Prevention of Catheter Associated Urinary Tract Infections (CAUTI) Driver Diagram and Change Package. The Scottish Patient Safety Programme

Transcription

1 Prevention of Catheter Associated Urinary Tract Infections (CAUTI) Driver Diagram and Change Package The Scottish Patient Safety Programme 1

2 Prevention of Catheter Associated Urinary Tract Infections Driver Diagram Outcomes Primary Drivers Secondary Drivers AIM: To reduce Catheter Associated Urinary Tract Infections (CAUTI) by 30% by end December 2015 Definition: CAUTI as defined by: Urinary Catheter in situ or removed within previous 48 hours and diagnosis of CAUTI documented in the medical notes and an antibiotic has been prescribed on the medication chart to treat a CAUTI Teams may wish to include signs & symptoms, as per the definition included in v1.0 of the measurement plan. Use the Model for Improvement and local data to target and drive improvement Improved clinical practice Patient and family Involvement Infrastructure and culture Define and collect process and outcomes data per measurement plan Communicate process & compliance measures to clinical staff and management teams Use Pareto charts to target local high prevalence areas Implement education & training for staff: ensure Staff knowledge and understanding of the Model for Improvement and data for Improvement Develop, test and implement Urinary Catheter Insertion Bundle Develop, test and implement Urinary Catheter maintenance Bundle Raise awareness of issues with clinical staff make the case Implement interventions to improve antimicrobial prescribing Ensure patient and family centred care Provide patient information on admission Involve Patient/Family with Care bundles and treatment process Promote open communication among team and family Optimise transitions to home or other facility Provide a culture and infrastructure to support safety and quality improvement Ensure executive sponsorship and clinical leadership Develop and implement a staff engagement strategy Establish a multi-disciplinary team to lead the work, including QI support Raise awareness of Urinary Catheter Bundles across the organisation 2

3 Change Package Use of the Model for Improvement and local data to target and drive improvement Use pareto analysis to determine prevalence of indwelling urinary catheters and provide feedback to senior charge Nurses, medical staff and management Start with high use areas to target improvement effort Provide training and education materials for the use the Model for improvement, Run Charts, how to interpret data for improvement and provide facilitated improvement support Provide local IT system for process measures Promote the use of run charts on Quality improvement Boards to display process reliability Utilise incident management system to record Outcome Measures ensuring the use of CHI at local level Investigate lab data re number of catheter related UTI in parallel with definition of CAUTI 3

4 Improved clinical practice HPS Key Recommendations t.nhs.uk/hai/infectioncontrol/bundles/cauti/uc-acutev1.pdf Urinary Catheter Insertion Bundle 1. Alternatives to urethral catheterisation have been considered and the clinical reason is clearly documented 2. Aseptic technique is performed at insertion of indwelling urinary catheter 3. The indwelling urinary catheter was the smallest gauge, once inserted, the balloon was filled to the recommended level i.e. 10mls (unless clinically indicated) 4. The urethral meatus was cleaned with sterile saline and single use sterile lubricant was used prior to inserting the indwelling urinary catheter 5. Aseptic technique was applied/maintained when connecting the indwelling urinary catheter to a sterile closed drainage system. Urinary Catheter Maintenance Bundle 1. Does patient still require indwelling urinary catheter? Remove if possible 2. Is the indwelling urinary catheter continuously connected to the drainage system and changed in line with manufacturers recommendations? 3. Meatal hygiene has been performed? 4. Is the drainage bag emptied when clinically indicated using a clean, disposable container for each patient? 5. Is hand hygiene performed immediately prior to access or manipulation of the indwelling urinary catheter? 6. Is the drainage bag situated below the bladder level and the tap is not in contact with any surface e.g. floor? 4

5 Definition of CAUTI for Indicator purposes Ensure the Outcome definition is clearly signposted within Process Interventions paperwork CAUTI as defined by: Urinary Catheter in situ or removed within previous 48 hours and diagnosis of CAUTI documented in the medical notes and an antibiotic has been prescribed on the medication chart to treat a CAUTI Teams may wish to include signs & symptoms, as per the definition included in v1.0 of the measurement plan. Raising awareness making the case Assemble evidence base and offer local promotional materials to raise awareness Implement education & training for staff Promote NES online short course to all clinical staff and where appropriate link to PDP/KSF objectives Ensure all staff are aware of local antimicrobial policy and UTI decision aid. Link to decision aid: SAPG/Catheter_associated_urinary _tract_infection_cauti Implement interventions to improve management of CAUTI and antimicrobial prescribing Promote use of the UTI decision aid to optimise recognition, management and antimicrobial treatment of CAUTI. Ensure urine samples for culture and sensitivity are used appropriately in patients with catheters. Ensure antimicrobial prescribing for CAUTI follows local policy for treatment choice and duration. Ensure that microbiology results are reviewed and antimicrobial treatment changed if required. 5

6 Measurement Plan Measure Name Identifier Operational Definition Data Collection Guidance Percent compliance with Urinary Catheter Insertion bundle CAUTIP1 1. Determine the numerator: the total number of patients who have all 5 elements of the Urinary Catheter Insertion bundle in place 2. Determine the denominator: the total number of patients with a Urinary Catheter insitu that have been reviewed 3. Calculate the percent compliance with the Urinary Catheter insertion bundle by dividing the numerator by the denominator and then multiplying the resulting proportion by 100 Use medical /nursing notes as the primary data source. Review each sheet for implementation of the Urinary Catheter Insertion bundle. Rotate the days of the week and shifts within a day. On the randomly selected day, all patients with urinary Catheters should be examined for evidence of urinary Catheter insertion bundle compliance. There is no sampling with this measure; include all patients with Urinary Catheters. If, however, there is a high volume of urinary Catheters you could select a random sample of 5 patients with Urinary Catheters on the day you select for the study. Only patients with all 5 aspects of Urinary Catheter insertion bundle in place are recorded as being in compliance. Note: The Urinary Catheter Insertion bundle includes 1. Alternatives to urethral catheterisation have been considered and the clinical reason is clearly documented 2. Aseptic technique is performed at insertion of indwelling urinary catheter 3. The indwelling urinary catheter was the smallest gauge, once inserted, the balloon was filled to the recommended level i.e. 10mls (unless clinically indicated) 4. The urethral meatus was cleaned with sterile saline and single use sterile lubricant was used prior to inserting the indwelling urinary catheter 5. Aseptic technique was applied/maintained when connecting the indwelling urinary catheter to a sterile closed drainage 6

7 Measure Name Identifier Operational Definition Data Collection Guidance system. Percent compliance with Urinary Catheter Maintenance Bundle CAUTIP2 1. Determine the numerator: the total patients with a urinary catheter receiving all 6 components of the Urinary Catheter maintenance bundle 2. Determine the denominator: the total number of patients with a urinary catheter insitu that have been reviewed 3. Calculate the percent compliance with the CAUTI maintenance bundle by dividing the numerator by the Report monthly to SPSP but report each week s prevalence. This means that there should be 4 data points for each month unless the volume is low (e.g., some weeks there are no urinary catheters in place) in which case the results for all urinary Catheter insertion bundle compliance for the month will need to be aggregated. NB. At the start of improvement you may wish to collect data each day to understand how your system is performing and where to target improvement effort. Data for each separate element of the Bundle should be observed for compliance. Exclusions: patients with suprapubic catheters Use medical /nursing notes as the primary data source. Review each sheet for implementation of the Urinary Catheter Maintenance Bundle. Rotate the days of the week and shifts within a day. On the randomly selected day, all patients with urinary catheters should be examined for evidence of Urinary Catheter maintenance bundle compliance. If measuring on a random day include all patients with Urinary Catheters If, however, there is a high volume of Urinary Catheters; you could select a random sample of 5 patients weekly with urinary catheters on the day you select for the study. Aggregate data and report monthly. Note: If a patient is not eligible for one of the bundle elements for medical reasons and that exclusion is documented, that patient is considered compliant for that element of the bundle Note: the CAUTI maintenance bundle includes: 7

8 Measure Name Identifier Operational Definition Data Collection Guidance denominator and multiplying the result by Does patient still require indwelling urinary catheter? Remove if possible 2. Is the indwelling urinary catheter continuously connected to the drainage system and changed in line with manufacturers recommendations? 3. Meatal hygiene has been performed? 4. Is the drainage bag emptied when clinically indicated using a clean, disposable container for each patient? 5. Is hand hygiene performed immediately prior to access or manipulation of the indwelling urinary catheter? 6. Is the drainage bag situated below the bladder level and the tap is not in contact with any surface e.g. floor? CAUTI count CAUTIO1 This measure is a count of the number of new CAUTI developed in the last month. At the start of improvement you may wish to collect data more frequently to understand how your system is performing and where to target improvement effort. Exclusions: patients with suprapubic catheters Number of CAUTI in the last month Inclusion: infection arises after insertion of a catheter or within 48 hours of removal of the catheter Exclusions: patients with suprapubic catheters. Caveats around hospital acquired infection prevail. Each event should be entered on to incident management systems ( or equivalent system provided a unique patient identifier is recorded) 8

9 Measure Name Identifier Operational Definition Data Collection Guidance CAUTI rate (catheter CAUTIO2a days) 1. Determine the numerator: The total number of CAUTI for the month Report the numerator and denominator monthly. Provide annotations as appropriate to reflect any interventions you made during the month. 2. Determine the denominator: The total number of Urinary Catheter days for the month N.B. reducing the number of indwelling urinary catheters days is a key element of CAUTI improvement. Wards/units undertaking this work will require a process to capture this information. CAUTI rate (occ. bed days) CAUTIO2b 3. The CAUTI rate is calculated by dividing the total numerator by the denominator and multiplying the result by 1000 to get the CAUTI rate per 1000 catheter days 1. Determine the numerator: The total number of CAUTI for the month Inclusion: infection arises after insertion of a catheter or within 48 hours of removal of the catheter Exclusions: patients with suprapubic catheters. Caveats around hospital acquired infection prevail. Report the numerator and denominator monthly. Provide annotations as appropriate to reflect any interventions you made during the month. 2. Determine the denominator: The total number of acute occupied bed days for the month. N.B. reducing the number of indwelling urinary catheters days is a key element of CAUTI improvement. Wards/units undertaking this work will benefit from developing a process to capture this information. 3. The CAUTI rate is calculated by dividing the total numerator by the denominator and multiplying the result by 1000 to get the CAUTI rate per 1000 acute occupied bed days Inclusion: infection arises after insertion of a catheter or within 48 hours of removal of the catheter Exclusions: patients with suprapubic catheters. Caveats around hospital acquired infection prevail. 9

10 Measure Name Identifier Operational Definition Data Collection Guidance CAUTI days CAUTIO3 between This measure is a count of the number of days that have gone by with no CAUTI being reported. Every time a CAUTI occurs the count is started over again. In this case, we are plotting successes between events. The longer the run of success (days with no CAUTI occurring) the better the outcome. Whenever events occur that are relatively rare in nature or when a ward or pilot area has sufficiently small numbers of events, the preferred way to analyse the data is to plot: (1) successes between events, or (2) time between events. Both of these techniques will be used in the SPSP work. Inclusion: infection arises after insertion of a catheter or within 48 hours of removal of the catheter Exclusions: patients with suprapubic catheters. Caveats around hospital acquired infection prevail. 10