Table 5 - uploaded by Joanne Booth
Content may be subject to copyright.
Source publication
To determine what influences the decision to insert an indwelling urinary catheter in acute stroke patients.
A prospective casenote review and semi-structured interviews were conducted and corporate catheterization policy in the study sites was investigated.
Three teaching hospitals, typical of stroke service provision in most developed countries....
Contexts in source publication
Context 1
... for catheterization were documented for 56 (80.0%) patients with the majority being retention-related (37.1%) or to monitor output (22.9%) ( Table 4). Half of all catheterizations occurred in acute stroke units (Table 5). There was no significant dif- ference between the numbers of catheteriza- tions performed during day and night shifts (chi-square: P ¼ 0.24). ...
Context 2
... 11 respondents indicated that a continence assessment would be carried out on post-stroke patients in their unit and if done, it would be of lower priority than other physiological and functional assessments. In contrast to the case- note review findings (Table 5), respondents gen- erally believed that few catheterizations occurred in stroke units. ...
Similar publications
Background
Indwelling urinary catheters are commonly used in hospitalized patients, which can lead to the development of urinary catheter complications, including catheter-associated urinary tract infection (CAUTI). Limited reports on the appropriateness of urinary catheter use exist in Japan. This study investigated the prevalence and appropriaten...
Citations
... National UK audit data suggest that, even with the available guidance, clinicians are unable to distinguish between types of UI, and poststroke UI is poorly managed. 17,18 A systematic review evaluating methods of assessing UI in the general adult population was conducted in 2002. 19 A review focussing specifically on the needs of people with stroke is required to determine which assessment methods are most accurate considering how stroke-related impairments complicate UI assessment. ...
Introduction
Urinary incontinence (UI) affects over half of people with stroke. It is unclear which methods are accurate in assessing presence and type of UI to inform clinical management. Diagnosis of UI based on inaccurate methods may lead to unnecessary interventions. The aims of this systematic review were to identify, for adults with stroke, clinically accurate methods to determine the presence of UI and type of UI.
Method
We searched seven electronic databases and additional conference proceedings. To be included, studies had to be primary research comparing two or more methods, or use a reference test.
Results
We identified 3846 studies with eight eligible for inclusion. We identified 11 assessment methods within the eight studies. Only five studies had sufficient comparator data for synthesis. Due to heterogeneity of data, results on the following methods were narratively synthesized: Core Lower Urinary Tract Symptom Score (CLSS), clinical history and physical examination, Barthel Activities of Daily Living Index, International Consultation Incontinence Questionnaire Short Form (ICiQ‐SF) and urodynamic studies (UDS). Most studies were small and of low to medium quality. All reported differences in sensitivity, and none compared the same assessment methods.
Conclusion
Current evidence is insufficient to support recommendations on the most accurate UI assessment for adults with stroke. Further research is needed.
... Poststroke bladder dysfunction is associated with poor outcomes including slower recovery, increased rates of hospitalization, disability, low health-related quality of life, and increased mortality risk [37,[39][40][41]. The use of standardised continence assessment tools and catheterisation policies are recommended, reducing the risk of urinary complications [44]. In this study, the proportion of dead people in 6 months poststroke is higher in the group with NOBD than without (76.9 ...
Purpose:
Bladder and bowel poststroke dysfunctions negatively impact patients' health. Stroke-related characteristics associated to these dysfunctions are poorly known. This study aims to estimate the prevalence of new-onset poststroke bladder and bowel dysfunctions, characterize their associated factors, and describe the dysfunctions' clinical approach.
Materials and methods:
Cross-sectional study including 157 patients admitted to a single hospital's stroke unit with a first-ever stroke, during 3 months. An 18-item questionnaire was applied to assess dysfunctions pre and poststroke. The McNemar test was used to compare pre and poststroke prevalence. A logistic regression was used to estimate associations (OR, 95% CI) between individual characteristics and new-onset dysfunctions.
Results:
We had 113 (72%) respondents. There was a significant increase in the prevalence of bladder and bowel dysfunctions poststroke (p < 0.001). Higher stroke severity was significantly associated with both new-onset poststroke bladder and bowel dysfunctions (OR = 15.00, 95% CI [4.92,45.76] and OR = 5.87,95%CI [2.14,16.12], respectively). Total anterior circulation strokes, cardioembolic strokes, and lower functionality at discharge were also significantly associated with both dysfunctions. Thirteen patients (11.5%) reported that health professionals addressed these dysfunctions.
Conclusions:
Poststroke bladder and bowel dysfunctions are highly prevalent. Being aware of their epidemiology helps draw attention to patients at higher risk of developing these dysfunctions, enhancing the rehabilitation process.IMPLICATIONS FOR REHABILITATIONPoststroke bladder and bowel dysfunctions are highly prevalent and under-recognised consequences of stroke.Being aware of their epidemiology and associated factors may help identify patients at higher risk of developing these dysfunctions.It is necessary to raise clinical awareness to ensure a more efficient diagnostic and therapeutic approach, enhancing patients' rehabilitation process, quality of life and lowering collateral societal burden.
... Furthermore, despite clinical guidelines stating indwelling urethral catheters (IUCs) should only be used to relieve retention [21], there is over-reliance on catheterisation as a management strategy for UI in stroke units, especially in the acute phase [19,22]. This puts patients at risk of IUC-associated urinary tract infection and its consequences [23][24][25][26], including increased morbidity, mortality and resource use [24,27,28]. ...
Lois Thomas, Christine Roffe, Joanne Booth, Christopher Chapple, Caroline Watkins, Brenda Roe, Christopher Sutton, Bruce Hollingsworth, Céu Mateus, David Britt, Cliff Panton and Kina Bennett; for the MRC Continence Programme and R&D Stroke and Incontinence Study
... Urinary retention or incontinence is a common complication in patients with acute stroke, and the placement of urinary catheter facilitates onward medical management by eliminating the need for frequent toileting or reducing the need for body cleaning and diaper changing by the nursing staff [24]. However, international guidelines suggested that the use of an indwelling urinary catheter should be avoided unless urinary retention or vulnerable skin condition is present [26]. In addition to the high risk of urinary tract infection, the use of a urinary catheter also hampers the participation of patients in the rehabilitation programs. ...
Background
The Chinese version of the Continuity Assessment Record and Evaluation (CARE-C) item set was developed to facilitate the assessment of post-acute care (PAC) patients in Taiwan. Considering that the length of hospital stay (LOS) has a significant effect on the total healthcare cost, determining whether the CARE-C scores could predict the LOS of PAC patients is of great interest to the PAC providers.
Methods
This prospective trial included PAC patients with stroke or central nervous system injuries. The demographic data and CARE-C scores were collected after admission and before discharge. A multivariable stepwise linear regression model was used to identify the predictors of the LOS using age, sex, tube placement status, CARE-C component scores at admission, and score differences between admission and discharge as independent variables.
Results
This study included 178 patients (66 women and 112 men), with a mean age of 61.9 ± 15.6 years. Indwelling urinary catheter placement status at admission (β = 0.241, p = 0.002) was a positive predictor of the LOS, whereas age (β = −0.189, p = 0.010), core transfer subscale score at admission (β = −0.176, p = 0.020), and difference in continence subscale score (β = −0.203, p = 0.008) were negative predictors of the LOS. The model explained 14% of the total variance.
Conclusions
Indwelling urinary catheter placement status at admission, age, core transfer subscale score at admission, and difference in the CARE-C continence subscale score were identified as predictors of the LOS. The explanatory power of these predictors might be limited due to the regulations of Taiwan’s National Health Insurance.
... In the hospital setting, nurses are the main providers of continence care (Dumoulin, Korner-Bitensky, & Tannenbaum, 2007). Nurses find managing continence in the context of stroke challenging (Booth, Kumlien, Zang, Gustafsson, & Tolson, 2009), with over-reliance on urinary catheterization (a drainage tube placed in the bladder) as a management strategy especially in the acute phase of illness (Cowey, Smith, Booth, & Weir, 2012). These difficulties are not limited to stroke services, with persistent reports of poor assessment and management practices in generic services (Wagg, Lowe, Peel, & Potter, 2008). ...
We explored health professionals’ views of implementing a systematic voiding program (SVP) in a multi-site qualitative process evaluation in stroke services recruited to the intervention arms of a cluster randomized controlled feasibility trial during 2011-2013. We conducted semi-structured group or individual interviews with 38 purposively selected nursing, managerial, and care staff involved in delivering the SVP. Content analysis of transcripts used normalization process theory (NPT) as a pre-specified organization-level exploratory framework. Barriers to implementing the SVP included perceived lack of suitability for some patient groups, patient fear of extending hospital stay, and difficulties with SVP enactment, scheduling, timing, recording, and monitoring. Enablers included the guidance provided by the SVP, patient and relative involvement, extra staff, improved nursing skill and confidence, and experience of success. Three potential mechanisms of consistency, visibility, and individualization linked the SVP process with improvements in outcome, and should be emphasized in SVP implementation.
... 20 Another study conducted semistructured interviews to explore clinician beliefs when placing a catheter with acute stroke patients and found practice varied considerably, unwritten rules dominated and clinicians perceived that clearer guidance was required. 21 No published studies have examined clinicians' decision-making for placing an IUC with individual patients or that compared clinical areas within an institution. Understanding clinicians' decision-making is fundamental to designing effective initiatives to change practice. ...
Indwelling urinary catheters (IUCs) placed in acute care are a leading cause of healthcare-associated urinary tract infection. Despite initiatives to minimise the placement of IUCs, levels of inappropriate use are still considered unacceptable. IUC practice is difficult to change, and factors influencing clinicians' decisions need to be better understood.
To explore why clinicians decide to place IUCs in acute medical care.
We conducted a qualitative study in the emergency department and acute medical wards of a 1200+ bed hospital, undertaking 30 retrospective think aloud and 20 semistructured interviews with nurses and physicians who made the decision to place an IUC. A purposive sample and thematic analysis were used.
Opinions on when an IUC was warranted varied considerably. Inconsistency in decision-making was caused by differing beliefs on when an IUC was appropriate for each clinical indication. Numerous patient and non-patient factors, including clinical setting, resources, patient age and gender and staff workload, also impacted on each decision. Assessing when the benefit of an IUC outweighed the risk could be problematic due to conflicting goals.
These findings help to explain why clinicians sometimes deviate from IUC best practice guidance and resist interventions to modify practice. In order to engage nurses and physicians in change, interventions to reduce IUC use should acknowledge and respond to the complexity and lack of clarity often faced by clinicians making the decision to place an IUC. However, it is equally important that inconsistencies in IUC-related beliefs are recognised, investigated and, where appropriate, challenged.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
... Lack of policy, assessment and documentation has been observed 14,24 together with a lack of communication with patients and their families in relation to catheterisation. 24 ...
Investigate the perspectives of patients and nursing staff on the implementation of an augmented continence care intervention after stroke.
Qualitative data were elicited during semi-structured interviews with patients (n = 15) and staff (14 nurses; nine nursing assistants) and analysed using thematic analysis.
Mixed acute and rehabilitation stroke ward.
Stroke patients and nursing staff that experienced an enhanced continence care intervention.
Four themes emerged from patients' interviews describing: (a) challenges communicating about continence (initiating conversations and information exchange); (b) mixed perceptions of continence care; (c) ambiguity of focus between mobility and continence issues; and (d) inconsistent involvement in continence care decision making. Patients' perceptions reflected the severity of their urinary incontinence. Staff described changes in: (i) knowledge as a consequence of specialist training; (ii) continence interventions (including the development of nurse-led initiatives to reduce the incidence of unnecessary catheterisation among patients admitted to their ward); (iii) changes in attitude towards continence from containment approaches to continence rehabilitation; and (iv) the challenges of providing continence care within a stroke care context including limitations in access to continence care equipment or products, and institutional attitudes towards continence.
Patients (particularly those with severe urinary incontinence) described challenges communicating about and involvement in continence care decisions. In contrast, nurses described improved continence knowledge, attitudes and confidence alongside a shift from containment to rehabilitative approaches. Contextual components including care from point of hospital admission, equipment accessibility and interdisciplinary approaches were perceived as important factors to enhancing continence care.
© The Author(s) 2015.
Background
Urinary incontinence affects around half of stroke survivors in the acute phase, and it often presents as a new problem after stroke or, if pre-existing, worsens significantly, adding to the disability and helplessness caused by neurological deficits. New management programmes after stroke are needed to address urinary incontinence early and effectively.
Objective
The Identifying Continence OptioNs after Stroke (ICONS)-II trial aimed to evaluate the clinical effectiveness and cost-effectiveness of a systematic voiding programme for urinary incontinence after stroke in hospital.
Design
This was a pragmatic, multicentre, individual-patient-randomised (1 : 1), parallel-group trial with an internal pilot.
Setting
Eighteen NHS stroke services with stroke units took part.
Participants
Participants were adult men and women with acute stroke and urinary incontinence, including those with cognitive impairment.
Intervention
Participants were randomised to the intervention, a systematic voiding programme, or to usual care. The systematic voiding programme comprised assessment, behavioural interventions (bladder training or prompted voiding) and review. The assessment included evaluation of the need for and possible removal of an indwelling urinary catheter. The intervention began within 24 hours of recruitment and continued until discharge from the stroke unit.
Main outcome measures
The primary outcome measure was severity of urinary incontinence (measured using the International Consultation on Incontinence Questionnaire) at 3 months post randomisation. Secondary outcome measures were taken at 3 and 6 months after randomisation and on discharge from the stroke unit. They included severity of urinary incontinence (at discharge and at 6 months), urinary symptoms, number of urinary tract infections, number of days indwelling urinary catheter was in situ, functional independence, quality of life, falls, mortality rate and costs. The trial statistician remained blinded until clinical effectiveness analysis was complete.
Results
The planned sample size was 1024 participants, with 512 allocated to each of the intervention and the usual-care groups. The internal pilot did not meet the target for recruitment and was extended to March 2020, with changes made to address low recruitment. The trial was paused in March 2020 because of COVID-19, and was later stopped, at which point 157 participants had been randomised (intervention, n = 79; usual care, n = 78). There were major issues with attrition, with 45% of the primary outcome data missing: 56% of the intervention group data and 35% of the usual-care group data. In terms of the primary outcome, patients allocated to the intervention group had a lower score for severity of urinary incontinence (higher scores indicate greater severity in urinary incontinence) than those allocated to the usual-care group, with means (standard deviations) of 8.1 (7.4) and 9.1 (7.8), respectively.
Limitations
The trial was unable to recruit sufficient participants and had very high attrition, which resulted in seriously underpowered results.
Conclusions
The internal pilot did not meet its target for recruitment and, despite recruitment subsequently being more promising, it was concluded that the trial was not feasible owing to the combined problems of poor recruitment, poor retention and COVID-19. The intervention group had a slightly lower score for severity of urinary incontinence at 3 months post randomisation, but this result should be interpreted with caution.
Future work
Further studies to assess the effectiveness of an intervention starting in or continuing into the community are required.
Trial registration
This trial is registered as ISRCTN14005026.
Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 26, No. 31. See the NIHR Journals Library website for further project information.
Background: Urinary tract infection is a leading cause of healthcare associated infection in hospitals with around half of these being attributable to indwelling urinary catheters. Overuse of urinary catheters in healthcare settings is a known problem yet the extent to which it is possible to avoid catheter use is unclear. Urine output monitoring is one of the main indications for short-term catheter use, with acute kidney injury (AKI) and sepsis as key drivers to detect oliguria (low urine output). However, published guidance lacks clarity on when a catheter is needed for urine output monitoring, fueling uncertainty and potential for overuse in clinical practice. Aim: The aim of this research is to explore how and why urine output is monitored in acute medical environments. Methods: A sequential, explanatory mixed methods study was designed. Two approaches to data collection were used: a point prevalence survey of 17 medical wards, using the whole source population as the sample and analysed using descriptive statistics, followed by a focused ethnography in an acute medical unit and a medicine for older people ward using a purposive sample and reflexive thematic analysis. Findings: The prevalence survey identified 107/389 (27.5%) patients had an indwelling urinary catheter. Almost half (n=49/107; 46%) were placed solely for the purpose of urine output monitoring. Most (n=87/107; 81%) catheters had a urine meter attached to enable 1-2 hourly measurements, but only 12% (n=7/60) were utilised for this purpose outside of critical care. The focused ethnography revealed how clinicians were influenced both by clinical and non-clinical rationales when justifying the need for a urinary catheter to monitor urine output. Distrust in the use of non-invasive collection methods was a significant contributing factor to catheter use. Conclusion: Urinary catheters are thought to champion the accuracy of urine output monitoring, but it is debatable whether the drive for accuracy is jeopardising rather than improving patient safety. The redundancy of most urine meters outside of critical care in one hospital reveals considerable potential for reduction in urinary catheters and thereby in catheter-associated infections. However, uncertainty about the reliability and practical application of non-invasive approaches for urine output monitoring is likely to hinder such reduction and requires further investigation.
While most acute treatments could still be given to a limited number of patients with stroke, stroke unit care has the advantage of being suitable to almost all stroke patients. This chapter characterizes stroke unit care, including all aspects of general stroke management that can optimally be delivered in stroke units. There is strong evidence that treatment of patients with stroke in dedicated stroke units results in significantly lower rates of death, dependency, and the need for institutional care compared to treatment in general medical wards. Stroke units are key elements in the organized stroke care pathway, preceded by prehospital and hyperacute care and followed by rehabilitation. This chapter covers stroke care after a patient has received acute treatment and has been transferred to a stroke unit.
