Approximately 15% to 25% of hospitalized patients receive urinary catheters (UCs), and nearly one-half million of those patients develop a catheter-associated urinary tract infection (CAUTI).1 The greatest risk factor for a CAUTI is prolonged UC use; each day the catheter remains in place, the CAUTI risk increases by 3% to 7%.1 Nurse-driven UC removal protocols are widely used and critically important for CAUTI prevention.2–4 However, early catheter removal is not indicated for all patients.
The extended use of an indwelling UC is often required for patients with acute urinary retention and complex patient conditions, such as an enlarged prostate gland in men. Catheter insertion for these patients is often difficult,5 increasing the risk of infection and iatrogenic urethral injury if the technique is ineffective.6 Although physicians routinely order UC insertions, they seldom indicate specific UC size, type, or alternative techniques. Moreover, standard UC kits available to nurses are typically inappropriate for these patients. With unsuccessful attempts, urology consults are required, which further delay the patient's relief from bladder distention and add to care costs.5 Consequently, to prevent infection, urethral injury, and distress, it is critical that nurses acquire the knowledge and skills for managing difficult urinary catheterizations (DUCs).
System-wide nursing education, though an important intervention for improving UC management among complex patients, is not in itself strong enough to reduce the risk of iatrogenic complications and infection for this population. Subsequently, to ensure that only trained, dedicated personnel safely insert UCs in patients with complex conditions, a multipronged approach is required. In 2012, an interdisciplinary team of nurses and physicians at an academic medical center led by an experienced clinical nurse specialist (CNS) developed the comprehensive DUC Program with the goal of preventing morbidities associated with UC placement among complex patients. The purpose of this study was to evaluate the effectiveness of the CNS-led DUC Program over a 4-year time period (2013-2017) in reducing patient CAUTIs and urology consults for difficult catheterization.
DIFFICULT URINARY CATHETERIZATION
Insertion of UCs in complex patients by inexperienced nurses can lead to avoidable iatrogenic urethral injury and infection.6 Men may be more difficult than women to catheterize because of the length of the urethral anatomy, enlargement of the prostate gland, or other potentially obstructive conditions in the lower urinary tract such as fistulas, false passages, and strictures.7–10 Villanueva and Hemstreet10 defined DUC as a patient history consistent with previous difficulty with urinary catheterization, failure to insert a standard UC following 2 or more unsuccessful attempts, or visual blood at the urinary meatus.
Inserting a UC into a male patient with blood at the urethral meatus, forcing the UC past the resistance point, and prematurely inflating the balloon may cause injuries ranging from mucosal tears to more serious false passages (perforations).5,10 Repeated unsuccessful attempts increase the patient's anxiety and pain, and injury to the urethra may predispose the patient to infection and increased costs related to increased length of stay, additional procedures or interventions, and permanent damage to the urethra.6,10 In addition to increased patient discomfort and increased mortality, the cost of surgical repair for iatrogenic urethral trauma adds thousands of dollars to the overall hospital stay.6,11 Iatrogenic urethral injuries and subsequent complications are believed to be preventable when well-trained care providers insert UCs.12,13
An interdisciplinary clinical team was formed in October 2012 at the University of Tennessee Medical Center (UTMC) to reduce patient CAUTIs for complex patients. This team was part of a larger clinical initiative to reduce patient CAUTIs at UTMC, a fully accredited and Magnet-designated 640-bed level I trauma center. From May 1, 2011, to April 30, 2012, there were 169 CAUTIs.
The team included urologists, CNSs, and the nurse executive. Issues associated with complex patients included failed UC insertion attempts by nurses observed by unit-based CNSs, incidences of prebladder UC balloon inflation, and frequent urological consults for difficult catheterizations. From May 1, 2011, to April 30, 2012, 13 patients were consulted by urology for a total of 40 visits.
The group concluded that in general, nurses lack specialized knowledge and skills to safely insert UCs in complex clinical situations. Staff nurses had little academic training or experience in coudé catheter insertion (bent tip) or suprapubic catheter exchange. The DUC team concept, operationalized as 24/7 access to expert nurses with specialized skills in DUC, was selected because of its success in preventing CAUTI and patient injury.14 The program included the DUC insertion protocol, DUC education course, and DUC RN insertion team.
DUC insertion protocol
The DUC protocol for catheter insertion, based on published DUC decision-making algorithms5,10 and modified for the nursing scope of practice, was developed by the DUC interprofessional team (see Supplemental Digital Content Figure, available at: http://links.lww.com/JNCQ/A683). It was approved by the UTMC Nursing Practice Council and in 2012, was incorporated in the UTMC indwelling UC policy.
The protocol begins with an assessment of patients by the staff nurses for the level of difficulty with catheterization. A DUC consult is ordered for patients with (a) previous documented patient history of DUC placement, (b) radical prostatectomy or prostate surgery, (c) urethral stenosis/stricture, (d) pelvic radiation, (e) difficulty visualizing the urethral orifice (female), (f) meatal stenosis (male) and hyper/hypospadias (male), and (g) urological gynecologic pelvic surgery (female). Female patients with a history of urological/gynecologic/pelvic surgery are referred to urology. For all other patients, catheterization is attempted by the nurse. Unless the patient has lidocaine allergies, 10 mL of 2% lidocaine jelly is instilled in the male urethra at least 2 to 5 minutes prior to attempting UC insertion.
If the nurse meets resistance, visualizes blood from the meatus, or is unsuccessful in catheterization after 2 attempts, the DUC team is consulted. The DUC nurse inserts an 18 Fr Coudé tip catheter if the male patient has a history of benign prostatic hyperplasia, or a 12 Fr silicone catheter if the male patient has a history of urethral stricture. Staff nurses provide assistance with proper positioning and lighting female DUC insertions. If catheterization is still unsuccessful after 1 attempt with each type of catheter, a urology consult is initiated.
In addition to the DUC protocol, the interdisciplinary team developed a policy and procedure allowing RN DUC team members to reinsert suprapubic catheters, which have been in place for 30 days or more. Prior to the DUC Program, only urologists and trained physicians were permitted to insert suprapubic catheters.
DUC education course
A 2-hour course including didactic and clinical training using high-fidelity simulation was developed by the DUC interdisciplinary team and clinical simulation staff. Practice sessions and mentored experiences with the CNS and urologist were also included. Nursing team leaders with 2 or more years of experience from the 4 clinical settings with the highest volume of UC insertions (3 inpatient units and the emergency department) were invited to participate. Five training sessions were offered during a 3-month period mid-2012. Thirty-four nurses and supervisors averaging 11.3 years of experience (range of 3-32 years) successfully completed DUC training.
Topics on general urological anatomy and pathophysiology as well as case studies and decision-making scenarios were presented by nursing and physician experts during interactive classroom presentations. Simulation provided multiple opportunities to advance psychomotor skills in UC insertion, suprapubic catheter exchange, and troubleshooting 3-way catheters for continuous irrigation.15 High-fidelity manikins and realistic urological models were used for practice and validation. Live models were also available for practice with patient positioning during each skill session. Coaching and guided debriefing concluded each simulation session. Finally, observational opportunities with physician DUC experts were provided and encouraged. Following completion of all training requirements, participants were presented with a DUC insertion team lapel pin. During the 4-year study period, a total of 94 team leaders and clinically advanced nurses throughout the medical center completed DUC training.
RN DUC insertion team
Information on the DUC Program was disseminated to nurses and providers via electronic Huddle Boards, nursing council meetings, and quality care meetings the week before implementation. In October 2012, the inaugural RN DUC team of 34 nursing team leaders and nursing house supervisors became available for consultation.
Staff nurses called one of the 4 DUC-designated units or nursing supervisor for a patient consult. Arrival time on the patient's unit was expected within 30 minutes of the request.
After each consultation, a billing sheet was sent to the central supply and patient-specific data were entered into the DUC Log since there were no specific DUC data fields in the electronic medical record (EMR). It was not until mid-2017 that a DUC team field was added to the EMR.
A retrospective cohort study design was used to evaluate the effectiveness of the nurse-led DUC Program over a 4-year time period (May 1, 2013, to April 30, 2017) in reducing patient CAUTIs and urology consults for difficult catheterization. All UTMC patients who had a UC placed while hospitalized during the study period were included in the study.
Measures for the RN DUC Team processes include number of consultations and patient descriptors, such as age, male gender, and setting. Measures also included the shift that the consult was made in addition to the length of time for the consultation (start to finish). The type of intervention was measured (UC insertion, suprapubic catheter insertion, intermittent catheterization, or catheter irrigation), as was adherence to the DUC protocol for male patients.
Outcome measures included (1) patient CAUTIs, (2) CAUTI rate for UTMC (CAUTIs per 1000 UC days), and (3) the number of CAUTIs for patients consulted by the RN DUC team. Measures also included RN DUC team UC success rate and number of urology consults (CPT codes 52001, 99203-5, 99213-14, 99222-26, and 99231-33).
Evidence to guide the DUC protocol, education course, and insertion team was retrieved from articles found in published peer-reviewed journals. The primary databases and search engines used for information discovery were the Cumulative Index to Nursing and Allied Health Literature, Index Medicus, ProQuest Nursing and Allied Health Source, and Google Scholar. Search terms included urinary catheterization, difficult urinary catheterization, difficult catheter placement, catheterization team, urinary catheter insertion, urethral trauma, iatrogenic urethral injury, urethral injury, urinary catheter complications, and urinary catheter simulation.
The DUC Program was developed in May 2012. The DUC nurses were trained during July and August, and the RN DUC team was piloted October 2012 to April 2013. During the pilot, the RN DUC team consulted 56 patients with an 82% success rate. The average time spent with patients during consultation was 41 ± 34 minutes (range: 5 minutes to 3 hours and 10 minutes). Improvements based on RN DUC team feedback were implemented, such as the DUC Insertion Team Response bag for each team to decrease the time interval from consult to insertion and reduce the time away from their assigned patient care unit. The formal RN DUC team began May 1, 2013.
Baseline organizational data were obtained from the EMR with the assistance of the performance improvement coordinator and information technology database programmer. Patient-specific data unavailable in the EMR were abstracted from the electronic DUC Log.
Patient CAUTI identification numbers were cross-referenced with RN DUC consult numbers to determine the incidence of CAUTI for RN DUC patients. Urology consult data were obtained from the urology department. Because the department did not record the frequency of consults for catheter insertion, all CPT codes for nonsurgical urology consults were used as a measure.
The lead CNS and principle investigator of this study met regularly with the RN DUC team during the 4-year study period to discuss outcomes and operational issues. The DUC education course was offered twice a year to maintain an optimal number of experts. Institutional review board approval was obtained in October 2017.
Descriptive statistics were used to analyze program data. Odds ratio using a 95% confidence interval was calculated for patient CAUTI. Data cleaning was completed for each variable to check for coding errors and inconsistent or missing data. Patients with missing procedural data were excluded in outcome analyses.
During the 4-year study period, 19 816 indwelling UCs were inserted for patients situated in inpatient, emergency department, and same-day surgical settings. During the same timeline, the RN DUC team received 465 patient consultations; completed outcome data were available for 435 patient consultations (Table).
DUC Program Description (N = 435)
|Difficult urinary catheterization team
|7 am to 7 pm shifta
|Consultation time, M (SD), min
||33 ± 30
|Urinary catheter insertion
|Suprapubic catheter exchange
an = 394 (surgery setting was excluded from analysis).
bn = 242 (all male patients consulted for indwelling urinary catheter insertion).
The patient mean age was 67 ± 17 years (range: 16-102 years) and 58.9% (n = 256) of the patients were men. Most patients were consulted in the acute care setting (73.1%), and more than two-thirds of the inpatient and ED consultations (69.3%) were initiated on the day shift. The most frequent RN DUC intervention was UC insertion (91%) with an average consult time of 30 minutes (range: 4.5-5 minutes). The DUC protocol was followed two-thirds of the time.
Over the 4-year implementation period, there was a significant decrease in documented patient CAUTIs for the medical center. Baseline number of CAUTIs was 169 versus 24 reported in study year 4 (odds ratio: 0.1889, 95% confidence interval = 0.1231-0.2898, P < .001) (Figure 1). Likewise, the CAUTI rate per 1000 catheter days declined post-DUC Program implementation; at baseline, the rate was 4.13 and at year 4, it was 0.78. In addition, only 2 of the 395 patients (0.46%) who received an indwelling catheter by the RN DUC team were reported to have a CAUTI.
Ninety-two percent of the patients (92%, n = 399) consulted by the RN DUC team had a successful outcome and did not need further intervention. Urology consults decreased almost 50% from baseline (N = 40) to postimplementation year 3 (N = 21). However, in year 4, there was nearly a 3-fold increase in URO consults (N = 57) from the previous year (Figure 2).
Patient age and percentage of male patients (58.9%) in the DUC Program were consistent with findings from the literature indicating that men may be more difficult to catheterize than women.6 As expected, the RN DUC team received the majority of consultations from the acute care setting (73.1%) where fewer patients are catheterized on admission and during the day shift (69.3%) when most patient procedures are scheduled.
The average RN DUC consultation time (33 ± 30 minutes) decreased by 8 minutes from the pilot (41 ± 34 minutes). This was a welcomed finding since 77.0% (n = 335) of the patients were located on a unit other than that of the DUC nurse. The DUC interdisciplinary team had identified time away from the DUC nurse-assigned patients as a potential unintended consequence of the RN DUC team. Including nursing supervisors in the inaugural training, expanding training to create unit-based DUC nurse experts, and providing ready access to DUC equipment were effective in reducing the DUC nurses' time away from their assigned unit.
As expected, most of the RN DUC consultations were for UC (90.8%). More than 5% (n = 22) of the consultations were for suprapubic catheter exchange. This finding is noteworthy since prior to the DUC Program, all 22 patients would have required a urology consult.
The DUC Protocol was followed only two-thirds of the time. During the 4-year period, performance monitoring focused on CAUTI rates and successful UC insertions with less emphasis on protocol adherence. Recommendations for achieving better adherence include adding the DUC protocol to the EMR with forcing functions and opt-out versus opt-in choices and communicating performance metrics monthly with the RN DUC team.
The number of RN DUC patient consults over the 4-year study period totaled 435. There was a 13.7% increase from year 1 (n = 124) to year 2 (141); however, the number of consults declined in year 3 (n = 95) and again in year 4 (n = 75). The decline in years 3 and 4 may have been due to underutilization of the DUC Log because the year following the study (2018), the DUC consult field was added the EMR and consults increased to 136. Another reason may have been the addition of unit-based DUC RNs who may not have considered inserting a UC in a patient on their unit as a consultation. A third reason is the increase in urology consults that occurred when the department added a residency program.
Catheter-associated urinary tract infection
The significant decline in patient CAUTIs and the organization's CAUTI rate were a result of the aggressive efforts by the medical center, including (1) simultaneous implementation of the DUC protocol and RN insertion team, (2) CAUTI reduction bundle (indwelling UC need assessment, insertion, maintenance, urine specimen collection, and removal guidelines), (3) change in culture allowing DUC nurses to replace suprapubic catheters, and (4) ongoing monitoring and communication. Although a single factor cannot be separated as being responsible, the combined multidisciplinary and multifactorial strategies have resulted in a significant decline (85.8%) in the incidence of CAUTIs at UTMC from 169 the year prior to DUC implementation to 24 in 2017. This important achievement in infection prevention compares similarly to organizations using multimodal strategies, such as system changes, education and training, outcome monitoring, reminders, and culture change.14
Findings suggest that the RN DUC team was essential in the success of the CAUTI reduction bundle, specifically for improving UC insertion technique for complex patients and providing guidance in catheter irrigation to less experienced RNs. Furthermore, their efforts were effective in reducing CAUTIs; only 2 RN DUC patients (0.46%) had a documented CAUTI. This outcome demonstrates the effectiveness of DUC nurses, given the results reported by Saint et al,16 showing a significantly higher UC complication (P < .001) and infection rate (P = .04) for complex patients with longer catheter duration compared with traditional surgical patients with short UC duration.
The RN DUC consultation success rate of 92% resulted in 399 fewer urology consults for the 4-year study period. This finding markedly exceeded the 64.7% skilled catheter nursing team success rate reported by Dave et al17 and approached the 95% insertion rate by trained DUC hospital technicians reported by Villanueva and Hemstreet.10
The number of urology consults was on a steady decline during years 1 (54) through 3 (28), though soared up to 80 in year 4. The likely reason for the spike in urology consults for year 4 was the addition of a urology residency in 2017, increasing the number of urologists by 50%. Important to note, though there was a dramatic increase in urology consults in year 4, the percentage of consults for urethral repair (CPT 52001) remained steady at 25%, which is lower than the 32.8% rate reported by Villanueva and Hemstreet.10 This finding suggests that the rise in urology consults was likely for catheter placement rather than for complications related to failed UC attempts or improper technique by nursing staff. It also, together with the significantly lower CAUTI rate, supports achievement of DUC Program goal in preventing morbidities associated with UC placement among complex patients.
As attention continues to focus on improving quality of care and maximizing patient safety, both governing agencies and commercial payers are seeking to link reimbursement to pay-for-performance and measurement outcomes.18 Nurse-led interventions by CNSs, which improve patient outcomes and reduce health care costs, such as the RN DUC team, enhance an organization's quality and contribute to a favorable revenue stream.19
A single episode of CAUTI may increase the length of stay by one-half to one full additional day,18 resulting in a bed cost of $1880 per day.20 The average cost for a cystoscopy with irrigation, evacuation of multiple obstructing clots, and urethral repair at UTMC is approximately $6000 and treatment costs range from $700 to $2700, depending upon the type and length of antibiotic therapy and/or development of bacteremia.6,10,21
Although difficult to establish a direct measurement, it is generally thought that the DUC Program has contributed indirectly with cost saving for the organization through the 81.3% reduction in CAUTIs incidence and the noteworthy 2 recorded CAUTIs among the 395 patients (.046%) consulted by the RN DUC team for UC insertion. It is also probable that the DUC team has contributed to reducing patient harm/discomfort, the additional cost of repairing iatrogenic urethral injuries, and the additional length of stay as evidenced by the 92% insertion success rate. And despite the 2-hour training cost for each of the 94 RN DUC team members, no additional staffing costs are incurred, as consultations are answered during previously scheduled work assignments and/or unit-based patient care assignments.
In addition to cost saving, the nurse-led DUC Program has provided value to the organization through better patient and physician satisfaction. A male patient, at the start of the DUC Program, declared after receiving 2% lidocaine jelly prior to UC insertion: “where were you when I got my last catheter?” Later in the program, a patient who received an RN DUC consult during his previous admission insisted that “forever more,” only a DUC RN insert his catheter. Physicians also noted the effectiveness of the DUC Program as urology consults are more likely to be for truly difficult patients requiring advanced instrumentation for UC placement.
Finally, the successful DUC Program has provided a platform to mentor new staff nurses in complex nursing practice. It also has provided a tested framework for other CNS-led clinical practice interventions, such as the difficult peripheral intravenous insertions program.
A limitation of the study was the inability to determine the explicit reason for urology consults, making it difficult to understand the impact of the DUC Program on preventing urethral injury. The urology consultation data supplied by the urology department were derived from a computer system, which was different from the medical center, challenging alignment of coding systems. However, evidence from a similar study suggests that the combined use of education, DUC algorithm, and skilled catheter nursing team is effective in reducing the frequency of catheter-associated trauma.17 Another limitation was the use of an electronic DUC Log, which was separate from the EMR. The DUC nurses voluntarily entered data in the log and may have underreported consultation information. In 2017, an RN DUC consult field was added to the EMR for ongoing program monitoring and evaluation.
The ability to safely and efficiently insert an indwelling UC impacts patients, staff, and administration. Nurse-led DUC teams improve patient safety and satisfaction and decrease complications, which financially benefits the organization and overall health care system. Urologists benefit from fewer consultations for DUC placement and the resulting additional time for scheduled procedures and office/clinic responsibilities. Staff nurses benefit by having ready access to experts for DUC insertions and the opportunity to learn advanced nursing care. Because of these benefits, CNSs and other nurse leaders should consider translating the findings of this study to other nursing-based cognitive and skill-dependent procedures and adopt DUC Program components to increase value-added practice resources in their organization.
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