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Using Essence of Care benchmarking to develop clinical practice Continence Care.

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Rachel Gilbert, RN, DipHE, continence nurse specialist, older people’s services, Kingston Primary Care Trust


VOL: 101, ISSUE: 02, PAGE NO: 54

Rachel Gilbert, RN, DipHE, continence nurse specialist, older people’s services, Kingston Primary Care Trust

Health professionals have a responsibility to provide safe and effective care (NMC, 2002) and nurses need to gain appropriate competences in any activity they are going to carry out. When the assessment of bladder problems is required they need to know how to perform a portable bladder ultrasound correctly. Ness and Addison (2000) discuss how formal training based on a competency framework can meet this need.



Measuring a post-void residual volume
A post-void residual volume is considered to be significant if it is greater than 100ml (Anderson et al, 1992). There are a number of possible causes (Box 1).



It is often associated with a variety of symptoms and complications, together with related psychosocial problems (Box 2).



Wagg and Malone-Lee (1999) suggest that a volume of 150ml in an older person is acceptable and unlikely to be problematic. Treatment may not be required even when a significant volume of urine is discovered - 300ml or over (Addison, 2000a). Nurses require clinical decision-making skills to facilitate an accurate review and assessment of their findings (Addison, 2000a).



Poor bladder emptying may be asymptomatic and if it remains undiagnosed the patient may not receive appropriate treatment and therefore may experience complications (Box 2).



Transient symptoms - A post-void residual volume may occur at varying times of the day and in varying amounts. The problem is particularly associated with multiple sclerosis (DasGupta and Fowler, 2003; Namey, 1997). Transient symptoms may be due to a detrusor sphincter dyssynergia (the urethral sphincter is unable to relax as the bladder contracts). This means that complete bladder emptying is not always possible.



Addison (2000a) suggests that all patients with multiple sclerosis should be offered bladder ultrasound at least once a year as a means of monitoring bladder emptying (see p49).



Scanning verses urethral catheterisation
The use of bladder scanning is now challenging urethral catheterisation as the best method of confirming post-void residual (Fader and Craggs, 2003; DasGupta and Fowler 1997; Wilson, 2003). It has the advantage of being a non-invasive procedure and there is no risk of introducing infection to the urinary tract. The advantages of bladder scanning are listed in Box 3.



Indications for ultrasound scanning
A nurse should perform a portable bladder ultrasound as part of a continence assessment. The procedure should be used to assess those at risk of poor bladder emptying even if they have no symptoms. Such patients would include men with symptoms of prostate enlargement, those with a neurological disorder, patients taking anticholinergic medications and any patients with associated symptoms. Indications for scanning the bladder by ultrasound are listed in Box 4 (Addison 2000a, 2003).



Benchmarking, as defined in Essence of Care (Modernisation Agency, 2003a), is an integral part of clinical governance. It is a valuable tool for developing clinical practice and can enhance patient services.



Benchmarking can be used to quantify the need for a change in clinical practice, and can also provide measurable outcomes for clinical services. The Modernisation Agency (2003a) has identified how the process provides a foundation on which to develop and advance practice. The process can lead to continuous improvement through comparing practice with other services and sharing ideas (Mason and Brady, 2003) (Box 5).



Benchmarking bladder ultrasound
As a clinical nurse specialist in continence care, I questioned whether nurses were regularly performing a portable bladder ultrasound scan as part of a continence assessment, and the benchmarking process provided a framework to examine this. I anticipated that benchmarking bladder ultrasound would help to identify any specific areas for education and development. To find out, I looked at this area of clinical practice using the stages identified in the Benchmarks for Continence and Bladder and Bowel Care document (Modernisation Agency, 2003b).



Stages of the benchmarking process
Stages One and Two - Agree best practice and assess the clinical area against best practice These two stages involved comparing and sharing practice with the continence service of a neighbouring trust. The service is led by a nurse consultant in bladder and bowel dysfunction and agreed statements on what constitutes best practice in portable bladder ultrasound had been developed by the trust.



I attended its bladder ultrasound scanning course, which proved to be extremely valuable when I was developing a local training programme, as it helped me to identify areas for practice development.



Attendance at the course also enabled me to be aware of potential problems, such as:



- An inadequate number of bladder ultrasound scanners - A small audit was completed to measure how often bladder ultrasound scanning was used in a continence assessment. The audit highlighted that scanning rates were low in comparison to the number of continence assessments taking place. One reason was that nurses had limited access to portable ultrasound scanners in the clinical areas. There was also a lack of knowledge about the use of ultrasound in bladder assessment.



- Lack of access to information My trust did not have local guidelines or procedures for the use of portable bladder ultrasound. A guideline can help to provide clinicians with information and clarify best practice (National Institute for Clinical Excellence, 2003). Furthermore, resource files containing relevant research about bladder ultrasound, literature, equipment manuals, and maintenance records had not been developed.



- Inadequate training - Reflection on current practice indicated that there was a gap between theory and practical experience. Staff had watched a manufacturer’s training video that showed how to use bladder ultrasound scanners, and they had received further information on the topic if they attended a continence promotion study day.



However, this training was not based on a competency framework that met with formal standards, such as the documents from the Medicines and Healthcare products Regulatory Agency (2000, 2001).



Stage Three - Produce and implement an action plan - An action plan was developed and specific outcomes and measurable criteria for success were set (Box 6). The action plan aimed to meet staff training needs and encourage more widespread use of the portable bladder ultrasound scanner in continence assessments.



Formal training sessions based on an agreed competency framework were planned, developed and started. Manufacturers supported these training sessions by providing literature and equipment, and they have proven to be a valuable source of advice and information. The action plan included the purchase of extra bladder ultrasound scanners to improve access to equipment.



Stage Four - Review achievements - Reviewing progress is an important element in the benchmarking process. Specific learning outcomes and success criteria had emerged during the action planning stage and these will be measured. We have found that bladder ultrasound scanning has become an integral part of continence assessment and access to the scanning equipment is being requested more frequently. This needs to be substantiated with further clinical audit, which will also help to quantify the outcome of the training.



Nurses are now completing a structured, competence-based training package. They are expected to prove and defend their competence by completing competency statements and gaining supervised practice. The course evaluation has been extremely positive.



A formal bid for funding to purchase more portable ultrasound scanners is to be submitted. It is anticipated that this will be successful as a result of the benchmarking project.



The trust values the process of benchmarking as developed in Essence of Care (Modernisation Agency, 2003a) and the contribution it makes to the delivery of quality services for patients.



Stage Five - Dissemination and review of the action plan - A significant stage of the benchmarking process is the dissemination of change and practice development. This should be combined with a critique of the action plan and revision of it if necessary.



Future priorities include the development of a best practice guideline that incorporates the competency framework. This will be used as a basis for developing and improving continence care further, facilitating multidisciplinary learning and providing measurable criteria for clinical audit.



The advent of integrated, multidisciplinary continence services as required by the Department of Health (DoH, 2001) means that the training and competency framework should be extended to include other health care practitioners.



Members of those disciplines closely involved in continence care should therefore be included. This will be discussed and implemented locally.



The continence service is now going to develop its own formal benchmark to provide a base for further reflection, comparison and sharing. The service will aim to share its work with other services in the NHS and independent sector. It is hoped that this will help facilitate further change and enhance working partnerships.



Stage Six - Agree best practice - It can be a challenge to continue benchmarking activity once the desired outcomes have been reached.



However, it is vital to ensure that improvements are sustained and practice is reviewed in the light of any new evidence and guidelines.



The continence link groups have been identified as the most appropriate and motivated forums to ensure the process is ongoing.



Ultrasound scanning of the bladder is often under-used in a continence assessment.



The clinical benchmarking project described here identified the need to develop practice locally and has already brought about change. There are still goals to achieve, but the process has been inspiring.



It is now anticipated that when a patient presents with a bladder dysfunction, a scan to identify emptying problems will be offered routinely and performed by a competent practitioner.

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