Let’s talk about commodes
Commodes are a wonderful piece of DME for toileting. They can be quite versatile, e.g, 3-in-1, are portable for use by patients in facilities and in the home. Some variations of commodes include drop-arm commodes, bariatric commodes, and technically a rolling shower commode counts as one.
In my head, I have been taking an unofficial survey of the top complaints of commodes from my patients as well as barriers I have seen to the function of commodes for toileting and toileting hygiene.
While they get the “job done”, there are many ways they can be improved.
#1 They are not big enough
This is the top complaint that I get from males and some females too. The toilet seat built into the commode often cannot accommodate an average-sized male. Males report it being nearly impossible to urinate sitting down on a standard commode, especially with an erection from having to urinate. So what ends up happening is patients either refuse to use it or end up using a urinal. In extreme cases, I have seen some patients rather soil themselves in bed than to try getting on a standard commode to urinate. Sure, it would be ideal for most males to stand and urinate, but there are a handful of males who prefer to sit, e.g., urinating at home to minimize making a mess. Due to difficulty with balance, poor endurance, or hemiparesis, most patients won’t be able to tolerate standing for the entire time needed to urinate. I have literally transferred male patients onto a commode and handed them a urinal.
Solution: make a slightly elongated version of a toilet seat for commodes, or just make it slightly larger in general.
#2 Commodes are not comfortable, especially the rolling shower commode
I have had people of all shapes and sizes tell me that commodes are not comfortable to sit on. Patients who have chronic low back pain, a new back procedure, or healing from trauma in ortho often have very low tolerance for sitting a commode, especially when pain medications wear off. Patients much rather prefer to sit on a regular toilet. If a standard commode is not comfortable, a rolling shower commode is the absolute most uncomfortable surface to sit on, ever in the toilet world. I’ve tried it and would have to agree.
Unfortunately, occupational therapy practitioners may not have many options for seating surfaces for showers besides a shower bench or shower chair. Often a rolling shower commode is practical for the patient because you can use it to transfer patients from the bedside or the chair onto a rolling shower commode and effectively reduce an additional transfer. They are also functional as patients who need to use the toilet (often unexpectedly) would benefit from the cut-out and a commode bucket. The side can also fold down for slide-board or squat pivot transfers. They also have a brake. But that rolling shower commode surface though – very uncomfortable.
Solution: make commodes more comfortable with better weight distribution for the bottom, peri-area, and lower extremity.
#3 Standard commodes should not exist
Standard commodes are probably more cost-effective for facilities and patients, but they are the least functional due to the lack of drop-arms on either side for more difficult transfers and other reasons. If a patient declines due to a chronic condition, older age, or decides to re-use it, e.g, for another family member, it is pretty much useless. Patients are unable to do a slide-board transfer with a standard commode and squat pivot transfers can be difficult if patients are unable to get good clearance over the commode armrests with their bottom. The permanent sides also make it “narrow” for patients who may be of larger habitus or even just have more “bulk”, e.g., lower extremity braces and some ex-fixes in ortho.
Standard commodes may make the job more difficult for caregivers assisting with donning/doffing lower body clothing and with pericare. With a drop-arm commode, each side can be lowered to allow a caregiver to get closer and assist the patient. And again, no slide board transfers.
Standard commodes also seem “lighter” and more prone to shifting during transfers and tipping over compared to drop-arm commodes. While a lighter weight is beneficial for transporting, I would rather have a more “sturdy” and “solid” product that I know I can count on when I am assisting a patient with a transfer or if they lean a little too far, I am confident that the commode won’t tip over.
Solution: Only purchase a drop-arm commode. Manufacturers should stop making them (I know this will never happen).
#4 Height Adjustments
Commodes always seem to be 1 height adjustment short of what patients need, either to be adjusted 1 click lower or 1 click higher. While I am not sure if this would compromise the safety of the commode, it would make a world of a difference if commodes had even just 2 more height adjustments. I have had to get patients step stools because some don’t go low enough and their legs dangle in the air. Of course, the trade-off of a lower commode is it is harder to stand up from.
Solution: Commodes should have more height adjustments.
#5 Your skin might get pinched
Some of my patients have reported or I have witnessed their skin, e.g., the thighs, getting pinched between the toilet seat and the bar that it rests on. While every patient and their anatomy is different, this is probably due to the toilet seat resting directly on top of the bar, so there is a high chance of skin getting pinched between it. If you think about it, people don’t really get their skin pinched on regular toilet seats on regular toilets because of the way it is designed. Perhaps this is due to a smaller gap or how the corners are rounded on regular toilets. It may also be due to how toilet seats on commodes are lighter and accidentally lift off when patients descend and sit on it and the skin gets pinched in the process. It’s much more difficult for regular toilet seats on regular toilets to “lift up” if bumped into probably due to their weight.
Solution: A locking mechanism that snaps the toilet seat onto the commode may be a solution, but would introduce additional points of failure (2) make it heavier (3) redesign it.
#6 If a rubber foot comes off from the base, the commode is essentially useless
If you look at the bottom of commodes, they have rubber feet that cover each of the 4 “legs”. These are nice as they provide friction to reduce the commode from moving during transfers and help to protect the floor from scratches. However, they can come off due to general wear and tear or abuse. These rubber feet can be ordered as spare parts, but there is no universal size. For example, the rubber feet for the standard commodes are different than the ones for drop-arm commodes. And it is very dangerous to use a commode without all 4 feet because it is uneven and can tip over. Without the rubber feet, the base is just a sharp piece of cylindrical metal that can damage floors, rust, and is more prone to tipping over.
Solution: provide spare rubber feet and/or standardize the size of the rubber feet.
#7 Bariatric commodes are way too big
It seems like you can either get standard commode, which is way too small for the average adult, or get a bariatric, which is way too large for most adults. I understand that bariatric commode are larger to accommodate bariatric sizes and a higher weight limit, but rarely do bariatric need such a large size. There should be a size in between a standard and a bariatric commode. It would be cheaper too. Bariatric commodes are also very heavy and difficult to transport (and clean). They are also so big that they are difficult to fit over regular toilets in the bathroom enviroment, so they can only really be used at the bedside or somewhere near it, but not in the bathroom.
Solution: Make a slightly smaller bariatric commode.
#8 Commodes don’t look cool
Many patients have to leave commodes by the bedside or in the bedroom. They look at it all the time. Theyr’e not the best things to look at. Commodes should at least look cool or be nicer to look at. They should come in different colors (like how there are pink front wheeled walkers and wheelchairs). They should blend in more with the environment, like a green one with leaves or something. Why not have a little fun with it? Many teenagers or younger adults would probably be willing to spend some money on a commode that isn’t so boring to look at. Even a decal skin for the toilet seat cover would be a good option to have. I’m thinking colorful designs like those training potty for toddlers. If Disney licensed a commode, it would probably sell many units. Hey, here’s an etsy idea for you entrepreneurs out there – toilet seat decals.
I never thought I would write so much about a commode in a blog post. Hopefully, this post will provide insight for OT students and new practitioners about the safety, pros, and cons of the types of commodes. If you are a commode manufacturer, consider some of these suggestions for a new design. Your customers will thank you for it!