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Catheter Urinary Tract Infections –

The Journey to reduce the number

of Catheters at Salford Royal

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2Where are you?

Catheter Urinary Tract Infections –

The Journey to reduce the number

of Catheters at Salford Royal.

John Bellerby – Senior Quality Improvement Lead

Daniel Rowbotham – Quality Improvement Lead

Aims

• Context for Project

• What we have done

• Results

• Future Plans

Why Did we do it?

Strategy 2011 - 14

Phase 2 Projects (2011-14)

This was our reality

• 15-25% pts have a urinary catheter inserted.

Of that 20%

– 38% have documentation

– 24% -41% have a CAUTI

• 60% medical teams unaware of presence of

urinary catheter

• How many patients die from Urinary Sepsis at

SRFT yearly?

Patient View

50 inpatients• 26% found it painful

• 24% found it embarrassing

• 26% found it inconvenient

• 18% of patients didn’t know why they were catheterised

• 70% were not given another option

• 30% felt they could have managed without

• 32% had experience of their catheter leaking

• 76% didn’t know or thought that they didn’t have a care plan

Urinary Catheter

Innocuous device?

OR

Convenient device

that can harm & kill?

How Did we do it?

Phase 1

The first phase ended in December 2012.

What: To reduce catheter associated urinary tract infections

How Much: To achieve a 30% reduction from baseline figure in pilot

wards

By When: December 2012

Outcome: 44% reduction in CaUTI, and successful development of flow

sheet to facilitate data capture

The Breakthrough Series

Collaborative (IHI)

The Break Through Series

Collaborative

The Break Through Series

Collaborative

People are generally better

persuaded by reasons which they

themselves discover,

than those which have come into

their mind by others"

Pascal (1670)

AIM

Source: Associates for Process Improvement

To reduce Catheter associated

Urinary tract infection ( CaUTIs )

by 30% by 31st December 2012

Measurement

Changes

Small tests of

change

Model for Improvement

Aim

MEASUREMENT

Source: Associates for Process Improvement

Measurement

through the data

collected from

the flow sheet.

CaUTI and catheter

days

CHANGES

Source: Associates for Process Improvement

These are the changes the

teams develop in order to

move us to the next phase

A Fact….

All improvement will require change,

but not all change will result in improvement

Therefore we need to ‘test’ change

The PDSA Cycle

Why catheterise at all?

Phase 2

The second phase of the project expanded the

work and ran through until December 2013:

What: To reduce catheter associated urinary

tract infections

How much: By 20% (across the whole Trust)

When: December 2013

Outcome: 12% reduction

Phase 3

• 2014 Aim was to identify the inappropriate

catheters in the organisation

• Was tied into our Harm Free Care CQUIN for

2014/2015

Challenges

• Developed a tool to collect data

– Form was explicit in the rationale for catheterisation

– Agreement on Rationale was a tricky place to get to!

• Aimed to carry out the audit on our senior nurse walkround

– Two a month

– Cover the entire hospital

What Happened

6 Audits

– Variation in results

– Review by clinical

experts showed

inaccuracy of data

– We did not yet have

accurate data for

inappropriate catheters

PDSA Outcomes

• Held two training sessions

• 16 nurses in total completed that training

• Then audited a small group of wards

• Validated by Urology Team

• 2 audits were undertaken showing that

25.57% were inappropriate

• One of our district Nursing teams are now

using the tool on a monthly basis

Bed

Number

Hospital

Number

Patient Consultant No

Catheter

T

Tissue

Viability

If sacral

pressure

sores and

incontinence

(both have to

be present for

a catheter to

be required)

R

Retention

Urine

(i) Unable to

pass urine

spontaneously

(ii) chronic

retention where

there has been

urological input

(evidence

required)

Please include

residual

volume

recorded in

insertion

flowsheet in

comments

A

Acutely

unwell

(i) Currently

requiring level 2 or

3 care or if a

senior decision

maker specifically

mentions the need

for a catheter

clearly in the notes

(specify reason)

P

Patient

Preference

For end of life

patients who

prefer a catheter

to ease distress

(this has been

discussed with

patient and

documented)

P

Peri-op

Max 24 hrs

after

surgery

(please

detail

specific

operation in

comment

box)

Other

If the reason for

catheterisation is

not in TRAPP

please tick

below and

choose one of

the reasons in

the box to the

right

Prolonged

immobilisation

due to spinal

fractures or

trauma

Urological indications

including intra-bladder

treatments, bladder

diagnostic tests &

visible haematuria

1

2

Is this Catheter

In-Situ

appropriately?

Yes or No?

Comments

Please provide:

(1) any additional information on the reason for

catheterisation if not included

(2) Operation details if appropriate

If "other" has been selected

were there any of the

indications below, please tick

as appropropriate

B7Ward

Date of survey

Urinary Catheters

If Patient is catheterised please indicate CURRENT reason for

the patient to be catheterised in the boxes below (We are not

interested in the initial reason for insertion but why the

catheter is still in situ today)

What next?

• The audits have highlighted an enormous

opportunity in hospital

• Wards have started to use the data collection

tool as an intervention tool

• The audits have also been successful in the

community

Catheter Days

Cath

ete

r D

ays

10. Trust Catheter Days

Month

IndividualsIndividualsIndividualsIndividualsSet 2: UCL = 5,059.58, Mean = 4,232.18, LCL = 3,404.79 (16 - 26) (mR = 2)

5299.62

4604.33

3909.04

5059.58

4232.18

3404.79

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2013

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2015

3,000

3,200

3,400

3,600

3,800

4,000

4,200

4,400

4,600

4,800

5,000

5,200

5,400

CaUTI

Trust CaUTI

CHARTrunnerPowered by:

www.chartrunner.com 800-777-3020PQ Systems

incorporated

c chartc chartc chartc chartSet 1: UCL = 44.57, Mean = 28.55, LCL = 12.52 (25 - 35)

UCL = 50.92

Mean = 33.54

LCL = 16.17

UCL = 44.57

Mean = 28.55

LCL = 12.52

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25

30

35

40

45

50

Data Following

introduction of

Audit tool

% of patients Catheterised

% Patients Catheterised

CHARTrunnerPowered by: PQ Systems

incorporated

p chartp chartp chartp chartSet 5: UCL = 22.38, CTL = 18.06, LCL = 13.73 (38 - 50)

Inspected Mean = 712.31, Counts Mean = 128.62

UCL = 27.05

CTL = 21.98

LCL = 16.91

UCL = 22.38

CTL = 18.06

LCL = 13.73

Scale up to 100% of the organisation

1st Audit of AppropriateCatheterisation

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26

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30

Community Catheters

Num

ber

of C

ath

ete

rised P

atients

145. Community Catheterised Patients

Month

IndividualsIndividualsIndividualsIndividualsSet 4: UCL = 261.41, Mean = 248.78, LCL = 236.14 (18 - 26) (mR = 2)

UCL = 320.35

Mean = 302.88

LCL = 285.40

UCL = 312.69

Mean = 279.44

LCL = 246.20

UCL = 261.41

Mean = 248.78

LCL = 236.14

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220

240

260

280

300

320

2015 Aim

In the hospital we will aim for:

• A 10% Reduction in Catheter Days by April 2016 in hospital

In the community we will aim for

• A 5% Reduction in Catheterised patients in the community by April 2016

Currently Testing

• Nurse Led Removal

• Support for Intermittent

Catheterisation (Staff

and Patients)

• Taking Formal Consent

• Locking Catheters away

Summary

• The quality improvement approach has

been the driver for the project, this has

been supported by the faculty (with links

to Trust board) providing the senior

leadership

• The Faculty provide direction and the

ideas for change are driven by the front

line teams