Reducing inappropriate urinary catheter use: quality care initiatives Catherine Buckley, Charlotte Clements and Adrian Hopper
Healthcare-acquired urinary infection presents a substantial burden for patients and the healthcare system. Urinary tract infections have not gained the same level of media attention as other healthcareassociated infections, yet interventions to reduce urinary catheter use are one of the top ten recommended patient safety strategies. To improve practice around urinary catheter placement and removal requires interventions to change the expectations and habits of nurses, medical teams and patients regarding the need for a urinary catheter. In the authors’ trust, a redesign of the existing urinary catheter device record was undertaken to help avoid unnecessary placement of catheters, and resulted in a reduction of urinary catheters in situ longer than 48 hours. Other strategies included implementation of catheter rounds in a high-usage area, and credit-card-sized education cards. A catheter ‘passport’ was introduced for patients discharged with a catheter to ensure information for insertion and ongoing use were effectively communicated. Key words: Urinary catheters ■ Catheter-related infections ■ Drug resistance ■ Clinical audit ■ Education
H
ealthcare-associated infections have been linked to significant morbidity and mortality (Fakih et al, 2012). Catheter-associated urinary tract infection (CAUTI) is the most common healthcare-associated infection worldwide and is a result of the widespread use of urinary catheterisation, much of which is inappropriate (Hooton et al, 2010). The third prevalence survey of healthcare-associated infections in England estimated that 31% of hospitalised patients have a urinary catheter during the course of their stay (Hospital Infection Society, 2007). Consequently, limiting the use of urinary catheters is consistently recommended across guidelines to prevent CAUTI (Hooton et al, 2010). This article will discuss the implementation of a strategy to reduce inappropriate use of urinary catheter and to reduce CAUTI in a large NHS trust. In the most recent national audit in England, 43% of patients with a urinary tract infection had a urinary catheter present within 7 days before the onset of infection (Health Catherine Buckley, project nurse; Charlotte Clements, Darzi Fellow and Paediatric Registrar; Adrian Hopper, Deputy Medical Director. all at Guy’s and St Thomas’ NHS Foundation Trust, London. Accepted for publication: March 2015
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Protection Agency, 2012). CAUTI is the leading cause of secondary nosocomial bloodstream infections, about 17% of which are from a urinary source, with an associated mortality of approximately 10% (Hooton et al, 2010). The insertion of a urinary catheter, and the duration of its use, is a contributory factor to the development of a urinary tract infection (Saint et al, 2008). On average, healthcareassociated urinary tract infections necessitate one extra hospital day per patient (Saint, 2000). In many trusts, the numbers of CAUTIs are not routinely measured but where audits have taken place, the rate has been shown to be as high as 32% (Ward et al, 2010). Despite the link between urinary catheters and urinary tract infections in hospitals, no strategy is consistently or universally used to prevent these infections. Although many CAUTIs are not life-threatening, complications of CAUTI can increase a patient’s length of hospital stay and healthcare costs, and may lead to a higher morbidity and mortality (Stevenson et al, 2008). The easiest and most effective method to prevent CAUTI is by restricting the use of a urinary catheter to patients who have a clear indication for one and removing the catheter as soon as it is no longer needed (Tiwari et al, 2012). Despite growing evidence on the role of inappropriate urinary catheter use in the development of CAUTI, data on risk factors associated with inappropriate urinary catheter use are scarce.
Catheter use at the trust The author’s trust is situated in inner London and is one of the largest NHS trusts in the UK. It provides services from two major hospital sites that serve local populations and is a national referral centre for specialist services. It also has integrated community services with over 2 million patient contacts each year. The Safety Thermometer, a local improvement tool that measures, monitors and analyses patient harms and ‘harm-free care’, provided a monthly audit of urinary catheter use. This highlighted that approximately 20% of adult patients across the trust had a urinary catheter in situ at any given time. This prompted the trust to focus on urinary catheter use to ensure that use was appropriate in clinical areas. Interventions to reduce urinary catheter use are one of the ‘top ten’ patient safety strategies that are encouraged for adoption to improve patient safety (Shekelle, 2013).
Healthcare-acquired urinary infection Healthcare-associated infections are a significant issue in the delivery of services for health and have been a priority for government and NHS trusts since 2003 (Chief Medical
© 2015 MA Healthcare Ltd
Abstract
British Journal of Nursing, 2015 (Urology Supplement), Vol 24, No 9
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.102.042.098 on October 4, 2015. For personal use only. No other uses without permission. . All rights reserved.
Figure 1. 48-hour antibiotic initiative on drug chart.
Figure 2. Close-up of the updated device insertion record showing prompts
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indwelling catheters tend to be over-used in treating urinary incontinence (Holroyd-Leduc et al, 2007). Reasons for this increased use include complexities of care, increased acuity, severity of illness, and decreased staffing levels. The literature and anecdotal evidence suggest that urinary catheters are often inserted without an appropriate indication, once inserted remain in situ without proper indications, and are not reviewed in a timely manner in order for them to be removed promptly (Tiwari et al, 2011). In a systematic review that examined strategies to reduce unnecessary use of urinary catheters and associated infections, the influence of nurses was paramount in reducing duration of indwelling catheter and subsequent infections in all the studies included (Meddings et al, 2014). This illustrates the scope for nurses to continue to have a positive effect on this issue. The Berwick review into patient safety recommended four guiding principles to help the NHS get better faster (National Advisory Group on the Safety of Patients in England, 2013: 44). One of these was to place the quality and safety of patient care above all other aims for the NHS. This was, the chairman argued, the safest and best route to lower cost. The authors’ trust has a clear focus on patient safety with a desire to be a world leader in this respect and achieve the best patient outcomes. Reducing inappropriate urinary catheter use and associated risks is an integral part of this agenda.
Initiatives at the trust A working group was set up to examine use of urinary catheter in the clinical areas at the trust. The aims of the catheter safety working group were to reduce avoidable harm to patients from urinary catheters, thereby improving patients’ care and experience, and consequently reduce the costs and implications of treating these harms. Multiple studies of interventions to decrease inappropriate catheter placement have demonstrated a decrease in the use of urinary catheters (Meddings et al, 2010). The interventions and initiatives at the trust were designed to facilitate this with improved awareness of appropriate indication for urinary catheter use and prompt removal of devices when no longer required as a key part of the strategy. Therefore, as part of the drive to improve appropriate use of urinary catheters, a redesign of the existing urinary catheter device record was undertaken. This record was designed to help avoid unnecessary placement of catheters and included prompts that were designed to empower nurses to remove catheters without seeking medical advice if no clear ongoing indication for catheter use was noted. An earlier initiative around antibiotic prescribing had been very successful in reducing inappropriate antibiotic use across the trust. This had involved staff (nurses, pharmacists or medical staff) hand-drawing an amber line on the drug chart at the point marking 48 hours of administration to ensure a clinical review of antibiotic prescription was undertaken at this time (Figure 1). This was emulated in the design of the urinary device record (Figure 2). A printed instruction on an amber background at day 2 of documentation of continued use prompted: ‘Is catheter still indicated? No—remove immediately. Yes— continue to review daily’. The form underwent four ‘plan, do study, act’ (PDSA) cycles and was amended on the feedback
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Officer, 2003). Healthcare-acquired urinary infection presents a substantial burden for patients and the healthcare system. The cost per CAUTI episode has been estimated at £1968 (Ward et al, 2010). Overall the financial burden from CAUTI remains difficult to establish due to a lack of reliable data. Despite these costs, and the effect on patients, urinary tract infections have not gained the same level of media attention as other healthcare-associated infections such as meticillin-resistant Staphylococcus aureus (MRSA) infection and Clostridium difficile. Of much concern is the increase in antimicrobial-resistant Gram-negative organisms (Nicole et al, 2005). Urinary tract infections are increasingly caused by multidrug-resistant organisms including strains that are resistant to all available therapeutic agents (Centers for Disease Control and Prevention, 2012). Presence of a urinary catheter increases the risk factors for acquiring resistant organisms (Shilo et al, 2013). However, infection is one of many potential complications of urinary catheterisation and there are numerous other reasons to reduce the duration of indwelling urinary catheters. Catheterisation can increase sacral skin breakdown due to lack of movement and where sacral pressure ulcers have occurred, catheter-related complications increase because of cross-infection from wound to bladder, potentially increasing risk of bacteraemia in this situation (Royal College of Nursing, 2012). There is wide variation in clinical identification of patients who need to be catheterised as many patients may be catheterised for convenience; therefore long-term
British Journal of Nursing, 2015 (Urology Supplement), Vol 24, No 9
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.102.042.098 on October 4, 2015. For personal use only. No other uses without permission. . All rights reserved.
© 2015 MA Healthcare Ltd
INFECTION PREVENTION received. Staff felt the form was more logical and triggered them to question continued need for the urinary device. Trust-wide audits of urinary catheter use in 33 inpatient wards were undertaken by student nurses before and after implementation of the new urinary catheter documentation. Engaging student nurses to undertake this audit on this important initiative was a meaningful way of helping them understand and identify best practice and ultimately to help facilitate their learning. The audit following introduction of the new documentation demonstrated that duration of catheter insertion had improved from 34% of catheters in situ up to 48 hours before the introduction of the form to 43% in situ up to 48 hours post introduction, indicating that catheters were being removed more promptly. Strategies for the community care settings to reduce avoidable harm to patients from catheters and improve their care focused on long-term catheterisation with agreed standardised care pathways to make catheter management highly reliable. A catheter passport, a patient-held document, has been introduced for patients discharged into the community with a urinary catheter. This ensures that information surrounding the reasons for insertion and ongoing use are effectively communicated to all involved in the patient’s care. Patients and carers are central to improving knowledge of catheter management and to acting rapidly if there are problems. For patients discharged with a catheter, a clear referral pathway to ‘trial without catheter clinics’ was provided to ensure that catheter use was reviewed appropriately. Education around care and appropriate use of urinary catheters was provided by the community continence nurse in very large care homes where district nurses visited patients and from which patients had been admitted into hospital with problems from urinary catheters. Education around urinary catheter use is an important driver in the vision of reducing and improving the issues around this. A student nurse representative from the catheter safety group, who had also participated in the trust urinary catheter audits, undertook some peer teaching to pre-registration students on placement within the trust from two higher education institutions. This was undertaken as part of the scheduled teaching sessions organised by the practice development teams. Peer teaching and learning is an effective educational intervention for students on clinical placements (Secomb, 2008). Since the publication of the first Francis Independent Inquiry report (Francis, 2010) it has become apparent that raising standards and bringing about changes in culture are critical to improving patient safety and making healthcare patient-focused. A safer NHS will depend far more on major cultural change than on a new regulatory regime (National Advisory Group on the Safety of Patients in England, 2013). Therefore it was important to ensure that student nurses received education on this topic. The student nurse representative received positive evaluation from the session, which was well attended. Within the acute trust, a rapid-review approach to CAUTI incidents is being established. Staff are requested to contact the catheter safety group if a patient develops a CAUTI to ensure a rapid case review of the incident is undertaken by the clinical team and any learning from this linked to
British Journal of Nursing, 2015 (Urology Supplement), Vol 24, No 9
the incident. They are also advised to report CAUTI as an incident. Feedback of catheterisation and CAUTI rates from the Safety Thermometer audit are provided to clinical areas each month. Ongoing surveillance and feedback is an important intervention to reduce catheter-associated infection and sustain prevention efforts (Fakih et al, 2012). Selection of these interventions is supported by a strong evidence base for the reduction of catheter use and the use of bundles (Figure 3) to prevent unnecessary CAUTI (Shekelle et al, 2013). The trust catheter safety group undertakes regular catheter awareness ‘walkrounds’ in clinical areas to assess performance in this key safety process and to enable the trust to improve practices to ensure the safety of patients. A range of staff (nursing, medical and allied health professionals) have been spoken with by the catheter safety group on these ‘walkrounds’ regarding awareness of best practice and barriers to removal of catheters. Key messages from the walkround have been communicated to clinical teams through quality improvement media from the chief nurse and offices of the medical directors. A screen saver is displayed on all trust computer screens for a 24-hour period once a month highlighting the importance of appropriate catheter use and reminding staff to review catheter use on a daily basis.
Next steps Even though CAUTI is a very common healthcareassociated infection, use of CAUTI-preventive practice is lagging behind efforts to prevent central-line-associated bloodstream infection and ventilator-associated pneumonia (Krein et al, 2010). There is much room for improvement in adopting catheter removal and CAUTI preventive strategies.
Avoiding unnecessary placement
Prompt removal
Rapid review of incidents (CAUTIs or bloodstream infections associated with catheter use) for learning and improvement
Quality improvement about the management of catheters out of hospital
Figure 3. Catheter care bundle
Figure 4. Credit-card-sized education card
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British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.102.042.098 on October 4, 2015. For personal use only. No other uses without permission. . All rights reserved.
n Catheter-associated urinary tract infection (CAUTI) is the most common healthcare-associated infection worldwide and is a result of the widespread use of urinary catheterisation much of which is inappropriate n Interventions to reduce urinary catheter use are one of the top ten recommended patient safety strategies n The interventions and initiatives introduced here were designed to facilitate improved awareness of appropriate indication for urinary catheter use and prompt removal of devices when no longer required n These drew on previous successful initiatives to address inappropriate antibiotic use n A patient-held document was introduced for patients discharged into the community with a urinary catheter to ensure reasons for insertion and ongoing use were effectively communicated to all involved in care
To improve practice around urinary catheter placement and removal requires interventions to change the expectations and habits of nurses, medical teams and patients regarding the need for a urinary catheter (Meddings et al, 2014). As a very large trust, the author’s institution continues to have clinical areas that need attention to improve appropriate use of urinary catheters. The trust is investigating further methods of empowering nurses to remove catheters, which include explicit orders to stop the catheter. Stop orders for catheters can be configured in a similar way to antibiotic orders and can empower nurses to remove the catheter without permission from the medical team on the basis of an appropriate indication list (Voss, 2009; Wenger, 2010). Nurse-led multidisciplinary rounds have been associated with a reduction in unnecessary urinary catheter use (Fakih et al, 2008). This has been successfully introduced in one surgical ward with high catheter use. Further audits of catheter use have been undertaken by two third-year student nurses as part of their undergraduate studies, which has helped the trust to further implement best practices and improvements in patient care. Monitoring catheter use and CAUTI rates requires considerable resources, therefore there is a need for continued development of strategies to address this issue. Credit-cardsized education cards are currently being produced as part of this strategy (Figure 4).
Conclusion Inappropriate urinary catheter use is an easy habit to start and a difficult one to break (Meddings and Saint, 2011). The authors’ trust intends to continue to raise the profile of this issue to ensure patients do not experience an adverse event as a result of urinary catheterisation. All those working in the NHS should understand that safety is a continually emerging property, and that the battle for safety is never ‘won’; rather, it is always in progress (National Advisory Group on the Safety BJN of Patients in England, 2013). Conflict of interest: none Centers for Disease Control and Prevention (2012) Carbapenem-resistant Enterobacteriaceae containing New Delhi metallo-beta-lactamase in two
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KEY POINTS
patients—Rhode Island, March 2012. MMWR Morb Mortal Wkly Rep 61(24):446-8 Chief Medical Officer (2003) Winning Ways: Working together to reduce Healthcare Associated Infection in England. http://tinyurl.com/na4q8bs (accessed 21 April 2015) Francis R (2010) Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust. January 2005 – March 2009 http://tinyurl.com/lrh42ch (accessed 21 April 2015) Fakih MG, Dueweke C, Meisner S et al (2008) Effect of nurse-led multidisciplinary rounds on reducing the unnecessary use of urinary catheterization in hospitalized patients. Infect Control Hosp Epidemiol 29(9):815-9. doi: 10.1086/589584.29(9) Fakih MG, Watson SR, Greene MT et al (2012) Reducing inappropriate urinary catheter use: a statewide effort. Arch Intern Med 172(3):255-60. doi: 10.1001/ archinternmed.2011.627 Health Protection Agency (2012) English National Point Prevalence Survey on Healthcare-associated Infections and Antimicrobial Use, 2011. Preliminary data. http:// tinyurl.com/l6bd788 (accessed 28 April 2015) Holroyd-Leduc JM, Sen S, Bertenthal D et al (2007) The relationship of indwelling urinary catheters to death, length of hospital stay, functional decline, and nursing home admission in hospitalized older medical patients. J Am Geriatr Soc 55(2): 227–33 Hooton TM, Bradley SF, Cardenas DD et al. 2010. Diagnosis, prevention, and treatment of catheter associated urinary tract infection in adults: 2009 International clinical practice guidelines from the Infectious Diseases Society of America. Clin Infect Dis 50(5): 625-63 Hospital Infection Society (2007) Third Prevalence Survey of Healthcare Associated Infections in Acute Hospitals in England 2006. http://tinyurl.com/qdytxnz (accessed 21 April 2015) Krein SL, Damschroder LJ, Kowalski CP, Forman J, Hofer TP, Saint S (2010) The influence of organizational context on quality improvement and patient safety efforts in infection prevention: a multi-center qualitative study. Soc Sci Med 71(9): 1692–1701. doi:10.1016/j.socscimed.2010.07.041 Meddings J, Saint S (2011) Disrupting the life cycle of the urinary catheter. Clin Infect Dis 52(11):1291-3. doi: 10.1093/cid/cir195 Meddings J, Rogers MA, Macy M, Saint S (2010) Systematic review and metaanalysis: reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients. Clin Infect Dis 51(5):550-60. doi: 10.1086/655133. Meddings J, Rogers MA, Krein SL, Fakih MG, Olmsted RN, Saint S (2014) Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review. BMJ Qual Saf 23(4):277-89. doi: 10.1136/bmjqs-2012-001774. Epub 2013 National Advisory Group on the Safety of Patients in England (2013) A Promise to Learn—A Commitment to Act. Improving the safety of patients in England. (The Berwick Report). http://tinyurl.com/q6a7zkh (accessed 21 April 2015) Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM for Infectious Diseases Society of America, American Society of Nephrology, American Geriatric Society (2005) Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 40(5): 643-54 Royal College of Nursing (2012) Catheter Care: RCN Guidance for Nurses. http:// tinyurl.com/c23aww (accessed 21 April 2015) Saint S (2000) Clinical and economic consequences of nosocomial catheter-related bacteriuria. Am J Infect Control 28(1):68-75 Saint S, Kowalski CP, Kaufman SR (2008) Preventing hospital-acquired urinary tract infection in the United States: a national study. Clin Infect Dis 46(2): 24350. doi: 10.1086/524662 Secomb J (2008) A systematic review of peer teaching and learning in clinical education. J Clin Nurs 17(6): 703-16. Epub 2007 Shekelle PG, Pronovost PJ, Wachter RM et al (2013) The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med: 158(5 pt 2): 365-9. doi: 10.7326/0003-4819-158-5-201303051-00001 Shilo S, Assous MV, Lachish T et al (2013) Risk factors for bacteriuria with carbapenem-resistant Klebsiella pneumoniae and its impact on mortality: A case-control study. Infection 41(2): 503–9. doi: 10.1007/s15010-012-0380-0. Epub 2012 Stevenson, K.B. Khan, Y. Dickman, J. et al. 2008. Administrative coding data compared with CDC/NHSN criteria are poor indicators of health careassociated infections. Am J Infect Control, 36(3), pp. 155-164. Tiwari MM, Charlton ME, Anderson JR, Hermsen ED, Rupp ME (2012) Inappropriate use of urinary catheters: A prospective observational study. Am J Infect Control 40(1): 51-4. doi: 10.1016/j.ajic.2011.03.032. Epub 2011 Voss AB (2009) Incidence and duration of urinary catheters in hospitalized older adults before and after implementing a geriatric protocol. J Gerontol Nurs 35(6):35-41. doi: 10.3928/00989134-20090428-05 Wenger JE (2010) Cultivating quality: reducing rates of catheter-associated urinary tract infection. Am J Nurs 110(8): 40-5. doi: 10.1097/01.NAJ.0000387691.47746. b5 Ward L, Fenton K, Maher L (2010) The high impact actions for nursing and midwifery 5: protection from infection. Nurs Times 106(31):20-1
British Journal of Nursing, 2015 (Urology Supplement), Vol 24, No 9
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.102.042.098 on October 4, 2015. For personal use only. No other uses without permission. . All rights reserved.
Healthcare-acquired urinary infection presents a substantial burden for patients and the healthcare system. Urinary tract infections have not gained the same level of media attention as other healthcareassociated infections, yet interventions to reduce urinary catheter use are one of the top ten recommended patient safety strategies. To improve practice around urinary catheter placement and removal requires interventions to change the expectations and habits of nurses, medical teams and patients regarding the need for a urinary catheter. In the authors’ trust, a redesign of the existing urinary catheter device record was undertaken to help avoid unnecessary placement of catheters, and resulted in a reduction of urinary catheters in situ longer than 48 hours. Other strategies included implementation of catheter rounds in a high-usage area, and credit-card-sized education cards. A catheter ‘passport’ was introduced for patients discharged with a catheter to ensure information for insertion and ongoing use were effectively communicated. Key words: Urinary catheters ■ Catheter-related infections ■ Drug resistance ■ Clinical audit ■ Education
H
ealthcare-associated infections have been linked to significant morbidity and mortality (Fakih et al, 2012). Catheter-associated urinary tract infection (CAUTI) is the most common healthcare-associated infection worldwide and is a result of the widespread use of urinary catheterisation, much of which is inappropriate (Hooton et al, 2010). The third prevalence survey of healthcare-associated infections in England estimated that 31% of hospitalised patients have a urinary catheter during the course of their stay (Hospital Infection Society, 2007). Consequently, limiting the use of urinary catheters is consistently recommended across guidelines to prevent CAUTI (Hooton et al, 2010). This article will discuss the implementation of a strategy to reduce inappropriate use of urinary catheter and to reduce CAUTI in a large NHS trust. In the most recent national audit in England, 43% of patients with a urinary tract infection had a urinary catheter present within 7 days before the onset of infection (Health Catherine Buckley, project nurse; Charlotte Clements, Darzi Fellow and Paediatric Registrar; Adrian Hopper, Deputy Medical Director. all at Guy’s and St Thomas’ NHS Foundation Trust, London. Accepted for publication: March 2015
S18
Protection Agency, 2012). CAUTI is the leading cause of secondary nosocomial bloodstream infections, about 17% of which are from a urinary source, with an associated mortality of approximately 10% (Hooton et al, 2010). The insertion of a urinary catheter, and the duration of its use, is a contributory factor to the development of a urinary tract infection (Saint et al, 2008). On average, healthcareassociated urinary tract infections necessitate one extra hospital day per patient (Saint, 2000). In many trusts, the numbers of CAUTIs are not routinely measured but where audits have taken place, the rate has been shown to be as high as 32% (Ward et al, 2010). Despite the link between urinary catheters and urinary tract infections in hospitals, no strategy is consistently or universally used to prevent these infections. Although many CAUTIs are not life-threatening, complications of CAUTI can increase a patient’s length of hospital stay and healthcare costs, and may lead to a higher morbidity and mortality (Stevenson et al, 2008). The easiest and most effective method to prevent CAUTI is by restricting the use of a urinary catheter to patients who have a clear indication for one and removing the catheter as soon as it is no longer needed (Tiwari et al, 2012). Despite growing evidence on the role of inappropriate urinary catheter use in the development of CAUTI, data on risk factors associated with inappropriate urinary catheter use are scarce.
Catheter use at the trust The author’s trust is situated in inner London and is one of the largest NHS trusts in the UK. It provides services from two major hospital sites that serve local populations and is a national referral centre for specialist services. It also has integrated community services with over 2 million patient contacts each year. The Safety Thermometer, a local improvement tool that measures, monitors and analyses patient harms and ‘harm-free care’, provided a monthly audit of urinary catheter use. This highlighted that approximately 20% of adult patients across the trust had a urinary catheter in situ at any given time. This prompted the trust to focus on urinary catheter use to ensure that use was appropriate in clinical areas. Interventions to reduce urinary catheter use are one of the ‘top ten’ patient safety strategies that are encouraged for adoption to improve patient safety (Shekelle, 2013).
Healthcare-acquired urinary infection Healthcare-associated infections are a significant issue in the delivery of services for health and have been a priority for government and NHS trusts since 2003 (Chief Medical
© 2015 MA Healthcare Ltd
Abstract
British Journal of Nursing, 2015 (Urology Supplement), Vol 24, No 9
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.102.042.098 on October 4, 2015. For personal use only. No other uses without permission. . All rights reserved.
Figure 1. 48-hour antibiotic initiative on drug chart.
Figure 2. Close-up of the updated device insertion record showing prompts
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indwelling catheters tend to be over-used in treating urinary incontinence (Holroyd-Leduc et al, 2007). Reasons for this increased use include complexities of care, increased acuity, severity of illness, and decreased staffing levels. The literature and anecdotal evidence suggest that urinary catheters are often inserted without an appropriate indication, once inserted remain in situ without proper indications, and are not reviewed in a timely manner in order for them to be removed promptly (Tiwari et al, 2011). In a systematic review that examined strategies to reduce unnecessary use of urinary catheters and associated infections, the influence of nurses was paramount in reducing duration of indwelling catheter and subsequent infections in all the studies included (Meddings et al, 2014). This illustrates the scope for nurses to continue to have a positive effect on this issue. The Berwick review into patient safety recommended four guiding principles to help the NHS get better faster (National Advisory Group on the Safety of Patients in England, 2013: 44). One of these was to place the quality and safety of patient care above all other aims for the NHS. This was, the chairman argued, the safest and best route to lower cost. The authors’ trust has a clear focus on patient safety with a desire to be a world leader in this respect and achieve the best patient outcomes. Reducing inappropriate urinary catheter use and associated risks is an integral part of this agenda.
Initiatives at the trust A working group was set up to examine use of urinary catheter in the clinical areas at the trust. The aims of the catheter safety working group were to reduce avoidable harm to patients from urinary catheters, thereby improving patients’ care and experience, and consequently reduce the costs and implications of treating these harms. Multiple studies of interventions to decrease inappropriate catheter placement have demonstrated a decrease in the use of urinary catheters (Meddings et al, 2010). The interventions and initiatives at the trust were designed to facilitate this with improved awareness of appropriate indication for urinary catheter use and prompt removal of devices when no longer required as a key part of the strategy. Therefore, as part of the drive to improve appropriate use of urinary catheters, a redesign of the existing urinary catheter device record was undertaken. This record was designed to help avoid unnecessary placement of catheters and included prompts that were designed to empower nurses to remove catheters without seeking medical advice if no clear ongoing indication for catheter use was noted. An earlier initiative around antibiotic prescribing had been very successful in reducing inappropriate antibiotic use across the trust. This had involved staff (nurses, pharmacists or medical staff) hand-drawing an amber line on the drug chart at the point marking 48 hours of administration to ensure a clinical review of antibiotic prescription was undertaken at this time (Figure 1). This was emulated in the design of the urinary device record (Figure 2). A printed instruction on an amber background at day 2 of documentation of continued use prompted: ‘Is catheter still indicated? No—remove immediately. Yes— continue to review daily’. The form underwent four ‘plan, do study, act’ (PDSA) cycles and was amended on the feedback
© 2015 MA Healthcare Ltd
Officer, 2003). Healthcare-acquired urinary infection presents a substantial burden for patients and the healthcare system. The cost per CAUTI episode has been estimated at £1968 (Ward et al, 2010). Overall the financial burden from CAUTI remains difficult to establish due to a lack of reliable data. Despite these costs, and the effect on patients, urinary tract infections have not gained the same level of media attention as other healthcare-associated infections such as meticillin-resistant Staphylococcus aureus (MRSA) infection and Clostridium difficile. Of much concern is the increase in antimicrobial-resistant Gram-negative organisms (Nicole et al, 2005). Urinary tract infections are increasingly caused by multidrug-resistant organisms including strains that are resistant to all available therapeutic agents (Centers for Disease Control and Prevention, 2012). Presence of a urinary catheter increases the risk factors for acquiring resistant organisms (Shilo et al, 2013). However, infection is one of many potential complications of urinary catheterisation and there are numerous other reasons to reduce the duration of indwelling urinary catheters. Catheterisation can increase sacral skin breakdown due to lack of movement and where sacral pressure ulcers have occurred, catheter-related complications increase because of cross-infection from wound to bladder, potentially increasing risk of bacteraemia in this situation (Royal College of Nursing, 2012). There is wide variation in clinical identification of patients who need to be catheterised as many patients may be catheterised for convenience; therefore long-term
British Journal of Nursing, 2015 (Urology Supplement), Vol 24, No 9
British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.102.042.098 on October 4, 2015. For personal use only. No other uses without permission. . All rights reserved.
© 2015 MA Healthcare Ltd
INFECTION PREVENTION received. Staff felt the form was more logical and triggered them to question continued need for the urinary device. Trust-wide audits of urinary catheter use in 33 inpatient wards were undertaken by student nurses before and after implementation of the new urinary catheter documentation. Engaging student nurses to undertake this audit on this important initiative was a meaningful way of helping them understand and identify best practice and ultimately to help facilitate their learning. The audit following introduction of the new documentation demonstrated that duration of catheter insertion had improved from 34% of catheters in situ up to 48 hours before the introduction of the form to 43% in situ up to 48 hours post introduction, indicating that catheters were being removed more promptly. Strategies for the community care settings to reduce avoidable harm to patients from catheters and improve their care focused on long-term catheterisation with agreed standardised care pathways to make catheter management highly reliable. A catheter passport, a patient-held document, has been introduced for patients discharged into the community with a urinary catheter. This ensures that information surrounding the reasons for insertion and ongoing use are effectively communicated to all involved in the patient’s care. Patients and carers are central to improving knowledge of catheter management and to acting rapidly if there are problems. For patients discharged with a catheter, a clear referral pathway to ‘trial without catheter clinics’ was provided to ensure that catheter use was reviewed appropriately. Education around care and appropriate use of urinary catheters was provided by the community continence nurse in very large care homes where district nurses visited patients and from which patients had been admitted into hospital with problems from urinary catheters. Education around urinary catheter use is an important driver in the vision of reducing and improving the issues around this. A student nurse representative from the catheter safety group, who had also participated in the trust urinary catheter audits, undertook some peer teaching to pre-registration students on placement within the trust from two higher education institutions. This was undertaken as part of the scheduled teaching sessions organised by the practice development teams. Peer teaching and learning is an effective educational intervention for students on clinical placements (Secomb, 2008). Since the publication of the first Francis Independent Inquiry report (Francis, 2010) it has become apparent that raising standards and bringing about changes in culture are critical to improving patient safety and making healthcare patient-focused. A safer NHS will depend far more on major cultural change than on a new regulatory regime (National Advisory Group on the Safety of Patients in England, 2013). Therefore it was important to ensure that student nurses received education on this topic. The student nurse representative received positive evaluation from the session, which was well attended. Within the acute trust, a rapid-review approach to CAUTI incidents is being established. Staff are requested to contact the catheter safety group if a patient develops a CAUTI to ensure a rapid case review of the incident is undertaken by the clinical team and any learning from this linked to
British Journal of Nursing, 2015 (Urology Supplement), Vol 24, No 9
the incident. They are also advised to report CAUTI as an incident. Feedback of catheterisation and CAUTI rates from the Safety Thermometer audit are provided to clinical areas each month. Ongoing surveillance and feedback is an important intervention to reduce catheter-associated infection and sustain prevention efforts (Fakih et al, 2012). Selection of these interventions is supported by a strong evidence base for the reduction of catheter use and the use of bundles (Figure 3) to prevent unnecessary CAUTI (Shekelle et al, 2013). The trust catheter safety group undertakes regular catheter awareness ‘walkrounds’ in clinical areas to assess performance in this key safety process and to enable the trust to improve practices to ensure the safety of patients. A range of staff (nursing, medical and allied health professionals) have been spoken with by the catheter safety group on these ‘walkrounds’ regarding awareness of best practice and barriers to removal of catheters. Key messages from the walkround have been communicated to clinical teams through quality improvement media from the chief nurse and offices of the medical directors. A screen saver is displayed on all trust computer screens for a 24-hour period once a month highlighting the importance of appropriate catheter use and reminding staff to review catheter use on a daily basis.
Next steps Even though CAUTI is a very common healthcareassociated infection, use of CAUTI-preventive practice is lagging behind efforts to prevent central-line-associated bloodstream infection and ventilator-associated pneumonia (Krein et al, 2010). There is much room for improvement in adopting catheter removal and CAUTI preventive strategies.
Avoiding unnecessary placement
Prompt removal
Rapid review of incidents (CAUTIs or bloodstream infections associated with catheter use) for learning and improvement
Quality improvement about the management of catheters out of hospital
Figure 3. Catheter care bundle
Figure 4. Credit-card-sized education card
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n Catheter-associated urinary tract infection (CAUTI) is the most common healthcare-associated infection worldwide and is a result of the widespread use of urinary catheterisation much of which is inappropriate n Interventions to reduce urinary catheter use are one of the top ten recommended patient safety strategies n The interventions and initiatives introduced here were designed to facilitate improved awareness of appropriate indication for urinary catheter use and prompt removal of devices when no longer required n These drew on previous successful initiatives to address inappropriate antibiotic use n A patient-held document was introduced for patients discharged into the community with a urinary catheter to ensure reasons for insertion and ongoing use were effectively communicated to all involved in care
To improve practice around urinary catheter placement and removal requires interventions to change the expectations and habits of nurses, medical teams and patients regarding the need for a urinary catheter (Meddings et al, 2014). As a very large trust, the author’s institution continues to have clinical areas that need attention to improve appropriate use of urinary catheters. The trust is investigating further methods of empowering nurses to remove catheters, which include explicit orders to stop the catheter. Stop orders for catheters can be configured in a similar way to antibiotic orders and can empower nurses to remove the catheter without permission from the medical team on the basis of an appropriate indication list (Voss, 2009; Wenger, 2010). Nurse-led multidisciplinary rounds have been associated with a reduction in unnecessary urinary catheter use (Fakih et al, 2008). This has been successfully introduced in one surgical ward with high catheter use. Further audits of catheter use have been undertaken by two third-year student nurses as part of their undergraduate studies, which has helped the trust to further implement best practices and improvements in patient care. Monitoring catheter use and CAUTI rates requires considerable resources, therefore there is a need for continued development of strategies to address this issue. Credit-cardsized education cards are currently being produced as part of this strategy (Figure 4).
Conclusion Inappropriate urinary catheter use is an easy habit to start and a difficult one to break (Meddings and Saint, 2011). The authors’ trust intends to continue to raise the profile of this issue to ensure patients do not experience an adverse event as a result of urinary catheterisation. All those working in the NHS should understand that safety is a continually emerging property, and that the battle for safety is never ‘won’; rather, it is always in progress (National Advisory Group on the Safety BJN of Patients in England, 2013). Conflict of interest: none Centers for Disease Control and Prevention (2012) Carbapenem-resistant Enterobacteriaceae containing New Delhi metallo-beta-lactamase in two
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KEY POINTS
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