Knowledge Translation in continence care: clinical audit as an instrument of

change

Adrian WaggProfessor of Healthy Ageing

Division of Geriatric Medicine

Moving evidence into practice:

• “Good practice in continence services” • National Service Framework for Older People• NICE guidelines

• Urinary incontinence in women• Faecal incontinence• Lower urinary tract symptoms in men (May 2010)

• International Consultation on Incontinence

Clinical Audit

• National Audit of Continence Care for Older People– Structure (organisational factors)– Process (care for older people with UI and FI– 2005 and 2006– Web based – excellent data quality– First National Audit to reach out from acute

hospitals• Primary care• Acute care hospitals• Care homes• Mental health care (2006)

Results

• Change management– Series of national workshops– Presentations from local participants– Action plans– Policy “pick and mix” on web

Did change result?

• Between the 2004 audit and 2006, in acute hospitals– Many of the

organisational measures improved

Did change result?

• However, care indicators did not consistently improve

Organisational “quality” does relate to care

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In the interim

• There has been a consistent approach to implementation of the national guidelines for incontinence with in E&W, from many different sources.

• The RCN particularly has concentrated efforts in care homes, using digital stories as a reflective tool

National Audit revisited

• The National Audit of Continence Care was re-run in late 2009, early 2010.

Region Type of

TRUSTS

Trusts Eligible to Participate

2009

Trusts registered

2009 (% of those

eligible)

Trusts participating 2009 (% of those

eligible)

Sites participating

2009

2006 Audit Participation of

Trusts

Acute 161 143 (89%) 135 (84%) 150 83%

Primary Care 144 96 (67%)

86 (60%) Including:36 both organisation & commissioning

97 43%

England

Mental Health 57 35 (61%) 26 (46%) 31 45%

Wales Combined 7 6 (86%) 6 (86%) 12 69%

Northern Ireland Combined 5 3 (60%) 3 (60%) 5 44%

Islands Combined 2 2 (100%) 2 (100%) 3 67%

Snapshot of temporal change

2005 2006 2010 Question

% N % N % N Does the facility utilise an Integrated care pathway or an evidence based treatment algorithm for patients with incontinence?

Integrated Care Pathway 21 36/168 25 40/157 38 57/151

Algorithm 18 30/168 29 45/157 44 66/151

Care Plan 41 69/168 41 65/157 52 79/151

None of these 36 61/168 31 49/157 24 37/151

Is it the facility's practice to ask a screening question relating to bladder and bowel problems as part of the initial assessment?

90 151/168 94 147/157 96 145/151

Is there a written protocol for providing a basic assessment for all people who indicate that they have problems with urinary and/or faecal continence?

40 67/168 50 79/157 54 82/151

Does the clinical team include a practitioner who has had training to:

Take a continence history? 76 127/168 85 133/157 90 136/151

Initiate a frequency-volume chart? 71 120/168 84 132/157 89 134/151

Perform a rectal examination? 90 152/168 94 147/157 95 143/151

Perform a urinalysis? 99 166/168 99 155/157 99 150/151

Does the facility have access to an integrated continence service? (as defined by “Good Practice in continence services”) (DoH 2000)

46 77/168 58 90/156 56 84/151

Conclusion

• Clinical audit can be used as a vehicle for positive change

• Awareness and knowledge increase with use of audit

• Clinical audit can probably drive change