Foundation of Nursing Studies

Transcription

1 Foundation of Nursing Studies Improving the patient experience of toileting and management of post-operative urinary retention following elective hip and knee replacement surgery: An evidence-based approach Final Report: October 2016 Background This 2-year project was based on the elective orthopaedic ward at University Hospital Southampton NHS Foundation Trust (UHSFT). It aimed to improve the patient experience of toileting and bladder care following elective hip and knee replacement surgery. Urinary retention (the inability to void in the presence of a full bladder) is a frequent and distressing complication for patients following hip and knee replacement surgery (Iorio et al, 2005). It is managed by assessment using a portable bladder ultrasound scanner, support with toileting and where necessary, bladder catheterisation. The project proposal was informed by previous audit and research on the ward. An audit of bladder management among patients (n=151) undergoing elective hip and knee replacement found considerable variation in use of indwelling urinary catheters, delays in recognising post-operative urinary retention and unnecessarily prolonged use of catheters. This revealed the need to avoid unnecessary catheterisation, improve assessment using the bladder scanner and remove catheters more promptly. Qualitative interviews with 32 patients identified their concerns about toileting and catheterisation. The temporary changes in bladder function experienced following surgery, together with increased dependency in the immediate postoperative period, were found to impact on comfort, privacy and dignity. This revealed the need to enhance support with toileting following hip and knee replacement surgery and promote more judicious use of urinary catheters. Aim and project goals The central aim of our FoNS improvement project was to implement an evidence-based approach to practice in order to improve the patient experience and achieve the following goals: Goal 1: To develop a more robust approach to establishing patients preferences and information needs regarding toileting options and having a catheter in order to provide a more responsive, individualised approach to bladder management post-operatively. Goal 2: To conduct a trial of toileting aids, including a female urinal, a prototype slipper pan and absorbent gel granules to promote successful toileting. Goal 3: To improve the timeliness of bladder volume measurement using the bladder scanner in the immediate post-operative period (within 1 hour following return to the ward) in order to intervene more promptly when a patient has urinary retention. Goal 4: To insert a urinary catheter without delay when a patient is unable to void spontaneously using alternative toileting methods and has a bladder volume greater than 500mls. Goal 5: To remove short-term indwelling catheters within 24 hours of surgery. partnership with the General Nursing Council for England and Wales Trust

2 Overview of project and timeframe The project commenced in June The core project team met at regular intervals throughout the two-year period to review progress towards goals and agree actions (see Appendix 1 Summary of project meetings and progress). In year 1, the focus for project work centred on the care received by patients on return to the ward from theatre recovery. Improvement in the timeliness of bladder volume measurement using the bladder scanner (Goal 3) was achieved by monitoring and providing feedback on the timing of bladder scans (see Appendix 2). This led to the development of an algorithm to support decision-making by nurses as part of their assessment process for post-operative urinary retention (see Appendix 3). A re-audit found improvements in the timeliness of catheterisation for urinary retention (Goal 4) together with a reduction in their dwell time (Goal 5). A product trial of toileting aids, including a female urinal, was undertaken to evaluate the options available to patients with reduced mobility in the immediate post-operative period who are unable to get to the toilet (Goal 2). There was mixed success with the female urinal, which benefitted some, but not all women (see Appendix 4). The project team have maintained contact with manufacturers to support further product developments. Engaging patients in the testing of products afforded opportunities for the nursing team to engage in active discussion with patients about their toileting needs and preferences (Goal 1). The elective nurse practitioner has also incorporated information about changes in bladder function, catheters and toileting as part of the educational session offered to patients prior to surgery. In Year 2, active engagement of the team of nurses and theatre practitioners in the theatre recovery ward led to further improvements in post-operative bladder management. Based on the initiatives in Year 1, a successful bid was made to the hospital charity to support the purchase of a bladder scanner for use in theatre recovery. This was installed in April 2015 and following training in its use, the theatre team initiated routine scans for all non-catheterised patients within an hour of hip or knee replacement surgery. Our work relating to post-operative urinary retention was expanded to incorporate assessment for acute kidney injury (AKI), which is also common in patients undergoing orthopaedic surgery (Bell et al, 2015). Together with the Trust s AKI Working Group, we re-designed the original algorithm to bring together all aspects of bladder assessment (see Appendix 5). The resulting pathway is now embedded into practice. In September 2015, two members of the project team presented an oral paper about the project at the RCN Trauma and Orthopaedic conference. Both were first-time presenters at a national conference and the paper was well-received. In January and February 2016, educational sessions were held in the Trauma and Orthopaedic Unit and Theatres to share project work and learning about best practice. All events were well attended by junior and senior clinicians representing nursing, medicine and peri-operative practice. Lively discussions took place, including ideas for future practice developments. In April 2016, work commenced on one such development, to introduce the use of intermittent catheterisation as an alternative to indwelling for the management of post-operative urinary retention. Although the FoNS project ended in May 2016, members of the project team have continued to work together with colleagues in other parts of the Trust to develop the resources required to implement use of intermittent catheterisation. 2

3 Successes Sept Instigated weighing scales for measuring urine output in bottles, bedpans and pads, leading to improved use of fluid balance charts on project ward Oct Introduced female urinal as an alternative to bedpan Feb Successful bid for new bladder ultrasound scanner for recovery ward April Improved team working between recovery and post-op wards May Presentation on FoNS project at UHSFT Nurses Day Conference June Change of Trust policy, instigated by FoNS project, to cease use of antimicrobial prophylaxis for catheter removal, reducing duration of catheterisation following orthopaedic surgery July Increase in the proportion of patients scanned within 2 hours of surgery from 10% to 85% July Earlier detection and management of post-operative urinary retention: 50% patients who develop retention are now catheterised in the recovery ward, minimising discomfort and risk of bladder over-distension July % increase in the proportion of catheters removed within 48 hours of surgery, from 58% to 68%) Sept Oral presentation of project work at RCN T&O national conference 2015 Jan-March Successful educational and drop-in events on project work held in theatre recovery and T&O Unit April Teamed up with UHSFT Catheter Working Group to collaborate on project work to implement use of intermittent catheterisation May Alison Barrow received Runner-up award for Registered Nurse of the Year at Trust International Nurses Day celebrations July Launched post-op pathway for reduced urine output and urinary retention Challenges Staffing on the ward remained a challenge throughout the duration of the project, with the ward running on a high percentage of agency staff and several changes of ward leadership Reconfiguration of the wards within the T&O Unit led to temporary closure of the project ward and transfer of nursing team members to other wards, leading to cancellation of elective cases and a period of low morale The bladder scanner was out of action for several months while it was sent off site for repair Value of the programme and working with FoNS The opportunity to participate in this programme and work together with FoNS provided not only funding, but also a wealth of guidance and support on strategies for practice development. Meeting together with the FoNS Practice Development Facilitators and also other project teams was hugely beneficial, as it helped us to consider different ideas and approaches to supporting changes in practice. Our project team implemented improvements using strategies that we may not otherwise have considered and these had an impact on practice. We would highly recommend the programme to other teams seeking to make a real difference to improving the quality of patient care. Teamwork among our clinical colleagues was strengthened as a result of this experience. 3

4 Appendix 1 Summary of project meetings Meeting date Focus Agreed actions and progress following meeting June 2014 October 2014 Feb 2015 Reviewed the evidence from an audit of practice and interviews with patients to identify preliminary goals for practice development. Reviewed data on bladder scanning to establish progress. Reviewed practice relating to management of catheters and use of alternatives. Established plans for evaluation of toileting aids. Reviewed data on the evaluation of VernaFem. Reviewed provision of patient information during pre-operative preparation. 5 project goals were identified (see Page 1). Meetings were held on the ward in July 2014 to consult the wider nursing team, gaining their input into refining the goals and agreeing actions. Data collection commenced in August 2014 to establish how quickly patients were assessed using the bladder scanner on return to the ward. Over 3 months, performance feedback was provided to staff via a designated notice board, including a Scanner of the week competition (see Appendix 2). Significant progress made in achieving Goal 2 (timely bladder scanning). The competition proved very popular and resulted in improvements both in the rate and timeliness of bladder scan assessments. Both registered nurses and healthcare assistants have taken ownership of this and routine scanning all of non-catheterised patients within the target time of 1 hour on return to the ward is now embedded in practice. The key benefit for patients is early detection and management of post-operative urinary retention. A cultural change has taken place on the ward, whereby staff now view catheters as one of many options rather than routine practice. Staff awareness of the length of time a catheter remains in situ has also improved. This has prompted appropriately timed removals, with most catheters being removed within hours of insertion, thereby aiding the recovery process and reducing the risk of infection. The nursing team have become advocates for alternative methods of monitoring urine output and the timely removal of catheters. The use of measuring scales to weigh urine has also supported this and helped to overcome doctors concerns about the accuracy of fluid balance monitoring. After initial testing of alternative toileting aids by a few patients, a wider evaluation of the VernaFem female urinal was planned, together with improvements in the ward sluice room to facilitate better storage and access to the range of products. A report of the evaluation of VernaFem was produced by a member of the project team and shared with the manufacturer (see Appendix 4). Whilst access to a wider range of products has increased the options available to patients, suitability for use of the VernaFem and the absorbent gel granules needs to be determined on an individual patient basis, as not all patients found them beneficial. Nonetheless, these products offer an alternative way to void with less discomfort, to ensure a catheter is the last option. The elective nurse practitioner, who is a member of the project team, has incorporated information about changes in bladder function, catheters and toileting as part of the educational session offered to patients prior to surgery. The team considered the development of an information sheet or leaflet to accompany this, but this has not yet been developed. 4

5 Meeting date Focus Agreed actions and progress following meeting Feb 2015 (cont) June 2015 Sept 2015 Feb 2016 Developed case for new bladder scanner and engaged theatre recovery team in project work. Reviewed impact of new scanner in theatre recovery ward. Reviewed algorithm. Advised on changes needed to new electronic observation system. Conference presentation Planned educational events in theatres and T&O unit. Reviewed impact of educational events Owing to the impact of timely bladder scanning on the ward, a case was put forward to the Hospital Charity to fund the purchase of a new bladder scanner for use in theatre recovery. This was successful and the new scanner was delivered in April Following training, the theatre team commenced use of the scanner and became involved in the project on a more formal basis. The theatre recovery team have been highly receptive to use of the new scanner and are aiming to scan all non-catheterised patients within the first two hours following hip and knee replacement surgery. Data collected on the first 40 patients found that 1 in 4 patients had more than 500mls bladder volume by two hours after surgery, requiring intervention before transfer to the ward. As a result of this, more catheters are inserted in recovery, therefore preventing the patients discomfort and the risks associated with retention. Fluid balance documentation has vastly improved from the recovery team during the time of the project. The ward handovers have also improved enabling the ward staff to be clear on any scans performed in recovery and time since last void. The project has aided in building the relationship between the ward staff and the recovery team. After discussions with a consultant urologist, an anaesthetist and a nephrologist, the algorithm was reviewed and expanded to include assessment and management of acute kidney injury (AKI) see Appendix 5. During the course of the project, the ward was selected to trial a new electronic observation system, for use across the Trust. Early testing proved problematic when documenting fluid balance, as it was not possible to record scanned bladder volume. To address this issue, the project team and AKI team met with the system developers to highlight the importance of clear recording of bladder scan results in order to inform nursing intervention. The project team were uniquely placed to identify this problem. Two team members presented findings of the project at a national conference (RCN T&O conference) in Nottingham. This was the first time both attending a conference and presenting. In order to disseminate project findings across the T&O unit and in theatres, a series of educational events and drop-in sessions was planned for January-March This incorporated the launch of the new post-operative pathway for reduced urine output and urinary retention. A 1-hour session on best practice in bladder management following elective orthopaedic surgery was provided by the project team for theatre nurses and practitioners as part of their monthly educational programme. This was well attended and very well received. 5

6 Meeting date Focus Agreed actions and progress following meeting Feb 2016 (cont) Reviewed impact of educational events (cont) Discussed plans to develop an approach to implementing intermittent catheterisation. Launch of AKI processes and paperwork Two drop-in sessions took place in January and February 2016 in the T&O unit. Both sessions had excellent turnout (25 staff per session), including orthopaedic surgeons, FY1 and FY2 doctors, nurses, healthcare assistants, senior nurses and the unit general manager. This enabled lively discussions about current and future practice, dispelling myths such as nurses preference for use of catheters and instigating debate about the potential use of intermittent catheterisation as an alternative to indwelling for management of post-operative urinary retention. The launch of the new post-operative pathway for reduced urine output and urinary retention was well received. The practical demonstrations of intermittent catheterisation delivered during to drop-in sessions generated interest as well as concerns about feasibility among the nursing workforce in T&O. Nurses and theatre practitioners in recovery ward are keen to implement with support and so this was agreed to be a good starting point, ahead of the ward. Training resources, together with guidance on determining which patients are suitable for intermittent catheterisation is needed. This project work is to be continued beyond the FoNS project, supported by the Trust s Catheter Working Group. The collaborative work with the Trust s AKI Group has led to the development of new processes and paperwork to assess and manage AKI in the peri-operative and post-operative period following elective hip and knee surgery. This paperwork is due to be launched in July 2016 following pilot work. Project team members have been instrumental in the development and testing of the new tools and will be well placed to support implementation and embedding in practice. 6

7 Final report: October 2016 Appendix 2 Performance feedback on use of the bladder scanner 7

8 Appendix 3 Algorithm to support bladder management 8

9 Appendix 4 VernaFem Evaluation Melissa Allen, Ward Sister, F1 Ward 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. Evaluation form one: YES NO Do you believe the new VernaFem female urinal would help 8 2 reduce the risk of healthcare associated infections? Do you believe the new VernaFem female urinal would save time 6 4 versus alternative methods? Do you believe the new VernaFem female urinal would help to 5 5 increase patient dignity? Do you believe the new VernaFem urinal is a genuine alternative 4 6 to your current toileting methods? Is there any reason why you wouldn t recommend the product? 5 5 Here are some of the additional comments we received: The VernaFem urinal is not strong enough for all shapes and sizes of patients. Most patients can self-use these. Varies usage depending on patient size. It seems to leak. Does not preserve patient dignity as if leaks they then need help to clean up and change sheets. Some patients require greater assistance e.g. putting them in place. Too small for first patients void post-surgery. It suits some patients and they found them very easy to use. Lack of capacity. Harder to use on air mattresses. 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. 9

10 2. Evaluation form 2: Hip Replacement Knee Replacement Other What type of operation did the patient have? What was the age group of the patient? Mild Moderate Severe What was the patient s pain score at the time of using VernaFem? Able to reposition self? Assistance of 1 Assistance of 2 How mobile was the patient in bed? In bed? Sitting on the edge of the bed? In the chair? Where was the VernaFem used? How easy was it to find a comfortable position for the patient to void using the VernaFem? Easy to Moderate repositioning Difficult to position? required? reposition? Approximately what volume did VernaFem contain? Various results from 5mls to 500mls YES Was there any spillage either during use or at removal of the product 8 On Removal NO 3 When the product was in position, how much assistance was required? Patient Independent Support to hold in place? 8 3 Better Same Worse How easy was the product compared to a bedpan? Some additional comments we received were: They seem good compared to bedpans and are easy to handle. Great product Patients found it more comfortable. Found there was more incidence of spillage. The Gel was getting stuck to the patients My patient felt embarrassed. Even though in place properly it still went over the sheets. Hard work and tricky to use. Would rather use a bedpan and not use these again. 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. 10

11 Final report: October 2016 Appendix 5 Post-operative pathway for reduced urine output and urinary retention 11

12 Appendix 6 References Bell S, Dekker FW, Vadiveloo T et al. Risk of postoperative acute kidney injury in patients undergoing orthopaedic surgery development and validation of a risk score and effect of acute kidney injury on survival: observational cohort study. BMJ 2015; 351: h5639. Bjerregaard LS, Bogo S, Raaschou S et al. Incidence of and risk factors for postoperative urinary retention in fast-track hip and knee arthroplasty. Acta Orthopaedica 2015; 86 (2): Halleberg Nyman M, Gustafsson M, Languis-Eklof A, Isaksson A. Patients experiences of bladder emptying in connection with hip surgery: an issue but of varying impact. Journal of Advanced Nursing 2013; 69 (12): Iorio R, Whang W, Healey WL et al. The utility of bladder catheterization in total hip arthroplasty. Clinical Orthopaedic Related Research 2005;