Continence

In hospital incontinence increases length of stay (1), in orthopaedic patients is associated with increased likelihood of discharge to an institutionalised setting (2) and can have a major negative impact, with many rating bowel and bladder incontinence as a health state the same or worse than death (3). Yet of the Geriatric Giants, it is given relatively little attention.

At a busy teaching hospital, we sought to raise awareness and improve management of incontinence across our 167 beds, by using a standardised, multi-disciplinary approach involving identification of patients and use of the components of BASICS (Bladder diary, A physical assessment, Symptom profile, Infection and Constipation check and a bladder Scan, figure 1).

Baseline data of a sample of 14 patients with new urinary incontinence with their aspects of continence assessment were added to a cumulative audit. Alongside checklists, a poster(figure 2) was designed and placed on each ward, a local teaching session about incontinence was delivered, and data shared at our local governance meetings. Following this, a further cycle of audit was performed. Reversible causes were identified and addressed appropriately. Between cycle 1 and 2 (February and June 2024), significant improvements were seen in most aspects of BASICS assessment with notable increases in use of the bladder diary (7 to 50%) and medical examination (7 to 57%). See figure 3 for breakdown.

As a consequence, there were multiple interventions aiming to improve patient symptoms. Paying consistent and sustained attention to this neglected area of practice has demonstrated a change of culture is possible. We are now incorporating continence assessment into our medical trainee audit programme to support a sustained multi- disciplinary approach and maintain improvements.

Background Constipation causes morbidity, delays discharge, and is treatable.

Aims Reduce constipation to minimise risk of sequelae.

Objectives 1. All patients to have a stool chart to a given standard

                    2. Improve doctors review and reaction to charts

Methods Weekly ‘snapshot’ of all ward patients on a geriatric ward in a large teaching hospital. Exclusion: gastrointestinal tract stomas.

All patients' computer notes were assessed to determine: presence of stool charts, level of quality, and whether action was required or had taken place. Days to laxative (from admission or last bowel opening) was calculated, and notes were checked to determine if rectal examination had been undertaken.

In the latest audit cycle drug charts were checked for compliance with prescribed laxatives.

Intervention Ward staff were encouraged to:

1. Write ‘0-No BO’ if pt has not opened bowels with staff

2. Use smart link to check if already documented

Doctors encouraged to:

1. Review charts and highlight non-completion to ward staff

2. Use smart link to import stool chart to note

Results: Stool charts were available for 92% and 85% of ward patients for the first two audit rounds pre-intervention. Of these 76% and 56% were of good quality. Following intervention 93% of ward patients had a stool chart, with 80% of these of good quality. After excluding charts not requiring action, 11 charts, 11 charts and 6 charts respectively were left that possibly required action.

There were between 0 and 4 days to laxative prescribing. No rectal examinations had been documented. In audit three laxative compliance was 37%.

Conclusions There is room for further improvement in chart quality and doctor action. In the future we will explore laxative compliance and consideration of rectal examination.

Drugs that have anti-cholinergic affects are known to have side effects such as urinary retention and constipation. In older people these drugs can also contribute to cognitive decline and loss of functional capacity leading to older patients being at risk of increased falls. Taking multiple medications with anti-cholinergic affects create a higher anti-cholinergic burden. Hilmer and Gnjidic (2022). Drugs that have anti-cholinergic affects block acetylcholine receptors (muscles do not receive neurotransmitter and therefore not functioning properly), Brown (2019). Some of these drugs are prescribed to have this effect but, in some patients’, this is an adverse effect. Although there are some drugs that are classed as anti-cholinergic drugs there are also drugs that have this effect which are not classed as anti-cholinergic such as anti-histamines, anti-depressants and anti-psychotics, Hilmer and Gnjidic (2022). This service improvement project will aim to introduce the anti-cholinergic burden scoring tool to a frailty unit for patients admitted with a fall with the aim of reducing the risk for patients who score highly being re admitted to hospital due to falls. Method This project will deliberate the development of change management using ADKAR (Awareness, Desire, Knowledge, Ability then Reinforce), Hiatt (2021) model of change management. By using this model, the author can prepare people for change, help people change and re-enforce the change allowing a successful service improvement. Results on completion of this project, the anti-cholinergic burden scoring tool will be successfully implemented onto the frailty unit and used by the medical team for patients admitted following a fall. By using ADKAR, Hiatt (2021) the author will be able to raise awareness, desire, build on knowledge and ability then reinforce the importance of reducing the risk of falls in older patients.

Introduction

Urinary incontinence significantly impacts the lives of older adults increasing their susceptibility to falls, social isolation and longterm care Intravesical Botulinum Toxin A (Botox) offers a well-established treatment for overactive bladders in women. In select centres, it can be administered under local anaesthetic, allowing access for frailer patients at higher risk from general anaesthetic and in whom anti-muscarinic therapies are best avoided. This project performed an analysis of geriatric patients who underwent intravesical Botox under local anaesthetic in an outpatient setting and assessed the tolerability and feasibility.

Method

50 women (mean age 66, range 34-88) with overactive bladders underwent Botox administration in 2023. The procedure utilised local anaesthesia (Instillagel) while patients held a supine position with abducted hips on an outpatient couch. A LiNA OperaScope and injeTAK® needle facilitated administration. A sub-analysis focused on patients aged 75+. Pain levels were compared to past cervical smear experiences for reference.

Results

All 50 patients successfully completed the procedure. 15 were aged 75+ (mean 80.8, range 76-88), with 8 classified as "frail" based on the Prisma 7 score (mean 2.3, range 0-5). The geriatric cohort reported lower average pain levels (1.8/10, range 1-3) compared to the non-geriatric group (2.2/10, range 1-5). Both groups pain perception was also lower than for past smears (2.9/10, range 1-4 vs. 3.4/10, range 1-7). Total ‘operative’ time was <3 minutes for all patients. Two non-geriatric participants experienced post-procedure UTIs, successfully treated with oral antibiotics (Clavien-Dindo II).

Conclusion

Intravesical Botox under local anaesthesia demonstrated promise as a safe and well-tolerated treatment for geriatric patients with overactive bladder, where lower levels of pain were reported compared to their younger counterparts. Tolerability was also better than previous smear tests and notably offers a relatable and novel comparison point to facilitate clearer counselling for patients and their families regarding this procedure.

Introduction

Effective bowel care is a key part of patient care which involves the accurate documentation of bowel movements. Older patients are at higher risk of delirium and increased length of stay if constipation and diarrhoea are not recognised. We aimed to identify the quality of bowel chart documentation comparing the use of paper and electronic bowel charts.

Methods

Data was collected on whether bowel charts were filled in at two timepoints over a two-day period. The first cycle in September 2020 using paper bowel charts and the second cycle in June 2023 using electronic bowel charts. All inpatients, on the geriatric wards were included unless they were on end-of-life care or had moved ward on the day of data collection.

The primary outcome was whether the bowel charts for both days were filled in fully. Secondary outcomes were whether the bowel charts were ‘easy to find’ and whether there was reference in the notes to the bowel chart. Data was analysed using a Mann-Whitney test.

Results

In the first cycle data was analysed on 129 inpatients, 4 were excluded and in the second cycle data was assessed on 128 inpatients, 16 were excluded.

Conclusion This quality improvement project shows how the introduction of electronic bowel charts has had a significant improvement in the charts being filled out and easy to find. 

Background:

This project was carried out in a district general hospital, it included multiple teams working under the supervision of the same clinical lead, between 2019 and 2021.

Introduction

Asymptomatic bacteriuria is commonplace among patients above 75 years of age (Manisha Juthani-Mehta MD, Volume 23, Issue 3, August 2007, Pages 585-594). Local guidelines informed by the Scottish Intercollegiate Guidelines Network on UTI management July 2012, therefore advise the importance of sending urine for culture only in cases, where minimum clinical diagnostic criteria are met.

Methodology

The initial baseline measurements was a retrospective study. It looked at 17 patients over the age of 65 years, who had admissions for urinary tract infections. During the 2^nd cycle, we designed a prospective study. It looked at all the patients considered to have a UTI in the first 72h of admission, during a 4-week period.

Results

The initial measurements showed that 53% of patients met the clinical diagnostic criteria. A teaching on the topic was organised for the medical team in the hospital and the learning points were disseminated further to senior ward staff. In the second cycle I found that 75% of the patients met the minimum clinical criteria for diagnosis. As a further intervention I designed warning cards containing a summary of local guidelines for diagnosis which were distributed across all medical inpatient wards.

Conclusion

Our QIP showed that in our trust even with initial intervention having been implemented, compliance with local guidelines was not 100%. Important discussion for the next cycle would be weather the local guidelines need to be updated as there have been recent updated in NICE guidelines for diagnosis of UTI’s in patients over 65 years of age.

Introduction:

Urinary incontinence, one of the original geriatric giants, is frequently overlooked despite its potential for reversibility and profound impact on older adults. The purpose of this audit was to evaluate the prevalence of continence and utilisation of incontinence wear among inpatients in a rehabilitation facility.

Methods:

Continence care quality in a medical gerontology ward was evaluated using the Royal College of Physicians (RCP) National Audit of Continence Care (NACC) standard. A prospective audit was conducted over a five-day period, documenting continence wear and urinary continence. Two interventions were implemented before re-auditing: incorporating continence as a teaching topic in the non-consultant hospital doctor (NCHD) teaching schedule and adapting the multi-disciplinary team (MDT) proforma to include patient-specific continence records. A snapshot re-audit was then conducted to assess any improvements resulting from these interventions.

Results:

The initial audit included 31 patients, with 26 (83.9%) wearing incontinence wear, of whom 21 (80.8%) opted for it voluntarily. Urinary incontinence was documented in 13 patients (41.9%).

In the re-audit, 40 patients were included, with 27 (67.5%) wearing incontinence wear, of whom 19 (70%) made the choice. Urinary incontinence was documented in 18 patients (45.7%).

Conclusion:

The re-audit revealed a slight decrease in incontinence wear usage (67.5% compared to the initial rate of 83.9%). Many patients wearing incontinence wear expressed a consistent preference for it in both audit cycles. The prevalence of urinary incontinence remained relatively consistent between the initial audit (41.9%) and the re-audit (45.7%).

The persistent prevalence of urinary incontinence calls for effective strategies to address this issue. Furthermore, the patients' preference for incontinence wear underscores the significance of engaging both the MDT and the patients themselves in future interventions. Future projects should focus on gaining a deeper understanding of patients' perspectives on continence care and evaluating the impact of incontinence on patient outcomes.

INTRODUCTION:

Constipation is common in older individuals and becomes prevalent in elderly inpatients. Those recovering from a hip fracture experience worsening constipation due to poor mobility, changes in diet and hydration, general anaesthesia and opioid use. This study explores the feasibility of the pelvic radiographs (PXR) already available in this population in assessing the severity of constipation in order to guide post-operative bowel management. AIM: To evaluate the effectiveness of diagnosis and management of constipation based on PXR findings of elderly patients presenting with hip fracture.

METHODS:

Retrospective analysis of consecutive patients aged 65 and above admitted with hip fracture to our hospital over a 5-week period. Patients without a PXR or experiencing severe complications were excluded. PXRs, medical records, drug charts and bowel charts were reviewed. Constipation was graded from 1+ to 3+ based on faeces in the sections of large bowel and rectum seen on PXR. A specific combination of oral and rectal laxatives was used based on such grading. The average time taken for the bowels to function was compared between patients with protocol-compliant management, minimally deviated management and non-compliant management.

RESULTS:

46 patients were included. Those with bowel management in line with our protocol (23) achieved bowel movement 1.7 days after surgery on average. By contrast, patients with minimal (9) and major deviations (14) from our protocol had a bowel movement respectively 3.6 and 4.2 days after surgery.

CONCLUSION:

These findings highlight the benefits of utilising admission PXRs in elderly patients with hip fracture to grade and manage constipation and, hence, reduce hospital stay and complications. Patients managed in line with our protocol experienced bowels functioning in less than 2 days, compared to over 4 days for patients with major deviations.

Introduction: Incontinence affects a significant proportion of older adults who reside in care homes. Incontinence symptoms have been linked to comorbidities, an increased risk of infection and reduced quality of life and mental wellbeing of residents. However, continence care provision can often be poor for residents, further compromising the health and wellbeing of this vulnerable population.

Method: A systematic qualitative evidence synthesis and thematic analysis established the current evidence-base of barriers and facilitators for the provision of continence care in care homes.

Results: The evidence synthesis revealed complex barriers and facilitators at three influencing levels: macro (structural, societal and external influences), meso (organisational and institutional influences) and micro (day-to-day actions of individuals impacting care provision). Macro-level barriers included negative stigmas relating to incontinence, aging and working in the older adult social care sector, restriction of continence care resources such as containment products (i.e. pads), short staffing in care facilities, shortfalls in the professional education and training of care home staff and the complex health and social care needs of older adult residents. Meso-level barriers included task-centred organisational cultures, ageist institutional perspectives regarding old age and incontinence, inadequate care home management and poor communication and teamwork among care staff. Micro-level barriers included both staff and residents’ poor knowledge of continence care and negative attitudes towards incontinence symptoms, management and treatment.

Conclusions: These findings help to outline the complexities of continence care provision in older adult care homes. Macro, meso and micro level influences demonstrate problematic and interrelated barriers across international contexts, indicating that improving continence care in this setting is extremely challenging due to the multiple levels at which care provision, services and individuals are impacted. Older adult social care policy-makers, researchers and service-providers must recognise this complexity in any intervention that aims to improve continence care in care homes.