Meredith Sunshine RN Georgia College and State University NRSG 4600 May 4, 2015

Evidence Based Practice Prevention of Catheter- Associated Urinary Tract Infections

Background Each of the five evidence based practice studies I utilized looked into ways of reducing infection rates and altering risk factors associated with CAUTI’s, such as reducing the duration of catheterization. The most common infection attained in the hospital is a catheter- associated urinary tract infection (CAUTI). While urinary catheters may be needed, studies have revealed that many patients do not need the procedure or the catheter (Mori, 2014). When a patient has a CAUTI and hospitals do not document the rational for the catheter use or the reason for its duration, it is presumed that proper care was not given while in the hospital stay (Welden, 2013, p. 3). Due to the incidence of 2 million cases of CAUTI infection cases per year the Centers for Medicare and Medicaid have decided that CAUTI’s are a “never event” and limit reimbursement to hospitals (Vacca & Angelos, 2013, p. 78). This mean’s that the hospitals are paying for these unnecessary infections.

Clinical Problem Catheter associated urinary tract infections (CAUTI) account for 40% of hospital acquired infections. The mortality rate for CAUTI is 2.8% (Vacca & Angelos, 2013, p. 78). Failure to minimize initiation and duration of catheter use is the most significant predictor of catheter associated urinary tract infections (CAUTI) (Welden, 2013, p. 2). Literature suggest that other risk factors such as severity of illness at admission, length of stay, use of antibiotics prior to admission, and attention to catheter care is associated with CAUTI risks (Temiz, et al., 2012, p. 346).

Current Practice ICU patients receive an indwelling urinary catheter for the reason of monitor urinary output or urinary retention (Temiz, et al., 2012, p. 344) Other reasons for urinary catheters include: skin healing, prostate issues, and surgery’s (ect) and the standard of care is not what is should be with CAUTI’s being the most prevalent Hospital Acquired Infection (HAI) (Welden, 2013, p. 3). The methods that are in place to reduce CAUTI’s in the hospital have been around for a long time but have been considered a low priority for nursing staff (Palmer, Lee, Maya Dutta-Linn, Wroe, & Hartmann, 2013, p.16).

PICOT Question In a hospital setting with patients with Urinary Catheters (P), how does various interventions such as, when to insert, remove catheters, and how to properly clean catheters (I) help prevent CAUTIs compared to the current treatments of urinary catheters (C), and how can the new interventions affect reduction rates of CAUTIs (O) within at least a six month period or more (T)?

Clinical Question In hospitalized patients with indwelling urinary catheters, does the utilization of nursing lead protocols, evidence based practices, and best recommendations result in decreased rates of catheter associated urinary tract infections throughout the hospital stay? In comparison to standard protocols for the insertion and removal of urinary catheters.

Methodology The Galileo search engine provided through the GCSU’s resources was utilized to search several databases. In addition to Academic Search Complete, CINAHL, CINAHL Plus, and MEDLINE were all used to obtain peer reviewed articles with relevance to the study. Key words in this search included: indication for catheter use, CAUTI, UTI, nurse-led interventions, Quality Improvement,and catheter removal. Articles were selected based on their relevance to the topic, the publication date, peer reviewed, and the credibility of the information that were relevant to my PICOT question. Studies included information from interviews, statistic’s analyzed, comparison groups, and retrospective chart reviews were analyzed in order to gain information on the topic. When researching I found over 700 articles on urinary catheters and I was only able to use 5 total articles that met all criteria for the project.

Synthesis of Data ArticleStudy TypePurposeFindings (Mori, 2014) Descriptive Research Quantitative Study To evaluate the effectiveness of a nurse- driven indwelling urinary catheter removal protocols. Nurse driven protocols decrease the duration of catheters which in turn lowers CAUTI’s. (Palmer, Lee, Maya Dutta-Linn, Wroe, & Hartmann, 2013) Cross-sectional qualitative study / Qualitative Analysis To examine Centers for Medicare and Medicaid Services (CMS) payment policy and its potential impact on hospital practices. When insured company’s refuse to pay for treatment there is incentive to prevent CAUTI’s. (Temiz, et al., 2012) Quantitative (urine studies) / Correlational Research Study incidence and risk factors of CAUTI’s in ICU’s to determine the risk on HAI. Findings show that the longer the catheter stayed in the higher rate of CAUTI’s. (Vacca & Angelos, 2013). Quasi- Experimental Quantitative Research CAUTI prevention was used by a process of proactively rounding. Able to estimate a cost avoidance of $55,000 with the start of their rounding. (Welden, 2013) Quantitative Quasi- Experimental Design The objective was to develop a strategy to prevent CAUTIs through documentation. More documentation sustained the care of patients, better outcomes

Results Nursing-driven protocol implemented systems which prompt nurses to evaluate the status of the indwelling catheter. This guides them to decide if the catheter is still necessary, or if it is time to remove it, based on certain criteria (Mori, 2014, p. 20). Updated policies and prevention strategies focused hospital wide; reminder systems, better documentation, education, and observing patient’s are all useful ways of reducing and preventing CAUTI (Palmer, Lee, Maya Dutta-Linn, Wroe, & Hartmann, 2013, p. 22). Nurses at the unit level must continue to increase compliance and recognize Electronic Health records (EHR) helps to support, motivate, and carry EBP in both care and documentation of CAUTI’s in the health care setting (Welden, 2013, p. 9). Several hospitals have implemented systems which prompt nurses to evaluate the status of the indwelling catheter. This guides them to decide if the catheter is still necessary, or if it is time to remove it, based on certain criteria (Vacca & Angelos, 2013, p. 79).

Results The duration of catheterization is most important and a well known risk factor for the cause of CAUTI’s. Our results show that the necessity of reducing the duration of catheterization will help avoid the development of CAUTI’s (Temiz, et al., 2012, p. 348) The effectiveness of nurse driven protocols on the incident and duration of urinary catheters with hospitalized adults shows the need for change in practice to lower the amount of CAUTI’s. A nursing driven protocol was developed to allow nurses to discontinue catheters without a physicians order if certain indications are met (Mori, 2014, p.17). Within 6 months of implementation of care practices and catheter insertions, this showed a downward trend from 30% of patients at baseline to 20% when implementations were continuously utilized (Welden, 2013, p. 7).

Implication for Nursing Practice From what I have already gone over, it is important to understand evidence-based practice of urinary catheters can help further prevention of CAUTI’s. The more we take the time to focus on catheter cleanliness every shift, proper insertion, and documentation, the less likely our patients will develop an infection that could have been prevented. Barriers to implementation of previous suggestions would include that nursing staff can assume this is not a priority when it comes to other patients who are consuming their time. As well as being busy and having your focus on other situations for other patients. Ways of overcoming these barriers would be: to have the mindset that catheters are another important vital sign to assess during your shift. Have it in your mind to assess every catheter when in the room giving medications, be open with the doctor about the importance of having the catheter, and document everything, every time you start and clean a catheter.

Conclusion Results show earlier removal of indwelling urinary catheters reduces the occurrence of urinary tract infections. While research proves early removal is effective in preventing infection, many nurses and physicians do not pay full attention to how long the catheter has been in place, or the true necessity of the catheter so it is important to be more cognizant of catheter necessity when taking care of patients. Research stated that implementing reminder systems through the electronic charting system ensured less negligence and improved quality patient care. Evidence has reported that reminder systems may improve adherence to evidence-based guidelines, related to CAUTI interventions. With healthcare and technology becoming more integrated reminder systems will be an easy and low cost way to decrease infection rates in the hospitalization. Use of reminder systems should not be fully relied on, technology does have its problem areas and can malfunction. The nurse and physician should keep track of the Foley catheters and be knowledgeable of timely removal.

References Mori, C. (2014). A-Voiding Catastrophe: Implementing a Nurse-Driven Protocol. MEDSURG Nursing, 23(1), Palmer, J. A., Lee, G. M., Maya Dutta-Linn, M., Wroe, P., & Hartmann, C. W. (2013). Including Catheter- Associated Urinary Tract Infections in the 2008 CMS Payment Policy: A Qualitative Analysis. Urologic Nursing, 33(1), doi: / X Temiz, E., Piskin, N., Aydemir, H., Oztoprak, N., Akduman, D., Celebi, G., & Kokturk, F. (2012). Factors associated with catheter-associated urinary tract infections and the effects of other concomitant nosocomial infections in intensive care units. Scandinavian Journal Of Infectious Diseases, 44(5), 344. doi: / Vacca, M., & Angelos, D. (2013). Elimination of Catheter-Associated Urinary Tract Infections in an Adult Neurological Intensive Care Unit. Critical Care Nurse, 33(6), doi: /ccn Welden, L., (2013) "Electronic Health Record: Driving Evidence-Based Catheter-Associated Urinary Tract Infections (CAUTI) Care Practices" OJIN: The Online Journal of Issues in Nursing Vol. 18 No. 3.