Victorian Stroke Clinical NetworkUrinary continence measures guide

AcknowledgementsThis measures package has been prepared by the Victorian Stroke Clinical Network,

Department of Health and Human Services, Victoria. The program would like to thank

the Redesigning Hospital Care Program for its support to develop this guide.

The program also acknowledges the contribution of health service stroke units that have

participated in the statewide Filling the Void Initiative. Special thanks to our consumer

representative for helping the program to better understand the patient experience.

Thanks finally to the Victorian Stroke Clinical Network Steering Committee for its

contribution, advice and support to develop this guide.

To receive this publication in an accessible format phone 9096 1297, using the National

Relay Service 13 36 77 if required, or email stroke.clinicalnetwork@dhhs.vic.gov.au

Authorised and published by the Victorian Government, 1 Treasury Place, Melbourne.

© State of Victoria, September 2016.

Except where otherwise indicated, the images in this publication show models and illustrative

settings only, and do not necessarily depict actual services, facilities or recipients of services.

This publication may contain images of deceased Aboriginal and Torres Strait Islander peoples.

Where the term ‘Aboriginal’ is used it refers to both Aboriginal and Torres Strait Islander people.

Indigenous is retained when it is part of the title of a report, program or quotation.

ISBN 978-0-7311-7080-7 (pdf/online)

Available at https://www2.health.vic.gov.au/hospitals-and-health-services/quality-safety-service/

clinical-networks/clinical-network-stroke/vscn-continence

(1606022)

Victorian Stroke Clinical NetworkUrinary continence measures guide

What is redesign? 1

How will this guide help you? 2

Why are measures important? 2

How do I select measures? 2

The important role of urinary continence for patient experience 2

Recommended routine performance measures 3

Key tips to remember when collecting and presenting data 4

Measuring urinary continence performance 4

Specific measures for effective urinary continence 5

The patient experience – through Jane’s eyes 10

Patient experience measures 11

Urinary continence measures for improvement 12

Case study 1: Northeast Health – continence diary 13

Case study 2: Monash Health Community Rehabilitation 14

Appendix 15

References 16

Contents

1

In general terms, process redesign in an approach to mapping, reviewing and

redesigning the patient journey to meet demand and ensure that care is safe,

effective and efficient. Simplifying the journey patients make through our healthcare

institutions can reduce errors, improve patients’ access to services, lower costs and

make better use of existing resources.

Evidence has shown that using an improvement method such as redesign yields

a greater impact by better understanding the problem (as defined) so the right

solution is applied and sustained. Having standardised clinical practice and value

measures in place helps to provide evidence as to how interventions are being applied,

what their impact is and opportunities for further improvement. It is important

to measure to know that a change is an improvement and that no matter what the

change, it can be tracked.

Further information about redesign is contained in the guide Introduction to redesign.

This guide provides a starting point and an overview of the redesign improvement

methodology and is available via the Redesigning Hospital Care Program website at

https://www2.health.vic.gov.au/hospitals-and-health-services/quality-safety-service/

redesigning-hospital-care

For contact details of your health service’s redesign lead, or to find out who your

service’s redesign lead is, check the Redesigning Hospital Care Program’s website

via the link above.

What is redesign?

2 Optional: Document header/footer – can be in document colour

How will this guide help you?This guide is one of a series of documents

published by the Redesign Hospital Care Program

to help health services select appropriate

measures for their redesign work. This guide

focuses on promoting urinary continence for

stroke survivors and accessing care within acute,

subacute or community services. It provides:

• detailed and high-level process maps

• a variety of recommended measures for stroke services process redesign.

This guide is not a standalone document or

a ‘how-to’ manual. It provides a suite of measures

that health services can choose from, depending

on their specific needs and priorities. It is designed

to be used in the context of a comprehensive

redesign and change management framework

and in conjunction with advice from the health

service redesign team. It is useful to read this

measures guide in combination with Introduction

to process redesign, which is the introduction

guide in the series.

Why are measures important?Measurement is an essential step in the redesign

process. It provides an external and objective

template against which to assess the impact

of process improvement. Measurement issues

need to be thought about at the beginning of

a process improvement program, not when the

program is running or complete. Measures can

be used through the life of the project to:

• identify and prioritise areas for projects

• develop a baseline against which to measure improvement

• track the impact of redesign

• demonstrate results at the end of the project.

How do I select measures?No two services are the same, and a well-

structured diagnostic phase is necessary

to ensure the focus of an improvement program

is clear and that appropriate measures are

selected. There are three viewpoints from which

to assess the benefits of redesign work. These

viewpoints are complementary; each contributes

a perspective and ensures multiple goals are met:

• The patient viewpoint: Have the safety, quality, access, adaptability and outcomes of care improved?

• The staff viewpoint: Are the care processes more acceptable to staff? Is staff time being used more efficiently and effectively?

• The organisational viewpoint: Does the improvement program align with institutional priorities? Has progress been made on those priorities?

The important role of urinary continence for patient experienceThe Victorian Stroke Clinical Network provides

support to health services to improve service

delivery to patients who have experienced stroke.1

Urinary incontinence is a major complication after

stroke and affects up to one-third of patients.2,3

Urinary incontinence can persist for up to one

year and has a major impact on the wellbeing

of the patient,2,4,5 often requiring an indwelling

catheter (IDC) to facilitate continence.6

Studies have demonstrated that up to a quarter

of patients who have experienced urinary

incontinence unnecessarily receive an IDC,

increasing their risk of urinary tract infection (UTI)

by 3–10 per cent each day the catheter is in situ.2,6

More importantly, it is an indicator of mortality.7

It is also associated with poor rehabilitation

outcomes and can slow the patient journey.6,7,8

The 2014 National Stroke Foundation audit results

revealed that less than 40 per cent of patients

received assessment of continence and no

subsequent management plan.9,10

3

It is recommended that a mechanism for the routine (for example, monthly) collection

and reporting of performance measures relevant to individual stroke services is in place.

A snapshot audit provides a sense of progress.

• Routine reporting is essential for assessing performance and improvements and to help with managing the stroke service.

• Consistent reporting among stroke services, although not mandated, can facilitate benchmarking across different services.

Table 1: Performance measures for urinary continence

Performance measures (KPI, capacity and check) Rationale

Continence assessment (early)

The earliest possible assessment of continence ensures timely implementation of a management plan and access to specialist expertise. It also reduces the risk of adverse events and delays to transfer or discharge. It increases patient satisfaction and improves the patient experience.

Continence management plan (CMP) in place

A CMP is the result of an assessment and formally documents the care goals of the patient.

Adverse events (falls, UTIs) Intermittent catheterisation is recommended in the context of urinary retention after stroke. IDC insertion may be an indication of a non-EBP, which can lead to complications such as UTI. Inappropriate IDC use can lead to diminished patient experience.

Staff educated The number of staff who are trained in continence management, bladder scanning, continence aids or IDC care.

Patient experience Understanding the needs and requirements of patients and learning opportunities for further improvement to care and services.

Recommended routine performance measures

4

Key tips to remember when collecting and presenting data• All measures should be collected prior to

implementing improvement initiatives in order to establish a baseline. For example, the same questions could be repeated in a follow-up staff survey, or staff tracking could be repeated at approximately the same time of day or day of the week.

• Processes will vary depending on the time of day, day of the week, and time of year. During the diagnostic phase it is necessary to collect data at different times of the day and days of the week in order to analyse and understand existing variations.

• It is recommended that a minimum of one month of historical data (for example, patient presentations) is used to establish baseline performance. However, to establish trends over time, at least 12 months of historical data would be required.

• Measures should be described by their range, median and percentage within the goal or target.

• When tracking patients and staff it is important to collect enough data so it is a representative sample of all patients and staff. It is difficult to make hard-and-fast rules about when this point is reached, but it will be clear that enough patients have been tracked when patterns start

to repeat.

Measuring urinary continence performance Measuring effective urinary continence

management that is evidence-based with clinical

guidelines can be grouped into four categories:

1. Key performance measures (KPIs)

These are measures of overall performance

and relate to the achievement of specific goals

or problems to be addressed. Unlike some services

(such as surgery and emergency departments),

urinary continence management currently does

not have any defined KPIs that are reportable

to the Department of Health.

2. Demand measures

These measures set the scene by defining

demand, capacity and activity. They also assist

when writing a problem statement for a process

redesign program of work.

3. Process measures

These measures capture, validate and track the

impact of improvement initiatives on process

performance, including times taken to perform

process elements of effective urinary continence

management.

4. Check measures

These measures capture the quality and

safety outcomes, as well as unintended effects

elsewhere in the patient journey or hospital

system. The choice of measures to monitor

and evaluate quality and safety will relate to the

focus of the program of redesign.

The feasibility of using the measures described

in this guide (page 15) will depend on the

availability of reliable data and/or the capacity

of health services to collect the data.

5

Specific measures for effective urinary continence

Key performance measures

1. Continence screening

2. Continence assessment

3. Formal continence plan

Demand measures

1. Number of admitted (separations) patients

with stroke (ISD codes R32, R33, N39.3, N29.4, ‘C’

or ‘Prefix’)

Process measures

1. Reduced incidence of UTI

2. Reduced use of IDCs

3. Continence plan in place

4. Post-void residuals (bladder scan and/or

intermittent catheterisation)

5. Documentation (clinical pathway, assessment

forms, fluid balance, bladder chart, consumer

information)

6. Protocols

Check measures

1. Readmission rates

2. Adverse events related incidents (falls, skin

integrity breakdown, UTI)

3 Patient experience and satisfaction rates

4. IDC in situ (duration in days)

5. Reduced urinary/bladder complications

Cost savings (as part of check measures)

1. Reduced length of stay

2. Reduced indwelling catheter use

3. Reduced antibiotic use

Figure 1: High-level stroke patient process map

Ambulance Emergency department

Decision to admit Stroke unit/ward

Self Rehabilitation/subacute

Referred Discharge

Community support (chronic stroke support)

Patient presents

7

Figure 2: Detailed acute stroke patient process map – generic representation of processes

Arrival Assess and initiate treatment Referral Treatment Transfer/discharge

Ambulance Emergency department

Triage Investigations

Radiology

Pathology

Stroke

review

Admit ICU/HDU Ongoing Referral and review

Transfer

Self Inpatient unit

Discharge

Referred (GP)

Patient presents to hospital Assess/resuscitate/reviewIdentify treatment: thrombolysis, ICU

Referral to stroke team

ICU/ward Assessment(UC)

Care until discharge or transfer for ongoing care at subacute or rehabilitation centre

Who

Medical, nursing Stroke team: medical Multidisciplinary stroke team

Subacute coordinator

Timeframes

Time from arrival to admission Investigation turnaround time Length of stay (days)

Time from decision to admit and admission

Figure 3: Detailed subacute stroke patient process map – generic representation of processes

Referral Assessment Treatment Transfer/discharge

Inpatient Referral review Transfer Allied health Physical assessment and specific goals set Transfer

External service Waitlist Nursing Ongoing assessment Discharge

Medical Case review

Patient requires ongoing care in post-acute phase

Assess/reviewIdentify treatment: subacute, rehabilitation, rehabilitation in the home or community rehabilitation

Assess/reviewProgress against discharge or transfer goals

Who

Stroke team Multidisciplinary rehabilitation team

Multidisciplinary team

Timeframes

Receipt of referral to waitlist Waitlist to admit Length of stay (days)

Figure 4: Detailed community stroke patient process map – generic representation of processes

Referral Assessment Treatment Transfer/discharge

Acute Triage Appointment scheduled

Physical assessment and primary goals set

Allied health Physical assessment and specific goals set

Subacute Clinical review Nursing Therapy: home/ community or centre

Refer to ongoing home-based services, HACC or home exerciseprogram

Community

CRCs/GPs

Appropriate

referral on

Medical Ongoing assessment

Case review and

ICF category

Who

Clerical receipt of referral

Allied health, medical and/or nursing

Senior clinician (nursing or allied health)

Coordinator (nursing or allied health)

Timeframes

24 hours

4–6 weeks for referral to assessment 4–6 weeks ongoing care

Care required

10

The patient experience – through Jane’s eyesCapturing the patient experience provides a basis for improving service delivery.

As health services understand the patient journey from a process perspective,

incorporating the patient experience provides clinical teams with the ability to

design and deliver better care. Through the Filling the Void Initiative, ‘Jane’, a stroke

survivor, participated in all workshops and was a member of the overarching program

steering committee.

Jane provided valuable feedback to clinicians about her experience when dealing

with continence post stroke. Hearing about the anxiety that urinary incontinence

had on Jane was a powerful trigger for clinicians to think differently about their

own service. In an evaluation of the Filling the Void Initiative, participants reported

Jane’s involvement to be one of the most beneficial elements of the program.

While involving patients in their care is important, improving care delivery can be

enhanced by understanding their experience and what matters most to patients.

11

Longer term, measures of patient experience using the Victorian Health Experience

Survey (VHES),11 while not specific to continence management, provides an opportunity

to understand the high level concerns of patients. When it comes to targeted issues

such as continence, the Picker Institute12 themes can be used. According to the Picker

Institute there are eight themes that are important to patients, carers and family that

can be aligned to clinical guidelines and subsequently clinical practice. Table 2 provides

the eight themes and suggested measures regarding urinary continence.

Table 2: Eight Picker principles of patient-centred care7 and possible measures

Picker theme Possible measure (urinary continence)

Respect for patients; values, preferences and needs

Maintaining dignity and privacy with toileting choices; documented preference of patients’ preferences to continence management

Coordination and integration of care

Allocation of a coordinator, regular review of progress towards goals, multidisciplinary care coordination meetings

Information, communication and education

Brochures, education, information sessions, face-to-face education and past history

Physical comfort Pain relief measured using a pain scale and documented; correct continence aid based on patients’ actual continence needs

Emotional support; alleviation of fear and anxiety

Documented discussions with patients and/or carers or family regarding concerns

Involvement of family and friends

Daily bedside handover with the family or carer present including regarding urinary continence

Continuity and transition Daily bedside handover including urinary continence; documentation using standardised transition forms

Access to care Documented discussion of treatment options for ongoing care needs such as community rehabilitation

Patient experience measures

Urinary continence measures for improvement

Demand and capacity measures Key performance measures Process measures Check measures

Purpose To define demand, capacity and activity

A direct measure of the goal you are trying to achieve or problem you are trying to solve

To capture, validate and track the impact of improvement initiatives on process performance

To demonstrate the improvement did not have unintended effects elsewhere in the patient journey or hospital system

Examples Demand: all patients admitted with stroke

• Number of patients admitted for stroke

• Demand by treatment type

• Admission to stroke unit

• Number of patients admitted with urinary incontinence post stroke (ISD code)

Capacity: resources available to provide a service to the patient, including staff

• Number of staff educated in bladder scanning

• Stroke care coordinator

• Continence/urology department

• Primary stroke unit/service

• Dedicated stroke team (acute and subacute)

Access to treatment:

• Number of patients with a documented urinary continence management plan

• Resources, education available, community support and follow-up

Assessment completed within agreed timeframe such as:

• 24 hours

• 72 hours

Utilisation

• Ready for discharge or transfer (waiting for)

• Clinic spots available

• Specialist clinics appointments

Process time

• Time from admission to assessment

• Time from completed assessment to documented management plan

• Time from IDC removal to first void

Process quality

• Number of staff trained in urinary continence assessment

• Number of staff accurately completing documentation

• Correct use of incontinence aid according to assessment

• Documented urinary output

Quality and safety measures: (review past histories)

• Number of patients with completed documentation of urinary continence (assessment and management plans)

• Number of patients with UTIs post stroke

• Number of falls associated with urinary incontinence

Patient experience

• Targeted surveys

• Information given

• Net promoter score (recommending the service to others)

• Qualitative patient feedback

Staff satisfaction

• Targeted surveys

• Turnover and sick leave

• Occupational health and safety incidents

Cost measures

• Performance against budget

• Reduced length of stay

• Reduced indwelling catheter use

• Workforce data

• Workforce hours per hour of patient treatment

Case study 1: Northeast Health – continence diary The subacute multidisciplinary team takes over management of patients on the acute

stroke unit as soon as they are medically stable. As such, they are able to provide stroke

patients with rehabilitation care as early as possible in their journey towards recovery

and get to know their patients over a longer period of time

The team identified that the way they were managing continence among stroke

patients was less than optimal due to lack of clear guidelines and poor documentation.

The solution was to modify the bladder and bowel diary to include a comprehensive

summary page. This enabled the team to clearly identify voiding patterns in patients

experiencing incontinence.

One patient in particular was very satisfied that his issue with significant nocturia and

faecal incontinence was resolved through interventions based on the findings from the

bladder diary. Success of the interventions was confirmed, and subsequent follow-up

using the bladder and bowel diary was done two weeks later.

Inspired by the results of the changes to the bladder and bowel diary, the multidisciplinary

team continue to refine and improve their assessment and management of urinary

continence for their patients.

14

Case study 2: Monash Health Community RehabilitationThe team at the Monash Community Rehabilitation Centre decided to develop a patient-

centred stroke program to provide information about their stroke care.

Feedback was obtained from 30 patients and carers to identify what information

and resources they wanted about living with a stroke. Of the topics identified, urinary

continence was a priority. The team then created a 13-week education program called

Brainwave, which launched in 2015.

Brainwave was considered a success according to patient feedback, and the team

continues to work with patients and carers to refine the program. The team evaluates

the program through feedback, attendance and patient outcomes.

15

Tools developed by the sectorTable 3: Sector-developed tools to assess and manage urinary continence

Tool Purpose Measure Health Service

Bladder diary (Bladder, Bowel and Fluid Diary)

Record bladder function and identify patterns/treatment options

Daily urine output and episodes of continence and incontinence

Northeast Health Wangaratta

Management of urinary incontinence post stroke

Policy document to support consistent clinical practice

Southwest Health

Urinary continence assessment reminder sticker

Visual reminder for staff to reassess urinary continence

Audit initial and reassessment rates by clinical staff

Monash Health Community Rehabilitation

Incontinence post-stroke pathway

Guide staff regarding the information and process post subacute

Post-stroke handouts and information given to patients

Austin Health Subacute Service

Appendix

16

1. Department of Health and Human Services, Victorian Stroke Clinical Network.

Available at: https://www2.health.vic.gov.au/hospitals-and-health-services/quality-

safety-service/clinical-networks/clinical-network-stroke

2. National Institute of Health Clinical Trials Results 2012, Pilot study of avoidance

of bladder catheters in stroke patients to avoid urinary tract infections.

Available at http://clinicaltrialsfeeds.org/clinical-trials/show/NCT01275261.

3. Thomas LH, Cross S, Barrett J, French B, Leathley M, Sutton CJ, et al. 2008,

Treatment of urinary incontinence after stroke in adults, Cochrane Database

Systematic Review Issue 1.

4. Jordan A, Mackey E, Coughlan K, Wyer M, Allnutt N, Middleton S 2010, Continence

management in acute stroke: a survey of current practices in Australia, Journal

of Advanced Nursing.

5. Pilcher M, MacArthur J 2012, Patient experiences of bladder problems following

stroke, Nursing Standard 26(36): 39–46.

6. Patel M, Coshall C, Rudd AG 2001, Natural history and effects on 2-year outcomes

of urinary incontinence after stroke, Stroke 32:122–127.

7. National Institute of Health Clinical Trials Results 2012, Pilot study of avoidance

of bladder catheters in stroke patients to avoid urinary tract infections.

Available at http://clinicaltrialsfeeds.org/clinical-trials/show/NCT01275261.

8. Dumoulin C, Korner-Bitensky N, Tannenbaum C 2005, Urinary incontinence

after stroke: Does rehabilitation make a difference? A systematic review of the

effectiveness of behavioral therapy, Top Stroke Rehabil 12(3): 66–76.

9. National Stroke Foundation 2014, National stroke audit acute services Victorian

state report 2013, National Stroke Foundation, Melbourne, Victoria.

10. Langhorne P, Pollock A 2002, What are the components of effective stroke unit care?,

Age Aging 31(5): 365–371.

11. The Victorian Patient Experience. Available at https://www2.health.vic.gov.au/

hospitals-and-health-services/quality-safety-service/patient-experience-survey.

12. The Picker Institute (2013) Eight Picker Principles of Patient Centered Care.

Available at http://www.ipfcc.org.

References