Selena Walsh

Name
Alexandra McKay

Role
Trainee Advanced Nurse Practitioner 

Place of work
Emergency Department, East Lancashire Hospitals NHS Trust 
 
Background 
Acute Urinary Retention (AUR) should be treated as a urological emergency needing urgent management including catheterisation to relieve pain and discomfort. Nationally it is a common presentation and in a 12-month period, 367 men attended the ED at ELHT.
 
An audit into the management of 27 patients revealed that thirteen areas of care, were not compliant with CEM (2013) and NICE (2015) guidelines. The findings included:

• 81% of patients waited over an hour for catheterisation.
• 74% of patients were admitted, 17% of these inappropriately and discharged within 24 hours.
• 71% of discharged patients did not have appropriate district nurse referrals.
• 57% of discharged patients did not have appropriate Urology referrals.

 
Aim 
To design, develop and implement a (male) AUR care bundle to reduce the variation of care by standardising practice and management as outlined by CEM (2013) and NICE (2015) national evidence based guidelines.
 
Method 
The bundle was devised in conjunction with key stakeholders, addressing the areas in need of improvement which were identified within the initial audit.
 
Lewin’s (1947) three stage change management model was used to assist the bundle’s implementation into the daily working ethics of the department by;

• Presenting audit results to key stakeholders at departmental, divisional and Trust level - sharing findings and vision.
• Devising a training skills matrix in male catheterisation to identify any skill deficits amongst staff. Training sessions were given to increase staff capabilities, facilitating prompt catheterisation.
• Introducing Tamsulosin within the ED for prescriptions where retention is secondary to benign prostatic hyperplasia.
• Produce a comprehensive patient discharge pack, which included information about AUR and its management with additional urine bags and night stand.

 
Evaluation 
A formative Plan, Do, Study, Act evaluation (Langley et.al, 2009) was used to implement, test and further develop the bundle using key stakeholder’s feedback following a trial period of one month. This successful stage, led to a six-month summative trial period from the 27th June 2016. Donabedian’s (1966) structure, process and outcome model was used to evaluate the quality of care given. A re-audit against the initial standards was carried out using 27 randomly selected patients along with a reassessment of male catheterisation skills amongst staff.
 
Conclusion 
The bundle ensures safe, personal and effective care to men with AUR. Encouraging timely evidence based care. Hospital admissions have been reduced along with the facilitation of comprehensive and safe discharges home where appropriate support networks are put in place.
 
Three key learning points
 
1. Importance of effective communication and the time needed to share a vision in detail.
2. How one project can lead to identifying new areas in need of innovation.
3. Encourage and embrace ideas and suggestions from others.