1. KEYS TO SUCCESS/INSIGHTS SUSTAIN/SPREAD CHANGES
Improving Adherence to the Nurse Driven Indwelling Urinary Catheter Removal Guidelines
Catherine Jackman RN, MSN, ACNS – BC, CNS Cynthia Engelhardt RN, BSN UE, Christine Halash RN, BSN UE
Nancy Price RN, BSN, NAM, Anna Sutton RN, BSN ACM
Henry Ford Hospital - MICU Pods 5 & 6
BACKGROUND
RESULTS
KEYS TO SUCCESS/INSIGHTS
Engaging the nurse in discussion and providing assistance to implement alternatives to a urinary catheter was key in changing the culture to adopt the use of the Nurse Driven Indwelling Urinary Catheter Removal Guidelines
Acknowledging frustration with barriers and providing alternatives such as; easier to change incontinence pads, an external female urine collection device, and additional types of condom catheters
Project champions helped energize staff to make the practice changes.
Ensuring that one fosters collaboration and communication with physicians and midlevel providers to consider alternate methods to evaluate fluid status such as daily weights or urine collected by external catheter devices, commode, urinal or bedpan.
Offering to assist the busy ICU bedside nurse with the task of urinary catheter removal and application of alternatives was cited as helpful by staff. Also performing follow up rounding again towards the end of the shift to ensure that the task of urinary catheter removal was completed by the nurse.
(Figure 2)
Catheter-Associated Urinary Tract Infections (CAUTI) are the most commonly reported hospital-acquired condition. More than 560,000 patients develop CAUTI each year, leading to extended hospital stays, increased health care costs, and patient morbidity and mortality (nursingworld.org/ANA-CAUTI 10/10/16). RNs can play a major role in reducing CAUTI rates to save lives and prevent harm.
In the ICU patient it is often unclear when is the correct time to remove a patient's urinary catheter. Nurses are hesitant to remove a catheter when a patient may not be able to indicate they need to urinate. There are also risks of increasing moisture associated skin damage if the urinary catheter removal causes incontinence as well as issues with patient dignity. One of the CDC indications for use of an indwelling urinary catheter is the accurate measurement of urinary output in critically ill patients. The term accurate measurement is currently not well defined but is often cited by staff as the criteria to maintain the catheter. Once the patient does not require accurate I & O for clinical decision making, they do not meet the "critical monitoring" criteria for the urinary catheter. Quality Rounds with the leadership staff can help identify patients that no longer meet criteria for having a urinary catheter and help offer solutions to prevent complications related to incontinence.
Quality rounds prior to implementing this change had been done by utilizing a computer data base that was reviewed by the physicians during rounds. There was no interaction with the nursing staff to discuss interventions to achieve improved patient outcomes. There was no improvement in quality indicators with this method.
The Urinary Catheter Utilization rate shows a 39% reduction after implementation of bedside quality rounds in July 2016 compared to the previous 8 months.
SUSTAIN/SPREAD CHANGES
The results have been sustained for an 8 month period. The project will be shared with the MICU Practice committee for evaluation to roll out to other MICU Pods. It will also be shared with other ICUs for consideration.
AIMS
(Figure 3)
Identify nurses perceived barriers to urinary catheter removal and provide alternatives to eliminate barriers
Reduce the urinary catheter utilization rate to below the National Healthcare Safety Network (NHSN) twenty fifth percentile benchmark
Reduce CAUTI rate to zero
CONCLUSION
Bedside Quality Rounds starting in July 2016 has been effective in reducing the urinary catheter utilization rate by 39% in MICU Pods 5 & 6
Identification of the nurses’ barriers to catheter removal and providing interventions to alleviate the barriers during quality rounds has improved adherence to the Nurse Driven Indwelling Urinary Catheter Removal Guidelines.
Discussions with RNs and providers during bedside quality rounds of alternatives reduced urinary catheter indication of Critical Monitoring and need for Accurate Output measurement by 91% July 2016 to September 2016
Comparing the Previous eight months to the eight months after the initiation of bedside quality rounds there has not been any CAUTIs in MICU Pods 5 & 6. This is an 80% drop in the CAUTI rate.
METHODOLOGY
Bedside Quality Rounds were completed Monday through Friday with the unit leadership staff and the MICU RN. Discussion regarding urinary catheter indications and the nurses perceived barrier to catheter removal were obtained. A deeper dialogue was opened when the CDC criteria “critical monitoring” was cited as the indication for use.
Nurses perceived barriers ( Figure 1) identified the need for more education and additional alternatives for incontinence care and skin protection. Once provided, a shift in the unit culture was identifiable and urinary catheter use began to decrease.
Perceived
Barriers
Patient Discomfort 2%
Incontinence
37%
Patient Dignity
11%
Nurses Increased Work Load
18%
Patient Diuresis
33%
Nurses Perceived Barrier to Urinary Catheter Removal
(Figure1)
The CAUTI Rate has dropped 80% in the 8 months since initiation of the bedside quality rounds in July 2016 compared to the previous 8 months.
ACKNOWLEDGEMENTS
The RNs in MICU Pod5 & 6.
The Pulmonary Critical Care physicians, PAs and NPs.