UTI collaborative event cohort one. Hosted by NHS Improvement.

1. NHS Improvement
Urinary Tract Infection Collaborative
Launch Event
24th May 2018
#improveipc

2. NHS Improvement National Team
#improveipc
Ruth May
Executive Director of Nursing,
National Lead for Infection,
Prevention & Control
NHS Improvement
Gaynor Evans
Clinical Lead, Gram negative
BSI,
NHS Improvement
Linda Dempster,
Head of Infection, Prevention
& Control
NHS Improvement
Jacqueline McKenna, MBE
Director of Nursing
Leadership
NHS Improvement
Gavin Eyres
Programme Manager
NHS Improvement

3. #improveipc
Quality Improvement Advisors
Ranvir (Rani) Virk
Ranvir.virk@nhs.net
Helen Wilkinson
Helen.wilkinson22@nhs.net
David Charlesworth
David.charlesworth@nhs.net
Esther Taborn
Esther.taborn@nhs.net
Lisa Ritchie
lisaritchie@nhs.net
Karen Shaw
Karen.shaw@phe.gov.uk
Clinical Fellows
NHS Improvement IPC Team

4. • To reduce the number of
patients acquiring UTI/CAUTI
associated with healthcare
• To deliver an improved
experience for those with
urinary catheters
• Ensure that your health
system has the information &
tools to undertake a quality
improvement project
Aims of the UTI reduction collaborative
#improveipc

5. Challenges in practice
5 #improveipc
Historic poor
governance related to
the urinary catheters
Need to have a clear
policy & effective
training of staff on
identification and
treatment of UTI/CAUTI
Cultural shift to
change the way
patients are cared for.
(Expectation of abx)
Involvement of
patients and family
Can be a difficult
experience for Service
Users and Staff with
repeated symptoms
Working across system
boundaries

6. What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Act Plan
Study Do
Model for Improvement
Aim
Measures
Ideas
Be specific! - SMART
• E.g. Decrease UTI/Cauti-
Where?
By how much? By When?
#improveipc

7. Today you will…
– 24th May - London
• Learn about improvement methodology (in practice) - Driver diagrams, and
Process mapping
• Review what baseline data you should be collecting and prepare to collect
data throughout the course of the programme
• Hear examples of successful interventions in reducing HCAI UTIs
• As a team complete a process map and submit to NHSI
• Prepare a poster to share your ideas at the next event
#improveipc

8. 2018/19 In Hospital approach to reducing
Healthcare associated E. coli BSI
1
• Urinary Tract Infection (including catheter associated infections) Collaborative with NHS England.
2
• Directors of Infection, Prevention and Control Executive Development Programme.
3
• Review of NHS Providers board assurance and action plans to support.
4
• Masterclass for Executives and Senior leaders on E.coli and urinary tract infections.
5
• Focused clinically led work streams on the highest known risk patients/interventions.
6
• Focused work stream linking with GIRFT and hepatobillary sepsis.
7
• CQC regulation and the well led domain.
8
• Quality Improvement v’s Performance Management of NHS Providers.
9
• Seek further advice from Advisory Committee on Antimicrobial Prescribing, Resistance and Healthcare
Associated Infection (APRHAI)

9. Infection, Prevention & Control - All E.coli Performance Data
2017/18 (healthcare associated and non-healthcare associated)
9

10. The Evidence Base – prevention,
diagnosis and treatment of UTI / CAUTI
Gaynor Evans,
Clinical Lead, GNBSI Programme, NHS Improvement
#improveipc

11. Challenges
11
• Delivering reductions, across health and social care, engaging with a wide
range of organisations and teams is critical.
• The E.coli causal data is needed to target interventions. It is included in the
Quality Premium. There is variation in the completeness of this data.
• Klebsiella and Pseudomonas data collection is in year one. PHE will not be
in a position to provide comparable data until Q1 of 2018/19.
• The Quality Premium offers an incentive to CCGs to reduce all E.coli .if the
requirements are achieved
• There is no additional funding to support local initiatives.

12. Source of E.coli Bloodstream Infections
0
10
20
30
40
50
60
%
15% unknown
Abernethy JHI 2017

13. Key Healthcare events
Key events related to BSI %
Antibiotics (4 weeks) 32.4
Urinary catheter in situ, inserted,
removed, manipulated ( 7 days)
21.0
Other devices in situ or removed
(4 weeks)
7.3
Other procedures (4 weeks) 12.4Abernethy JHI 2017

14. Prevention of UTI Prevention of CAUTI
Hydration – 6-8 glasses Avoid catheter if possible
Healthy diet – avoid
constipation
Aseptic procedure
Maintain diabetes Documentation including date
of removal
Stop bacteria spreading from
your bowel to your bladder
- Wipe genitals front to back
after toilet
- Change pads and clean
genitals if soiled
- Keep the genital area clean
and dry
- Wash with water before and
after sex
Maintenance of catheter to
avoid infection
- Hand hygiene
- Catheter hygiene
- Avoid if possible breaking the
connection with catheter and
drainage system
- Fix tubing & leg bag to leg
- Document changes

15. Keeping well watered
• Adults need 6-8 large glasses a day. Do you?
• Identify those with poor intake – plan, monitor and record
intake
• Consider ice pops or serving hot or cold water with slices
of lemon or orange
• Give water with every meal and serve water fresh and
chilled
• In warm weather offer water more often
• Ensure glasses are topped up and water is accessible
• Consider fruit and veg with high water content
• Great example of work in care homes (Oxford AHSN Led by
Katie Lean)

16. Do you need that catheter?
HOUDINI on Insertion
• Haematuria
• Obstruction
• Urology or gynaecology surgery
• Decubitus ulcer
• Input / Output recording
• Nursing in the end of life
• Immobility – i.e. spinal or hip fracture
unstable or neurological deficit

17. To Dip or Not to Dip?
• Do not use urine dipsticks to diagnose UTI in
any patient over 65 years
• Do not use urine dipsticks to diagnose CAUTI
in any patient of any age
• In patients over 65 or with a urinary catheter
diagnosis must be based on patients
symptoms

18. 18
Leah Ffion Jones BJGP Conference
23/03/18 -
www.rcgp.org.uk/targetantibiotics
THE FINAL LEAFLET

20. The PHE UTI diagnostic quick
reference guide is now out for
public consultation until 5pm,
30th May 2018.
Please send responses to:
TARGETAntibiotics@phe.gov.uk
https://www.gov.uk/government/consultatio
ns/diagnosis-of-urinary-tract-infections-
quick-reference-guide

21. References
https://www.nice.org.uk/guidance/conditions-and-diseases/urological-
conditions/urinary-tract-infection#pathways
http://www.rcgp.org.uk/clinical-and-research/resources/toolkits/target-antibiotic-
toolkit.aspx
https://www.gov.uk/government/consultations/diagnosis-of-urinary-tract-
infections-quick-reference-guide

22. What baseline data should we be
collecting?
David Charlesworth, QI Advisor, NHS Improvement

23. UTI Collaborative Programme structure
LAUNCH
DAY
Event 2 –
28th June
Event 3 –
27th
September
Celebration
Event – 30th
October
Support from national HCAI quality improvement advisors

24. The Breakthrough Series -
IHI’s Collaborative Model for Achieving
Breakthrough Improvement

25. Model for Improvement
Associates in Process Improvement (The Improvement Guide, Jossey-Bass, 1996)
AIM:

26. Sometimes its obvious when
things need to change…

27. Model for Improvement
Associates in Process Improvement (The Improvement Guide, Jossey-Bass, 1996)
AIM: To reduce UTIs / CAUTIS in your chosen
population (Be specific! - SMART e.g.
decrease UTI / CAUTI - Where? By how much?
By When?)
MEASUREMENT:

28. Why measure?
28

29. Model for Improvement
Associates in Process Improvement (The Improvement Guide, Jossey-Bass, 1996)
AIM: To reduce UTIs / CAUTIS in your chosen
population (Be specific! - SMART e.g.
decrease UTI / CAUTI - Where? By how much?
By When?)
MEASUREMENT: Choosing the right
measures and planning for how you will
collect the right information.
MAKE CHANGES: Come up with ideas
on how to improve the current state
IMPLEMENT SMALL TESTS OF
CHANGE

30. Example: National GNBSI
Improvement Programme
AIM:
• (Ambition of 50% reduction of healthcare
associated GNBSIs by 2020/21).
• A 10% reduction (or greater) in all E. coli BSI
reported at CCG level based on based on 2016
performance data.
MEASUREMENT:
• Monthly counts of E.coli bacteraemia reported
to PHE HCAI DCS (baseline 2016)

31. Aim
• Local aim must be to deliver contribution to national aim
• Table Question – 5 minutes only:
• Given the evidence presented earlier, in your system what
might you want to improve, to reduce UTI/CAUTI?
• If you can, write the AIM down in SMART format

32. Baseline Measurement
• The number of UTI
• (The number of CAUTI)
The definition we’re using is :
Quality standard [QS90] Urinary Tract Infections in Adults
(https://www.nice.org.uk/guidance/qs90):
• ‘A UTI is defined by a combination of clinical features and the presence of bacteria in
the urine. Asymptomatic bacteriuria is the occurrence of bacteria in the urine without
causing symptoms. When symptoms occur as a result of bacteria this is referred to as
symptomatic bacteriuria.
• Symptoms of urinary tract infection include dysuria, increased frequency of urination,
suprapubic tenderness, urgency and polyuria’

33. Baseline Measurement
• The number of UTI
• (The number of CAUTI)
• Table Question – 5 minutes:
• What is the available data across YOUR system related to UTI/CAUTI?
• What do you currently collect, what might be the gaps?
• Can I collect it easily?
• Given your AIM, what other baseline data might you want to collect?

34. Next steps
• Meet with your team within the next week (do you
need anyone else?)
• Agree your project AIM
• Undertake BASELINE MEASUREMENTS
• More next time on using measurement for
improvement (see ‘Making Data Count’ NHSI resource)

35. Resources
• The Breakthrough Series -
IHI’s Collaborative Model for Achieving Breakthrough Improvement:
http://www.wales.nhs.uk/documents/Breakthrough%20Series%20WhitePape
r%202003.pdf
• Patient Safety First (2009) The How-to Guide for Measurement for
Improvement:
https://eoeleadership.hee.nhs.uk/sites/default/files/Patient%20Safety%20Firs
t%20How%20To%20Guide%20measurement%20for%20improvement.pdf
• Making Data Count: https://improvement.nhs.uk/resources/making-data-
count/

36. Catheter Associated Urinary
Tract Infections
The Journey to reduce the number of
CaUTIs at Salford Royal.
Julia Taylor MSc RGN
Consultant Nurse Urology
British Association Of Urological Nurses (BAUN) President.

37. Aims
• Context for Project
• What we have done
• Results
• Next Steps

38. Why did we do it?

39. Strategy 2011 - 14

40. Phase 2 Projects (2011-14)

41. This was our reality
• 20% pts have a urinary catheter inserted.
• 38% have documentation
• 24% -41% have a CAUTI
• 70% CAUTI preventable
• 60% medical teams unaware of presence
of urinary catheter
• How many patients die from Urinary
Sepsis at SRFT yearly?

42. Patient View
50 inpatients
• 26% found it painful
• 24% found it embarrassing
• 26% found it inconvenient
• 18% of patients didn’t know why they were catheterised
• 70% were not given another option
• 30% felt they could have managed without
• 32% had experience of their catheter leaking
• 76% didn’t know or thought that they didn’t have a care plan
Derbyshire, D et al. (2016). Surveying patients about their experience with a urinary
catheter. International Journal of Urological Nursing. 10 (1), 14 - 20

43. Urinary Catheter
Innocuous device?
OR
Convenient device
that can harm & kill?

44. How did we do it?

46. Phase 1
The first phase of the project ended in
December 2012.
What: To reduce catheter associated urinary tract infections
How Much: To achieve a 30% reduction from baseline figure in
pilot wards
By When: December 2012

47. The Breakthrough
Series
Collaborative (IHI)

48. The BreakThrough
Series
Collaborative

49. The Break Through
Series
Collaborative

50. People are generally better
persuaded by reasons which they
themselves discover,
than those which have come into
their mind by others"
Pascal (1670)

51. Measurement
Changes
Small tests of
change
Model for Improvement
Aim

52. A Fact….
All improvement will require change,
but not all change will result in improvement
Therefore we need to ‘test’ change

53. The PDSA Cycle

54. Phase 2
The second phase of the project expanded
the work from the pilot wards across the
Trust and ran through until December 2013:
What: To reduce catheter associated urinary tract
infections
How much: By 20% (across the whole Trust)
When: December 2013

55. Phase 3
• 2014 Aim was to identify the inappropriate
catheters in the organisation
• Was tied into our Harm Free Care CQUIN
for 2014/2015

56. Why catheterise at
all?
TRAPP acronym

57. Inappropriate Catheters
• On discussion TRAPP meanings appeared to
have variations in answers
• ? ‘Shoe horning’…………. ‘Probably get away
with’
• Decided to test an audit tool to capture the
number of inappropriate catheters in the trust

58. Audit Tool
Bed
Number BedStatus
Hospital
Number PatientConsultant
No Catheter Tissue Viability
Ifsacralpressuresores
andincontinence
Retention Urine
(i)Unabletopassurine
spontaneously
(ii)chronicretentionwhere
therehasbeenurological
input
Acutely unwell
Currentlyrequiringlevel
2or3care
EWS of4orgreater
withinlast12hours
Patient Preference
Forendoflifepatientswho
preferacathetertoease
distress
Peri-op
Afterspinal
anaesthesiaor
pelvicsurgery
including
urological
surgery
Other
Ifthereasonfor
catheterisationisnot
inthelistpleasetick
belowandchoose
oneofthereasons
intheboxtotheright
Prolonged
immobilisation
due to spinal
fractures or
trauma
Urological
indications
including intra-
bladder treatments,
bladder diagnostic
tests & visible
haematuria
Please write the
criteria below if
the reason for
catheterisation
has not been
listed in this table
1
2
B8Ward
Date of survey
If "other" has been selected were there
any of the indications below, please
tick as appropropriate
Catheters
If Patient is catheterised please indicate CURRENT reason for the patient to be
catheterised in the boxes below (We are not interested in the initial reason for
insertion but why the catheter is still in situ today)
If Patient
Does not
have a
catheter
please tick
below
First draft – Senior nurse walkround – 1st PDSA cycle

59. What Happened

60. PDSA 1
Act Plan
Study Do
P: Senior nurses
provided draft tool
to audit all patients
catheterized in the
hospital. Prediction :
Tool may need
‘refining’.
D: Faculty member
attended the pre-
walkround briefing to
give a 5 minute
introduction to tool
and provide copies
to the senior nurses
S: There were
gaps in data. The
faculty were
unable to
effectively identify
if the catheter was
inappropriate
A: A column was
added with the
express aim of
identifying if a
catheter was
needed

61. PDSA 2
Act Plan
Study Do
P: Document
‘refined’ and
faculty thought that
an effective audit
tool had been
developed
S: Data complete.
However :
When clinical notes
analysed ( by
urological experts )
there was disagreement
with appropriateness
A: The tool was defined
to identify if catheter
needed
BUT
There was a need to
focus on the training of
the auditors
D: Faculty member
attended the pre-
walkround briefing to
give a 5 minute
introduction to tool
and provide copies
to the senior nurses

62. PDSA 3
Act Plan
Study Do
D:Held a training
session for the nurses
and then revisited prior
to the audit to reconfirm
S: The
Urology
experts
agreed with
the sample
A: Now had a tool
and a process that
provided the number
of inappropriate
catheters.
Need to spread
implementation
/training
P: A training session for
6 senior nurses
undertaken THEN they
audit a smaller sample
of the hospital
Prediction : Improve the
consistency of accurate
data collection

63. PDSA 4
Act Plan
Study Do
P: A training session
for 12 senior nurses
prior to them
undertaking
walkround.
Prediction : Improve
the consistency of
accurate data
collection
D: Training session
held before the audit
AND repeated twice
S:
Data was
accurate
A: Now data on
inappropriate
catheters
consistent with
Urology experts (12
nurses) AND a
system in place to
capture data every
month

64. Updated Audit Tool
Bed
Number
Hospital
Number
Patient Consultant No
Catheter
T
Tissue
Viability
If sacral
pressure
sores and
incontinence
R
Retention
Urine
(i) Unable to
pass urine
spontaneously
(ii) chronic
retention where
there has been
urological input
A
Acutely
unwell
(i) Currently
requiring level 2 or
3 care or if senior
decision maker
specifically
mentions the need
for a catheter
clearly in the notes
(specify reason)
P
Patient
Preference
For end of life
patients who
prefer a catheter
to ease distress
P
Peri-op
Max 24 hrs
after
surgery
(please
detail
specific
operation in
comment
box)
Other
If the reason for
catheterisation is
not in TRAPP
please tick
below and
choose one of
the reasons in
the box to the
right
Prolonged
immobilisation
due to spinal
fractures or
trauma
Urological indications
including intra-bladder
treatments, bladder
diagnostic tests &
visible haematuria
1
2
Is this Catheter
In-Situ
appropriately?
Yes or No?
Comments
Please provide:
(1) any additional information on the reason for
catheterisation if not included
(2) Operation details if appropriate
If "other" has been selected
were there any of the
indications below, please tick
as appropropriate
H4Ward
Date of survey
Urinary Catheters
If Patient is catheterised please indicate CURRENT reason for
the patient to be catheterised in the boxes below (We are not
interested in the initial reason for insertion but why the
catheter is still in situ today)

65. Video

66. Are we using the TRAPP
acronym?
DON’T GET CAUGHT IN THE CATHETER TRAPP
 Non TRAPP insertions have reduced from 25% (Nov-
April) to 12% (May- October).
 Still room for improvement, a catheter should only be
inserted with clinical indication – TRAPP.

67. Success – Plan
• Accurate means of identifying inappropriate catheters
• Data indicated approximately 25% of catheters
(hospital) could have been removed on the day of audit
• Plan to provide training across organisation
• However elsewhere in the hospital another
PDSA had started………………………………………

68. Ward PDSA
Act Plan
Study Do
P: The ward used
the audit tool and
used it as an
intervention tool to
prompt the removal
of catheters
D: Every morning
all catheterised
patients were
checked against
the criteria and
removed if no
longer required
S:
Ward data
42%
reduction in
catheter days
A:
Implementation
spread wider
across the trust

69. Community team
Our district Nursing teams are now using the
tool on a monthly basis

70. What did the data tell us ?

76. Safety Thermometer Catheters
% Patients Catheterised
CHARTrunner
Poweredby:
PQ Systems
incorporated
p chart
Set 5: UCL = 22.38, CTL = 18.06, LCL = 13.73 (38 - 50)
Inspected Mean = 712.31, Counts Mean = 128.62
UCL = 27.05
CTL = 21.98
LCL = 16.91
UCL = 22.38
CTL = 18.06
LCL = 13.73
01/05/2011
01/06/2011
01/07/2011
01/08/2011
01/09/2011
01/10/2011
01/11/2011
01/12/2011
01/01/2012
01/02/2012
01/03/2012
01/04/2012
01/05/2012
01/06/2012
01/07/2012
01/08/2012
01/09/2012
01/10/2012
01/11/2012
01/12/2012
01/01/2013
01/02/2013
01/03/2013
01/04/2013
01/05/2013
01/06/2013
01/07/2013
01/08/2013
01/09/2013
01/10/2013
01/11/2013
01/12/2013
03/01/2014
07/02/2014
07/03/2014
04/04/2014
02/05/2014
06/06/2014
04/07/2014
01/08/2014
05/09/2014
03/10/2014
07/11/2014
05/12/2014
02/01/2015
06/02/2015
02/03/2015
06/04/2015
01/05/2015
05/06/2015
03/07/2015
07/08/2015
04/09/2015
14
16
18
20
22
24
26
28
30

79. Summary
• CaUTI can be effectively reduced by healthcare professionals by
implementing a range of relatively simple measures across hospital and
community settings.
• Requires leadership and commitment at all levels
• Ward and community staff can make huge differences to patient safety by
using PDSA cycles
• The use of a structured training programme, shared learning, and patient
engagement has demonstrated a significant difference in reducing in our
CaUTI rates.
• This is consistent with the overall aim to be the safest organisations in the
NHS by reducing patient harm, reducing mortality, improving reliability and
improving patient experience.

80. Widespread
introduction of
these initiatives
have the potential
to reduce the
unacceptable
morbidity and
mortality
associated with
Ca UTI.

81. Faculty Sharing Practice
Federation of Infection Societies Oral Presentation
Annual Conference 2013
BAUN 2013 Oral Presentation
Annual Conference Taylor, J (2013) Take Me Out -Reducing Catheter Associated Urinary Tract Infections.
(Awarded best oral presentation BAUN conference)
BAUS 2014 Poster
Annual Conference Shackley, D et al(2014) Urinary Catheters. How the Introduction of an Educational Programme, an Electronic Catheter data
tool and a change
package can lead to reduced catheter related infections
BMJ 2014 Clarke,L et al (2014) Catheter associated urinary tract infections (CAUTIs) in a UK teaching hospital: what lessons can we
learn ?
BAUS 2015 E Poster Clarke ,L et al (2015) Better care at lower cost; Reducing harm from catheter-associated urinary tract infections
BAUN 2015 Oral Presentation Taylor, J (2015) Don’t get caught in the catheter TRAPP
Annual Conference
Published article IJUN 2016 Derbyshire, D et al. (2016). Surveying patients about their experience with a urinary catheter. International Journal of
Urological Nursing. 10 (1), 14 - 20.
Society of Urologic Nurses and Associates
of America 2016 Poster
Annual Conference Washington DC: Taylor,J et al (2016) Saving Lives – Don’t fall into the Catheter TRAPP – Reducing Catheter Associated Infections
Infection Prevention Conference 2018 Taylor, J The Journey to reduce the number of CAUTIs at Salford Care Organisation
UTI Collaborative (cohort one) 2018 Case study “ The Journey to reduce the number of CAUTIs at Salford Care Organisation”

82. Driver Diagrams
Esther Taborn – Clinical Fellow, NHS Improvement

83. What are they – lets recap?
• Also known as action effect or tree
diagrams
• A starting point for any improvement project
• Simple and allows you to breakdown your
goal into drivers and projects
• Allows you to deal with complex change
when you cannot easily unpick the
difference between cause and effect

84. What do we do – lets recap?
• Start with a goal clearly defined and
measurable – what do you want to achieve?
• Link this goal to around 3 sub factors that will
have a direct impact on what you want to
achieve
• These 3 sub- factors are drivers as they ‘drive’
what you want to achieve either acting alone or
together
• You can carry this on to secondary and tertiary
drivers for each sub factor depending on the
complexity of your project.

85. Getting Started…..

87. Primary Drivers Secondary DriversAim Actions

88. • Excel tool developed by Central London
Community Healthcare NHS Trust
• https://improvement.nhs.uk/resources/crea
ting-driver-diagrams-for-improvement-
projects/

89. In Conclusion
• Use the tool in the project planning stage and regularly
throughout the project
• Use it to communicate to each other and the wider MDT re
what your doing and why – helps with engagement
• Use to maintain the big picture
• Use to select quick wins..
• Lots of resources on the NHSI Website – main document at:
https://improvement.nhs.uk/documents/2109/driver-
diagrams.pdf

90. Over to you…
1. Start with your aim/goal – make sure it is clearly defined and measurable. Think about the
what, how, when and why?
2. Using the Post-it Notes Brainstorm potential drivers – “To achieve our goal, the things we
need to improve are...” Concentrate on generating ideas at this stage, don’t try to allocate
the label of primary or secondary driver at this stage
3. Once you’ve completed the brainstorming, cluster the ideas to see if there are groups
that represent a common driver. Make sure you use language like ‘improve’ or
‘decrease’ and that each driver is clearly defined (and is potentially measurable)
5. At this stage, you may want to expand the groups as new ideas may come to mind
during the clustering stage
6. Now you can identify the links between the drivers and create the driver diagram format
7. Add projects/actions for the drivers
8. Finally decide which drivers and projects/actions you want to prioritise and which you
want to measure.