Redesigning a continence prescription service to improve patient safety and experience

Author

Joanne Mangnall, RN, MSc, BSc(Hons), Independent Nurse Prescriber, is continence adviser, NHS Rotherham.

Background

Concerns about prescribing continence related products such as indwelling urinary catheters, drainage bags and sheath drainage systems were first raised in NHS Rotherham in 2004. Variations in prescribing practice and increasing costs resulted in the development of a prescribing formulary, which aimed to guide prescribing practice and act as an information resource for clinicians.

Unfortunately, subsequent reviews of prescribing data indicated the formulary had not been widely used in clinical practice and did not appear to have had any impact on prescribing costs. Analysis of continence product prescribing data for 2007-08 found a total of 13,363 items had been prescribed at a cost of just over £500,000. Trend analysis found a cost growth of 5.2% in continence prescribing in 2007-08 versus 0.45% for overall prescribing.

The situation was further compounded by reports of increasing numbers of referrals to acute care with catheter related problems. On investigation, a significant percentage of these had been made because community staff felt they could not access supplies of equipment such as catheters that they needed to care for patients in the community setting.

As the formulary had been ineffective in containing increasing prescribing costs and consultants in A&E were beginning to raise concerns about inappropriate referrals to acute care for catheter related problems, the medicines management and continence teams decided to carry out a review of prescribing processes. The aim was to identify any areas in which improvements to service delivery could be made

Review of prescribing practice

Central to the review process was an audit of continence product prescribing practice. Two large GP practices were selected as the audit sample; the clinical records of all patients registered with these practices who had been prescribed continence related products during the previous financial year were identified. Prescribing data was measured against best practice guidance in relation to urinary catheters, drainage equipment, catheter supporting devices and other related products (Department of Health, 2006; National Institute for Health and Clinical Excellence, 2003). Clinical records were reviewed for evidence of an annual review, which should be carried out to ensure patients’ prescribed products remained effective (DH, 2000).

Patients were also invited to participate in the data gathering process. All those identified as having received prescriptions for continence related products were invited to attend a review clinic. The review’s purpose was to discover more about the day to day issues patients faced and to offer product advice or reassessment, if appropriate.

A semi structured interview approach was adopted during the patient reviews. Questions were based on four core areas:

• Clinical care - who do you contact if you have problems? Are your product needs regularly reviewed?

• Stock control - how long do you have to wait for your products to be dispensed once you have given in your prescription? Where do you usually store your products?

• Product performance - have you had any problems with leakage, sore skin or discomfort that you think might be a result of the products you use?

• Appropriateness of product - is it always easy to use, for example if you go out for the day?

Patients were encouraged to highlight any specific concerns or problems they had in relation to product use. This semi structured approach enabled us to gather information on areas we felt were important and gave a voice to those who use continence products every day.

Audit results

The results suggested that annual product reviews to ensure prescriptions remained effective were not carried out in routine clinical practice. We did recognise that for some patients a product review may have been undertaken by a district nurse or in an acute care setting; however we found no evidence in the records we examined that this had occurred. This was of particular concern for those who had indwelling urinary catheters, as a lack of clinical review may result in them continuing with these when they were no longer clinically indicated.

A number of other issues directly related to prescribing practice were identified including:

• Prescribing 6ml of lubricant for men for catheter changes instead of the recommended 11ml;

• Prescribing sterile drainage bags for men using sheath drainage systems when non sterile is appropriate and less costly;

• Prescribing quantities of products which do not reflect recommended in use times; for example, a short term indwelling catheter which should be changed every 7-10 days was on a repeat prescription cycles of 12 weeks.

• Prescriptions for large quantities of catheter maintenance solutions;

• Little evidence of prescriptions for catheter securing devices to reduce patients’ risk of accidental trauma.

We were able to gain some understanding of how these problems affected patients through the many stories they told during their review interviews. They reported poorly supported drainage bags, difficulties obtaining appropriate quantities of catheters for intermittent use, taps on drainage bags they found difficult to work and products that leaked or fell off regularly.

Once all the data had been reviewed it was clear that service provision at the time was failing in all three of Lord Darzi’s (DH, 2008) quality domains:

• Patient experience – they were reporting poor experiences in relation to product use;

• Safety – patients reported they sometimes re-used single use catheters as they could not access supplies in appropriate quantities;

• Effectiveness – sterile products were often prescribed where non sterile were indicated, increasing prescribing costs unnecessarily.

Although we had only 128 patients in the audit, we felt the information gained was likely to reflect other GP practices in the area, and supported our view that an alternative method of service delivery was needed.

Service redesign

To achieve improvements in all quality domains (DH, 2008) we decided to radically redesign the process by which patients obtain prescriptions for continence related products. As some local GPs had previously raised concerns about their lack of knowledge about prescribing such products, we decided to transfer responsibility for continence product prescribing from GPs to the clinical nurse specialists (CNSs) working in the continence service. We felt this centralised approach, led by CNSs, would offer specialised input which was currently unavailable. The continence service now has total financial and clinical responsibility for prescribed continence products, and the NHS prescription service has issued it with its own practice code to ensure effective budget management.

A new system

The new system means patients now contact the continence service to request prescriptions for continence related products instead of their GP. Clinical reviews are a core element of the new service. Each time patients contact our service to order a prescription, our prescription coordinator carries out telephone triage to ensure it is safe and appropriate to issue a prescription. A clinical template, which is held on patients’ electronic record, guides the coordinator in asking the following questions:

• Have you had treatment for a urinary tract infection (UTI) since your last prescription was issued?

• Have you had any problems with skin soreness or breakdown since your last prescription?

• Have you had any problems with the performance of your product since your last prescription (for example, sheaths falling off)?

• Have you had any faulty products since your last prescription?

If patients answer “yes” to any of these questions the prescription is not issued and a referral to the continence nurse specialist is automatically generated. This ensures a clinical review is undertaken before any further products are issued. If patients answer “no” to all questions it is considered safe to issue a prescription, which is then printed, ready for checking and signing by the CNS.
Patients are asked where they would like the prescription to be sent. This could be to:

• Their home address;

• A dispensing pharmacy patients have selected;

• An appliance delivery company they have selected.

A record of when and where the prescription has been sent is completed, providing a robust audit trail which is invaluable if we have to address no/poor supply issues on patients’ behalf.

Telephone contact with the prescription coordinator ensures product related problems can be quickly identified, as the coordinator asks direct questions. Patients had reported during the project’s review phase that they felt reluctant to contact healthcare professionals with what they perceived to be “minor” product related issues. They often felt these problems did not warrant contacting a busy GP or district nurse and would often tolerate problems until they deteriorated significantly. The telephone contact gives patients the opportunity to raise product related issues and for any problems to be resolved quickly and safely. Each telephone call is also an opportunity for proactive patient/ carer education, reinforcing best practice guidance such as the use of link drainage systems or catheter supporting devices.

Benefits

The new service has resulted in considerable cost savings that have been reinvested in the continence service. Cost savings have enabled us to appoint two band 6 CNS’s and a band 3 prescription coordinator.

We have gathered patient feedback on the new service model via patient opinion (www.patientopinion.org.uk). Feedback to date suggests they are extremely happy with the new service and appreciate the rapid access to help and advice.

Ongoing work includes developing a patient user group to contribute to the evaluation of new products and a surveillance project with our infection prevention and control team in relation to catheter associated UTI.

• You can read more about this service development on Joannae Mangnall’s blog here.

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