Incontinence management is inadequate, UK audit showsBMJ 2005; 331 doi: http://dx.doi.org/10.1136/bmj.331.7527.1226-a (Published 24 November 2005) Cite this as: BMJ 2005;331:1226
The first national audit of incontinence care for older people in the United Kingdom has found widespread failure to diagnose and manage continence problems in results reported this week.
The audit, funded by the Healthcare Commission and undertaken by the Royal College of Physician's Clinical Effectiveness and Evaluation Unit, examined the quality of care for 9197 older people (65 years and above) with urinary and faecal incontinence in primary and secondary care and 749 residents in care homes in England, Wales, and Northern Ireland. It compared their continence care to standards set in the National Service Framework for Older People and the Department of Health guidance Good Practice in Continence Services (www.dh.gov.uk).
Results showed that specialist NHS staff had good levels of knowledge about continence, but patients were often not examined thoroughly or given full assessments. Even if these had been done effectively, there was limited effort to determine the underlying cause of incontinence. In most patients, only the symptoms are managed, when in some cases the researchers considered that there could be a cure.
In addition, the audit found a lack of written policies on continence, missing documentation about the problem, limited provision of staff training, high use of indwelling catheters in hospital settings, and widespread rationing of continence pads.
Only 59% of primary and 32% of secondary care sites taking part in the audit had written policies on continence care for older people. Nearly all sites routinely asked a screening question relating to bladder and bowel care, but only 64% of primary and 44% of secondary care sites had a protocol for providing basic continence assessment. Integrated continence services—the only compulsory requirement in the National Service Framework for Older People—were present in 53/138 of primary care and 50/195 secondary care sites and in 10 out of 27 care homes taking part in the audit. Only half (49%) of secondary care trusts offered structured training on the management of continence to their staff.
Sixty per cent of primary and 70% of secondary care patients with bladder or bowel problems received pads as a way of managing their condition rather than efforts to treat the underlying problem. Also, provision of pads was generally rationed. Despite 80% of services having a written policy that continence pads should be available on the basis of clinical need, 81% of primary care and 76% of care home services limited the maximum number of daily pads for patients.
Adrian Wagg, consultant and senior lecturer in geriatric medicine at University College Hospital, London, and chairman of the continence working party, said, “This study, one of the largest audits of continence care worldwide, shows that care for people with continence problems is patchy at best, that a cure is seldom attempted, and that the single mandatory target for continence in the [National Service Framework] has not been met.”
He continued, “One of the most disappointing findings was that although healthcare professionals often detect that a patient has a continence problem they do nothing about it, or put a pad on it. There is no major effort to make a diagnosis and manage it correctly.” More training in continence assessment and management is essential, he concluded.
National Audit of Continence Care for Older People is available at http://www.rcplondon.ac.uk/.