continence audit

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Age and Ageing The Author 2007. Published by Oxford University Press on behalf of the British Geriatrics Society.doi:10.1093/ageing/afm163 All rights reserved. For Permissions, please email: [email protected]

National audit of continence care for older

people: management of urinary incontinenceADRIAN WAGG

1, JONATHAN POTTER 2, PENNY PEEL

2, PENNY IRWIN2, DEREK LOWE

2, MICHAEL PEARSON2

1Geriatric Medicine, University College Hospital, 25 Grafton Way, London WC1E 6AU, UK 2Clinical Effectiveness and Evaluation Unit, Royal College of Physicians of London, London NW1 4LE, UK

Address correspondence to: Adrian Wagg. Tel: 0207 380 9910; Fax: 0207 380 9652. Email: [email protected]

Abstract

Introduction: the Department of Health report ‘Good practice in continence services’ highlights the need for proper

assessment and management of urinary incontinence. The National Service Framework for Older People required serviceproviders to establish integrated continence services by April 2004. A national audit was conducted to assess the quality of continence care for older people and whether these requirements have been met.Method: the audit studied incontinent individuals of 65 years and over. Each site returned data on organisational structureand the process of 20 patients’ care. Data were submitted via the internet, and all were anonymous.Results: thenationalauditwas conductedacross England,Walesand Northern Ireland. Data on thecare of patients/residents

with bladder problems were returned by 141/326 (43%) of primary care trusts (PCT), by 159/196 (81%) of secondary caretrusts (involving 198 hospitals) and by 29/309 (9%) of invited care homes. In all 58% of PCT, 48% of hospitals and 74% of care homes reported that integrated continence services existed in their area. Whilst basic provision of care appeared to bein place, the audit identified deficiencies in the organisation of services, and in the assessment and management of urinary incontinence in the elderly.Conclusion: the results of this audit indicate that the requirement for integrated continence services has not yet been met.

Assessment and care by professionals directly looking after the older person were often lacking. There is an urgent need tore-establish the fundamentals of continence care into the practice of medical and nursing staff and action needs to be taken

with regard to the establishment of truly integrated, quality services in this neglected area of practice.

Keywords: urinary incontinence, older people, audit, clinical effectiveness, elderly

Introduction

Urinary incontinence (UI) is associated with a range of medical conditions, many of which are common withincreasing age. UI affects some 20% of community dwelling older people and 30–60% of people in institutionalcare [1–4]. It remains an under-reported problem despitea significant impact on quality of life and associatedmorbidity [5, 6]. Many sufferers either do not present forcare, cope in silence or do not receive effective treatment fortheir condition [7, 8].

Caring for a person with UI has an equally negativeimpact on quality of life of the carer [9], and UI may often precipitate a move to institutional care [10]. The coststo both health and social care services of providing careare considerable [11] so, there is a great opportunity forimproving the lot of older people if UI can be betterassessed and managed. The Department of Health report

Good Practice in Continence Services (2000) recognised the

need for proper assessment and management, identified

a wide geographical variation in access to services and

called for regular audit [12]. The National Service Framework for

Older People (2001) required the establishment of integrated

continence services for older people by April 2004 but

allocated no resources to promote this objective [13]. Recent

evidence suggests that there has been only limited action

toward this end [14]

The Clinical Effectiveness and Evaluation Unit has

developed measures for defining the quality of continence

care and a comprehensive audit package to assess this across

primary, secondary and care homes [3, 15–17]. The aims of

this National audit were to describe the organisation and

processes of care for older people with continence problems

to describe variation in care and to produce data to enable

the comparison of care between organisations.

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A. Wagg et al .

Method

Audit tool development

Full details of the audit tool development have beenpublished elsewhere [18]. Patients’ views on the quality of services added patient-defined standards [19]. The resulting package was piloted and modified [20].

Patient inclusion and data retrieval

Data were returned on 20 patients aged 65 andabovewith UIas defined by the clinical record in each participating site. Inacute care hospitals, consecutive patients were identifiedfrom current inpatients. In primary care hospitals they came from the records of a single GP practice; data wereobtained from any practice records and computer systems.In care homes, residents were identified and data obtainedfrom the care home records.

Recruitment of sites

Theaudit included England,Wales, NorthernIreland and theChannel Islands. Primary care trusts (PCTs)/Local HealthBoards were identified and each was asked to identify one of their GP practices for the audit. Totally, 326 invitations weresent, of which 179 registered an interest to participate. Allacutecare National Health Service Trusts were identified andof 196 invited to participate 175 registered to do so. Majorcare home providers were invited with a target total of 100homes; 309 invitations were sent and 85 registered. Regional

workshops were held for training with the audit tool prior todata collection.

Data were submitted via the Internet to a secure website, and all were anonymous. Help buttons were provided

online alongside the questions and an extensive printed helpbooklet was also issued to participants. Each participating site was asked to use another auditor to independently audit their first five cases to conduct a reliability study (results not presented here).

Data were expressed in percentage and absolute termsand where data were not applicable the denominator wasadjusted accordingly. Missing data were regarded in thenegative. The input method guaranteed that missing datalevels (i.e. ‘blank’ entries) were very low (less than 1%).

Analyses were performed using SPSS v11.5.No ethical committee permission was sought for this

clinical effectiveness work which involved no intervention.Data transfer was in accordance with standards of practicelaid out by the Patient Information Advisory Group.

Results

In all, 138 primary care sites, 195 hospitals and 27 carehomes returned data, these included information on 2,717primary care, 3,683 hospital and 488 care home patients andresidents.

Organisation of care

Fifty eight percent of PCTs (79/137), 48% (94/195) of hospitals and 74% (20/27) of care homes (CHs) reportedthat integrated services existed in their area, but in only 67% (53) of PCTs, 53% (50) of hospitals and 50% (10)of CHs did that integrated service have a designated leadclinician. Seventy-five percent of PCTs, 90% of hospitalsand 100% of CHs had a policy of routinely asking patientsabout bladder problems, but fewer of them guaranteed anassessment should a problem be found. Of the hospitalbased services only 32% had a written policy for managing continence, 49% had a structured training programme and35% performed regular audit.

Specialist assessments were performed by staff trained tocarry out abdominal, vaginal and rectal examinations in only 54% of cases. The number of specialist continence advisorsis summarised in Table 1.

Where a written policy for continence care existed,services reported that products were supplied on the basis

of clinical need rather than cost in 88% (71/81) of PCTs,76% (48/63) of hospitals and 86% (19/22) of CHs. In 84%(108/128) of PCTs, 53% (86/163) of hospitals and 76%(19/25) of CH patients’ views were sought in selecting therange of products supplied. Despite this there was evidenceof rationing in both PCT (104/129) sites and CH (19/25)sites, this practice being less common in hospitals (39/166sites). The median number of products supplied per patient per day in each sector was four.

Patients surveyed

Patients/residents were older in hospitals (mean 82, SD8 years) and in CHs (mean 86, SD 8 years) than in PCTs(mean 80, SD 8 years). The majority of the sample for whichdata were available had significant levels of cognitive and

functional impairment (Figure 1). Seven percent (196) of PCT patients, 2% (61) of hospital patients and 2% (99)of CH residents had no reported associated co-morbidity.

The distribution of continence-associated co-morbidities isshown in Table 2.

Process of care

A continence history was documented in 73% (1984/2,717)of PCT patients, 70% (344/488) of CH and 45%

Table 1. Numbers of continence advisors available to sites

Number of WTE

con tinence specialist Primary Seco ndary Ca re

available care care homes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .From the PCT 121 sites 109 sites 13 sites

Median 1.8 1.6 1.0

Interquartile range 1.0 –2.7 1.0 –3.0 0.6 –6.0

From the hospital 80 sites 134 sites 8 sites

Median 0 0.6 1.0

Interquartile range 0– 1 0– 1.0 0– 2.8

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Audit of continence care for older people

0

10

20

30

40

50

60

70

80

Yes Mild Moderate Severe Yes Mild Moderate Severe

Cogniti ve impai rment Functional impai rment

%

Primary care

Secondary Care

Care Homes

Figure 1. Proportion of cognitive and functional impairment by care setting.

Table 2. Distribution of co-morbidity

Primary Secondary Care

care (2,717) care (3,682) homes (488)

(%, N ) (%, N ) (%, N ). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Bladder cancer/stones 1 34 2 60 2 11

Chronic cough 7 196 4 153 5 22

Dementia 14 375 31 1,125 41 199

Depression 11 296 11 394 17 81

Diabetes 16 431 15 564 9 45

Faecal loading or chronic constipation 4 118 8 307 13 62

Heart failure 14 365 16 597 20 99

Hypertension 30 814 29 1,074 17 82

Impaired mobility 26 710 48 1,767 66 324

Neurological disease 7 193 14 504 12 57

Obesity 8 219 3 121 7 36

Pelvic radiotherapy 0.8 23 0.4 15 0 0

Pelvic surgery 12 322 4 159 2 9

Prolapse 8 217 3 98 1 7

Prostate disease or surgery 9 252 8 293 5 24

Recurrent falls 6 157 22 792 22 108

Spinal cord disease/trauma 3 79 2 69 2 12

Smoking 5 126 5 195 2 9

Stroke 12 325 30 1,106 28 137

Trauma at childbirth 2 44 0.4 13 0 0

Urinary tract infection 19 502 26 974 20 100

Other∗ 31 836 29 1,060 29 140

No documentation of any including ‘other’ 7 196 2 61 2 9

∗ Other included nocturnal polyuria ‘incontinence’, ‘loss of control’, renal cancer.

(1,651/3,682) of hospital patients. The most common

lower urinary tract symptoms documented were: in

PCTs— urgency (43%, 1,158/2,717), urgency inconti-

nence (42%, 1,143/2,717) and stress incontinence (40%,

1,094/2,717); in hospitals—urinary frequency (22%,

806/3,682), nocturnal frequency (22%, 799/3,682) and noc-

turnal enuresis (21%, 774/3,682); and in CHs—nocturnalenuresis (43%, 211/488), nocturnal frequency (33%,162/488) and urinary frequency (32%, 156/488). Perma-

nent catheters were present in 17% (618/3,682) of hospital

patients, 13% (62/488) of CH residents and 3% (87/2,717)of PCT patients. Among 2,176 PCT patients with doc-

umentation of symptoms, 36% (788) had a diagnosis of

stress incontinence (SUI), 42% (904) had urgency inconti-

nence (UUI) and 19% (404) had mixed urinary incontinence

(MUI). Among 1,746 secondary care patients with documen-tation 18% (314) had a diagnosis of UUI, 12% (204) had SUI

and 8% (132) had MUI.

Details of assessment and management of UI are shown

in Table 3.It was found that 89% (435) of CH residents had a

documented care plan, compared with 51% (1,398) of PCT

and 41% (1,513) of hospital patients. In all 94% (1,416) of

hospital patients and 82% (356) of care home residents hadbeenreviewedwithin the last6 months, though longer review

times were evident in PCT patients. Where appropriate

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A. Wagg et al .

Table 3. Assessment and care

Primary Secondary Care

care (2, 717) car e ( 3,68 2) h omes ( 488). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ASSESSMENT % N % N % N Documented evidence of:

Rectal examination 10 272 24 902 9 43

Urinalysis 72 1,969 73 2,672 65 317

Use of a bladder diary 32 779/2,466 16 441/2,725 34 115/341

Evidence that medication that may exacerbate urinary incontinence has

been reviewed/altered to minimise impact

33 739/2,222 23 623/2,703 29 100/339

Specialist examination performed (YES) 37 997 52 1,897 20 100

Documented evidence of:

Examination of abdomen for palpable mass or bladder retention 60 600 92 1,748 77 77

Examination of perineum and pelvis to identify prolapse and excoriation,

and to assess pelvic floor contraction and urogenital atrophy

52 520 22 412 44 44

Rectal examination to exclude faecal loading/prostate size 25 246 36 680 25 25

Measurement of post-void residual volume (PVR) using ultrasound or

catheterisation

25 641/2,608 22 735/3,403 20 90/448

C lea r id enti fic at ion of t he t ype/ca use of uri na ry i nc onti nence 63 1,670/2,633 25 919/3,609 40 166/418

Specific treatment plan 68 1,835 45 1,670 82 400

TREATMENT (used or planned)

Advice on general health 33 907 9 338 25 122 Advice on lifestyle 18 477 4 133 16 79

Behaviour modification 5 146 4 147 6 29

Bladder training regimens 16 429 8 279 16 80

Containment 48 1,294 56 2,070 63 307

Electrical stimulation 0.6 16 0.3 11 0 0

Management of faecal impaction 2 61 6 229 16 79

Oestrogen treatment 3 76 0.8 28 0.4 2

Pelvic floor training 22 596 3 120 3 15

Pharmacological interventions 23 634 12 446 14 68

Surgery 5 149 3 101 1 5

Toileting schedules 12 320 16 583 60 291

Treatment of co-morbidities 5 148 14 527 10 48

Treatment of urinary tract infection 16 426 24 868 22 105

Other 10 274 8 295 6 28

None of above documented including ‘other’ 12 317 19 687 6 29

46% (1,112/2,443) of PCT patients, 21% (528/2,508) of hospital patients and 41% (122/299) of CH residents hada documented discussion about the cause and treatment of their incontinence.

Discussion

This is the largest and widest study of continence care inthe United Kingdom and provides a picture that reflects thecurrent state of services and care in primary and hospitalcare. Given the different considerations which affect thethree different settings, the level of engagement with thisfirst round of national audit was encouraging.

Hospitals

Most hospitals were able to complete the audit and animpressive 81% returned good data. Cases were identifiedby audit departments and clinical staff with an interest incontinencecare. Casesshouldhave beenconsecutive,but thismay not have been as rigidly applied as intended. Some sitesreported difficulty in accessing records and may thereforehave submitted a small sample of patients that was not

truly representative of their normal case mix. The samplein hospitals was, for the most part, drawn from inpatientsunder thecare of geriatricians— this introduces some bias, to

what extent fitter, although incontinent, older people might populate other wards is not known, but our results shouldbe viewed in this light. Nevertheless, the data are likely to begenerally representative of care in this sector.

Primary care

Primary care participation was good; this may reflect thebudgetary importance of continence and the fact that Continence Advisors were the professional group most motivated to carry out the audit. However, only one practiceper PCT was nominated to take part and it may not be

possible for the results to be generalised across the wholearea. A high proportion of primary care sites returned data via their continence services and thus these results may therefore not represent the experience of the ‘average’ GPpatient. Using the GP record as a source for patient notesproved difficult as there was often no mention of continencestatus; linking these records to those held by district nursing,

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Audit of continence care for older people

product supply databases or continence service records wasthen necessary, but again difficult.

Care homes

It was particularly difficult to recruit care homes, and thosethat were recruited had difficulties with data collection. Thishighlighted the challenge of carrying out audit in settings

where resources, staffing and culturedo notroutinely support it. A lack of access to a single central set of records, limitedinformation technology and staff shortage was often cited asa contributing difficulty. Many homes noted that continencestatus was assessed prior to admission and that the roleof care home staff was to enact a management plan ratherthan repeat the assessment process. It is also likely that only enthusiasticcare homes took part andthus theability to draw conclusions regarding care in that sector is severely limited.

The reported organisation of services suggests a goodbasic provision of care, particularly within primary care.Sectors ranged from 48 to 74% in reporting access to anintegratedservice but many had missing elements,suggesting that the perception of integration was optimistic and varieddepending upon the perspective of the reporting site. Thelack of a designated lead in most services is a specific barrierto development and quality improvement. The ultimate goalcontained in the NSF for Older People has not been met.

In general

The reported availability of specialist continence advisorsrepresents approximately one continence advisor per 40,000population over 65 years or about 8,400 men and women

withUI. This seemstoo fewpersonnelto provide anadequateservice for so many, particularly given the variable remit of existingadvisors, themajorityof whomwill coverbladderand

bowel care for the entire population. Department of Healthguidance unfortunately makes no firm recommendation onstaffing levels upon which to base these figures.

All settings reported a very high level of regard for privacy anddignityin relationto continence care.Thisis a particularly important observation given the sensitivities of bladder andbowel management and the importance given to privacy anddignity in the NSF follow-up document ‘A new ambition forold age’ [21]. There is concern that the impression of careproviders may not be shared by olderpeople themselves [22].

There may be institutionalised ‘blindness’ to deficiencies andan acceptance of a level of privacy and dignity, which might not meet the true wishes of older people.

These real-life, cross-sectional data illustrate the realnature of UI in the elderly in terms of medical co-morbidity;

cognitive and functional impairment. The audited samplerevealed a high distribution of functional and cognitiveimpairment, the ‘fittest’ patients being in the primary caregroup as might be expected. The small number of patients

with available AMTS or Barthel scores was not reported inour results, which therefore underestimate the true level of associated functional or cognitive impairment.

Most sectors claimed to ask routinely about bladderproblems but unfortunately, in many sites, elicitation of a positive response to the question did not guarantee anassessment of the problem and audit of the process of care

gave further cause for concern. A history was seldom takenin hospital, suggesting that continence is not a priority inacute care. A bladder diary, an essential component of theassessment, was seldom used in primary care, where onemight expect its uptake to be high. Likewise, a review of medication was seldom performed. Although recommendedas part of the specialist assessment, a rectal examination isinfrequently done.Very few people underwentan assessment of post-micturition residual urine as part of their evaluation.

Although there are no published data which support theroutine performance of this procedure in women, it is wellestablished that in men thepresence or absence of symptomsdo not predict finding of a significant residual, requiring thispart of the examination.

Importantly, a clear cause of incontinence was docu-

mented in only 25–63% of cases. Without a known cause,evidence-based, effective treatment could not be provided.Given the reported levels of training in assessment

and management across all sites, there appears to be adisparity between education, training and practice. This isnot uncommon, but does not serve patients well.

Management plans where they existed, alltoo often,reliedon containment. There was also ample evidence of rationing of continence products despite ‘free pads’ being availableto those in care homes. This is consistent with previous

work which suggests that the NHS provides only a thirdof the pad requirement associated with UI [23]. Patients

within the hospitals appeared to have unfettered access topads and products, perhaps reflecting the different budgetary pressures but encouraging indiscriminate usage.

Theremayhavebeenmarkeddifferencesinhowapatient’s

incontinence was managed in practice and that which wasdocumented. It is unlikely however, that key elements of theexamination areroutinely notdocumented and thus theaudit is likely to reflect actual practice in these areas.

This audit demonstrates that the requirement for inte-grated continence services contained within the NationalService Framework for Older People has not yet been met.

Action stillneedsto be takenwith regardto theestablishment of truly integrated, quality services in this neglected area of practice. Many services appeared to be reliant upon the input from specialist continence advisors at the expense of basicassessment and care undertaken by clinical staff. Regardlessof the organisation of care, these data illustrated an urgent need to re-establish the fundamentals of continence care

within the daily practice of medical and nursing staff looking

after patients. The cost of continence care is high, whether measuredin health care or financial terms. Services which deliverhigh quality evidence-based care should be able to manageand thus reduce the associated morbidity and ensure that financial costs are based on cost-effective decisions. If specialist continence services are to cater to the needs of

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A. Wagg et al .

all people with continence problems then there is a largeresource problem, particularly in the lightof current financialpressure which has resulted in a withdrawal of continencecare in some areas of the country.

Key points• Assessment and management of older people is under-

assessed and under-treated.• There is an over-reliance on containment as the sole

source of management of the condition.• The rectal examination is seldom undertaken as part of

the assessment of urinary incontinence.• There is a great opportunity to improve the treatment and

lot of older people with bladder problems.

Conflicts of interest

None

Acknowledgements

To the Continence Working Party, for their support andguidance

To all those nationally who gave time and energy insubmitting data to the audit.

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2007

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