The experiences and support needs of people living at home with an enteral tube: a qualitative interview study.

BACKGROUND: The number of people with an enteral tube (ET) living at home is increasing globally and services to support them to manage this complex and life-changing intervention vary across regions. The present study aimed to gain an understanding of the experiences of people living at home with an ET and their carers, as well as to explore their views of supporting services and ET-related hospital admissions. METHODS: A qualitative inductive descriptive design was employed. Semi-structured, face-to-face interviews with a purposive sample of people with an ET living at home and carers were undertaken. Interviews were transcribed, initial codes were assigned for salient constructs, and these were then grouped and developed into themes and sub-themes. RESULTS: Nineteen people with ETs and 15 carers of people with ETs were interviewed. Five themes were generated: home better than hospital, feelings about the tube, living with the tube, help when you need it and cost for health service. Participants indicated the ET significantly influenced daily life. Participants described becoming used to coping with the ET at home over time and developing strategies to manage problems, avoid hospital admission and reduce resource waste. Variation in supporting services was described. CONCLUSIONS: People with ETs and their carers need considerable support from knowledgeable, responsive healthcare practitioners during the weeks following initial placement of the ET. Twenty-four hour services to support people with ETs should be designed in partnership with the aim of reducing burden, negative experience, waste and hospital admissions. National frameworks for home enteral nutrition could set the standard for support for people with ETs.

A two phased study on health care professionals' perceptions of single or multi-use of intermittent catheters.

AIMS: This two phase study aimed to explore health care professionals' teaching and prescribing practice related to intermittent catheterisation and to identify their perceptions about the possible implementation of a mixed (single and multi-use) package for intermittent catheterization. INTRODUCTION: Single-use intermittent catheters are the norm in the UK although multi-use is common in some other countries. A recent Cochrane review found no difference in complications, including urinary tract infection rates, between those using single or multi-use catheters. A flexible option of both multi-use and single use intermittent catheters could provide users with more flexible choices in self-care. However, understanding health care professionals' perspectives is one of the keys to developing a multi-use intervention. DESIGN: A qualitative research framework using in-depth interviews to inform an on line survey. METHOD: In-depth interviews were conducted with health care professionals based in the UK who prescribe catheters, teach intermittent catheterisation or manage an intermittent catheterisation service. The interviewees were selected to represent a range of clinical areas, experience and professions - continence advisors, urology, multiple sclerosis (MS) and spinal cord injury specialist nurses, and General Practitioners. Following framework analysis the themes and factors identified were used to develop an on-line survey which was disseminated through health care professional networks whose members saw patients who use intermittent catheters. RESULTS: Nineteen health care professionals participated in the telephone interviews; 206 completed the survey. A wide range of professionals in terms of experience and specialty afforded rich information regarding the contextual issues around the teaching and prescribing of intermittent catheters. The primary finding was that health care professionals were concerned about 'minimising health risk' and maximising 'normalcy' for those using intermittent self-catheterisation. Health care professionals who worked in the acute setting or had no experience of re-use were most resistant to the re-use of catheters. Professionals requested evidence that a multi-use package would not increase the risk of developing a urinary tract infection or increase the burden of use to a patient before a mixed package would be considered. CONCLUSIONS: For multi-use to be acceptable, evidence based guidelines must be available for healthcare professionals and cleaning methods must be acceptable and safe for intermittent catheter users. Further evidence may be required to establish that a mixed catheter package is equivalent to single use only, particularly for outcomes such as urinary tract infection, urethral injury and quality of life. RELEVANCE TO CLINICAL PRACTICE: This paper highlights that if multi-use catheters are to be successfully introduced into clinical practice, the ease of use, safety and effectiveness of the cleaning technique will need to be convincingly demonstrated by a range of well-defined users.

Barriers and facilitators to screening for malnutrition by community nurses: a qualitative study.

BACKGROUND: A substantial proportion of individuals who live in community settings in the UK experience malnutrition. Routine screening for malnutrition by healthcare practitioners has been recommended in many regions. The present study aimed to understand community nurses' perceptions of barriers and facilitators to undertaking nutritional screening. METHODS: A qualitative study was undertaken with a purposive sample of community nurses working in one UK healthcare organisation. Semi-structured interviews were used to elicit perceptions of barriers and facilitators. Interviews were digitally recorded, anonymised and transcribed. Initial codes were assigned for salient constructs identified in the transcripts, refined by grouping, and a thematic list was developed. RESULTS: Twenty district nurses and community matrons were interviewed at which time saturation of the data was achieved. Six themes emerged: supportive organisational culture, time and resource to screen and intervene, ease and acceptability of the screening tool, professional judgement as good as screening, the need for training and sharing good practice, and enhancing communication between care settings. CONCLUSIONS: The findings of the present study suggest that screening is more likely to be completed where an organisation is perceived to have a clear expectation that it is undertaken and also demonstrates this through training and availability of resources. The need for a process or tool that nurses find easy to use and relevant to their practice area was highlighted. Further research should examine the effect of the use of a nutritional screening tool by community nurses on nutritional care planning and intervention.

Development and preliminary testing of a standardized method for quantifying excess water in over-hydrated skin using evaporimetry.

Although evaporimetry (the measurement of water vapour flux density from the skin) has often been used to study the impact on skin hydration of using products such as baby diapers and incontinence pads, it is difficult to interpret results and to compare data from different studies because of the diversity of unvalidated methodologies used. The aim of this work was to develop a robust methodology for measuring the excess water in over-hydrated skin and test it on volar forearm and hip skin which had been occluded with saline soaked patches. Three repeat measurements were made on the volar forearm and the hip of five young (31-44 years) and six older (67-85 years) women and moderately good within-subject repeatability was found for both skin sites for both subject groups. Measurements taken from the hip were significantly higher (P = 0.001) than those from the arm and had larger coefficients of variation (3.5-22.1%) compared to arms (3.0-14.0%). There were no significant differences between young and older skin, implying that women for future studies could be recruited without regard to age. This is the first time that a robust evaporimetric methodology for quantifying excess water in over-hydrated skin has been described and validated, and it will form a solid basis for future work.

Absorbent products for urinary/faecal incontinence: a comparative evaluation of key product designs.

OBJECTIVES: To compare the performance and cost-effectiveness of the key absorbent product designs to provide a more solid basis for guiding selection and purchase. Also to carry out the first stage in the development of a quality of life (QoL) instrument for measuring the impact of absorbent product use on users' lives. DESIGN: Three clinical trials focused on the three biggest market sectors. Each trial had a similar crossover design in which each participant tested all products within their group in random order. SETTING, PARTICIPANTS AND INTERVENTIONS: In Trial 1, 85 women with light urinary incontinence living in the community tested three products from each of the four design categories available (total of 12 test products): disposable inserts (pads); menstrual pads; washable pants with integral pad; and washable inserts. In Trial 2a, 85 moderate/heavily incontinent adults (urinary or urinary/faecal) living in the community (49 men and 36 women) tested three (or two) products from each of the five design categories available (total of 14 test products): disposable inserts (with mesh pants); disposable diapers (nappies); disposable pull-ups (similar to toddlers' trainer pants); disposable T-shaped diapers (nappies with waist-band); and washable diapers. All products were provided in a daytime and a (mostly more absorbent) night-time variant. In these first two trials, the test products were selected on the basis of data from pilot studies. In Trial 2b, 100 moderate/heavily incontinent adults (urinary or urinary/faecal) living in 10 nursing homes (27 men and 73 women) evaluated one product from each of the four disposable design categories from Trial 2a. Products were selected on the basis of product performance in Trial 2a and, again, day time and night-time variants were provided. The first phase of developing a QoL tool for measuring the impact of using different pad designs was carried out by interviewing participants from Trials 1 and 2a. MAIN OUTCOME MEASURES: Product performance (e.g. comfort, discreetness) was characterised using a weekly validated questionnaire. A daily pad change and leakage diary was used to record severity of leakage, numbers of laundry items and pads. Skin health changes were recorded weekly. At a final interview preferences were ranked, acceptability of each design recorded, and overall opinion marked on a visual analogue scale (VAS) of 0-100 points. This VAS score was used to estimate cost-effectiveness. In addition, a timed pad changing exercise was conducted with 10 women from Trial 2b to determine any differences between product designs. RESULTS: Disposable inserts are currently the mainstay of management for lightly incontinent women (Trial 1) and they were better for leakage and other variables (but not discreetness) and better overall than the other three designs. However, some women preferred menstrual pads (6/85) or washable pants (13/85), both of which are cheaper to use. Washable inserts were worse both overall and for leakage than the other three designs (72/85 found them unacceptable). For disposable inserts and disposable diapers, findings from the community (Trial 2a) and nursing home trials (Trial 2b) were broadly similar. Leakage performance of disposable inserts was worse than that of the other designs for day and night. Pull-ups were preferred over inserts for the daytime. The new T-shaped diaper was not better overall than the traditional disposable one. However, there were important differences in performance and preference findings for men and women from both trials. Pull-ups (the most expensive) were better overall than the other designs for women during the day and for community-dwelling women during the night. Although disposable diapers were better for leakage than disposable inserts (the cheapest), women did not prefer them (except in nursing homes at night), but for men the diapers were better both overall and for leakage and were the most cost-effective design. No firm conclusions could be drawn about the performance of designs for faecal incontinence. Nursing home carers found pull-ups and inserts easier to apply (in the standing position) and quicker (in the pad change experiment) than the diaper designs; the ability to stand was associated with preference for pull-ups or inserts. The T-shaped diaper was not easier or quicker to change than the diaper. The washable products (Trial 2a) gave diverse results: they were better for leakage at night, but were worse overall for daytime than the other designs. Three-quarters of the women (27/36) found them unacceptable, but nearly two-thirds of men (31/49) found them highly acceptable at night. Findings from the two community trials (Trials 1 and 2a) showed that there were many practical problems in dealing with washable products but, together with the less effective and less expensive products, such as menstrual pads, they were more acceptable at home (and, in the case of washables, at night). This suggests that cost-effective management may involve combining products by using more effective (for a given user) but more expensive designs (e.g. pull-ups) when out and less effective but less expensive designs when at home. The interviews examining the impact of pad use on QoL provided themes and domains that can be further developed into a tool for further evaluation of absorbent products. CONCLUSIONS: This study showed that there were significant and substantial differences between the designs of absorbent products and for moderate/heavy incontinence some designs are better for men/women than others. There was considerable individual variability in preferences and cost-effective management may best be achieved by allowing users to choose combinations of designs for different circumstances within a budget. Further research is needed into the feasibility of providing choice and combinations of designs to users, as well as into the development of more effective washables and of specifically male disposable products. QoL measurement tools are needed for users of absorbent products, as are clinical trials of designs for community-dwelling carer-dependent men and women with moderate/heavy incontinence.

A computerised real-time measurement system to locate the position of the urine stream in designing urine collection devices for women.

A computerised real-time measurement system has been developed and tested for locating the position of the urine stream into a handheld urinal and onto a body-worn pad using arrays of resistive or optical sensors. Experimental data indicates that urine streams were usually scattered over quite a large cross-sectional area (typically 30mm in the anterior/posterior direction) at the point of entry into handheld urinals. However, a correctly placed aperture of length 90mm would have successfully received all the urine from the total of 36 clinical experiments run with seven women. Similarly, experiments to determine the initial position of the urine stream onto body-worn pads indicated that a target area of length 120mm would have received the initial stream of urine from all 54 clinical experiments with 18 women. These data have been used to help with the design of a handheld urinal and a body-worn urine collection interface (the latter using the body-worn pad data) to be used in two variants of a new urine collection device for women (NICMS). Although both resistive and optical sensors provided useful data, the reliability of optical sensors was often compromised by droplets of urine splashing onto light sources or detectors. Future work should focus on protecting them from splashing.

Long-term bladder management by intermittent catheterisation in adults and children.

BACKGROUND: Intermittent catheterisation (IC) is a commonly recommended procedure for people with incomplete bladder emptying not satisfactorily managed by other methods. The most frequent complication of IC is urinary tract infection (UTI). It is unclear which catheter types, techniques or strategies, affect the incidence of UTI. There is wide variation in practice and important cost implications for using different catheters, techniques or strategies. OBJECTIVES: To compare sterile versus clean catheterisation technique, coated (pre-lubricated) versus uncoated (separate lubricant) catheters, single (sterile) or multiple use (clean) catheters, self-catheterisation versus catheterisation by others, and any other strategies designed to reduce UTIs in respect of incidence of symptomatic UTI, haematuria, other infections and user preference, in adults and children using intermittent catheterisation for incomplete bladder emptying. SEARCH STRATEGY: We searched the Cochrane Incontinence Group Specialised Trials Register (searched 19 June 2006), MEDLINE (January 1966 to June 2007), EMBASE (January 1988 to June 2007), CINAHL (January 1982 to June 2007), ERIC (January 1984 to June 2007), the reference lists of relevant articles and conference proceedings, and we attempted to contact other investigators for unpublished data or for clarification. SELECTION CRITERIA: Randomised controlled trials comparing at least two different catheterisation techniques, strategies or catheter types. DATA COLLECTION AND ANALYSIS: Three reviewers assessed the methodological quality of trials and abstracted data. For dichotomous variables, relative risks and 95% confidence intervals (CI) were derived for each outcome where possible. For continuous variables, mean differences and 95% CI were calculated for each outcome. Because of trial heterogeneity, data were not combined to give an overall estimate of treatment effect. MAIN RESULTS: Fourteen studies met the inclusion criteria; all were small (less than 60 participants). There was considerable variation in length of follow-up and definitions of UTI. Participant drop-out was a problem for several studies. Several studies were more than ten years old and outcome measures varied between studies. Where there were data, confidence intervals around estimates were wide and hence clinically important differences in UTI and other outcomes could neither be identified nor ruled out reliably. AUTHORS' CONCLUSIONS: Intermittent catheterisation is a critical aspect of healthcare for individuals with incomplete emptying who are otherwise unable to void adequately to protect bladder and renal health. There is a lack of evidence to state that incidence of UTI is affected by use of sterile or clean technique, coated or uncoated catheters, single (sterile) or multiple use (clean) catheters, self-catheterisation or catheterisation by others, or by any other strategy. The current research evidence is weak and design issues are significant. In light of the current climate of infection control and antibiotic resistance, further, well-designed studies are strongly recommended. Based on the current data, it is not possible to state that one catheter type, technique or strategy is better than another.

Absorbent products for light urinary incontinence in women.

BACKGROUND: Incontinence is a common and embarrassing problem which has a profound effect on social and psychological well-being. Many people wear absorbent products to contain urine leakage and protect their clothes. It can be difficult to define light urinary incontinence because urine volumes, flow and frequency rates may vary substantially whilst still being considered 'light'. Light incontinence may encompass occasional (monthly) leaks of very small amounts (e.g. 1 g to 2 g) up to frequent leaks (several times per day) of larger amounts (e.g. 20 g to 50 g). A practical definition is urine loss that can be contained within a small absorbent pad (typically 50 g to 500 g; ISO 1996). OBJECTIVES: To assess the effectiveness of different types of absorbent product designs for women with light urinary incontinence. SEARCH STRATEGY: We searched the Cochrane Incontinence Group Specialised Trials Register (3 May 2006) and the reference lists of relevant articles were perused. SELECTION CRITERIA: TYPES OF STUDIES: All randomised or quasi-randomised trials of absorbent products for women with light urinary incontinence. TYPES OF PARTICIPANTS: Women with light urinary incontinence. TYPES OF INTERVENTION: Absorbent products (disposable insert pads, menstrual pads, washable pants with integral pad, washable insert pads) suitable for light incontinence. DATA COLLECTION AND ANALYSIS: Two review authors assessed the methodological quality of potentially eligible studies and independently extracted data from the included trial. MAIN RESULTS: One study with 85 participants met the selection criteria. This trial studied all the absorbent product designs included in this review. Data were presented on all included outcomes. For preventing leakage, for preference and for overall acceptability disposable insert pads are better than disposable menstrual pads which are better than washable pants with integral pad which are better than washable insert pads. There is no strong evidence that either disposables or washables are better for skin health. The disposable insert is the most expensive design and there is no dominant design for cost-effectiveness. There is evidence that some women will prefer alternative designs which are all cheaper than disposable inserts. AUTHORS' CONCLUSIONS: Although data were available from only one eligible trial the data were sufficiently robust to make recommendations for practice. Disposable insert pads are typically more effective than the other designs considered. However, because they are the most expensive, providing choice of designs (or combinations of designs for different circumstances) is likely to be cost-effective.

A critical investigation of ISO 11948-2 and ISO 11948-1 for predicting the leakage performance of small disposable incontinence pads for lightly incontinent women.

ISO 11948-2--an international standard laboratory method developed to predict the leakage performance of small disposable pads for lightly incontinent women--was investigated. The repeatability and reproducibility (precision within and between laboratories, respectively) of two variants on the method were found to be poor. The coefficient of variation for each method variant in each laboratory (two laboratories ran each variant) was higher than 40% for about half the 12 products evaluated. Results differed by up to 94% between laboratories for a given product. The ability of the method to predict the leakage performance of pads was investigated by measuring correlations between the clinical evaluations of the 12 products, and technical evaluations using ISO 11948-2. Correlations were very weak (r < or= 0.487). Accordingly, it is recommended that 11948-2 is withdrawn. A second international standard method (ISO 11948-1)--developed for evaluating large pads, but sometimes used on small ones--was also investigated. Correlations between the clinical evaluations of the 12 products and technical evaluations using ISO 11948-1 were weak (r < or = 0.560). Accordingly, it is recommended that ISO 11948-1 is not used for evaluating small disposable bodyworn pads for women.

How well does ISO 11948-1 (the Rothwell method) for measuring the absorption capacity of incontinence pads in the laboratory correlate with clinical pad performance.

The ability of ISO 11948-1 (the Rothwell method) to predict the leakage performance of disposable bodyworn pads for heavy urinary incontinence was investigated by measuring correlations between models based on clinical evaluations of 138 diapers and inserts (the two major design categories), and technical models based on their Rothwell absorption capacities and design features. Correlations were poorer than in the original 1993 study for the standard (r < or =0.87 compared with r < or =0.95), but still strong enough to help with purchasing choices. For a given Rothwell capacity, the leakage performance of diapers was far superior to inserts; for example, diapers containing 450 and 300 g of urine performed, as well as inserts containing 300 and 100 g, respectively. No evidence was found for any other design feature having a significant impact on leakage performance. The coefficient of variation for Rothwell capacity (a measure of product consistency) had significant impact on the leakage performance of diapers, but not inserts. The probability of diapers with the poorest consistency leaking exceeded that for the best by about 10 percentage points. Similarly, diapers were about 10 percentage points more likely to leak when used at night than during the day. Differences between day-time and night-time use of inserts were not studied.

Review of current technologies for urinary incontinence: strengths and limitations.

A wide range of continence products is available, and this paper focuses on products to prevent incontinence (such as urinals and commodes) and to contain or manage urinary incontinence (such as absorbent pads, penile sheaths and urethral catheters). Drawing on results from published clinical evaluations at the Continence Product Evaluation Network at UCL and at other centres, the strengths and limitations of the major categories of incontinence products currently on the market are reviewed. It is concluded that, although products for continence have improved considerably over the last 20 years, there is considerable scope for the designer and engineer to improve on current products.

The further development of the active urine collection device: a novel continence management system.

Continence difficulties affect the lives of a substantial minority of the population. Women are far more likely than men to be affected by urinary incontinence but the range of management options for them is limited. There has been considerable interest in developing an external urine collection system for women but without success to date. This paper describes the development and preliminary clinical testing of an active urine collection device (AUCD), which could provide a solution for sufferers. The device uses stored vacuum, protected by a high bubble point filter, to remove urine as quickly as it is produced. This allows a small battery-operated pump to provide the required vacuum, enabling the device to be portable. Two different types of non-invasive patient/device interface were developed, and tested by volunteers: urinal and small pad. The slimline urinal was popular with users although liquid noise was a problem. The pad interface was successful on occasions but further work is necessary to produce a reliable pad. This study has successfully demonstrated that a prototype AUCD liquid handling system can remove urine at clinically relevant flowrates. While further development is required, volunteer tests have shown that the AUCD could be a useful advance in continence management.

A system for logging incontinence events using a simple disposable sensor.

Many elderly people entering residential or nursing care are already incontinent to some degree, relying on incontinence pads to deal with the consequences. A proportion of these people have been shown to exhibit a regular pattern in their incontinence, which opens up the possibility of mitigating the problem by instituting an individual toileting regime for the person. This can reduce their reliance on incontinence pads, both improving their quality of life, and reducing the cost of care. This paper covers the development and evaluation of a sensor for detecting incontinence events, suitable for use in this setting, and describes the design of an associated electronic logger. The devices form part of an assessment system intended to identify a pattern in incontinence where it exists, and to help with the design of the toilet regime for an individual. The requirement is that the system must reliably record incontinence events, and present the information describing them in a manner appropriate to the users of the devices, who are likely to be non-technical and non-specialist.

Sheaths for urinary incontinence: a randomized crossover trial.

OBJECTIVE: To evaluate the full range of self-adhesive continence sheaths for men available in the UK and thus provide clinicians and consumers with a basis for product selection. PATIENTS AND METHODS: Fifty-eight volunteers (aged 30-89 years) tested each of six different self-adhesive sheaths available in the UK in September 1998 for 1 week each. Thirty subjects applied the sheaths themselves and 28 subjects relied on a carer to do so. During each week subjects completed a diary recording sheath changes and the result of skin inspection, to note any unscheduled sheath changes (because of sheath detachment) and any skin problems. At the end of each week an 11-item questionnaire was completed using a three-point rating scale ('good', 'acceptable', 'unacceptable') to assess the key aspects of product performance. RESULTS: A significantly higher proportion of subjects scored the 'Aquadry Clear Advantage' sheath as 'good' than four of the other sheaths (P < 0.01) and a significantly higher proportion found the 'Incare' sheath to be 'unacceptable' than all of the other sheaths (P < 0.001) for the 'overall opinion' question. Sheath detachments (sheath falling off or blowing off) for the 'Incare' were significantly more common than for four of the other products (P < 0.01). Sheath detachments for the 'Aquadry Clear Advantage' were significantly less common than for two of the other products (P < 0.01). A significantly higher proportion of subjects found sheaths with an applicator to be 'unacceptable' than sheaths with no applicator (P < 0.001) for the 'ease of putting on' and 'overall opinion' questions (when adjusted for previous product use and person applying the sheath). CONCLUSIONS: There were substantial differences between products in their general performance and ergonomics, and for the frequency of detachment as recorded in the diary. The 'Aquadry Clear Advantage' was particularly successful and the 'Incare' particularly unsuccessful when compared with the other sheaths. Sheaths with no applicators were preferred to those with applicators. Applicators are mainly designed to make sheaths easier to put on, especially for carers, but there was no evidence that carers preferred applicators. This may have implications for manufacturers.

Coated catheters for intermittent catheterization: smooth or sticky?

OBJECTIVE: To evaluate the current range of hydrophilic-coated catheters for intermittent self-catheterization, focusing on the adherence of the catheter to the urethral mucosa at the end of catheterization. PATIENTS AND METHODS: In a prospective randomized study, 61 community-based men tested each of four different hydrophilic-coated catheters available in the UK at the time. Subjects used each of the four test catheters for 1 week in a random order, and were provided with the number and size of catheter they normally used. To assess the products, the subjects: (i) timed seven catheterizations using a stop-watch to determine the time taken from extracting the catheter from the water-filled package, to removing the catheter from the penis, having emptied the bladder; (ii) recorded the severity of 'sticking' on catheter removal on a three-point scale (not at all, a little, a lot); and (iii) completed a product-performance questionnaire. RESULTS: There were no significant differences in ratings of 'sticking' between the 'Easicath' and 'Lofric' (P > 0.05), but there were significant differences between these two products and the 'Aquacath' and the 'Silky', which were found to 'stick' more (P < 0.001). The 'Silky' was reported to stick significantly more than the 'Aquacath' (P < 0.001). CONCLUSIONS: Adherence to the urethral mucosa on catheter removal was a common problem, occurring with all catheters, but two products were significantly more likely to stick than the other two. The clinical importance of 'sticking' and the long-term implications are currently unknown. The relative 'sticking' of uncoated catheters has also not been established.

The CPE network: creating an evidence base for continence product selection.

Selecting continence products for an individual patient or hospital contract is often a daunting task. This article describes the evaluation process developed for a program of government-funded multicenter evaluations of continence products established in the United Kingdom to provide an evidence base for product selection. The essential requirements of an evaluation are discussed, together with the methodologic and statistical issues that such evaluations present. The strengths and limitations of multicenter trials are examined and suggestions are made regarding other areas of nursing in which this approach could be usefully adopted.

Is there a risk of cross-infection from laundered reusable bedpads?

The risk of cross-infection from reusable incontinence bedpads was assessed by determining their microbial content after one night's use by incontinent adults and after laundering using the standard foul wash procedure specified by the NHS Executive (NHS E, 1995) (which includes heat disinfection at 71 degrees C for 3 minutes). Measurements were made on a total of 145 bedpads from five different product designs. It was found that effective laundering destroyed all known pathogenic organisms, although some commensal flora were isolated in small numbers (mean 12.2 colony forming units/ml). It is concluded that laundering reusable incontinence pads using the foul wash procedure leaves pads safe for multiple patient reuse with no demonstrable risk of cross-infection.