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Development of a continence assessment pathway in acute care.

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VOL: 101, ISSUE: 18, PAGE NO: 46

Claudia Clayman, MSc, RGN, is clinical nurse specialist, continence services

Victoria Thompson, BSc, DipHE, RN, is lead nurse, practice development and quality; Helen Forth, BSc, SRP, MACPWH, is clinical specialist physiotherapist - women's health; all at the Royal Free Hampstead NHS Trust

Surveying continence care in an acute trust

Surveying continence care in an acute trust
High quality continence services should be based on the principles of proactive detection of continence problems and early treatment of incontinence (DoH, 2001; 2000).

The Royal Free Hampstead NHS Trust is a large acute teaching hospital with over 1000 beds. In 2001, in a bid to find out about the nursing assessment and management of patients with continence problems, the continence team distributed a survey questionnaire to 420 qualified nurses in 40 wards.

The nurses were asked their opinion on a number of continence issues, such as the importance of continence care, their experience of using a continence assessment tool, the provision of continence pads and pants, use of barrier creams and educational opportunities. Two hundred and twenty questionnaires were returned, a response rate of 58%.

Survey results - The results highlighted that:

- Continence care for patients, including assessment, care planning and product use, depended on individual clinical judgement;

- There were problems with the quality and availability of continence products;

- There was a lack of knowledge about when to use barrier creams, and high use of them;

- There was a need for more education about continence care.

Survey recommendations - These were to:

- Develop a continence assessment tool;

- Review the use of barrier creams;

- Consider undertaking a trial of one-piece continence products;

- Initiate a plan for ward-based teaching.

Establishing a benchmarking group
A multidisciplinary continence benchmarking group, which included colleagues from the local primary care trusts, was convened in 2001. It had a number of aims (Box 1), which included developing new continence assessment documentation for all patients admitted to the acute trust. The goal was to develop a pro-active continence assessment pathway that would allow early identification of patients who had a continence problem and who required further assessment.

Developing the continence pathway
A pathway of care was developed by the continence benchmark group that uses a series of documents that can be used in different clinical situations. The pathway was comprised of:

- The adult continence pathway assessment;

- The adult continence assessment form;

- The bladder/bowel assessment form;

- The toileting programme plan.

The adult continence pathway assessment has a trigger question that the nurse should ask the patient during the admission process (Fig 1): 'Does your bladder ever cause you embarrassment, pain or concern?' Patients who answer 'yes' to this question are then assessed using the adult continence assessment form. This is a colour-coded symptom index that patients can complete. It is based on work carried out by the Continence Care Pathways Development Group (Bayliss et al, 2001; 2000a; 2000b;). A trigger question on assessment for bowel continence has been incorporated into the Royal Free Hospital pathway.

Each colour-coded section of the adult continence assessment form relates to a particular continence problem, such as stress incontinence or constipation. On the reverse of the form are colour-coded guidelines about fundamental care that should be incorporated into the patient's plan of care. The guidelines also suggest appropriate patient information literature and when referrals should be made for specialist assessment.

Assessment of patients with communication problems - The group also designed a bladder/bowel assessment form specifically for patients who are unable to answer questions. It uses key questions to elicit information about previous bladder/bowel history and habits, and the nurse must identify from whom she obtained the information about her patient. Again, there are guidelines relating to nursing care, relevant referrals and patient information leaflets. A toileting programme plan is also included.

Patient information leaflets
As part of the project, the benchmarking group designed colour-coded in-house patient information leaflets for the four most common forms of incontinence :

- Stress incontinence;

- Urgency/urge incontinence;

- Loss of bowel control;

- Constipation.

Each leaflet gives basic information on the condition, self-help advice, local contact numbers and other sources of help. For example, the stress incontinence leaflet gives information about pelvic floor exercises, while the constipation leaflet gives information about developing good bowel habits, and tips for emptying the bowel correctly.

Posters in the wards and outpatient areas have been used to raise continence awareness among patients, relatives and visitors. They feature the continence trigger question and guidance about access to patient information leaflets, and advice about accessing further help.

Piloting the documentation
Before the documents and leaflets were put into use by staff and patients, they were piloted to ensure they met the needs of those who would be using them. The documents were piloted in five different wards throughout the trust, covering a broad selection of specialties. Some minor changes were made following comments from the staff.

A group of patients attending a mixed urology/gastroenterology clinic were asked to review and comment on the patient information leaflets and again small changes were made in response to their suggestions.

Staff education
An intensive teaching package about the continence pathway was provided for staff. This included:

- Holding two weeks of drop-in teaching sessions about general continence awareness and how to use the new documentation;

- Providing a resource folder for all clinical areas.

The benchmark group also developed a number of initiatives to ensure that the work was disseminated in a number of different ways so that the momentum of the project would be maintained (Box 2).

Ongoing evaluation
Once the documentation had been launched across the trust, and the training programme set up, a benchmark scoring pack for continence and bladder and bowel care was developed. This will enable the clinical areas to audit both the use of the new documents and the clinical practice of the staff. Once the clinical areas have completed the scoring pack, the information will be collated, and a report produced. This will be disseminated across the trust by means of its intranet, newsletters, and multidisciplinary meetings.

Conclusion
The benchmark group found all steps of the project both challenging and rewarding. The pilot study on the documentation was immensely helpful in ensuring that the pathway was satisfactory.

The comprehensive teaching package provided for all nursing staff was vitally important in ensuring that they were aware of the need for the new continence assessment pathway and that they knew how to use it.

It has been very useful to have a continence resource folder in every ward and outpatient area, as this provides information for staff who are new to the trust and have not yet attended one of the continence training sessions. In addition, it acts as an accessible resource and reminder for existing staff.

Patient/user involvement was extremely important in the development of the continence and bladder and bowel care information leaflets. These are available throughout the trust and are an essential part of the package.

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