Management of Urinary Incontinence in females: Are we really NICE?

Urinary incontinence (UI) is a common symptom that can affect women of all ages, with a wide range of severity and nature. While rarely life-threatening, incontinence may seriously influence the physical, psychological and social wellbeing of affected individuals. The impact on the families and carers of women with UI may be profound, and the resource implications for the health service considerable. Urinary incontinence is distressing and socially disruptive. It may be the cause of personal health and hygiene problems. It may restrict employment and educational or leisure opportunities, and lead to embarrassment and exclusion.

Aims and Objectives:

• To evaluate the implementation of the NICE guideline on the management of urinary incontinence in women
• To assess the work of the multidisciplinary team (MDT) based on the NICE guideline

Cornwall has a population of 550,000, average age range of 50-70 years. 99.5% population is caucasian. There is an excellent continence service consisting of community based team (consultant continence nurse specialist, 2 specialist nurses & 2 physiotherapists) who work closely together with a team of 7 gynaecologists with interest in urogynaecology with the leadership of lead subspecialist urogynaecologist at The Royal Cornwall Hospital (RCHT).

With the initiation of subspecialist urogynaecology clinics, a need was assessed of regular education and teaching to ensure on-going compliance to NICE guidance on urinary incontinence. The team conducted an audit to assess compliance to NICE guidelines on urinary incontinence when referred to secondary care. They noted that every 4-6 months, compliance to referral for conservative measures (pelvic floor physiotherapy, bladder retraining and life style modification) needed re-emphasis. It was also noted that there were no multidisciplinary team reviews for women with overactive bladder (OAB) or stress urinary incontinence (SUI) symptoms before they were offered surgery or other invasive treatment.

They registered and conducted an audit of 50 case notes to assess compliance to NICE guidelines on urinary incontinence when referred to secondary care. A proforma was completed and results were collated. They noted that women who had not received conservative management were needed to be sent back to primary care for conservative measures and this added to the waiting time, patients' inconvenience, consultant time in GOPD and ultimately an added cost.

The team met with the GPs and pathways team to emphasise the importance of adhering to the referral pathway for female UI (in concordance with NICE guidance). Feedback was received from primary care that they would prefer a simpler 'easy step' guide to assess women with symptoms of UI.

The community continence team and gynaecologists at RCHT therefore worked together and developed an 'easy step' referral pathway for women with symptoms of UI. This has been in use now and has now ensured a more streamlined and easy to follow guidance pathway. Overall, this has improved patient satisfaction and has improved appropriate referrals to the secondary care service thus saving costs. Moreover, quite a few women when appropriately received conservative management, did not require referral to secondary care, again saving cost and avoiding unnecessary medical and/or surgical intervention.

Barriers:

• Pressures to see the patients soon (e-mails and telephone calls to see the patients soon)-bypassing guidance.
• Waiting time to see consultant was more (by 8-12 weeks) if inadequately referred in the first instance. This creates inconvenience for the patient.
• Rejection of referral (12/50 referrals were rejected during the audit period) - disappointing for the patient and doctor.

How did the team overcome the barriers?

•  Referrals were audited based on NICE guidance and based on the audit results, we have now developed an 'easy step' guide for referral pathway for management of women with symptoms of UI.
• They noticed a need for regular re-education and refreshing of knowledge of the subject. Therefore we arranged for regular teaching sessions every 6 months for GPs.
• Compliance to NICE guidance on UI is now conducted as a rolling audit every year and results are disseminated to the staff.
• A need for Urogynaecology nurse specialist was identified and subsequently approved. The post holder would also be contributing towards on-going education and teaching.
• Lack of MDT review process was identified. The need for this was emphasised to the Trust and to the directorate with special reference to compliance with NICE guidance.

The team registered and completed the audit based on compliance to NICE guidance on UI and its quality standards and presented the results in our governance meeting. The audit results were very well received and were disseminated to all relevant staff.

Key results included:

• The need for regular teaching on management of UI especially conservative management was identified.
• Need for making referral criteria 'Easy To Follow' was identified. We have now developed and implemented an 'easy step' guide for management of women with UI.
• Lack of MDT review process was highlighted, its importance and need was emphasised to the directorate in line with NICE recommendations.

After the introduction of easy step guide for referrals to the continence service, we re-audited 50 case notes and noticed 99% compliance to NICE guidance on UI. This audit is now a mandatory yearly rolling audit in our directorate.

The need for an MDT review was identified for women with overactive bladder (OAB) or stress urinary incontinence (SUI) symptoms before they were offered surgery or other invasive treatment. A team of subspecialist urogynaecologist, gynaecologists, consultant of care of the elderly, consultant continence nurse, physiotherapists and urogynaecology nurse specialist now meet regularly. This is a voluntary initiative for most of the team. However, with time and with demonstratable improvement in patient outcome measures, we hope for the MDT review to be acknowledged and be accepted as a regular part of the job specification of the team members.

The team have avoided 10-14 unnecessary referrals/month. There was an estimated cost saving of £4810-6734/month (saving £481/patient on an unnecessary referral [£131 for consultation and £350 for unnecessary urodynamics).

Moreover, urodynamics would be an unnecessary invasive test which can also lead to UTI, patients feel embarrassed during the test. Whereas dedicated pelvic floor muscle exercises may improve patients' symptoms and they may not need urodynamics. This is in addition to patient's inconvenience to attend for an appointment which could have been avoided and also adds to physical and emotional stress of a consultation and examination especially when is not required or may would be repeated after a conservative treatment.

• Make it easy: If the referrers find it difficult to follow a complex pathway, it is unlikely to work. Therefore, make it easy for them and this would make things easier for you as well as for the patients. I have attached the 'easy step' guide to this document for those who want to access it.
• Human factor: It is included as a 'human factor' reason 'to default back to old days' every now and then. Regular education and teaching has proven to improve outcomes in many subjects and proved to be the case in our NICE compliance audit.
• Make a start! Make an initiative!: The team started regular MDT review process on a voluntary basis in our own time. With passing months, the directorate is acknowledging its importance and would hopefully be accepted as a regular session. MDT review process improves patient safety by offering patients adequate and thorough assessment of their symptoms, avoiding unnecessary/complicated medical/surgical interventions.