No Catheter, No CAUTI Scenario 1 Urinary catheter-trauma Course lead Colette Laws-Chapman Faculty Course / Curriculum Scenario name No Catheter, No catheter associated urine infection (CAUTI) Scenario 1- Urinary catheter- Trauma Target Delegates Group Size Doctors, acute nurses and nursing assistants and allied health professional?? Patients Name: Paul Clarke Patients Age: 78 Major Problem Medical Inappropriate use of catheter resulting in trauma/ blocked catheter Learning Goal Medical / Clinical Assessment of patient with catheter-inappropriate use. Treatment of traumatic catheter insertion Calling for help. A-E assessment Infection control & dignity. Suggested NTS / Technical Effective communication Utilising available resources Calling for help Decision making Care & Compassion Narrative Description Staffing Paul Clarke 78 was admitted to A&E with a mild temperature, tachycardia and a cough. A urinary catheter was inserted in A&E to get a urine sample which has been sent for MC+S. Over the past few days he has had worsening urinary incontinence and is feeling generally unwell. His mobility has declined and he has not got out of bed for three days. He has developed a grade 1 pressure ulcer on his sacrum. He was admitted to the MAU ward 1 hour ago and is yet to be seen by the admitting doctor. He has become increasingly agitated secondary to pain from the catheter region. There is haematuria and visible clots in the urine. Past medical history: Hypertension,Tinnitus, Diabetes-Type 2, AF, Benign Prostatic Hypertrophy Drug history: Amlodipine 10mg OD, Metfomin-500mg BD, Warfarin- 3mg OD, Digoxin 125mcg OD, Tamsulosin 400mcg OD Allergies: CT contrast Social history: Non-smoker. Lives alone. NOK is his daughter who visits daily. Mobilising independently with a stick. Can walk to local shops. He is a retired train driver. Faculty Control Room: 1 x technician 1 x debriefer No catheter, No CAUTI - Scenario 1-Inappropriate urinary catheter-trauma Page 1 of 8 Candidates 1xnurse, 1xNA, 1xDr or
Faculty Role Players: Nursing assistant 1xAHP, 1x Nurse, 1xDr Case Briefing Manikin preparation Room set up Simulator operation Props needed Notes to faculty To All Candidates Paul Clarke 78 was admitted to A&E with a high temperature and rigors. He has a suspected infection but the cause is not yet known. His mobility has declined in the last week and he has been in bed for the last three days. He has a grade 1 pressure ulcer to his sacrum. A urinary catheter was inserted in A&E and a urine sample was obtained which was negative. Nurse-You have come to complete your admission assessment. AHP-You have come to assess the patient to mobilise Nursing assistant-you have been asked to do regular observations To Role Players Nursing assistant-you are competent and can do anything that is asked of you. You don t know too much about the patient but can locate notes and equipment. Manikin in chair with indwelling catheter. No observation equipment attached. IV access x1 Indwelling catheter with pinkish tinged urine and blood clots Standard ward space environment-jug of water, cup, various props from home Patient voice x1 Manikin operator x1 Walking stick Ward notes Catheter with pink urine and blood clots (haemturia) The delegates will hopefully pick up on the traumatic catheter insertion from a&e and will escalate the concerns about the hameturia. They will take bloods and speak to urology as the patient is symptomatic. They may consider bladder irrigation.. No catheter, No CAUTI - Scenario 1-Inappropriate urinary catheter-trauma Page 2 of 8
Observations: Initial PAR score HR 100 AF 0 O2 sats 99% 0 BP 105 / 82 0 Temp 36.5 C 0 RR 24 0 Urine 10mls/hr 3 Output GCS E=4 V=5 M= 6 0 Total 15 Total PAR Score BM = 5.8 Capillary refill=3secs After 5 mins PAR score HR 120 AF 2 O2 sats 95% 0 BP 130 / 82 0 Temp 36.5 C 0 RR 27 2 Urine 10mls/hr 3 Output GCS E=4 V=5 M= 6 Total 15 0 BM = 5.8 Capillary refill=3secs Total PAR Score 3 After 8 mins PAR score HR 128 2 O2 sats 94% 1 BP 189 / 100 0 Temp 36.5 C 0 RR 30 3 Urine 10mls/hr 3 Output GCS E=4 V=5 M= 6 1 Total 15 AVPU Total PAR Score 10 BM = 5.8 Capillary refill=4secs No catheter, No CAUTI - Scenario 1-Inappropriate urinary catheter-trauma Page 3 of 8
Results of Investigations Bloods WCC 13.6 Hb 12.5 MCV 88 Plt 168 N s 10.7 L s 1.5 M s 1.2 CRP 98 Na+ 139 K+4.1 Urea 9.1 Creat 109 Prothrombin Time (INR) 2.0 APTT 1.3 Fibrinogen 3.9 Gases ph 7.43 pco2 4.1 po2 11.0 HCO3 28 BE -1 Lac 1.3 Imaging CXR: NAD Other Chest examination: slightly reduced AE left base Abdominal examination: suprapubic pain, palpable bladder No catheter, No CAUTI - Scenario 1-Inappropriate urinary catheter-trauma Page 4 of 8
Patient Role Paul Clark, 78 (manikin) Scenario You were admitted to A&E with a temperature and suspected infection. You have been feeling unwell for the past week and in the last three days you have not moved from your bed. Your daughter came to visit, saw how unwell you looked and called the ambulance. You were in A&E for a long time and do feel slightly better after the antibiotics and paracetamol. Your bottom feels quite sore as you have been in bed and occasionally suffer from incontinence which has been worse in the last week. Your mobility has declined in the last week and you have not got out of bed for the past three days. You have also developed a grade 1 pressure ulcer on your sacrum. You had a catheter put in A&E because the doctor said they needed a sample just in case that was where the infection was from. You are a bit traumatised by the catheter insertion as it was very painful at the time and took quite a few attempts. You have had longstanding problems with your prostate and have been seen a number of times by Urology in their outpatient clinic. As far as you know, they are happy with your prostate currently. Past medical history: Hypertension, Tinnitus, Diabetes-Type 2, AF, Benign Prostatic Hypertrophy Drug history: Amlodipine 10mg, Metfomin-500mg BD, Warfarin-3mg, Digoxin 125mcg OD, Tamsulosin 400mcg OD Allergies: CT contrast Social history: Non-smoker. Lives alone. NOK is his daughter who visits daily. Mobilises independently with a stick. Can walk to local shops. He is a retired train driver. Instructions You are feeling a lot of pain from the catheter site and it feels very uncomfortable. You are also suffering from abdominal pain. You want the nurses to take the catheter out as you think this might be the source of the pain. You start to feel more unwell due to worsening pain as the scenario progresses. No catheter, No CAUTI - Scenario 1-Inappropriate urinary catheter-trauma Page 5 of 8
Nursing assistant (Plant) Scenario Paul Clarke was admitted to A&E with a temperature, cough and suspected infection. A urinary catheter was inserted in A&E because the team wanted a urine sample. He has recently has worsening urinary incontinence and has not been feeling well. His mobility has declined in the last week and he has not got out of bed for three days. He has developed a grade 1 pressure ulcer on his sacrum. He was been admitted to the MAU ward 1 hour ago and is yet to be seen by the admitting doctor. He becomes increasingly agitated secondary to pain from the catheter region. There is haematuria and visible clots in the urine. Past medical history: Hypertension, Tinnitus, Diabetes-Type 2, AF, Benign Prostatic Hypertrophy Drug history: Amlodipine 10mg OD, Metfomin-500mgBD, Warfarin-3mg OD, Digoxin 125mcg OD, Tamsulosin 400mcg OD Allergies: CT contrast Social history: Non-smoker. Lives alone. NOK is his daughter who visits daily. Mobilising independently with a stick. Can walk to local shops. He is a retired train driver. Instructions You are competent and can do anything that is asked of you. You don t know too much about the patient but can locate notes and equipment and are very helpful as you work on the ward regularly No catheter, No CAUTI - Scenario 1-Inappropriate urinary catheter-trauma Page 6 of 8
Medical registrar (phone)/ Urology registrar Scenario Paul Clarke was admitted to A&E with a temperature, cough and suspected infection. A urinary catheter was inserted because the team had requested a urine sample. Over the past few days, he has had worsening urinary incontinence and been feeling generally unwell. His mobility has declined in the last week and he has not got out of bed for three days. He has developed a grade 1 pressure ulcer on his sacrum. He was been admitted to the MAU ward 1 hour ago and is yet to be seen by the admitting doctor. He becomes increasingly agitated secondary to pain from the catheter region. There is haematuria and visible clots in the urine. Past medical history: Hypertension, Tinnitus, Diabetes-Type 2, AF, Benign Prostatic Hypertrophy Drug history: Amlodipine 10mg, Metfomin-500mg, Warfarin-3mg, Digoxin 125mcg, Tamsulosin 400mcg OD Allergies: CT contrast Social history: Non-smoker. Lives alone. NOK is his daughter who visits daily. Mobilising independently with a stick. Can walk to local shops. He is a retired train driver. Instructions You ask for a SBAR handover. You request that some repeat bloods are taken including a VBG to check the Hb and also a bladder scan. You ask why the catheter was needed in the first place and conclude that it was not necessary. You suggest a urology opinion and that he will likely will need an irrigation catheter for clot retention. He may also need to be discussed with Haematology regarding reversing INR in view of problematic bleeding. No catheter, No CAUTI - Scenario 1-Inappropriate urinary catheter-trauma Page 7 of 8
Learning cue card for transition This scenario was designed to show inappropriate catheterisation resulting in trauma. The reason for catheter insertion from A&E is unclear and it is documented that it was for urine sample however it may have been for incontinence/ grade 1 pressure ulcer or reduced mobility-these maybe discussed as inappropriate reasons for catheter insertion. This scenario helps to support the first part on the proposed catheter care bundle in the no catheter, No CAUTI south London project-avoid unnecessary placement. For discussion-how it is important to challenge why catheters are inserted in the first place-not for the above reasons and the risks of catheterisation are real-trauma/ CAUTI/ blocked, dignity ( altered body image), delirium, increase risk of falls etc.. A substantial proportion of catheter use is not justified by clinical need; nearly one third of urinary catheter-days have been shown to be inappropriate in inpatients, 26% of catheters inserted in A&E are inappropriate. Specific factors that increase the risk of a traumatic insertion particularly known prostate enlargement (BPH), patient s with prostate cancer, previous difficult catheter insertion, urethral strictures, patient s on any anticoagulants (Warfarin/NOACs) and even aspirin. For a sample a in/ out catheter may have been used as documented in the a&e notes Please refer to the catheter record sheet and the EPR request form to demonstrate what to consider when inserting a catheter and challenging its use. Also page 6 of the current guidelines for appropriate use. No catheter, No CAUTI - Scenario 1-Inappropriate urinary catheter-trauma Page 8 of 8