A recent development at Ashford and St Peter’s Hospitals NHS Foundation Trust (ASPH) has been the inception of The National Catheter Training Project (NCTP) – a multi-professional educational (MPE) project that is linked to a systems-change goal. This is serving as a proof-of-concept endeavour and learning tool which, ultimately, aspires to embed similar education-centred systems-change projects within NHS organisations. It is also being linked to a variety of measures to establish if this approach truly improves patient safety, experience and, the betterment of whole-systems working.
The project is closely aligned to a Government initiative. In 2014, NHS England published a five-year forward view. One of the main goals described was to improve out-of-hospital care by designing services that are both integrated and responsive to patient’s needs. This was to be built on a framework of ‘redesigned services that are fit for-the-purpose of modern-day healthcare needs’. For patients with urinary catheters, recent evidence has pointed starkly to a markedly disjointed service between primary, secondary, and community care. Not surprisingly, this is seen as a clear systems-failing that requires address. An important contribution to our current understanding of this problem, has been provided by a collaboration of clinicians in South London. The Health Innovation Network (HIN) is one of the Academic Health Science Networks (AHSNs) in England that also hosts a Patient Safety Collaborative (PSC). This South London group (HIN PSC) have completed an important two-year baseline project (2015-17). This will receive further discussion herein, but our own project (as a group from a neighbouring AHSN) is building on these foundations.
But for the immediate discussion, it is suffice to remark that, in addition to the South London collaboration mentioned above, similar systems-change initiatives – out-with the NHS – have also been described in the United States. A key learning point from both these large projects, has been the central importance of clinical education in driving improvement. The lexicon used by the different authors varies, and different dimensions to the perceived educational needs are identified. However, a useful collective term that couches these many facets of learning, is that of a ‘socio-adaptive change’ being mediated through clinical education. Indeed, socio-adaptive change driven by education, is seen to be an absolute requirement to deliver such improvements. Our catheter project fulfils such a requirement, in that it provides a comprehensive educational course that is targeted to a multi-professional audience, all of whom, whether directly or indirectly, deal with catheterised patients. It is also showing to be an important forum that catalyses inter-professional group discussion and idea-integration. The stated goal of the project is to show that improvements in catheter-care across primary and secondary care can be achieved through the large-scale delivery of a universalised multi-professional educational product. The key measures will be to show a reduction in Accident and Emergency (A&E) department attendance (often by ambulance conveyance), shorter length of hospital stay (when hospital admission happens), with a clear, rational, and limited use of antibiotic therapy – being administered only for the briefest of duration, and when clinically necessary.
The educational course is modular and comprises eleven  short animated lectures that have an iterative feedback self-assessment for each module. In a multi-professional group setting, the training sessions conclude with structured case-studies that are designed to enable reflective learning and the sharing of experience across inter-disciplinary boundaries. The course also has an on-line version with e-learning components including self-test and self-certification options. All told, the goal of this course is to universalise an understanding of important clinical concepts, language, and principles of practice across all professional groups. The course faculty also comprises a team of Specialist Nurses who contribute to the delivery the educational content and, oversee the care of all the catheterised patients in the hospital, and liaise with those who care for catheterised patients in the community. They are responsible for maintaining standards, record keeping, data collection and, the seamless care of catheterised patients across all domains of the healthcare system. The teaching that has been delivered in the framework of the formal course, is reinforced and, taken back to the clinical frontlines for ad-hoc and opportunistic teaching sessions. However, the core messages of the teaching content are standardised and allied to the centrally developed modular project. The concept of such care-specific Specialist Nurses is not new, and many other programmes have been able to demonstrate their worth.
However, for the course to be effective in driving a systems-change agenda, it needs to achieve widespread, comprehensive, and near complete penetration through the population of professionals who, care for catheterised patients. That is the central challenge for this project. To achieve this end, the cardinal principle is to ensure that the teaching product is a ‘high-end’ and engaging learning tool that has ‘content-consensus’ across professional groups, is evidence-based, relevant, and constantly evolving as-a-consequence of feedback from shared learning, clinical science, and knowledge gained from local audit. Understanding how this project works as an extended MPE endeavour, requires an overview of the clinical problem, contextualised within the currently changing and fragmented healthcare service. Also, it is important to understand prevailing political imperatives, and contemporary global health initiatives.
What are catheter associated problems?
To understand the nature and goals of our project, it is necessary to describe the current clinical issues relating to urinary catheter-care. First, it is a problem of scale: At any one time, an estimated 900 million humans on the planet have a urinary catheter in-situ – it is the most widely used medical appliance on Earth. Second, there are many different catheter-associated problems encountered in clinical practice, and third, they can cause considerable morbidity.
The longer a catheter is in place, the greater are all problems. For example, one study of patients who had been catheterised for more than two-years, reported that more than three-quarters of those patients required some kind of professional intervention (or help), at-the-very least, at least once, over an eight-month period; for some patients, this amounted to more than ten call-outs in that eight month time-frame. Finally, there are complexities regarding catheter-associated-sepsis and antibiotic resistance. The first three problems will be described in brief, and the latter, will receive further deliberation as a distinct – albeit integrally related, catheter specific issue.