Have Confidence with Continence

Project completed as part of the 2023-4 Northampton General Hospital NHS Trust Green Team Competition.

Team members

• Holly Slyne - Assistant director infection prevention and control (IPC)
• Ros Pound - IPC Matron  
• Natalie Clews - IPC Clinical Nurse Specialist
• Elizabeth Lomax-Enfield - Falls prevention coordinator,
• Janet Jousiffe -Deputy falls prevention coordinator.
• Lystra Cunningham -Tissue viability specialist nurse,
• Jade Moss -Tissue viability specialist nurse,
• Sara Hollis -Tissue viability specialist nurse,
• With Recognition of support with great thanks to Continence product information support from procurement team, local company representatives of products used and trial assessment ward staff

Introduction:

The Falls Prevention, Infection Prevention and Control (IPC) and Tissue Viability Shared Decision-Making Council was created 6 years ago as a collaboration to work in a proactive way to make a sustainable change by protecting our patients from harm from falls, pressure ulcers and infections at the same time as there were commonalities of challenges.

One area in which our work commonly overlaps is in relation to continence care, with a focus on patient well-being and the prevention of complications. Clinical continence care generates a significant amount of waste and continence pads take 500 years to biodegrade, so we are keen to implement initiatives to reduce this waste and decarbonise care processes. 

Setting / patent group: two trial ward where continence care related issues were reported, focussing on patients over age of 65. some changes made Trust wide.

Issue:

Poor continence management can have significant implications, including an increased risk of sacral pressure ulcers due to improperly fitting products leading to leaks and prolonged exposure of the skin to urine or fecal matter. This exposure can compromise skin integrity, leading to various skin conditions and infections. Additionally, reliance on containment strategies such as pads for individuals who could otherwise walk to the toilet contributes to distress and loss of dignity, creating unnecessary work for staff. Moreover, poor continence management can lead to complications such as catheter-associated urinary tract infections (UTIs) and an increased risk of inpatient falls due to prolonged periods of inactivity, which can result in deconditioning. At NGH, there is a focus on individualized assessment and care to promote mobility, independence, and prevent falls, but there is a concern regarding the provision of poorly fitting or unnecessary continence products, which can further exacerbate these issues. Addressing these concerns through optimized continence care is crucial for patient well-being and reducing associated financial and environmental costs.

With engagement with staff who provide continence care, several problems were identified

• Lack of individualised continence assessment and documentation:
  • not all patients received a full assessment to ascertain their individual need as no care plan for continence was in place, only for incontinence and catheter care. 
  • continence care was mostly recorded on care rounding care plans, input /output charts and stool charts if required for that patient.
• Lack of awareness of wider impact of continence care:
  • not all staff were aware of connections to continence care and deconditioning, fatigue relating to admitting condition, comorbidities and length of stay, and how promoting continence can also promote functional physical activity. 
• Lack of staff confidence:
  • From the survey results, staff were not confident in measuring and selecting appropriate continence products.
  • Many staff requested further training. 
• Incorrect stock on wards:
  • wards did not have the correct / most appropriate items ordered or a correct range of items to make appropriate choices. Without the correct options, and with limited capacity, staff need to make do with what is available at the time. 
  • Wards did not have barrier creams on regular order process.
  • No appropriate items for “just in case” requirements. For example, staff commented that for a patient that wants a small pad just in case of urgency incontinence while they get used to the ward and where the toilet is had to be given a very large pad as there was no other options.
• Incorrect sizing of continence products
  • patients were being given inappropriate products, likely due to a combination of stock availability and staff confidence.

Intervention:

We aimed to

• reduce the number of continence aids used in 2 elderly medical wards in the Trust by 20% by January 2024
• increase the number of patients mobilising to the toilet in 2 elderly medical wards
• reduce the number of moisture associated skin damage, pressure ulcers and falls in 2 elderly medical wards
• reduce the number of urinary catheters in situ in 2 elderly medical wards, and further across the Trust
• increase staff knowledge on continence products
• increase the patient experience of being in hospital and maintaining continence

We implemented the following changes:

Confident Continence half day study day where company representatives provided training on the barrier creams, how to select the correct pad, how to measure a patient correctly for pants.  TVNs provided training on how to prevent moisture associated skin damage, IPC nurses provided training on catheter prevention strategies and the Falls Prevention Team provided training on mobilising patients out to the toilet safely.  

A guideline for catheter avoidance and appropriate selection of continence products was written by IPC Team and the IPC team conducted weekly catheter prevention ward rounds to teach staff, prompt removal and prevent catheter insertions. This also included teaching staff about the barrier creams and correct use of incontinence aids.  The Team decided to launch this Trustwide rather than on the 2 pilot wards as it was easier to implement and measure on a wider scale through the electronic VitalPAC system.

Changes planned / Next steps

Unfortunately, winter operational pressures and a delay in different sizing of continence products arriving to NGH had an impact on the pace of this project.  Therefore, the following changes are scheduled to take place in the coming months

• Provision of small pads and pants to trial wards
• an Out to Toilet training initiative  will commence in March.  This will involve a pop up video on the Trust Facebook page showing how to safely walk patients to the toilet and supportive visits from the FIT Team to wards to reinforce it and ensure staff are walking patients to the toilet.  Weekly data collection of number of patients mobilising will be collected.  The FIT team have recruited 2 new voluntary team members from the IPC Team who can support the pilot.  We will then trial for 2-3 months on the two trial wards before evaluating the impact and potentially expanding the pilot wider

Outcomes:

Clinical

• Reduced urosepsis related bloodstream infections caused by catheters (66% in Oct 2023 to 0% in Jan 2024.
• With further changes reduced risk in moisture associated skin damage, pressure ulcers, falls and deconditioning is anticipated.

Environmental

• 6,105 kgCO2e, equivalent to driving 18,029 miles from reduced catheter use.
• A 20% reduction in continence product use could save 2,260 kgCO2e from two wards (33,900 kgCO2e Trust wide)

Financial

• £12,579 saved annually from reduced catheter use Trust wide.
• A 20% reduction in continence product use could save £3,484 on two wards (£52,000 trust wide) per year.

Social

• Improved staff knowledge and confidence - staff commented they require more training in continence care prior to the project.
• Address staff concerns of environmental impact of care
• Improved patient dignity, comfort, confidence
• Improved experience for patients and families.

Key learning point

Through this project we have identified that optimal continence care encompasses a much wider range inter-related issues than first realised. Staff engagement from our Confidence Continence Day was key to success of this project.  Staff were very willing to attend and take part in surveys and conversations while being open about their knowledge and confidence.  We learned valuable information on why staff find it challenging to optimise their care, to best inform our changes.  Showing multiple benefits for patients, costs and the environment was supportive for motivating staff to change practice.