Improving the patient experience of toileting and...

ThisprojectwassupportedbytheFoNSPracticeBasedDevelopmentandResearchProgrammeinpartnershipwiththeGeneralNursingCouncilforEnglandandWalesTrust

FoundationofNursingStudies

Improvingthepatientexperienceoftoiletingandmanagementofpost-operativeurinaryretentionfollowingelectivehipandkneereplacementsurgery:Anevidence-basedapproach FinalReport:October2016 Projectleads:JacquiPrietoandAlisonBarrow BackgroundThis2-yearprojectwasbasedontheelectiveorthopaedicwardatUniversityHospitalSouthamptonNHSFoundationTrust(UHSFT).Itaimedtoimprovethepatientexperienceoftoiletingandbladdercarefollowingelectivehipandkneereplacementsurgery.Urinaryretention(theinabilitytovoidinthepresenceofafullbladder)isafrequentanddistressingcomplicationforpatientsfollowinghipandkneereplacementsurgery(Iorioetal,2005).Itismanagedbyassessmentusingaportablebladderultrasoundscanner,supportwithtoiletingandwherenecessary,bladdercatheterisation.Theprojectproposalwasinformedbypreviousauditandresearchontheward.Anauditofbladdermanagementamongpatients(n=151)undergoingelectivehipandkneereplacementfoundconsiderablevariationinuseofindwellingurinarycatheters,delaysinrecognisingpost-operativeurinaryretentionandunnecessarilyprolongeduseofcatheters.Thisrevealedtheneedtoavoidunnecessarycatheterisation,improveassessmentusingthebladderscannerandremovecathetersmorepromptly.Qualitativeinterviewswith32patientsidentifiedtheirconcernsabouttoiletingandcatheterisation.Thetemporarychangesinbladderfunctionexperiencedfollowingsurgery,togetherwithincreaseddependencyintheimmediatepost-operativeperiod,werefoundtoimpactoncomfort,privacyanddignity.Thisrevealedtheneedtoenhancesupportwithtoiletingfollowinghipandkneereplacementsurgeryandpromotemorejudicioususeofurinarycatheters.AimandprojectgoalsThecentralaimofourFoNSimprovementprojectwastoimplementanevidence-basedapproachtopracticeinordertoimprovethepatientexperienceandachievethefollowinggoals:

• Goal1:Todevelopamorerobustapproachtoestablishingpatients’preferencesandinformationneedsregardingtoiletingoptionsandhavingacatheterinordertoprovideamoreresponsive,individualisedapproachtobladdermanagementpost-operatively.

• Goal2:Toconductatrialoftoiletingaids,includingafemaleurinal,aprototypeslipperpanandabsorbentgelgranulestopromotesuccessfultoileting.

• Goal3:Toimprovethetimelinessofbladdervolumemeasurementusingthebladderscannerintheimmediatepost-operativeperiod(within1hourfollowingreturntotheward)inordertointervenemorepromptlywhenapatienthasurinaryretention.

• Goal4:Toinsertaurinarycatheterwithoutdelaywhenapatientisunabletovoidspontaneouslyusingalternativetoiletingmethodsandhasabladdervolumegreaterthan500mls.

• Goal5:Toremoveshort-termindwellingcatheterswithin24hoursofsurgery.

Finalreport:October2016 Projectleads:JacquiPrietoandAlisonBarrow


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OverviewofprojectandtimeframeTheprojectcommencedinJune2014.Thecoreprojectteammetatregularintervalsthroughoutthetwo-yearperiodtoreviewprogresstowardsgoalsandagreeactions(seeAppendix1–Summaryofprojectmeetingsandprogress).Inyear1,thefocusforprojectworkcentredonthecarereceivedbypatientsonreturntothewardfromtheatrerecovery.Improvementinthetimelinessofbladdervolumemeasurementusingthebladderscanner(Goal3)wasachievedbymonitoringandprovidingfeedbackonthetimingofbladderscans(seeAppendix2).Thisledtothedevelopmentofanalgorithmtosupportdecision-makingbynursesaspartoftheirassessmentprocessforpost-operativeurinaryretention(seeAppendix3).Are-auditfoundimprovementsinthetimelinessofcatheterisationforurinaryretention(Goal4)togetherwithareductionintheirdwelltime(Goal5).

Aproducttrialoftoiletingaids,includingafemaleurinal,wasundertakentoevaluatetheoptionsavailabletopatientswithreducedmobilityintheimmediatepost-operativeperiodwhoareunabletogettothetoilet(Goal2).Therewasmixedsuccesswiththefemaleurinal,whichbenefittedsome,butnotallwomen(seeAppendix4).Theprojectteamhavemaintainedcontactwithmanufacturerstosupportfurtherproductdevelopments.Engagingpatientsinthetestingofproductsaffordedopportunitiesforthenursingteamtoengageinactivediscussionwithpatientsabouttheirtoiletingneedsandpreferences(Goal1).Theelectivenursepractitionerhasalsoincorporatedinformationaboutchangesinbladderfunction,cathetersandtoiletingaspartoftheeducationalsessionofferedtopatientspriortosurgery.InYear2,activeengagementoftheteamofnursesandtheatrepractitionersinthetheatrerecoverywardledtofurtherimprovementsinpost-operativebladdermanagement.BasedontheinitiativesinYear1,asuccessfulbidwasmadetothehospitalcharitytosupportthepurchaseofabladderscannerforuseintheatrerecovery.ThiswasinstalledinApril2015andfollowingtraininginitsuse,thetheatreteaminitiatedroutinescansforallnon-catheterisedpatientswithinanhourofhiporkneereplacementsurgery.Ourworkrelatingtopost-operativeurinaryretentionwasexpandedtoincorporateassessmentforacutekidneyinjury(AKI),whichisalsocommoninpatientsundergoingorthopaedicsurgery(Belletal,2015).TogetherwiththeTrust’sAKIWorkingGroup,were-designedtheoriginalalgorithmtobringtogetherallaspectsofbladderassessment(seeAppendix5).Theresultingpathwayisnowembeddedintopractice.InSeptember2015,twomembersoftheprojectteampresentedanoralpaperabouttheprojectattheRCNTraumaandOrthopaedicconference.Bothwerefirst-timepresentersatanationalconferenceandthepaperwaswell-received.InJanuaryandFebruary2016,educationalsessionswereheldintheTraumaandOrthopaedicUnitandTheatrestoshareprojectworkandlearningaboutbestpractice.Alleventswerewellattendedbyjuniorandseniorcliniciansrepresentingnursing,medicineandperi-operativepractice.Livelydiscussionstookplace,includingideasforfuturepracticedevelopments.InApril2016,workcommencedononesuchdevelopment,tointroducetheuseofintermittentcatheterisationasanalternativetoindwellingforthemanagementofpost-operativeurinaryretention.AlthoughtheFoNSprojectendedinMay2016,membersoftheprojectteamhavecontinuedtoworktogetherwithcolleaguesinotherpartsoftheTrusttodeveloptheresourcesrequiredtoimplementuseofintermittentcatheterisation.



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Successes

• Sept2014-Instigatedweighingscalesformeasuringurineoutputinbottles,bedpansandpads,leadingtoimproveduseoffluidbalancechartsonprojectward

• Oct2014-Introducedfemaleurinalasanalternativetobedpan• Feb2015-Successfulbidfornewbladderultrasoundscannerforrecoveryward• April2015-Improvedteamworkingbetweenrecoveryandpost-opwards• May2015-PresentationonFoNSprojectatUHSFTNurses’DayConference• June2015-ChangeofTrustpolicy,instigatedbyFoNSproject,toceaseuseofantimicrobialprophylaxis

forcatheterremoval,reducingdurationofcatheterisationfollowingorthopaedicsurgery• July2015-Increaseintheproportionofpatientsscannedwithin2hoursofsurgeryfrom10%to85%• July2015-Earlierdetectionandmanagementofpost-operativeurinaryretention:50%patientswho

developretentionarenowcatheterisedintherecoveryward,minimisingdiscomfortandriskofbladderover-distension

• July2015-10%increaseintheproportionofcathetersremovedwithin48hoursofsurgery,from58%to68%)

• Sept2015-OralpresentationofprojectworkatRCNT&Onationalconference2015• Jan-March2016-Successfuleducationalanddrop-ineventsonprojectworkheldintheatrerecovery

andT&OUnit• April2016-TeamedupwithUHSFTCatheterWorkingGrouptocollaborateonprojectworkto

implementuseofintermittentcatheterisation• May2016-AlisonBarrowreceivedRunner-upawardfor‘RegisteredNurseoftheYear’atTrust

InternationalNurses’Daycelebrations• July2016-Launchedpost-oppathwayforreducedurineoutputandurinaryretention

Challenges

• Staffingonthewardremainedachallengethroughoutthedurationoftheproject,withthewardrunningonahighpercentageofagencystaffandseveralchangesofwardleadership

• ReconfigurationofthewardswithintheT&OUnitledtotemporaryclosureoftheprojectwardandtransferofnursingteammemberstootherwards,leadingtocancellationofelectivecasesandaperiodoflowmorale

• ThebladderscannerwasoutofactionforseveralmonthswhileitwassentoffsiteforrepairValueoftheprogrammeandworkingwithFoNSTheopportunitytoparticipateinthisprogrammeandworktogetherwithFoNSprovidednotonlyfunding,butalsoawealthofguidanceandsupportonstrategiesforpracticedevelopment.MeetingtogetherwiththeFoNSPracticeDevelopmentFacilitatorsandalsootherprojectteamswashugelybeneficial,asithelpedustoconsiderdifferentideasandapproachestosupportingchangesinpractice.Ourprojectteamimplementedimprovementsusingstrategiesthatwemaynototherwisehaveconsideredandthesehadanimpactonpractice.Wewouldhighlyrecommendtheprogrammetootherteamsseekingtomakearealdifferencetoimprovingthequalityofpatientcare.Teamworkamongourclinicalcolleagueswasstrengthenedasaresultofthisexperience.



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Appendix1 SummaryofprojectmeetingsMeetingdate Focus Agreedactionsandprogressfollowingmeeting

June2014 Reviewedtheevidencefromanauditofpracticeandinterviewswithpatientstoidentifypreliminarygoalsforpracticedevelopment.

5projectgoalswereidentified(seePage1).MeetingswereheldonthewardinJuly2014toconsultthewidernursingteam,gainingtheirinputintorefiningthegoalsandagreeingactions.DatacollectioncommencedinAugust2014toestablishhowquicklypatientswereassessedusingthebladderscanneronreturntotheward.Over3months,performancefeedbackwasprovidedtostaffviaadesignatednoticeboard,includinga‘Scanneroftheweek’competition(seeAppendix2).

October2014 Revieweddataonbladderscanningtoestablishprogress.Reviewedpracticerelatingtomanagementofcathetersanduseofalternatives.Establishedplansforevaluationoftoiletingaids.

SignificantprogressmadeinachievingGoal2(timelybladderscanning).Thecompetitionprovedverypopularandresultedinimprovementsbothintherateandtimelinessofbladderscanassessments.Bothregisterednursesandhealthcareassistantshavetakenownershipofthisandroutinescanningallofnon-catheterisedpatientswithinthetargettimeof1houronreturntothewardisnowembeddedinpractice.Thekeybenefitforpatientsisearlydetectionandmanagementofpost-operativeurinaryretention.Aculturalchangehastakenplaceontheward,wherebystaffnowviewcathetersasoneofmanyoptionsratherthanroutinepractice.Staffawarenessofthelengthoftimeacatheterremainsinsituhasalsoimproved.Thishaspromptedappropriatelytimedremovals,withmostcathetersbeingremovedwithin24-48hoursofinsertion,therebyaidingthe recovery process and reducing the risk of infection. The nursingteam have become advocates for alternative methods of monitoringurineoutputandthetimelyremovalofcatheters.Theuseofmeasuringscales toweighurinehasalsosupportedthisandhelpedtoovercomedoctors’concernsabouttheaccuracyoffluidbalancemonitoring.Afterinitialtestingofalternativetoiletingaidsbyafewpatients,awiderevaluationofthe‘VernaFem’femaleurinalwasplanned,togetherwithimprovementsinthewardsluiceroomtofacilitatebetterstorageandaccesstotherangeofproducts.

Feb2015 Revieweddataontheevaluationof‘VernaFem’.Reviewedprovisionofpatientinformationduringpre-operativepreparation.

Areportoftheevaluationof‘VernaFem’wasproducedbyamemberoftheprojectteamandsharedwiththemanufacturer(seeAppendix4).Whilstaccesstoawiderrangeofproductshasincreasedtheoptionsavailabletopatients,suitabilityforuseofthe‘VernaFem’andtheabsorbentgelgranulesneedstobedeterminedonanindividualpatientbasis,asnotallpatientsfoundthembeneficial.Nonetheless,theseproductsofferanalternativewaytovoidwithlessdiscomfort,toensureacatheteristhelastoption.Theelectivenursepractitioner,whoisamemberoftheprojectteam,hasincorporatedinformationaboutchangesinbladderfunction,cathetersandtoiletingaspartoftheeducationalsessionofferedtopatientspriortosurgery.Theteamconsideredthedevelopmentofaninformationsheetorleaflettoaccompanythis,butthishasnotyetbeendeveloped.



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Meetingdate Focus Agreedactionsandprogressfollowingmeeting

Feb2015(cont)

Developedcasefornewbladderscannerandengagedtheatrerecoveryteaminprojectwork.

Owingtotheimpactoftimelybladderscanningontheward,acasewasputforwardtotheHospitalCharitytofundthepurchaseofanewbladderscannerforuseintheatrerecovery.ThiswassuccessfulandthenewscannerwasdeliveredinApril2015.Followingtraining,thetheatreteamcommenceduseofthescannerandbecameinvolvedintheprojectonamoreformalbasis.

June2015 Reviewedimpactofnewscannerintheatrerecoveryward.Reviewedalgorithm.

Thetheatrerecoveryteamhavebeenhighlyreceptivetouseofthenewscannerandareaimingtoscanallnon-catheterisedpatientswithinthefirsttwohoursfollowinghipandkneereplacementsurgery.Datacollectedonthefirst40patientsfoundthat1in4patientshadmorethan500mlsbladdervolumebytwohoursaftersurgery,requiringinterventionbeforetransfertotheward.Asaresultofthis,morecathetersareinsertedinrecovery,thereforepreventingthepatientsdiscomfortandtherisksassociatedwithretention.Fluidbalancedocumentationhasvastlyimprovedfromtherecoveryteamduringthetimeoftheproject.Thewardhandovershavealsoimprovedenablingthewardstafftobeclearonanyscansperformedinrecoveryandtimesincelastvoid.Theprojecthasaidedinbuildingtherelationshipbetweenthewardstaffandtherecoveryteam.Afterdiscussionswithaconsultanturologist,ananaesthetistandanephrologist,thealgorithmwasreviewedandexpandedtoincludeassessmentandmanagementofacutekidneyinjury(AKI)–seeAppendix5.

Sept2015 Advisedonchangesneededtonewelectronicobservationsystem.ConferencepresentationPlannededucationaleventsintheatresandT&Ounit.

Duringthecourseoftheproject,thewardwasselectedtotrialanewelectronicobservationsystem,foruseacrosstheTrust.Earlytestingprovedproblematicwhendocumentingfluidbalance,asitwasnotpossibletorecordscannedbladdervolume.Toaddressthisissue,theprojectteamandAKIteammetwiththesystemdeveloperstohighlighttheimportanceofclearrecordingofbladderscanresultsinordertoinformnursingintervention.Theprojectteamwereuniquelyplacedtoidentifythisproblem.Twoteammemberspresentedfindingsoftheprojectatanationalconference(RCNT&Oconference)inNottingham.Thiswasthefirsttimebothattendingaconferenceandpresenting.InordertodisseminateprojectfindingsacrosstheT&Ounitandintheatres,aseriesofeducationaleventsanddrop-insessionswasplannedforJanuary-March2016.Thisincorporatedthelaunchofthenewpost-operativepathwayforreducedurineoutputandurinaryretention.

Feb2016 Reviewedimpactofeducationalevents

A1-hoursessiononbestpracticeinbladdermanagementfollowingelectiveorthopaedicsurgerywasprovidedbytheprojectteamfortheatrenursesandpractitionersaspartoftheirmonthlyeducationalprogramme.Thiswaswellattendedandverywellreceived.



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Meetingdate Focus Agreedactionsandprogressfollowingmeeting

Feb2016(cont)

Reviewedimpactofeducationalevents(cont)Discussedplanstodevelopanapproachtoimplementingintermittentcatheterisation.LaunchofAKIprocessesandpaperwork

Twodrop-insessionstookplaceinJanuaryandFebruary2016intheT&Ounit.Bothsessionshadexcellentturnout(25staffpersession),includingorthopaedicsurgeons,FY1andFY2doctors,nurses,healthcareassistants,seniornursesandtheunitgeneralmanager.Thisenabledlivelydiscussionsaboutcurrentandfuturepractice,dispellingmythssuchasnurses’preferenceforuseofcathetersandinstigatingdebateaboutthepotentialuseofintermittentcatheterisationasanalternativetoindwellingformanagementofpost-operativeurinaryretention.Thelaunchofthenewpost-operativepathwayforreducedurineoutputandurinaryretentionwaswellreceived.Thepracticaldemonstrationsofintermittentcatheterisationdeliveredduringtodrop-insessionsgeneratedinterestaswellasconcernsaboutfeasibilityamongthenursingworkforceinT&O.Nursesandtheatrepractitionersinrecoverywardarekeentoimplementwithsupportandsothiswasagreedtobeagoodstartingpoint,aheadoftheward.Trainingresources,togetherwithguidanceondeterminingwhichpatientsaresuitableforintermittentcatheterisationisneeded.ThisprojectworkistobecontinuedbeyondtheFoNSproject,supportedbytheTrust’sCatheterWorkingGroup.ThecollaborativeworkwiththeTrust’sAKIGrouphasledtothedevelopmentofnewprocessesandpaperworktoassessandmanageAKIintheperi-operativeandpost-operativeperiodfollowingelectivehipandkneesurgery.ThispaperworkisduetobelaunchedinJuly2016followingpilotwork.Projectteammembershavebeeninstrumentalinthedevelopmentandtestingofthenewtoolsandwillbewellplacedtosupportimplementationandembeddinginpractice.



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Appendix2 Performancefeedbackonuseofthebladderscanner



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Appendix3 Algorithmtosupportbladdermanagement



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Appendix4 ‘VernaFem’Evaluation MelissaAllen,WardSister,F1Ward As part of our Bladder Care project on F1 we have been able to trial a new product from Vernacare, a female urinal the Vernafem. This is designed to help female patients pass urine without the need to life or roll for bedpans. It hopes to give independence to female patients in the way that males can with the use of a bottle. We were given full training on this product and this was cascaded down to the ward staff. It was initially met with excitement and felt it would help our female patients voiding urine and avoid catheterisation. We trialled the product for a month and feel we gave this a fair chance; we received 10 completed evaluation forms. We asked staff to fill out two evaluation forms and we were met with mixed responses from the results. Below is a table of the responses we gained from the evaluation forms.

1. Evaluationformone:

YES NO Do you believe the new VernaFem female urinal would help reduce the risk of healthcare associated infections?

8 2

Do you believe the new VernaFem female urinal would save time versus alternative methods?

6 4

Do you believe the new VernaFem female urinal would help to increase patient dignity?

5 5

Do you believe the new VernaFem urinal is a genuine alternative to your current toileting methods?

4 6

Is there any reason why you wouldn’t recommend the product? 5 5 Here are some of the additional comments we received:

• TheVernaFemurinalisnotstrongenoughforallshapesandsizesofpatients.• Mostpatientscanself-usethese.• Variesusagedependingonpatientsize.• Itseemstoleak.• Doesnotpreservepatientdignityasifleakstheythenneedhelptocleanupandchangesheets.• Somepatientsrequiregreaterassistancee.g.puttingtheminplace.• Toosmallforfirstpatientsvoidpost-surgery.• Itsuitssomepatientsandtheyfoundthemveryeasytouse.• Lackofcapacity.• Hardertouseonairmattresses.

After receiving these initial responses, we contacted Vernacare with our results and they suggested adding Gel Sachets into the VernaFem to soak up the urine and aim to decrease the amount of spills we were having and aim for a larger capacity. We also changed the evaluation forms. Below are the results of the second attempt of the product. We received eleven completed evaluation forms.



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2. Evaluationform2:

Hip Replacement Knee Replacement Other

What type of operation did the patient have? 6 4 1

20-29 30-39 40-49 50-59 60-69 70-79 80+ What was the age group of the patient? 1 0 2 2 1 4 1

Mild Moderate Severe

What was the patient’s pain score at the time of using VernaFem? 4 7 0

Able to reposition self? Assistance of 1 Assistance of 2 How mobile was the patient in bed? 3 7 1

In bed? Sitting on the edge of the bed? In the chair?

Where was the VernaFem used? 9 2 0

Easy to position?

Moderate repositioning required?

Difficult to reposition?

How easy was it to find a comfortable position for the patient to void using the VernaFem?

4 6 1

Approximately what volume did VernaFem contain? Various results from 5mls to 500mls

YES NO

Was there any spillage either during use or at removal of the product 8 On Removal

3

Patient Independent Support to hold in place?

When the product was in position, how much assistance was required?

8 3

Better Same Worse

How easy was the product compared to a bedpan? 4 4 3

Some additional comments we received were:

• Theyseemgoodcomparedtobedpansandareeasytohandle.• Greatproduct• Patientsfounditmorecomfortable.• Foundtherewasmoreincidenceofspillage.• TheGelwasgettingstucktothepatients• Mypatientfeltembarrassed.• Eventhoughinplaceproperlyitstillwentoverthesheets.• Hardworkandtrickytouse.• Wouldratheruseabedpanandnotusetheseagain.

After some careful consideration we have decided not to go ahead with the use of VernaFem as we felt it was not benefiting our patients. It is something that we may again consider in the future if the product was to change slightly. Our main reasons for not continuing with this product and, the lack of volume it holds and the spillage we have been getting.



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Appendix5 Post-operativepathwayforreducedurineoutputandurinaryretention



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Appendix6 ReferencesBellS,DekkerFW,VadivelooTetal.Riskofpostoperativeacutekidneyinjuryinpatientsundergoingorthopaedicsurgery–developmentandvalidationofariskscoreandeffectofacutekidneyinjuryonsurvival:observationalcohortstudy.BMJ2015;351:h5639.BjerregaardLS,BogoS,RaaschouSetal.Incidenceofandriskfactorsforpostoperativeurinaryretentioninfast-trackhipandkneearthroplasty.ActaOrthopaedica2015;86(2):183-188.HallebergNymanM,GustafssonM,Languis-EklofA,IsakssonA.Patients’experiencesofbladderemptyinginconnectionwithhipsurgery:anissuebutofvaryingimpact.JournalofAdvancedNursing2013;69(12):2686-2695.IorioR,WhangW,HealeyWLetal.Theutilityofbladdercatheterizationintotalhiparthroplasty.ClinicalOrthopaedicRelatedResearch2005;148-52.

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