A whole healthcare economy approach

1
A whole healthcare economy approach

• Cheryl Trundle
• Senior Nurse Infection Control

2
Setting the scene

3
Some facts and figures

• Foundation trust with approximately 1,000 beds
  and 6,500 staff
• National and regional centre for cancer,
  haematology, liver transplant, other organ
  transplantation, neurosciences and genetics
• Links with medical research and medical education
• Local DGH for 0.5 million people across
  Cambridgeshire, parts of Huntingdon,
  Bedfordshire, Hertfordshire, Essex and Suffolk

4
Patient history

• 86 year old gentlemen living at home with his
  wife, both suffering from mild to moderate
  dementia
• Previous admission to renal medicine ward in late
  September 2006
• At that time suffering from ARF secondary to
  retention and urinary tract infection

5
Patient history .

• Blood culture and CSU taken during that admission
  showed no growth
• Attempted to manage patient using intermittent
  self-catheterisation
• Unable to cope therefore discharged home with
  indwelling urinary catheter
• Community staff to monitor patient and the
  urinary catheter
• Patient not known to be MRSA positive

6
Patient history .

• 5/10/06 patient pulled out his catheter with
  attendant urethral trauma
• Increasing confusion noted by community staff
• 6/10/06 AM recatheterised by community staff
• 6/10/06 PM Visited by GP who advised admission
  to acute hospital

7
The patient .

• Admitted to hospital 6/10/06 under care of
  general medical physicians
• GP letter stated worsening confusion, unsteady
  on feet, abdominal discomfort, possible UTI
• No accompanying documentation regarding
  re-catheterisation
• Mild pyrexia, raised WCC 16.8 and CRP 80 on
  admission

8
The patient .

• Patient acutely confused and septic
• 6/10/06 blood cultures, MRSA screen and CSU
  taken
• Prescribed IV Benzylpenicillin and Ciprofloxacin
• 7/10/06 results showed MRSA bacteraemia and
  positive CSU, screen also positive when result
  available 4 days later

9
The patient .

• IV antibiotics changed to vancomycin and
  meropenem on Microbiology advice
• At that time CRP gt250
• Patient isolated and barrier nursed
• RCA performed with members of the clinical team,
  noted to be pre-48 hours

10
Points to ponder .

• Was antibiotic cover considered when the patient
  was recatheterised?
• Were staff aware of the policy?
• Should risk factors for possible MRSA have been
  recognised and therefore have informed choice of
  antibiotic?

11
Points to ponder .

• What are the community hospital policies for
  antibiotic cover for catheter insertion?
• Are they concordant?
• Are staff able to easily access the relevant
  information?
• What training do hospital / community staff
  receive on urinary catheter care in general and
  infection control principles of catheter care
  specifically?
• How do we ensure that evidence-based principles
  are incorporated into every day practice?

12
Initial actions ..

• Contacted CICPN to ascertain what their
  guidelines were-
• Catheter care does not form part of the specific
  infection control policies
• Guidelines formulated by the Continence Advisory
  Service based at three of the seven PCTs
• Sent out in paper form to all District Nurse
  practices
• Obtained a copy of the policy, over 50 pages
  long!!

13
Initial actions

• Spoke with lead CIPCN to ascertain what training
  was available-
• General mandatory infection control training
  given on induction and yearly thereafter for
  clinical staff
• Does not include urinary catheter care
  specifically
• Voluntary update days were held 4 times a year
  for staff and carers

14
Community urinary catheter audit results (April
2006) .

• 11 patients reviewed in a continuing care setting
• Wide range of documentation
• 3/11 had a Catheter Diary as recommended
• Some records had no space for patient details,
  others no space for HCW name and signature
• Daily recording of care was variable
• Date of catheter change only recorded in 9 of
  cases
• 3 patients had a catheter change, no reason
  recorded
• Review of documentation and practice advised

15
Extracts from HIS web page discussion

• 25 of our bacteraemias are associated with
  catheter changes
• We have found similar problems
• Does anyone have a view on whether AB
• prophylaxis at catheter change has
• contributed to selection of MRSA CDT
• We have found from RCA that risk factors
• include MRSA colonisation long term
• catheterisation and blockage ..

16
Confounding factors .

• Changing configuration of PCTs, with need to
  consolidate new roles and responsibilities and
  explore effective communication strategies
• GPs are independent practitioners and are under
  PCT commissioning
• Some problems with access to e-learning package
  and monitoring of uptake
• We all think what we do is best!

17
How can we work together to provide integrated
care in practice

• All suggestions gratefully received

18
What we did .

• Met with PCT to explore joint initiatives to
  reduce MRSA eg screening
• Discussed the use of High Impact Interventions to
  form the basis for standardisation of policies
• Explored use of common documentation eg ICP for
  urinary catheter care
• Suggested clarification of existing policies to
  make clear the need for antibiotics
• Work to achieve access to PCT wide / region wide
  information systems
• Joint study days for hospital and PCT staff
• Consider representative attendance at ICCs (PCT
  and acute hospital)

19
Standardise policies and procedures ..
20
Education training .
21
Management commitment .
22
Some thoughts to finish with .

• Act as if what you do makes a difference
• William James 1842 -1910
• Never tell people how to do things. Tell
• them what to do and they will surprise
• you with their ingenuity.
• George S. Patton 1885 -1945

23
Teamwork