Washable pads or disposable diapers?

Washable Pads or Disposable Diapers? A three-month study produced clear answers for the hospital where it was conducted. RICHARD GRANT This study was conducted in a large southwestern psychiatric hospital to determine the advisability of changing from the established procedure for incontinence care to the use of disposable diapers. A search of the literature revealed no studies that reported hiformation about the cost and care effectiveness of using disposable diapers with adults who are incontinent. It seems important, therefore, to determine whether the change would benefit patients and save the hospital money. At any given time, approximately 60 patients on the unit to be studied required incontinence care. The established procedure was to 1. Thoroughly cleanse the patient with commercially prepared cleanser, followed by rinsing and drying. 2. Change the clothing and/or bedding if necessary. 3. Use washable incontinence pads. Prior to the study, a brief survey of the staff was done. Nursing personnel said" that each incontinence Richard Grant, RN, PhD (anthropology), is an assistant professor at the College of Nursing, Arizona State University, Phoenix. He has been a nursing director in several convalescent centers, and a nurse administrator in the large psychiatric hospital where he later conducted the research reported here.

248 Geriatric Nursinl1; July/August 1982

care procedure required two people for some period of time, up to 10 times in each 24-hour period. They estimated that about 140 hours of nursing time each day were spent on incontinence care. A review of patient records revealed that each patient was changed an average of five times daily. In spite of this considerable investment of time, an average of 15 patients on any given day had some kind of skin breakdown that required professional nursing inter'" vention. These treatments, each taking approximately 15 minutes, were done once on each shift. This accounted for about 11 hours of registered-nurse care each day. The dollar costs for incontinence care, based on the above data, were estimated at" $330,324 per year. That figure included costs of materials used but did not include costs of pharmacy personnel for preparing and dispensing drugs used in skin treatments or the costs of personnel to handle supplies and laundry. The cost information generally available, primarily from manufacturers, compared the _cost of linen with the cost of disposable diapers. Manufacturers' information shows that linen costs are significantly higher. The present study was designed to determine patient and unit condition and the costs of personnel (in man hours) rather than linen costs. The Problem Six questions were to be answered during the study: " 1. Are there significant differences in the skin condition of the

patients in two groups: a control group (established procedure) and an experimental group (disposable diapers)? 2. Is there a significant difference in the number of patients in each group who require professional treatment for skin breakdown? 3. Is there a significant difference between the two groups in the time required for the routine incontinence care and professional treatments? 4. What is the exact cost difference for both supplies and man hours between the two groups? 5. Can differences be measured and described regarding safety for patients and personnel in terms of such hazards as urine on floors, exposure to contact with feces on floors, door knobs, linens, furnishings? 6. Can differences be measured in the esthetic quality of the unit in terms of odor and appearance? The Design Thirty patients (half of the 60patient target population) were selected by the psychiatric nursing administrators (comparable to supervisors) in consultation with the unit head nurses for inclusion in the study. Subjects were selected in pairs, matched for sex, age (plus or minus five years) and general physical condition. Degree of ambulatory ability, size, weight, and level of health were all considered. All 30 subjects were grossly incontinent; IS were essentially bedridden (called "total care"); and 15 were ambulatory or semiambulatory. One subject from each pair was assigned to the con-

INFIRM TREATMENT UNIT DISPOSABLE DIAPER STUDY-TREATMENT RECORD PATIENT'S NAME: ::.r;;""l_s. ~..-e ~ HOSPITAL # ~""'1::l ~" Ir WEEK I ok -..:..;;..;..;.;.;;;.;;:.-.;:;.::,.,::.:=.-=-----.G"'R... OO"'P......,.....:,A b ...

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TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL TIME INITIAL

DATE DISCONTINUED:················· changes (nurse aides) recorded the time required for each change. For example, if one person changed the patient and it took 10 minutes, 10 minutes were recorded; if two people changed the patient and it took 8 minutes, 16 minutes were re· corded. The person(s) changing the patients initialed each recording on the flow sheets. Space was allowed on the forms for PRN changes. Each day the registered nurse assigned to do treatments assessed the skin condition of all study patients from waist to upper thigh, and recorded it on the flow sheet on

a scale from healthy skin to total breakdown. If the patient required professional treatments for skin care at the time the study began, this was recorded on the first form and a Treatment Record was started. If patients developed skin problems during the study, this fact was reflected in the daily assessment portion of the flow sheet. Each flow sheet covered one week, from Monday at 12:01 AM to 11:59 PM the following Sunday. A designated member of the nursing staff was responsible to protect patient identification by following

this prescribed procedure: • At the end of each study week, place patient's code number (Group A or B, plus individual number 1 through 15) in the lower right hand corner of the data sheet. • After form is completed and patient is matched with a patient in the other group (l A with 1 B), cut off the identifying information at the top of the form. • Deliver forms to the investigator. All data sheets were filed until completion of the study. The data were then put into the computer

Geriatric Nursing July/August 1982249

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DISPOSABLE DIAPER STUDY-TREATMENT RECORD.

trol group and one to the experi. mental group by the PNAs and head nurses. Each subject was assigned a code number for purposes of data analysis. For 90 days, the control group received incontinence care and treatment according to established policy and procedure, while the experimental group received care according to the procedure of the compa· ny supplying the disposable diapers. Before the study began, personnel were oriented to its purposes and procedures, and' simple flow sheets were designed for data col-

250 Geriatric Nursing July I August 1982

lection (see illustrations). The unit physician was also oriented to his role in the study, a weekly assessment of each subject's skin. Approval for the study was obtained from the Committees for the Protection of Human Subjects in Research of Arizona State University and the Arizona Department of Behavioral Health, and from the state's attorney general. Data collected were analyzed through the Statistical Packages for the Social Sciences program on the WYLBUR computer of Arizona State University. Statistical manipUlations included one- and

11 /

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two-tailed F and T-tests, chi square, and mean, median, and mode identification for times required to change patients and record skin conditions. Conduct of the Study

Patient's reusable pads or disposable diapers were changed on a rigid four-hour schedule (six changes per 24 hours). While each patient could be changed at slightly different times, the schedule was established so that not more than IS to 20 minutes of deviation would occur for each patient. Personnel involved in the

and the raw data forms destroyed, thus ensuring the complete anonymity o( the study population and nursing personnel involved. The Results In group A (experimental), two patients developed skin problems during the study. One had skin problems requiring professional intervention for 14 days; one had 26 days of such problems. In group B, two patients had skin problems: one had 8 days of professional intervention; the other, 13. As a result of the above findings, the .chi square showed absolutely no difference between the two groups.. The F value was 5.4 with a 2-tail probability of 0.06. The T value was 1.83 with a 2-tail probability of 0.092. The results therefore demonstrated that there was no significant difference in the skin condition of the two groups. SKIN CONDITION

TIME REQUIRED FOR INCONTINENCE CARE AND PROFESSIONAL TREATMENT The mean time for

changing a patient using established procedure (B group) was 2.347 minutes with a standard deviation of 1.356 minutes. The mean time for changing a patient using the disposable diaper was 3.5488 minutes with a standard deviation of 0.653 minutes. While this seems to show that using disposable diapers required slightly more time, the F value was 4.31 with a 2-tail probability of 0.095 and the T value was 2.13 with a 2-tail probability of 0.053. These statistical measures indicate that the time difference was not significant. COST. INCLUDING PURCHASE OF SUPPLIES AND MAN HOURS Because

there was no significant difference in man hours used for the two procedures or in the time and supplies used in professional treatments for groups A and B, the issue of cost boils down to the difference between the cost of linens and of diapers. In this hospital, which has its own laundry, the cost of the reusable incontinence pads ($2,100 per year) is a small part of the total

laundry budget. The estimated cost of the disposable diapers was $55,000 per year, which would cause a significant increase in total costs. SAFETY AND ESTHETIC DIFFERENCES It was apparent to everyone

that there was a marked reduction in the amount of smearing and the number of urine puddles on the floors, which present safety hazards for both patients and personnel. Staff members consistently praised the use of disposable diapers, especially for the ambulatory incontinent patient. For these reasons, as well as to reduce the embarrassment of patients and others when incontinent patients leave the hospital grounds, the annual purchase of enough dis-

For the hospital that was studied, which had its own laundry, the estimated cost of using disposable diapers outweighed the cost of washable pads.

posable diapers to accommodate ambulatory patients was recommended. The overall esthetic quality of the unit did not seem remarkably changed. However, while the study was going on, half of the 60 P;ltients were not involved. Therefore, this variable could not be determined accurately. Conclusions and Recommendations First and foremost~ it was quickly determined that the diapering procedure was much more difficult, and in some respects less effective, with the bedridden patients than the established procedure. Personnel still had to change bed linens, mainly because patients tore the diapers to shreds or pulled them off between changes.

Because of this, no statistically significant differences emerged between the control and experimental groups on any measured item. Indeed exactly the same number of patients experienced skin break. down in each group. In this hospital, the cost of reusable incontinence pads was $175 per month; disposable diapers (of the type studied) fqr 60 patients would cost around $5,400 per month. For a switch to disposables to be cost effective, considerable savings would have to be realized by reducing costs for laundry personnel, water, and utilities, and by much less use of linens other than the pads. In this particular institution, such reductions were seen as extremely difficult. The study demonstrates the value of determining whether a new product or procedure will be cost and patient-care effective in a par.ticular health care setting. There is little doubt that disposable diapers may be extremely useful in some settings, but such was not the case in the institution studied. Manufacturer claims about potential savings may not consider the most important variables for everyone. This is especially true where an established procedure is care effective, because resistance to change on the part of personnel may increase' man-hour costs, which are by far the largest part of . any hospi.tal budget. The study also indicated that institutional and nursing administrators can benefit by conducting preliminary studies of new products or procedures before adopting them. For this purpose, hospitals should employ nurse researchers who can design and conduct such studies, and train and supervise other staff members in the research process. All studies should measure cost effectiveness in relation to equipment and supplies, the effect on patient care, and the effect on the tasks of nursing personnel. An important finding of this study was that nur.sing personnel were providing cost~effective incontinence care through the use of an established procedure. GN

Geriatric. Nursj~g_ July/August 1982251