Catheter-associated urinary tract infections (CAUTIs) are a significant problem in hospitals despite considerable spending on education and prevention. About 560,000 CAUTIs are reported to the CDC each year.1 Because CAUTI is considered a preventable complication, the Centers for Medicare & Medicaid Services no longer reimburses hospitals for the cost of treating CAUTI unless the patient is admitted with the infection.2,3
This article describes how one facility used the Quality and Safety Education for Nurses (QSEN) project principles to develop a quality improvement initiative aimed at decreasing device-days (the number of days a patient has an invasive device) for indwelling urinary catheters.4 (For more, see About QSEN.) Risk factors for CAUTI include long duration of catheterization, urine retention, female gender, older age, a history of diabetes, immunocompromise, and being catheterized during childbirth.4
Prompt removal of an indwelling urinary catheter can improve patient mobility, reduce the risk for CAUTI, and reduce hospital costs.
Nurse-driven prevention
The pressure to remove urinary catheters as early as possible has caused nurses anxiety: would removing catheters early lead to incontinence, skin breakdown, and a dramatic increase in workload for nurses? Direct caregivers have a primary role in CAUTI prevention because many preventive interventions fall directly under their scope of practice. Although many patients, especially those in the ICU, are ill enough to require a urinary catheter, the nurse can recognize when the patient no longer needs the catheter and can communicate that to the healthcare provider, who can direct catheter removal.
The University of Pittsburgh's Passavant Hospital used the QSEN principles as a guide to develop a CAUTI-reduction project in the 16-bed cardiovascular-surgical ICU. The goal was to reduce the number of catheter device-days and thus patients' CAUTI risk. Despite protocols that identified when a urinary catheter should be removed from a surgical patient, staff hesitated to remove catheters in a timely manner, especially if the patient was receiving diuretics. Additionally, recent changes in the surgical staff added confusion: The new surgeons eliminated the existing protocols, which had called for removing urinary catheters the morning after surgery if the patient was extubated and wasn't receiving vasopressors or inotropes. Instead, the surgeons preferred to manage each case independently, discontinuing urinary catheters when they felt the patient was ready.
A multidisciplinary team developed the project and researched and defined best practices. The team created a slide presentation on CAUTI prevention strategies and an online survey that served as a posttest and assessed staff willingness to change practice to improve patient outcomes.
Unit-based nurse "champions" were selected to make daily rounds in the ICU for the specific purpose of identifying at-risk patients, discussing interventions, and educating staff on CAUTI prevention strategies (see Best practices for preventing CAUTIand Some indications for indwelling urinary catheters.). Staff viewed the slide presentation and then completed the 10-question survey.
Fostering patient-centered care
Our CAUTI project reflected patient-centered care because it sought to improve patient safety and reduce harm, took into consideration patient and family values and preferences, and encouraged the healthcare team to be proactive. Although a urinary catheter is often indicated for an acutely ill patient, once the determination has been made that the catheter is no longer needed, prompt removal of the catheter is in the best interest of the patient and family.
For nurses, CAUTI prevention began with educating the patient and family (with the patient's permission) about the patient's current condition and explaining why the patient required a urinary catheter. Nurses also explained alternative options, such as condom catheters, to the patient.
How the project worked
The CAUTI project's goals were to decrease device-use days, thus reducing the risk of infection for the patient.5 The educational presentation detailed several nursing strategies that could reduce the risk of CAUTI. For example, in accordance with the Surgical Care Improvement Project standards of practice, surgical patients should have urinary catheters removed 24 to 48 hours postoperatively unless the healthcare provider determined that the catheter is still necessary.6
Another strategy was to implement a daily rounder-one or two staff nurses who would round on all of the patients in the unit. The rounder educated staff and promoted awareness of the surgical protocols. The rounder also reviewed all patient medical records daily, noted which patients had urinary catheters, and checked if an order was present to maintain the device. Rounders also discussed patient-care status with the nurse to determine if the patient still needed the catheter.
Direct caregivers who volunteered to make patient rounds became not only more proactive patient advocates, but also mentors, leaders, and educators for the rest of the staff.
How electronic medical records help
With the advent of electronic medical records (EMRs), tracking urinary catheter dwell times has become easier. Systems are being built that include reminder-only interventions and automatic stop orders reminding healthcare providers to discontinue the urinary catheter or document why it needs to be maintained.7
When accessing a patient's EMR, healthcare providers will be reminded that the patient has a urinary catheter, triggering an evaluation of the catheter's necessity. Nursing assessments now require documentation justifying why a urinary catheter is in place. If criteria aren't met, the nurse must contact the healthcare provider to obtain an order to discontinue the device.
New EMR systems require nurses to document urinary catheter necessity on a shift-by-shift basis under the patient's physical assessment. Some systems have implemented automatic stop orders for the nurse so a catheter may be discontinued without a physician order if certain criteria are met.7
However, in a recent survey, only 1.5% of U.S. hospitals have comprehensive EMRs in place, and 17% of hospitals have computerized provider-order entry.8 That means that most patient-care issues are still being communicated person to person. Nonelectronic interventions have included placing stickers on medical records as a reminder to all staff that a patient has a urinary catheter in place.
Whether tracked by EMR or manually, a report is generated for each patient with a urinary catheter which details the date and time the catheter was ordered, inserted, scheduled for removal, and removed.
Reports also include how many patients acquired an infection while the catheter was in place. The infection control department also has special software that can analyze patient medical records. Using technology in this fashion, data can be quickly obtained, organized, and disseminated throughout the nursing units, resulting in efficient changes to patient care.
Follow-up
After 6 months, our unit's CAUTI rate has remained at zero for patients undergoing open-heart surgery. Device days for indwelling urinary catheters have decreased from 3.2 to 2.9. Pretest survey results showed that 75% of nurses reported always routinely assessing whether their patient actually needed a urinary catheter; posttest survey results showed a 20% increase in that figure (see Measuring the program's effectiveness). The percentage of nurses who said they were always willing to initiate a conversation with the patient's healthcare provider about removing a urinary catheter increased 39%. This increase appears to indicate that educating nurses about infection control issues increases their perception of autonomy and confidence in acting as patient advocates.
Employing QSEN principles, consistency in rounding, continuing staff education, and proactive nursing care were effective strategies to prevent CAUTI and promote optimal patient-care outcomes.
About QSEN
QSEN, funded by the Robert Wood Johnson Foundation, aims to prepare future nurses with the knowledge, skills, and attitudes needed to continuously improve healthcare system quality and safety.
The first phase of the project identified six competencies: patient-centered care, evidence-based practice, quality improvement, teamwork, safety, and informatics. In the second phase, pilot schools integrated these competencies in their nursing programs and shared their teaching strategies and resources on the QSEN website (http://www.qsen.org).
The third phase, which started in November 2008, aims to continue promoting innovation in teaching the six competencies, developing faculty expertise, and creating ways to improve all nursing programs through the content in textbooks, accreditation and certification standards, licensure exams, and continued competence requirements.
Source: Quality and Safety Education for Nurses, http://www.qsen.org/overview.php.
Best practices for preventing CAUTI4,9
* Insert an indwelling urinary catheter only for appropriate indications, and leave in place only as long as necessary
* Only properly trained personnel should insert and maintain indwelling urinary catheters
* Minimize indwelling urinary catheter use and duration of catheter use in patients at high risk for CAUTI (women, older adults, and those with immunocompromise)
* Maintain strict sterile technique during insertion, and a closed drainage system after insertion
* Perform hand hygiene before and after manipulating the catheter
* Properly secure the catheter
* Maintain an unobstructed flow by hanging the collection bag below the level of the patient's bladder (but not resting on the floor) and ensuring that the tubing is free from kinks
* Avoid routinely changing catheters or drainage bags
* Routine antimicrobial prophylaxis and routine screening for asymptomatic bacteriuria aren't recommended
* Cleaning the periurethral area with antiseptics or using antimicrobial bladder irrigation isn't recommended.
Some indications for indwelling urinary catheters4
* Acute urine retention or bladder outlet obstruction
* Accurate measurement of urine output in critically ill patients
* Perioperative use for some surgeries, including urologic or genitourinary surgery, prolonged surgery, surgeries involving large-volume infusions or diuretic use, and when urine output must be monitored intraoperatively
* To help heal open sacral or perineal wounds in patients with incontinence
* In patients who require prolonged immobility, for example for multiple traumatic injuries such as pelvic fractures
* As a comfort measure during end-of-life care.
Indwelling urinary catheters shouldn't be used as a substitute for nursing care of patients with incontinence, or as a way to obtain urine for diagnostic tests if the patient can void voluntarily. Urinary catheters also aren't indicated for prolonged postoperative use without appropriate indications, such as prolonged effect of epidural analgesia.
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