VOL: 101, ISSUE: 18, PAGE NO: 68
Ian Pomfret, RGN, NDNCert, PWT, is district continence adviser
Julie Vickerman, DipCOT, SROT, is clinical specialist occupational therapist (continence), both at Chorley & South Ribble Primary Care Trust; Pauline Tonge, RGN, DipN, DipHSM, is specialist nurse stroke co-ordinator, Lancashire Teaching Hospitals TrustIdentifying a problem in secondary care
Identifying a problem in secondary care
Once the community urinal lending library was established, it became evident that many patients in secondary care were experiencing problems finding suitable toileting aids, especially in rehabilitation settings before discharge.
These patients did not have access to the wide range of hand-held urinals available in the community and were restricted to using the disposable urinals, bed pans, pads or catheters held in hospital.
While the disposable urinals were reasonably acceptable for male patients, those for females were less effective because of their design, and alternative models were not available.
The continence team members, who are based in a district general hospital, are frequently asked to see patients in secondary care. Observation and experience showed that there appeared to be a discrepancy in continence care for male and female patients.
They noted that whereas male patients who were unable to access toileting facilities were offered a disposable male urinal and/or body-worn urine collection aid such as a penile sheath, female patients with similar levels of disability were offered only bed-pans or commodes, and that poor mobility and dexterity would often lead to their using body-worn, disposable absorbent incontinence aids (pads) or indwelling catheters.
The continence team felt that if re-usable, hand-held female urinals were to be introduced in secondary care, and staff were educated in their use, the number of patients discharged from hospital who were dependent on pads and catheters could be reduced.
Introducing hand-held urinals in secondary care
A plan was made to introduce re-usable, hand-held urinals into secondary care, but certain issues needed to be addressed first:
- Would the urinals be care-/cost-effective in enabling patients to manage their toileting needs?
- Would the new products have advantages over existing disposable products? - How would patients be assessed for the most appropriate aid?
- How would the aid be supplied?
- Who would teach the patient to use the aid?
- How would the project be funded?
- How would products dispensed from the urinal library be replaced?
- How would used products be cleaned before being returned to the library?
- What would happen on patients' discharge?
It was decided to try to introduce hand-held urinals for patients following a stroke, with a view to extending the service to other patients undergoing general rehabilitation if the project proved to be successful.
Funding - Funding to establish the urinal library was discussed with members of the acute services management team, but progress was not made until a specialist nurse for stroke patients had been appointed. She was enthusiastic about establishing such a library, initially for patients following a stroke, and felt that this could develop into a wider service for all patients undergoing rehabilitation.
A study session was held in the hospital's medical unit in April 2004 to assess the attitude of staff to the use of hand-held urinals and continence care. Nurses, occupational therapists and physiotherapists working in the unit were invited to attend. The session was facilitated by the nurse continence adviser, the specialist continence occupational therapist and the newly appointed stroke specialist nurse.
The aim of the session was to see if there were any differences in attitude to male and female patients when interventions to promote continence were being considered. The staff were first given a brief overview of continence assessment for stroke patients, following which they were split into two groups, each one including representatives of the three professions attending. The group members were given a short case history of a stroke patient and asked to assess the patient's needs and plan appropriate care and interventions (Box 1). Neither group knew that the two case histories were identical except that one group had to assess a male patient while the other one assessed a female.
On completion of the group work, the members were brought back together and the reason behind the exercise was explained to them. They indicated that they were aware that female urinals other than the current disposable ones were available but were unaware of the wide range and different designs.
The specialist continence occupational therapist then showed the group the range of male and female urinals it was intended to introduce, initially as a pilot study, for patients who had had a stroke. There was a very positive response from all the staff and they felt that this was a service that would benefit their patients.
Establishing the urinal library Following benchmarking of existing services, a selection of hand-held urinals was purchased using money donated from the Women's Royal Voluntary Service. Included were:
- 10 bridge urinals;
- 10 saddle urinals;
- 10 male drainage jugs;
- 10 Beambridge funnels.
These are all available on prescription in the community and are the most popular products used by patients in primary care.
Training - The continence team recognises that using hand-held urinals can be more difficult than wearing absorbent incontinence aids, especially at night when carers are not available. However, educating patients in secondary care to use toileting aids effectively can help to prevent problems when the supply of absorbent aids is limited or if they are not available following a patient's discharge.
In November and December 2004, an intensive multi-professional training programme was provided for nursing, occupational therapy and physiotherapy staff. The aim of the project was described to them, and they were then able to look at the range of urinals available in the hospital and try the products themselves (outside their clothing) in different positions.
Obtaining replacement products - In the community, urinals are available from community pharmacists on medical/nursing prescription. However, the hospital pharmacy and appliance service would not accept responsibility for supplying the products. It was decided, therefore, to include in the library urinals that were available on prescription in the community so that patients could replace the urinal they selected using a prescription from their general practitioner. When this is not possible, we purchase urinals as non-stock items from NHS Logistics.
This system of replacement will be sustainable for the pilot study, but it is an issue that will need to be addressed if the project is extended for all patients who are undergoing rehabilitation.
Box 2 lists the urinals currently available on medical or nursing prescription.
Cleaning the urinals - Urinals that have been used by a patient but are found to be unsuitable have to be cleaned before being used by another patient. Following extensive discussions with the hospital infection control service, it was decided that because the design of some of the urinals meant they could not be cleaned effectively by the hospital's sterilisation services and decontamination unit, they would be washed in the stroke unit and then sent to the community equipment stores for washing/disinfecting.
The continence team occupational therapist is now working with a major manufacturer of the urinals with a view to changing their design so that they are suitable for hospital cleaning.
The primary care trust's continence advisory service, together with the acute services rehabilitation services and the specialist stroke co-coordinator, will carry out an audit of current clinical practice with regard to patients admitted to hospital following a stroke. It will focus on the management of continence and find out if an appropriate hand-held urinal can prevent/reduce the use of pads, or catheters. The results will be published in a future issue of Nursing Times.
Chorley & South Ribble Continence Team believe that hand-held urinals, both male and female, offer an effective alternative method of continence management for many patients in acute and primary care and are an undervalued resource in the management of continence.
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