The Nurse Consultant at Newcastle upon Tyne Hospitals NHS Foundation Trust led on the development and implementation of a programme of work to improve catheter care and reduce urinary tract infection rates locally. This programme has led to improved outcomes, experiences and use of resources by addressing unwarranted variation in practice.
Where to look
The Specialist Continence Service at Newcastle upon Tyne Hospitals NHS Foundation Trust provides specialist advice and support to facilitate patient-centred care, offering effective management of bladder and bowel dysfunction within the acute and community setting. The service also provides a continence product delivery service, which facilitates a controlled regular supply of products direct to clients.
The National Institute of Clinical Excellence (NICE) provides a wide range of clinical guidance, quality standards and best practice clinical pathways for adults as well as children who are suspected of having a urinary tract infection as well as guidance regarding urinary catheter care. NICE (2014) highlights that catheter-associated urinary tract infections (CAUTI) comprise a large proportion of healthcare-associated infections and can occur whether a person has either a short-term or a long-term catheter, with strong association between duration of urinary catheterisation and risk of infection. This evidence base identifies that catheters are sometimes inserted inappropriately or there is a delay in removing them and that this risk can be greatly reduced by complying with all parts of the process for safe catheter insertion, maintenance and removal as soon as it is no longer needed. This is important in terms of both infection prevention and patient comfort and experience.
The Nurse Consultant identified unwarranted variation in knowledge, practice and urinary tract infection rates, which needed addressing to improve outcomes for patients and to reduce the number of blood stream infections (BSIs) at the Trust.
What to change
As part of a national programme to improve practice within this area and to reduce the number of infections in people with urinary catheters, the Nurse Consultant at Newcastle upon Tyne NHS Hospitals Foundation Trust reviewed local data such as patient safety thermometer results. The Nurse Consultant also engaged with national bench marking initiatives such as Royal College of Physicians ‘continence care’ and ‘IPC Society surveillance schemes’ to analyse current practice and identify areas for improvement.
To develop effective approaches to address the unwarranted variation seen in practice, the nurse consultant established a Trust-wide Catheter Care group. This group embarked upon analysing data and developing several UTI/CAUTI initiatives to improve awareness, practice and compliance with evidence based practice across the organisation.
The catheter care group is a multi-disciplinary team (MDT) of professionals who are committed to exploring and implementing new developments in and around the topic of catheter care.
How to change
The developments and changes have been made through skilled leadership, working effectively with nursing staff and the wider MDT. The following changes were agreed and piloted on specific wards, prior to further evaluation and consideration for roll out across the wider Trust:
- A new catheter care plan was developed and rolled out to provide personalised patient catheter care, based firmly on evidence based guidance;
- Clinical pathways have been redesigned to support health promotion to the wider health economy, highlighting the importance of bladder health care and the prevention of UTI/CAUTI. This includes guidance to support staff in assessing the need for a urinary catheter, flagging catheterised patients and providing ongoing care, as well as assessing for alternatives as treatment needs change;
- The development for a patient/carer DVD/audio tape which provides guidance regarding healthy bladder approaches and how to prevent a UTI;
- A new education and training programme for staff was introduced to embed effective practice into CAUTI/UTI and catheter management. Each ward now has a Bladder Health, CAUTI/UTI champion who advocates consistent practice implementation and fosters commitment;
- Newly integrated working approaches were embedded to ensure collaboration between the infection, prevention and control team, the continence team, nurses from the local Clinical Commissioning Group for older people and other key stakeholders;
- Review of the Trust’s catheter formulary to ensure evidence-based quality and cost-effective products are available and that staff are aware of the options available;
- Introduction of a new digital platform which supports the new catheter care plan to ensure that consistency with patient care flow is established and maintained;
- Development of a new personalised catheter Application (App);
- Established patient/carer focus groups regarding catheter care, to help inform and guide developments.
Better outcomes – The work has been measured through Plan-Do-Study-Act (PDSA) cycles, capturing data from the patient safety thermometer, comparing and bench marking against similar organisations. Patient and staff satisfaction and feedback has also been collated. Results indicate a reduction in the number of catheters inserted and in-situ for >28 days as per guidance and demonstrate appropriate use of catheters. Alternatives to urinary catheters are now being widely explored and used as routine practice. There has also been a significant reduction in the number of new CAUTIs, which corresponds with the reduction in urinary catheters, which has been associated with the introduction of this programme.
Better experience – Patients and carers have anecdotally reflected positively about the work being undertaken with an encouraging response. The programme continues to address the needs of patients as it develops.
Better use of resources – Collaborative, joined up working across the health care economy, from primary, secondary and tertiary care has meant more effective use of resources and improved efficiency in establishing the programme in practice. A reduction in the number of catheters in use locally and more effective engagement with patients and their carers has also had a positive impact on resources.
It is envisaged that clinical staff will take ownership for the continued audits of care – assessing documentation, staff knowledge and patient/carer feedback, to identify any further developments and ongoing projects.
Challenges and lessons learnt for implementation
This work has emphasised the importance of integration and involving other healthcare professionals to effectively implement new developments and changes.
The main challenge of working on the project was time management as programmes such as these require adequate time and resources to ensure they are successful; in this case meeting the aims of reducing the incidence of UTIs and inappropriate use of catheters.
The advice to be shared to others; start small, collaborative working and constant monitoring. Enthusiasm to embrace high standards of clinical practice to achieve effective patient outcomes is a prerequisite.
The programme is now being rolled out more widely across the Trust as well as across local care homes via clinical commissioning groups.
Find out more
For more information contact:
- Jackie Rees – Nurse Consultant, Newcastle upon Tyne NHS Hospital Foundation Trust, firstname.lastname@example.org