Documented history-Bladder Our Site:

Guys and St Thomas’Guys and St Thomas’Department of Ageing and HealthDepartment of Ageing and Health

National Audit of Continence Care forNational Audit of Continence Care forOlder PeopleOlder People

Carlene Carlene IgbediohIgbedioh, Continence Nurse Specialist, Continence Nurse SpecialistDr Danielle Harari, Consultant Dr Danielle Harari, Consultant GeriatricianGeriatrician

1919thth January 2006 January 2006

Achieving changeNACC – Acute Hospital Setting

Guy’s and St Thomas’ NHS Foundation Trust

Older Persons Continence Service

Carlene Igbedioh, Continence Nurse SpecialistDr Danielle Harari, Consultant Physician

[email protected]





Issues specific to acute hospitalsIssues specific to acute hospitals

Risk of urinary or faecal incontinence higher due to acute illness

Affects recovery and rehabilitation in hospital Serious complications (pressure sores,

catheter-related infection, bowel obstruction from constipation)

Staff under-confident in managing incontinence

Patients sent home with pads and no ongoing plan – impacts quality of life





CaseCase--finding and screeningfinding and screening

Incontinence is a hidden problem especially for vulnerable people (older, disability)

Patients don’t say, and providers don’t ask We screen every person aged 65+ acutely

admitted to hospital Embedded screening into routine nurse

assessment document 7 trigger questions – positive responses(s)

prompts assessment





CaseCase--finding and screeningfinding and screening

Using trigger Q: 1 in 3 suffer from UI and 1 in 5 from FI

New problem in approx 30%Longstanding problem – often years –

first time patients have spoken about itAlso identify bladder and bowel

problems in younger people with disability (e.g. stroke, MS)

Cover acute medicine, surgery, A&E

Documented history-BladderDocumented history-Bladder

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acute(n=3282,2813)

Primary care(n=2612,1880)

mental health(n=539,114)

%

<65

65+

Our Site: <65 95% 65+ 89% (52% 2006)

Impact of symptoms on Quality of Life Impact of symptoms on Quality of Life measuredmeasured

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acute (n=2254) Primary care(n=1435)

mental health(n=69)

Care home(n=34)

<65

>65

Our Site: <65 50% 65+ 62% (12% in 2006) – need to ask about impact of incontinence on daily life (question on proforma) and patient’s attitude (may be passive through ignorance)

Summary of results (comparison 2010vs 2006)Summary of results (comparison 2010vs 2006)

Was frequency of FI documented?Was frequency of FI documented? 65+

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Hospital PrimaryCare

MentalHealth

CareHomes

Sector

%

Our Site: Documented 65+ 100% (100% in 2006)

<65 100%

Is there documented evidence of a bowel Is there documented evidence of a bowel

history?history? 65+

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Acute(Hospital)

Primary Care mental Health Care Home

%

Acute (Hospital)

Primary Care

mental Health

Care Home

Our Site: 65+ 100% (80% 2006) <65 100%

Does patient have documented treatment Does patient have documented treatment plan?plan?

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65+ <65

%Acute (Hospital)

Primary Care

Mental Health

Care Home

Our Site: 65+ 94% (73% 2006) <65 100%

Documented evidence of full discussion with Documented evidence of full discussion with patient of causes and treatments of FI?patient of causes and treatments of FI?

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65+ <65

%

Acute (Hospital)

Primary Care

Mental Health

Care Home

Our Site: 65+ 75% (60% 2006) <65 92%

What works in our service?What works in our service?

• Community and inter-speciality liaison• A comprehensive service• Integrated service provision• Assessment led service• Multidisciplinary teamwork• Link Nurses• Continence nurse ward rounds• Teaching and training

What works in our service?What works in our service?

• Agreed pathways urogynaecology urology colorectalAgreed referral criteria(in keeping with NICE)OPAL team (older persons Liaison) screens all in-

patients age 70+ in acute medicinePOPS team (proactive older person undergoing

surgery) screens all in-patients undergoing surgery

What works well in our service?What works well in our service?

• Clinical Governance

• Improved documentation by regular audits

• 2monthly MDT integrated pelvic floor continence service meeting

• 2monthly CNS forum meeting-which includes the community services and the contruted universities

What works well in our service?What works well in our service?

• Patient involvement

guidelines

Information leaflets

patient user group meetings

BarriersBarriers

• Institution providing insufficient time for link nurses training days

●wards short of staff (nurses/doctors state this as reason for not completing assessment)

Patient’s acceptancePatient’s perception

Areas for improvement - FIAreas for improvement - FI

GSTFT in upper quartile for 65+ and <65 (nominated centre of excellence at NACC launch) BUT

• Stool charts• Clear documentation of causes in 65+• Sharing of treatment plans with patients / carers• Quality of life• Patient own goals for treatment (65+)• Patient information (e.g. contact for Bladder and

Bowel Foundation)





Assessment and treatmentAssessment and treatment

Non-specialist nurses and doctors can provide continence care

Trigger questions lead hospital staff to assessment proforma and 1-page treatment algorithm

We provide advice, support, and care for complex cases

Ward link nurses drive process Regular training across disciplines, including

case by case teaching





FollowFollow--through carethrough care

Fast access clinic so patients discharged earlier and seen quickly (e.g. for catheter removal, faecal impaction, urinary infections)

Shorten hospital length of stay and prevent readmissions = cost savings

Telephone follow-up with patients, who also have our phone number (reassurance)

Fast-track to clinic from A&E and GPs reduce emergency admissions

Community links for ongoing care (district nurses etc.)





PatientPatient--centred servicecentred service

Proper assessment including how incontinence affects life activities

Information – including increasing expectations of improvement and possibly cure

Easy access to help and advice (direct phone-line)

Patient education covering all topics Patient choice in both treatments and in types

of products Continence User group





Effectiveness study Effectiveness study –– Urinary incontinenceUrinary incontinenceAge Ageing 2009Age Ageing 2009

N=112, mean age 80, x% post-hospital discharge, high comorbidity

Lifestyle measures (exercises, bladder retraining, fluids) in 70%

Only 38% received bladder medications One-third improved with change in other

medications (e.g. diuretics) and/or treatment of other medical conditions (e.g. diabetes)

By 4 months, 23% were completely continent and a further 45% described an improvement





Patient storiesPatient stories

“I don’t even need to wear pads now, and I though that nothing coul d be done!”

“It made me feel so insecure and embarass ed.”I jus t want to be able to control my bladder and bowel. “I cannot believe that there’s s omethi ng that could be done!"





Funding the ServiceFunding the Service

Trust-wide audit to identify level of need High rates of unrecognised incontinence Low l evels of staff knowledge and awareness Inappropriate usage of pads and cathetersDelayed discharges (length of stay – make it pay!) Urinary retention, severe constipation, FI,

pressure soresPreventable admissions Catheter problems, faecal impaction in A&E Urinary tract infections in frail older people

• Elderly care - winners of UK integrated continence Team of the Year

Documented history-Bladder Our Site:

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