This project was supported by the FoNS Practice Based Development and Research Programme in partnership with the General Nursing Council for England and Wales Trust Foundation of Nursing Studies Improving the patient experience of toileting and management of post-operative urinary retention following elective hip and knee replacement surgery: An evidence-based approach Final Report: October 2016 Project leads: Jacqui Prieto and Alison Barrow Background This 2-year project was based on the elective orthopaedic ward at University Hospital Southampton NHS Foundation Trust (UHSFT). It aimed to improve the patient experience of toileting and bladder care following elective hip and knee replacement surgery. Urinary retention (the inability to void in the presence of a full bladder) is a frequent and distressing complication for patients following hip and knee replacement surgery (Iorio et al, 2005). It is managed by assessment using a portable bladder ultrasound scanner, support with toileting and where necessary, bladder catheterisation. The project proposal was informed by previous audit and research on the ward. An audit of bladder management among patients (n=151) undergoing elective hip and knee replacement found considerable variation in use of indwelling urinary catheters, delays in recognising post-operative urinary retention and unnecessarily prolonged use of catheters. This revealed the need to avoid unnecessary catheterisation, improve assessment using the bladder scanner and remove catheters more promptly. Qualitative interviews with 32 patients identified their concerns about toileting and catheterisation. The temporary changes in bladder function experienced following surgery, together with increased dependency in the immediate post- operative period, were found to impact on comfort, privacy and dignity. This revealed the need to enhance support with toileting following hip and knee replacement surgery and promote more judicious use of urinary catheters. Aim and project goals The central aim of our FoNS improvement project was to implement an evidence-based approach to practice in order to improve the patient experience and achieve the following goals: • Goal 1: To develop a more robust approach to establishing patients’ preferences and information needs regarding toileting options and having a catheter in order to provide a more responsive, individualised approach to bladder management post-operatively. • Goal 2: To conduct a trial of toileting aids, including a female urinal, a prototype slipper pan and absorbent gel granules to promote successful toileting. • Goal 3: To improve the timeliness of bladder volume measurement using the bladder scanner in the immediate post-operative period (within 1 hour following return to the ward) in order to intervene more promptly when a patient has urinary retention. • Goal 4: To insert a urinary catheter without delay when a patient is unable to void spontaneously using alternative toileting methods and has a bladder volume greater than 500mls. • Goal 5: To remove short-term indwelling catheters within 24 hours of surgery.
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SignificantprogressmadeinachievingGoal2(timelybladderscanning).Thecompetitionprovedverypopularandresultedinimprovementsbothintherateandtimelinessofbladderscanassessments.Bothregisterednursesandhealthcareassistantshavetakenownershipofthisandroutinescanningallofnon-catheterisedpatientswithinthetargettimeof1houronreturntothewardisnowembeddedinpractice.Thekeybenefitforpatientsisearlydetectionandmanagementofpost-operativeurinaryretention.Aculturalchangehastakenplaceontheward,wherebystaffnowviewcathetersasoneofmanyoptionsratherthanroutinepractice.Staffawarenessofthelengthoftimeacatheterremainsinsituhasalsoimproved.Thishaspromptedappropriatelytimedremovals,withmostcathetersbeingremovedwithin24-48hoursofinsertion,therebyaidingthe recovery process and reducing the risk of infection. The nursingteam have become advocates for alternative methods of monitoringurineoutputandthetimelyremovalofcatheters.Theuseofmeasuringscales toweighurinehasalsosupportedthisandhelpedtoovercomedoctors’concernsabouttheaccuracyoffluidbalancemonitoring.Afterinitialtestingofalternativetoiletingaidsbyafewpatients,awiderevaluationofthe‘VernaFem’femaleurinalwasplanned,togetherwithimprovementsinthewardsluiceroomtofacilitatebetterstorageandaccesstotherangeofproducts.
Appendix4 ‘VernaFem’Evaluation MelissaAllen,WardSister,F1Ward As part of our Bladder Care project on F1 we have been able to trial a new product from Vernacare, a female urinal the Vernafem. This is designed to help female patients pass urine without the need to life or roll for bedpans. It hopes to give independence to female patients in the way that males can with the use of a bottle. We were given full training on this product and this was cascaded down to the ward staff. It was initially met with excitement and felt it would help our female patients voiding urine and avoid catheterisation. We trialled the product for a month and feel we gave this a fair chance; we received 10 completed evaluation forms. We asked staff to fill out two evaluation forms and we were met with mixed responses from the results. Below is a table of the responses we gained from the evaluation forms.
1. Evaluationformone:
YES NO Do you believe the new VernaFem female urinal would help reduce the risk of healthcare associated infections?
8 2
Do you believe the new VernaFem female urinal would save time versus alternative methods?
6 4
Do you believe the new VernaFem female urinal would help to increase patient dignity?
5 5
Do you believe the new VernaFem urinal is a genuine alternative to your current toileting methods?
4 6
Is there any reason why you wouldn’t recommend the product? 5 5 Here are some of the additional comments we received:
After receiving these initial responses, we contacted Vernacare with our results and they suggested adding Gel Sachets into the VernaFem to soak up the urine and aim to decrease the amount of spills we were having and aim for a larger capacity. We also changed the evaluation forms. Below are the results of the second attempt of the product. We received eleven completed evaluation forms.
After some careful consideration we have decided not to go ahead with the use of VernaFem as we felt it was not benefiting our patients. It is something that we may again consider in the future if the product was to change slightly. Our main reasons for not continuing with this product and, the lack of volume it holds and the spillage we have been getting.