

Thankfully we are seeing a gradual shift in the way healthcare professionals and policy makers perceive disability, and this shift can change the way we approach hygiene and toileting. With the introduction of the World Health Organization’s International Classification of Function, Health, and Disability (ICF) in 2001, the focus of healthcare has moved from functional limitations and disability to activity and participation.² Included in the ICF is the assessment and removal of environmental and social barriers to allow for as much patient participation as possible regardless of diagnosis or disability.² This could be as simple as a change in attitude towards prevailing treatment protocols or providing the most appropriate and supportive equipment to facilitate independence. A therapist’s role then, is to continually look for ways to increase patient participation and independence in all areas of life.

Considering hygiene care within the framework of the ICF, an individual should have the opportunity to actively participate in the toileting process. Research shows that when we do this, even patients with severe disabilities can demonstrate continence.^3,4 While there are toilet chairs that can accommodate a patient with severe disabilities, using the toilet is only a small fraction of the actual toileting procedure. To complete a toileting episode, a patient requires transfer and balance skills in order to stand and adjust clothing. Many do not have these skills and require much assistance. Many caregivers will choose to diaper or catheterize these people to avoid the daily hassle of coordinating a two- or three-person toilet transfer with max assist.

It was for these people (and their caregivers) that Rifton created the Support Station. Mounted to the wall in a bathroom or locker room, this piece of equipment provides the patient with severe disabilities an opportunity to actively participate in the entire toileting procedure while at the same time maintaining their dignity and furthering opportunities for transfer practice. Using the slots, handholds, and elbow curves, a patient can assist in pulling themselves to a standing position. The padded board comfortably supports the user and can be adjusted for the weight-bearing abilities of different users. A patient can then remain standing during diaper change and may even be able to assist with clothing adjustments. The caregiver has easier access to the area of hygiene and the stress of lifting and transferring is completely eliminated. Using the Support Station, a patient may also be able to transfer to a commode chair or stationary toilet depending on the circumstances.

Take for example, Francie, an enrollee in the day program at Chesapeake Care Resources in Maryland. Unable to stand or transfer independently, she needed the assistance of three or four staff for hygiene care on a changing table. They installed a Support Station and Francie began using it, at first with a lot of help. Over time she became increasingly independent and now she is able to perform her toileting privately, with help required only for clothing. Since the installation of the Support Station at Chesapeake, there has been a decrease in staff injuries, fatigue, and stress related to toileting, and so much time saved.

Then there is Maria, an elderly client at Casa Pacifica in California. After having a stroke and aneurysm, she required extra assistance with toileting. She left a previous center because they had wanted to have her catheterized. However, at Casa Pacifica, Maria uses the Support Station and loves it. By avoiding catheterization, Maria has avoided increased risks of infection and loss of mobility. Instead she has daily opportunities to practice transfers and assist with her ADLs.

To understand and use the Support Station appropriately requires a paradigm shift away from the “traditional” methods of dependent patient toileting and diapering to a method in which the patient plays an active part. Ann Caragher, principal of special education services for Kern County in California, likens this change to switching from a typewriter to a computer. With anything new, there is first resistance and skepticism, and so it was with the Support Station at her facility. However, the values and benefits of this piece of equipment quickly became clear and now the staff and patients fully embrace their new toileting system using the Support Station. At the same time, Ann has also noticed a decrease in workers’ compensation claims resulting from lifting.

With so many benefits for patient, caregiver, and facility, we therapists are in a position to lead the way for great outcomes and a richer quality of life for those that need it most.

References

1. Holder N, Clark H, Di Blasio J et al. Cause, prevalence, and response to occupational musculoskeletal injuries reported by physical therapists and physical therapist assistants. Phys Ther. 1999;79:642-652.

2. World Health Organization. ICF Beginner’s Guide. Available at: http://www.who.int/classifications/icf/site/beginners/bg.pdf. Accessed April 2, 2008.

3. Roijen LE, Postema K, Limbeek VJ, Kuppevelt VH. Development of bladder control in children and adolescents with cerebral palsy. Dev Med Child Neurol. 2001;43(2):103-7.

4. Singh BK, Masey H, Morton R. Levels of continence in children with cerebral palsy. Paediatr Nurs. 2006;18(4):23-6.