AUDITING CURRENT PRACTICE IN CONTINENCE ASSESSMENT IN MEDICINE OF THE ELDERLY

BACKGROUND TO URINARY INCONTINENCE Definition – involuntary leakage of urine Prevalence – 20 – 32% of community dwelling elderly - 30 – 60% of elderly in institutional care Negative impacts – individual/carers/society

BACKGROUND Department of Health: Good practice in continence services 2000 National Audit of Continence Care for Older People: Management of Urinary Incontinence 2008. Quality Improvement Scotland: Continence – adults with urinary dysfunction. Best practice statement. November 2005.

OBJECTIVES To determine the no. of pts who have been identified as having urinary incontinence To determine the no. of pts with urinary catheters in situ To determine the no. of nursing staff who have received continence training To assess the extent to which pts with urinary incontinence are being assessed Perhaps you could mention that we had performed a few small local audits which had identified problems in the first place

OBJECTIVES To identify if there is any documentation of pts being involved with the continence assessment process To identify what containment products are being used

STANDARDS All wards should have a dedicated person with an interest in continence All nursing staff should have had some training in continence All patients should have continence status documented All incontinent patients should have a continence history taken and basic continence investigations performed

STANDARDS All patients, unless unable to, should have their continence diagnosis and management plan discussed with them

METHODOLOGY Audit tool developed based on best practice statements from QIS Data collected over a 3 week period in June 2009 from all Medicine of the Elderly rehabilitation units in NHS Lothian Data forwarded to clinical effectiveness facilitator for assimilation

RESULTS 13 wards completed audit forms – 64 patients included 47/64 pts were incontinent All sites had access to working bladder scanners 12/13 (92%) of wards had a person with a specific interest in continence assessment There should be 65! But 1 has been lost from ward 7 at liberton somehow – that is the only lost bit of data I would raise! – unclear how it happened. Need to mention about there was backgrounfd question about design of ward and staffing.

% of Nursing Staff With Continence Training

Training Although there were people with an interest in continence, in 2 cases they had no formal training Training could just be a course on pad selection Our audit did not assess Doctors training levels and competency. Doctors need to understand reasons for Ix and how and when to prescribe medication

RESULTS Staffing numbers varied with a median of 5 patients per nurse (range 3 – 7) No. of pts per toilet varied between 2 – 7 (median 4) No correlation between staffing ratios and continence assessment completion rate! It is not specifically the staffing numbers that is the issue – need better awareness

RESULTS Documentation of continence status was present 61/64 (95%.) Continence status documentation present only in medical notes in 34/61 (55%), only in nursing notes in 4/61 (7%) and in both in 23/61 (38%)

Continence Assessment I think this speaks for itself – the fact is that no patient had a complete assessment – patchy when you look at the data

Results Documented mainly in medical notes in all sites. Difficulty locating information was a common theme. Assessment was poorly performed in all sites. Frequency volume charts and pelvic examination most likely not to be done. FVC and pelvic exam are the most likely not to be done – FVC a pain for nurses although shouldn’t be hard, docs not confidenty doing pelvic so avoid it? No excuse for not doing urinalysis – should be done in all admissions and documented clearly Main take home message should be that we think a checklist would help as it would trigger investigation and assessment

RESULTS 12/47 (26%) of all incontinent pts had been commenced on urologically active Mx. In all but 1 patient this was commenced during this hospital stay. Containment products used in 42/47 (91%.) Catheter numbers varied from 3 – 14 per ward (median 5) These 3 slides all highlight the failings of our treatment – it is blind essentially as we have not assessed properly . One patient was started on meds but hadn’t had a bladder scan, 2 hadn’t had urinalysis

Containment Products Used

Treatment and Containment Although no complete continence assessments were performed, 26% of patients were commenced on medication. Containment products can be costly and frequently used. High proportion of catheters in place at time of audit.

Audit Limitations Limitations of audit – designed for ease of computer use with little opportunity for commentary when abnormal results given.

AUDIT CONCLUSIONS Staff training poor Poor systems of assessment Lack of uniformity in documentation As a result of the above pts are less likely to receive optimal assessment and management of their incontinence

RECOMMENDATIONS Continence assessment checklist – to be piloted in Liberton Ward 6 initially To ensure each ward has a dedicated individual in continence care and to ensure that they have had formal continence training Ward based training To develop further training opportunities for staff – ? online resource Re-audit once changes implemented

Continence Assessment Checklist

ANY QUESTIONS?

SUMMARY Urinary incontinence is an important issue in geriatric medicine Currently, we are not meeting expected standards of care for incontinent pts. Need to implement changes and then re-audit to ensure that standards are improving

Acknowledgements Dr Amanda Barugh, STR Geriatric Medicine* Dr Alistair McVean, STR Geriatric Medicine* Maria Pilcher, Clinical Skills Facilitator * Caroline Steven, Clinical Effectiveness Facilitator * Wendy Ford, Clinical Effectiveness Facilitator * Dr Andrew Coull, Consultant Geriatrican* * NHS Lothian

REFERENCES Scottish Intercollegiate Guidelines Network. Management of Urinary Incontinence in Primary Care. Clinical Guideline 79. December 2004. Wagg A et al. National Audit of Continence Care for Older People: Management of Urinary Incontinence. Age and Ageing 2008; 37:39-44. Aftab A et Potter J. Management of Urinary Incontinence. Gerimed November 2007; 53-56. Urinary Continence Management In Older People. Nursing Standard 2008; 23(suppl 1): 22.

REFERENCES Nygaard I et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008;300:1311-6. National Institute for Health and Clinical Excellence. Urinary Incontinence. The Management of Urinary Incontinence in Women. Clinical Guideline 40. October 2006. Morrison A et Levy R. Fraction of Nursing Home Admissions Attributable to Urinary Incontinence. Value Health 2006;9:272-4.

REFERENCES The-Wei Hu et al. Costs of Urinary Incontinence and Overactive Bladder in the United States: A Comparative Study. Urology 2004;63:461-5. Department of Health. Good Practice in Continence Services. London: HMSO, 2001. Royal College of Physicians. Incontinence: Causes, Management and Provision of Services. London: The Royal College of Physicians, 1995. Quality Improvement Scotland. Continence – adults with urinary dysfunction. Best practice statement, November 2005.