A HOSPITAL-ACQUIRED INFECTION (HAI) is an infection that is not present at the time of patient admission, but rather is acquired while inpatient, during hospitalization at a health care facility. HAIs can have a detrimental effect on morbidity, mortality, and patient safety, and can result in increased lengths of stay and cost. According to the 2018 National and State Healthcare-Associated Infections (HAI) Progress Report, 1 in 31 hospitalized patients will acquire an HAI during hospitalization.1 Five HAIs are monitored by the Centers for Disease Control and Prevention (CDC) and the National Healthcare Safety Network hospital-associated infections, including central line–associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), Clostridium difficile infection (CDI), surgical site infection (SSI), and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia.2 While reduction of HAIs is always a primary focus for health care institutions, reduction of CAUTIs was given increased focus at the large urban teaching hospital featured in this article. When compared with other hospitals of similar size and case mix index, the featured hospital was experiencing a higher-than-expected number of CAUTIs, as well as an increased number of indwelling urinary catheter days.
The CDC reports that urinary tract infections (UTI) are the most common type of reported HAI and around 75% of those UTIs are catheter-associated UTIs, as they involve an indwelling urinary catheter.3 Multiple factors contribute to CAUTIs; however, the CDC suggests that prolonged use of an indwelling urinary catheter is the most important risk factor for developing a CAUTI.3
The Institute for Healthcare Improvement recommends implementation of process measures to monitor and improve the following patient outcomes: CAUTI rate, assessment of unnecessary indwelling urinary catheter, and monitoring unnecessary indwelling urinary catheter days.3
CAUTIs are not only unexpected and inconvenient for the patient; they are painful, expensive to treat, and negatively impact the well-being of the patient. Additionally, CAUTIs have an adverse impact on a hospital's financial status and can be detrimental to the hospital's ratings, in terms of public reporting and the perception of the quality of the care provided by the institution. As a mechanism of informed consumer care, the Centers for Medicare & Medicaid Services (CMS) reports quality metrics to a consumer-focus website, Hospital Compare, where comparisons can be made regarding hospital quality and informed decisions can be made regarding where to receive care.2
The hospital, a large urban teaching hospital in a multiple hospital network, featured in this article monitored and implemented process measures, with the goal of improving patient outcomes and decreasing overall CAUTI rates and indwelling urinary catheter days. Primary focus involved education concentrated on a nurse-driven protocol for indwelling urinary catheter removal and assessment for necessity, aseptic technique, rationale behind removal, and use of alternate methods of urinary management.
EVIDENCE
According to the CDC, CAUTI is the most common preventable HAI in the United States.4 Approximately 16% to 25% of hospitalized patients have an indwelling urinary catheter placed.5 The literature reflects, after the first 48 hours, bacterial colonization in the urinary tract of catheterized patients increases approximately 5% each day the catheter remains in place, and infection rates are then noted to be between 10% and 25%.6
Additionally, negative outcomes associated with CAUTIs include increased mortality rates, lengthened hospital stays, and amplified costs.7 It is estimated that, annually, the United States spends $400 million to $500 million on preventable CAUTIs.5 Programs have been designed by insurers, such as the CMS Hospital-Acquired Condition (HAC) Reduction Program, to limit the unintended complications that impact a patient during a hospital stay.8 All HAIs are considered HACs, and are undesirable and inconvenient for everyone involved: patient, family, practitioner, facility, insurer, and health care as a whole. Incentive programs help to mitigate the financial impact the insurance companies face with HAIs, as well as incentivize hospitals to improve their quality of care and reduce the frequency of HAIs.2
BACKGROUND
The populations cared for by this large urban teaching hospital are approximately 70% Medicare and Medicaid or CMS insured, and 30% commercially insured. To benefit from the CMS HAC Reduction Program, HAI reduction needed to be prioritized. Multiple interdepartmental teams were developed to collaborate and target CLABSI, CAUTI, CDI, SSI, and MRSA. All teams noted a reduction of infections, but the CAUTI team continued to struggle.
HOSPITAL-WIDE CAUTI TEAM
CAUTI rates continued to remain above target, leading to a reenergized creation of a hospital-wide CAUTI team. The CAUTI team consisted of a registered nurse Lean coach, a bedside nurse from each inpatient area, an education specialist nurse, a nurse manager, an infection prevention nurse specialist, and a physician champion.
The Lean coach, trained to incorporate Lean methodology, guided the CAUTI team through identification of current practice, what optimal care delivery should look like, and barriers associated with achieving the desired outcomes. The Lean coach helped team members focus on current practice, observe current conditions, reflect on the results, and develop countermeasures for process improvement.
Each bedside nurse on the CAUTI team was identified as their unit's CAUTI champion. The CAUTI champion's role was to be the “go to” person on their unit to answer any questions concerning CAUTIs, indwelling urinary catheters, external urinary management devices, or any other educational needs on the topic. The CAUTI champions were also responsible for doing a root cause analysis on any CAUTI that occurred on their unit, and were asked to involve many of the staff nurses that cared for the patient in the process. Once the root cause analysis was completed, the findings were discussed by the CAUTI champion in the morning huddle with their peers. If appropriate, recommendations were highlighted on ways that the CAUTI may have been avoided. Additionally, CAUTI champions committed to evaluating each indwelling urinary catheter on their unit 2 times a month for necessity, care, and documentation. Real-time peer-to-peer education was performed based on their findings.
The role of the nurse manager on the CAUTI team was to remove barriers and help facilitate process changes. The education specialists gave input on best practice guidelines and policy and procedure currently in place at the hospital. The CAUTI physician champion contributed the physician perspective to the team and was able to hold the medical staff accountable to the CAUTI reduction efforts.
The infection prevention nurse specialist looked at CAUTIs from an epidemiology viewpoint, which differed from the vantage point of the bedside nurse. It is important to understand the epidemiology of CAUTIs from this expert and what constitutes an infection. (See the Supplemental Digital Content Descriptive Case Study, available at: https://links.lww.com/CNQ/A12).
Retrospectively, it was noted that having a collaborative team that included bedside nurses cultivated ideas on CAUTI reduction at monthly meetings and was a catalyst in changing the culture at the hospital. Early in the journey, many of the CAUTIs were insertion-related infections that occurred within 2 to 3 days of catheter insertion. The CAUTI team researched best practices, collaborated with bedside nurses, and performed direct observations of indwelling urinary catheter insertions. The first year the team discovered inconsistencies in insertion practices among nurses by doing direct observations of indwelling urinary catheter insertions. This led the team to invite the representatives of the indwelling urinary catheter manufacturer to attend a team meeting. While examining the indwelling urinary catheter kit, the team realized it was not set up intuitively for nurses to achieve a successful and sterile insertion. This discovery led the team to work with the manufacturer of the indwelling urinary catheter to develop a kit that labeled each step of the process with numbers and positioned the items in the tray from left to right in the order of the correct use for insertion. Over the next year, after education and use of the new insertion kit, the insertion-related CAUTI rates improved; however, CAUTIs continued to remain an area of opportunity for improvement.
The following year, the CAUTI team's research revealed the use of bath basins as a culprit for bacteria colonization. According to Marchaim et al,9 62.2% of the hospital basins used for bathing patients in their study were contaminated with pathogens commonly found in the HAIs. In order to “ban the basin,” the hospital began using prepackaged bathing cloths, meatal care wipes for indwelling urinary catheter care, and incontinence cloths impregnated with dimethicone. Banning the basin and using prepackaged cloths provided a 7% decrease in CAUTIs from the previous year, but the team continued their efforts knowing there was still room for improvement.
NURSE-DRIVEN PROTOCOL
A nurse-driven protocol for the removal of an indwelling urinary catheter had been initiated at the hospital in 2013 and was rolled out by the education specialist nurses. The policy contained a process for nurses to do a daily assessment for medical necessity of the indwelling urinary catheter and to remove the catheter if the patient does not meet the criteria. Reasons to maintain an indwelling urinary catheter were established as gross hematuria, obstruction or neurogenic bladder, specific surgical procedures, open sacral or perineal wound in an incontinent patient, critical intake and output for hemodynamically unstable patients, end-of-life care, immobility due to physical constraints (unstable fracture, intra-aortic balloon pump), or a long-term indwelling urinary catheter.
At the CAUTI team's monthly meetings, rounding occurred on every inpatient nursing unit. During these rounds, peer-to-peer discussions with the nursing staff revealed that a knowledge deficit existed on the nurse-driven protocol for indwelling urinary catheter removal. Some nurses reported reluctance to follow the nurse-driven protocol, stating their hesitancy resulted from a knowledge deficit, potential of physician disapproval, and lack of peer support. Even though nurses had the autonomy to perform the removal of unnecessary indwelling urinary catheters, it was evident the strategy was not hardwired into nursing practice. Since the primary responsibility for performing the care and maintenance of the indwelling urinary catheter is that of the bedside nurse, the CAUTI team pursued further conversations with the nurses regarding lack of implementation of the protocol. The most frequent reason expressed by nurses was the convenience of an indwelling urinary catheter, particularly in women, where no alternative devices were available. One potential alternative approach to urine collection for incontinent patients was the use of a diaper; yet nurses expressed the belief that these had the potential to cause an increase in hospital-acquired pressure injuries.
The CAUTI team reviewed the existing policy against evidence-based practice, found it still to be applicable, and then set about reinvigorating the policy. During the team's monthly rounding, it was noted that once nurses received education on the nurse-driven protocol and understood that the protocol was supported by administration and physicians, they felt empowered to remove indwelling urinary catheters when patients did not meet the criteria to maintain it.
It used to be the norm to hear a patient had a Foley and abnormal to hear that the patient had an external device. Now it's the opposite. It is abnormal if your patient has a Foley. (NICU-RN)
ALTERNATIVES TO INDWELLING URINARY CATHETERS
Condom catheters were available as an alternative to indwelling urinary catheters for male patients; however, there was a lack of an alternative for the female patient. In 2018, the CAUTI team began investigating alternatives to indwelling urinary catheters for females and discovered a female external urinary management device called PrimaFit. The representative from the manufacturer of this device was invited to attend the monthly CAUTI team meeting to educate and demonstrate the device and share its success in CAUTI reduction. The external device was much like a circular, elongated manufactured sanitary pad that was placed between the labia. A wicking material covers the area that makes contact with the patient's skin and the device was connected to continuous suction. Once urine hit the pad, it was suctioned away to a canister that allowed for urine output measurement. The hospital agreed to trial this device on 2 units that were experiencing a high rate of CAUTIs, and had patient populations that would benefit from the use of a female external urinary management device.
The CAUTI team collaborated with the nursing staff from the 2 units, who agreed to a 2-week trial period. The nurses were asked to fill out an evaluation form if they used the device on a patient by answering questions with agree, neutral, or disagree. The evaluation questions were about the ease of application and set up of the device, whether it effectively collected urine without leakage, patient satisfaction if the patient could express an opinion, and the nurse's overall satisfaction with the device. The results from the evaluations indicated that nurses wanted to continue the use of the device. Nurses reported no leakage around the device when it was correctly applied and the patient was not agitated or frequently moving in the bed. Additionally, patients that could give feedback gave the product a high approval rating. One patient during the trial period refused to be transferred to a step-down unit from the intensive care unit unless she could be assured the continued use of the female external urinary management device. Due to the successful trial, the hospital agreed to continue the use of PrimaFit.
STAFF EDUCATION
Educating nurses in a large teaching hospital on any new product or policy can be a challenge. Each morning the dayshift and nightshift staff gathered for a morning huddle a few minutes before shift hand-off report, where they were updated on hospital happenings and any other pertinent information. The manufacturer's representatives and the CAUTI champions took advantage of the morning huddles and used the opportunity to introduce the PrimaFit. Additionally, the team attended staff and physician group meetings, and rounded on all shifts on the nursing units to educate and increase awareness of the female external urinary management device. A CAUTI prevention poster was developed and displayed on every unit to educate staff on CAUTI myths, facts, and prevention (Figure 1). Annual competency days for evaluating nursing and ancillary staff competence and skills occurred a few months after the introduction of PrimaFit. Over the 3-week competency period, the CAUTI team divided into shifts to provide education utilizing the CAUTI poster, the PrimaFit device, and a mannequin for simulation education on proper placement of the female external urinary management device. This effort enabled them to reach a majority of staff and increase awareness of the device and the importance of CAUTI prevention. In 2019, the demand for the product increased from 2019 devices in quarter 1 to 5362 devices in quarter 4, reassuring the team that staff were adopting and using the device (Figure 2). While the hospital was experiencing a decrease in female CAUTIs, the CAUTI rates for the male population remained stagnant (Figure 3).
;)
Figure 1.: Catheter-associated urinary tract infection prevention poster. Source: Allegheny General Hospital. Stages of Biofilm and Root Cause used by permission-CBE, MSU-Bozeman.
Figure 2.: PrimaFit use. Source: Allegheny General Hospital.
Figure 3.: Catheter-associated urinary tract infection rates by gender. Source: Allegheny General Hospital.
NURSING LEADERSHIP
Although there was an increased use of the PrimaFit over the next several months, it was identified that catheter days remained high as approximately 25% of the inpatients continued to utilize indwelling urinary catheters. Each morning, all nursing management met for a “bed huddle,” where a brief overview of the day was reviewed in relation to hospital operations. In November 2018, the team asked the chief nursing officer for time during this meeting to review all indwelling urinary catheters. The chief nurse dedicated time during the Wednesday and Friday morning bed huddles for indwelling urinary catheter necessity review. The manager from each department reported on the number of current indwelling urinary catheter on their units. This report included the rationale for the use of each indwelling urinary catheter and the potential for discontinuation. During this process, the CAUTI team members verbalized suggestions and/or alternatives to keeping the indwelling catheter. It was noted that the consistent practice of reporting out to the group allowed for healthy competition between the nursing units to have less indwelling urinary catheters than their peers, and brought the management team closer to the bedside challenges and successes of indwelling urinary catheter reduction (Figure 4). By December of 2018, there was a 5% decrease in CAUTI rates from the previous year. It was evident progress was being made, nursing culture was changing, and CAUTI reduction efforts needed to continue.
Figure 4.: Indwelling urinary catheters identified for removal in leadership bed huddle. Source: Allegheny General Hospital.
PHYSICIANS
In January 2019, the CAUTI team partnered with the medical director of quality to engage the physicians in the efforts to reduce indwelling urinary catheter days and CAUTIs. For 2 months, twice a week, the Lean coach, a frontline nurse, the medical director of quality, and other members of the quality department rounded on each nursing unit and noted every patient with an indwelling urinary catheter. During rounds, the team spoke to the bedside nurse caring for the patient and provided one-on-one education regarding the importance of removing unnecessary indwelling urinary catheters and using the nurse-driven protocol to prevent CAUTIs. The medical director of quality would then contact the attending doctor to increase physician awareness regarding the team's efforts to reduce catheter days and ultimately CAUTIs. Education provided to the physicians by the medical director of quality was vital to the change in culture and allowed nurses to feel comfortable removing indwelling urinary catheters per the nurse-driven protocol, without the order of a physician.
It is best for our patients to remove Foleys as soon as possible. I really love the PrimaFit™ and so do our patients! (Medical Telemetry-RN)
OUTCOMES
Overall, there was an 11.79% decrease in catheter days (Figure 5) and a 38% reduction in CAUTI rates for the calendar year 2019 (Figure 6). Engaging a nurse from every unit was an essential part of the process for CAUTI reductions. Peer-to-peer education and accountability from both nurses and physicians contributed to the success experienced to date. Staff nurses gained confidence in their knowledge of best practices for CAUTI reduction and felt empowered to question a physician or peer if an indwelling urinary catheter was ordered inappropriately. Every month a point prevalence study was conducted as part of the CAUTI team's meeting to gain an understanding of knowledge gaps and opportunities that existed for continuing the efforts to decrease CAUTI rates and indwelling urinary catheter days.
Figure 5.: Indwelling urinary catheter days. Source: Allegheny General Hospital.
Figure 6.: Catheter-associated urinary tract infection rates. Source: Allegheny General Hospital.
CONCLUSION
HAIs, specifically CAUTIs, threaten patient safety and cause unnecessary stress and burden on the patients, caregivers, hospital systems, and insurers. Because CAUTIs place a financial burden on health care organizations by nonreimbursed funds and extended hospital stays, finding ways to reduce the incidence of this HAI is paramount.6 The large urban teaching hospital featured in this article chose to focus on CAUTI reduction through the use of engaging frontline nurses to participate on the CAUTI team. These nurses along with the other disciplines involved took ownership of the effort and worked toward goals to decrease CAUTI rates and indwelling urinary catheter days. The keys to success included the involvement of bedside nurses, physicians, and the hospital's leadership team. Successful education focused on assessment for indwelling urinary catheter necessity, the nurse-driven protocol for removal, and the use of the female external urinary management device. To date, the best available evidence in reducing CAUTIs was to remove the catheter as soon as medically possible and to avoid unnecessary use of indwelling urinary catheters altogether.4 (Please see the Supplemental Digital Content Descriptive Case Study, available at: https://links.lww.com/CNQ/A12).10,11
