UTI collaborative 28th June 2018 presentations

Welcome - agenda
1
Time Session
10.00 Welcome
Linda Dempster, Head of Infection Control, NHS Improvement
10.15 Storyboard feedback
Facilitated by QI Advisors
11.00 HOUDINI – Dr Debra Adams, Senior Infection Prevention and Control
Advisor (Midlands and East), NICE Fellow.
11.30 Refreshments
11.45 Measurement for Improvement – Karen Hayllar, Senior Improvement
Analyst, NHS Improvement
12.30 Case study Hydration in care homes – Dr Jennie Wilson, Richard Wells
Research Centre, University of West London
13.00 Lunch
13.40 Case study Hydration in hospital – Team Hydr8, University of South Wales
14.05 Panel Q&A
14.25 PDSA – Rani Virk, QI Advisor, NHS Improvement
15.25 Evaluation and next steps – Helen Wilkinson, QI Advisor, NHS
Improvement
15.40 Closing remarks – David Charlesworth, QI Advisor, NHS Improvement
15.45 CLOSE

NHS Improvement
Urinary Tract Infection Collaborative
Second Event
28th June 2018
#improveipc

Welcome & Purpose of the day
Linda Dempster, Head of Infection Prevention and Control,
NHS Improvement
#improveipc

House Keeping
Please Tweet! #improveipc

5 |
Continuous improvement of the collaborative
https://improvement.nhs.uk/documents/2142/plan-do-study-act.pdf
More clearly signpost
collaborative members
to national catheter and
UTI guidance and
related evidence base.
Provide a list of
delegates and
trusts. (We need to
seek your permission
first)
Ensure shared examples
and experiences are from
across health care and
include, acute, community
and primary care.
Include
evaluation /
feedback
during the day
Provide
baseline
measurement
tools earlier
Less
ice-breakers
Make the
Collaborative
aims more
explicit
Reinforce on Day 1 - focus is on
developing QI skills & using these to
deliver IPC improvement. Some
examples we use may be linked to
other IPC improvement experiences but
the process is the same.

Measures
6
All the trusts in the UTI collaborative will need to demonstrate:
• a 5% reduction in the number of patients acquiring UTI/CAUTI
associated with healthcare in the pilot settings from the trust’s
baseline data
• a 5% reduction in the number of catheters in the pilot settings.
• 100% of the participating trusts using quality improvement tools to
identify the key areas for improvement in the 90day rapid
improvement programme

7 |
Driver diagram
Healthcare associated Urinary Tract
Infections/ catheter associated urinary tract
infections
• Identify current national and
international guidance.
• Identify barriers to the
implementation of guidance.
• Establish data collection.
• Agree definitions.
• Signpost current national and
international guidance on
extranet.
• Engage with trusts /systems
that are demonstrating good
practice.
• Engage with local and national
champions.
• Identify and promote local and
national campaigns.
• Share best practice through
local and national media.
• Create communities of special
interest.
• Write articles for publication.
• Identify partners/ system teams
to implement QI methodology.
• Identify and agree interventions.
• Encourage the use of the
extranet to demonstrate
improvements.
• WebEx seminars and master
Improved
implementation
of current
guidance and
data collection
Sharing
evidenced base
and good
practice
Supporting the
System in
implementing
improvement
methodology
Support the
Health &
Social care
system to
reduce HCA
UTI/CAUTI
NATIONAL METRICS
5% reduction in UTI /CAUTI

Webexes
8
• The 1st webex is planned for 12th July 1-2pm
• Other webexes will be provided in July/August
• Suggestions we have received:
* Process mapping
* Driver diagrams
* Measurement
* Other suggestions?

Evaluation
9
• We have a 10 minute session in the afternoon to complete the evaluation
for the 2nd day
• Very important that we get feedback so we can make any necessary
improvements to the collaborative as we go along and for other cohorts

Today you will
28th June - Manchester
10
• Have the opportunity to view and share storyboards from the trusts
involved in the collaborative
• Hear examples of successful interventions in reducing HCAI UTIs,
focussing on hydration
• Learn about measurement for improvement to enable you to collect
data & understand the impact of your changes
• Learn about PDSA cycles

Storyboards
11
• Corner 1 - BLACKPOOL and NEWCASTLE UPON TYNE (David)
Northumbria Calderdale Barts Gloucestershire East Kent
• Corner 2 - SOUTHAMPTON and POOLE (Helen)
Leeds Lancashire Kettering Cambridge London NW
• Corner 3 – LEICESTER and WIRRAL (Rani)
Hull Coventry & Warwickshire Frimley Guys
• Corner 4 – SOUTHPORT and SHEFFIELD (Gaynor)
St Helens Heart of England Salford Mid Essex Norfolk and Norwich

HOUDINI.
THE URINARY CATHETER
DISAPPEARING ACT.
Dr. Debra Adams R.N. PhD.
NICE Fellow
Senior Infection Prevention Advisor (ME)
NHS Improvement

I have the following potential links of interest to report:
• NICE (National Institute for Clinical Excellence) fellow.
• FIT (Forum for Injection Technique) Board member.
• Co-chair; Infection Prevention Society High Impact
Intervention tool review 2017.
• In the last 5 years, honorariums received from BD, 3M.

Objectives
• Overview of some of the National drivers to prevent
CAUTI (catheter associated urinary tract infection) in
England.
• Discuss; Are Urinary Catheters an infection risk?
• Present: HOUDINI; a nurse led protocol.

National IP Improvement Drivers in
England
• 50% reduction in Gram negative HCA BSI by 2020.
• Over 5 years - an extra 6,000 deaths will be attributable to
pan-resistant Gram–negative bloodstream infections
(GNBSIs).
• Extra NHS (National Health Service) costs to manage resistant
infections: estimated to be £280 million.
• Estimated cost of treating Gram-negative infection:
• For a straightforward case = at least £3,000
• For a highly resistant case = at least £6,000
• Cost of £1m per resistant infections outbreak in a hospital.

National Guidelines
• NICE: Quality Standard QS61 and Clinical
Guideline CG139… “Reviewed regularly and the
urinary catheter removed as soon as
possible”.
• EPIC 3: Assess and record the reasons for
catheterisation every day. Remove the catheter
when no longer clinically indicated.

Are Urinary Catheters a Risk?
• The Foley catheter was introduced in the 1930s and
hasn’t changed in its design!!
• DVD…….

Context
• 15–25% of hospitalised patients have a UC inserted
during their stay (EPIC 3).
• UTI are the most common HCAI in acute hospitals: 19%
(HPA, 2012, Smythe et al; JHI 2008).
• The major predisposing factor for healthcare associated
UTI is the presence of an indwelling UC (Tenke, Koves, Johansen. Curr Opin
Infect Di. 2014; 27:102-107).
• In acute care facilities, the risk of developing bacteriuria
increases 5% for each day of UC. (Saint. AJIC. 2000;28:68-75).

Improvement Issue:
• To evaluate the effectiveness of a nurse led HOUDINI UC
removal protocol in reducing the number of UCs used.
Therefore, potentially reducing the associated risk of a
catheter associated urinary tract infection (CAUTI).

Method:
• TEAM WORK!!
• The Infection Prevention Nurses, Continence Nurse Specialist and
Urology Nurse Practitioner implemented an adapted HOUDINI
urinary catheter removal protocol.
• Quality Improvement process:
• A Plan Do Study Act (PDSA) cycle was utilized to evaluate to
HOUDINI protocol; two months pre and two months post
implementation.

HOUDINI
The Urinary Catheter DisappearingAct!!!
• Haematuria- visible?
• Obstruction- urinary?
• Urology surgery?
• Decubitus Ulcer- open sacral or perineal wound in an
incontinent patient?
• Input/Output fluid monitoring?
• Not for resus/Comfort care/(Physician required?)
• Immobility due to physical constraints e.g. unstable
fracture?
If NO; then make that urinary catheter disappear!
Ammended from:
Development of a Nurse-Driven Protocol to Remove Urinary CathetersE Trovillion1, J Skyles, D Hopkins-Broyles, A Becktenwald, A Rogers, K
Faulkner, H Babcock, KF Woeltje. Presented at; SHEA. 1-4 April 2011. Abstract 592.

Key Performance Indicators.
Chosen because;
•8.5% of hospital acquired BSI may be
associated with a CAUTI (Public Health Laboratory
Service, 2002).
•E. coli is the most prevalent pathogen
causing UTIs
• (Hidron et al., 2008. Abernathy et al 2017).

Driver Diagram for QI
Reduce the
number of
inappropriate
UCs by the
introduction
of HOUDINI
principles
over a 2
month pre-
post trial
period.
Right
Leadership
Right
Environment
Right System
Develop a Multi-professional group
with DIPC support.
Review National guidelines and impact
on project.
Review equipment
Review current policies,systems and
processes associated with UCs
Identify a pilot and control wards:
garner engagement.
KPI: Identify and monitor the number
of urinary catheters, e-coli BSI and
UTI pre/post introduction.
Introduce HOUDINI principles.
Develop communication strategy.

Data Collection:
Monitored Two Months Pre and Post
HOUDINI:
• UC usage was monitored utilizing a monthly
point prevalence audit.
• Non-duplicated Escherichia coli laboratory
confirmed urine samples were monitored (note
we were not identifying UTI but laboratory
confirmed diagnosis of E-coli present.
• Non-duplicated E-coli blood stream infection
(BSI) on the pilot wards were monitored.

Approach
• Keep it simple!
• Put posters where staff access them; ward round trollies,
behind toilet doors.
• Develop credit card style HOUDINI cards.
• Win hearts and minds.
• Work with, and not do to.

Evidence of Improvement:
 UC per patient population usage decreased by greater than 17%
following the implementation of HOUDINI on the trial wards.
 Non-duplicated E. coli laboratory confirmed CSU decreased by
70% compared to the control group de-duplicated E-coli laboratory
confirmed MSU which increased by 25%
 Non-duplicated E. coli BSI from patients with UC remained
unchanged at 0%

Results
0
5
10
15
20
25
30
35
%ofpatients
catheterizedonthe
threetrialwards
%ofpatients
catheterizedon
Ward10
%ofpatients
catheterizedon
Ward11
%ofpatients
catheterizedon
Ward12
TRIAL;Ecoli+ve
urinesamples:CSU
CONTROL;Ecoli
+veurinesamples:
MSU
2 months pre HOUDINI
2 months post HOUDINI

Recommended Future Steps:
• The implementation of HOUDINI
demonstrated a decrease in both
UC usage and E. coli UC associated
positive urine samples.
• Therefore, an assumption may be
made that implementing the
HOUDINI protocol can reduce the
risk for patients developing a CAUTI.
• Ref: Adams D, Bucior H, Day G, Rimmer J. HOUDINI: make
that urinary catheter disappear; A nurse led protocol. Journal
of Infection Prevention. 2012; 13(2):44-46
DOI:10.1177/1757177412436818.
• This data was presented at the Infection Prevention and
Control Conference- Bournemouth 2011 and was awarded
“Best Poster”.

Others Experiences: UHB NHSFT.
• HOUDINI was used as part of a series of interventions at
The University Hospitals Birmingham NHS FT:
• Outcomes:
• CAUTI decreased by >50%,
• Prevalence of indwelling catheters reduced from 22% to 17%
• E-coli BSI reduced from 17% to 10%.
• Ref: Bradley, Flavell, Raybould et al., (2018) Reducing E-coli bacteraemia associated
CAUTI in secondary care settings. Journal of Healthcare Infection; in press).

Chesterfield NHS FT
• Utilized HOUDINI as part of a multi-modal strategy.
• Outcome:
• A comparison of audit data between March 2013 and January 2015
showed:
• a 30% reduction in the number of patients with a UC
• a 71% reduction in the number of patients with a UC who developed a
CAUTI
Ref: https://www.gov.uk/government/case-studies/reducing-catheter-associated-uti-rates-
in-hospital

A patient experience:
ProfessorJennieWilson.
RichardWellsResearchCentre, Universityof West London
• Mr. A was admitted to the ward with an indwelling catheter.
• He told us that the GP had inserted the catheter for a swollen abdomen some 18
months previously.
• Since that time Mr A said he had suffered a recurrent UTI whenever the catheter
was changed.
• According to his wife having the catheter "Ruined his life for the last 18 months.
Indeed he spent Christmas at home as he was afraid the bag would leak”
• The IPC team and ward staff could find no record of a formal referral to the
urology service and so the rational behind the catheter was unclear. Following
HOUDINI principles the catheter was removed
• Mr A passed urine normally and was discharged without a urinary catheter.

Finally.
Get the message across!
Sometimes its not that staff don’t know,
its that we haven’t made the message
simple………
• https://www.youtube.com/watch?v=Hzgzim5m7oU
(Power of Words)

Top tips from my QI journey
1. Make sure you remember what your aim was- it is easy to get side tracked and
therefore drift. Take regular opportunities to re-visit.
2. Secondary drivers are your actions to do. Therefore, frame the sentences with an
action.
3. Undertake the 5-10 minute multi-professional meeting each week. It is an
essential part of identifying and driving change and getting ownership.
4. Audit results; use these to drive further change. Don’t just accept.
5. Ensure your PDSA cycles are noted in the template, 1 per page so that you can
see each test, the outputs of each and the subsequent amendments you plan make
(ramping up).
6. Ensure you document all your PDSAs. It is easy to initiate a change but forget to
document it.
7. Remember that PDSA is a small change not a large research project.
8. The tools that you develop along the way should be able to support the scale-up
of the project without a major education strategy- think intuitive, think design out the
problem.
9. Annotate your audit/data result charts as you go along so you can see which
changes made the difference.
10. Always remember to look for any unintended consequences of change e.g.
financial costs associated with additional screening etc.

Thank you!
Merci!
Grazie!
Gracias!

Coffee break
Please return by 11:45am
36

Making Data Count,
Using data to make better decisions
Karen Hayllar Senior Improvement Analyst
28th June 2018

Introduction
• Karen Hayllar (Senior Improvement Analyst)
Statistician
Developer of measurement for improvement tools to help front line staff
ask the right questions and make more effective decisions with their data.
Recent projects:
• Red2Green
• PJ Paralysis
• SPC Templates for QI Projects.

Aims for today
39
1. Why do we measure
2. What should we measure
3. How should present our results

Why do we need to measure?
40
1. We need to know how we are performing now
2. We need to know how variable our process is
3. We need to know if the changes we make are an
improvement or not

The importance of taking a baseline
41
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05/02/2008
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Hours
Mean
UCL
East Surrey Hospital Movement in A&E Daily Wait Mean & UCL over Time for Surgical Admits
Guaranteed wait for 99% of patients
Intervention made

43
Now John comes back...
Minutes
Days
7pm

44
Mary arrives at 18:50
John asks, why have you arrived 10 minutes early?
Minutes
Days

45
Mary arrives at 19:00.
John asks: yesterday you arrived at 18.50 – why have you
arrived at 19:00 today?
Minutes
Days

46
Mary arrives at 19:05
John asks: yesterday you arrived at 7pm – why are you
late?
Minutes
Days

47
Mary arrives home at 18:55.
John: Yesterday you arrived at 19:05, why are you early
today?
Minutes
Days

48
Minutes
Days
Thoughts on the John & Mary story?
Understanding the normal variation in any process is important

….over-reacting to variation.
This leads to additional variation induced by
adjustments made in response to common cause
variation.
Increases costs
49
Tampering…..

What should we measure?
• What is your aim and key area of focus?
• What should you measure?
• What can be measured?
– Already collected?
• Is this data good enough?
• (Perfection should not become an enemy of the good enough)
– Can I/should I collect additional data?
– How will I collect it?
• What else should I measure?
– Might there be unintended consequences?
– Qualitative data
• How to collect a baseline
• Presenting the data in a meaningful way – plot the dots
• Use the data!
50

What should you measure : 80/20 rule
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157
143
117
87
65
15
31%
49%
66%
80%
90%
98% 100%
0%
20%
40%
60%
80%
100%
120%
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Grumpy Happy Sleepy Dopey Bashful Sneezy Doc
Seven Dwarfs mining defects
1 January to 31 March 2017
A Pareto Chart identifies important measures

Presenting your results
How not to do it!

A sea of green
Improving Access to Psychological Therapies (IAPT)

Choosing the right graph
55
We
might
assume
Existing trend – did the change make a difference? Sustaining the gains?
A real improvement?
Plotting data over time shows us what is really going on

56
A&E 4 Hour Performance
Performance
Latest Previous month Change
Most improved St Excellent Trust 77.6% 71.2% 6.5%
Exemplar Trust 87.3% 81.9% 5.4%
Rebound Trust 88.0% 82.8% 5.2%
Pleasant Surprise Trust 77.3% 73.1% 4.2%
Well Led Trust 86.3% 82.5% 3.9%
Biggest decline Could Do Better Trust 73.9% 82.8% -8.9%
Disappointed Trust 85.7% 94.4% -8.7%
Bottom of the Pile Trust 80.6% 88.8% -8.3%
Challenger Trust 81.4% 89.5% -8.1%
Downhill Trust 71.3% 79.3% -8.0%

St Elsewhere NHS Trust : A&E performance
57
Most improved ?

58
Interpreting your data
How many trends do you see in this graph?
Turnaround
Upward trend
Downward trend
Downturn
Downward trend
Rebound

Plotting your data using SPC
59
Christmas
Some variation is normal and some is unusual but which is which and how do
we know?
Bank holidays

Statistical Process Control
60
mean Process limits
How do I know when something might have changed or needs investigating?
The Rules
1.) Extreme values
2.) Run of 7 points above or below the mean
3.) Rising or falling trends of 7 points
……. and some others

Why is 7 points significant?
61
Considering a random system with 50% chance of improvement and 50% of
decline (e.g. based on a coin toss)
A trend of 2 has the probability of 25% occurrence (one in four)
= (0.5)*(0.5).
A trend of 4 has the probability of 6.25% occurrence (one in sixteen)
= (0.5)*(0.5)*(0.5)*(0.5) = 6.25%
A trend of 7 has the probability of 0.8% occurrence (one in one hundred
and twenty-eight)

62
Are your efforts making a difference?
What we would all like to achieve!
http://m.futurehospital.rcpjournal.org/content/4/1/30.full.pdf

https://improvement.nhs.uk/resources/statistical-process-control-tool/
Free SPC tool : frontline staff

Just because you can measure everything doesn’t mean you
should*
64
* W. Edwards Deming

Where to go for help……..
66
• On-line community
– Resources
– Discussions
– Sharing good practice
– Virtual support network
• Nearly 900 members
• Series of webinars planned
• Email Sam if you would like to join!
• Samantha.riley1@nhs.net @samriley

Useful videos
67
• An introduction to measurement for improvement
https://www.youtube.com/watch?v=Za1o77jAnbw
• 60 seconds with Kate Cheema
– Choosing measures http://www.haelo.org.uk/films/60-seconds-of-safety-
with-kate-cheema-choosing-your-measures/
– Using data effectively http://www.haelo.org.uk/films/60-seconds-of-
safety-with-kate-cheema-using-your-datat-effectively/
– Presenting your data http://www.haelo.org.uk/films/60-seconds-of-
safety-with-kate-cheema-presenting-your-data/
• How to become an improvement measure expert in 60 minutes
https://prezi.com/3alg2jdmi5ea/how-to-become-an-improvement-
measure-expert-in-60-minutes-final/
• Using your data to drive action
https://www.youtube.com/watch?v=YqUIsuzJwx4&feature=youtu.be

New interactive guide launched May 2018

The I-Hydrate project
Optimising the hydration of older people
residing in care homes
Professor Jennie Wilson
Richard Wells Research Centre
College of Nursing Midwifery & Healthcare
University of West London

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2004.1 2004.2 2004.3 2004.4 2005.1 2005.2 2005.3 2005.4 2006.1 2006.2 2006.3 2006.4 2007.1 2007.2 2007.3 2007.4 2008.1 2008.2 2008.3 2008.4
Year and quarter
E. coli S. aureus Klebsiella spp S. pneumoniae Pseudomonas spp Total (consistent laboratories)
No of episodes of infection
by organism
No of episodes of
infection - all organismsTrends in England of microorganisms causing
bacteraemia
Why hydration?
(Wilson et al CMI 20

Trends in E.coli bacteramia by age group

Characteristic Proportion of cases
Onset day 0-1 68.3%
Healthcare exposure in last month 55%
Urogenital tract source 51.2%
*
[70% where
source
known]
- Previous treatment for UTI (4
weeks)
62.4% [176/282]
Urine catheter last 7 days 21%
- For urinary retention 27.1%
- incontinence 11%
- unknown 19.1%
Epidemiology of E.coli bacteraemia
Abernethy et al 2017
73
*Hepatobiliary 16%; Gastrointestinal 7%, Unknown 15%
Sentinel surveillance: 35 NHS hospitals in England; n = 1731

Changes as the body ages
 Kidneys concentrate urine less
 Less muscle –  stored water
 Loss of thirst reflex
Physical/cognitive impairments
 Difficulty swallowing
 Difficulty holding cups
 Dementia
 Fear of incontinence
• Constipation
• UTI, other infections
• Falls
• Stroke
• Kidney failure
• 10% of the elderly admitted as emergencies
are found to be dehydrated
Dehydration in elderly people is common
74
Dependence on others to meet needs
Why are older adults vulnerable to dehydration?

I-Hydrate – what was the project about?
Aim: to optimise the hydration of residents in nursing homes
Key objectives:
• Increase the number of residents consuming minimum daily fluid intake
of 1500ml
• Reduce morbidity associated with dehydration
• Improve experience and quality of life of residents
Improvement science methods:
• Co-design with staff and residents/families
• Plan Do Study Act (PDSA) cycles to test change
75

1. Unit-wide observations of how and when fluid is delivered
• Patterns of fluid delivery and types of fluid available/offered
• Variation between resident location (own room, dining room/sitting room)
• Observed between 6am and 9pm
2. Baseline measures of fluid intake
• Followed individuals for whole day to determine mean intakes
• Stratified into three groups: independent, needs prompting, needs assistance
• Observed between 6am and 9pm
3. Information from staff, residents and relatives
• Logistics and organisation of care
Understanding hydration practice in two care homes
76
Baseline data collected Oct 2015 – Dec 2015

Patterns of hydration care
• Only 7 opportunities
- Refills rarely offered
• Small cups (150ml)
- = 1000ml/day if fluids at all opportunities
• Limited choice of drinks
- Tea, squash, water
- preferences assumed
• Hydration low priority
• Lack of system for monitoring intake
77

How much do residents drink?
Metric Mean fluids consumed
(ml)
[as % fluids served]*
Fluids served 1512
Mean fluids consumed 1031 [68%]
- Resident independent 1071 [68%]
- Resident needs prompting 1040 [54%]
- Resident needs assistance 946 [81%]
* Fluid consumption observed 6am – 9pm for 14 residents

79
Opportunity Proportion of residents served
drinks
Early morning No drinks served
Breakfast All residents served drink
Midmorning Few drinks served to residents in
communal areas only
Lunch 90% in dining room
60% in rooms
Mid-afternoon 80% in lounge
50% in rooms
Dinner 90% in lounge
80% in rooms
Evening 50% served drinks (in rooms)

What can we do to improve?
80
Mealtime guides for each resident
Drinks menu
Evaluate drinks preferences; extend
choice
Protected Drinks Time
Documenting fluids & monitoring at risk
residents
Evaluate cup preferences; extend choice
Drinks & other fluids with meals
Staff training on hydration
Understanding each residents’ drinking
needs, preferences and abilities
Residents provided with the drinks and
fluids to meet their needs, preferences
and abilities
Increased opportunities for fluid
consumption in daily care
Identifying & responding when hydration
needs are not met
Key components of care
Proposed interventions

Education not a solution…..
• Knowledge before training rated ‘good’,
• Knowledge after training rated “very good/excellent’
 Staff do not recognise their own training needs
 Lack of skills in ‘Reflection’?
 Learning not translated into practice
• Support by ‘huddle’ training on the units
- On shift 10-15 minute training about key messages
- Whole team involved
- Role modelling key behaviours
81

Protected Drinks Time
Aim: To focus HCA on hydration during a routine
care activity
Intervention:
• All HCA focus on resident hydration during 3pm drinks round
• Assist residents who need help to drink
• Allocate to staff to roles
• Offer refills
• Ensure sufficient equipment (trollies, cups, fluids)
• Takes around 45mins
82

Outcome of Protected Drinks Time
Results of PDT
 % of residents getting drinks
 number of drinks per resident
 amount of fluids consumed
Positive staff/resident feedback
However, a few weeks later….
 No. drinks & No. residents receiving drinks
returned to baseline levels
 Strong leadership to ensure prioritised
Critical to success
Leadership
• Clear allocation of roles & responsibilities
• Ensuring hydration is the priority
• Embedding as a routine activity
Equipment
• Trolley or trollies
• Adequate stock of drinks
• Clean and appropriate cups/mugs
Skills
• Training in assisting & positioning to drink
83
“Allocating roles means everyone is
contributing to the drinks round”
(HCA)

Resident drink preferences
84
• Residents preferred fruit juices
to squash
• Water was not a popular drink
• Preferred drinks available in
home but rarely given
• 47 residents tested 28 different
drinks tested

Aim:
• To enable residents to choose their preferred drink
• Encourage consumption of more than one drink
Intervention:
• Visual drinks menu created
• Available in own rooms and communal areas
• Staff asked to use it during PDT
• Pureed fruit made available as alternative to cake
Drinks menu
85
“I am not always being given
what I like” (Resident)
“I like my morning cup of tea; I do
get one, but I would like more…”
(Resident)

Drinks menu combined with PDT
Key outcomes
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194
219
202
157 149
246 240
0
50
100
150
200
250
300
350
Baseline PDSA 1 -
Drinks
menu*
PDSA 2 -
Drinks
menu +
HCA in
lounge*
PDSA 3 -
Drinks
menu +
HCA in
lounge*
PDSA 4 -
Drinks
menu +
HCA in
lounge
PDSA 5 -
Drinks
menu +
HCA in
lounge
PDSA 6 -
Protected
drinks time
PDSA 7 -
Protected
drinks time
Mean fluid intake for residents receiving a drink in mid-afternoon (ml)
86
Drinks menu  the types of fluids available and  consumption of juice
Residents offered more choice - even if menu is not used
Staff were surprised by the choices residents made

Aim (Home A)
Drinks given to residents brought
to dining room before breakfast
Drinks before/after meals
87
Aim (Home B)
Hot drinks offered to residents in
lounge/dining room after lunch and dinner
Intervention
 Tea/coffee dispensers set up in dining room (juice/squash available)
 Encourage choice by using the drinks menu
Outcomes
•  fluid consumption (intake not reduced at the next drinks opportunity)
• Independent drinkers drank more than those who needed assistance
• Mostly benefited residents in lounge/dining room (more likely to be independent)
with residents in their rooms or who need full assistance less likely to get a drink

“The handle on the
teacup burns my
fingers” (Resident)
Drinking vessel that meets needs of residents
Standard cup
• 150ml
• Small handle, difficult to hold
• Thick china
Trial mug
• Scored highest in resident testing
• 250-280ml
• Lightweight (<250g)
• Large thick handle, easy to hold
Impact of new mugs
Increased fluid consumption (some drank full mug -280ml)
Serve more fluid at one opportunity
Staff must not assume full mug is too much for residents
“It’s great! It works,
he’s drinking so
much more now”
(Family member)

Monthly fluid intakes – Home B
89Routine monthly observations (6am – 9pm) of 4-6 randomly selected residents (includes fluid-rich foods)

Laxative consumption (Home A)
90
0.00
0.20
0.40
0.60
0.80
1.00
1.20
dosesoflaxatieperresident/week
weekly doses/resident mean
lower natural process limit upper natural process limit

91
1. Leadership & Culture
 Strong senior management support - reinforcing hydration as a priority
 Allocation of roles and responsibilities – clear communication
 Mentoring and role modeling of good practice
 Embedding hydration as a routine activity – otherwise progress can be lost
2. Training & Skills
 Competence in assisting & positioning residents to drink
 Confidence in communicating with residents to support and enable choice (Mental Capacity Act)
 ‘Huddle’ training to reinforce learning & practice in care team
 Accuracy of recording fluid intakes and taking appropriate action
3. Equipment/Resources
 Ensuring adequate stock of drinks, appropriate cups/mugs available
 Trolleys equipped and available to distribute drinks
Success criteria for improvement

Conclusions
• Hydration is of care home residents is inadequate but problem not
recognized by care staff
• Education has limited impact
• Translation of practical solutions:
 Local measurement and tests of change
 Embed into routine of care
 Leadership
 Consistent supply of appropriate equipment/resources
92

What next?
93
www.uwl.ac.uk/i-hydrate

AIMS
1. Prevalence survey of indwelling urethral catheters
managed by district nursing teams
2. Indication and management plan for newly placed
catheters (in last 4 weeks)
3. Data capture coordinated by IPC via electronic survey
Community Urinary Catheter Management Study
Infection Prevention Society R&D Group
94

• Survey included 149 DN teams from 20 NHS organisations
• Catheter prevalence = 11% (range 2.4 – 22%)
• 269 newly placed IUC:
- 76% in men
- 75% >70 years old
- 84% had clinical indication
- 61% = retention
- 4% = incontinence; poor mobility; patient choice
Main findings
95

• 149 District Nursing teams
- 20 NHS organisations
• Catheter prevalence = 11%
- Range 2.4 – 22%
• 269 newly placed IUC:
- 76% in men
- 75% >70 years old
- 84% had clinical indication
 61% = retention
 4% = incontinence; poor mobility; patient choice
Main findings
96

• Defined as: date for review of need or referral for TWOC
• Only 50% had AMP (range 20 – 96%)
• Less likely to have active management plan if discharged from general ward
• Only 13% had Catheter Passport
- More likely to have AMP
• Alternatives to IUC considered for 40%
Active management plan
97

• HOUDINI Protocol
• Controlled before and after study (Baseline + intervention & control ward at 8 hospitals (569 IUD)
• Device utilization significantly  on HOUDIONI wards
- HOUDINI 18.% (95%CI 17.93 – 18.89)
- Non-HOUDINI 23.4% (95% CI 22.89 – 23.97) (p=0.000)
- All intervention wards had lower rates of device utilization (6/8 p<0.05)
• Mean duration of IUD (on wards ) = 9 days
• Rate of catheter removal varied (18 – 75%); associated with with HOUDINI assessment (p = 0.04)
• 24% discharged with IUD
Nurse-initiated removal of IUC project
98

• HOUDINI protocol provided a structure for nurse decision-making
• Removal delayed when HCA made assessment (not authorized to remove)
• Checklist fatigue
• Delay (of 24-48hrs) between decision and actual removal
• Document reason for IUD not just that the HOUDINI assessment made
• Need to develop local ownership
Focus groups
99

A HOUDINI patient experience
• Mr. A was admitted to the ward with an indwelling catheter.
• He told us that the GP had inserted the catheter for a swollen abdomen
some 18 months previously.
• Since that time Mr A said he had suffered a recurrent UTI whenever the
catheter was changed.
• According to his wife having the catheter "Ruined his life for the last 18
months ” Indeed he spent Christmas at home as he was afraid the bag
would leak”
• The IPC team and ward staff could find no record of a formal referral to the
urology service and so the rational behind the catheter was unclear.
Following HOUDINI principles the catheter was removed
• Mr A passed urine normally and was discharged without a urinary catheter.

LUNCH
Please return at 1.40pm
101

Copyright © to Team Hyrd8: Donna Walker, Charlotte Phillips, Rachael Lloyd-Jones, Cellan Howells, Tamara Konten, Cerys
Davies
Year 3 Student Nurses
Leadership &
Management Project
University Of South
Wales
Team Hydr8

Objectives
• Give background to
project
• Explain why we have
chosen this topic
• Show our idea
• Present statistics to
back up theory
• Show results of our
trials/polls
• Invite you to come on
board with our
exciting journey
Davies

Low
cost/cost
effective
Innovative
Relevant
Realistic
Fresh
Davies

Urinary tract infections
Davies

Key standards for UTI
treatment, prevention &
management
• Standard 4d- Involving
the patient and their
family in understanding
the benefits of good
hydration
• Standard 4e- Accurate
recording of fluid
balance so that
hydration can be
assessed properly
• Standard 4f- Tools and
drinking equipment that
allows the patient to
participate in
maintaining their own
hydration
Public Health
Wales 2018
Davies

Dehydration & Kidney disease
Davies

Did you
know?
According to a
leading
Government
advisor, thirst
is needlessly
killing 33
patients a day
in British
hospitals.
Hydrateforhealth.co.uk
(2014)Copyright © to Team Hyrd8: Donna Walker, Charlotte Phillips, Rachael Lloyd-Jones, Cellan Howells, Tamara Konten, Cerys
Davies

Did you
know?
Acute kidney injury
affects 1 in 5 people
admitted to hospital
5 in 100 patients will
develop acute kidney
failure that can lead to
permanent damage and
eventually death
This costs the NHS an
estimated £500 million a
year — which is more
than lung and skin
cancer together!
Hydrateforhealth.co.uk
(2014)Copyright © to Team Hyrd8: Donna Walker, Charlotte Phillips, Rachael Lloyd-Jones, Cellan Howells, Tamara Konten, Cerys
Davies

Fluid restriction
Davies

Why restrict?
• Heart problems including
Congestive Heart Failure
(CHF)
• Kidney problems, including
End Stage Renal Disease
(ESRD) and people
undergoing dialysis
• Endocrine System and
Adrenal gland disorders,
including Adrenal
Insufficiency
• Conditions that cause the
release of stress hormones
• Treatment with medications
called corticosteroids
• Low levels of Sodium in your
body also known as
Hyponatremia
Davies

OUR
PROPOS
AL
Davies

At present
Staff only know if
someone is on a fluid
balance chart or fluid
restriction if they read
their handover sheet or
there is a board above
the patients bed
So we created a poll and
asked staff:
Can you be confident that
you know which of your
patients need their fluid
recorded or restricted
during a shift?
Davies

405 student nurses, HCSW's and
current practitioners took part
and ONLY 24% said that yes they
were confident that they knew
That leaves a massive 76% of
current practitioners that are
DAILY not recording an accurate
picture in our hospitals as they
cannot identify quickly the
patients in question
Results
were
shocking!
Davies

Davies

Our Project
We would like all
healthcare
professionals to feel
confident that they
could quickly, safely
and accurately
identify those
patients either on a
fluid balance chart
or fluid restriction
without the need to
check paperwork
first, by using a
yellow jug lid as a
visual cueCopyright © to Team Hyrd8: Donna Walker, Charlotte Phillips, Rachael Lloyd-Jones, Cellan Howells, Tamara Konten, Cerys
Davies

What we've
done
• Sourced unique
samples from the
company who
supplies the NHS
currently, therefore
all lids will fit the
existing jugs for
70p per lid
• Sourced a ward
willing to test these
out for us
• Received backing
from the university
and our peers to
approachCopyright © to Team Hyrd8: Donna Walker, Charlotte Phillips, Rachael Lloyd-Jones, Cellan Howells, Tamara Konten, Cerys
Davies

Davies
Social
media
• Immediately created our twitter
page with unique hashtags to gain
attention #PutALidOnIt
#CheckYourJugs
• Followed 273 of the most
influential people on twitter
including some of you here today
• Daily recognition and retweets
from new sources and health
boards excited about our ideas

Davies
Posters

In 10 days we
reached 156,000
people on facebook
Davies
Number of days since Facebook
launch

International Nurses
Day
Davies
• Featured on BBC Wales
evening news & on BBC
radio Wales
• Top feature on the BBC
interactive red button

Davies
National interest in
our project
Nurses as far as
Australia and
America wanting to
know more
Members of the
public saying they
believe their
relatives may still
be alive if this was
in place for them
Support received from
some of the most
influential people
in healthcare
Secured a
supplier who
will only order
through us to
help us
control
statistics
Poll results
show a
massive
backing from
our colleagues
in the health
board for safer
practice
Other health trusts
wanting to join in
the excitement-
including Glossop &
Teeside &
Southmead, Bristol
Sheffield Hospital
have ordered 125
lids and are part of
our trial right now

Davies
Project launch

Davies
405 Healthcare professionals were
asked would they currently be able to
safely, quickly and accurately identify
which of their patients were on a fluid
balance chart or fluid restriction without
looking at their handover sheets?
24%
76%

Davies
607 Healthcare professionals took part in our poll which
asked:
If there were yellow lids on the jugs of patients who
were on a fluid balance chart or fluid restriction, would
you be able to safely, quickly and accurately identify
them without looking at handover sheets or notes?
94%
A 300%
improvement

Davies
We then carried out a physical poll of 108 people including Nurses,
Doctors, HCSW & relatives where the lids are on trial at the Royal
Glamorgan Hospital
• 52% said that they had already heard about the project
• 49% said they had heard via social media
• 35% had heard via word of mouth
• One consultant offered to purchase lids for a whole ward as she
was so impressed
• 96% said the yellow lids would benefit patients on the wards
with their hydration needs

Why should you get
involved?
• Cost effective at 70p per
lid
• Could save money long
term on hospital stays,
UTI's, antibiotics, saline
drips
• Reduce number of
dehydration cases
• Improve staff awareness
and therefore improve
ward audits
• Reduce number of AKI
alerts on patients
• Reduce likelihood of
accidental fluid overload
• Speed up nurses role
• Make the patient's
hospital stay swift and
relevantCopyright © to Team Hyrd8: Donna Walker, Charlotte Phillips, Rachael Lloyd-Jones, Cellan Howells, Tamara Konten, Cerys
Davies

Why should you get
involved?
Over 90% of current staff are
saying that by having yellow lids it
will allow them to identify potential
hydration issues quicker and
therefore make patients safer and
potentially save money and reduce
their length of stay
Without them.....
76% of current staff will by their
own admission remain unable to
quickly, safely and accurately
identify patients most at risk,
meaning higher costs to the NHS
for infection eg UTI, increased
complaints, lengthy hospital stays
and unfortunately more
unnecessary deaths
Davies

Davies
Our idea is spreading
• Sheffield Teaching Hospital contacted us via
twitter
• 1st hospital outside of wales to get on board
• Purchased yellow lids for their wards
• Used in trial for #GIAG2018
• Results are positive already
• https://www.youtube.com/watch?v=Hw-
3qoY1BxI&authuser=0

We also welcome you to
join us
If you are interested in joining us
and really making a difference
Follow us on Facebook and Twitter
@NHShydr8
#PutALidOnIt
#CheckYourJugs
The more teams we get on board
the more we can make hydration at
the forefront of patient care
Davies

Thank you for inviting us today
Team Hydr8 welcome any
questions/feedback you may have
during the Q & A session
Davies

Presentation title
https://youtu.be/8Q7qnNpTWxM
http://www.ihi.org/education/IHIOpenSchool/resources/Pages/Activities/PDSACyclesFromCLABSIsToCucumbers.aspx

Next steps
160
• Continue to update your storyboard to reflect your progress as you go
through the collaborative journey
• Sign up for the webexes on offer – or send other suggestions
• Continue to link in with your QIAs and ask if you want any specific
support
• Thursday 27th September
Park Regis Birmingham, Broad Street Five Ways, B15 1DT
10.00am – 15.45pm
At this event you will:
Have the opportunity to view and share updated storyboards from the
trusts involved in the collaborative
As in days 1 and 2 hear further examples of successful interventions in
reducing HCAI UTIs
Learn about methods to scale, sustain and communicate your changes

Day 3- overview
Storyboard feedback
Facilitated by QI Advisors
Spread and sustainability
Communications session
Case study – Katie Lean, Patient Safety Manager, Oxford AHSN
Whole health approach to reducing UTIs - Esther Taborn, Clinical Fellow, NHS Improvement
Introduction to Pecha Kucha

UTI collaborative 28th June 2018 presentations

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