Documented adherence to standards and guidelines: an audit.

摘要

The authors conducted a cross-sectional audit within Newcastle-upon-Tyne Hospitals NHS Foundation Trust to determine the prevalence of urethral catheterisation and documented adherence to relevant NHS standards. An on-line audit questionnaire was completed for all 80 inpatient wards within the Trust on a single day during the third week in June 2009. The tool collected data on prevalence and care requirements detailed in the Department of Health's (DH) Saving Lives High Impact Intervention 6 (2007). Data were analysed using Snap survey software. Overall, 172 of 1187 (14.5%) inpatients were catheterized and all were using a closed drainage system or catheter valve. Evidence of correct continuing catheter care was documented for 168 (98%) patients, while details of catheter insertion were identified in 153 (89%) patient records. Eight (4.5%) patients were being treated for a urinary tract infection. The authors found satisfactory adherence to basic documentation standards with regard to catheter care. This was associated with a low prevalence rate of catheterization and catheter-associated urinary infection within the Trust relative to previously published figures. Details of catheter insertion were missing from 10% of patient records, requiring further development of accessible and transferable documentation tools. Provision of relevant information to patients is also a target for development.