NATIONAL AUDIT OF CONTINENCE CARE FOR OLDER PEOPLE

Transcription

1 NATIONAL AUDIT OF CONTINENCE FOR OLDER PEOPLE Health Care of Older People Programme NATIONAL AUDIT OF CONTINENCE FOR OLDER PEOPLE Report of the National Audit of Continence Care for Older People (65 years and above) in Royal College of Physicians of London Clinical England, Effectiveness Wales and & Evaluation N Ireland Unit St. Elsewhere s Hospital Prepared on behalf of the Continence Working Party By: Dr. Adrian Wagg, Miss Penny Peel, Mr. Derek Lowe & Dr. Jonathan Potter November 2006

2 CONTENTS FOREWORD 2 EXECUTIVE SUMMARY 4 INTRODUCTION 8 Aims of the national audit 9 Page METHOD 10 Note on terminology Continence audit package Data collection Auditors Recruitment of sites Audit success criteria Data submitted by sites within sector Data quality & anonymity Presentation of results RESULTS Organisational audit 14 Case-mix and process audit Bladder Problems 21 Case-mix and process audit Bowel Problems 31 Service workload 40 DISCUSSION 42 REFERENCES 46 APPENDICES see separate document Measuring change from 2005 to 2006 audits in hospitals 2. Continence Working Party 3. Audit participation list 4. Questionnaires

3 LIST OF TABLES Page Table 1: Site recruitment 12 Table 2: Numbers of sites and cases in audit 13 Tables 3-12: Organisational audit Table 3: Auditor discipline 14 Table 4: Policies and procedures 14 Table 5: Screening 15 Table 6: Staff (1) 16 Table 7: Staff (1) for those claiming to have an integrated service 17 Table 8: Staff (2) 18 Table 9: Environment 19 Table 10: User evaluation of the service 19 Table 11: Continence products 20 Table 12: Patient/carer information & support 20 Tables 13-26: Casemix & Process (Bladder) Table 13: Demographic information 21 Table 14: Where cases obtained from 21 Table 15: Symptoms (1) 22 Table 16: Symptoms (1) main combinations 22 Table 17: Symptoms (2) 23 Table 18: Symptoms (3) 24 Table 19: Cognitive status 25 Table 20: Functional status 25 Table 21: Assessment 26 Table 22: Examination 27 Table 23: Treatment 28 Table 24: Containment 29 Table 25: Care plan 29 Table 26: Communication & information 30 Tables 27-39: Casemix & Process (Bowel) Table 27: Demographic information 31 Table 28: Where cases obtained from 31 Table 29: Symptoms (1) 31 Table 30 Symptoms (2) 32 Table 31: Symptoms (3) 33 Table 32: Cognitive status 34 Table 33: Functional status 34 Table 34: Assessment 35 Table 35: Examination 36 Table 36: Treatment 37 Table 37: Methods of containment 38 Table 38: Care plan 38 Table 39: Communication & information 39 Tables 40 41: Service workload Table 40: Primary care 40 Table 41: Care homes 41

4 ACKNOWLEDGEMENTS We are, once again, extremely grateful to all who have participated in the National Audit of Continence Care for Older People We recognise that this has involved many individuals spending time over and above an already heavy workload with no financial recompense. We very much hope that everyone will feel it has been worthwhile and that the audit represents a small but significant step in raising the profile of continence and contributing to the improvement in the quality of care for older people with bladder and bowel problems. The continence data collection web tool was developed by programmer Paul Cripps (Director, Net Solving Limited). We wish to acknowledge their cooperation, timely responses and attention to detail in developing the web based audit tool with us. We value all feedback about the conduct of the audit and suggestions for improvement and on behalf of the Clinical Effectiveness and Evaluation Unit at the Royal College of Physicians (RCP) and the Continence Working Party we additionally wish to thank all those who have participated in the development and conduct of the audit. This audit has been funded by the Healthcare Commission. 1

5 FOREWORD The purpose of this re-audit was to allow clinicians and those involved in managing continence to compare their services performance with evidence based quality standards (National Service Framework for Older People, Good Practice in Continence Services (Department of Health 2000, 2001)) and against other audit participants. This allows variations in the standards of care between different Trusts, PCTs and care homes to be highlighted and should lead to improvement in the standard of care provided to older people with continence problems. Additionally, those hospital sites who have participated in both rounds of audit will be able to compare their performance with that from the first round and measure change (or its absence). Hospital and mental health care trusts, PCTs and care homes providing care for older patients with incontinence in England, Wales and Northern Ireland participated in what is still the largest audit of continence care in the United Kingdom. Data on bladder and/or bowel incontinence care and problems were analysed. Inevitably there are flaws in the process of audit, especially a snapshot audit such as this. Submitted data from individual trusts may not be representative of their normal case mix and data from a single GP practice may not reflect all GP practices in local primary care. It is therefore important to look carefully at the case mix variables at the beginning of the audit report to see how your patients compare to others from each similar healthcare setting. The major findings, and their implications for care, are set out below. To achieve change in the management of continence care the efforts of many people within health and social care are required. Please therefore circulate this report as widely as possible and take appropriate action in areas where your centre is performing poorly against other centres. Data concerning your participation in the audit will be returned to the Healthcare Commission as part of its Annual Health Check. An executive summary report will be sent to Chief Executives of Trusts, PCTs, executive members of care home providers as appropriate, and to Strategic Health Authorities, Local Health Boards, the Department of Health, the Healthcare Commission, the Commission for Social Care Inspection and Continence charities. Presentations at an international level and peer-reviewed papers will be produced in due course. We shall, in addition, revise the master slide set into which you can import your site specific data for local use. This will be available on the National Audit of Continence Care for Older People website. Additionally, we will provide a pick and mix continence policy for primary, secondary and care home sites and an implementation toolkit for sites working to change their provision of care. By maximising the impact of the audit we hope to keep the issue of continence care in the forefront of people s minds and on the political agenda. We are interested in receiving feedback to this report, so please contact one of us if you want to comment on your results, your experience of the audit and any 2

6 lessons you have learned from it. We will share specific examples of good practice on our website Penny Peel Adrian Wagg Jonathan Potter Project Manager Director, Continence Director, CEEu November

7 EXECUTIVE SUMMARY The first Healthcare Commission sponsored National Audit of Continence Care for Older People was published in November The results from that audit generated much interest and harnessed an impetus for change. This report presents the results from the reaudit which once again aimed to examine the quality of care for older people with urinary and faecal incontinence in primary care, secondary care and care homes in England, Wales and Northern Ireland. This re-audit has shown: Where a continence problem is identified, assessment or management of that problem is still not guaranteed. People with continence problems often suffer for years before presenting with the problem. To neglect or ignore a problem once detected is clearly inadequate care. This is a point of action for all healthcare staff, in all settings. Whilst the majority of sites have access to continence services, truly integrated services are few. The goal of integrated continence services for all adults, contained in Good Practice in Continence Services and reiterated in the National Service Framework, remains a distant one in most areas. A considerable amount of organisational change is still required to meet the target. Commissioners of services need to bear this in mind when specifying their needs. Just over half of hospital sites and care homes, and only a third of mental health sites, offer structured training in continence care. Incontinence is a common problem for older people. All staff should be trained in basic assessment and management of this troublesome condition. Training should be accessible to all and should be made a mandatory component of basic training for staff. Documentation of continence assessment and management for older people is wholly inadequate. This is clearly an example of substandard practice and should be relatively easy to improve upon. Handover between staff caring for older people with continence problems relies upon adequate documentation to maximise efficient use of resources. The re-audit has achieved a higher participation rate from acute trusts, primary care and care homes. For the first time, mental health trusts have been included. A key aim of the National Service Framework for Older People (2001) was to establish integrated continence services by April The organisational audit demonstrates that whilst there 4

8 is basic infrastructure for continence services, finding a problem does not guarantee an assessment and there remains inadequate access to integrated services. The objective of establishing a Director of Service has seldom been reached and only 30% of services have a person with leadership responsibility within their job description or plan. In each service there should be a designated lead with responsibility for organisational change towards an integrated service. Commissioners need to ensure that provision, probably across provider units, with the relevant skilled staff is available to their population. Effective management of continence depends on thorough assessment leading to diagnosis of the cause. The audit indicates that, for specialist assessment of continence, continence knowledge of practitioners is good as is the ability to gather relevant details about the incontinence [the history]. However, there is still inadequacy in the thorough examination of patients (especially the rectal examination) and in the use of routine assessments, such as bladder diaries and the measurement of residual bladder volumes to evaluate the nature of incontinence. Furthermore, the number of patients with documented causes for their incontinence is totally inadequate, even after a specialist assessment and especially in secondary care where two-thirds have no cause documented. While it is recognised that patients included in the audit may represent those in whom it has not been possible to achieve continence, treatment will prove difficult unless the underlying cause is established. These results suggest that the underlying cause is frequently not established. This may go some way to explain why management relies more on containment than treatment. An accurate diagnosis is unlikely to be made without proper assessment. A lack of proper assessment will lead to either unnecessary treatment or inappropriate reliance upon containment of the problem, as has been demonstrated in the original audit. The needless use of pads is expensive and potentially undignifying. Management regimes for older people demonstrate the predominance of containment using pads and catheters. The inevitability of the need for containment in this highly prevalent condition remains to be proven, but demonstrates how very costly the management of incontinence is. The pressure to control these costs is demonstrated by the frequent rationing of supplies in three-quarters of primary care settings and care homes. Good Practice in Continence Services (DH 2000) indicates that the use of catheters should be avoided if possible. The results of the audit in primary care and care homes suggest that catheter use is limited. However, secondary care reports catheter use for control of incontinence in 30% overall, in 33% following a specialist examination. This cannot be solely explained by case mix, as secondary care and care homes reported similar prevalence of patients with stroke, falls and impaired mobility. Catheters should only be used for the management of incontinence after a thorough assessment of the problem and where other methods have either failed or the patient is too frail or too distressed to tolerate other more labour intensive measures (see NICE Guideline 40 Urinary Incontinence in Women). 5

9 Findings include: 73% of primary care sites and 90% of care homes report the existence of a written policy for continence care. This existed in only 37% of hospitals and 10% of mental health care sites. Whereas it is the practice of nearly all sites to ask a screening question relating to bladder and bowel care as a case finding exercise, in only 74% of primary care, 52% of hospital and 30% of mental health care sites was there a written protocol for providing a basic assessment if a problem is found. Integrated continence services were said to be present in 66% of primary care sites, 56% of hospital sites, 63% of mental health care sites and 69% of care homes. In only 10% of primary care services was there a Director of services, and in only one-third a person with a designated lead role, the situation being worse for secondary care. These services have variable access to other, necessary components of an integrated service. Only 55% of secondary care trusts offered structured training on promoting continence to their staff. Most services provided for complaints to be made but few had user input. Despite about 90% of services having a written policy stating that pads should be available on the basis of clinical need, most primary care services and care homes had a limit on the type and number of products supplied per day. Only one third of hospital and primary care patients with faecal incontinence, 22% of mental health patients and 10% of care home residents had a rectal examination as part of their assessment. In hospitals, only 51% of the patients with urinary incontinence had a history taken and only 55% had a specialist assessment. In only a third (34%) of cases is a diagnosis documented. Half had no documented evidence of a specific treatment plan, 58% were given pads and 30% were catheterised. In mental health care trusts, 24% of patients had a documented diagnosis for their urinary incontinence. Documented management consisted almost entirely of toileting schedules and pads. These results are particularly of concern since these patients are amongst the most vulnerable. In primary care, 77% of patients with urinary incontinence had a history taken and 67% a documented diagnosis. This led to a documented management plan in 73%. Documented management consisted mainly of either lifestyle advice and/or pads. In care homes, two thirds of residents with urinary incontinence had a documented history which led to a diagnosis in 40%. Management mainly comprised pads and toileting schedules. 6

10 In only 59% of cases in primary care, and less so (27-40%) for other sectors, was there documented evidence that an explanation had been given to patients about their condition and treatment when it was appropriate to do so. Reports of poor attention to privacy and dignity on the wards were important in the inception of the National Service Framework for Older People and have been re-iterated in its follow up document A Healthy Ambition for Old Age. Few conditions could be more important than continence with regard to privacy and dignity. The audit demonstrates that sites feel confident that privacy and dignity are well maintained: primary care (94%), hospitals (88%), mental health care (97%) and care homes (99%). However, it would be interesting to know whether patients/users agree with this assessment and it is notable that only a minority of services have user group involvement: primary care (27%), hospitals (22%), mental health care (16%) and care homes (24%). Overall this audit suggests that a basic infrastructure is still in place to deliver improved continence services, but that there has been little progress in the pursuit of truly integrated continence services as envisaged in Good practice in Continence Services (Department of Health 2001). There is a suggestion from hospital trusts of a reduced availability of continence specialist nurses. This would be a concern as continuing inadequate assessment of incontinence with an emphasis on containment does not constitute high quality care. In the face of the great daily cost of containing continence, the audit once again indicates a missed opportunity to assess, treat and reduce the numbers of incontinent people and the associated financial costs, estimated to be in the region of 743 million per year. The Department of Health indicates that all necessary policy with respect to continence is in place; what is clearly lacking, as shown by this audit, is implementation of that policy. In addition, the current reforms in health care have perhaps served to fragment, rather than consolidate, cross-trust working. What can be done to encourage change and to empower people to seek better care for either themselves or for those for whom they care? After all, many sufferers are from the older, more vulnerable groups in society and services for such people are an easy target for cuts in times of financial pressure; especially as they are neither high profile nor subject to a government target. At a local level, much can be done and simply participating in an audit such as this will identify areas of practice which are relatively easy to change. Primary Care Trusts, Local Health Boards and Strategic Health Authorities should use these data to check that their commissioned services meet the necessary standards and should ensure that the wherewithal to deliver these is in place. Work by the charitable sector will undoubtedly continue to raise awareness of the problem, encourage people to seek help and lobby at political level for better services. 7

11 INTRODUCTION Bladder and bowel incontinence, although not confined to older people, become increasingly prevalent with age. In addition, people s experience of incontinence becomes more severe as they age 1. Despite this only approximately 25% of women seek care and the subject is still not talked about openly, and people adopt various abnormal strategies to cope with the problem. Incontinence isn t life threatening, but it is associated with a significant negative impact upon quality of life for sufferers and is associated with depression, an increase in the number of urinary tract infections, falls and fractures. In addition, there is mounting evidence that sufferers are more likely than continent people to be institutionalised. Urinary incontinence affects some 10% of older people and 30 60% of people in long-term care settings 1-2. Faecal incontinence occurs in approximately 1 4% of community dwelling adults and up to 25% of people in institutional care 3. Both cause much individual distress, particularly to the sufferer but also to carers 4. The Department of Health report Good Practice in Continence Services (2000) 5 highlighted the need for proper assessment and management of the problem, identified a wide geographical variation in access to services and called for regular audit of services. In addition, the National Service Framework for Older People (2002) 6 set the requirement that service providers should establish integrated continence services for older people by April However evidence suggests there has been only limited action toward this and that provision of services remains extremely variable 7. The NHS has undergone considerable change since the first round of audit. The reorganisation of primary care trusts and the reaction to the NHS financial position has meant that some continence services have not recruited into vacant posts or have been subject to a reduction in staff. In addition, the impetus for change engendered by the results of the first audit may have been lost, or energies may have been diverted into other more pressing areas. This will undoubtedly have an impact upon the provision of quality care to patients. On a positive note, the National Institute for Health and Clinical Excellence has published guidelines for the care of incontinence in women, and is working on those for faecal incontinence, both of which should result in national standards for quality care. This second report presents the results from the re-audit cycle of the National Audit of Continence Care for Older People (NACCOP). 8

12 AIMS OF THE NATIONAL AUDIT 1. Improve care for older people with continence problems as highlighted in Good Practice in Continence Services (DH, 2000). 2. Demonstrate variation in standards of care relating to the management of continence problems in older people across different healthcare settings. 3. Enable healthcare settings (in primary care, secondary care (including mental health care) and care homes) to compare the quality of their continence care to evidence based criteria. 4. Monitor the NSF for Older People milestone for establishing integrated continence services (April 2004). 9

13 METHOD Note on terminology Throughout this report, distinction between the various sources of data is made as follows: Sector refers to the type of care audited, rather than the provider; therefore data collected by a PCT from a care home has been allocated to the care home sector rather than the primary care sector. Likewise, PCT data originating from a hospital has been allocated to the hospital sector. Secondary care is used to cover the hospital and mental health care sectors. Hospital refers to data collected from acute and specialist trusts. Mental Health trusts are also referred to separately. Continence audit package The web audit tool indicators cover aspects of organisation and process. The audit tool applies to all older people with lower urinary tract symptoms (voiding and storage disorders), bladder and bowel dysfunction, urinary incontinence, faecal incontinence and constipation. The audit tool consisted of various e-forms: Organisational one per site assessing the quality of care provided by the organisation, including staffing. Sites were also asked to comment (freetext) on any changes observed since the first round. Case mix and clinical process (bladder problems) the case mix captures the characteristics of patients, and the process assesses the quality of care experienced by a patient with urinary incontinence. One per patient. Case mix and clinical process (bowel problems) - the case mix captures the characteristics of patients, and the process assesses the quality of care experienced by a patient with faecal incontinence. One per patient. The web audit tool was accessible via the internet (using Internet Explorer v5.0 or above for Windows 98 and later versions) and was hosted on the Royal College of Physicians website. All data submitted to the audit were collected directly from case notes, were anonymous and access to the web-tool was password-protected for confidentiality. Each site was allocated a site code by which they were identified and each case entered was automatically allocated a unique audit number. Help buttons were provided online next to questions and an extensive help booklet was also issued to participants. Feedback regarding use of the audit tool was collected from round 1 participants and used to modify the audit tool slightly for round 2; however the audit tool remains essentially the same and data from the two rounds are comparable. 10

14 Data collection Each site was required to complete: One organisational online form. 25 online forms for consecutive patients with urinary incontinence only. 15 online forms for consecutive patients with faecal or double incontinence. All sites were asked to collect data on older people aged 65 and over. Primary care data were to be collected from a single GP s practice (identified by the PCT), from patient records including practice records, computer system, district nursing notes and continence advisor/specialist records. Secondary care patients were to be identified from current inpatients (eg medical, elderly, surgical, long-term care wards), and should there be a continuing need, retrospectively using the nursing and medical records to achieve 40 cases. Data were to be extracted from patient records including medical, nursing and multidisciplinary notes. Care home cases were to be identified from current residents and retrospectively thereafter to achieve 40 cases. Data were collected from care home records. For the first round of audit, sites were invited to attend regional workshops for training on the use of the audit tool prior to data collection. In the second round new sites were given one-to-one support from the audit helpdesk. Following the first round of audit, 7 regional meetings were held to further disseminate the results, provide more localised feedback, discuss change management strategies and to enable networking/exchange of ideas. Audit participants presented to the meetings on their initiatives for improving continence services. The meetings were attended by 337 delegates, representing clinicians, managers and audit staff. A template presentation of audit results was made available to participants, into which individual site results could be entered, to encourage local dissemination. Auditors The advice given was that the organisational audit be completed by the clinical lead supervising the audit (eg clinician, continence/nurse specialist, manager) and that the case mix and clinical audit be completed by the person responsible for the data collection (eg member of the primary health care team or audit co-ordinator). Recruitment of sites The audit recruited sites from England, Wales and Northern Ireland. Organisations were asked to choose a site (or sites) to audit, such as a hospital or GP practice, and to collect data from each site on 25 patients/residents with urinary incontinence and 15 with faecal incontinence. Some organisations providing primary/community care elected to audit a care home or hospital, as reflected in the following table: 11

15 Table 1: Site recruitment Region England Wales The Islands Northern Ireland Independent Care Homes Type of trust Acute/ Specialist Mental Health Primary Care *only 1 of these 22 LHB s provide continence services (which participated), the remainder commission from their local trust. The reasons for not taking part in the audit included: merger of PCTs coinciding with data collection time, lack of resources (embracing staff shortages, annual- or sick leave, unforeseen changes to or reduction in staffing, change in management), too short an interval between round 1 and round 2, difficulty in involving a GP practice, having a continence service which is hosted by another organisation, or not being able to identify enough incontinent patients/residents. The vast majority of organisations that declined did not give any reason. Audit success criteria Total eligible trusts Participation - Trusts (Sites) Participation rate (trust level) Self-set targets (for a successful project) were 80% participation for hospital trusts (England and Wales), improvement on 23% for PCTs (England) and improvement on 11% (equivalent to 100) of care homes. These latter two figures came from our pilot experience. In the first audit round 43% of PCTs and only 9% (n=29) care homes participated. There was no target for mental health trusts. Participation rates in this second round were 82% (139/169) for hospital trusts (England and Wales), 43% (130/300) for PCTs (England), and 104 care homes. Other targets for a successful project were for project stages to be delivered within timescale and for an improvement in patient care to be observed between the 2 audit rounds (dependent on the sites taking part in the re-audit). Timescales have been to target and results indicating small positive changes in many areas for acute hospital sites are shown in Appendix 1. Trusts (sites) by sector (154) 83% Hospital 130 (154) (32) 45% (151) 43% Trusts 13 9 (13) 69% Local Health Boards 22* 1 (1) 5% Hospital 1 (1) All 3 2 (4) 67% All 18 8 (8) 44% Mental health 24 (31) GP 1 (1) GP 102 (102) Care home 27 (35) Hospital 13 (14) (16 PCTs audited sites in >1 sector) GP 1 (1) Hospital 8 (12) GP 1 (1) Care home 1 (1) Hospital 2 (2) (1 trust audited >1 sector) GP 3 (3) Hospital 3 (5) Care home sites represented 10 providers. Promotion was, in some cases, internal as well as by the RCP so no participation rate is known. 68 care homes provided data independently. 12

16 Data submitted by sites within sector The national data for each sector used as a benchmark in the main report comprises the following numbers of sites and cases. Table 2: Numbers of sites and cases in the audit Audit HOSPITALS HEALTH HOMES Organisational 101 sites 173 sites 30 sites 83 sites Urinary Incontinence 107 sites 187 sites 30 sites 96 sites 2439 patients 4297 patients 512 patients 1429 residents Faecal 98 sites 178 sites 30 sites 96 sites Incontinence 946 patients 2525 patients 416 patients 1316 residents Most sites submitted all three types of data (organisational, bladder and faecal). A small number of sites submitted only one or two types of data. The breakdown of sites with data by country is given below: Primary care (GP): England 103, Wales 1, Northern Ireland 3, Islands 1. Hospitals: England 168, Wales 13, Northern Ireland 5, Islands 2. Mental health: England 31. Care homes: England 80, Wales 0, Northern Ireland 21, Islands 1, Scotland 2. Data quality & anonymity No identifiable data left care facilities. The use of anonymised data for central input meets the requirements of confidentiality and data protection legislation. Presentation of results The statistical summary of results is organised by care environment. Results are shown for the 4 sectors, with results for your site in the last column. Data are expressed in percentage and absolute terms and where data were not applicable the denominator is adjusted accordingly. The audit designated a-priori specified circumstances where measures did not apply for example if someone has problems of mental incapacity or there is documentary evidence that a particular procedure was not performed as it was too distressing to the patient. The electronic input method guaranteed that missing data levels (i.e. blank entries) were again very low and it was made clear in documentation that any missing data would be regarded in the negative for the measures in the audit. 13

17 ORGANISATIONAL AUDIT Organisational forms were completed by 101 general practices, 173 hospitals, 30 mental health sites and 83 care homes. Table 3: Auditor discipline (101) HOSPITAL (173) HEALTH (30) HOMES (83) % N % N % N % N Doctor Nurse Therapist Manager Other* *Others included audit co-ordinator, audit facilitator, or clinical audit dept (n=18), and continence advisor/specialist (n=7) For all sectors the majority of forms were completed by nursing staff. The rest were completed mainly by doctors (for hospitals), managers (for mental health and care homes) and doctors and managers (for primary care). Your Site Doctor Table 4: Policies and procedures HOSPITAL (101) (173) HEALTH (30) HOMES (83) Does the facility (GP practice/hospital ward/care home), or the service covering the facility, have a written policy for the management of continence? % N % N % N % N Yes Yes If Yes, policy includes: Training for staff in Your Site /73 Yes continence care Assessment & treatment of incontinence /74 Yes A means for regular audit of continence services /73 Yes Does the facility utilise an Integrated Care Pathway or an evidence based treatment algorithm for patients with incontinence? % N % N % N % N Integrated Care Pathway No Algorithm No Care Plan Yes None of these No Almost all care homes had a written policy for the management of incontinence, compared with around one third of hospitals, two thirds of primary care sites and one in ten mental health sites. The policy included: training for staff in continence care in % the assessment and treatment of incontinence in % the means for regular audit of continence services in 0-66% An integrated care pathway was used more frequently in primary care. Care plans were used in less than half of primary care and hospital sites, in half of mental health sites and in three-quarters of care homes. One third of hospitals and one fifth of primary care sites did not use a structured means of planning or delivering care. 14

18 Table 5: Screening (101) Your site HOSPITAL (173) HEALTH (30) HOMES (83) Is it the facility s practice to ask a screening question relating to bladder and bowel care as part of the initial assessment? % N % N % N % N Yes Yes Is there a written protocol for providing a basic assessment for all people who indicate that they have problems with urinary and/or faecal continence? Yes No Does the facility routinely use a standardised measure to record functional ability (eg: Barthel / MDS-RAI)? Yes No Does the facility routinely use a standardised measure to record mental state (eg Abbreviated Mental Test Score, Mini-Mental State Examination) Yes Yes Does the facility routinely use a clinically defined measure of severity of symptoms Yes Yes Does the clinical team include a practitioner who has had the training to: Take a continence history? Yes 95% (96) D:28 N:90 O:3 Yes 85% (147) D:107 N:120 O:11 Yes 63% (19) D:6 N:18 O:0 Yes 77% (64) D:4 N:59 O:8 Yes D & N Initiate a frequency volume chart? Yes 90% (91) D:20 N:87 O:7 Yes 85% (147) D:70 N:140 O:13 Yes 60% (18) D:3 N:17 O:1 Yes 70% (58) D:4 N:55 O:8 Yes D & N Perform a rectal examination? Yes 95% (96) D:53 N:70 O:3 Yes 92% (160) D:147 N:80 O:2 Yes 93% (28) D:25 N:11 O:0 Yes 45% (37) D:13 N:24 O:5 Yes D & N Perform a urinalysis? Yes 98% (99) D:35 N:96 O:9 D=Doctor, N=Nurse, O=Other Yes 98% (170) D:69 N:164 O:19 Yes 90% (27) D:8 N:26 O:2 Yes 94% (78) D:5 N:74 O:10 Yes D & N A screening question relating to bladder and bowel care as part of the initial assessment was used in most primary care (72%) and almost all hospitals (93%), mental health sites (90%) and care homes (95%). However, a written protocol to provide a basic assessment for all who indicate they have problems was absent in 48% of hospitals and 70% of mental health trusts. Standardised measures of cognitive and physical functioning were most commonly used in secondary care functional ability in 55% and cognitive function in 71% of hospitals. Standard assessment was used least frequently in primary care. A clinically defined measure of the severity of symptoms (e.g. subjective assessment of symptom impact or bother, validated quality of life questionnaire) was however used more often in primary care (54%) than elsewhere. 15

19 The requirements for an integrated continence service are set out in Good Practice in Continence Services (DoH 2000). To what extent are these being met? Table 6: Staff (1) (101) HOSPITAL (173) HEALTH (30) HOMES (83) Your site Access to integrated continence service, defined by Good practice in continence services DOH 2000 % N % N % N % N Yes No Integrated service with Director No Integrated service with Lead person No Continence nurse specialists Yes Specialist continence physiotherapists Yes Specialist continence occupational therapists No Designated referral pathways: Gynaecology (inc uro-gynaecology) Yes Colorectal surgery Yes Urology Yes Gastroenterology Yes Geriatric Medicine Yes Neurology Yes None of the above pathways No Investigation and treatment facilities, which include access to: Urodynamics Yes Urinary or gastrointestinal tract imaging Yes Anorectal physiology Yes None of the above facilities No Two-thirds of care homes, general practices and mental health sites had access to what they regarded as an integrated continence service, compared with about half of the hospitals. These services do not meet the standard of integrated services compared to the DH guidelines which defines a Director of Service, present in only 10% of primary care and 5% of hospital sites. A dedicated lead for continence was present in less than one-quarter of the integrated services of the care homes. Only in half of hospitals and general practices and 10% of mental health sites was a clinical lead identifiable for the integrated service. Most primary care sites (90%) have continence specialist nurses, around half (47%) have specialist continence physiotherapists and, as in the previous audit, very few (10%) have specialist continence occupational therapists. A similar pattern exists in secondary care, but with only two thirds having continence nurse specialists. 84% of the care homes have access to nurse specialists but few have specialist physiotherapists or occupational therapists. 16

20 For those sites who said they had an integrated service and using a more inclusive definition than that of continence lead the distribution of available services is as follows: Table 7: Staff (1) for those claiming to have with an integrated service HOSPITAL HEALTH HOMES (67) (97) (19) (57) % n % n % N % n Other staff: Continence nurse specialists Specialist continence physiotherapists Specialist continence occupational therapist Designated referral pathways: Gynaecology (inc uro-gynaecology) Colorectal surgery Urology Gastroenterology Geriatric Medicine Neurology None of the above pathways Investigation and treatment facilities, which include access to: Urodynamics Urinary or gastrointestinal tract imaging Anorectal physiology None of the above facilities Continence nursing services are available for almost all the integrated services. Access to continence physiotherapy is available for half in the primary sector, two-thirds in hospitals and is relatively uncommon (19%) for the few care homes and mental health sites (5%) claiming to have integrated services. Referral pathways to other relevant disciplines are present in most services but the disciplines vary by site. About one in six integrated services for general practice and hospitals, one in four mental health sites and one in two care homes have no referral pathway to any discipline. Nearly half of all care homes and 37% of mental health trusts which claim to have an integrated service have no access to diagnostic imaging or specialist investigation. 17

21 Table 8 : Staff (2) (101) HOSPITAL (173) HEALTH (30) HOMES (83) Your site Is there a structured programme of staff training on promoting continence within the facility? % N % N % N % N Yes Yes If Yes, does the programme include basic assessment (i.e. all of history taking, urinalysis, rectal examination and frequency/volume charting) Yes Yes Do patients have access to a local continence specialist, who is able to give advice on continence, and bladder and bowel care? Yes Yes If Yes, is the specialist Hospital based 2 2/ / Community based 98 96/ / Community Is specialist continence assessment always being carried out by a practitioner with continence training in: Knowledge of aetiology of urinary/faecal incontinence Yes Experience in taking history Yes Able to do abdominal, rectal & vaginal exam Yes Able to perform urinalysis Yes Able to do residual volume measurement Yes None of the above No Number of WTE Continence Specialists available to Median 2.0 Median 1.4 Median 1.0 Median 1.7 PCT IQR N = 93 sites IQR N = 101 sites IQR 0 to 2.6 N = 9 sites Range 1.0- to 3.0 N = 47 sites 3 Hospital Service IQR: Inter-Quartile Range Median 0 IQR 0 to 1.0 N = 63 sites Median 0.8 IQR 0 to 1.0 N = 132 sites Median 0.1 IQR 0 to 1.0 N = 11 sites Median 0 Range 0 to 1.0 N = 22 sites 2 Only in primary care did most sites have a structured programme of staff training on promoting continence. In nearly half of hospital sites, there was no such programme. In 37% of care homes the training did not include a basic assessment. Nearly all sites had access to a local continence specialist. With the exception of secondary care, the specialist was mainly based in the community. Practitioners carrying out the continence assessment were most likely to lack training in carrying out abdominal, rectal and pelvic examinations. Training levels were generally better in primary care. Generally, more continence specialists were employed in PCT rather than in Hospital service. 18

22 Table 9: Environment (101) HOSPITAL (173) HEALTH (30) HOMES (83) Your site Do the areas for both assessment AND treatment of patients with bladder and bowel problems preserve the patient s privacy and dignity? % N % N % N % N Yes No If Yes to Q1.4.1 which of the following facilities does this include (tick all the apply): Privacy around bed area (eg curtains) No Privacy around toilet area (eg curtains) No Easy access to toilet facilities No Privacy when staff speak to patient in No confidence Steps taken to reduce odour No Other Almost all sites indicated that their facilities for both assessment and treatment ensured the preservation of people s privacy and dignity. Even so, 32% of primary care sites did not take steps to reduce odour and 29% of hospitals did not have facilities to ensure privacy when staff spoke to patients in confidence. Regardless of whether the answer to Q1.4.1 was Yes or No, auditors were asked to state as free-text any areas of concern that they had. The majority of these concerns related to inadequate privacy provided by curtains on open wards or in bays and perceived inadequacy of available and appropriate toilet facilities. Table 10: User evaluation of the service HOSPITAL (173) (101) HEALTH (30) Are there means in the care setting by which service users/patients can make: HOMES (83) Your site % N % N % N % N Suggestions / /80 Yes Complaints / /81 Yes Is the bladder or bowel care delivered by the service subject to regular audit? Yes 71 68/ / / /69 Yes If Yes, does the audit assess patient s concern regarding privacy and dignity? Yes 71 42/ / / /41 No Does the continence service have a user group? Yes 27 24/ / / /50 Yes If Yes, is this group involved in service planning and delivery? Yes 83 20/ / / /12 No If Yes, is this group a support group? Yes 58 14/ / /3 42 5/12 Yes Does the continence service have a system in place for the review of any complaints made by the users/patients? Yes 97 93/ / / /59 Yes Almost all sites had the means for patients to make suggestions or complaints. As a measure of quality assurance, auditing of bladder or bowel care services in hospitals was not routine. However, when done, privacy and dignity was a frequent topic for audit. Only one quarter of all services had a user group. Where such a group existed, it was more likely to be involved in service planning and delivery than to be simply a support group. 19

23 Table 11: Continence products (101) HOSPITAL (173) HEALTH (30) HOMES (83) To which continence products do NHS patients have access? % N % N % N % N Bed pads Yes Body-worn pads of all absorbencies/sizes Yes All-in-one products Yes Disposable products Yes Reusable products No Other* No Does the written policy (ref 1.2.1) indicate that products are supplied on the basis of clinical and patient need rather than cost? Yes 90 64/ / / /67 No Are patients /carers views sought in selecting the range of products to be supplied? Yes 78 76/ / / /80 No Is there a policy for eliciting patient/carer views? Yes 44 40/ / / /70 Yes Do you have a limit on the type of products supplied per day? Yes 73 72/ / / /82 Yes Do you have a limit on the number of products supplied per day: Median (IQR) number, if stated N=67 sites N=23 sites N=1 site N=49 sites *Other included: continence appliances, sheaths, drainage devices, urinals, commodes, vaginal cones, anal plugs, home electrical stimulators Primary care patients had most access to the continence products listed, particularly all-in-one and reusable products. Where written policies existed, they generally indicated that products are supplied on the basis of need rather than cost. Hospitals were least likely to seek patients views about selecting products. A policy for eliciting patient/carer views on continence products was absent for three-quarters of hospitals and for about half of sites in the other sectors. Most primary care and care home sites had a daily limit on products supplied. For those sites with a daily limit on the number of products the median number was 4 products. Your Site Table 12: Patient/carer information & support HOSPITAL (173) (101) HEALTH (30) HOMES (83) Is evidence-based information about bladder and bowel care freely available to patients and carers? Your site % N % N % N % N Some areas 41 40/ / / /81 Some All areas 56 55/ / / / Does the facility utilise patient information literature e.g. from charities to promote continence? Yes 96 92/ / / /75 Yes Evidence-based information for patients and carers about bladder and bowel care was freely available to patients in all areas in just over half of primary care sites and care homes but only in 21% of hospitals and 14% of mental health sites. Evidence based information to promote continence was used by nearly all primary care sites, by about three quarters of hospitals and less than half of mental health sites and care homes. 20

24 CASEMIX AND PROCESS BLADDER PROBLEMS Data on patients/residents with urinary incontinence were returned by 107 general practices (2439 patients), 187 hospitals (4297), 30 mental health sites (512) and 96 care homes (1429). Table 13 Demographic Information (2439) NK=Not known Ethnicity was not documented in 30% of cases HOSPITALS (4297) HEALTH (512) HOMES (1429) The average age was: primary care 80 years, hospitals 82 years, mental health 79 years and care homes 85 years. In all the sectors, most were female and English speaking. YOUR SITE (27) Age Mean (SD) 80 (8) 82 (8) 79 (7) 85 (8) Mean: 81 Gender %Male (n) 26% (623) 38% (1613) 40% (205) 23% (322) 15 Ethnicity Documented % (n) 57% (1390) 85% (3638) 96% (492) 87% (1243) 100 Ethnicity (non-white inc mixed) % Yes (n) 7% (96/1390) 4% (150/3638) 5% (23/492) 3% (32/1243) 11 English speaking (excl NK) % Yes (n) 98% (1538/1576) 99% (3588/3638) 99% (443/446) 99% (1282/1290) 96 Table 14: Where cases obtained from HOSPITALS (2439) (4297) Indicate which records the data are returned from: HEALTH (512) HOMES (1429) Current resident of nursing home Past resident of nursing home Outpatients Current inpatient Past inpatient Community dweller Patient of host continence service Other* *Other: (not documented, not known, independent) 21

25 Table 15: Symptoms 1 (2439) HOSPITALS (4297) HEALTH (512) HOMES (1429) % N % N % N % PATIENT HAS:- Urinary frequency (>7voids/24h) Nocturnal frequency (>2voids/night) Nocturnal enuresis Urinary urgency Urge incontinence Stress urinary incontinence (urine YOUR SITE (27) loss with coughing, straining) Significant post void residual volume Voiding difficulty Permanent catheter Constipation Table 16: Symptoms (1) Main documented combinations (of urinary, urgency, urge and stress urinary incontinence): (2439) HOSPITALS (4297) HEALTH (512) HOMES (1429) Urinary frequency Urgency Urge UI SUI % N % N % N % N Y Y Y Y Y Y Y N Y Y N Y Y Y N N Y N Y Y Y N Y N Y N N Y Y N N N N Y Y Y N Y Y N N Y N Y N Y N N N N Y Y N N Y N N N N Y N N N N N to urinary, urgency, urge, SUI but combinations of other 6 symptoms N to all 10 listed symptoms The most common symptoms documented in: Primary care were urinary urgency (47%), urge incontinence (45%), urinary frequency (42%) and stress urinary incontinence (39%). Secondary care were urinary frequency (25%), nocturnal enuresis (25%) and nocturnal frequency (24%); Mental health were nocturnal enuresis (39%), nocturnal frequency (38%) and urinary frequency (30%). Care homes were nocturnal frequency (38%), nocturnal enuresis (35%) and urinary frequency (35%). Permanent catheters were present in 15% of hospital patients, 9% of care home residents, 4% of mental health patients and 3% of primary care patients. 22