Prevention of Catheter-Associated Urinary Tract Infection   22  

Heidi L. Wald, Regina M. Fink, Mary Beth Flynn Makic, and Kathleen S. Oman

OVERVIEW

Health care–associated infections (HAIs) have received increasing scrutiny over the past decade. It is now widely recognized that HAIs are often preventable adverse events related to medical care. CAUTIs are among the most common HAIs, occurring at a rate of 0.2 to 4.8 infections per 1,000 catheter days for adult inpatient units (Centers for Disease Control and Prevention [CDC], 2013), CAUTIs are associated with significant morbidity and excess health care costs (Klevens et al., 2007; Tambyah, 2002). Catheter use and CAUTIs are disproportionately reported among older adults (Fakih et al., 2010; Vincitorio et al., 2014). Although once largely overlooked as part of the price of doing business in hospitals, a significantly changed regulatory environment has emerged that has brought increased scrutiny to HAIs in general, and CAUTIs in particular. Examples of this oversight include process and outcome measurement and reporting and financial incentives to improve these measures. Since 2008, the Centers for Medicare & Medicaid Services (CMS) no longer reimburses for additional costs required to treat hospital-acquired urinary tract infections (UTIs; CMS, 2007). Long-term care facilities also follow CMS regulatory guidance and their federal regulations (F-315 Tag) mandate that IUC use must be medically justified and care rendered to reduce infection risk in all residents with or without an IUC (CMS, 2005). Enhanced public reporting and financial incentives figure prominently in the Patient Protection and Affordable Care Act of 2010; HAIs were singled out for inclusion in both of these initiatives (Patient Protection and Affordable Care Act, 2010). In related rulemaking, CAUTI is included as a measure in the new HAI reduction program and the value-based purchasing composite measure (PSI 90) for acute care hospitals (Agency for Healthcare Research and Quality, 2013a; CMS, 2007, 2008). Therefore, it is imperative that health care professionals in all settings develop strategies and interventions to reduce IUC duration and prevent CAUTIs, thus benefitting both clinical and financial outcomes.

This focus on reducing harm occurs even as the evidence base for the prevention of CAUTI continues to evolve. Between 2008 and 2014, multiple stakeholder organizations, including the CDC, and several major professional societies critically examined the literature on CAUTI prevention (Cottenden et al., 2005; Gould et al., 2010; Greene et al., 2008; Hooten et al., 2010; Joanna Briggs Institute, 2010; Lo, Nicolle, & Classen, 2008; Lo et al., 2014; Society of Urologic Nurses, 2006; see Resources section). Also, the CDC’s National Healthcare Safety Network (NHSN) significantly revised the surveillance definition for CAUTI several times since 2009, including a major revision in January 2015, with the cumulative effect of focusing surveillance efforts on only the most clinically important events (CDC, 2015). Despite this attention, CAUTI rates have been stable. A 2012 data report showed an overall 3% increase in CAUTIs reported to the CDC nationwide, even as rates of other HAIs decline (CDC, 2013). However, a large national collaborative reported preliminary success in CAUTI reduction by pairing a technical bundle with a socio-adaptive change model (Agency for Healthcare Research and Quality, 2013b).

In light of these rapid changes in the field and the regulatory focus on CAUTI, the regular review of policies, procedures, practices, and products is imperative for all health care facilities. In this chapter, we review the rationale for CAUTI prevention strategies, suggest an approach to implementing a comprehensive CAUTI prevention program, and catalog the most important CAUTI prevention strategies.

BACKGROUND AND STATEMENT OF PROBLEM

Health care–associated UTIs are frequent and costly, resulting in increased morbidity and possible mortality in hospitalized elders. There are estimated to be more than 400,000 hospital-acquired UTIs in the United States annually (Klevens et al., 2007; Scott, 2009; Tambyah et al., 2002). At a mean cost of $589 per episode, this epidemic results in $250 million of excess health care costs each year (Tambyah et al., 2002). In a multihospital study in Quebec, 21% of bacteremias were from a urinary source, with 71% associated with IUCs. Thus, CAUTI is an important cause of hospital-acquired bacteremia (Fortin, Rocher, Frenette, Tremblay, & Quach, 2012).

The majority of UTIs are associated with the ubiquitous IUC, also known as a Foley catheter, after urologist Frederick Foley who developed the modern device. Urinary catheters are among the most widely used medical devices. Despite their utility in acutely ill patients, they have many downsides, including the CAUTI. Other complications include delirium (Inouye, 2006), accidental removal, gross hematuria, leakage, urethral injury, and restriction of mobility. Taken together, these complications of IUCs occur as frequently as CAUTI (Hollingsworth et al., 2013; Saint, Lipsky, & Goold, 2002). Therefore, the benefits of managing urinary output with an IUC must be weighed against the many risks.

Unfortunately, the indiscriminate use of IUCs is widespread. IUCs are used in up to 16% of adult hospital inpatients and are more commonly used in the older patient (Vincitorio et al., 2014). Older age and female sex are risk factors for catheterization, and older women are more likely to have no clear indication for catheterization than other patients (Vincitorio et al., 2014). Of Medicare patients undergoing elective surgery, 86% have an IUC (Wald, Ma, Bratzler, & Kramer, 2008). According to the Infectious Diseases Society of America, 21% to 54% of all IUCs are inappropriately placed and are not medically indicated (Fakih et al., 2010; Gokula, Murthy, Hickner, & Smith, 2004; Hooten et al., 2010). Thus, interventions aimed at evidence-based use of catheters are needed to reduce unnecessary catheter days, and to prevent CAUTIs. To better understand the potential approaches to prevention of CAUTIs, an understanding of CAUTI pathogenesis is essential.

CAUTI Pathogenesis

The urinary tract is normally a sterile body site, therefore, any positive urine culture can be considered abnormal. Asymptomatic bacteriuria is of questionable clinical significance, however, and should not be treated except in pregnant patients or those undergoing urologic surgery (Nicolle et al., 2005). The CDC’s surveillance definition therefore only focuses on symptomatic or bacteremic infections, which occur in the presence of an IUC (CDC, 2015).

When a patient has an IUC, microorganisms can gain access to the urinary tract on either the extraluminal surface of the IUC or intraluminal surface through breaks in the catheter system (Figure 22.1). Extraluminal infection can occur early if bacteria are introduced during insertion, but more commonly, extraluminal infection occurs later (Tillekeratne et al., 2014). Once they gain access to the urinary tract, microorganisms can thrive in a “biofilm” layer on either the extra- or intraluminal surface of the IUC. The biofilm, made up of bacteria, host proteins, and bacterial slime, is thought to be important in the development of late CAUTIs. Because the formation of a biofilm and colonization with bacteria takes time, most CAUTI occurs after 48 hours of catheterization and increases approximately 5% per day (Schaeffer, 1986; Stamm, 1975).

The mechanisms described earlier provide the rationale for evidence-based care of IUCs and highlights four potential opportunities for intervention during the use of IUCs (Figure 22.2). The first opportunity is avoidance of catheters at the time of the decision for insertion, the second is evidence-based product selection and care practices regarding IUCs (including insertion and maintenance), and the third is minimizing duration through timely removal. A fourth set of additional strategies for CAUTI prevention includes education of providers, surveillance of processes, and reporting practice outcomes and CAUTI rates. This set of strategies can be applied at any of the opportunities for intervention. A comprehensive program to eliminate CAUTIs includes elements of each of the aforementioned strategies.

FIGURE 22.1

Routes of entry of uropathogens to catheterized urinary tract.

Source: Maki and Tambyah (2001).

FIGURE 22.2

Stages of catheter use and potential intervention strategies.

ASSESSMENT OF THE PROBLEM

Surveillance Definition of CAUTI

Although clinical diagnosis of CAUTI allows for clinical judgment, the CDC has developed explicit surveillance criteria for CAUTI in acute care for use by infection control practitioners (CDC, 2015). In brief, the patient must have:

All elements of the definition must occur within a 7-day window. A CAUTI diagnosed within 48 hours of arrival to a health care facility or unit is attributed to the previous location.

In nonbacteremic cases, this surveillance definition requires that the patient have symptoms referable to the urinary tract or a fever without another cause. For the purposes of infection-control surveillance in acute care, new alterations in mental status do not meet the diagnostic criteria for CAUTI. Of note, the CDC’s surveillance definition for UTI in long-term care facilities differs substantially from the acute care definition. Practitioners in long-term care facilities should acquaint themselves with that definition (Stone et al., 2012).

CAUTIs are generally reported as infections per 1,000 catheter days on a given patient care unit. More than half of all states require public reporting of HAIs, among them many specify reporting of CAUTIs. Hospitals participating in the Medicare program must report all CAUTIs to the CDC’s NHSN for the purposes of surveillance, public reporting on Hospital Compare, and incentive programs.

Additional important process measurement includes the catheter usage ratio reported as catheter days per patient-days. Since October 2009, the Surgical Care Improvement Project (SCIP) collects a measure of postoperative catheter removal on catheterization day 1 or 2 for all surgical patients (The Joint Commission, n.d.).

Indications for IUC

Avoidance of unnecessary IUCs may reduce CAUTI incidence and complications such as bloodstream infections. A decrease in IUC use is expected to result in decreases in length of stay, cost of hospitalization associated with treatment of CAUTI and bloodstream infections (Apisarnthanarak et al., 2007b; Meddings et al., 2014). Elpern et al. (2009) evaluated the inappropriate use of IUCs among inpatients and found them to be more common in female, nonambulatory, and medical intensive care unit (ICU) patients. Risk factors associated with the development of CAUTI in hospitalized patients include older age, not maintaining a closed drainage system, neutropenia, renal disease, and male gender (Greene et al., 2012; Lo et al., 2014). Explicit criteria for appropriate insertion may result in significant reductions in catheter duration and CAUTI prevalence. The University of Colorado Health System developed criteria for appropriate insertion of IUCs in hospitalized patients based on evidence (Chenoweth et al., 2014; Fuchs, Sexton, Thronlow, & Champagne, 2011; Lo et al., 2014; Mori, 2014) and disseminated this information to nursing and physician staff through the integration of a nurse-driven protocol for IUC removal within the electronic health record (EHR; Figure 22.3).

An IUC should not be used for routine care of patients who are incontinent, as a means to obtain urine culture or other diagnostic tests in a patient who can void, for prolonged postoperative duration without appropriate indications, or routinely in patients receiving epidural anesthesia/analgesia.

INTERVENTIONS AND CARE STRATEGIES

It is estimated that 20% to 69% of CAUTIs are preventable (Gould et al., 2009). Specific interventions to prevent CAUTIs are summarized as follows and organized with regard to the four strategies illustrated in Figure 22.2. Many of these recommendations are supported by low-quality evidence and expert opinion. Further study may impact these recommendations. A proposed approach to a comprehensive CAUTI intervention follows.

Strategy 1: Avoidance

To reduce the incidence of CAUTI, it is important to rethink practice, systems, and examine the “why” behind the clinical indication for the IUC. Elimination options other than an IUC should be explored before insertion. Similarly, providing documentation of a clear indication for the IUC can reduce inappropriate device use (Lo et al., 2014; Uberoi et al., 2013). The use of explicit criteria (as in Figure 22.3) to guide the insertion decision may be of assistance. If an IUC is placed, an algorithm may be used to determine continued need for the device or promote prompt removal.

To avoid catheterizations, alternative strategies for managing urine output are necessary. Completing a systems evaluation of available equipment to provide alternatives to IUC for urinary elimination is an important first step in reducing use. Developing toileting schedules and providing assistance with toileting incorporated into frequent nursing staff rounding is another strategy that can be used to reduce urgency and incontinence episodes (Uberoi et al., 2013). If the patient is mobile or has limited mobility, alternatives to an IUC include the use of a bedside commode with a toileting schedule (Gray, 2010; Uberoi et al., 2013), condom catheters for male patients (Dowling-Castronovo & Bradway, 2008; Saint et al., 2013), moisture-wicking incontinence pads (Covidien Maxicare Underpad; Medline Ultrasorb Underpad), intermittent straight catheterization with the use of a bladder scanner to determine bladder urine volume (Hooten et al., 2010; Parry et al., 2013; Saint et al., 2013), as well as urinals and bedpans. Careful consideration of products and how and where they are stocked is essential to success. For instance, commodes need to be available in multiple sizes and need to include bariatric commodes; urinals need to fit snugly on bedrails; bladder ultrasound needs to be readily available for assessment.

FIGURE 22.3

University of Colorado Health System nurse-driven indwelling urinary catheter removal protocol.

I&O, input and output; IUC, indwelling urinary catheter; LDA, lines, drains, airways; PVR, postvoid residual.

© 2015. University of Colorado Hospital Authority. All information contained on this form is copyright protected and may only be downloaded and/or reprinted for personal use. Permission to use these materials in whole or in part for any commercial use is expressly prohibited unless prior written consent is granted by the Department of Professional Resources, University of Colorado Hospital, Mail Stop 901, 12401 E. 17th Ave., Aurora, CO.

For less mobile male patients, the condom catheter is an effective alternative to an IUC, although there is still a small risk of infection with condom catheters (Saint et al., 2013). Moisture-absorbing or wicking underpads for incontinence management are an alternative for the acute care environment (Covidien Maxicare Underpad, n.d.; Medline Ultrasorb Underpad n.d.) and long-term care or home environments (NAFC.org). Incontinence underpad products pull effluent moisture/urine away from the skin and can absorb up to 2 L of fluid before becoming saturated (Junkin & Selekof, 2008; Padula Manish, Makic, & Sullivan, 2011). For a full discussion of incontinence management, please refer to Chapter 21, “Urinary Incontinence.”

Urinary retention postsurgery or after initial IUC removal may pose clinical care challenges. To prevent IUC insertion or reinsertion, intermittent catheterization should be considered as an avoidance strategy. The bladder scanner, which uses ultrasound technology, is clinically beneficial in determining urinary retention, reducing unnecessary intermittent catheterizations, enhancing patient comfort, and saving costs associated with inappropriate catheterizations, and possible CAUTIs (Palese, Buchini, Deroma, & Barbone, 2010; Saint et al., 2013).

Strategy 2: Evidence-Based Product Selection, Insertion, and Routine Care

If an IUC is determined to be clinically indicated, selection of the right catheter, proper technique during insertion of the device, and evidence-based ongoing care management are needed to reduce infection.

Catheter material remains an area of ongoing debate. Although antimicrobial catheter materials have been shown to reduce catheter-associated bacteriuria (Lo et al., 2014; Pickard et al., 2012), the impact of antimicrobial catheters on symptomatic CAUTIs remains unproven. Research syntheses have failed to conclusively demonstrate effectiveness of silver-coated or antibiotic impregnated catheters on prevention of CAUTIs for short-term catheterization of adult patients versus standard materials (Pickard et al., 2012). There also is insufficient evidence to determine whether selection of a latex catheter, hydrogel-coated latex catheter, silicone-coated latex catheter, or all-silicone catheter influences CAUTI risk (Hooten et al., 2010; Lo et al., 2014). The decision to use a silver-coated or antibiotic impregnated catheter should be made with the understanding that it does not substitute for a comprehensive CAUTI prevention program.

Selecting the smallest IUC size, when possible, is an additional consideration to reduce the risk of infection (Gould et al., 2009; L. Greene, Marx, & Oriola, 2008; Hooten et al., 2010). The selection of a smaller catheter (e.g., less than 18 French) reduces irritation and inflammation of the urethra and reduces infection risk (Gray, 2010).

Placing an IUC is a fundamental skill for nurses; however, current evidence supporting sterile versus aseptic technique for the procedure is inconclusive (Lo et al., 2014). A strict sterile technique involves using a sterile gown, mask, prolonged hand washing (greater than 4 minutes), opening and using a sterile insertion kit, donning sterile gloves, cleansing the urethral meatus and perineal area with an antiseptic solution, and inserting the catheter using a no-touch technique (Gray, 2010). Wilson et al. (2009) reviewed the literature and found that most clinicians employ an aseptic technique, which was most frequently defined as the use of sterile gloves, sterile barriers, perineal washing using an antiseptic cleanser, and no-touch insertion. Current recommendations suggest an IUC insertion be placed under aseptic technique with sterile equipment (Gould et al., 2009; Greene et al., 2008; Hooten et al., 2010; Joanna Briggs Institute, 2010; Lo et al., 2014).

Once an IUC is placed, optimal management includes care of the urethral meatus according to “routine hygiene” (e.g., daily cleansing of the meatal surface during bathing with soap and water and as needed following a bowel movement; Gould et al., 2009; Greene et al., 2008; Hooten et al., 2010; Joanna Briggs Institute, 2010). Metal cleansing with antiseptics, creams, lotions, or ointment has been found to irritate the meatus, possibly increasing the risk of infection (Jeong et al., 2010; Joanna Briggs Institute, 2010; Lo et al., 2014).

Securing the IUC after placement to reduce friction from movement is an important element of catheter management supported by current guidelines, researchers, and expert opinion panels (Clarke et al., 2013; Darouiche et al., 2006; Gould et al., 2009; Hooten et al., 2010; Joanna Briggs Institute, 2010). Maintaining a closed catheter system is also supported by current guidelines (Gould et al., 2009; Greene et al., 2008; Hooten et al., 2010; Joanna Briggs Institute, 2010; Lo et al., 2014) to eliminate the introduction of microbes that occurs when breaking the prepackaged seals on the IUC. A systems analysis should be conducted to purchase and stock the most commonly needed IUC insertion and drainage-bag kits to optimize the maintenance of a closed system. Similarly, maintaining the urine-collection bag below the level of the bladder minimizes reflux into the catheter itself preventing retrograde flow of urine (Clarke et al., 2013; Gould et al., 2009; Greene et al., 2008; Hooten et al., 2010; Joanna Briggs Institute, 2010). Establishing workflow protocols to routinely empty the drainage bag frequently and before transport are important in reducing urine reflux and opportunities for CAUTI.

Strategy 3: Timely Removal

Developing systems that prompt health care providers to review the need for the IUC and encourage early removal have been found to reduce IUC use and CAUTI rates (Alessandri, Mistrangelo, Lijoi, Ferrero, & Ragni, 2006; Alexaitis et al., 2014; American Nurses Association CAUTI Prevention Tool, 2015; Andreessen, Wilde, & Herendeen, 2012; Carter, Reitmeier, & Goodloe, 2014; Fakih et al., 2012; Fuchs et al., 2011; Knoll et al., 2011; Marigliano et al., 2012; Meddings et al., 2014; Mori, 2014; Parry, Grant, & Sestovic, 2013; Purvis et al., 2014; Rosenthal et al., 2012; Saint et al., 2013; Titsworth et al., 2012). Meddings et al. (2014) updated an earlier systematic review and meta-analysis and found that urinary catheter removal reminders and stop orders appeared to reduce CAUTI rates. Implementation of systems that provide physicians and nurses with routine reminders to evaluate the need for the IUC or automatic stop orders were found to reduce the CAUTI rate by 53% (p ≤ .0001). In this study, automatic stop orders were more effective than reminders in reducing catheter duration (p < .0001 and p = .071, respectively).

Other approaches to reducing catheter days include audit and feedback and reminders to recommend reevaluation of the need for the IUC (Marigliano et al., 2012; Meddings et al., 2014; Parry et al., 2013; Purvis et al., 2014; Saint et al., 2013) and early removal (Alexaitis et al., 2014; American Nurses Association CAUTI Prevention Tool, 2015; Fuchs et al., 2011; Meddings et al., 2014; Mori, 2014; Parry et al., 2013; Saint et al., 2013; Titsworth et al., 2012). EHR icons (Purvis et al., 2014) or flags that calculate the number of days the IUC has been placed are effective forms of electronic reminders that can easily be incorporated into the EHR. Automatic stop orders or IUC orders that expire in a defined time frame have shown to reduce both catheter usage and CAUTI (Fuchs et al., 2011; Knoll et al., 2011; Saint et al., 2013). Daily nursing rounds (Alexaitis et al., 2014; Fakih et al., 2012; Purvis et al., 2014), and the use of checklists (Andreessen et al., 2012; Fuchs et al., 2011) have also been shown to reduce catheter usage and CAUTI.

Nurse-driven catheter removal protocols are being developed and implemented successfully in many acute care settings (Andreessen et al., 2012; Carter et al., 2014; Fakih et al., 2012; Knoll et al., 2011; Purvis et al., 2014; Saint et al., 2013; Titsworth et al., 2012). Protocols range in degree of nurse autonomy in catheter removal decision making; some require a physician order, most allow the nurse to remove the catheter when there is no evidence-based indication for continuation. Protocols also differ in complexity, with some only addressing the IUC removal aspect of the protocol and others that address follow-up bladder management strategies with bladder scanning guidelines (Alexaitis et al., 2014; American Nurses Association CAUTI Prevention Tool 2015; Carter et al., 2014; Mori, 2014; Purvis et al., 2014; Saint et al., 2013). Figure 22.3 is an example of a nurse-driven IUC removal protocol developed and implemented by the University of Colorado Hospital.

If premature, early removal of IUCs poses the risk of unnecessary recatheterization. It is important to monitor the need for recatheterization to avoid unintended harm. In the meta-analysis conducted by Meddings et al. (2014), low recatheterization rates were noted in studies using reminders and automatic stop orders.

Most of the implementation and quality-improvement research employs multiple interventions (or bundles), as CAUTI prevention is a multifaceted issue. These bundled approaches are also effective and are providing explicit criteria for catheter usage and structured approaches to CAUTI reduction (Andreessen et al., 2012; Fakih et al., 2012; Knoll et al., 2011; Purvis et al., 2014; Rosenthal et al., 2012; Titsworth et al., 2012).

It is well established that duration of IUC increases CAUTI risk. The SCIP is a national quality partnership of organizations interested in improving surgical care by significantly reducing surgical complications (The Joint Commission, n.d.). One of the key performance measures in this program is CAUTI prevention; specifically that IUCs be removed by postoperation day 2, also known as SCIP-inf-9. This SCIP performance measure has had significant impact on decreasing catheter usage in surgical patients (CMS, 2015).

Keeping the IUC as long as thoracic epidural analgesia is maintained (higher than T9) may result in a higher incidence of CAUTI and increased hospital stay. IUC removal on the morning after surgery while the thoracic epidural catheter is still in place does not lead to increased incidence of urinary retention, infection, or higher rates of recatheterizations (Basse, Werner, & Kehlet, 2000; Chia, Wei, Chang, & Liu, 2009; Stubbs et al., 2013; Zaouter, Kanera, & Carli, 2009; Zaouter, Wuethrich, Miccoli, & Carli, 2012).

Strategy 4: Surveillance and Education

Ensuring that leadership of organizations and systems are in place to effectively evaluate and sustain practice change is essential to improving patient outcomes (Kabcenell, Nolan, Martin, & Gill, 2010; Reinertsen, Bisognano, & Pugh, 2008). In particular, surveillance is a cornerstone of CAUTI prevention but is resource intensive, typically relying on manual surveillance by trained infection prevention personnel (Wald, Bandle, & Richard, 2014). There is emerging evidence that electronic surveillance, using EHR algorithms, are effective in increasing the efficiency of CAUTI identification (Shepard et al., 2014; Wald et al., 2014). Catheter usage data and CAUTI rates are key data elements to collect and trend. IUC usage is determined by the number of catheter days divided by the number of patient days and is expressed as a ratio. CAUTI rate is determined by the number of CAUTIs divided by 1,000 catheter days. Both data elements can then be benchmarked against the NHSN pooled means to assess unit level performance. However, the use of a catheter days denominator can produce unstable CAUTI rates when catheter usage is low (Wright, Kharasch, Beaumont, Peterson, & Robicsek, 2011).

Measurement must be accompanied by provision of knowledge and skills to frontline providers through appropriate education and training, which may be central to a multicomponent CAUTI intervention. Multiple studies and quality-improvement projects found that multifaceted educational interventions bundled with the use of algorithms/checklists, automated stop orders, physician EHR reminder prompts, and/or nurse-driven removal protocols are effective in decreasing CAUTIs and catheter usage (Alexaitis & Broome, 2014; Andreessen et al., 2012; Apisarnthanarak, 2007a; Carter et al., 2014; Knoll et al., 2011; Marigliano et al., 2012; Mori, 2014; Purvis et al., 2014; Roser et al., 2012). Ongoing system evaluation, nursing reeducation, practice reminders, and public reporting of unit-based CAUTI rate data are strategies to inform the health care team of current practice outcomes and effectiveness of CAUTI prevention strategies. Implementing systems that encompass the whole health care team to question the need for the IUC and, when indicated, ensuring proper care and early removal can be pivotal in reducing CAUTI rates (Wenger, 2010).

Approach to a Comprehensive CAUTI Intervention

Evidence-based practice (EBP) guidelines derived from valid, current research and other evidence sources can successfully improve patient outcomes and quality care. However, simply disseminating scientific evidence is often ineffective in changing clinical practice. Learning how to implement findings is critically important to promoting high-quality, safe care. How EBPs are adopted in practice depend on the type, complexity, and strength of the evidence and how the knowledge is communicated to clinicians (Titler, 2011). There are a number of models that can guide the implementation of EBP (Rycroft-Malone & Bucknall, 2010) but there is not a single way to implement new findings into practice. What works in one setting may need modification to be successful in another context (Titler, 2011). Understanding health care provider decisions, experiences, practice processes, and barriers is considered essential. These elements must be explored to successfully implement practice change based on best evidence (Melnyk & Fineout-Overholt, 2011).

The explicit use of a socio-adaptive model has been employed in large-scale HAI prevention activities, including the Agency for Healthcare Research and Quality’s On the Comprehensive Unit-based Safety Program (CUSP): STOP CAUTI initiative. Here, the technical interventions for CAUTI reduction were paired with the CUSP developed by Pronovost et al., which provides tools for improving safety climate on clinical units (Pronovost et al., 2005). The preliminary results of this work are promising for a decrease in CAUTI, but show no change in IUC usage (Agency for Healthcare Research and Quality, 2013a).

At a minimum, the development of an interdisciplinary champion team and the creation of a multifaceted intervention to implement evidence-based procedures for IUC insertion and maintenance must be a priority in all practice settings. The ultimate goals are to reduce routine catheter insertions, provide evidence-based catheter care, and prompt early removal when possible, thus decreasing the risk of and prevention of CAUTI.

Steps used for protocol development at the University of Colorado Hospital are highlighted as follows. Improved patient outcomes (decreased catheter days, decreased CAUTIs) and decreased costs have been realized.

Protocol Development

  1.    Recruit an interdisciplinary champion team to include nurses (clinical, educators, operating room [OR] RNs, emergency department [ED] RNs); physicians [hospitalists, infectious disease, ED MDs, surgeons, anesthesiologists]); rehabilitation therapists and transport personnel; infection control preventionists; and quality-improvement, central supply, and clinical informatics representatives.

  2.    Examine and synthesize the evidence (search, review, critique, and hold journal clubs in various care areas to present the evidence).

  3.    Identify and understand product use, availability, and costs in your health care setting. Refine product use based on the best evidence and cost analysis. Examine:

            Urinary catheter materials, sizes, kits, drainage bags

            Catheter securement device

            Urinal and bedpan availability

            Commodes (availability and size)

            Bladder scanners

            Alternatives (incontinence pads, condom catheters, etc.)

  4.    Identify barriers to optimal IUC care practices by surveying staff or holding focus groups throughout your health care setting.

  5.    Update your policy and procedures related to IUC insertion and care based on the evidence.

  6.    Consider dividing the project into manageable phases. Avoidance strategies may require a different approach than care or removal strategies. For instance, avoidance starts in the ED and OR; removal occurs on inpatient floors.

  7.    Develop and use algorithms, decision aids, and factoid posters displaying evidence-based caveats.

  8.    Development of a nurse-driven IUC removal protocol.

            Recruit an interdisciplinary team to include nurses (clinical educators, physicians [hospitalists, infectious disease physicians, surgeons, anesthesiologists]) and clinical informatics representatives.

            Examine and synthesize the evidence (search, review, critique) and protocol examples.

            Develop protocol with interdisciplinary and key stakeholder (clinical nurses, charge nurses, educators, physicians [all specialties], midlevel providers, regulatory personnel) input and feedback

            Incorporate protocol into hospital policy/procedure.

            Develop EHR interface.

            Plan education and implementation procedures.

                a.    Identify champions to assist with implementation: infection control champions, nurse educators, clinical nurse educators, and specialists.

                b.    Journal club presentations, RN tip sheets, provider tip sheets, EHR screenshot tip sheets, nursing unit posters/clings, PowerPoint presentations.

            Plan evaluation strategies

                a.    Verbal feedback from clinicians

                b.    EHR reports on protocol usage/documentation

                c.    Audits

  9.    Update patient and family educational materials on the importance of prompt and early removal of IUCs.

10.    Educate staff (including radiology, transport, rehabilitation therapy staff [physical therapy, occupational therapy]) focusing on policy and procedure revision, insertion indication guidelines, insertion procedures, maintenance and care, catheter-bag placement, removal prompts or removal protocols, and bladder scanner use and procedures.

11.    Work with infection control and clinical informatics staff to audit and measure outcomes. Provide feedback to staff. Potential measurable outcomes include:

            CAUTIs/1,000 catheter days

            Catheter days/hospital days

            Postoperative catheter days/patient

            Proportion of catheterized/admitted patients from ED or OR

12.    Continually evaluate and update practice changes based on new evidence.

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