Achieving
change
Guys
and St Thomas’
NACC – Acute Hospital Setting
Department of Ageing and Health
Guy’s and St Thomas’ NHS
National Audit
of Continence
Care for
Foundation
Trust
OlderContinence
People
Older Persons
Service
Carlene
Igbedioh,, Continence
Igbedioh
Continence Nurse
Specialist
Carlene
Igbedioh,
Nurse
Specialist
Danielle Harari, Consultant Geriatrician
Dr Dr
Danielle
Harari, Consultant Physician
Carlene.Igbedioh@gstt.nhs.uk
19th January 2006
Issues specific to acute hospitals
Guys and St Thomas’
 Risk of urinary or faecal incontinence higher
Department
of Ageing and Health
due to acute illness
Affects recovery and rehabilitation in hospital
Audit of Continence
Care
for
 National
Serious complications
(pressure
sores,
catheter-related
infection,
Older
People bowel obstruction
from constipation)
Carlene
Igbedioh,, Continence
Igbedioh
Nurse Specialist
 Staff
under-confident
in managing
Dr Danielle Harari, Consultant Geriatrician
incontinence
th January
 Patients sent
with
pads and no ongoing
19home
2006
plan – impacts quality of life

Case-finding and screening
Guys and St Thomas’
 Incontinence is a hidden problem especially
Department
Ageing
and
Health
for vulnerableof
people
(older,
disability)
Patients don’t say, and providers don’t ask
Audit
of Continence
for
 National
We screen
every
person agedCare
65+ acutely
admitted to hospital
Older People
 Embedded screening into routine nurse
Carlene Igbedioh
Igbedioh,
, Continence Nurse Specialist
assessment
document
Dr Danielle Harari, Consultant Geriatrician
 7 trigger questions – positive responses(s)
prompts assessment
19th January 2006

Case-finding and screening
Guys and St Thomas’
 Using trigger Q: 1 in 3 suffer from UI
Department
of Ageing
and Health
and 1 in 5 from
FI
New problem in approx 30%
Audit ofproblem
Continence
Careyears
for
National
Longstanding
– often
–
Older People
first time patients
have spoken about it
 Also identify bladder and bowel
Carlene Igbedioh
Igbedioh,, Continence Nurse Specialist
problems
in younger people with
Dr Danielle Harari, Consultant Geriatrician
disability (e.g. stroke, MS)
19thmedicine,
January 2006 surgery, A&E
 Cover acute

Documented history-Bladder
100
90
80
70
%
60
<65
50
65+
40
30
20
10
0
acute
(n=3282,2813)
Primary care
(n=2612,1880)
mental health
(n=539,114)
Our Site: <65 95% 65+ 89% (52% 2006)
Impact of symptoms on Quality of Life
measured
70
60
50
40
<65
30
>65
20
10
0
acute (n=2254)
Primary care
(n=1435)
mental health
(n=69)
Care home
(n=34)
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)
Was frequency of FI documented?
65+
100
90
80
70
%
60
50
40
30
20
10
0
Hospital
Primary
Care
Mental
Health
Care
Homes
Sector
Our Site: Documented 65+ 100% (100% in 2006)
<65 100%
Is there documented evidence of a bowel
history?
65+
Acute (Hospital)
100
90
Primary Care
mental Health
80
Care Home
70
%
60
50
40
30
20
10
0
Acute
(Hospital)
Primary Care mental Health
Care Home
Our Site: 65+ 100% (80% 2006) <65 100%
Does patient have documented treatment
plan?
Acute (Hospital)
100
Primary Care
90
Mental Health
Care Home
80
70
%
60
50
40
30
20
10
0
65+
<65
Our Site: 65+ 94% (73% 2006) <65 100%
Documented evidence of full discussion with
patient of causes and treatments of FI?
Acute (Hospital)
Primary Care
100
90
Mental Health
80
Care Home
70
%
60
50
40
30
20
10
0
65+
Our Site: 65+ 75% (60% 2006) <65 92%
<65
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?
• Agreed pathways
urogynaecology
urology
colorectal
Agreed referral criteria
(in keeping with NICE)
OPAL team (older persons Liaison) screens all inpatients age 70+ in acute medicine
POPS team (proactive older person undergoing
surgery) screens all in-patients undergoing surgery
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?
• Patient involvement
guidelines
Information leaflets
patient user group meetings
Barriers
• 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 acceptance
Patient’s perception
Areas 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 treatment
Guys and St Thomas’
 Non-specialist nurses and doctors can
Department
of Ageing
provide continence
care and Health
Trigger questions lead hospital staff to
assessment proforma and 1-page treatment
National
algorithmAudit of Continence Care for
 We provide Older
advice,People
support, and care for
complex cases
Carlenelink
Igbedioh,
Igbedioh
, Continence
Nurse Specialist
 Ward
nurses
drive process
Dr Danielle Harari, Consultant Geriatrician
 Regular training across disciplines, including
case by case
19thteaching
January 2006

Follow -through care
Guys and St Thomas’
 Fast access clinic so patients discharged
Department
of Ageing
and
earlier and seen
quickly (e.g.
forHealth
catheter
removal, faecal impaction, urinary infections)
 Shorten hospital length of stay and prevent
National
Audit =ofcost
Continence
readmissions
savings Care for
Older People
 Telephone follow-up
with patients, who also
have our phone number (reassurance)
Carlene Igbedioh
Igbedioh,
, Continence
Nurse and
Specialist
 Fast-track
to clinic
from A&E
GPs reduce
Dr Danielle Harari,
Consultant Geriatrician
emergency
admissions
 Community 19
links
for ongoing
care (district
th January
2006
nurses etc.)
Patient-centred service
Guys and St Thomas’
 Proper assessment including how
Department
Ageing
and Health
incontinence of
affects
life activities
Information – including increasing
expectations of improvement and possibly
National
Audit of Continence Care for
cure
Older
People
 Easy access
to help
and advice (direct
phone-line)
Carlene Igbedioh
Igbedioh,
, Continence
Nurse
 Patient
education
covering
allSpecialist
topics
Dr Danielle Harari, Consultant Geriatrician
 Patient choice in both treatments and in types
of products 19th January 2006
 Continence User group

Effectiveness study – Urinary incontinence
Age
Age Ageing
Ageing 2009
2009
Guys and St Thomas’
 N=112, mean age 80, x% post-hospital
Department
of comorbidity
Ageing and Health
discharge, high
Lifestyle measures (exercises, bladder
retraining, fluids) in 70%
National Audit of Continence Care for
 Only 38% received bladder medications
Older People
 One-third improved with change in other
medications (e.g. diuretics) and/or treatment
Carlene
Igbedioh,
, Continence
Nurse
Specialist
of
otherIgbedioh
medical
conditions
(e.g.
diabetes)
Dr Danielle Harari, Consultant Geriatrician
 By 4 months, 23% were completely continent
and a further
described
an improvement
th January
1945%
2006

Patient
Patient stories
stories
Guys and St Thomas’
 “I don’t ev en need to wear pads now,
Department
of
Ageing
and
Health
and I though that nothing coul d be
done!”
of Continence
Care
for
National
“It madeAudit
me feel
so insec ure
and
Olderjus
People
embarass ed.”I
t want to be able to
control
my
bladder
and
bowel.
“I
cannot
Carlene Igbedioh
Igbedioh,, Continence Nurse Specialist
believe
that
there’s
s omethi
ng that
Dr Danielle
Harari,
Consultant
Geriatrician
could be done!"
19th January 2006
Funding
Funding the
the Service
Service
Guys
and
St
Thomas’
Trust-wide audit to identify level of need
Department
Ageing and
Health
 High rates of of
unrecognised
inc ontinence
Low l evels of staff knowledge and awareness
Inappropriate us age of pads and c atheters
National
Audit of Continence
Care for
Delayed
discharges
(length of stay – make it pay!)
Oldersevere
Peopleconstipation, FI,
 Urinary retention,
pressure sores
Carlene Igbedioh
Igbedioh,
, Continence Nurse Specialist
Preventable
admissions
Dr Danielle
Harari, Consultant
 Catheter
problems,
faec al Geriatrician
impaction in A&E
 Urinary tract infections
in frail older peopl e
th


19 January 2006
• Elderly care - winners of UK
integrated continence Team of the
Year