A Risk Management Approach to Continence Care Poststroke

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A Risk Management Approach to Continence Care
Post-stroke

• Denise Shanahan MSc BSc(Hons) RGN
• Stroke Care Coordinator
• Belinda Smith MSc BSc RGN
• Continence Advisor

Supported by Iechyd Morgannwg RD Consortium
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Background

• New specialist nurse post developed for stroke
  care in early 2003
• Continence high priority in previous role as
  manager regional stroke unit
• Contacted local continence nurse specialist for
  advise regarding in patient assessment and
  service provision
• Nothing suitable locally for complex needs of
  stroke patients as either
• specialist service driven
• focus on rationalising product provision
• too time consuming

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Inter-directorate working
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Identified problems

• Anecdotal
• only approach seemed to be crisis intervention
  for bladder bowel care
• increasing amount of nurse time spent mopping
  up incontinence
• lack of guidance for staff regarding assessment,
  investigation treatments
• seen as a low priority by multi-disciplinary team

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Identified problems (continued)

• Patients with stroke have complex needs
• Continence assessment is not clearly documented
• No suitable support tools for assessment or
  decision
• making which may lead to inconsistent care
  provision
• Continence care appears to be generally
  overlooked in
• discharge planning
• Lack of knowledge and application of evidence
  base to
• inform the initial nursing management of bladder
  and
• bowel care

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Initial exploratory work
Current tools

• Too complicated and time consuming
• Product or specialist services driven
• Not transferable to patients with complex needs
• Fail to address bladder and bowel equitably
• Lack of evidence-based guidance for generic,
• nurse-led follow-up interventions

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Project aim

• To develop and evaluate a continence risk
  assessment tool and accompanying bladder and
  bowel management protocols, based on current
  evidence, in the context of patients presenting
  with stroke.

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Action Research
Identify a problem
Implementation evaluation
Case note audit
Toolkit development
Literature review
Staff questionnaires interviews
Consider alternatives
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Quantifying the Problem

• Literature review
• Case note audit
• Nursing staff informal group interviews
• Discussions with medical, therapy and pharmacy
  staff
• Investigation of existing tools internal
  external

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Working documents

• National Clinical Guidelines for Stroke (2004)
• Good practice in continence services (2000)
• Fundamentals of Care (2003)
• NSF for Older People in Wales (2006)

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Best practice

• Service delivery should include
• pro-active questioning of patient groups at risk
• agreed care pathways
• adequately trained staff
• appropriate record keeping
• continence management plan for discharge

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Literature review

• Comparative studies FI (1985-2003)
• New onset FI post stroke ranged between 30 73
• Rarely found in the absence of urinary
  incontinence
• Late onset FI ranged between 4.5 -6
• Majority of late onset FI is potentially
  preventable as often secondary to constipation
  (Harari et al 2003)
• Anticholinergics were independently associated
  with late onset FI
• NSAIDS also associated

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Urinary incontinence in stroke patients
Comparative studies for UI (1985-2003)

• New onset urinary incontinence ranged from 40
  75
• Anticholinergics commonly used to treat UI
• Late onset ranged between 1 6
• Usually associated with further stroke and
  increased
• morbidity

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Faecal incontinence in stroke patients
Comparative studies FI (1985-2003)

• New onset faecal incontinence post stroke ranged
  
• between 30 73
• Rarely found in the absence of urinary
• incontinence
• Late onset ranged between 4.5 and 6

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Faecal incontinence (continued)

• Harari et al concluded that a significant number
  
• was potentially preventable as secondary to
• constipation
• Anticholinergics were independently associated
• with late onset FI
• The strongest independent risk factor for FI at
  3
• months post stroke was needing help to use the
  
• toilet

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Late Onset Faecal Incontinence

• Majority of late onset FI is potentially
  preventable as often secondary to constipation
  (Harari et al 2003)
• Anticholinergics were independently
  associated with late onset FI
• NSAIDS also associated with this phenomenon

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Incontinence in stroke patients

• Is not uncommon
• Is distressing for the patient and
• family
• Sometimes regarded as inevitable
• Patients are often dehydrated and
• malnourished
• Is a poor prognostic indicator

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Audit of Continence Care, Incidence and
Management Post Stroke

• 50 case notes examined retrospectively using two
  Fundamentals of Care practice indicators for
  continence (WAG, 2003)
• Practice indicator 11.1 Peoples need of
  assistance to get to or use the toilet
  are assessed
• Practice indicator 11.2 A person who has
  difficulty in controlling their
  bladder or bowel functions is offered an
  assessment by a professional health
  worker and a plan of care is agreed.

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Audit findings

• Documentation was generally poor particularly in
  support of some interventions
• Patients who may require assistance to use the
  toilet did not have their needs assessed and
  documented effectively
• Similarly patients with bladder and/or bowel
  function problems were not systematically
  assessed and the few plans of care that were in
  place were seldom evaluated  
• Polypharmacy was evident
• Significant deficits between identified problems
  and plans of care

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Gaining Perspective

• These findings represent nationally recognised
  problems rather than a problem restricted to the
  local organisation or stroke care
• Documentation, assessment and approach to bowel
  care and management can be significantly improved

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Questionnaires semi-structured group
discussions

• The nurses described how much of their time was
  spent dealing with incontinence..felt it was
  continual
• Little consideration given as to why patient is
  incontinent
• Vast amounts of time spent dealing with
  incontinence management

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More staff observations

• Consensus that no trigger questions were
  routinely asked relating to incontinence
  (especially pre existing symptoms)
• Nutrition and hydration was seen as the closest
  time investment compared with incontinence, but
  better planned (proactive)
• Positive attitude to risk assessment as an
  approach to informing nursing care.

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Identified learning needs

• Normal v abnormal (bladder bowel function)
• Criteria for catheterisation
• Risk factors in patients with complex needs
• Pelvic floor assessment
• Bladderscanner

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Finding a Solution

• Staff wish list generated from informal
  interviews regarding tool development
• systematic, multidisciplinary approach
• to include documentation guidance for
  assessment of bladder bowel, investigations,
  treatment protocols and evaluation
• to facilitate a pro-active approach to care
• quick and easy to use with minimum need for
  writing!!!

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Clinical Governance
Clinical Risk Management
Evidence Based Practice
QUALITY CARE
Audit Research
Life-long Learning (CPD)
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Template for Toolkit Development

• Clinical risk assessment tool to include timely
  review
• Risk specific nursing care plans, incorporating
  guidance for referral to Nurse Practitioner/Medica
  l team
• Algorithmic symptom-led pathfinder designed to
  facilitate appropriate investigation, establish
  diagnosis and determine treatments
• Treatment protocols specific to diagnosis
• Constipation
• Chronic constipation
• Faecal impaction

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Toolkit Process
Treatment monitoring
Risk Assessment
Implement care plans
Investigation diagnosis
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Models considered

• Traditional v Contemporary
• Continence Assessment tools/documents
• Integrated care pathway (ICP)
• Symptom/risk scoring

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Why Risk Management?

• A component of clinical governance model
• Facilitates a more preventative, proactive
  approach
• Ensures that all aspects of care are considered
  and addressed to minimise risk
• Improves documentation and supports staff to work
  systematically
• Considers patient safety regarding prescribed
  interventions

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Risk assessment

• The success of risk assessment as an approach to
  pressure sore prevention is well documented

• The use of risk assessment tools as an approach
  
• to continence care has been limited
• Post-natal urinary problems (Dandy 1999)
  
• Constipation prevention in in-patients
  (Zernike Henderson 1999)
• Preventing constipation
• (Richmond 2003)
• The Eton Scale
• (Kyle et al 2005)

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Acknowledging or Scoring Risk?

• Traditional scoring systems require the setting
  of predictive values thresholds to balance
  sensitivity specificity to accurately predict
  risk.
• Focusing on each risk factor in order to generate
  appropriate nursing actions meets the needs of
  patients, nurses and the organisation.
• The Shanith continence risk assessment tool
  indicates a tendency towards developing
  continence problems rather than predicting risk

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Promoting Patient Safety

• Primary interventions are embedded in health
  promotion - fluid, diet exercise/mobility.
• The continence risk management toolkit requires
  the investigation of symptoms leading to
  diagnosis and access to treatment monitoring
  protocols
• The use of effective oral laxatives, licensed
  for the treatment of faecal impaction and chronic
  constipation, allows for the reduction of
• - high risk rectal interventions
• - inappropriate and high risk oral treatments

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Risks associated with incontinence

• Reduced fluid intake
• Reduced dietary intake

• Compromised mobility
• Coordination dexterity

• Cognitive changes
• Communication problems

• Medication

• Pelvic floor trauma/ childbirth

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Care Planning

• The core care plans include
• care standard statement
• nursing actions required
• documentation and monitoring required
• guidance regarding referral to team members
  (including timescales)
• references relating to evidence base

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Assessment of Bowel Function

• Establishing pre-admission status enables
  reasonable comparison with bowel habits post
  admission informs diagnosis
• Monitoring is an essential component of assessing
  function early detection of changes in bowel
  habits
• Effective documentation empowers nurses in
  adopting a preventative approach to constipation
  faecal incontinence
• Awareness of risk factors also ensures
  appropriate care planning for the individual

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Send stool for C S
Loose stools
Frequency
Urgency
Faecal leakage
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Bowel Management

• A baseline assessment is essential
• Pre-admission bowel status must be established
• Monitoring bowel function ensures timely and
  appropriate detection of problems
• Acknowledging modifying risk factors can
  prevent problems arising

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Conclusions

• This approach has been received with enthusiasm
  by the multidisciplinary team, they see it as
  valuable in improving patient care
• The different components enable the selection of
  only what is required by the individual patient
  so reducing duplicity and the amount of
  paperwork!
• The Shanith Risk Assessment Tool can be used
  generically and has been positively evaluated
• The pathfinders and treatment/monitoring
  protocols require further longitudinal evaluation
  to gather meaningful data on outcomes for patients

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Project limitations

• Time constraints
• Lack of resources
• Current ongoing workload of both researchers
• Early success of risk assessment tool has
  detracted from the development of rest of toolkit

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Implications for nursing practice
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Dissemination of project

• RCN International Nursing Research Conference
  2004
• Association for Continence Advice International
  Conference (Awarded Best Free Poster) 2004
• South Wales Incontinence Group (SWIG) 2004
• Sheffield Stroke Nurses Conference 2004
• Bro Morgannwg Annual Nursing Conference 2004
• The Stroke Association 4th National Stroke
  Nursing Conference 2004
• RCN Congress (symposium) 2005
• Addenbrookes Hospital Stroke Unit 2005