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.

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.

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. 

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.

Introduction: Bowel health is affected in acutely admitted patients due to illness, change in diet, dehydration, and reduced mobility. Constipation is common and older patients are particularly at risk of constipation due to reduced bowel transit speed. Bowel motion monitoring can help improve bowel health and reduce complications including delirium, which can prolong hospital admission. To increase detection of constipation, a quality improvement project was carried out in the Department of Medicine for the Elderly at Southend Hospital, with aims to increase compliance of daily stool chart entries. Early detection will prompt patient review, investigation, and treatment of constipation, thereby managing symptoms and preventing complications. Methodology: Stool charts of patients across the geriatric wards were reviewed weekly for daily entries up to the last 7 days of their admission. Baseline compliance was determined on day 0 by dividing total days of stool chart entries over total days of admission (up to 7 days). Patients newly admitted or transferred to the ward on the day of stool chart review were excluded from the data. Interventions included verbal reminders to stakeholders (nurses, HCAs, doctors) at morning handovers, an electronic reminder with emails to stakeholders, and lastly a visual reminder with copies of a poster around the ward. The interventions were implemented separately on a weekly basis to quantify their effectiveness on compliance through further stool charts reviews on days 7, 14 and 21, and compared to baseline data. Results: Overall compliance increased by 16.9%, and the largest improvement was in response to the poster strategically placed next to all patient charts. Conclusion: The QIP was time and resource efficient, helping to identify constipation early and flag patients at risk for or for treatment of constipation. It is also easily repeatable and similar principles can be applied across other wards and specialties.