Go with the Flow: Working together to improve bladder health and reduce urinary tract infections Transcript of video Indwelling urinary Catheters Insertion and Maintenance Gillian Rankin, Infection Control Nurse and Hazel Clark, Quality Improvement Adviser, NHS Ayrshire & Arran Hello, I m Gillian Rankin, I m one of the infection control nurses and along with Hazel Clark from the quality improvement team - both teams have been working together over the last few years - feels like a lifetime - on implementing the care and maintenance bundles and reducing the levels of catheter associated urinary tract infections. We re doing a bit of a double act here. So I m going to recap on some of the information that s already been given today obviously everyone does their own presentations and gets their slot so some of it might be a bit repetitive. Just talking about how the organisms can be introduced to catheters and into the bladder then Hazel s going to talk about what the local picture is and how we re going forward and the challenges we ve faced then we ll talk about the insertion and maintenance bundles. So, just as we ve heard already today UTI are the biggest contributors to healthcare associated infection rates with locally 60% of those being contributed to urinary catheters. So it s a big problem that we really need to be dealing with. Obviously, associated with those infections are other implications to the patient themselves so - an increased length of stay for treatment, possible rehabilitation - various things like that, increased risk of secondary infection as we ve already heard about ecoli infections including bacteremias could go into the kidneys sometimes - no all cases but sometimes will develop a staff aureus bacteremea which has got it s own problems and that s a completely different topic and then the mortality rate for these infections is pretty high as well. Obviously that depends on the patient themselves, their co- 1
morbidities, what organism it is and how it s managed. So, there s various things that contribute to that as well. Then, we ve heard already about the antibiotic resistance - again affects the management of the infections but also again affects the health care management of those patients depending on what that resistance could be. It might mean that they need to be isolated to a single room which has it s own issues for wards, it has an issue for the patient - the psychological impact of being isolated, the precautions that we have to put in place as well so all of those are affected and impacted by these resistance patters to antibiotics. The Healthcare Improvement Scotland through the Scottish Patient Safety Program have given us a target of reducing CAUTI by 30% and I m quite sure that s a historical figure because of the various issues that we ve had in implementing all these maintenance bundles and things like that it s taken us a while to get there. And assessing CAUTI rate can be a problem so reducing that by 30% is difficult when you don t actually know what your rate is to start off with. So the main factor being - if we don t put the catheters in - as we ve already said - then we won t get the CAUTIs so then we don t have to reduce the rate because we won t have a rate in the first place. So, as we know they re commonly used in health care for a variety of reasons. As with any invasive device they have their own risk - an increased risk of patients developing infection. Patients with an invasive device are 7 times more likely to develop an infection and if you add to that the 3% risk every day of developing bacteria in the urine associated with a catheter then you can see why we have such an issue with patients developing CAUTI. It s a portal of entry for organisms either in through the catheter itself into the bladder or externally. And Margaret said everything this morning I don t think I need to embellish too much on the impact to the patient themselves - she explained it very well this morning - the discomfort, embarrassment and all the issues that affect the patient through that. So - the risks once the catheter is in - how the patient gets these infections - how the bacteria can get in to the patient. The perineum is colonised with usually your gut organisms your ecoli. It is one of the sites that we screen routinely for MRSA. If the patient meets the clinical risk assessment for MRSA then the perineum is one of the areas we will swab for that. 2
Hands of the healthcare worker either at the point of insertion or during the day to management of a catheter. Also the patient themselves because patients will poke about their doing their own catheter management so they can introduce the organisms themselves through their own handling of their catheter and through contaminated equipment at the point of insertion. If we don t use an aseptic technique and we don t do our hand hygiene at the point of insertion then we will introduce infection at that point. So, CAUTI is an avoidable harm as long as we do everything that we need to do and manage them appropriately then it is an avoidable harm. We ll go into that in a bit more detail in a bit. Hazel: So basically I took over from Gillian towards the end of last year as the lead for CAUTI. As Gillian has already said it was the CAUTI rate that we were initially looking at. But there s been a general rethink not only in Ayrshire and Arran but also from HIS and the SPSP program where the ideas is if we can reduce the use of catheters we can reduce the CAUTI rate. So because when I took over I didn t have a clue about the scale of how many catheters were getting used within Ayrshire and Arran. So I did a few wee reccys myself and discovered that we had ordered last year 18,933 catheters within Ayrshire and Arran which is an average of 1,577 catheters every month. Which is quite a lot of catheters. That s not to say that s how many were used - that s just how many we actually ordered. Also did a mini point prevalence study in the wards at Ayr hospital in January and my data comes out much the same as they had the previous year in that we had a sort of 25-35% of patients within 7 wards out of 15 at Ayr hospital had catheters in at any one time. Which works out roughly about 30% average. So we re going to be using the catheter days as our measurement for CAUTI when we re reporting. And what we ve done is we ve identified the wards with high catheter usage and that s the areas we re going to concentrate on initially for taking forward. So, Gillian, prior to me taking over Gillian had actually done a couple of wards she d introduced a couple of wards - she d used the bundle. She had some difficulties - I don t know if you want to speak about the problems you had? Gillian: I think a lot of the issues were just around the time for people to actually do the bundles and take on the education and things like that and it was a new piece of paper. They already had a catheter 3
care plan that they were using so this was seen to be something completely new. It wasn t really it was just an updated version and once they got used to it and they saw it they were actually much happier with the tool that we used. Hazel: It s interesting to note that it was introduced in one of the community hospitals which was Biggart and we ve already heard that there s been a reduction in usage at Biggart. So we need to look into that a wee bit more. So at the moment where we stand. We are way behind all the other health boards as far as reporting our catheter usage or CAUTI. So we ve had a rethink we are reintroducing the catheter bundles and maintenance bundles. What I ve done up to date is some data collection trying to identify the usage in the medical high care wards at Ayr hospital. It was identified as a high user because it s a high care area. We are starting as from Saturday to collect the data in station 16 which is a stroke rehab ward. It s also been identified as a high area of catheter usage. From there we ll introduce the insertion and maintenance bundles. So this is our driver diagram. it s similar to the original diagram just with a few changes. What we ve decided is that our aim is going to be to reduce the usage of catheters in identified wards by 30% by the end of this year. To do that we re using the model of improvement. We re collecting data, we re going to be looking at education, we ve already tested the urinary catheter insertion and maintenance bundles. We re in a process working with infection control and incontinence nurses for developing an education program. We ve already got the NES program online we re starting in the next couple of weeks we re going to have a catheter awareness week within Crosshouse and Ayr, where we have posters throughout and drop in sessions just raising awareness about catheters and CAUTI in general. We re making sure that we provide information to patients. We want to ensure that their family is involved if the patients going to be going home with a catheter which brings in nicely the passport and things like that. generally we want the ward staff to take on and the community staff because these bundles can be used in care homes, they can be used in the community as well and it s about moving forward with 4
these to try to reduce the amount of CAUTI that we have and reduce the amount of catheters that we re using. Gillian: Now we re onto the actual insertion and maintenance bundles. Obviously, people do end up with urinary catheters in situ but it should be a last resort. I know listening to the girls earlier today on all the different products that are available that most of them I didn t even know were there and all the different options. There are alternatives there but it s about us being aware of them and not just automatically going to a catheter for whatever reason the patient needs it in. Again, if you don t put a catheter in you won t get a CAUTI. But once the catheter goes in then we have recommendations from the safer patient program as to what measures should be in place for inserting the catheter and then for the ongoing daily maintenance of that catheter so the recommendations for insertion were: hand hygiene immediately before catheter insertion so not 5 minutes before you put your gloves on and you ve gone and got your equipment and various bits and pieces like that it s at the immediate point of entry you do your hand hygiene, the same as you would do for any other activity that you re doing your 5 moments for hand hygiene, Aseptic technique both at the point of insertion and at the point where you re attaching your drainage bag or system - which ever one you re going to use. using the catheter of the smallest gauge possible for the patient and then inflating the balloon as per the manufacturers recommendation, and appropriate cleaning of the meatus at the time of insertion as well. All of that we have put into the maintenance bundle which is - not working! there we go. Hazel: So this is our redesigned insertion and maintenance care plan we ve put it on one sheet which makes it easier because it ll follow the patient when they move from ward to ward. We ve only made minor tweaks and it s only little things like what we did - we put the reason to catheterise and the alternatives to catheterisation up the top. Prior to that it was below the insertion criteria. We wanted to make sure that we were considering - does this patient need this catheter? Is there something else we can put in or try before we insert a catheter? The insertion criteria - that s all the criteria that s needed to prevent the infection. We ve put little things like the important that you maybe don t need to know straight away but - is it a long term catheter, is it a short term catheter, Where was it inserted? Was it inserted prior to coming to your ward? Was it inserted in the community? Was it in A&E? Just to give you an idea of what was going on for your peace of mind. 5
We ve also put for the maintenance we ve put a daily maintenance - little suggestions there - just reminding you that you should wear gloves and apron and perform your hand hygiene - about the urine bag being emptied. Using a clean, disposable container for each patient. Maintaining and accurate fluid balance and encouraging fluid intake. All the things that we ve heard earlier. Although we re not definitely going to be collecting CAUTI numbers it would still be a good thing if we could get them so we ve also put to check if the patient fulfils the CAUTI criteria which is on the back of the bundle. We ve got the data collection which will sit beside the walking stick and the safety cross that you re already collecting for falls and pressure ulcers. And that s how we ll collect the data daily for how many patients have got a catheter. It ll be how many patients have got a catheter?, how many patients have you got on the ward? Then there ll be another part that says does the patient fulfil the CAUTI criteria. it s very straightforward, nothing to write home about but every day is does this patient still need this catheter? Then the questions about the infection risk. Is the catheter continuously connected to a closed drainage system? is it changed as per the manufacturers instruction? The meatal hygiene. Drainage bag situated below the level of the bladder - all the things we ve heard about that prevent infection. And does the patient have a CAUTI? We ve also put date removals, time, reason for removal. Below on the front page as well as on the back page because quite often of you don t see it you don t think about it so you don t actually document things. One of the things when we were doing the audits there s very little written in any of the notes - be it medical notes or nursing notes - there s very little written about why the catheters s in. Who decided to put the catheter in? Has anybody thought about taking it out? There really is nothing written. You just know the catheter s in - no plans - no anything - that s it. When going round and looking at the notes in January when I was doing the audits and asking staff you were getting various answers as to why a catheter was in. Because they were in retention, because they went to theatre and they re still in theatre, or I don t actually know why it s in. One of the answers was because there s no toilet facilities in the high care unit. So there s various reasons - are they the right reasons to keep a catheter in? There must be other alternatives that we could be using. 6
Yeah, some people need a catheter, there s a lot of people who do but it s about how do we get it out as soon as they don t need it? And what s the criteria that they need? There s tools to help you out like the Houdini tool that I m going to be looking at - hopefully we ll be able to introduce something like that to get these catheters out as soon as possible. Gillian: She stole my thunder a bit. (laughs) I was just going to talk about the next stage which is the recommendations for the maintenance which Hazel s already went over - which are in the bundle. This is just the second page of the bundle which carries on with your daily checks. You can see all the different questions are up there. Because we re not doing CAUTI rate we thought it was important to make sure that the patients were still being assessed as to whether they have a CAUTI or not and that we re using the right criteria. So there is the national definition of a CAUTI which we ve added down here. So the patient needs to meet all of these criteria to be defined as having a true CAUTI. So they must have a urinary catheter in situ or having had one removed within the previous 48 hours, they also have to have either pyrexia or hypothermia, two episodes in the previous 12 hours and one or more of your typical UTI symptoms: So your signs of sepsis shivers, rigors, costovertebral pain or tenderness, and new onset or worsening delirium. So they need to have all of that to be symptomatic as such. And, also having been prescribed antibiotics for a UTI so that s the criteria that we would assess your patient as having a CAUTI. So that s the technical definition - we ve created that - it didn t transfer over to the slide very well but there are copies of this out at the desk in the hallway there. Which is just a flow chart really, guiding you so you would go through the motions there so the patient s got a catheter in, yes, do they meet those signs of sepsis there in the last 12 hours? so if you re saying no then it s definitely not a CAUTI, if you re saying yes you re moving down to your signs and symptoms. Again, if it s a no it s not a CAUTI but I would still be monitoring that patient because there s potential for them to then go on and develop those symptoms. Also are they prescribed an antibiotic for a UTI? Once you get down and you ve said yes to all of them then they re definitely a CAUTI. Also gives some guidance here on the appropriateness of sending samples so if you re - as Chloe was saying this morning - if the patient s urine is cloudy or smelly is that an appropriate reason to send a sample? If somebody has sent a sample on that basis and it does come back with a positive culture what does that mean? 7
Are they symptomatic of a UTI? or is it just your asymptomatic bacteria urea and they ve just grown some sort of bacteria and they re colonised with it so it s about guiding for that assessment as well. So as I say there s copies out at the front. That ll help you to make that definition. Just on the work I did in the wards I was in before I handed over to Hazel - I was in station 9 at Ayr hospital, ward 5e at Crosshouse and McMillan ward and they all used an earlier version of the insertion and maintenance bundles. They all responded positively. It took us a while to get established but once we got into the swing of it the feedback was fairly positive. They all felt it gave them more of a focus on the catheters they were actually paying attention to the fact that the patient did have a catheter, do they still need to have that catheter in? And they found that it meant that they were removing the catheters earlier than they probably would have done before. Awareness of what a true CAUTI is - the true signs and symptoms of a CAUTI again not just on your cloudy urine, your smelly urine, or just the patient s not quite right so we ll send a sample off anyway and we ll start them on antibiotics. It was focussing them more on that true definition. They also felt - and we don t have the data at the moment but they did fell that they were sending less samples because they were sending the samples based on the clinical picture of the patient to help as well. A few challenges that we had - education being one of them. It was myself going into the wards and catching people on a one to one basis going through the tools, going through the CAUTI definitions, we had the safety cross as well for the data collections and that was quite challenging and time consuming so obviously going forward you can t keep doing that for every single clinical area or community area you need to get people together in a session like this and get everybody together for that. Getting the buy in. Again sometimes it s that reluctance - what s this, this is new? What else do you want me to do it s a new piece of paper? It s something else I need to think about, you want me to collect more data on something so getting that buy in. As I say once they were established and they knew what they were doing and comfortable with it they were positive and that went forward to the rest of their teams. We still got the feedback that they re still begin asked to take samples during ward rounds and things like that although the patient s not meeting the criteria and they re saying the patient doesn t meet the criteria for UTI/CAUTI but they re still being told to send a sample of just in case anyway. So we re still getting those inappropriate samples. But I think in time that ll come with education of all clinical teams not just your ward based staff or your nursing staff or your community areas. 8
I believe the insertion and maintenance part is included in the passport? Yes? so that will carry on out in the community as well then it can be transferred onto the tool if it s a new catheter when they come into hospital. Hazel: This is a slide I stole shamelessly (laughs) because I thought it summed it up about catheters and I believe Margaret would think the same if she had been here. I just thought it was a good one to put up for the end just to make us think. Has anybody ever had a catheter? You know how horrible it is isn t it. You know we shouldn t be putting them in unless we really have to. They are torturous (laughs) This resource may be made available, in full or summary form, in alternative formats and community languages. Please contact us on 0131 656 3200 or email altformats@nes.scot.nhs.uk to discuss how we can best meet your requirements. NHS Education for Scotland 2017. You can copy or reproduce the information in this resource for use within NHSScotland and for non-commercial educational purposes. Use of this document for commercial purposes is permitted only with the written permission of NES. 9