Reducing catheter-acquired urinary tract infections in surgical patients

Dianne Jolley Quality and Safety Manager Nepean Hospital, Nepean Blue Mountains Local Health District,NSW

Background

Australia is falling behind many other countries when it comes to urinary tract infections (UTIs) in hospitals. A total of 1.7% or 95,000 patients acquire a UTI annually in hospital. These patients stay about 4 days longer in hospital, which equates to 280,000 public hospital beds each day. (1) The Nepean Hospital Surgical Department is part of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). The NSQIP is a data-driven, risk-adjusted, outcomes-based programme to measure and improve the quality of surgical care. Data have been collected from the Nepean Surgical Department for the past 18 months and submitted to the NSQIP for evaluation of a range of complications including, but not restricted to, morbidity and mortality, length of stay, venous thrombosis/ embolism, surgical site infections, UTIs and readmission rates.

Problem/Aim

From the abovementioned data collection, it was identified that the number of patients acquiring UTIs following surgery was above the benchmark and that the majority of these were due to catheterisation during and after surgery. The division of surgery embarked on the project to reduce the number of catheteracquired UTIs.

Design

This improvement plan involved a colorectal surgeon, the quality and safety manager, the newly appointed clinical nurse consultant (CNC) urology and the NSQIP data manager. A working group was formed incorporating key personnel from surgical specialties, exclusive of orthopaedics, and an executive sponsor was found. The working group identified a number of issues that it considered contributed to the catheter-acquired UTIs, and to test these theories, a number of focus groups were held with frontline staff for their impressions. Workflow for patients attending theatre for minor procedures was reviewed, and it was identified that indwelling catheters were being inserted with no evidence of the benefits and usually by the most junior medical staff. In addition, the NSW Ministry of Health had recently released a policy guideline in 2016 outlining best practice, and a procedure for the local health district (LHD) was developed for the insertion and management of indwelling catheters. It was recognised that there were a number of areas to target from the information gathered from the focus groups and from the literature reviewed.

The group acknowledged that, in addition to an LHD procedure for catheterisation of adult patients in the acute setting, the following interventions were required: • reduce the number of unnecessary catheterisations • run a ‘get it off the floor’ campaign • review the equipment available • review the resources available for patients • improve the education of staff. The ‘get it off the floor’ campaign was run as a poster competition during Urology Week to identify how to improve compliance with hanging catheter bags from hangers rather than placing them on the floor. Education workshops were run by the CNC

urology on aseptic technique and catheterisation, and the colorectal surgeon worked with the surgeons to reduce the number of unnecessary catheterisations in theatre.

Results

For October 2016 – October 2017, the number of patients with identified catheter-acquired UTI at Nepean Hospital in the patient cohort for this project reduced from 2.91% to 1.71% of average risk as described by ACS NSQIP data. Below is the NSQIP report, which shows a steady reduction in UTI from March 2017, when the programme began, to July 2018.

Conclusion

All the initiatives were introduced as a bundle and it is difficult to identify any one practice change that has affected the outcome, but the most significant practice change appears to be the reduction of unnecessary catheterisations in the operating theatres by the surgeons.

References

1. Mitchell BG, Ferguson JK, Anderson M, Sear J. Barnett A. Length of stay and mortality associated with healthcareassociated urinary tract infections: a multi-state model. J Hosp Infect 2017; 93( 1):92-9.