‘The catheter valve has changed my life.’
Bob, 50s, uses indwelling catheter
The Health Innovation Network delivered a two-year catheter quality improvement programme across south London, reducing patient harm with a 30% reduction in the rate of catheter-associated urinary tract infection (CAUTI), and bringing attention to urinary catheter risks. Our Catheter Care Awareness week campaign, from 20 – 24 June 2016, had over 13 million Twitter impressions and face-to-face contact with over 1000 patients and healthcare professionals.
We improved catheter practice and promoted spread of good practice in south London through engagement of staff and patients, and demonstrated improvement in quality through patient feedback and repeat audits, and hospital CAUTI reduction.
Nine acute hospitals and eight community services signed up to our programme, and we adopted the Institute for Healthcare Improvement ‘Breakthrough Series Collaborative’ methodology to form a south London collaborative, for organisations to share and learn from one another. We widely embedded the message of “no catheter without a plan for removal” and encouraged commissioners to develop an out of hospital response as an alternative to emergency admission.
We carried out baseline measurements of catheter practice across most south London hospitals and a number of emergency services, before sharing findings within the collaborative, presenting at conferences and publishing these to ensure learning spread outside the collaborative.
What was the problem?
We estimate that there are 152,000 inpatients with catheters each year across south London (18.8% of inpatient admissions), and of these over 9,000 develop urinary tract infections. Nearly one third of urinary catheter-days have been shown to be inappropriate in inpatients, with 26% of catheters inserted in the Emergency Department deemed unnecessary (Tiwari et al. 2012).
Long-term catheterisation carries the risk of CAUTI, as well as haemorrhage, blockage, and trauma. The annual cost of catheter-associated excess bed days in south London is currently estimated at £15.8 million1. Many additional patients are catheterised in community settings including residential and nursing homes.
Healthcare acquired infections (HCAIs) cost the National Health Service (NHS) in excess of £1 billion per year (NICE 2014) and urinary tract infections (UTIs) account for 28% of HCAIs (HPS 2012). UTIs are the most costly single-site infection and total treatment cost is estimated at £124 million per year (Plowman et al. 2000), and 56% of all UTIs are associated with the presence of an indwelling urinary catheter (Smyth et al, 2008).
 Analysis conducted by Insight Health Economics for South London Health Innovation Network, based on NHS-ST and HES data
The HIN worked as a collaborative with hospitals and community trusts in south London, to improve catheter care and reduce the rate of CAUTIs by 30% by March 2017. The work was undertaken using the Institute for Healthcare Improvement (IHI) ‘Collaborative Model for Achieving Breakthrough Improvement’ approach (IHI 2003), across four themes:
- Empower patients and their carers to self-care: Co-produced catheter care materials with patients and healthcare professionals to reduce social stigma, increase knowledge and awareness of local services, to improve access.
- Improve Clinical practice: Bundle of interventions that participating sites could use, based on audit results that identified problem areas.
- Infrastructure and culture change: Encouraged integration of services to improve identifying and sharing best practice, improve procurement of catheter products across systems, clarified/ improved catheter pathways and improved gaps across the system and created an awareness campaign. Catheter Care Awareness week ran from 20-24 June 2016, to empower patients and professionals to question current practices, improve knowledge and reduce stigma.
- Use the model for improvement and local data to drive improvement: Identified patients at greatest risk through post-infection review, hospital and emergency department audits; defined interventions, tested them and measured outcomes.
- A before and after audit was performed for all adult catheterised patients at four hospitals. Use of catheter securement – a marker of quality of ward catheter care – increased from 12% (range 10-23) to 37% (6-69), and a clear plan for trial without catheter increased from 12% (0-19) to 24% (14-31). This change reflected an improvement, particularly in complex multi-morbid patients.
- Safety Thermometer data is collected each month in all acute hospital trusts using a standard definition of CAUTI. Analysing time-series data from Safety Thermometer, we found that overall catheter use reduced among the participating hospitals from 15.4% to 13.5%, while there was no reduction observed in other NHS hospitals. There was a reduction in CAUTI in our providers of >30% during the collaborative.
- In five of our hospitals, we estimate that 150,000 catheters were used pa (2013/4) with 9000 CAUTIs, which require antibiotic treatment and may extend hospital stay. Minimum cost of treating a CAUTI is £1700, and the 30% reduction in rate of CAUTI we observed will result in a saving of £4 million per annum just from excess bed days.
- Catheter Care Awareness Week ran from 20 – 24 June 2106, to raise awareness and reduce unnecessary patient harm resulting from urinary catheters. Along with patients and our stakeholders we created a catheter passport, other educational materials and a short animation, to raise awareness around catheter care. Each of our stakeholders ran a catheter safety event, and we produced a digital pack of resources for stakeholders, including pledge cards, films, the animation, and patient stories, and we raised awareness of the campaign through social media with the hashtag #cathetercare and hosted a tweetchat with @WeNurses. We had 13 million Twitter impressions during this week, and over 1000 staff and 250 patients coming to these events, who made 561 individual pledges to improve catheter care.
- We created a collaborative involving nine acute hospitals and seven community trusts, which met and shared best practice over the two years of our collaborative. We are sustaining this improvement by creating a catheter safety community of practice.
‘Since using the catheter passport, anyone caring for me can read my catheter history and get enough information to address any problems I have with my catheter’
John, 83, house-bound patient
Plans for the future
We designed the programme as a collaborative to learn and spread best practice from a wide range of providers in south London. We discovered many examples of good practice that could be adopted in other settings, including: case finding of bacteraemia, reality rounds, trial without catheter management and guidelines, catheter change guidelines, audit tools, monitoring of duration of insertion, procurement costs, out of hours community response service, ambulatory service as an alternative to ED, Catheter Care Awareness Week, CAUTI animation, patient stories and catheter passport/materials.
Many of the interventions designed in our programme were tested in a variety of healthcare settings from small community providers to large tertiary care hospitals and are suitable for generalisation and application to different organisations and settings. We aim to extend this work to other hospitals in south London using a community of practice model, and have created packages of interventions that can be used throughout the NHS.
This could be brief information about plans to spread and scale. It is essential to articulate next steps – i.e. one off projects/ trials that will go no further will have no impact with our national stakeholders.
Which national clinical or policy priorities does this example address?
- Care and Quality
- Funding and Efficiency
- Health and Well Being
Find out more
Visit the Catheter care programme web page for more information.
Start and end dates
March 2015 – December 2016
Contact for help and advice
Sally Lawton, Project Manager Patient Safety & Capacity Building, Health Innovation Network