An end to shame: enabling patients to self-manage catheters

A project led by adult continence nurses is supporting people struggling to cope with indwelling urinary catheters

A project led by adult continence nurses is supporting people struggling to cope with indwelling urinary catheters

Adult continence team members (L-R): assistant director of enhanced services Roisin
Toner, continence nurse Sharon Ross, continence nurse specialist Deborah Connelly,
head of specialist primary care services Martina Thompson, continence nurse specialist
/team lead Joanne Spence, director of older people’s services Melanie McClements and
lead nurse enhanced services Wendie McQuillan. Picture: Simon Graham

When a patient comes home from hospital with a catheter in place they are at risk of infections. They may be afraid, their self-image is affected and often they feel embarrassed or even ashamed about the whole thing.

So when adult continence service team lead Joanne Spence wanted to launch a continence project she knew there was a need to tread carefully. But she also knew she could make a huge difference to people’s lives.

‘We felt there were opportunities to offer better support for patients, their carers and families’

Joanne Spence, adult continence service team lead

She had become aware of a lack of communication between staff in the acute and community sectors when it came to follow-up and ongoing care of patients with an indwelling urinary catheter.

Joanne Spence: ‘Partnership with
patients.’ Picture: Simon Graham

Where to go for help

High numbers of patients were making repeated visits to their GP, the emergency department or the GP out-of-hours service due to problems related to catheters.

Ms Spence, the leader of a community team in Craigavon, Armagh, says she felt she had to do something. ‘Having a catheter inserted is an intimate, invasive procedure for the patient and they want information so they can manage their device and know where to go for help if anything goes wrong.

‘We felt there were opportunities to offer better support for patients, their carers and families while at the same time reducing the demands on our hard-pressed services.’

Care pathways

The specialist continence team introduced a quality initiative called IMPACCT (Improving the Management of Patient Access to Community Catheter Treatment) that focused on care pathways for patients with indwelling urinary catheters.

Cost of catheters

  • Catheters are the leading risk factor for urinary tract infection (UTI), and their cost to the NHS is an estimated £99 million a year
  • Around 60% of healthcare-associated infections are related to catheter insertion
  • The cost of a UTI is estimated at £1,122 per patient

(Pratt et al 2007)

The aim was to ensure the patients were supported by improving communication between acute, primary, secondary and private-sector care. There was a focus on educating patients so they could self-manage their care.

Step one to setting up the scheme was engaging with all the major stakeholders including patients and their families, GPs, the emergency department, the urology department and district nursing – including twilight nursing and Marie Curie nurses.

The specialist continence service became a single point of access, triaging all new referrals of patients with catheters. The team began collecting weekly attendance slips from the emergency departments at Craigavon Area Hospital in Portadown and Daisy Hill Hospital in Newry for patients presenting with acute urinary retention or with catheter-related complications.

Ms Spence explains: ‘Initially there were hurdles to overcome getting that in-reach into the acute departments so that the staff there were happy and would trust us to look after their patients with catheters in the community. But now we have forged strong links.

‘We try our best to keep the patient out of the acute sector. We need to reduce the demand on services because they are overwhelmed’

Joanne Spence

‘We also had to reassure the patients as they naturally think: “The hospital did this for me so is it okay for someone in the district to look after me?” But once they realise that we are a highly specialised nursing team, with an enthusiasm for bladder and bowel management, they are happy for us to lead them on their journey.’

Continence nurse specialist Deborah Connelly. Picture: Simon Graham

‘A privilege’ to be a continence nurse

Ms Spence believes it is ‘a privilege’ to be a continence nurse. ‘Apart from the urologist and the gynaecologist nobody else deals with “down there”. Catheters can get blocked, or leak or cause bladder spasms.

‘People need information on how to care for their devices, such as how to prevent problems and how much to drink. And there are delicate issues around sexuality. Patients confide in us and they trust us. And I trust my team as I know they have the knowledge base to support vulnerable patients.

‘We try our best to keep the patient out of the acute sector. We need to reduce the demand on services because they are overwhelmed. The good thing is that we can achieve that while knowing that we have the right staff with the right skills in the community doing what’s right for the patient.’

Empowering the patient

ED triage of new patients

For April-October 2017 (Craigavon Area Hospital and Daisy Hill Hospital):

  • 54 catheter patients seen
  • 22 trial removals of catheters
  • 14 successful removals
  • 40 had a patient-centred treatment plan agreed

Ms Spence leads a team of three specialist nurses, two continence nurses and two band 5 nurses. They offer training in management of indwelling urinary catheters to district nurse colleagues as well as staff in the hospital emergency department, call handlers for the GP out of hours service and non-acute ward staff.

Patients discharged from hospital with a catheter will have a plan drawn up for its removal – this forms part of their individualised catheter passport. Previously patients would be seen before the start of clinic or at the end, but the team have now set up dedicated catheter clinics.

And after joint work with GPs in the out-of-hours service a podcast is to be made available offering advice to patients with catheters. An important aim is to enable and empower the patient, through education, to self-manage their own care.

Face-to-face contact

‘If a patient has a catheter fitted today my staff will be ringing tomorrow with information on how to manage it, where to get supplies and who to contact if they have an issue,’ says Ms Spence.

‘And after that first contact within 24 hours, within two weeks they will be seen – whether or not they need their catheter changed – because that face-to-face contact is important in a sensitive area like this.’

The team believes its work has eased stress among patients, carers and families, and reduced the risks associated with poorly managed catheter care. Ongoing evaluation of the project is being carried out using the Plan, Do, Study, Act cycle.

Promoting the service

Plans for developing the initiative include further work with acute wards over the process for referring patients out to the community setting. The team also realises it has more work to do promoting the service among GPs, as not all are aware of it.

At present the scheme is confined to the Southern Health and Social Care Trust in Northern Ireland, but Ms Spence has high hopes for the future. ‘My dream would be that every patient who comes through an A&E department or a urology department in the region – or even nationally – will have access to a service that offers full information for a patient so they know where they are going with this piece of medical equipment.

‘They should also get a prompt care plan and hopefully, if it’s possible, prompt removal of their catheter.’

Safe at home

This new system has worked well in one area – so why not everywhere else?

‘From my point of view as a continence nurse the fact that we can offer a service in the community that was not there before is great. And we’ve been able to introduce this innovation without additional funding into the service, which is also good news. 

‘But what it’s really all about is working in partnership with the patients and keeping them safe at home, which is where they’d rather be as they feel more comfortable and relaxed.  If we achieve that then, for me, we have won the battle.’

Continence nurse Sharon Ross. Picture: Simon Graham

Janet Snell is a health journalist

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