The NICE guideline on the assessment and management of women with urinary incontinence provides recommendations ranging from initial assessment to specialist techniques.
The Liverpool Women’s Hospital provides services in line with these recommendations for all women with urinary incontinence within their locality. Clinicians in primary care identify women with urinary incontinence and then refer the patient directly to Liverpool women’s hospital for initial assessment and resulting management.
This example was originally submitted to demonstrate implementation of NICE guideline CG174. The guideline has now been updated and replaced by NG123. The example has been amended to reflect this and remains consistent with the updated guideline. NG123 should be referred to if seeking to replicate any aspects of this example.
Aims and objectives
• To provide high quality care for women with urinary incontinence in line with NICE guidance
• To enhance patient outcomes and patients satisfaction
• To offer a service to GP’s to assess and manage their patients with urinary incontinence
Reasons for implementing your project
Liverpool Women’s Hospital has had a urogynaecology service since early 1990’s and the hospital is a stand-alone centre focused on the care of women and babies. This has meant that for many years experts and specialists in urogynaecology have worked at the hospital and have continued to drive forward developments and enhancements to the services provided. Indeed, a number of the specialists have contributed to the development of NICE guidance which has motivated them to ensure their own services are in line with the recommendations. The current service sits within the urogynae department and is run by 4 sub speciality gynaecologist, 3 nurse continence advisers and 2 women’s physiotherapists and a sub speciality trainee.
The service has two elements:
• The first is the initial assessment and conservative management: This is for women who do not require referral to specialist service in line with the NICE.
This service offers initial assessment and conservative management covering the recommendations on Lifestyle intervention, physical therapies, bladder training and pharmacological treatment. The nurse clinician or specialist physiotherapist offers a trial of supervised pelvic floor muscle training in line with NICE recommendations. The initial appointment is for one hour with follow up appointments lasting 30 minutes.
The patient will see the physio 4 times during this trial. The nurse specialist offers bladder training in line with the NICE recommendations for women meeting the criteria.
• The second element is the specialist service offering management of complex cases and invasive interventions in line with NICE recommendations. This service is focused around the weekly multidisciplinary team (MDT). All major cases for surgery and first administration of Botox are discussed at the weekly MDT. There is also inout monthly from a reconstructive Urologist and a separate colorectal MDT.
One of the extremely valuable elements to the way these pathways function is that there is overlap and cross cutting between them. The same team care for patients in both pathways which allows the sharing of expertise and resources. For example the physio could check on a clinical issue regarding a patient in pathway 1 with the speciality Urogynaecologist. Depending upon the outcome this may save the need for a separate consultation with the speciality Urogynaecologist.
How did you implement the project
One of the main levers to supporting continued development of this service has been the way the team have used regulations (CQC), national guidance and opportunities for accreditation (British Society of Urogynaecology) of the service to underpin business cases and implementation projects aimed at enhancing the service.
The team used details of what was expected from these sources to gain senior management support for the changes. As the service has developed a number of methods of capturing patient outcome and experience data have been implemented including employing a data clerk to complete the national BSUG database and purchasing the patient symptom ePAQ service.
The continuous data and information about the service which is now readily available to staff has helped ensure the quality of the care provided continues to be enhanced. Offering this service in community settings has been tried in the past however, the team found that it was often inefficient and patient attendance was low. Offering the service in an easy to access location and in a setting where the team are familiar with the systems and processes and have access to colleagues with expertise in the area has been found to be the most effective and efficient was to offer the service.
This pathway has been embraced by the local GP’s.
Within the local area there are a number of male lone GP practices. For some patients this may be a barrier to presenting or may influence their satisfaction of the service. A service which cares for patients from initial assessment helps address this need for local GP’s. They are charged a new patient attendance but it is a one-stop service with the nurse or physiotherapist.
Pathway 2 :
The MDT reviews all women in whom invasive therapy for OAB and/or SUI symptoms is offered in line with NICE guidance recommendation 1.1.1.
MDT’s were first started in 2008 and is incorporated into job plans as a 2 hour meeting. The first part of the meeting is dedicated to cases and the second part on team business for example research, the database, outcomes, meeting with management and organising capacity and demand etc. The MDT comprises of the relevant members identified in recommendation 1.1.2 of the NICE guideline.
Owing to the fact the women’s hospital is standalone, the urologist and colorectal surgeon are not able to attend weekly therefore, the urologist comes monthly to the MDT and for the colorectal surgeon the relevant cases are saved for the monthly colorectal MDT at Liverpool Royal Hospital.
An audit was carried out with the aim to evaluate physiotherapy quality of care at Liverpool Women’s Hospital by assessing patient reported outcome measures (PROMs) in the form of the electronic questionnaire ePAQ. This audit includes 94 patients consecutively discharged from the Physiotherapy Department, although the plan is to continue to collect data and audit outcome measures on an ongoing basis.
The following criteria were used based on best available evidence:
- Rates of combined cure and improvement for SUI with PFM training have been reported in the range of 65-75% (Abrams et al., 2005; Fan et al., 2013).
- A Cochrane review showed that improvements in POP symptoms were seen in 67-74% undergoing PFMT (Hagen & Stark, 2011).
- ePAQ It is a valid, reliable and valuable tool for the comprehensive evaluation of pelvic floor symptomatology in women and the assessment of symptom responsiveness to implemented therapies. Patients attending the Urogynaecology Department should complete an ePAQ prior to their consultation as part of their routine clinical care.
- On completion a printout is available and domains scores are presented both graphically and numerically providing both an overview as well as details of PFM problems.
- Every patient discharged from the Physiotherapy Department is asked to complete a new ePAQ in the Department (some choose to complete it at home due to different circumstances). The ePAQ system reports on symptom score, degree of bother and quality of life (QoL) score.
The software provides analysis from a set of questions covering 4 main dimensions:
1) Urinary/bladder function
Each of these dimensions contain four or five domains (total of 19 domains), each comprising between 3 and 7 items.
All items are scored between 0 (best health status) and 3 (worst health status). The 19 domains are finally scored on a scale form 0-100, lower scores indicating lesser symptoms and better health status.
Our results found that: high percentages of patients were discharged to GP (77%), constituting an indicator of physiotherapy treatment success. Another indicator of treatment success was the overall condition change of “much better” or “somewhat better”, which 78% of discharged patients reported. This represents the overall improvement in all patient symptoms, rather than measuring improvement in specific domains. Most bothersome symptoms reported by patients in the Physiotherapy Department are SUI, OAB, and POP. SUI (64.5%), OAB (66.7%) and POP (90% ) of patients presenting with the above complaints felt improved or cured after physiotherapy intervention, therefore meeting the standards set out in this audit.
Key learning points
• Design and develop the services to reflect local circumstances
• Use national guidance, regulations and opportunities to showcase your service to gain support from senior management for the improvements you want to make
• Drive the team to keep up to date with recent developments in the field by attending significant meetings and conferences. In Liverpool ran and organised the annual United Kingdom Continence Society conference in 2012. Following that the team were motivated to again look at their service and see how it could be improved.
• Think flexibly for example take some MDT meetings to the specialists who are not on site. Consider teleconference facilities to get the MDT together or where perhaps only one urogynaecologist is at an organisation consider creating an MDT between a few similar organisations.