The Documentation of Urethral Catheterisation S.Nandhra, J.Martson, E.Clapham, G. Urwin, R.Wilson Are we Getting It Right?

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 Eg AUR with residual of 500ml vs 2000ml Enables effective planning for TWOC 3 Allows communication between healthcare professionals Infection control prevention: 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 Nursing 1, NHS Quality Improvement Scotland 4 and the Department of Health 6 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 Criteria90% DateYesNo 65%35%NO TimeYesNo 63%37%NO NameYesNo 51%49%NO RoleDoct or Nurs e Othe r Not State d 24%29%2%45%NO No docume ntation at all 29% 3/5ths had both the date and time documented Alarmingly no documentation at all in 1/3 In roughly half of the pts the healthcare professional was not identifiable.

Documentation Results Criteria>90% AllergiesYesNo 2%98%NO ConsentYesNo 12%88%NO Draining Urine YesNo 55%45%NO DifficultyEasyDifficu lt Not State d 33%2%65%NO 98% had no allergy status documented. One latex allergic patient had a latex catheter in situ. Just over a tenth of pts had consent documented.

Documentation Results Criteria> 90% VolumeYesNo 39%61%NO AppearanceYesNo 27%73%NO DipstickYesNo 16%84%NO Specimen Sent YesNo 18%82%NO No Documentatio n at All 53% 61% did not have a volume recorded. (interestingly the majority being from the AUR group). Over half had no documentation at all In total only 2% of catheters have >90% documentation (out of the 15 items needed)

How does York compare? Tempest et al, (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

Implementation Posters for awareness Matron/ward manager Infection control Urethral Catheter Insertion Documentation 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 ) Dipstick requested: Yes/No Dipstick result:. CSU requested: Yes/No Name:. Designation:. Size: 12Ch/16Ch/22Ch Type: 2-way/3-way Duration: Long T/Short T Balloon Vol: mls

Re-audit Documentation Criteria>90% DateYesNo 100%0%Yes TimeYesNo 100%0%Yes NameYesNo 100%0%Yes RoleDoctorNurseOtherNot Stated 79%21%0% Yes No docum entatio n 0% Criteria>90% AllergiesYesNo 93%7%Yes ConsentYesNo 93%7%Yes IndicationYesNo 100%0%Yes DifficultyEasyDifficu lt Not State d 79%14%7%Yes

Documentation – urine observations Criteria> 90% VolumeYesNo 79%21%NO AppearanceYesNo 93%7%Yes DipstickYesNo 79%21%NO Specimen SentYesNo 79%21%NO No Documentatio n at All 0% 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.

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. Royal College of Nursing (2008). Catheter Care. RCN guidance for nurses. 2. 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 Nazarko L (2009). Providing Effective Evidence Based Catheter Management. British Journal of Nursing. 18(7) p S4-S12 4. NHS Quality Improvement Scotland (2004). Best Practice Statement – Urinary Catheterisation and Catheter Care. Edinburgh. 5. Bhardwaj R, Pickard R, Rees J (2010). Documented Adherence to Standards and Guidelines: An Audit. British Journal of Nursing. 19(18) p S26-S30 6. Department of Health (2007). Saving Lives. High Impact Intervention No 6. Urinary Catheter Care Bundle. 7. Conybeare A, Pathak S, Imman I (2002). The Quality of Hospital Records of Urethral Catheterisation. Ann R Coll Surg Engl. 84 p Brennan ML, Evans A (2001). Why catheterise? Audit findings on the use of urinary catheters. British Journal of Nursing. 10(9) p Bray L, Sanders C (2007). Urethral catheter audit. Paediatric Nursing. 19(3) p