Healthcare Associated Infection (HAI) catheter care aide memoire

Transcription

1 Healthcare Associated Infection (HAI) catheter care aide memoire Hospital: Ward/Department: Inspector: Date: Guidance note and methodology: This aide memoire has been developed to align with the guidelines developed by Health Protection Scotland Preventing catheter associated urinary tract infections - acute settings, when inserting and maintaining a urinary catheter (Appendix 1) and in accordance with Healthcare Improvement Scotland Healthcare Associated Infection Standards (February 2015) Standard 7: Insertion and maintenance of invasive devices. Further additions are taken from Healthcare Improvement Scotland s draft Quality of Care framework (July 2015). To select the urinary catheters to be examined, the inspector should ask a member of the nursing staff to identify patients with a urinary catheter. However, the inspector may identify patients themselves from observations in discussion with a member of the nursing staff. A member of the nursing staff must accompany the inspector when reviewing the placement of urinary catheter drainage bags and their documentation. Nursing staff will assist inspectors to locate the appropriate documentation for the purposes of the inspection. Observations and findings are to be recorded on the attached form. Where feasible, the inspector should review a representative number of urinary catheters on the wards visited. Produced by: HEI Page 1 of 7 Review Date: October 2018

2 1. Questions for the patient based on HAI Standard 7 (7.2, 7.3, 7.4). 2. Inspectors should determine if the urinary catheter was inserted in this hospital. Is there documentation in the patient notes to support this? Inspector will capture this information (where and when) and continue with all other aspects of Section 4: Maintenance. Was the catheter inserted in this hospital? If no, proceed to Section 4: Maintenance. te where urinary catheter was inserted - other hospital, community setting. Patient 1 Patient 2 Patient 3 Patient 4 Was verbal consent gained for urinary catheter procedure and explanation given for requirement of invasive device? / / NA If no, is this a patient with incapacity or not able to consent at time of insertion? Are staff able to describe the process in place? Were other options discussed? / / Don t know Do you feel staff considered your privacy and dignity during the procedure? / / Don t know When the urinary catheter was inserted was personal protective equipment (gloves and apron) worn by the person who inserted it? / / Don t know Have you been provided with any (written or verbal) patient information about your urinary catheter? Have staff spoken to you about removal of your urinary catheter? / / NA Produced by: HEI Page 2 of 7 Review Date: October 2018

3 3. Inspector review of urinary catheter insertion documentation: Prior to inspection, review the local guidelines and documentation for the management of urinary catheter, indicated by NHS board. (Question 7 in HAI self-assessment). Questions based on Health Protection Scotland s Preventing catheter associated urinary tract infections - acute settings, when inserting and maintaining a urinary catheter. Inspector to indicate YES/NO in responses below. UC 1 UC 2 UC 3 UC 4 Was the catheter inserted in this hospital? If no, proceed to Section 4: Maintenance. Alternatives to urethral catheterisation have been considered and the clinical reason is clearly documented. The insertion procedure was clearly documented. Aseptic technique is performed at insertion of indwelling urinary catheter. The smallest gauge was used consistent with proper drainage and minimising urethral trauma. Once inserted, the balloon is filled to the recommended level ie 10mls - unless clinically indicated. The urethral meatus was cleaned with sterile saline and single use sterile lubricant was used prior to inserting the urinary catheter. Aseptic technique was applied/ maintained when connecting the indwelling catheter to a sterile closed drainage system. Produced by: HEI Page 3 of 7 Review Date: October 2018

4 4. Inspector review of urinary catheter maintenance: Questions based on Health Protection Scotland s Preventing catheter associated urinary tract infections - acute settings, when inserting and maintaining a urinary catheter. Observe and check for documentation of all below. Inspector to indicate YES/NO below. UC 1 UC 2 UC 3 UC 4 Does the patient still require a urinary catheter? Is the indwelling catheter continuously connected to the drainage system? Has catheter bag change been considered in line with manufacturer s guidelines between 5-7 days? (discuss with staff) Is date for removal documented? Record that daily meatal hygiene has been performed. Hand hygiene is performed immediately prior to access or manipulation of the indwelling catheter. (WHO Moment 2) Drainage bag is situated below the bladder level and the tap is not in contact with any surface, for example floor? Produced by: HEI Page 4 of 7 Review Date: October 2018

5 5. Questions for staff who are trained to insert urinary catheter: Discussion on how a urinary catheter is inserted and maintained to ascertain knowledge of practice. Questions are based on Health Protection Scotland s Preventing catheter associated urinary tract infections - acute settings, when inserting and maintaining a urinary catheter and are aligned to NHS Education for Scotland (NES) urinary catheter care and aseptic technique e-learning modules. NHS Education for Scotland has developed education and training resources related to urinary tract infections. These resources vary in education content and delivery modes and include online modules, educational toolkits, workbooks and posters and are accessible to all NHS boards. Ask staff to talk through the process of insertion and maintenance of a urinary catheter. Tick or cross as staff answer each question. Staff will take part in practical session to demonstrate the procedure with practice pack. te staff designation Aseptic technique is described and maintained throughout practical demonstration. Staff member 1 Staff member 2 Staff member 3 Staff member 4 Can staff member identify the use of the smallest most appropriate guage of catheter (NES selecting a urinary catheter)? Can they explain rationale behind choice of size? Can staff member identify closed drainage system in use and placement of catheter bag (below bladder level and not on floor)? Can staff member identify technique for changing catheter bag and in line with manufacturer s guidelines? Produced by: HEI Page 5 of 7 Review Date: October 2018

6 If staff member is required to access the urinary catheter, can they describe the correct process for accessing the port aseptically? Can staff member describe the process of support for when there are complications during a catheterisation? When did staff member last receive or carry out training on the insertion of a urinary catheter? Is staff member aware of audits taking place about insertion and maintenance criteria? Can staff member describe how information is shared on the results of audits? Change to procedures? How is learning from any internal investigation shared with staff? Produced by: HEI Page 6 of 7 Review Date: October 2018

7 Appendix 1 Produced by: HEI Page 7 of 7 Review Date: October 2018