The Documentation of Urethral Catheterisation Are we Getting It Right? S.Nandhra, J.Martson, E.Clapham, G. Urwin, R.Wilson Audit Aims and Objectives To ensure correct and accurate documentation of urethral catheterisation. To enhance the care of catheterised patients by: Encouraging consideration of the indication and the appropriate infection control methods. Good Documentation is fundamental in clinical care and provides a legal record 1, 2, 4, 6 If it’s not documented it didn’t happen!! Why is this audit important Documentation of important information helps with diagnosis and management 1 Infection control prevention: Eg AUR with residual of 500ml vs 2000ml Enables effective planning for TWOC 3 Allows communication between healthcare professionals 60% of healthcare acquired UTIs are related to catheter insertion 6 20% of patients with a catheter develop asymptomatic bacteriuria and 2-6% symptomatic UTI. 4 Of which 1-4% develop a bacteraemia accounting for approximately 1500 deaths annually in the UK. 5 Each hospital acquired UTI results in an increased length of stay of 5-6 days, costing £1327 to treat. 4 Current guidance Audit criteria based on approved guidance and recommendations from the Royal College of Nursing1, NHS Quality Improvement Scotland4 and the Department of Health6 Recommendations were used to create specific items of necessary documentation. Our end aim was to achieve 90% of the criteria completed for each catheter. Our Proforma 15 specific items that included Patient demographics Indication for catheterisation and specifics about the process Urine observations including residual The type of catheter Data Collection 3 sessions of data collection during January 2011 Both medical and nursing notes reviewed Range of wards included surgical and medical Catheters inserted in theatre were excluded Catheter inserted by investigators were excluded In total a data set of n=51 results were collected during the first cycle of the audit Documentation Results Criteria 3/5ths had both the date and time documented Date Alarmingly no documentation at all in 1/3 Time Name Role 90% In roughly half of the pts the healthcare professional was not identifiable. No docume ntation at all Yes No 65% 35% Yes No 63% 37% Yes No 51% 49% Doct or Nurs e Othe r Not State d 24% 29% 2% 45% 29% NO NO NO NO Documentation Results 98% had no allergy status documented. Criteria Allergies One latex allergic patient had a latex catheter in situ. Consent Draining Urine Just over a tenth of pts had consent documented. Difficulty >90% Yes No 2% 98% Yes No 12% 88% Yes No 55% 45% Easy Difficu lt Not State d 33% 2% 65% NO NO NO NO Documentation Results Criteria 61% did not have a volume recorded. (interestingly the majority being from the AUR group). Over half had no documentation at all Volume Appearance Dipstick Specimen Sent In total only 2% of catheters have >90% documentation (out of the 15 items needed) No Documentatio n at All > 90% Yes No 39% 61% Yes No 27% 73% Yes No 16% 84% Yes No 18% 82% 53% NO NO NO NO How does York compare? Tempest et al, 20052 (USA): Only 3% full documentation without stickers Rose to 84% with stickers at re-audit Bhardwaj et al (2010)5 (Newcatle, UK): 89% with some written documentation Brennan & Evans (2001)8: No documentation in 19.6% Bray & Sanders (2007)9 London: (Paediatric) Unable to identify duration of catheterisation in 13% Conybeare et al (2002)7 Boston, lincolnshire: Indication not documented for any patient Only 25% documented in medical notes Urethral Catheter Insertion Documentation Implementation Posters for awareness Matron/ward manager Infection control Date: Time: . Consent: Yes/emergency/incapacitated Indication: . Aseptic Technique: Yes/No Ease of insertion: Easy/resistance/hard Attempts: . Latex Allergy: Yes/No Urine Draining: Yes/No Colour: Clear/Haematuria/cloudy Volume of residual: mls Catheter: (affix catheter sticker here) Size: 12Ch/16Ch/22Ch Type: 2-way/3-way Duration: Long T/Short T Balloon Vol: mls Dipstick requested: Yes/No Dipstick result: CSU requested: Yes/No Name: Designation: . . . Re-audit Documentation Criteria >90% Criteria Allergies Date Yes No 100% 0% Name Role Yes No 100% 0% Yes No 100% 0% Doctor Nurse 79% No docum entatio n 0% 21% Yes No 93% 7% Yes No 93% 7% Yes No 100% 0% Easy Difficu lt Not State d 79% 14% 7% Yes Yes Consent Time >90% Yes Yes Other 0% Indication Difficulty Not Stated 0% Yes Yes Yes Yes Documentation – urine observations Volume – improvement but not >90% However this is most useful in AUR where it was completed in the majority of cases. Dipstick and MSU now being requested where indicated. Criteria Volume Appearance Dipstick Specimen Sent No Documentatio n at All > 90% Yes No 79% 21% Yes No 93% 7% Yes No 79% 21% Yes No 79% 21% 0% NO Yes NO NO Conclusions Successful implementation with excellent uptake Positive feedback from the nursing and medical staff. Not felt to add to work load or burden. Massive increase in compliance in all categories -High proportion 100% compliance Most >90% standard compliance met Outcome York Teaching hospital Trust-wide implementation Successful integration into the surgical directorate Rolled out across the trust – awaiting printers Thank you Any Questions? References 1. 2. 3. 4. 5. 6. 7. 8. 9. Royal College of Nursing (2008). Catheter Care. RCN guidance for nurses. Tempest HV, Kumar N, Rucker J, Knight A, Saleemi A (2005). An Audit Investigating Documentation of Hospital Urethral Catheterisation and the Improvement Using Proforma Stickers. Clinical Governance: An Internation Journal. 10(2) p 165-167 Nazarko L (2009). Providing Effective Evidence Based Catheter Management. British Journal of Nursing. 18(7) p S4-S12 NHS Quality Improvement Scotland (2004). Best Practice Statement – Urinary Catheterisation and Catheter Care. www.nhshealthquality.org, Edinburgh. Bhardwaj R, Pickard R, Rees J (2010). Documented Adherence to Standards and Guidelines: An Audit. British Journal of Nursing. 19(18) p S26-S30 Department of Health (2007). Saving Lives. High Impact Intervention No 6. Urinary Catheter Care Bundle. Conybeare A, Pathak S, Imman I (2002). The Quality of Hospital Records of Urethral Catheterisation. Ann R Coll Surg Engl. 84 p 109-110. Brennan ML, Evans A (2001). Why catheterise? Audit findings on the use of urinary catheters. British Journal of Nursing. 10(9) p 580-590 Bray L, Sanders C (2007). Urethral catheter audit. Paediatric Nursing. 19(3) p 14-16.