Shared learning database

Berkshire Healthcare NHS Foundation Trust
Published date:
April 2017

A clinical audit was undertaken covering the Trust’s inpatient units in order to assess the compliance of staff in the use of documentation for a catheter care bundle for patients with an indwelling catheter in line with the NICE clinical guideline for Healthcare-associated infections: prevention and control in primary and community care (CG139) and the NICE Quality Standard 61 for Infection control and prevention.

Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

The aim of the clinical audit undertaken by the trust was to assess the compliance with the use of documentation for the urinary catheter care bundle by healthcare professionals in the Trust's inpatient units.


  • To identify whether the catheter care bundle is in use in the inpatient units
  • To ascertain the compliance of documentation within the catheter care bundle
  • To analyse and compare the data against the standards in the catheter care bundle in line with NICE guidance
  • To ascertain whether any amendments need to be made to the catheter care bundle in line with the NICE Quality Standard 61
  • To provide evidence of compliance for NICE Quality Standard 61.

Reasons for implementing your project

Catheter-associated urinary tract infections (CAUTI) comprise a large proportion of healthcare-associated infections, and can occur whether a person has either a short-term or a long-term catheter in situ. The two main concerns around the development of CAUTI are unnecessary urinary catheterisations and prolonged catheter days.

Between 43% (male) and 56% (female) of patients’ Urinary Tract Infections (UTI) are associated with urinary catheters.

Apart from the risk of developing CAUTI and subsequent blood stream infections, other complications can include nonbacterial urethral inflammation, urethral strictures, mechanical trauma, and mobility impairment reported in patients.

To assist clinical staff in reducing the risk of CAUTI and to ensure that care provided for patients with an indwelling urinary catheter is consistent with evidence based best practice, the trust has developed urinary catheter guidelines in line with national evidence based practice guidelines.

Due to increased number of blood stream infections associated with Escherichia coli (E.coli), The Department of Health (2011) introduced a mandatory surveillance system where all NHS Trusts are required to report all cases of E.coli bacteraemia to Public Health England.

The local NHS trust has an acute mental health hospital consisting of 8 inpatient units and 7 community inpatient rehabilitation units situated in 5 different localities.

A post infection review undertaken by the Infection Prevention and Control Team, identified the presence of urinary catheter as the focal point of E.coli bacteraemia in 6 out of 11 cases during November 2013 - January 2015 (based on Trust data from 2015) suggesting that these infections may have been preventable.

A prolonged presence of a catheter in situ was identified in all these cases. One possible reason for this prolonged use may be resultant from not having a robust system in the clinical environment for reviewing the need for the catheter on a daily basis.

The majority of the patients transferred from the acute trust with a catheter in situ did not have clear information for the reason for catheterisation or a review plan in place.

How did you implement the project

A clinical audit was undertaken by the Infection Prevention and Control Specialist Nurse as part of an MSc Dissertation and the Infection Prevention and Control annual audit programme 2015-16 across physical health inpatient units of the Trust.

The development of the audit tool included review of the best practice guidelines which specifically included NICE Quality Standard 61. The tool was finalised with expert support from the Infection Prevention and Control Team (IPCT). Once the tool was finalised, a pilot study was undertaken in one clinical area which helped the author to identify a few minor issues which were rectified in order to robustly undertake the data collection and analysis.

The plan for delivery of the clinical audit was discussed in various clinical staff forums including the trust’s IPC link practitioners meeting, IPC working groups and a strategic meeting where front line clinical staff, service managers and senior managers represent various parts of the organisation.

The data collection was undertaken in 7 physical health wards over a 6 week period during May-June 2016. As there were no multiple data collectors, no additional training was required and no issues were raised due to potential misinterpretation of the tool.This project did not incur any additional cost and therefore required no additional funding.

As there were no catheterised patients present during the data collection period in the mental health inpatient units, these were not included in this audit report. Following the completion of the data collection, the data was entered into an excel spreadsheet and analysed.

Key findings

  • Data was obtained from 60 catheterised patients
  • 35 out of 60 catheterised patients had a catheter care bundle in place
  • In the remaining patients 16 had a blank care bundle (non-compliant) and 9 had no care bundle in place.
  • The number of care bundles audited varied from 3-10 per individual inpatient unit and the total compliance within individual care bundles varied from 10% - 100%
  • Along with the care bundle and a separate care plan was found to be in use for catherized patients .Due to the time required for completing both documents, a significant amount of information was missing.

A catheter care bundle and a care plan were found to be in use for all catheterised patients. Although some criteria in both documents are repeated, not all the criteria as part of the NICE guidelines are included in both documents.

The rationale for keeping the urinary catheter in situ has been reviewed and documented in 40% of patients

In order to reduce the number of unnecessary catheter days and prolonged presence of catheters, a daily review and documentation of the need for keeping the catheter in situ is required in hospitalised patents.

Staff are required to complete a checklist (criteria 16-30 on the attached audit tool which can be found in the supporting material) as part of the care bundle during an active intervention for example; catheter insertion and clinical specimen.

The current checklist contains requirements for an active intervention and on-going management. The audit found that 20 out of 35 care bundles had no documented evidence of completing this checklist resulting in non-compliance. These patients were either admitted to Berkshire Healthcare from neighbouring trusts or from home with a catheter already in situ. For those patients who were admitted from home with a catheter already in situ, and not accompanied by documentation on catheter insertion in an NHS setting, there is potential for staff to miss the requirements of adherence to the on-going management of catheterised patients.

This may be addressed, both for catheterised patients admitted from other Trusts and from home by using an amalgamated checklist which first requires staff to ensure key information is documented on the care bundle before moving onto the documentation requirements of the care plan itself. This ensures that staff cover both the documentation requirements of catheter insertion and maintenance when completing the checklist.

By undertaking this project, the author was aiming to improve patient safety by reducing the risk of CAUTI. This exercise has also been aimed at increasing staff awareness around the NICE Quality Standard for Infection Prevention and Control, when providing care for catheterised patients.

The completion of the audit led to the following recommendations being made:

  • The Continence Advisory Team in collaboration with the Infection Prevention and Control Team to update the care bundle in line with the NICE guidance and findings of the audit
  • To amalgamate the care plan and care bundle
  • To divide the checklist in order to separate the requirements of insertion and maintenance of indwelling catheters
  • To update the catheter guidelines to include the frequency of the review of the need for keeping a catheter in situ (daily review for inpatient units and frequent review for community patients).

Key learning points

Actions were taken at the trust as a result of the audit recommendations.

The continence team and the IPCT updated the care bundle in line with the recommendations from the audit and this was communicated to staff via various channels including IPC link practitioner meetings, the trust communications department and the trust catheterisation study days.

A review of the recommendations from this audit with the progress on actions will be undertaken by the author during 2016-17. The results from the re-audit will be added to this example to demonstrate the effects over time.

Based on this work, other organisations especially those hosting both inpatient and community services can learn and consider the recommendations from this audit.

Contact details

Mrs Smithamole Anil
Infection Prevention and Control Specialist Nurse
Berkshire Healthcare NHS Foundation Trust

Primary care
Is the example industry-sponsored in any way?