Continence

Background: Prostate cancer and bladder outlet obstruction, often treated surgically, are increasing in the aging population, leading to more cases of stress urinary incontinence (SUI). While implantable continence devices are beneficial for many, a growing number of frail patients are unsuitable for surgery and rely on incontinence pads or penile clamps, which are limited to three-hour use to prevent tissue ischaemia. We present the first UK evaluation of the new PaceyCuff penile clamp, designed for 24-hour wear while maintaining blood flow, to assess its efficacy, safety, and impact on patient quality of life.

Methodology: Men with urodynamically-proven SUI were identified. Baseline penile and finger peripheral oxygen saturation (SpO2), three-hour pad weight, 24-hour pad count and patient-reported outcomes (ICIQ-UI, QoL) were measured. Participants were then fitted with the PaceyCuff, and reassessed immediately, at three hours post-application and (via telephone) after two weeks.

Results: 13 men (average age 74, range 62-82) were recruited. ICIQ-UI scores decreased from 17 to 10, and QoL scores from 13 to 9. Average three-hour pad weight dropped from 94g to 10g and daily pad usage decreased from 4 to 0.9 pads. Participants reported good tolerance, with an average pain score of 1.8/10 and only 2 minor adverse effects (skin abrasion, transient pain). Penile SpO2 remained stable before, immediately after, and three hours post-use (76%, 82%, and 81% respectively). Sub-group analysis of patients over the age of 80 (n=4) confirmed equal effectiveness. (ICIQ-UI decreased 18 to 10, QoL decreased 13 to 9, three-hour pad weight decreased 77g to 9g, daily pad usage decreased 4 to 1.5 pads, average pain 1.5/10).

Conclusions: The PaceyCuff has demonstrated both efficacy and tolerability in managing SUI in a UK cohort for the first time and offers a potential treatment option for elderly patients ineligible for surgical intervention.

Background:  

Urine retention is a common reason for catheterization in elderly patients in hospitals. Early focus on regular bowel movements, and bladder or prostate issues can facilitate timely TWOC planning. Inaccurate or incomplete documentation leads to unnecessarily prolonged catheter use, and extended hospital stays. Identified problems were –1: Fragmented documentation across different Portals.2: Dual Documentation Systems- paper and digital 3: Lack of documentation at Admission.4: Delayed TWOC planning.

Aims:

1. Standardization of Documentation: Transition to using the NerveCentre(digital) catheter bundle as the primary documentation portal. 2. Improvement in TWOC Planning: Ensure TWOC planning is initiated early, well before the patient reaches MFFD status.

Method:

1. Survey: The project begins with a survey of HCOP staff. Their feedback reflects the challenges of current practices.

2. Standard documentation instruction, teaching sessions, involvement of frailty in reach team at ED, posters at admission units, awareness of nurse in charge, discussion at board meetings and within hospitals internal communication groups.

3. Data collection of 25 patients before and after intervention.

Results:   documentation in Nervecentre & paper improved. Accuracy improved from 60% to 100% and 32 % to 80%, respectively. An increase in TWOCs conducted before MFFD was observed, indicating progress toward earlier TWOC planning. The number of failed TWOCs slightly increased in Phase Two, but these were well-documented, and no patient experienced multiple failures. The delay of the first attempt of TWOC after 7 days also reduced from 44% to 24%.

Conclusion- Overall, the intervention addresses the issues of streamlining documentation and improving TWOC planning.

Introduction

Lakeside unit at the University Hospital of Wales is a rehabilitation and complex discharge planning facility for elderly patients. Recognising the importance of good sleep in rehabilitation, our quality improvement project aimed to assess the feasibility and evaluate the impact of introducing decaffeinated coffee and tea as alternatives to the standard caffeinated options routinely provided to patients. Caffeine is a diuretic and stimulant that disrupts sleep and increases urinary frequency, urgency, and volume. Reducing caffeine can reduce falls related to toileting. Addressing nocturia should be considered in the design of comprehensive fall prevention programs for older adults.

METHODOLOGY

We educated staff and patients about the benefits of decaffeinated drinks through informational sessions and ensured a variety of decaffeinated beverages were available to patients after 5 PM. Over two weeks, our study implemented a controlled intervention, with Week 1 as the baseline control phase. During this period, we assessed falls, frequency of nocturnal toilet visits, and sleep quality. In Week 2, we introduced decaffeinated coffee and tea after 5 PM and continued to monitor the same metrics. Most patients chose decaffeinated drinks when offered.

RESULTS

Data from 202 patient nights in the control week and 240 patient nights in the intervention week were reviewed.

- Sleep:

  - Control: 78% good(157), 22% bad(45)

  - Intervention: 85% good(203), 15% bad(37)

- Falls:

  - Control: 1 fall(0.083 per night per patient)

  - Intervention: 2 falls(0.133 per night per patient)

- Toileting:

  - Control: 0.87 trips per patient per night

  - Intervention: 1.27 trips per patient per night

CONCLUSION

Our small feasibility study noted some improvement in sleep quality, with no significant difference in toileting needs and falls per patient per night. The acceptability of decaffeinated drinks was high. Larger and longer studies are needed to further examine the effects of decaffeinated drinks

Introduction and Background- Bowel obstruction poses a considerable medical dilemma, demanding swift identification and intervention due to its propensity for severe complications. This challenge is exacerbated in elderly individuals who may be frail and less amenable to surgical interventions. Alvimopan, a peripherally acting μ-opioid receptor antagonist renowned for its pro-kinetic effects on the bowel, has shown promise in clinical trials. Nevertheless, despite its efficacy, it remains underutilised in many clinical hospital settings. Thus, our systemic review aims to underscore the potential benefits of Alvimopan, reintroducing its significance in managing bowel obstruction, particularly in elderly patients.

Methods- Four databases were searched to identify relevant studies investigating the use of Alvimopan for treating ileus. Included studies measured time for first bowel motion, and was compared with controls. Animal and non-original research articles were excluded.

Results- Ten randomised controlled trials (RCTs) were incorporated, each showcasing the significant reduction in both time to initial bowel movement and hospital stay attributed to Alvimopan. Findings indicated that Alvimopan can decrease the duration until the first bowel movement by an average of 14 hours compared to placebo, as well as abbreviate the time until discharge by an average of six hours.

Conclusion- Consistently, Alvimopan has demonstrated favourable results for patients experiencing bowel obstruction. Its utilisation could potentially circumvent the necessity for laparotomy in frail patients. Moreover, employing this medication contributes to shorter hospital stays, thus potentially mitigating associated complications. Consequently, we strongly advocate for its use and advocate for additional research to incorporate it into clinical guidelines.

Introduction

The ongoing rise in prostate cancer rates and consequent prostatectomy have led to an increase in rates of male stress urinary incontinence. ATOMS is an adjustable sling requiring no manual input and suitable for frailer patients. We investigated the long term efficacy of the ATOMs in managing SUI and performed a subanalysis within the geriatric population (aged 75+).

Method

69 men (mean: 70.2, range 50-81) underwent an ATOMS insertion between 2015-2019. Follow up data for up to 9 years were analysed (mean: 5.8, range 5-9 years). Out of the 69 men in the original cohort, 19 were aged 75+ (mean: 76.5, range: 75-81). 17 had SUI post radical prostatectomy, 1 post TURP and 1 post AP resection.

Results

Out of the 19 men, 14 (74%) were dry post ATOMs implant insertion (ie using maximum one pad per day for reassurance). This rate is lower compared with the original cohort (79.7%). The average number of top ups to achieve dryness was 3 (same as the initial cohort). Out of the 14 men who remained incontinent in the initial cohort, 5 were 75+. Of these, 2 reported a significant improvement in their incontinence without meeting the ‘dry’ criteria. 1 had his ATOMs device removed due to infection. 1 was switched to an artificial urinary sphincter. 1 remains incontinent and is being managed with botox injections. There were no cases of mechanical failure.

Conclusions

ATOMS appears to be an efficacious and safe procedure in the geriatric population, with only marginal difference in dry rates compared to the non-geriatric cohort. The main benefit over an artificial sphincter is that it exerts a passive effect to prevent incontinence and requires no patient input for every void. This is especially prudent as geriatric patients may lose hand dexterity or cognitive ability over time.

Catheter-associated urinary tract infections (CAUTIs) represent a large proportion of nosocomial infections. Hence, catheters should be inserted only when indicated and plans should be made to remove them as soon as possible. This will reduce the incidence of CAUTIs, lead to a better patient experience and reduce overall NHS burden. The aim of this audit is to identify whether the catheter care bundle is being filled as per NICE guidance.
This is a prospective audit involving 50 patients from the geriatrics ward who were catheterised from November to December 2021. We analysed the documentation of the rationale of catheterisation, whether regular reviews of the need for catheterisation were done and the quality of documentation on removal of catheter.
The audit showed that only 9 out of 50 patients had daily reviews done and documented. The decision to remove catheter in 40% of the patients with successful removal of catheter was only done on an average 1 to 3 days prior to discharge. 40% of the sample size was treated for CAUTI. A prolonged length of catheterisation was identified in majority of these patients, when in fact trial without catheter could have been attempted much earlier if there was a robust system to ensure daily reviews for the need for catheter are performed.
The results of this audit were presented in a departmental meeting and staff training on catheter care was held. A recommendation was made to the local Continence Working Group to modify the catheter care bundle to improve adherence.

Introduction

A suspected urinary tract infection (UTI) is the most common reason to prescribe antibiotics in a frail older patient. Therefore, correct recognition and documentation of UTIs, as well prescribing of antibiotics, is important for optimising patient care.

Methods

We reviewed UTI antibiotic prescribing practice across the Health and Ageing Unit (HAU) wards at Kings College Hospital over a two-month period. Weekly data we collected from all patients commenced on antibiotics for a suspected UTI highlighted key areas for improvement. We designed and delivered a multifaceted educational intervention to all healthcare professionals caring for older adults across the HAU. This consisted of teaching sessions, distribution of posters, and board round reminders.

Results

A further two months of data post-intervention showed improvements in several outcomes. Correct prescribing rose from 61% to 93%. The number of prescriptions with stop dates went up from 50% to 68%. The number of patients with urine samples processed in the laboratory rose from 64% to 93%. We also saw an improvement in the management of patients with catheter associated UTIs.

Conclusions

A multidisciplinary team intervention of teaching and visual cues improved the management of UTIs. This shows the power of multifaceted educational interventions for improving the care of older adults.

Around 40% elderly patients need urinary catheters during hospital stay.

Most common indications are acute urinary retention(due to constipation), AKI and sepsis. According to NHS and trust guidelines, the review should be performed by the medical team to establish whether catheter is still required,when to remove and plan following TWOC of the catheter during every ward round. For example if catheter was inserted due to acute retention due to constipation,catheter should be removed after adequate bowel movement.The aim of audit was to gauge whether elderly patients with catheter are managed with standard guidelines or not.

Retrospective data was collected using quisionnaire(5 questions? documented indication of the catheter,?plan when to TWOC during every ward round,?documented plan after failed TWOC,? Patient is medicaly stable with catheter,?medically stable patient had catheter-associated UTI) , looking into 80 patient records admitted on geriatric wards from 15/4/23 to 16/5/23.

The result after data collection from 80 admitted patient with catheter revealed that 78% patients had documented indication of catheterization,24% patients had review of catheter and TWOC plan everyday.3%patients had documented management plan following failed TWOC,33% medically stable platients had catheter with no documented plan when to remove catheter,14% medically stable patients were treated for catheter associated UTI.In summery,the initial stage of audit revealed that the catheter management standard was not met as there is discrepancies beetween guidelines and clinical practise.The audit has shown the need for standardization of urinary catheter management in admitted elderly patients.Therefore,audit report was presented during geatric doctors meeting ,education and teaching was provided to improve standard of care.The audit will be repeated after 3 months following implimentation of requested changes(catheter management guideline flowchart printed on doctors room, including catheter management guideline flowchart during doctors induction,regular teaching and re audit).

 Introduction: Indwelling urinary catheters (IUC) are well-known to cause serious adverse outcomes in older adults; such as catheter associated urinary tract infections (CAUTI), direct trauma, delirium, deconditioning, falls, restrain, prolonged length of stay etc. (Lee E., Malatt C, 2011). Removal of IUCs as soon as the indication is resolved, results in better outcomes (Dawson et al, 2017). We identified high rates of inappropriate catheterisations as a regular practice or part of sepsis protocol in our hospital. This QIP was designed to compare our practice against the standards set by NICE and Royal College of Nursing.

Methods: Two PDSA cycles of 30 patients each, were completed between 2021-2022 (4 months apart), in Acute Frailty Unit and two Elderly Care wards. New IUCs in patients above 65 years were included. Data were collected on, documentation of IUCs, indications, plans for Trial without catheters (TWOC), appropriate management plans and CAUTI. Interventions post first PDSA cycle were; organised teaching to the nurses and doctors, discussing catheters at by-daily board rounds (BR), displaying flowcharts and reviewing IUCs during ward rounds.

Results: Documentation of IUCs improved significantly from 17/30 to 24/30. There was a small reduction in inappropriate indications from 16/30 to 12/30. Documentation of TWOC plans improved from 4/30 to 11/30. Collection of urine samples for CAUTI’s improved from 11 to 18. Our interventions were shown to produce positive outcomes.

Conclusion: Despite continuous education and BR discussions, there’s still room for improvement. Better understanding of catheter associated harm by frailty teams resulted in positive outcomes. Next steps prior to the 3rd PDSA cycle include educating Emergency and medical teams through wider teaching platforms and integrating changes to hospital electronic systems on appropriate documentation and TWOC plans. Our study would be applicable in similar settings nationally and globally to achieve better catheter care in older adults.