Evidence-Based
Practice Change
Laura
Roberson
Grand
Canyon University: NUR 699
Dr.
Hampton
September
25, 2016
Abstract
This paper reports
evidence found through a thorough evidence-based literature search and review. Reason was found to implement a nurse driven practice
improvement project to reduce catheter associated urinary tract infection
(CAUTI). Using The Iowa Model of
Evidence-Based Practice to Promote Quality Care (Titler et al. 2001), the
problem of CAUTI was identified as a priority for the organization and an
implementation plan was executed. A
daily urinary catheter reminder sheet was developed using an instrument found
to be reliable for criteria for catheter insertion and removal that had
previously been used in similar projects.
Because institutions initiating nurse driven daily reminders
consistently reduced rate and incidence of CAUTI, the same method is used in
this project (Lo et al. 2014).
Keywords:
urinary catheter, criteria, reminder, and nurse driven
Evidence-Based
Practice Change
Organizational
Culture
After conducting an evaluation of the Organizational
Culture and Readiness for System- Wide Integration of Evidence Based Practice
(EBP) at UF Health Shands, the level of readiness was assessed to be 3.45 out
of 5. Levels of readiness range from 1 being no readiness at all to 5 being
very much readiness (Melnyk & Fineout-Overholt, 2011). A level of 3.45 correlates to somewhere
between somewhat and moderately ready to integrate system-wide integration of
EBP (Melnyk & Fineout-Overholt, 2011).
Organizational
Readiness Level
Although most nurses at this institution can adequately
describe what evidence-based practice is, barriers to readiness include the
lack of a critical mass of nurses that have a strong knowledge of evidenced-based
practice research techniques, as well as knowledge of access to databases. Although access is available to evidence-based
search engines, nurses at this institution at the unit level are not taught the
techniques to conduct literature searches.
The extent to which librarians are used to help with evidence based
practice questions was the lowest marker of readiness. All unit level nurses who were queried were
either unaware that librarians on site were available or thought that the
library on site was only for medical and dental students.
Analysis of
project barriers. The technique this project uses to overcome lack of
research techniques is to have a librarian and a clinical nurse specialist
create a one hour training module consisting of: PICOT question basics,
conducting a literature search, and explaining the steps of The Iowa Model. This tutorial will be made available for self-assignment
in our hospital’s myTraining education platform. The
core team and all nurses on the unit will be required to complete training
before initiation of a practice improvement
project.
Project facilitators. Strengths lie
within the project facilitators at this organization. There is a very high level of knowledge and commitment
at the administrative level to evidence-based practice. Four years ago, UF Health Shands required all
administrators to obtain Doctorate level nursing education. In addition, all those in management,
education and Clinical Leadership were required to obtain at least a Master’s
Degree in nursing in order to remain in their positions. This high level of commitment has been
bolstered by the recent addition of several Clinical Nurse Specialists who were
hired specifically to facilitate evidence-based projects at the unit
level. Each unit in this hospital is now
required to conduct yearly evidence-based practice projects and present at the
annual “Safer Gator” nursing research day.
Integrating
clinical inquiry. Teaching nurses at the unit level the basics of forming a
question and searching that question will be a key factor in integrating the
gap between the initiatives of the organization and the way in which those at
the unit level are prepared to implement projects.
Problem Description
Following is a description of the problem of infection
caused by catheters and a practice project meant to improve outcomes by
reducing infection rates. Catheter associated urinary tract infections (CAUTI)
cause up to 40% of all hospital acquired infections (Chen et al., 2014). In the adult critical care setting, up to
eighty-nine percent of patients will have a urinary catheter placed (Edwards et
al., 2009). Multiple authors cite time
left in place as the largest risk factor for CAUTI and early removal as the
biggest priority for reduction of infection (Lo et al., 2014). A protocol that
will prompt nurses to evaluate criteria for keeping catheter in place on a
daily basis and prompt early removal is proposed as a way in which to reduce
infection rate.
Stakeholders
and Change Agents
Patients, hospitals, nurses, and physicians are all
stakeholders in this CAUTI reduction practice project. Patients adversely affected by infection are primary stakeholders
in reducing CAUTI. Hospitals are stakeholders
because beginning in 2008, the Medicare and Medicaid no longer pay for hospital
infections that could have reasonably been prevented (Kawai et al., 2015).
Nurses are stakeholders in the reduction of CAUTI in
their role as patient advocates. In
addition, nurses have a vested interest in seeing that they implement
evidenced-based practice by reducing catheters that serve no patient care
function and finally, nurses are being held to nurse sensitive indicators when
being evaluated for raises. CAUTI is
considered a nurse sensitive indicator because it is a patient outcome that is
directly affected by nursing care (Wilson, 2011). Nurses are also change agents in this
project. Nursing will be the change
agent that ensures that all patients with catheters meet criteria on a daily
basis, which is a practice change and a great responsibility.
The group of doctors under which intensive care patients
are cared for will be both stakeholders and change agents. Physicians have a vested interest in preventing
their patients from acquiring infections after entering the hospital. Physicians may see the added benefit of
reduced length of stay. Historically, catheter dwell time was driven solely by
physicians. Because patient care as it relates to urinary catheters will be
driven based on a protocol and carried out by nursing, these doctors are also
considered change agents for engaging in a practice change.
PICOT
Question
This author developed components of a searchable question
using the PICOT method outlined by Melnyk and Fineout-Overholt (2011). The PICOT question for this problem is: In
adult ICU patients with urinary catheters (P) how does the implementation of an
insertion and discontinuation protocol (I) compared to no protocol (C) affect
catheter associated urinary tract infection rates within twelve months (T)?
Purpose
and Project Objectives
The purpose of this
project is to reduce CAUTI and improve patient health in the adult intensive
care setting by implementing a criteria based protocol for urinary catheter
insertion and removal which will be tracked for reduction over a period of
twelve months.
This project will
set forth a list of physician approved and evidenced-based criteria for
insertion of urinary catheters. In
addition, once these criteria are no longer met, a standing order for removal
will allow nursing staff to remove catheters.
In order to assure that all catheters on a particular unit meet
criteria, a criteria sheet will be filed out by night shift. Catheter criteria sheets will be given to the
charge nurse in the morning who will then report in rounds which patients meet
criteria for continued catheterization and which patients had catheters removed
during the previous twenty four hours. The results of the next twelve months of
CAUTI will be compared to the previous twelve months when no protocol was
used. CAUTI infection rates will be
tracked by: number of cases, rate of infection, percentage of infection, rate
per patient day, and rate per catheter days.
Supportive
Rationale
Lo et al. (2014)
conducted a systematic review of strategies to prevent CAUTI and found that
having a reminder or protocol or standing order to remove catheters earlier
based on a set criteria were shown to reduce CAUTI by fifty three percent. In addition, the Centers for Disease Control
recommend insertion of urinary catheters based on strict criteria and removal
when criteria are not met (Gould, Umscheid, Agarwal, Kuntz, & Pegues,
2010). This finding supports
implementing a protocol for insertion and removal that follows strict criteria
in order to reduce catheter days and urinary tract infections. One of the main ways hospitals were
successful in implementing the protocol for meeting criteria for insertion and
early removal was to have some sort of reminder sheet in place (Bernard,
Hunter, & Moore, 2012). Several
other authors noted reminders as an essential piece to ensure the protocol was
followed. An initial reference list of findings was created (see Appendix A).
Literature Support
The method used to complete an electronic search for an
evidenced-based practice proposal to decrease catheter associated urinary tract
infections was completed using the CINAHL database provided by Grand Canyon
University’s online library. Using the reason why a catheter reduction
initiative might be implemented, this author used the terms, “urinary
catheter,” the Boolean operator “AND,” and the term “reduction.” Further inclusion criteria were English language
articles between the years 2009 and 2016 that were peer reviewed. This initial search resulted in twenty-three
articles of which two were chosen for further research. These articles were by Carter, N. M., Reitmeier,
L. & Goodloe, L. R. (2014) and Quinn (2015) and both suggested CAUTI reduction
is possible with early removal driven by nursing. Keywords
identified : indwelling urinary catheter and duration reduction. (See appendix A and B).
Secondary
and Tertiary Searches
Because length
of time urinary catheters remain in place was a key factor cited in the initial
search of literature, a secondary literature search was conducted using the
phrases, “indwelling urinary catheter,” the Boolean operator “AND,” and the
term, “duration reduction.” Again, inclusion criteria for the search was English
language, peer reviewed articles between the years 2009 and 2016. This resulted in ten excellent articles, of
which two were chosen for their level of evidence and applicability to a nurse
driven evidence-based practice project with proven techniques to reduce CAUTI,
such as reminders of insertion criteria.
Narrowing the search to articles that suggested reminders
of insertion criteria, a tertiary search using the same inclusion criteria but
this time narrowing the search dates to 2013-2016 with the terms “urinary
catheter,” the Boolean operator “AND,” and the term “reminder” with reminder
searched by “all TX” (all text) resulted in 243 articles. Because of the large number of articles
found, the last search took out the all text criteria and narrowed the
inclusion criteria to meta-synthesis articles only. This resulted in 194
articles of which two were chosen as well as one that was also found in the
initial search. Keywords identified: indwelling, urinary catheter, criteria,
reminder, and nurse driven process.
Summarization
of Articles
Author: Bernard,
M. S., Hunter, K. F., & Moore, K. N. (2012). Level of evidence: III. Methodology: Analysis
of several peer reviewed articles that included published studies of
interventions to reduce CAUTI by searching databases and finding 53 abstracts,
9 of which met their criteria for early removal of catheters and CAUTI
reduction. Type of article: Article synopsis.
Purpose of article: To identify primary strategies to reduce CAUTI. Summary of
findings: Two major types of interventions were identified as successful: nurse
led early removal based on criteria and initiatives led by information
technology. Why chosen: Level III
evidence, hospitalized patients, applicability to a nurse led practice
improvement project and meeting the overall objective of reducing CAUTI.
Author: Carter, N. M., Reitmeier, L. & Goodloe, L. R.
(2014). Level of evidence: Level I.
Methodology: Literature search for best practice and cohort study. Type article: Both a literature search and a
cohort study of pre and post intervention over eight quarters after initiation
of a nurse driven protocol. Purpose of
the article: To search the literature for best practices to reduce CAUTI and
then implement that practice on a 28 bed unit. Summary of findings: Data was
collected for 8 quarters pre and post interventions. The nurse driven protocol showed a greater
than 50% decrease in CAUTI. Why chosen: This article was a Level II article
about hospitalized patients in an acute care setting similar to this author’s
population , was applicable to a nurse led practice improvement project, and
met the overall objective of reducing CAUTI.
Author: Chen, Y., Chi, M., Chen, Y., Chan, Y., Chou, S.
& Wang, F. (2013). Level of
evidence: Level I. Methodology: Randomized Control Trial of two intensive care
units. Type article: Randomized controlled trial. Purpose of the article: The purpose of this
article was to describe the way in which a randomized controlled trial of two
intensive care units of adults with catheters in place greater than two days
and on the unit for greater than two days, was able to reduce CAUTI with a
urinary catheter reminder protocol.
Summary of findings: CAUTI was reduced by 48% in the intervention
group. Why chosen: This article was
chosen because it has Level I evidence, met the overall objectives of reducing
CAUTI and agreed with several articles that found a reminder for catheter
appropriateness driven by nursing was an effective strategy.
Author: Elpern, E. H., Killeen, K., Kethcem, A., Wiley,
A., Patel, G., & Lateef, O. (2009). Level of evidence: Level II. Methodology: A single center cohort study
over a period of six months. Type of article: Cohort study analysis. Purpose of
article: The purpose of this article was to describe CAUTI reduction in a
single center over a 6 month period using a nurse driven protocol. Summary of findings: Both CAUTI and duration
of indwelling urinary catheter days were reduced using a nurse driven protocol.
Why Chosen: This article was chosen because it contains Level II evidence,
meets the overall objective of reducing CAUTI, as well as being a nurse drive
protocol.
Author: Lo, E., Nicolle, L. E., Coffin, S. E., Gould, C.,
Maragakis, L. L., Meddings, J., …Yokoe, D. S. (2014). Level of evidence: Level I. Methodology: Meta-analysis. Type of article:
This article is a synthesis of many studies and critically appraised articles
citing evidence on the topic of preventing CAUTI rates in critical care
hospitals. Purpose: The purpose of this
article was to create a synopsis of best practice guidelines to prevent CAUTI
in acute care hospitals. Summary of findings: A summary of findings was created
and this sixteen page synthesis was specifically designed as expert guidance
and includes a urinary catheter reminder sheet for use by nurses in
implementing their own practice project.
This was a collaborate effort from multiple highly respected
sources. Why Chosen: This article was
chosen because it contains Level I evidence and is applicable to this author’s
patient population, as well as being a guide for implementing a nurse driven
practice project.
Author: Quinn, P. (2015).
Level of Evidence: Level II.
Methodology: Single center cohort study.
Type article: Single center cohort study of a nurse driven protocol for
daily surveillance of patients with urinary catheters. Purpose of the article: The purpose of this
article was to describe a long term five and half year study in a single center
that made nursing accountable for urinary catheter surveillance on a daily
basis in order to reduce CAUTI. Summary of findings: Like previous articles,
this center was able to decrease the number of CAUTI in their hospital by
50%. This article supports previous
articles in the ability to apply a nurse driven protocol for considering the
appropriateness of indwelling urinary catheters in their patient population and
removing catheters that no longer meet criteria. Why chosen: This article was
chosen for level of evidence, meeting the primary goal of reducing CAUTI, and
finally, meeting a project goal of reducing CAUTI with a nurse driven practice
project.
Internal and
external validity. All articles
chosen were chosen for their inherent internal validity in terms of how studies
were conducted and which patients were chosen for study. The internal validity for choosing inpatients
with urinary catheters is not a particularly hard population to study, nor is
there much chance for bias. Although
reduction rates of CAUTI were astonishingly high, this author found similar
reduction rates throughout the literature.
Because literature was chosen that is applicable to an in-hospital adult
acute care atmosphere, the external validity is high. In addition, because articles were chosen
that included a component driven by nursing, the external validity is
sufficiently similar to the project this author wishes to pursue.
Description of Solution
The proposed solution to decreasing catheter associated
urinary tract infections (CAUTI) will be to use an insertion and
discontinuation protocol that will be checked daily by night shift Charge
Nurses. Catheters not meeting criteria will be removed. A list of removed catheters as well as those
still meeting criteria will be handed off to the day shift Charge Nurse who
will present those catheters in rounds.
A collaborative conversation between critical care medicine, surgery,
and nursing will be had regarding removed catheters and criteria for remaining
catheters.
The literature supports a nurse guided effort for daily
tracking of catheters and literature has shown that daily tracking reduces
catheter days and decreases CAUTI.
Carter, Reitmeier, and Goodloe (2014) describe interventions that
reduced CAUTI on a 28 bed unit, among which was nursing driving the
determination of catheter necessity following an evidenced-based criteria list.
Elpern, Kileen, Ketchem, Wily, Patel, and Lateef (2009) also found that over a
six month period of nurses judging appropriateness for urinary catheterization,
CAUTI was dramatically reduced. Bernard,
Hunter, and Moore (2012) analyzed several studies related to CAUTI reduction
and found that nurse led intervention was successful. Lo et al. (2014) engaged in a meta-analysis
that showed evidence that using a daily urinary catheter reminder led by
nursing that included a list of evidenced-based criteria reduced CAUTI. Lo et al. (2014) included in their
meta-analysis paper, a catheter reminder sheet that will be used in this
proposed solution.
Organizational
Culture
The
organizational culture of the hospital in which this practice project will be
conducted is highly favorable to evidenced-based practice. The organization is a Magnet hospital, a
teaching hospital, and finally, the Vice President of Nursing made
institutional changes whereby all those in upper management must obtain their
Doctorate degrees in nursing and those in mid-level management must obtain
their Master’s degrees in nursing and complete an evidence-based practice
improvement project yearly.
Potential barriers are the level of training in
evidence-based practice by the bedside registered nurse. Prior to implementation of the practice
improvement project, nurses on the unit will complete an evidence-based
tutorial on the nursing education intranet website. After successful completion, these unit
champions will complete in-services to their specific team cohorts and a go
live date will be decided upon. Because this project relies on a simple daily
check of criteria for catheters, resources required are minimal.
Expected
Outcome
In adult intensive care
patients with urinary catheters, the implementation of a nurse driven insertion
and discontinuation protocol is expected to decrease catheter associated
urinary tract infections over a one year period. In addition, the prevalence of urinary
catheters as well as the catheter days may also see a decrease.
Outcome impact. This quality improvement project aligns
with the culture of the organization as an evidence-based teaching
hospital. Quality should improve as this
patient centered infection reduction initiative is implemented. Efficiency of processes will increase as this
project includes daily, thoughtful decision making regarding urinary catheters
in a systemized way. Previously, the
discussion of urinary catheter criteria was discussed well after lack of
criteria being met was obvious. Making
nursing responsible for this daily talk is an environmental change from
physician driven practice to nurse driven practice and will therefore change
the way in which this group of nurses and physicians view their role in
improving patient care.
Change Model
In order to implement an evidence-based change project,
incorporating a change model can be helpful.
There are several models from which to choose. Examples of change models are The Stetler
Model, The Iowa Model, and The Clinical Scholar Model (Melnyk &
Fineout-Overholt, 2011). This
evidence-based improvement project to reduce Catheter Associated Urinary Tract
Infection (CAUTI) uses The Iowa Model to work through the project. The Iowa Model, “provides guidance for nurses
and other clinicians in making decisions about day-to-day practices that affect
patient outcomes” (Melnyk & Fineout-Overholt, 2011, p 251). Ease of use is a primary advantage to The
Iowa Model with easy to plug in steps and its emphasis on forming teams, asking
critical decision point questions and keeping up momentum by continuous
monitoring of results (Melnyk & Fineout-Overholt, 2011). In addition to ease of use, the institution
in which the practice improvement project will be piloted uses The Iowa Model (see
Appendix D).
Problem
Focused Trigger
The Iowa Model first asks to identify if one’s
project is a problem focused trigger and then moves to a key decision point
that asks if the problem is one of organizational priority. The institution in
which this practice project will be implemented has identified CAUTI as a
problem, so this initiative is a topic of priority for the organization. In addition, the cost of CAUTI as it relates
to extended length of stay, impacts both the hospital and the patient. Benchmarking poorly against other
organizations can also impact hospital reimbursement (Kawai et al., 2015).
Team forming and training. During
week one, a team will be formed comprised of Charge Nurses, nurse
practitioners, a critical medicine attending, a surgical attending, the Clinical
Leader and nurse manager. Organizational culture results, problem description,
literature review and proposed practice change will be reviewed. During weeks two and three team members and
unit nurses will be required to complete a hospital evidence-based practice one
hour training module on the hospital’s intranet training site, myTraining. The
training module will teach the basics of asking a PICOT question, turning that
question into relevant search topics, and how to conduct a literature search
using the databases provided in the hospital library, as well as introduction
to the steps of The Iowa Model.
Pilot
the change. In order to implement the evidence
found, a daily reminder sheet for Charge Nurses will be used. This check list will include all
evidence-based criteria for patients to have a urinary catheter. If catheters do not meet criteria, bedside
nurses will be asked by the Charge Nurse to remove catheters. All catheters removed in the previous
twenty-four hours will be presented by bedside nurses during rounds in order to
keep critical care medicine and surgery physicians informed. Next, core team Charge Nurses will present
the proposed pilot to all unit Charge Nurses.
A check-off sheet stating that all charge nurses have been informed of
the pilot and process will be signed.
This process will happen over weeks four and five in order for all
charge nurses to be captured in the information and teaching period and in
order to ask questions and bring up any practice barriers. The change in practice will then be taught to
all bedside nurses during weeks six and seven.
A “soft” opening of the project will be conducted in week eight. During
this soft opening, charge nurses will conduct a daily criteria check for all
patients with a catheter and then disseminate the results to the group during
rounds. During this time, doctor’s orders
for discontinuing catheters will still be required, with the understanding that
in week nine, all catheters not meeting criteria will be identified by Charge
Nurses, removed by bedside nurses without physician orders, and communicated to
the multi-disciplinary team during rounds.
Go
live. The evidence-based practice improvement project
pilot will go live during week nine. After
initiation of a pilot, The Iowa Model suggests asking questions about the
appropriateness for adoption into practice (Melnyk & Fineout-Overholt,
2011). If the answer to this question is
yes, then the project is able to move on to the monitoring phase. The answer to this question should be
answered by all stakeholders. The
success of this change will be measured over a period of one year using quality
data provided by the Clinical Leader and the institution. Quality measures will be calculated five
ways: number of CAUTI cases, rate of infection, percentage of infection, rate
per patient days and rate per catheter days. In order to continue motivation
and celebrate gains, The Iowa Model requires dissemination of results and a
continual re-evaluation of all questions within the model (Melnyk &
Fineout-Overholt, 2011).
Implementation Methods
A nurse driven
urinary catheter removal protocol that follows criteria outlined on a daily
reminder sheet will be filled out by Charge Nurses on each twelve hour
shift. The Charge Nurse will tell
bedside nurses if catheters do not meet criteria and bedside nurses will remove
those catheters. During morning rounds,
all catheters removed will be communicated to the multi-disciplinary team.
Setting
and Subjects
The setting is an eight bed Intensive Care Unit in a
teaching hospital that operates two twelve hour shifts per day with one Charge
Nurse per shift. Patients will not require consent, as the intervention is an
improvement of standards and eventual removal of urinary catheters after
insertion is something that the patient expects. This intervention simply attempts to remove
catheters once they no longer fit evidence-based criteria. Comparison group data will be recorded using
quality data from the prior twelve months during which no removal criteria
protocol was used. Quality data is
gathered and submitted monthly by Decision Support Services (DSS). Because quality data exists, no retrospective
analysis or consent is needed to quantify the comparison (non-intervention) group.
Time
needed
Nine weeks are needed to implement this protocol with
protocol and data surveillance continuing for a period of twelve months
(Appendix E). After creation of a one
hour evidence-based training module by a Clinical Nurse Educator and a hospital
librarian, a team will be formed. One week will be needed to explain evidence
found for practice change and explain implementation plan to the core team.
Next, the core team, Charge Nurses, and bedside nurses will spend two weeks
completing evidence-based practice training. During weeks four and five, core team Charge
Nurses will train unit Charge Nurses on integrating the protocol reminder
sheets into practice. Next, two weeks
will be used for training of bedside nurses on integrating the protocol
reminder sheets into practice. The
protocol will be integrated into practice for one week as a pilot. This pilot week is to ensure all nurses and
physicians understand the protocol and implementation practice variance is
eliminated. The project will go live week
nine. Stakeholders will decide if project is appropriate for adoption and if
so, project will continue for twelve months.
Resources
Needed
The resources needed (Appendix F)
for this project are a core group of people including four unit Charge Nurses,
two nurse practitioners, one Critical Care Medicine attending, one Surgery
attending, the Clinical Leader and the Nurse Manager. In addition, an education
team will be needed to design a one hour training module. The education team will consist of a Clinical
Nurse Educator and a hospital librarian. The Clinical Leader will design the
catheter reminder sheet and hand off to Publication Services for printing and
lamination. The reminder sheet is an adaptation of that presented in a
meta-analysis by Lo et al. (as cited in Saint, Kaufman, Thompson, Rogers, &
Chenoweth, 2005). An
implementation team will consist of eight unit Charge Nurses and forrty bedside
nurses. Physical resources will require library space, reservation of meeting
rooms, and finally, computers in nursing education for nurses to complete
training modules during weeks two and three.
Methods and instruments. The
daily reminder sheet (Appendix G) will be laminated. There will be one laminated sheet for each of
eight patients. A questionnaire will be
filled out by Charge Nurse on each shift using a wipe-off marker. If patient meets criteria, catheter will
remain in place. If catheter does need
meet criteria, Charge Nurse will give sheet to bedside nurse who will remove
catheter and present this to the day shift multi-disciplinary team. Laminating the reminder sheet will enable
them to be reused.
Delivering the intervention. The
process for delivering the intervention will be education of the core group as
well as the larger staff using a training module. Education will cover how a PICOT question is
formed, how evidence-based literature is found, and review The Iowa Model,
which will overcome knowledge barriers and set the stage for
implementation. In addition to the
training module, the core group of Charge Nurses that helped to form the team
will have two weeks to show staff the reminder sheet and explain how the
process will work in practice. During
the following weeks, the intervention will be piloted using reminder sheets in
the manner earlier described. During
this period, stakeholders will have a chance to discuss barriers,
appropriateness of criteria used in the reminder sheet, and decide if the
project is appropriate for adoption on the unit. If the decision is made that
the reminder sheet is appropriate for adoption, the sheets will be used for a
period of twelve months.
Data collection. Fortunately,
the data being collected is already sent out on a monthly basis by DSS directly
to Clinical Leaders, managers and the physician group. Data is placed on a “unit report card” on the
intranet that is available for review at any time. Unit report card data is contained within an
Excel Spreadsheet that can easily be manipulated into graph and chart form for
dissemination of results. DSS uses standards of infection calculation for rate
and incidence (Appendix H).
Barriers
Lack of
knowledge and buy-in of evidence-based practice is addressed using the training
module. Collaboration barriers are addressed by using a multi-disciplinary team
with all stakeholders represented. Lack
of education and resistance to change at the unit level will be addressed using
the training module, a two week practice change education period on the unit
and a pilot before initiation into practice. All shifts and all nurses are
represented in this practice change. Criteria for catheter removal will be
approved by practitioners, the management team, and the physician group, prior
to creation by the Clinical Leader.
Feasibility
This project has
internal and external validity based on levels of evidence found in the
literature search and its applicability to the patient population in the
unit. A budget of $1,150 is enormously
cost effective (appendix I). Most members
of the core team are salaried, however, Charge Nurses must be compensated for
their time meeting with the group. Four Charge
Nurses at an average hourly rate of 25 dollars for one hour equals 100 dollars.
Both Charge Nurses and bedside nurses must be compensated for their one hour
myTraining module. Forty-four total nurses undergoing one hour of training at
an average hourly rate of 25 dollars will cost 1,100 dollars. Paper and lamination
for the reminder sheets cost 50 dollars.
Maintenance
CAUTI
incidence and rate will be shared monthly, quarterly, and after one year.
Dissemination of results will be the responsibility of the Clinical Leader, who
will post results on the unit quality board. Four quarterly huddles will be
conducted with the core team to ensure that the process is continuing in the
expected manner, that outcomes are leading in the right direction, and that the
practice change is still one that is appropriate for the unit. After twelve months of using reminders
sheets, catheter criteria should be enculturated, at which time, reminder
sheets can be discontinued, but daily discussion of removed catheters will remain
a unit practice.
Conclusion
After a robust
search of the literature and finding that a nurse driven catheter reminder
protocol has decreased CAUTI rates in several other like populations, a
practice change will be initiated in an eight bed intensive care unit for a
period on twelve months. Data will be
compared with the previous twelve months.
This unit hopes to realize the approximate 50% decrease in CAUTI that other like institutions reported.
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K., Kethcem, A., Wiley, A., Patel, G., & Lateef, O. (2009). Reducing use of indwelling urinary catheters and associated
urinary tract infections. American Journal of Critical Care, 18, 535-542.
Lo, E., Nicolle, L. E.,
Coffin, S. E., Gould, C., Maragakis, L. L., Meddings, J., …Yokoe, D. S. (2014). Strategies to prevent catheter-associated
urinary tract infections in acute care hospitals:
2014 update. Infection Control and
Hospital Epidemiology, 35(5), 464-479.
Gould, C. V., Umscheid,
C. A., Agarwal, R. K., Kuntz, G., and Pegues, D. A. (2010). Healthcare
infection control practices advisory committee guideline for prevention of catheter-associated urinary tract
infections. Infection Control and Hospital Epidemiology,
31(4), 319-326.
Kawai, A. T., Calderwood, M. S., Jin, R., Soumerai,
S. B., Vaz, L. E., Goldmann, D., & Lee, G.
M.
(2015). Impact of the Centers for Medicare and Medicaid Services
hospital-acquired
conditions
policy on billing rates for 2 targeted healthcare-associated infections. Infection
Control & Hospital
Epidemiology, 36(8), 871.
Melnyk, B. M. and
Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare: A guide to best practice, 2nd
ed. Philadelphia, PA: Wolters Kluwer, Lippincott,
Williams and Wilkins.
Quinn, P. (2015). Chasing zero: A nurse-driven process for
catheter-associated urinary tract infection
reduction in a community hospital. Nursing Economics, 33(6), 320-325.
Saint, S. Kaufman, S.
R., Thompson, M., Rogers, M. A., Chenoweth, C. E. (2005). A reminder reduces
urinary catheterization in hospitalized patients. Joint Commission Journal on Quality
and Patient Safety, 31(8), 455-462.
Titler, M. G., Kleiber,
C., Rakel, B., Budreau, G. Everett, L. Q., Steelman, V., …Goode, C. (2001). The Iowa model of evidence-based
practice to promote quality care. Critical Care
Nursing Clinics of North America, 13(4), 497-509.
Utah Department of
Health (2016). Calculation of infection
rates. Retrieved: http://health.utah.gov/epi/diseases/HAI/resources/Cal_Inf_Rates.pdf
Wilson, M. (2011).
Addressing the problems of long-term urethral catheterization: part 1. British Journal
Of Nursing, 20(22), 1418-1424.
Appendix
A
Initial
Reference List
Bernard, M. S., Hunter,
K. F., & Moore, K. N. (2012). A
review of strategies to decrease the duration
of indwelling urethral catheters and potentially reduce the incidence of
catheter- associated urinary tract
infections. Urologic Nursing, 32(1), 29-37.
Carter, N. M.,
Reitmeier, L. & Goodloe, L. R. (2014).
An evidence-based approach to the prevention
of catheter-associated urinary tract infections. Urologic
Nursing, 34(5), 238- 245.
Chen, Y., Chi, M.,
Chen, Y., Chan, Y., Chou, S. & Wang, F. (2013). Using a criteria-based reminder to reduce use of indwelling
urinary catheters and decrease urinary tract infections. American
Journal of Critical Care, 22(2), 105-114.
Elpern, E. H., Killeen,
K., Kethcem, A., Wiley, A., Patel, G., & Lateef, O. (2009). Reducing use of indwelling urinary catheters and associated
urinary tract infections. American Journal of Critical Care, 18, 535-542.
Lo, E., Nicolle, L. E.,
Coffin, S. E., Gould, C., Maragakis, L. L., Meddings, J., …Yokoe, D. S. (2014). Strategies to prevent
catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infection Control and Hospital Epidemiology, 35(5), 464-479.
Quinn, P. (2015). Chasing zero: A nurse-driven process for
catheter-associated urinary tract infection
reduction in a community hospital. Nursing Economics, 33(6), 320-325.
Appendix
B
Rapid
Critical Appraisal Checklist
Bernard, M. S., Hunter,
K. F., & Moore, K. N. (2012). A review of strategies to decrease the duration of indwelling urethral catheters
and potentially reduce the incidence of catheter- associated urinary tract infections. Urologic
Nursing, 32(1), 29-37.
Systematic Review of Clinical Intervention Studies
1. Are
the Results of the Review Valid?
A. Are
the studies contained in the review randomized controlled trials? Some yes/some no. This is an analysis of five
studies. Two quasi-experimental, one
prospective, one mixed prospective and retrospective and one includes a
randomized controlled study.
B. Does
the review include a detailed description of the search strategy to find all
relevant studies? Yes
C. Does
the review describe how validity of the individual studies was assessed? Yes
D. Were
the results consistent across studies? Yes
E. Were
individual patient data or aggregate data used in the analysis? Mixed among the
studies.
2. What
Were the Results? All decreased CAUTI
A. How
large is the intervention or treatment effect? 2 studies range from 4.7/100
catheter days to 10.6/100 catheter days. Another reduced CAUTI by 40%.
B. How
precise is the intervention or treatment? All good, except one where frequency
of intervention is not described.
3. Will
the Results Assist Me in Caring for My Patients?
A. Are
my patients similar to the ones included in the review? Yes
B. Is
it feasible to implement the findings in my practice setting? Yes
C. Were
all clinically important outcomes considered, including risks and benefits of
the treatment? Yes
D. What
is my clinical assessment of the patient and are there any contraindications or
circumstances that would inhibit me from implementing the treatment? No
E. What
are my patient’s and his or her family’s preferences and values about the
treatment that is under consideration? Patients prefer not to be catheterized
and prefer earlier removal except for a select group that has large BMI or
immobility.
Carter, N. M., Retmeier, L. and goodlow, L. R.
(2014). An evidence-based approach to
the
prevention
of urinary tract infections. Urologic Nursing, 34(5), p 238-245.
Rapid
Critical Appraisal Checklist for Cohort Studies
1.
Are the Results of the Study Valid?
a. Was there a representative and well-defined sample of
patients at a similar point in the course of the disease? Yes. Data was collected on all patients with
urinary catheters for 4 years.
b.Was follow-up sufficiently long and complete? n/a No
follow-up needed
c.Were objective and unbiased outcome criteria used? Yes
d.Did the analysis adjust for important prognostic risk
factors and confounding variables? Yes
2.
What Are the Results?
a.
What is the magnitude of the relationship between predictors (ie, prognostic
indicators) and targeted
outcomes? Rate of CAUTI was proven to decrease by well over 50%. Pre and
post intervention over 8 quarters were looked at.
b.
How likely is the outcome event(s) in a specified period of time? Although the reduction rate of 40 to 50% seem large, the
reduction rates cited tend to be consistent over
multiple nurse driven early removal protocols.
c.
How precise are the study estimates?
3. Will
the Results Help Me in Caring for My Patients?
a.
Were the study patients similar to my own? Yes, this was implemented in an
acute care setting at an
Academic Health Science center and included patients from the ED and ICU.
b.
Will the results lead directly to selecting or avoiding therapy? Selecting
c.
Are the results useful for reassuring or counseling? Communicating reassurance
of early removal to patients
undergoing catheterization.
Chen, Y., Chi, M.,
Chen, Y., Chan, Y., Chou, S. & Wang, F. (2013). Using a criteria-based reminder to reduce use of indwelling
urinary catheters and decrease urinary tract infections. American
Journal of Critical Care, 22(2), 105-114.
Rapid
Critical Appraisal Checklist for Randomized Clinical Trials
1. Are the Results of the Study Valid?
A.
Were
the subjects randomly assigned to the experimental and control groups? Yes
B.
Was
random assignment concealed from the individuals who were first enrolling
subjects into the study? Yes. There was randomization. Out of 509 patients, 278 were included.
Intervention group included 147 patients and the control group included 131
patients.
C.
Were
the subjects and providers blind to the study group? Yes.
D.
Were
reasons given to explain why subjects did not complete the study? Yes. All patients were considered eligible who had
a urinary catheter. Patients were thrown
out if exclusion criteria occurred including a) having catheter removed prior
to day two (NHSN criteria would not report a CAUTI even if infection occurred
if catheter was not in place for > 24 at infection onset) and b) leaving the
study unit prior to 2 day length of stay (for same reasons).
E.
Were
the follow-up assessments conducted long enough to fully study the effects of
the intervention? Yes
F.
Were
the subjects analyzed in the group to which they were randomly assigned? Yes
G.
Was
the control group appropriate? Yes. The
control group did not vary from the intervention group other than lack of
protocol use.
H.
Were
the instruments used to measure outcomes valid and reliable? Yes. IBM SPSS
Statistics 17 Software.
I.
Were
the subjects in each of the groups similar on demographic and baseline clinical
variables? Yes. Both control and intervention groups had similar N as related
to sex, main diagnosis, underlying illness, use of antibiotics etc. These demographics and clinical characteristics
of control and intervention group are outlined thoroughly on p 110 of the
journal article.
2.
What are the Results?
A. How large is the intervention or treatment effect (NNT,
NNH, effect size, level of significance?) 278 patients. Utilization stats (95%
CI, 0.76-0.80; P< .001) Median duration of catheterization was reduced by 4
days (P< .001). CAUTI incidence reduced by 48% (95% CI, 0.32-0.86); P=
.009).
B. How precise is the intervention or treatment (CI)? 95%
3.
Will the Results Help Me in Caring for My Patients?
A. Were all
clinically important outcomes measured? Yes
B. What are the risks and benefits of the treatment? None
C. Is the treatment feasible in my clinical setting? Yes
D. What are my patients/family’s values and expectations
for the outcome that is trying to be prevented and the treatment itself? Patients prefer
not to be catheterized and prefer earlier removal except for a select group
that has large BMI or immobility.
Elpern, E. H., Killeen,
K., Kethcem, A., Wiley, A., Patel, G., & Lateef, O. (2009). Reducing use of indwelling urinary catheters and associated
urinary tract infections. American Journal of Critical Care, 18, 535-542.
Rapid
Critical Appraisal Checklist for Cohort Studies
1.
Are the Results of the Study Valid?
a. Was there a
representative and well-defined sample of patients at a similar point in the
course of the disease? Yes. Medical ICU, all patients with a urinary
catheter. Inclusion and exclusion
criteria explained. 337 patients with 1432 catheter days.
b.Was follow-up sufficiently long and complete? Yes, 6
months.
c.Were objective and unbiased outcome criteria used? Yes.
d.Did the analysis adjust for important prognostic risk
factors and confounding variables? Yes
2. What Are the Results?
a.
What is the magnitude of the relationship between predictors (ie, prognostic
indicators) and targeted
outcomes? 456 device days did not meet criteria (32%). Pre-intervention catheter day mean was 311.7 days. Post intervention catheter days were 238.7.
CAUTI rate 4.7/1000 catheter days pre
and 0/1000 catheter days post intervention.
b.
How likely is the outcome event(s) in a specified period of time? Somewhat
likely. Practice
change proposal is over a period of 12 months.
This study reduced CAUTI to zero
in just 6 months.
c.
How precise are the study estimates? Excellent. Study met criteria for IRB and
NHSN standards for measurement
were used.
3. Will
the Results Help Me in Caring for My Patients?
a.
Were the study patients similar to my own? 613 bed hospital, non-profit
academic medical center and
Medical ICU patients are very similar to my patient population.
b.
Will the results lead directly to selecting or avoiding therapy? Yes. Selecting
intervention.
c.
Are the results useful for reassuring or counseling ? Communicating reassurance
of early removal to patients
undergoing catheterization.
Lo, E., Nicolle, L. E.,
Coffin, S. E., Gould, C., Maragakis, L. L., Meddings, J., …Yokoe, D. S. (2014). Strategies to prevent
catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infection Control and Hospital Epidemiology, 35(5), 464-479.
Rapid
Critical Appraisal Checklist for Evidence-based Clinical Practice Guidelines
Credibility
(1)
Who
were the guideline developers? A panel of experts including the Society for
healthcare Epidemiology of America, the Infectious Diseases Society of America,
the American Hospital Association, the Association for Professionals in
Infection Control and Epidemiology, and The Joint Commission.
(2)
Were
the developers representative of key stakeholders in this specialty
(interdisciplinary)? Yes
(3)
Who
funded the guideline development? Those listed in question 1 were all sponsors.
(4)
Were
any of the guidelines developers funded researchers of the reviewed studies? No
(5)
Did
the team have a valid development strategy? Yes. The synopsis of best practice
guidelines was developed using Level I evidence.
(6)
Was
an explicit (how decisions were made), sensible and impartial process used to
identify, select and combine evidence? The decisions made were explicit and
included rationale, statements of concern, published guidelines informing
decision making, performance measure, efficacy of existing prevention programs,
etc. Grading of quality of all evidence
was included. Section 5, page 471
included methods for calculating performance measures.
(7)
Did
its developers carry out a comprehensive, reproducible literature review within
the past 12 months of its publication/revision? Yes. All studies included in the recommendations
were pre and post intervention studies and urinary catheter reminder tool is
included for immediate implementation.
(8)
Were
all important options and outcomes considered? Yes
(9)
Is
each recommendation in the guideline tagged by the level/strength of evidence upon
which it is based and linked with the scientific evidence? Yes
(10)
Do
the guidelines make explicit recommendations (reflecting value judgments about
outcomes) Yes. The entirety of the 16 page document is a recommendation
document.
(11)
Has
the guideline been subjected to peer review and testing? Yes
(12)
Is
the intent of use provided (e.g.) national, regional, local) All
(13)
Are
the recommendations clinically relevant? Yes
(14)
Will
the recommendations help me in caring for my patients? Yes
(15)
Are
the recommendations practical/feasible (e.g., resources-people and
equipment—available? Catheter reminder is easy to use, easy and inexpensive to
reproduce.
(16)
Can
the outcomes be measured through standard care? Yes
Quinn, P. (2015).
Chasing zero: A nurse driven process for catheters-associated urinary tract infection reduction in a community hospital.
Nursing Economics, 33(6), p 320-325.
Rapid
Critical Appraisal Checklist for Cohort Studies
1. Are
the Results of the Study Valid?
a. Was there a representative and well-defined sample of
patients at a similar point in the course of the disease? All patients with
urinary catheters, although not well defined as far as illness, age, sex, etc.
b. Was follow-up sufficiently long and complete? 5 years
data is included.
c. Were objective and unbiased outcome criteria used? Yes.
CAUTI incidence rate used same measurement criteria all 5 years and was
calculated using NHSN criterial of rate per 1,000 catheter days.
d. Did the analysis adjust for important prognostic risk
factors and confounding variables? Yes.
Confounding variables in early year intervention period included lack of
training especially as it relates to physician training. Results of
intervention proved more dramatic as physician support increased, informatics
support was integrated and targeted education occurred.
2.
What Are the Results?
a.
What is the magnitude of the relationship between predictors (ie, prognostic indicators) and targeted outcomes? During the intervention periods tracked, CAUTI went from 4.9/1000 catheter days the
first year, 3.9/1000 catheter days the second year, down to a final rate of
0.2/1000 catheter days.
b.
How likely is the outcome event(s) in a specified period of time? Over a 5 year
period the likelihood of reproducing this
outcome are quite good.
c.
How precise are the study estimates? Study estimates are sound but do not
include measures other than cost reduction and
CAUTI reduction. Other statistical outcomes such as P and CI are not included.
3. Will the Results Help Me in
Caring for My Patients?
a.
Were the study patients similar to my own? Hospitalized patients with urinary catheters is similar. Using a nurse driven protocol is similar to
practice project proposal (as are all articles used for
practice project). The setting in this
study is roughly one-half the size of this author’s
hospital. Study setting is non-academic, yet principals are sound.
b.
Will the results lead directly to selecting or avoiding therapy? Selecting intervention.
c.
Are the results useful for reassuring or counseling? Communicating reassurance
of early removal to patients undergoing
catheterization.
Appendix
C
Evaluation
Table Template
|
Citation
|
Research
Design
|
Data
Collection Methods
|
Sample
Characteristics
|
Key
Findings
|
Appraisal:
Worth to Practice
|
|
Bernard,
M. S., Hunter, K. F., & Moore, K. N. (2012). A review of strategies to decrease the
duration of indwelling urethral catheters and potentially reduce the
incidence of catheter-associated urinary tract infections. Urologic
Nursing, 32(1), 29-37.
|
Analysis
of several peer reviewed articles (article synopsis). A systematic review of clinical
intervention studies and controlled trials.
|
Data was
collected using published studies of interventions in hospitalized patients
aimed at reducing CAUTI.
The
authors searched databases (not named) and found 53 abstracts. 9 of 53 met
their criteria of early removal of catheters and CAUTI reduction.
This
author concentrated on 5 that spoke to nursing interventions and their
success.
|
Study 1:
CAUTI and catheter duration decreased in MICU pts in an 11 month period.
Study2:
Quasi experimental design measured for 43 days in three distinct phases.
Sample numbers not provided, but 4,963 pt. days were observed.
Study 3:
CAUTI decreased from 10.6 to 1.1 per 100 patients (P=0.003)
and the incidence decreased from 12.3 to 1.8 per 1000 catheter-days (P=0.03).
Study 4:
Retrospective and prospective analysis of hospitalized patients. A nurse
driven process decreased CAUTI by 13.3% and duration of catheter days from
8.57 to 4.5 over a period of 2 weeks.
Study 5:
Time sequenced non-randomized intervention for a 2 year period that decreased
CAUTI from 11.5 to 8.3 per catheter days (P=0.009). The duration of catheters was decreased
from 7.0 to 4.6 (p<0.001).
|
Two major
interventions were identified as successful:
catheter time reduction led by1. Nurse led protocols and IT led
interventions.
|
Worthy of implementing into practice for these
reasons:
1.
Level 3
evidence
2.
Hospitalized
patients
3.
Applicable to a
nurse led practice improvement project
4.
Meets the overall
objective of reducing CAUTI
|
|
Carter, N.
M., Reitmeier, L. & Goodloe, L. R. (2014). An evidence-based approach to the
prevention of catheter-associated urinary tract infections. Urologic
Nursing, 34(5), 238-245.
|
After
conducting a literature analysis of best practices for urinary catheter
insertion and maintenance, authors found nurse driven protocols reduce
CAUTI. Pre and post intervention
studies of 8 quarters of patients without the intervention with nurse driven
protocol and 8 quarters after initiation of a nurse driven protocol showed a
greater than 50% decrease in CAUTI.
|
Data was
collected for 16 quarters (4 years) for patients who had urinary catheters.
|
The sample
included all patients admitted to an acute care medical ICU unit with patients
with multiple complex diagnoses such as HIV, kidney failure, pneumonia and
CHF.
Strength
of the study is the duration (2 years) as well as the results (>50%
reduction) and the critical nature of the patient population.
|
Prevalence
was measured from the first quarter of 2010 to the 4th quarter in 2011 with a
rate of 13 CAUTI. After intervention, from the 1st quarter in 2012
to 4th quarter in 2013, CAUTI rate was 6.
After this
unit’s success, the initiative was rolled out the larger hospital as the new
standard of care. In addition, the evidence-based approach was approved by
the Society of Urologic Nurses and Associates for 1.3 contact hours of
continuing education credit.
|
Worthy
of implementing into practice for
these reasons:
1.
Level 2
evidence-Evaluation and synthesis of multiple studies were used (and cited)
in order to create the practice change.
2.
Hospitalized
patients in an acute care setting that are comparable to the patients this
author will apply intervention
3.
Applicable to a
nurse led practice improvement project
4.
Reduced CAUTI
by roughly 50%.
5.
Meets the
overall objective of reducing CAUTI with a nurse driven protocol.
|
|
Chen, Y.,
Chi, M., Chen, Y., Chan, Y., Chou, S. & Wang, F. (2013). Using a criteria-based reminder to reduce
use of indwelling urinary catheters and decrease urinary tract
infections. American Journal of Critical Care, 22(2), 105-114.
|
Randomized
control trial.
|
Randomized
control trial of two ICU’s. Inclusion
criteria were adults w/catheter greater than two days and on the study unit
> 2 days. Randomization was used (random assignment). Out of 509 admitted patients, 278 were
included. The intervention group (n=147) had a urinary catheter reminder
protocol in place and the control group (n=131) had none and standard of care
was used.
“Criteria
for insertion and removal were based on CDC standards and the Society for
healthcare Epidemiology of America/Infectious Diseases Society of America,”
(Chen et al., 2013, p. 107).
|
Data was
collected for an eight month period of patients who did and did not have a
CAUTI. Both intervention and control
groups were separated out by unspecified UTIs, Onset after the first catheter,
and onset after a second catheter insertion.
All three
groups’ incidence was reported and incident per 1000 urinary catheter days.
|
Key
findings were a utilization reduction of
22% in the intervention group.
CAUTI was
reduced by 48% in the intervention group.
|
Worthy of implementing into practice for these
reasons:
1.
Level 4
evidence-randomized control trial.
2.
Utilization and
CAUTI both reduced.
6.
Agrees with all
articles found that a reminder for catheter appropriateness was key in
reducing CAUTI.
7.
Criteria for
insertion and removal based on respected sources.
8.
Meets the
overall objective of reducing CAUTI with a nurse driven protocol.
|
|
Elpern, E.
H., Killeen, K., Kethcem, A., Wiley, A., Patel, G., & Lateef, O. (2009).
Reducing use of indwelling urinary catheters and associated urinary tract
infections. American Journal of Critical Care, 18, 535-542.
|
Single
center study over a period of 6 months.
|
For 6
months, every patient in a Medical ICU with a catheter was discussed for
inclusion or exclusion criteria for catheterization by nursing and the daily
evaluation was discussed during rounds with doctors.
|
Sample included 337 patients with 1432 catheter days. 58% were female and from the ages of 18-99
(mean of 61).
|
Both CAUTI
and duration of indwelling urinary catheter days were decreased. A key
finding was that 456 device days did not meet criteria-a full 32 percent.
Pre
intervention catheter day mean was 311.7 days per month and post intervention
catheter days were 238.6. CAUTI 4.7
per 1000 catheters days pre intervention and dropped to zero after the
interventions. Numbers concluded to be
statistically significant.
|
Worthy
of implementing into practice for
these reasons:
1.
Reduced CAUTI
2.
Meets the
overall objective of reducing CAUTI with a nurse driven protocol.
3.
Although a case
controlled study, this study’s findings align with all others found in this
literature search.
|
|
Lo,
E., Nicolle, L. E., Coffin, S. E., Gould, C., Maragakis, L. L., Meddings, J.,
…Yokoe, D. S. (2014). Strategies to prevent catheter-associated urinary tract
infections in acute care hospitals: 2014 update. Infection Control and Hospital Epidemiology, 35(5), 464-479.
|
Meta-analysis
|
This 16 page article is a synthesis of many studies and
critically-appraised articles citing evidence of the topic of preventing
catheter associated urinary tract infections in critical care hospitals.
|
Data was collected regarding: Incidence, outcomes, risk
factors, strategies to detect CAUTI, Strategies to prevent CAUTI, Recommended
strategies based on systematic review, performance measures, and examples of
implemen-tation strategies.
|
A key finding extracted from this meta-analysis was that
using a catheter criteria based reminder reduced the catheter days and
incidence of CAUTI. In addition, a sample urinary catheter reminder sheet is
included.
|
Worthy
of implementing into practice for
these reasons:
1.
Level
I evidence
2.
A
synopsis of best practice guidelines to prevent CAUTI in acute care
hospitals.
3.
Specifically
designed as “expert guidance” for acute care hospitals
4.
A
collaborative paper from multiple highly respected sources (IDSA, SHEA, APIC,
and SHEA).
5.
Includes
urinary catheter reminder.
|
|
Quinn,
P. (2015). Chasing zero: A
nurse-driven process for catheter-associated urinary tract infection
reduction in a community hospital. Nursing Economics, 33(6), 320-325.
|
This is a single center study that also found making
nursing accountable for daily surveillance of criteria for patient
catheterization can reduce CAUTI.
Nurses daily evaluation of catheter criteria.
|
Data was collected using catheter days. CAUTI decreased from 4.9 per 1,000 catheter
days to 0.2 per 1,000 catheter
days.
|
Sample included all catheterized patients over5 ½ years
from 2008 through the first two quarters of 2013.
Intervention
started in 2008.
Patients with catheters, total catheter days, avg.
catheter dwell days, no. of CAUTIS, and incidence rate were tracked.
|
A nurse driven practice project for early removal of
urinary catheters decreased the number of CAUTI by 50%.
|
Worthy
of implementing into practice for
these reasons:
1.
Reduction
of CAUTI by 50% after implementation of a nurse driven protocol is consistent
throughout my literature search.
2.
Meets
project goals of reducing CAUTI and is a nursing practice project.
|
Appendix
D
Conceptual
Model: The Iowa Model
Appendix
E
Timeline
Week One: Form a team
and review project and evidence
Week Two: Complete
myTraining module
Week Three: Complete
myTraining module
Week Four: Team
conducts Charge Nurse training
Week Five: Team
conducts Charge Nurse training
Week Six: Charge Nurses
teach unit nurses
Week Seven: Charge
Nurses teach unit nurses
Week Eight: Soft
opening
Week Nine: Go live
Week Ten: Stakeholders
to decide if project is appropriate and if yes, institute new protocol
Week Eleven through 12
Months: Monitor CAUTI incidence and rate over a period of twelve months and
compare to previous twelve months’ data
Appendix
F
Resources
Human Resources:
Core
Team
1.
Core group of four unit charge nurses
2.
Two nurse practitioners
3.
One Critical Care Medicine Attending
4.
One Surgery Attending
5.
Clinical Leader
6.
Nurse Manager
Education Team:
1. Clinical
Nurse Educator (design of myTraining module)
2. Librarian
(design of myTraining module)
3. Clinical
Leader (design of protocol criteria check-off list)
4. Publication
Services (creation of the check-off list)
Implementation
Team
1. Eight
unit charge nurses
2. 40
bedside nurses
Physical
Resources
1. Meeting
room for Core Team week 1
2. Nursing
Education for myTraining weeks 2 and 3 for ten people at a time (computers
available in nursing education). Alternately, training module is available on
the intranet site which is available to nursing at any location.
Financial Resources
1. Budget
to create and laminate 8 cards (1 per patient) with publication services. Cost: $50
2. 1
hour training for people on initial project team x 4 charge nurses @ $25 (avg
pay)each = $100. The rest on the core
team are salaried.
3. 1
hour training for 40 bedside nurses for final training @ $25 (average pay) =
$1,000
Data Collection Resources
1. Clinical
Leader already disseminates data on a monthly basis from hospital provided ICU
Quality dashboard.
Appendix
G
Proposal
Instrument
Daily Urinary Catheter Reminder
DATE: _____________ Patient
Name/Rm Number: _________________
This patient has had an indwelling urethral catheter
since ______________ (date)
Please indicate below EITHER (1) that the catheter
should be removed OR (2) that the catheter should be retained. If the catheter should be retained, please
state ALL of the reasons that apply.
__ Remove
indwelling urethral catheter; OR
__ Continue indwelling urethral catheter
because patient requires indwelling catheterization for the following reasons (check all that apply):
__
Urinary retention
__
I/O monitoring without ability to use urinal or bedpan (Consider condom
catheter for men). (Consider weighing diapers 1 gm =
1mL UOP).
__
Open sacral wound or perineal wound in patient with urinary incontinence
__
Hemodynamic instability requiring close monitoring of fluid status
__
Shock/Burn fluid resuscitation period
__
Patient too ill or fatigued to use other urine collection strategy (consider
skin barrier cream and diapering patient)
Charge nurse on each twelve hour shift will check
all patients for criteria.
Those patients not meeting criteria will be
communicated by charge nurse to bedside RN who will then remove catheter.
All patients who had catheters removed in the
previous 24 hours will be presented on rounds by bedside RN.
Urinary Catheter Reminder adapted from:
Saint, S. Kaufman, S. R., Thompson, M., Rogers, M.
A., Chenoweth, C. E. (2005). A reminder reduces
urinary catheterization in hospitalized patients.
Joint Commission Journal on Quality and Patient
Safety, 31(8), 455-462.
Appendix
H
Data
Collection Tool: Calculating Rates
Monthly infection rate
lists are sent from Decision Support Services (DSS) with the following values
pre-calculated for ease of use:
·
Number of cases
·
Rate of infection
·
Percentage of infection
·
Rate per patient day
·
Rate per catheter days
Data collection is interpreted using the following
methods:
Number
of Cases simply is the number of infections on the eight bed
Intensive Care Unit. This is a raw
number without taking into account the number of patients on the unit per day
or per month. This raw number does not
take into account how many patients had a urinary catheter.
Rate
of Infection is calculated using the number of cases
(infections) in the month divided by the population at risk (number of patients
on unit that month) and then multiplied by the constant 1,000.
Percentage
of Infection is calculated using the number of
infections in the month divided by the number of patients during the month
being calculated multiplied by 100.
Rate
Per Patient Day is calculated by first multiplying the
number of patients on the unit in the month multiplied by number of days in
that month to find resident days. Next,
the number of infections during the month divided by the number of resident
days multiplied by 1,000 equals the rate per patient days.
Rate
Per Catheter Days is found by multiplying the number of
patients on the unit with catheter during a given month by the number of days
in that month to find catheter days.
Next, number of infections during the month divided by catheter days
multiplied by 1,000 equals rate per catheter days.
Appendix
I
Budget
Total budget to
implement practice improvement project is $1,150
1.
Budget to create and laminate 8 cards (1
per patient) with publication services.
Cost: $50
2.
1 hour training for people on initial
project team x 4 charge nurses @ $25 (avg pay)each = $100. The rest on the core team are salaried.
3.
1 hour training for 40 bedside nurses
for final training @ $25 (average pay) = $1,000
