Abstract
Introduction
Catheter insertion is an invasive procedure associated with significant morbidity, including urinary tract infections (UTIs), prolonged hospital stays and patient discomfort. UTI is the commonest hospital-acquired infection, accounting for 19% of cases. We conducted a clinical audit to assess patients who had a catheter during their hospital stay, focusing on the indications for catheterization and the incidence of UTIs. Based on the findings of the first audit, we introduced guidelines for out-of-hours catheter insertion and inpatient Trial Without Catheter (TWOC) protocols. These were presented at departmental grand rounds, and a re-audit was performed to evaluate the impact.
Method
Retrospective analysis of patient data utilising the electronic patient record (EPR) over two one-month audit cycles was performed, focusing on admissions to the elderly care wards.
Results
- Comparing the two cycles, inpatient catheterization decreased from 67% to 60.7%,
- Long term catheter (LTC) use rose from 33% to 39.3%.
- Retention is the main reason for insertion of new catheters; bladder scanners are usually being used appropriately to diagnose this. Catheter use for output monitoring has declined.
- Across both cycles, 10 patients were diagnosed with UTIs during hospitalization, which was associated with a prolonged hospital stay of 10–15 days among patients with bacteraemia
- Bacteraemia occurs mostly in patients with LTC
- Notably, successful TWOCs increased significantly after the second cycle (60% vs. 10%).
Conclusion
Audit data can be used to influence practice around catheter improve TWOC rates. A smart phrase has been introduced in our electronic notes that will improve documentation and will act as a reminder for early TWOCs
Comments
Indications for Catheterisation?
A common issue I noticed when reviewing geriatric patients is that the indications for catheterisation were often unclear. I wonder from your study how what percentage of patients who were catheterised actually had explicit reasoning for needing it?
Thank you for your question.
That is indeed what we thought before we started working on this project. However, we noted that for patients who had a new urinary catheter inserted during the hospital admission, about 90% had a documented indication in the first cycle and 93% in the second cycle, which is a comparable percentage. The impression, however, was that for some of the patients, the documentation followed the catheter insertion at some point in their journey, as team members may have dug deeper for more information through the notes or from the nursing team, and then essentially documented it, our EPR system making it easier for us to identify the indication during data collection.
Thank you for your question!
That’s indeed the impression that we had prior to commencing data collection. However, we noted that for the cohort of patients that had a new urinary catheter inserted during the hospital admission, in the first cycle 90% patients had a documented indication and 93% in the second cycle. That said, we suppose it was easier to look for it, because we use EPIC as our EPR and we noticed that for some patients indications were documented following the catheter insertion at a later point in their journeys as team members may have dug through the notes a bit deeper or corroborated with nursing team for completeness/CGA. The above percentages reflect the quantitative documentation, and not adherence to our guidelines for catheter insertion.
This is often an overlooked…
This is often an overlooked aspect of care of geriatric patients and a significant infection risk. Very clinically relevant project.
Catheters
Removing unnecessary catheters to reduce infection risk and improve mobility in inpatients is very important, so a good audit topic. I noticed your successful TWOCs increased dramatically. Can I ask, was there anything in particular you did to improve TWOC rate eg ensured bowels opening?
Thank you for your question!
That is an excellent question, and one that we often think about. The rate of TWOCs mentioned on the poster reflect the percentage of successful TWOCS over the 2 cycles. From the data for patients that underwent a TWOC, in the first cycle only 10% were successful and 90% were unsuccessful. Following this our guidelines for Indications of catheterisation and timely TWOCs were introduced and promoted with education at different levels via our departmental teachings and also the trust wide Grand round. Besides defining the appropriate indications for a new catheter insertions, the guideline was instrumental in defining the TWOC process and encouraging timely TWOCs after identifying indications of insertion and correcting them whenever possible like you suggested in the question, and also providing step by step guidance to follow through for the process and building confidence to retry for a TWOC in 48 hours if unsuccessful the first time around. It also emphasised on clear documentation of a discharge plan if there was a plan for a community TWOC. We feel that the introduction of the guidelines has contributed to increased confidence for an early TWOC and also lead to more number of TWOCs being attempted whilst the patient is admitted following correction of the indication wherever appropriate, which is what our data set reflects as well, showing that 60% of TWOCs were successful in the second cycle and 40% were unsuccessful. Thank you.