High Impact Actions: reducing CAUTIs

Protection from Infection is one of the areas targeted by the High Impact Actions (HIAs) for nursing and midwifery. HIAs were developed by the NHS Institute for Innovation and Improvement as part of its Quality, Innovation, Productivity and Prevention programme (QIPP) to increase quality and cost effectiveness. The list of eight target areas was drawn up following a “call for action” which gave frontline nursing staff the opportunity to submit examples of high quality and cost effective care that, if adopted widely across the NHS, could make a big difference, giving nurses and midwives an opportunity to demonstrate the difference that nursing can make. Commenting on HIAs, Dr Lynne Mather, interim director for design and innovation at NHS Institute for Innovation and Improvement said: “The purpose of HIAs is to take really good evidence of what is working well and to spread it across the NHS which will have a huge impact.” A large proportion of healthcareassociated infections (HCAIs) are the result of indwelling catheters, so this is one obvious area for improvement as part of the Protection from Infection HIA. The Nurse Sensitive Outcome Indicators for NHS commissioned care1 suggests that 60% of all UTIs are related to urinary catheter insertion and that the estimated cost for each catheter associated urinary tract infection (CAUTI) is in excess of £1,000 per patient. The latest Hospital Infection Society (2007) prevalence study suggested that up to 31% of hospital inpatients had a urinary catheter in situ and that up to 23% of patients may be catheterised during their hospital stay. The duration of catheterisation has also been strongly correlated with the risk of infection. The longer a catheter is in place the higher the incidence of CAUTIs. Establishing a nationally agreed definition for a urinary tract infection associated with catheterisation has proved problematic. The Department of Health’s Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection has advised that, given the problems with the interpretation of urinary isolates for patients with indwelling catheters and the difficulty of establishing an agreed standardised definition, routine surveillance of CAUTI is not recommended. However, it is recommended that organisations undertake ongoing assessment of urinary catheters, with a view to minimising their inappropriate use.

A form of success

The infection control team at Winchester and Eastleigh Healthcare NHS Trust recognised UTIs as one of the most common hospital-acquired infections, often associated with the insertion of urinary catheters. The issues surrounding catheterisation were highlighted when the Trust undertook a Saving Lives audit.2 Sue Dailly, lead nurse infection prevention and control at the Royal Hampshire County Hospital Winchester explains: “One result of the audit was the discovery that there was confusion over who was responsible for removing catheters. Doctors thought it was the nurse’s responsibility to remove the catheter, while the nurses thought it was the doctor’s responsibility. “The audit also identified that there was often no evidence of any care having been carried out on catheters. Some of the recommendations of the Saving Lives document include catheter care tasks which should be carried out each day to prevent infection. At the time of the audit we had no proof that these tasks were being done.” A three-month trial was immediately initiated with the aim of finding ways of reducing inappropriate catheterisation and, where a catheter was deemed necessary, to ensure reliable care and prompt removal when clinically appropriate. The result was the introduction of a Urinary Catheter Assessment and Monitoring (UCAM) form to record and document all insertion and ongoing urinary catheter care. The UCAM was developed and refined through contributions from nursing staff, the infection control team and the specialist urology team. The plan for measuring the success of implementation includes weekly assessment through the nursing quality indicators audit. The forms are designed to make it easy to monitor catheter use and govern the catheter care provided by staff. The Trust-wide introduction of the UCAM has helped to streamline catheter care and has clarified staff responsibilities regarding the use and care of catheters. Nursing staff now routinely challenge whether a catheter is appropriate, particularly when the issue relates to continence. The Trust is supporting staff to ensure that all other options are considered, including a full continence assessment. The UCAM consists of a single sheet that provides a 28-day history of the patient’s catheter, recording when the bag is changed and whether daily hygiene has been carried out. It also ensures that staff regularly review whether the catheter is still required. This is supported by a weekly audit measuring compliance. Commenting on the success of the UCAM, Sue Dailly said: “The Hospital already had low infection numbers so we haven’t compared the number of CAUTIs before and after the introduction of the form. However, we now have evidence to show that we have improved the quality of documentation. Also, with staff being prompted to remove catheters as soon as appropriate the form has succeeded in reducing the length of time that patients are catheterised and has made staff think more carefully about whether a catheter is actually needed.” Alison Davis, staff nurse at the Winchester and Eastleigh Healthcare NHS Trust, believes that the introduction of the form has been a positive step. She said: “The UCAM flags up that the patient has a catheter, that it should be reviewed and that good catheter care is established. It is a really useful tool that tells each nurse what they need to do and when.” Andy Ractoo, clinical assistant on the gastroenterology ward agrees that the forms have been a positive step in improving patient care and that they are also a time-saving tool. He said: “Before the UCAM was introduced, a patient would arrive on the ward and we would be told verbally that they had a catheter. We then had to wade through notes to find out when it was put in. Our ward has three shifts so a patient could be checked three or four times a day. Now this is only done once and is documented, helping to protect the patients dignity and reducing the need for invasive reviews.” In conclusion, the UCAM form has helped to provide evidence of quality of patient care at Winchester and Eastleigh Healthcare NHS Trust. The reduction in catheterisation has reduced workloads and has helped staff to deliver high quality care to patients. Although the cost reduction implications of UCAM are difficult to accurately determine, the Trust has suggested that an alternative proxy indicator is the number of patients who are catheterised. Between 2007 and 2009 this figure fell by 23%. If it is assumed that 25% of these patients would have acquired a CAUTI then the reduction in catheter usage has released just under £10,000. Other savings accrue from patients not being catheterised and reduced use of specialist urology nurses. In support of this, urology nurses at the Trust have confirmed that they are required on the wards less since the introduction of the UCAM form.