Guidelines for undertaking a bladder scan for the purpose of identifying residual urine

SH CP 155 Guidelines for undertaking a bladder scan for the purpose of identifying residual urine Summary: Keywords (minimum of 5): (To assist policy search engine) Target Audience: These guidelines are to ensure the provision of evidence based practice, which will ensure that all patients who have a bladder scan have the best quality of care, minimising infection risk and other side effects and maximising quality of life. Bladder, bladder scan, residual urine, residual Employees of Southern Health Foundation Trust Next Review Date: February 2021 Approved & Ratified by: Patient Safety Group Date of meeting: 23 January 2018 Date issued: February 2018 Author: Sponsor: Alison Wileman, Continence Service Lead Julie Dawes, Chief Nurse 1

Version Control Change Record Date Author Version Page Reason for Change 07/09/15 Marion Houghton 14/09/17 Marion Houghton 23/1/18 Alison Wileman, Amanda Bennett 1 Review no changes required. Review date extended to January 2018 2 Throughout Updated the document 3 P6, section 4 Review and update wording P7, section 6 Cleaning probe, remove information on using glove over probe P7 Section 7 Maintenance information updated Reviewers/contributors Name Position Version Reviewed & Date Gina WinterBates Head of Specialist Pathways 22/11/13 Diane Stephenson Lead Clinical Nurse Specialist 30/01/14 Theresa Lewis Lead for Infection Control 30/01/14 Steve Coopey Practise Development Specialist Nurse 30/01/14 Susannah Elvy Continence Nurse Advisor 30/01/14 Sharon Guy Clinical trainer 22/11/13 Alison Wileman Continence Service Lead 23/1/18 Amanda Bennett Lead Clinical Nurse Specialist 23/1/18 Jacky Hunt Lead for Infection Control 23/1/18 Susannah Elvy Continence Nurse Advisor 23/1/18 Tracy Hammond Medical Devices Advisor 23/1/18 2

Contents 1. Supporting materials 4 2. Clinical indications for scanning of the bladder 4 3. Practical issues to consider bladder scanning 5 4. Procedure 6 5. Reporting 6 6. Infection Control 7 7. Maintenance programme: 7 8. Competency in scanning 7 9. References 9 Page Appendices A Levels of competency rating scale 10 B Bladder scanning clinical competencies 11 C Referral to Southern Health Continence Team form 13 D Equality Impact Assessment 15 3

Guidelines for undertaking a Bladder Scan for the purpose of identifying residual urine 1. Supporting materials These guidelines and competencies are to be used in conjunction with: 1) NICE Guidelines (2015) Urinary Incontinence: The management of urinary Incontinence in women. 2) NICE Guidelines (2012) Urinary Incontinence in neurological disease: Management of lower urinary tract dysfunction in neurological disease 3) Nursing & Midwifery Council (NMC) (2015) The Code: standards for conduct; performance and ethics for nurses and midwives. 4) Southern Health (2014) Hand Hygiene Procedure Version 3 5) Southern Health (2017) Standard Precautions Policy Procedure (Infection, Prevention and Control Policy Appendix 4) 6) Southern Health (2017) Competencies of catheter Insertion 2. Clinical indications for scanning of the bladder Clinical indications To determine: Urinary retention Bladder emptying To monitor: Onset of urinary retention following indwelling catheter removal To assist: Bladder retaining by determining the bladder volume Role of ultrasound Benefits to patients: Non-invasive procedure capable of avoiding intermittent catheterisation Benefits to patients: Minimise catheterisation of patients while preventing bladder distension and additional complications e.g. infection Facilitate a voiding schedule Bladder scans are undertaken to help professionals in their clinical judgement by providing information to assist in ongoing patient management. Scan results help to inform decisions about treatment options recommended for use by the patient. It is important that every nurse is accountable for his/her own competency and must take appropriate steps if they believe they are incompetent to undertake a specific procedure. 4

Advantages Non-invasive procedure Complements the findings and other investigations providing a more complete picture Reduce the necessity to refer patients to ultrasound department Simple monitoring of residuals bladder at set intervals Eliminate the need for urinary catheterisation to measure urine volumes Enhance patient care, Cost benefits and best use of resources Disadvantages Training of staff to undertake ultrasound scanning is required Patients may still need further investigations after scanning Maintenance of equipment must be considered False positive results can be shown 3. Practical issues to consider bladder scanning Assessment Calculation of the residual volume, the bladder must be as empty as possible. The patient should ideally void/ have voided no more than 30minutes prior to scanning. Ideally the patient should be in the supine position, although if necessary the scan can be carried out with the patient in the standing or sitting position. Risk Assessment Healthcare professionals may need to take particular care when scanning patients who have a pacemaker, those allergic to latex and helping patients on/off the couch. Patient s consent Patients should be approached for consent in all cases prior to performing a bladder scan in line with trust protocol. Chaperone Patients should be given an opportunity to decide whether or not they want a chaperone during an ultrasound examination. Explanation of the procedure Healthcare professionals must provide a full explanation of the procedure and its implications, whenever and at appropriate times. This will allow the patient to fully comply with the examination procedure, ensuring a satisfactory outcome. Reporting results If there is a residual of greater than 150mls, in accordance with best practise patient should return 4 weeks later for a repeat scan, stop any anticholinergics after first scan. (Inform prescriber) If there remains a residual at 4weeks, inform GP and referring health professional. Report all findings on RIO and in patients notes For further information see section 5. 5

4. Procedure Using the Ultrasound Bladder Scanner The Ultrasound bladder scanner should only be used by health professionals providing they have received the training by the company and the continence specialist team and are deemed and competent in the procedure. All practitioners using the bladder scanner should read the manual prior to using the scanner.( also some bladder scanners have the instructions written on the inside of the lid) The patient should be in a supine position, with the suprapubic area exposed clean hands, apply ultrasound transmission gel to the abdomen/probe Apply a small amount of gel on to the scan head to facilitate contact between the skin and scanner probe The scan head is then applied to the patient s abdomen just above the pubic bone. Activate scan by pushing appropriate button on scanner Hold the scan head steady to locate the bladder, the urine volume will then be displayed To maintain an accurate reading it is recommended to take 3 reading as volumes change Clean the scan head with clinell sanitizing wipes, clean hands and record all readings and scan to RIO. 5. Reporting Patient complains of incomplete emptying Report to GP/Doctor on ward 400mls scan 150mls Repeat scan in 4wks Stop anticholinergics if taking (Inform prescriber) <150ml >150ml Rescan 8wks, if all clear discharge. Refer to continence service Using referral form at Appendix A 6

6. Infection Control Clean the user s hands before and after every episode of patient contact. If scanner gel is on the user s hands they must be washed with soap and water. Do not use near broken skin. All scanning equipment must be cleaned between patients to prevent the possibility of cross contamination. Clinell sanitizing wipes must be used and all surfaces dried after use. For evidence of cleaning a record should be kept stating the probe & scanner has been cleaned before and after use. 7. Maintenance programme Bladder scanners must be commissioned and asset tagged before being put into use. A maintenance plan is in place for them to be serviced annually by BCAS Biomed. Service schedules and maintenance records are maintained by BCAS Biomed and can be requested as necessary. Contingency plans must be in place in the event of a scanner that is likely to be out of commission for any length of time (e.g. Servicing/ recalibration/unforeseen fault) 8. Competency in scanning Continuing professional development is a key to delivering highly effective healthcare and supporting clinical governance. Safe practice is facilitated by linking to a programme of training which provides basic skills leading to a competent practitioner. Bladder scanning training ran by the specialist continence service is recommended as a minimum training requirement The achievement and maintenance of competence is a continuous process which involves the integration of theory and learning with practice. Evidence based practice demonstrates the application of knowledge and skill in clinical practice and therefore the purpose of the competency assessment tool is to provide the documentary evidence that this is taking place for every member of clinical staff. To achieve this, the competency tool must be completed over an agreed period of time during which the nurse moves from a state of novice to competent practitioner. This includes gaining theoretical knowledge which is then applied and assessed in practice. The three stages of assessment are: Attendance at formal / initial training Assessment in practice Verification by line manager Attendance at formal / initial training The initial training which incorporates how to use the scanner and its care is under taken by the bladder scan company, once completed the theory training by a competent trained nurse who has already have completed both stages of training and completed the competencies must be completed. Assessment in practice Once initial theory training has been completed the process of developing competence in practice can commence. For newly acquired skills these should always be assessed by 7

another competent practitioner, or where specific expertise is required by a practitioner with an additional level of competence. The assessing practitioner must always be able to demonstrate competence to at least level 4 for the competency being assessed. Assessment in practice should take place once sufficient supervised practice and formative assessment has been undertaken. The assessor must be by a competent practitioner who is able to spend clinical time in direct observation of practice. The signing of the performance criteria should not be completed until the assessor is confident that the clinical skill can be consistently demonstrated to the required standard. Once all the performance criteria have been completed to the required level, then both the assessor and practitioner being assessed can complete the documentation stating that all elements of the competency have been completed and that the nurse can demonstrate competence for that specific clinical skill. Continuing Professional Development Where clinical competency has already been demonstrated previously and there is no need for either retraining or formal reassessment of competence, and then the competency tool can be used as a self- assessment tool. In this situation for example where annual updating or self-assessment is required the tool can be completed by the practitioner his/herself. The tool in this case can be used to help identify any training needs. It is the responsibility of the practitioner to ensure that self assessment of competency and evidence of updating is maintained You must recognise and work within the limits of your competence as stated by your professional body. The ability to maintain and developed expertise is dependent upon the continued practice and use of knowledge and skills You must take part in appropriate learning and practice activities that maintain and develop your competence and performance as stated by your professional body. Verification by line manager Once all the competencies in the competency framework have been completed the line manager will be responsible for the final overall verification. This can be at appraisal or on completion if sooner. Progress towards completion of the framework should be reviewed at agreed intervals with the line manager. Competency Rating Scale (level descriptors) (Table 1) This scale identifies the progression from novice (level1) to expert (level 6). It defines level 3 as the minimum standard for competence stated as Can perform this activity with understanding of theory and practice principles without assistance and/or direct supervision. All assessors must be practicing at this level or above to assess competence and ideally should hold a mentorship qualification. 8

9. References National Institute for Clinical Excellence (NICE), (2015) Urinary Incontinence: The management of urinary Incontinence in women. National Institute for Clinical Excellence (NICE) (2012) Urinary Incontinence in neurological disease: Management of lower urinary tract dysfunction in neurological disease Nursing & Midwifery Council (NMC) (2015) The Code: standards for conduct; performance and ethics for nurses and midwives.6o8 Southern Health (2014) Hand Hygiene Procedure Version 3 Southern Health (2017) Standard Precautions Policy Procedure (Infection, Prevention and Control Policy Appendix 4) Southern Health (2017) Competencies of Catheter Insertion 9

Appendix A: Levels of competency Rating Scale Novice Competent Practitioner Expert Level of achievement Cannot perform this activity satisfactorily to the level required in order to participate in the clinical environment Can perform this activity but not without constant supervision and assistance Can perform this activity with a basic understanding of theory and practice principles, but requires some supervision and assistance Can perform this activity with understanding of theory and practice principles without assistance and/or direct supervision Can perform this activity with understanding of theory and practice principles without assistance and/or direct supervision, at an appropriate pace and adhering to evidence based practice At this level competence will have been maintained for at least 6 months and/or is used frequently (2-3 times /week) The practitioner will demonstrate confidence and proficiency and show fluency and dexterity in practice This is the minimum level required to be able to assess practitioners as competent Can perform this activity with understanding of theory and practice principles without assistance and/or direct supervision, at an appropriate pace and adhering to evidence based practice. At this level the practitioner will be able to adapt knowledge and skill to special/ novel situations where there may be increased levels of complexity and/or risk Can perform this activity with understanding of theory and practice principles without assistance and/or direct supervision, at an appropriate pace and adhering to evidence based practice. Demonstrate initiative and adaptability to special problem situations, and can lead others in performing this activity At this level the practitioner is able to co-ordinate, lead and assess others who are assessing competence. Ideally they will have a teaching and /or mentor qualification Level 0 1 2 3 4 5 6 Adapted from: Herman GD, Kenyon RJ (1987) Competency-Based Vocational Education. A Case Study, Shaftsbury, FEU, Blackmore Press, cited in Fearon, M. (1998) Assessment and measurement of competence in practice, Nursing Standard 12(22), pp43-47. 10

Appendix B: Bladder scanning clinical competencies Name: Base: Role: Date initial training completed: Competency Statement: The purpose of these competencies is to demonstrate knowledge and skills expected of practitioners, to ensure safe practice in assessing an individual for residual urine using a portable scanner. Performance Criteria Assessment Method Level achieved Date Assessor/self assessed The Participant will be able to: 1. Demonstrate knowledge and skill in bladder scanning a) Identify the local protocol regarding bladder scanning Questioning b) Identify and describe own professional accountability Questioning c) State a condition when bladder scanning for residual urine may be required. Questioning d) 1. Describe the anatomy bladder Questioning/ discussion 2. Explain the physiology of the urinary system e) Demonstrate the procedure of bladder scanning Questioning/ observation f) 1) Discuss the implications of bladder scanning Questioning g) What is the appropriate action for the following: residual greater than 150mls Questioning/ reporting 11

Performance Criteria Assessment Method Level achieved Date Assessor/self assessed ii) Residual greater than 400mls. iii) no residual iv) patient unable to void h) Demonstrate in depth knowledge of how to use the ultrasound scanner safely, how to read the results and when/who to refer the patient to dependent on results i) An understanding of how to decontaminate the ultrasound scanner, recording cleaning and correct maintenance/servicing. Questioning/ observation Questioning / observation Date all elements of Competency Tool completed to level 3 Name Signature..Role..Date. I confirm that I have assessed/observed the above named individual and can verify that he/she demonstrates competency in Bladder scanning for post void residuals. Assessor Signature Role..Date. Review Dates: Competent Yes / No Nurse Signature Verifier signature Comments 12

Appendix C Continence Service Referral Form Surname Forename(s) Address: DOB: NHS NO GP Practice: Postcode: Tel No: Tel No: Key Code No: Name of Next of Kin: Relationship: Tel. No. Reason for Referral: Relevant Medical/Surgical History: Is the patient EOL? Yes Please refer to the CCT/ICT. See overleaf. No Is the patient palliative? Yes Please note patient will be seen within 28 days, see overleaf. No Is patient aware of referral? Yes No Unknown Does the patient require a: Clinic Appt Home Visit Yes (please detail): Are there any known risks when visiting the patient (pets etc)? No Referred by (Please Print): Job Title: Date: To be reviewed June 2018 Please email completed referral to: hp-tr.clinicaladmin@nhs.net 13

Referral Criteria for the Southern Health Continence Service Please be aware we are not an emergency service Days / Hours of operation: 9am - 5pm Monday to Friday excluding Bank Holidays. The Southern Health Continence Service will accept any patient 18 years and over with or without bladder/bowel incontinence, excluding:- End of life due to the patient having to wait up to 28 days for an appointment. If incontinence pads are required, if you have access to the product request form, complete and email to hp-tr.continenceservice@nhs.net.if you do not have access to the form please refer on to the ICT/CCT to complete. Catheterisation Excluding teaching of Clean Intermittent Self Catheterisation Bowel preparations such as suppositories and enemas. Those patients that require a clinic appointment under the Solent Bladder & Bowel Service should continue to be referred to Community Bladder and Bowel Service, Bitterne Health Centre, Commercial Street, Southampton SO18 6BT Snhs.bladderandbowelwest@nhs.net Patients registered with practices or surgeries of New Forest Central, New Milton Health Centre, Barton, Chawton House, The Arnewood and Wisteria & Milford. The Southern Health continence service is able to offer information and support to individuals who require advice regarding the promotion of continence, the management of incontinence; we offer joint visits for patients with complex bladder / bowel needs. On receipt of this referral the Southern Health Continence Service will scan this information onto RIO. It will then be triaged and allocated to the appropriate clinician within 5 working days, which maybe with Solent or Salisbury Bladder & Bowel Service (dependant on area). For Patients being seen by Southern health -clinic appointments- patients will be sent a letter inviting them to ring to make an appointment at one of the clinic locations within Southern Health; For home visits, patients will be sent an appointment letter. We aim to offer an appointment within 28 calendar days. Failure to respond in one month the patient will be discharged from the service and the referrer informed. All appropriate patients will be asked to complete a 3 day bladder / bowel diary and a questionnaire in relation to their bladder / bowel symptoms. 14

Appendix D: Equality Impact Assessment The Equality Analysis is a written record that demonstrates that you have shown due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations with respect to the characteristics protected by the Equality Act 2010. Stage 1: Screening Name of policy/procedure Guidelines for undertaking a bladder scan for the purpose of identifying residual urine Name and job title of person completing the assessment: Date of assessment: September 2017 Responsible department: Intended equality outcomes: Ricky Somal Head of Engagement These guidelines are to ensure the provision of evidence based practice, which will ensure that all patients who have a bladder scan have the best quality of care, minimising infection risk and other side effects and maximising quality of life. Promoting privacy and dignity at all times Who was involved in the consultation of this document? Please describe the positive and any potential negative impact of the policy on service users or staff. In the case of negative impact, please indicate any measures planned to mitigate against this by completing stage 2. Supporting Information can be found be following the link: www.legislation.gov.uk/ukpga/2010/15/contents Protected Characteristic Age Disability Gender reassignment Marriage & civil partnership Pregnancy & maternity Race Religion/Belief Sex Sexual orientation Impact Appropriate and risk assessments will be undertaken to deliver the requirements of this procedure in a safe, caring, effective, responsive, and well led manner. The Trust provides interpreting and translation services to aid communication for patients with a disability. Privacy, dignity and respect will be demonstrated to patients who are in the process of or are undergoing gender reassignment. Appropriate risk assessments will be undertaken to deliver the requirements of this procedure in a safe, caring, effective, responsive, and well led manner. No negative impacts identified at this stage of screening Appropriate and risk assessments will be undertaken to deliver the requirements of this procedure in a safe, caring, effective, responsive, and well led manner. The Trust provides interpreting and translation services to aid communication for patients whose first language is not English No negative impacts identified at this stage of screening No negative impacts identified at this stage of screening No negative impacts identified at this stage of screening Stage 2: Full impact assessment What is the impact? Mitigating actions Monitoring of actions 15