P-BAG Hospital Trial
by Susan Foxley Consultant Nurse, Ruth Baadjies Clinical Nurse Specialist – Continence Care. Kings College Hospital NHS Foundation Trust, London. UK
How one simple solution can improve lives for those with urinary incontinence
Introduction
Continence is a skill basic for everyone that lives in a complex social environment. Helping people achieve continence or manage incontinence is a core essential nursing skill used on a daily basis suggests (Norton 2001) furthermore this significantly increases patient dignity and quality of life. Historically methods of urinary collection have favored the male gender; it is only in recent years that portable urinary collection devices for both genders have been available.
Previous product evaluations reveal that urinary collection devices that aid continence do not come without their problems as is outlined later in this article; the results of a small survey undertaken in secondary care of a new portable urinary collection device will be shared.
The user
Early reports of urinary incontinence date back to Egyptian times highlights (Gomez 2003), what's more Greek medicine outlined several cures for incontinence, which originated from the work of Hippocrates in 460 – 377 BC (Murphy 1972). Seeking to cure incontinence Gomez (2003) describes early remedies such as an infusion of white chrysanthemums in lukewarm water, or to consume a powder made from burnt cock’s testicles. Alternatively, the sufferer could attach a frog to his belt (Gomez 2003).
Getliffe and Dolman (2003) highlight the fact that during the 19th Century the effect of certain food and drinks upon the bladder’s function was identified. Gomez (2003) urges the sufferer to refrain from tea and coffee. Bonner (2005) advocates this continued advice. Taking a further positive approach in searching for a cure for incontinence, one could pray to the patron saint of incontinence Saint Catherine of Alexandria (Catherin 2006). On the other hand is it purely the selection of the most appropriate continence product to suit a users needs that could simply solve a short or long term continence problem?
Most nurses’ will see patient’s with continence problems every day, but might not necessarily recognize that they have a difficulty with continence, because this is not usually the presenting problem. It is likely to be in addition to existing health problems possibly those of a chronic nature.
Patients with continence problems present a challenge to nurses’ particularly if their incontinence is a consequence of an acute health problem. While the acute health problem may need to be dealt with immediately, the use of containment measures such as continence pads and urinary catheters without a through continence assessment can have a detrimental effect on the patient’s health and well- being.
There are many demands on the time of health care professionals; nurses must prioritise their workload as a continence assessment may be a low priority among other pressing needs. Nonetheless incontinence has a high priority with patients and carers.
Potential portable urinal users
A full continence assessment precedes any issue of a continence management product to the patient and this ideally should be undertaken over a period of time enabling full comprehensive bladder and bowel assessment. The assessment needs to be undertaken by a competent practitioner (Skills for Health, 2008) who demonstrates a sensitive and supportive approach to continence care. Those patients who may benefit from a portable urinal could include:
- Patients to use as an aid to promote independence
- Those with mobility problems
- Patients with Chronic Obstructive Airway Disease and associated breathing difficulties
- Wheel – chair dependency
- Post-operative during the acute phase
- Post orthopedic surgery – hip and knee surgery
- Bed-bound
- End of life care those on the Liverpool Care Pathway
- Neurological disability including Stroke and Multiple Sclerosis
- During an invasive clinical procedure like urodynamic investigation
- Emergency Room treatment
- Those with poor toilet access
- At night to reduce risk of falls
- Dementia and those who are confused
- Those with a chronic health problem
- Care home residents the frail elderly
- Obese patients
- Symptoms of urgency to void preventing urgency incontinence
Literature review
Fader et al (1999) indicated that there was little published information pertaining to female urinals in particular these would be used for women to empty their bladder whilst away from the toilet thus promoting greater independence. Supplementary work by Fader and Cottenden (2007), undertaken during 2003 – 2005, involved designing and producing a non-invasive continence management system. Initially the system was rated as “good” by 75% of users however reliability, product size, weight and noise gave negative feedback. White (1999) advocates that hand held urinals have the capability of escalating independence for those with limited mobility suffering from the additional misery of a continence problem.
Macintosh (2001) and Vickerman (2003) both reviewed the product designs available and their suitability for use in women with limited mobility concluding that these particular products do increase independence in toileting for this client group.
Evans (2005) describes that when men are offered specific products like male urinals to suit their individual continence care needs their quality of life drastically improves when accessibility to the toilet is limited.
Macaulay et al (2006) undertook a review of the range of female urinals available for women with impaired mobility and concluded that female urinals can provide a very acceptable alternative for those with difficult toilet access and to using disposable containment products. Additional work by Vickerman (2006) looked at selecting urinals for male patients concluding that an appropriately selected urinal that meets the patient’s needs can significantly enhance his quality of life.
Interestingly Cottenden (2008) indicates that there is Level 3-4 evidence for female urinals for specific groups of patients in need particularly those with mobility and poor access to toileting facilities. However particular consideration is required for those patients that demonstrate problems such as the inability to stand, crouch, or move forward in a chair possibly indicating that these products are difficult to use.
Sanicare (2009) a company with a focus on aged care report on an Australian trial of the P Bag in surgical and “aged” care wards over a two month period as part of its ongoing assessment of new products aimed at continence promotion. Thirteen survey forms were returned and demonstrated very positive findings namely that the “success of the P-Bag at ward level is determined by the ability of the nursing staff to educate, support and encourage patients in its use”. Interestingly the fact that the P Bag was quicker to use and used up less nursing time than putting the patient on a bed pan was an important factor raised by the participants in the trial.
The “P” Bag
A new urine collector featuring a compact design and non-spill capability has been designed for both genders, marketed by Verathon Medical. The company is marketing the product highlighting the positive features listed in Box 1
Box 1
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- Increases ward storage space as the bags can be flat packed
- Reduces the need to lift patients before voiding
- Perform visual checks on urinary output and restore patient independence and dignity
- Reduce nursing time required for emptying / assistance tasks
- Saves time and money while providing better environment for patients and personnel
- Substitute for bedpan and urine bottle in emergency and nursing wards
- Substitute for where it is difficult to use the toilet
- For patients on rehabilitation or wheel chair users
- No washing of bedpans / urinals
- Less changing of bed linen through spills
- P Bag closes after use and does not emit unpleasant odours.
- Can be used comfortably by patients
- Patients often do not need assistance to use product
www.verathon.co.uk accessed 3rd August 2009
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The system comes in two parts a re-usable funnel that is anatomically shaped with a functional handle and disposable bags which can hold up to 1500 mls of urine when at capacity. There are currently two different types of bags available:
1. clear plastic with graduated markings to ease measurement
2. one with a super-absorbent solidifying agent.
Each bag features a one way valve which prevents spillage and reduces odour see Fig 1
Fig 1
Pictures taken from Verathon web site and used with their kind permission
Product Evaluation
Product evaluation of the new urinary collection device was undertaken in secondary care over a one month period, twelve clinical areas took part Box 2
Box 2
- Emergency Department
- 2 Orthopedic wards
- Stroke Unit
- Private Patients Ward
- Neurological Rehabilitation Ward
- Neurosurgery
- Neurological out-patients
- General Medicine
- Health Care of the Elderly
- Mental Health Ward
- Urogynaecology - Urodynamic Clinic
The limited availability of the new portable urinary collection device only allowed 70 products to be evaluated within the selected clinical areas. These particular areas were selected intentionally to give good all round feedback from different user groups throughout the hospital. Informal nursing staff education was undertaken within the ward environment in the form of a product demonstration on the use of the P Bag with individual staff and patient groups. Interestingly the initial verbal feedback from staff was that “it would be easy to use” no problems were envisaged.
59 completed evaluation forms were returned, 11 forms were unreturned, several ward staff stated that they were “too busy” to complete it, but may do so at a later date!
A structured evaluation form see Box 3 was completed by the health care professional after assisting the individual patient to use the P Bag.
Box 3
| Question. Please give one answer only eithe YES or NO | Yes | No |
| Did you find the P Bag easy to assemble? | ||
| Did you find it easy for the patient to use? | ||
| Did the product leak? | ||
| Did the successful use of this bag avoid the patient being catheterised? | ||
|
Was the patient?
|
||
| Gender and age of patient |
Gender: _____________ |
Age: _________ |
Evaluation results
taken from the 59 completed returned evaluation forms Box 4
Box 4
| Question | Yes | No |
| Did you find the P Bag easy to assemble? | 57 | 2 |
| Did you find it easy for the patient to use? | 43 | 16 |
| Did the product leak? | 17 | 42 |
| Did the successful use of this bag avoid the patient being catheterised? | 49 | 10 |
|
Was the patient?
|
28 14 39 14 |
“other problems” cited some positive and negative responses from users these included:-
The P Bag was used during an uro gynaecological investigation; the patient had mental health problems including depression and behavioral issues; male patient who had suffered a stroke found the P Bag easier to use with one hand than a urinal; patients who were predominantly right handed and for one reason or another this hand was compromised they had difficulty using the product with their left hand, used for clean urine specimen collection thus avoiding an invasive procedure like intermittent catheterization for this to be obtained ; female patient did not like the nurse assisting her with the use of the P Bag; when the P Bag was left in situ for more than ten minutes a red mark appeared around the gentalia in both genders, possibly from pressure of keeping the product in place. Additionally an obese female patient found that the P Bag cut into the top of her legs.
Gender of patients
Age of patients who took part in the evaluation
Results
47 women aged between 18 – 90 years of age and 12 men aged between 40 -81years of age took part in the P Bag evaluation.
57 participants found the P Bag easy to assemble and easy to use as an alternative to a bedpan or disposable containment product. The fact that the product leaked in 17 cases was not associated with the advancing age of the user or the more compromised their mobility was. Clearly in the initial phase of the evaluation some users demonstrated a difficultly using the product due to lack of education on its successful use. This was easily resolved with patient education and repeated successful use of the product by the user.
Nine women aged over 75 years of age commentated on the fact that the P Bag was uncomfortable to use and that they felt undignified using it stating it was more like a “male thing”! These women were totally against trying the product again.
A reduction in those patients who would initially have been catheterised via the urethra was most significant and was seen as one of the most positive outcomes of the product evaluation this amounted to 49 out of the 59 patients in total.
Most patients in the evaluation experienced some form of limited mobility whilst 28 were completely bed bound. 14 specifically were recovering from orthopedic surgery.
Case studies
Case study 1
Rehabilitation following his extensive stroke proved very challenging for Mr A aged 74 years appreciably it was going to take a very long time. Urinary incontinence was an added hindrance he could not accept. Mr A found it extremely difficult to use the male urinal offer him on the ward, especially as he only had the use of one arm! Plus every time he put the near full urinal down he spilt it. The P Bag proved a suitable alternative he used successfully.
Case study 2
The ward nursing staff was desperately trying to obtain a clean specimen of urine from a most difficult patient. The avoidance of catheterizing the patient was paramount therefore the use of the P Bag was suggested, the urine specimen was obtained successfully with great relief all round.
Case study 3
Mrs R aged 85, was undergoing a period of enforced bed rest postoperatively. The nursing staff keen to avoid catheterizing the patient tried the P Bag as a appropriate alternative to the conventional bed pan. “I cant use that it’s a male thing” shouted Mrs R. “I am not holding that there”! It also proved difficult to position the product correctly as Mrs R weighted in excess of twenty stone. “Its cutting into me – get it away” A slipper bed pan proved a more acceptable option but urine spilt out when it was removed.
Discussion
The P Bag appears to be a fairly new continence product to the British market despite being successfully evaluated in the secondary care environment in Australia and New Zealand during 2005.
Gettliffe and Dolman (2003) affirm that urinals available for women have design features that are more suitable for men. The P-Bag produced has been designed with a woman’s perspective as it has a funnel shape that fits the perineal area snugly allowing women to void without needing to use a bedpan if bed bound or even a commode if their mobility is compromised. Annotations made from patients who have tried using this product interestingly incorporated the declaration that men no longer have the advantage of using a hand held urinal in the bed or even to voiding standing up as the device allows you to stand sit or even lie down when you need to void and cannot get to the toilet in time.
For several other women the P-bag has not proved as successful, an 85 year old female stated that it was not comfortable holding the device and that she was not able to place it in the correct position to prevent leaking, an additional patient recovering from hip surgery commented on the fact that it was painful to abduct her legs to position the P-bag correctly and had to use a bed pan instead.
A small number of women found the concept of voiding into a bag unacceptable as it is intended that they should abduct their legs to void which is not a usual method that women employ when voiding. The majority of women when sitting down on a toilet, commode or when using a bed pan will most likely have her legs not spread apart when compared with the usual voiding pattern of men.
An additional factor became apparent during the evaluation, women were not comfortable from a dignity point of view to use the device under the bed clothes as anecdotal evidence indicates that men using hand held urinals where not affected by other men seeing them using a urinal under the bed cloths and would not necessarily ask staff to draw curtains around their bedsides. A recent study undertaken by Alaszewski et al (2009), indicate that people with incontinence problems are particularly vulnerable to a feeling of a loss of dignity. Possibly social and cultural influences learned in early childhood impacts on how an individual responds to challenges faced in successful continence management.
All of the men who participated in the evaluation found the product most acceptable. The P Bag was certainly easy to adapt to their needs, the most positive aspect was the fact that the product did not leak when you put it down, as a consequence avoiding any infection control issues surrounding the spillage of human waste in the clinical environment.
This evaluation clearly demonstrated that the P Bag was a practical alternative to the bedpan or for the patient who would have used a disposable containment product for incontinence. However it does have its limitations and does not prove as an option for all patients thus demonstrating that comprehensive continence assessment has to be undertaken by a competent practitioner before product selection is considered.
Conclusion
The P Bag is acceptable to use in secondary care in a variety of circumstances to suit user need this fact being positively evaluated throughout the evaluation. In addition the use of this portable urinary collection device has certainly paved the way for avoiding inappropriate urinary catheterisation across the Trust noticeably in the Emergency Department and Health and Ageing Unit. Further evaluation of its use will remain ongoing throughout this care environment ideally identifying and reporting any further positive / negative findings ensuring safe evidence-based practice throughout the organization.
References
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Bonner, L. (2005) Behavioural and lifestyle interventions and best practice. In Addison, R (editor) Nurse Led Continence Clinics. Peterborough: Coloplast Limited. p125-141.
Catherin, M. (2006) Saint Catherine of Alexandria Virgin, Martyr C. 310 AD (Online) Available at www.ewtn.com (accessed 1st August 2009).
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Sanicare (2009) A better alternative to bed pans for nurses and patients. Telephone 1800 655 152 available Online at www.sanicare.com.au accessed 7th August 2009
Skills for Health (2008) Published 2008 (0nline) Available at www.skillsforhealth.org.uk Accessed 3rd August 2009
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