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Changing practice, saving lives

John, Sherley, BSN, RN, CCRN; Jacob, Merin Thomas, MS, RN, ANP-C, CCRN; Meskill, Katie, BSN, RN; Moolsankar, Kishun, BSN, RN, CCRN; Altman, Marian, PhD, RN, CCRN-K, CNS-BC

doi: 10.1097/01.NUMA.0000547258.15086.30
Feature: Safety solutions: Infection control

Reduction of CAUTIs in the neurosurgical ICU

Read how one unit launched its “TakeCAUTIon” change project to achieve a sustained decrease in catheter-associated urinary tract infections as part of the American Association of Critical-Care Nurses Clinical Scene Investigator Academy.

At North Shore University Hospital in Manhasset, N.Y., Sherley John, Merin Thomas Jacob, and Katie Meskill are neurosurgical ICU clinical nurses and Kishun Moolsankar is a nurse manager. Marian Altman is a clinical practice specialist for the American Association of Critical-Care Nurses in Aliso Viejo, Calif., and a Nursing Management editorial board member.

The authors have disclosed no financial relationships related to this article.

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Change is the only constant. Those of us working in healthcare can attest that this statement remains true today. There are new patient safety and quality initiatives, a move toward digitization, and cutting-edge equipment. Due to rising healthcare costs, consumers, payors, and regulators are seeking innovative methods to meet a variety of regulatory and consumer demands, maintaining financial viability in a highly volatile market. However, there's much resistance to change; 70% of all change efforts fail. Threats to successful and long-term change include change fatigue, lack of support, lack of buy-in, and victory being declared too early.

Initiating and creating lasting change is difficult and complicated, requiring dedication to an intentional process. One method to ensure a successful change outcome is to utilize a change management tool. Leadership and change management expert John Kotter developed eight steps for leading organization change.1 Used successfully to lead change in healthcare, Kotter's change management model focuses on leading change rather than managing it. (See Table 1.)

Table 1

Table 1

In response to the 2012 Future of Nursing report and out of a desire to help clinical nurses develop leadership skills, the American Association of Critical-Care Nurses (AACN) created the Clinical Scene Investigator (CSI) Academy. The AACN's CSI Academy is a 16-month, hospital-based leadership and innovation training program designed to empower bedside nurses as clinician leaders and change agents whose quality science initiatives measurably improve patient and fiscal outcomes. The CSI Academy empowers clinical nurses with the knowledge and support necessary to become leaders who guide their peers in creating unit-based change that's easily scaled hospital-wide.

North Shore University Hospital's (NSUH) neurosurgical ICU (NSCU) participated in the CSI Academy and applied Kotter's change management model to their “Take CAUTIon” change project.

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“Take CAUTIon” action plan

Create a sense of urgency. The NSCU is a 160-bed ICU specializing in the care of patients with subarachnoid hemorrhage, traumatic brain injury, intracerebral hemorrhage, complicated stroke, spine surgery, and other neurologic disorders. This patient population is especially vulnerable to catheter-related infection secondary to cognitive impairment, neurogenic bladder, and prolonged length of stay. Analysis of the unit's clinical data showed an increase in catheter-associated urinary tract infection (CAUTI) rates, with the NSCU's rate being the highest at the hospital. In 2013 alone, there were 18 CAUTIs and the infection rate was 6.45%.

NSUH was selected as one of only seven hospitals in the New York cohort to participate in the AACN's CSI Academy. Due to the high CAUTI rate, the team decided to focus on this problem. The purpose of the CSI project was to decrease CAUTI incidence on the NSCU by 25%, increase compliance with catheter care, and prevent reinsertion of indwelling urinary catheters (IUCs).

Form a guiding coalition. The CSI team created a guiding coalition by identifying and collaborating with healthcare team members who were essential stakeholders for CAUTI reduction: hospital administration, nursing management, licensed independent practitioners, RNs, and patient care associates. The CSI team members further collaborated with the multidisciplinary team to develop an evidence-based CAUTI bundle encompassing insertion and maintenance of IUCs. Another goal was to promote collaboration between nurses and the interdisciplinary team to review catheter necessity during daily patient rounds and facilitate timely IUC removal.

Create and communicate a strategic vision and initiatives. The third step in Kotter's model is to develop a change vision and communicate the vision. The CSI team operationalized this step by creating a slogan and logo to communicate the project within the unit. The slogan for the project was “Take CAUTIon” and the acronym NSCU (Nurses Stopping Catheter Usage) was printed on T-shirts and distributed to unit team members during a week highlighting the project. Activities included educational sessions and skill validation of perineal care, IUC insertion and maintenance, the straight catheterization procedure, and proper bladder scanning technique. Nurses and patient care associates also participated in one-on-one return demonstrations of IUC insertion and maintenance.

In addition to the “Take CAUTIon” slogan, a visual aid was utilized to communicate the project's vision. A CAUTI sunflower was created and strategically placed next to the unit information board to spread awareness about CAUTIs to the team, patients, and visitors. One petal represents one CAUTI free day for the NSCU and the goal is to keep the sunflower blooming.

Enable action and remove barriers. The CSI team served as CAUTI champions for the unit. Volunteer CAUTI champions are identified by the unit manager; they serve as the point person for any CAUTI-related issues and may renew their role yearly. For example, they participate in daily rounds to discuss the need for an IUC; conduct root cause analysis if there's an incidence of CAUTI; update the sunflower visual aid daily; and are responsible for maintaining the CAUTI resource binder, which consolidates current protocols, educational material, evidence-based practices, frequently asked questions, and clinical data.

The CSI team empowered their colleagues to act utilizing several strategies. For example, an anti-IUC cart was designated to provide easy access to supplies needed for IUC maintenance and removal. The cart includes urinals, condom-catheters, urine emptying canisters, cleaning supplies, and incontinence pads. CSI team members also developed an early catheter removal and straight catheterization protocol that was tailored to the unit's patient population to promote early IUC removal.

The CAUTI champions, manager, and physician met to discuss the use of pharmacologic therapy for patients with urinary retention. Initiation of this intervention was based on the neurocritical care attending physician's judgment, with consideration of the patient's clinical status. An evidence-based IUC reinsertion bundle was created for patients who couldn't be treated with pharmacologic therapy due to higher systolic BP requirements.

In addition, the routine practice of ordering and sending a urine culture for a febrile patient underwent a major change. When a patient is febrile, a clean urine sample is sent for analysis and only followed-up with a culture if the urine analysis tests positive.

The CSI team created a series of questions to ensure that an IUC is appropriate for the patient. The NSCU utilizes a “buddy system” that requires an experienced nurse or a CAUTI champion to be present at the bedside during an IUC insertion. The buddy system is reinforced to maintain proper insertion technique and promote accountability. Key stakeholders also determined that an order is required for intermittent catheterization and followed as per the NSCU straight catheterization protocol, as well as for an IUC reinsertion.

Various meetings were held with the CSI team, management, CNO, and the central supply department to coordinate the supply of IUC kits with an attached urimeter. These kits were distributed to the ED and OR to prevent any break in the system as patients move through the hospital. The CSI team identified the need for an additional patient care associate due to increased frequency in changing patients because of the new protocol. The CSI team and the unit manager met with the CNO and were successful in incorporating an additional patient care associate shift (3 p.m. to 11 p.m.) into the budget for the following year.

At the beginning of the project, the NSCU was sharing a bladder scanner among several units. Frequently borrowing the bladder scanner from other units was time-consuming and created a barrier to following the straight catheter protocol. As a result of the project's initial outcomes, a designated bladder scanner was purchased for the unit.

Celebrate. The team celebrated short-term wins. For every 200 CAUTI-free days, nursing administration provided lunch and dinner for day and night staff, respectively. The support from management propels nurses to continue their hard work and dedication to reduce CAUTI rates and create a safe and healthy environment for patients.

Build on change. Structured retrospective chart reviews were conducted for each CAUTI incident to isolate contributing factors. Female patients with a diagnosis of subarachnoid hemorrhage grade II or greater were identified as being at risk. Based on these findings, the straight catheterization policy was revised and bladder scanning frequency for female patients with a subarachnoid hemorrhage grade II or greater was increased. In addition, 16Fr size catheters were replaced with a smaller 14Fr size to detect if there was an association between the catheter size and the number of CAUTI incidents.

The protocol was revised several times based on the results of root cause analyses and trial and error. The first revision was increasing the frequency of bladder scans post IUC removal from every 6 hours to every 4 hours. This change was made to account for factors that increase urinary output, such as the administration of hypertonic saline solution or osmotic agents. Another revision was to the criteria to perform intermittent catheterization. Originally, intermittent catheterization was performed for residual volumes of 500 mL or greater post bladder scan; this was later modified to 300 mL or greater.

Anchoring the change. The CSI team took several actions to anchor and sustain the change. Yearly education with a return demonstration is conducted by the CAUTI champions. Education about evidence-based practices recommended by the CDC is incorporated into monthly staff meetings, daily rounds, and journal club sessions.2 Staff members wear their NSCU T-shirts every Friday and the CAUTI sunflower is still utilized as a visual aid to represent progress toward the goal of eliminating CAUTIs on the NSCU. New nurses are mentored to advocate for their patients and the practice is reinforced by their preceptors. CAUTI champions take on an active role in assessing the need for an IUC during daily multidisciplinary rounds and continue to focus on early IUC removal. Reassessing the need for an external device has become second nature for the NSCU nurses. The team continues to sustain project success by encouraging and empowering frontline staff.

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Project outcomes

We surpassed our initial goal of reducing CAUTIs by 25%. By the conclusion of the CSI project (2013 to 2014), we noted a 33.3% CAUTI reduction: 12 infections compared with 18 infections from the previous range of dates. (See Figure 1.) We also noted a 31% reduction in device days: 2,040 days compared with 2,937 days. (See Figure 2.) Looking back at the last 5 years, to date there's been a 94% reduction in CAUTIs and a 92% reduction in device days on our unit (2013 to 2018).

Figure 1

Figure 1

Figure 2

Figure 2

In addition, over the years we noted that enhanced staff awareness regarding CAUTI led to increased awareness about all hospital-acquired infections (HAIs) and prevention strategies with positive outcomes. Factors that contributed to our success include greater focus on hand hygiene, universal precautions, improved compliance with alcohol impregnated disinfectant caps on all needleless I.V. ports, and the use of proton pump inhibitor alternatives for Clostridium difficile prevention.

The NSCU CAUTI champions initially presented their best practices at the organization's CAUTI Carnival. The success of the NSCU CAUTI reduction project led to a hospital-wide implementation of our urine culture collection practice, bladder scan, and intermittent catheterization protocols.

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Sustainable and positive

As a result of their participation in the AACN's CSI Academy and through the application of Kotter's change management model, the NSCU nurses at NSUH embraced the change agent role and were able to positively impact patient and fiscal outcomes through a sustained decrease in CAUTI rates. Nursing care can be transformed at the bedside by conducting routine competencies and engaging in sustainable measures for staff buy-in and support from leadership and nursing management.

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REFERENCES

1. Kotter J. Leading Change: An Action Plan from the World's Foremost Expert on Business Leadership. Boston, MA: Harvard University Press; 2012.
2. Centers for Disease Control and Prevention. Guideline for prevention of catheter-associated urinary tract infections (2009). http://www.cdc.gov/infectioncontrol/guidelines/cauti/background.html.
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