Equipment Corner Issue 2: Bathroom Buddies – Toilet Edition
Alyssa DeCarlo, MS, OTR/L, MSCS, CSRS, LSVT
You know them, you love them; but is the 3-in-1 Bedside Commode or an elevated toilet seat the best option for your patient? While the 3-in-1 model is one of only a few options typically covered by insurance, there are quite a few factors that should be considered when selecting the most appropriate piece of standard/basic bathroom equipment to meet patient needs.
What to consider when selecting toileting devices:
- Transfer status
- A patient that requires the use of a transfer board or completes a lateral transfer will likely benefit from a drop arm commode or elevated toilet seat with removeable arms as compared to a standard device with consideration of safety on stability of the surface (locking mechanism vs. no locking mechanism – see below).
- Adding grab bars may provide the increased support required to independently transfer onto/off of a toilet seat. Grab bars typically come standard with 3-in-1 commodes; however, there are options for elevated toilet seated with and without arms. Elevated toilet seats with arms generally have the option for the arms to be removed if needed. However, arms attached to the seating system itself may not be in the ideal location to maximize independence with transfers and an elevated toilet seat without arms may be considered with consideration of how the seat is secured to the toilet itself.
- There are many options for installing grab bars; from professionally installed by a contractor, to adjustable/removeable options.
- Things to consider include: environmental constraints (see below), mobility and UE ROM of the patient to effectively utilize the grab bars, toilet design to accommodate the grab bars based on design of the grab bars themselves (see below), and design of the legs of the bars to reduce tripping hazards as seen here.
- Adding grab bars may provide the increased support required to independently transfer onto/off of a toilet seat. Grab bars typically come standard with 3-in-1 commodes; however, there are options for elevated toilet seated with and without arms. Elevated toilet seats with arms generally have the option for the arms to be removed if needed. However, arms attached to the seating system itself may not be in the ideal location to maximize independence with transfers and an elevated toilet seat without arms may be considered with consideration of how the seat is secured to the toilet itself.
- The addition of a Toilet Lift System may improve transfer function. These can include automatic systems such as the Dignity Lift that provides anterior tilt to the seat and allows for independence in transfers. Please note, that these many times do not work in conjunction with other features such as bidets (see below) and can be costly as they are not covered by insurance typically; however, there are Dignity Lift options that have lift and bidet features built in one.
- Adding height without changing the seat can be beneficial without needing to transition to a new toilet to meet height needs, as that can be costly. The use of the Toilevator system can add ~3.5” to the height of the existing toilet itself.
- Patient height
- Many times a patient that is shorter in nature (5’ or less) or has a shorter femur length, struggle to have their feet touch the floor when using various elevated toilet seats, especially if this is added to the comfort height toilet ADA standard of ~18”. This is where grab bars vs. an additional device may be most appropriate.
- Body habitus
- Insurance typically covers a bariatric commode that is 5”-7” wider (brand dependent) for those greater than 250-300lbs. However, patients may have a hip width that is greater than the 18” of a standard commode without meeting the weight limit insurance requires for coverage. This may be an indicator to encourage your patient to seek private pay options.
- Note, a bariatric commode can also come in a drop arm style and be height adjustable; however, there is typically less back support.
- Insurance typically covers a bariatric commode that is 5”-7” wider (brand dependent) for those greater than 250-300lbs. However, patients may have a hip width that is greater than the 18” of a standard commode without meeting the weight limit insurance requires for coverage. This may be an indicator to encourage your patient to seek private pay options.
- Note that there are also elongated toilet bowls/seats that are also typically not a covered benefit by insurance companies. However, the elongated feature can help support more targeted and comfortable voiding as well as personal and caregiver based comfort while engaging in hygiene in which the hand must enter the toilet bowl itself for access to the perineal region. These are typically seen as seats more oval vs. circular in nature.
- Skin integrity
- Commodes have options to have a padded surface (standard and drop arm options available), however, from an insurance perspective; this only applies to those with current or recent medical history of skin breakdown. What we know to be true as OT’s is that with reduced mobility, body habitus that may result in increased bony prominences of the sacrum/spine, impaired sensation, and increased length of time seated on a hard surface due to impaired emptying or for lengthy bowel programs can increase the risk of skin breakdown. Acting in a preventative fashion with appropriate surfaces is important. Therefore, seeking private pay options or documenting the risks thoroughly in order to attempt insurance coverage should be considered.
- Hygiene
- Various factors can lead to difficulty with ability to complete independent pericare and thoroughness of hygiene. Options to consider include various assistive devices such as a Bottom Buddy to aid in reaching, toilet seats with ability to change orientation of opening for caregiver support, or a bidet.
- A transition to bidet style toilets can be financially challenging; however, there are amazing options to change a current toilet seat to a bidet by switching to a bidet topper. These are typically commercially available on Amazon or places like Home Depot in very simple formats, all the way to ones with all the bells and whistles.
- When considering a bidet topper, it is important to note:
- Any impaired sensation such as difficulty distinguishing hot/cold that should be considered with heated bidet system to prevent burns/skin injuries.
- Drying features to prevent moisture related skin injuries after use.
- Limitations of the bidet topper in conjunction with an elevated toilet seat or lift system can be limited; however, some brands may work together such as the Clean Sense Bidet or PreserveTech systems. However, these do not come with grab bars to assist with transfers which should be considered in conjunction.
- One option that can support caregivers are Active Aid 202 and Raz Designs that allow for the orientation of the opening to be change in order to fit environmental constraints and allow for easier access to complete dependent or assisted pericare with good overall body mechanics. These devices typically can also be utilized for showering with customized options for all levels of assistive care.
- Toilet Design and Environmental Constraints
- When considering all devices there are constraints that need to be considered including the size of the space in which the toilet resides, the design of the toilet itself, and the size of the bathroom.
- For example, if a toilet is situated between a wall and sink or tub; or exists in its own section of the bathroom behind a separate door, this may limit the space available for grab bars that are portable/removable.
- In addition, some bidet toppers and grab bar systems lock behind the toilet seat and between the tank, however, not all toilets have this gap.
- Some of the elevated toilet seated have a locking mechanism, however, how it connects depends on the style of toilet and has a propensity of breaking quickly due to the material.
- The size of the space itself may limit the ability for a wheelchair to successfully get as close to the toilet surface as possible or limit ability of a caregiver to be present in which professionally installed grab bars that are not moveable provide stability to support more independent and safe transfers.
- When considering all devices there are constraints that need to be considered including the size of the space in which the toilet resides, the design of the toilet itself, and the size of the bathroom.
There are currently multiple durable medical equipment locations across the state of Ohio that sell these products, including, but not limited to the following in each of the OOTA districts. However, many times there are opportunities to find some of these products through donations at local churches, Goodwill, lending libraries, grant programs with diagnosis specific organizations (i.e. National MS Society), etc which should be considered for those with financial disparities.
Northwest District: Hart Medical Equipment
North Coast District: Buckeye Medical Supply
https://buckeyemedicalsupply.com/
West Central District: New Visions Medical Equipment https://www.newvisionsmedical.com/
Central District: Advanced Medical Supply
North Central District: Med Mart
https://medmarthome.com/medical-supply-equipment-store-akron/
South District: Jackson Medical Supply
https://www.jcmh.com/services/home-health-products/medical-equipment/
Southwest District: Med Mart
https://medmarthome.com/medical-supply-equipment-store-warren-county/
DISCLAIMER: The inclusion of links to products in this article does not reflect a formal endorsement from OOTA, nor are the products listed in this article a comprehensive list of the available products to address the needs of individuals requiring the use of assistive technologies
And if you’re interested in exploring working with the adult population, join us for the FIRST Older Adults Special Interest Section meeting on July 30!
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