Hypothesis / aims of study
With increasing population age, growth, and obesity, the prevalence of urinary and faecal incontinence and the resultant demand on continence services is an ever-growing problem. Long waiting times for services mean that assessment and management are not delivered in a timely manner, delaying the improvement or resolution of continence problems, and impairing patients’ quality of life. Services must innovate to meet this demand and stream‐line care to provide timely and cost‐effective services.
To address this, we developed and implemented a first‐point‐of‐contact ‘Healthy Bladder, Bowel and Pelvic Floor’ group education session in 2016 and 2017. The aims of this session were to provide timely information on good bladder and bowel habits and basic self‐management techniques that patients could implement while awaiting individual continence assessment. Initial subjective assessment tools were completed and a bladder chart was explained and given out so that patients could complete this before their individual continence assessment. Furthermore, we hoped that implementing this session as the first point of contact would decrease patient non‐attendance to later individual appointments.
Study design, materials and methods
The information for the group education session was developed in consultation with all staff members in our multi‐disciplinary continence team, which included highly training continence nurses, physiotherapists, geriatricians and a dietician. This education session was delivered once a month to newly referred patients who spoke and understood English and did not have cognitive or physical impairments that would prevent them from attending or understanding the information. The process for booking patients into, and the content of, the sessions was implemented, evaluated and refined over 2 years. Patients who attended the group were given feedback forms to complete at the end of the sessions, with a form using a 5-point Likert scale ranging between strongly agree to strongly disagree implemented from December 2018. A sample of 49 consecutive patients (who attended from 28/2/2018 to 13/02/2019) later completed a short subjective assessment on any self‐management strategies they had implemented.
Data on patient attendance to their individual continence assessment appointments, patient eligibility and attendance to the group information session, and staff time allocated to the group information session was accessed retrospectively from the clinic bookings and recording systems, Harrison Scheduler and HMS, while staffing levels were accessed from the Health Service staffing reports, for the baseline period (January 2015‐June 2015 inclusive) before the implementation of the group sessions and the intervention period (January 2018‐June 2018 inclusive) when the group process had been finalised and fully implemented at both sites.
Results
Table 1 shows the number of referrals, number of patients allocated an individual assessment appointment, staffing levels, waiting times and patient non-attendance (DNA) levels in the baseline and intervention time periods.
A total of 351 patients were booked for individual assessment appointments in the baseline period and 366 in the intervention period. In the intervention period, 20.22% of patient booked for initial assessments were allocated to the group education session. Of these, 10.81% cancelled the group session in advance and 9.46% did not attend their scheduled session, without cancelling in advance. Patients who did not attend their group session either with or without cancelling in advance, were more likely to not attend their individual assessment appointment, than those who did attend the group session, with 60% (9/15) of non-attenders to the group session also not attending the individual assessment appointment, compared to 9% (5/56) of those who attended the group session.
Patient feedback about the group sessions was overwhelmingly positive, with 96% (23/24) of attendees agreeing or strongly agreeing that the group was relevant and easy to understand, and 92% (22/24) of attendees agreeing or strongly agreeing that the group was interesting. All patients completed self-reported outcome measures at the group session and 88% (43/49) of patients brought a properly completed bladder chart to their individual continence assessment session. Furthermore, 78% (38/49) of patients reported that they had implemented new self‐management techniques after attending the group session.
The number of referrals increased from 458 in the baseline period to 479 in the intervention period. Staffing levels were 5.39 equivalent full-time (EFT) staff in the baseline period, and 5.36 EFT in the intervention period, with average unplanned leave rates of 0.49 EFT in the baseline period and 0.69 EFT in the intervention period.
Overall non‐attendance to individual assessment appointments for all patients, whether they were allocated to the group sessions or not, were similar between the two periods, with a slight increase in the intervention period. In the intervention period, 16.67% of patients did not attend their booked individual assessment appointments, without prior cancellation, compared to 15.60% of patients in the baseline period.
Waiting times to first contact increased from an average of 71 days in the baseline period to an average of 101 days in the intervention period, while waiting times to first individual assessment appointment increased from 71 in the baseline period to 118 days in the intervention period. In contrast, the average waiting time for a group session was 61 days.
Interpretation of results
Introducing a first point‐of‐contact ‘Healthy Bladder, Bowel and Pelvic Floor’ group education session provided an early point of contact for patients to access condition-specific health information and start assessment tasks, while awaiting their individual continence assessment.
Because patients who attended the group session completed patient‐reported outcomes and were likely to bring a completed bladder diary to their individual appointment, clinicians did not need to complete these tasks within this assessment appointment. This allowed clinicians to focus on individualised assessment and treatment.
Non-attendance a group education session may predict non-attendance to individual assessment appointments. A group education session could possibly be used to filter out patients who are less likely to attend appointments, while minimising the impact on clinic utilisation. In our intervention period, we still booked individual assessment appointment for patients who did not attend the group session if they requested this. Based on the non-attendance rate of these patients to individual assessment appointments, we now require them to attend a group session first, unless they have a medical reason that would prevent them attending or understanding the session.
The waiting time to first face-to-face contact was 44% longer in the intervention period. As our concerns about increasing waiting times were our reason for implementing the group, an increase in waiting times did not surprise us, although it was larger than we expected. We plan to repeat this data collection for our 2019-2020 waiting times in order to assess whether there has been a reduction in waiting lists in the time since the 2018 intervention period.