A nurse-driven protocol for removal of indwelling urinary catheters across a multi-hospital academic healthcare system.
Key Words: Performance improvement, nurse-driven removal protocol (NDRP), catheter-associated urinary tract infection (CAUTI), indwelling urinary catheter (IUC).
Catheter-associated urinary tract infections (CAUTIs) are one of the most common hospital-acquired infections in the United States (U.S.) (Centers for Disease Control and Prevention [CDC], 2015), and strategies aimed at CAUTI prevention are a global priority (World Health Organization [WHO], n.d.). In fiscal year (FY) 2013, one acute care hospital within our healthcare system had one of the highest CAUTI rates in the state of Pennsylvania. A prior clinical decision support (CDS) intervention utilizing evidence-based electronic alerts to remind providers regarding timely removal of indwelling urinary catheters (IUCs) (Bailie et al., 2014) was associated with a decline in this hospital's CAUTI rate from 3.6 infections per 1,000 device days in FY2010 to 2.5 in FY2012.
However, in spite of this intervention, CAUTI rates increased to 3.5 in FY2013. In response, a decision was made by executive leadership across our healthcare system to implement a performance improvement nurse-driven removal protocol (NDRP) for IUCs. All three urban acute care hospitals with our academic healthcare system (all in Pennsylvania) were targeted for the performance improvement project; in 2015, these hospitals had an average daily census of 789 (hospital #1), 354 (hospital #2), and 496 (hospital #3). Steps in this process, including a literature review, development and refinement of specific IUC orders, a system-wide education and implementation plan, and impact evaluation, are described in this article.
Basic practices aimed at CAUTI prevention are recommended for all acute-care hospitals and include infrastructure (e.g., providing guidelines and systems for documentation; appropriate personnel, supplies, and training); surveillance, including standardized criteria and a process for providing feedback; ongoing education and assessment of provider competencies; and appropriate insertion and management of IUCs (Yokoe et al., 2014). Special approaches to prevent CAUTIs (Yokoe et al., 2014), such as protocol development for management of post-operative urinary retention, systematic reporting and analysis of IUC use and adverse effects, and implementation of an organization-wide program to identify and remove IUCs when no longer necessary, are also recommended. Nurse-directed interventions have been highlighted as an important component of comprehensive CAUTI prevention efforts (Bernard, Hunter, & Moore, 2012; Fink et al., 2012; Oman et al., 2012; Saint et al., 2009, 2013; Underwood, 2015; Yokoe et al., 2014).
Three studies describe IUC management and CAUTI prevention strategies focused on either North American data (Fink et al., 2012) or a statewide (Saint et al., 2009) followed by national comparative (Saint et al., 2013) approach. Fink and colleagues (2012) employed an electronic survey method to collect and examine IUC practices for CAUTI prevention in 75 acute care hospitals in the U.S. and Canada where the Nurses Improving Care of Healthsystem Elderly (http:// www.nicheprogram.org/) geriatric nursing program was implemented as a standard of care. Although this study provides detailed information on nursing care practices focused on IUC care and CAUTI prevention, and many facilities reported having some type of IUC or CAUTI-prevention strategy(ies) in place, considerable variation was identified in all areas (e.g., equipment, training, management, documentation). For example, although recommended as a standard of care, 44% of the facilities surveyed had no strategy in place to address early IUC removal. Recommendations include emphasis on the nursing role in leading efforts to implement and standardize evidence-based techniques and policies, including annual training and staff education specific to IUC insertion and maintenance techniques.
In 2007, the state of Michigan launched the "Keystone Bladder Bundle Initiative" as a comprehensive strategy for reducing CAUTIs (Saint et al., 2009). This was followed by a mail survey to compare Michigan data (n = 78 Michigan hospitals) with data from a sample of hospitals across the U.S. (N = 392 non-Michigan hospitals) of CAUTI-prevention practices and CAUTI-specific infection rates (Saint et al., 2013). Key practices and measures in the Bladder Bundle include a NDRP and additional practice recommendations primarily initiated and performed by nurses (e.g., portable bladder ultrasound monitoring; IUC reminders and removal prompts; IUC care and consideration of alternatives to IUC placement) (Saint et al., 2009). When compared with other U.S. hospitals, Michigan hospitals reported more frequent use of CAUTI prevention practices, including reminders or nurse-directed IUC stop-orders (p < 0.001) (Saint et al., 2013). In addition, during a one-year period, Michigan hospitals reported a 25% decrease in CAUTI rates, while non-Michigan hospitals reported only a 6% reduction during that same time period (Saint et al., 2013).
Oman and colleagues (2012) described hospital-wide yet individualized (unit-based) nurse-directed interventions that incorporated other members of the interprofessional healthcare team, competency-based nursing staff education, appropriate selection and use of products (e.g., IUCs, bedside commodes, catheter tubing securement devices), regular catheter care nursing rounds, and patient and family involvement in the development of English and Spanish language educational materials. As an integral part of the process, almost all (96%) nursing staff completed training modules and in-service training on the use of a portable bladder ultrasound device (95% of staff on selected units). Although overall impact on CAUTI rates varied among units, the number of catheter days decreased on two units (surgery and medicine; p = 0.018 and p = 0.076, respectively), and discontinuation of silver alloy IUCs as a choice of device for use (which, prior to the study, were being used as the primary IUC device) resulted in a $52,000/year savings. The authors highlight the importance of considering a unit-based (rather than hospital-wide) program, particularly if hospital-wide approaches achieve only partial rather than all desired outcomes (Oman et al., 2012).
In a more recent publication, Underwood (2015) detailed a unit-specific (Neurosurgical and Neurological Intensive Care Unit) quality improvement (QI)/safety program to address CAUTIs and IUC utilization. A multi-faceted approach, titled the Comprehensive Unit-Based Safety Program (CUSP), included staff education focused on proper techniques for IUC insertion and documentation, optimal IUC care, guidelines for considering and obtaining urinalysis, urine culture and sensitivity, and IUC removal, and nursing staff's commitment to and responsibility for following established guidelines and adhering to educational standards. Retrospective data were collected to compare the impact of CUSP interventions. Implementation of new QI initiatives resulted in a significant decrease in total catheter days [p = 0.001), number of catheter days per month [p = 0.001), and overall catheter utilization (p = 0.001). CAUTI rates did not change significantly (pre- vs. CUSP: 21 vs. 17; p = 0.95). Recommendations stress the importance of nursing leadership, IUC guidelines and standards, and ongoing strategies to educate and empower healthcare providers in delivering excellent patient care.
These studies suggest that nurse-directed strategies are an important component for reducing unnecessary IUC utilization on a unit, hospital, and national level. In our healthcare system, all three acute care hospitals were involved in efforts to provide IUC care and prevent CAUTIs. Policies and procedures among the three acute care hospitals were similar but not standardized, and we had limited data on the effectiveness or utilization of these strategies. Our objective was to standardize and then evaluate IUC care and CAUTI prevention across the acute care facilities in our healthcare system.
The overall purpose of this project was to implement a NDRP for IUC in three acute care hospitals within our academic healthcare system. Specifically we aimed to: 1) reduce IUC utilization rates and 2) reduce CAUTI rates.
Performance Improvement Methods
First, a multidisciplinary workgroup came together and worked with our healthcare system's Center for Evidence-Based Practice to perform a systematic evidence review of IUC care and CAUTI prevention strategies (unpublished in-house document; Penn Medicine's Center for Evidence-Based Practice). Next, our group worked together to assess our current IUC ordering and removal process and identify requirements to build a nurse-driven IUC removal decision support tool, and ongoing nurse monitoring and removal documentation. A target date for deployment was determined, followed by additional essential steps to address the healthcare system's needs and meet the project timeline (see Table 1). Education and awareness were keys to adoption, and much of this was accomplished by leveraging existing unit-based and system committees as well as healthcare system-wide education online. Education provided for nursing included the development and deployment of an interactive self-learning module, unit-based educational in-services, clinical nurse specialist (CNS) day and night rounds, and the appointment of a unit-based clinical nurse "Champion" resource.
A pilot was deployed at the end of April 2014 in several units for which NDPR Default On was the pre-selected option for all IUC removal processes. Within the pilot units, providers would be required to unselect the NDRP if either of the two remaining options were desired. The remaining options included 1) Time and Condition, and 2) Provider Will Assess. First, the provider could select the specific time or a specific condition that needed to be met before the IUC could be removed. Once time or condition was met, the nurse could independently remove the IUC. Then, the provider would assess IUC need daily and enter a removal order when deemed appropriate. At the end of the pilot period (June 2014), a full-scale deployment was implemented, and the NDRP became the default option for IUC removal in all three of the acute care hospitals within the healthcare system (see Figure 1).
Data Collection and Analysis
To determine utilization of the NDRP, we measured NDRP "adoption rates" (defined as the proportion of provider orders where NDRP was selected as the removal option each month) following implementation of the NDRP in May 2014. To assess the clinical impact of the NDRP, we compared CAUTI rates and IUC device utilization for the 12-month baseline period (May 2013-April 2014) to the 12-month NDRP implementation period (June 2014-May 2015) for each hospital and for the healthcare system combined. CAUTI rates were calculated using device day and patient day denominators (Wright, Kharasch, Beaumont, Peterson, & Robicsek, 2011). Data from May 2014 were excluded from these analyses. The Stat Calc program in EpiInfo 7 (https:// www.cdc.gov/epiinfo/userguide/StatCalc/introduction. html), a free statistical and epidemiology software program from the CDC, was used to calculate the rate ratios, 95% confidence intervals, and p values for IUC device utilization and CAUTI rates. We adjusted CAUTI rates by excluding cases of CAUTI pre-2015 that met CDC CAUTI Surveillance Criteria 2 a (urine culture with 1,000 to 100,000 colony forming units per mL of a pathogen) or urine cultures growing greater than 100,000 Candida or yeast. These exclusions reflect changes to the CDC CAUTI surveillance definition effective January 2015 (CDC, 2015).
[FIGURE 1 OMITTED]
Adoption of the NDRP increased rapidly following the golive date and was selected for 40% to 60% of all IUC removal orders depending on the hospital (even after the go-live date, providers had options, such as Time and Condition or Provider Will Assess, and could choose these options based on clinical judgment and individual patient-related factors) (see Figure 2). For the healthcare system, NDRP was associated with no significant change in IUC utilization (see Table 2) and with a 19% reduction in CAUTI rates per 1,000 IUC days compared to the baseline period (p = 0.13) (see Table 3). The impact of the NDRP was greatest at hospital #1, where IUC utilization was reduced 6% and CAUTI rate per 1,000 IUC days was reduced 28% from baseline. The reduction in the CAUTI rate at hospital #1 was greater still using the patient day rather than device day denominator for comparison to baseline (relative reduction: 32% vs. 28%). Of note, hospital #1 had the highest baseline CAUTI rates and highest overall adoption of the NDRP. IUC utilization and CAUTI rates both increased significantly at hospital #2 following implementation of the NDRP. At hospital #3, where adoption of the NDRP was lowest, IUC utilization and CAUTI rates remained essentially unchanged.
[FIGURE 2 OMITTED]
The goal of this performance improvement project was to implement a NDRP for IUC in three acute care hospitals within our healthcare system, and in so doing, reduce IUC utilization and CAUTI rates. Management and ongoing care of an IUC is within the purview of nursing practice and plays an important role in reducing the risk of both infectious and non-infectious complications associated with IUC use (Saint et al., 2013; Underwood, 2015; Yoke et ah, 2014). Similar to descriptions of others published in recent years (Carter, Reitmeier, & Goodloe, 2014; Oman et al., 2012; Saint et al., 2009), our NDRP focused on a multi-faceted, evidence-based, interprofessional approach. Thus, by examining current, best evidence and then building a process that included engagement of an interprofessional team (e.g., staff nurses, physicians, nurse managers, unit-based CNSs, representatives from the health system's Clinical Information Systems and Center for Evidence-Based Practice departments), we re-educated nursing staff in three acute care hospitals regarding the assessment, placement, management, and early removal of IUCs. Education of ordering providers resulted in the selection of the NDRP for 40% to 60% of all IUC orders, and enhanced the decision-making skill and autonomy of the nurse providing direct patient care in assessing the daily need for an IUC. In addition, while providers did not choose the NDPR 100% of the time, we believe this reflects that in day-today practice, alternatives such as Time and Condition and Provider Will Assess are also important options that take into account individual patient needs and the provider's clinical judgment.
The NDRP was associated with negligible reduction (0.5%) in the overall IUC device utilization ratio for our three hospital healthcare system, but with wide variation at the level of individual hospitals, ranging from a relative 6% decrease to 18% increase in IUC device use. These results are consistent with previously published studies and performance improvement projects, where overall results varied among hospital units (Oman et al., 2012) and across individual hospitals nationwide (Fink et al., 2012). The observed differences were seen despite moderate and sustained selection of the NDRP by ordering providers at each of the hospitals. An order for NDRP will not result in earlier removal of an IUC if the patient continues to have an appropriate indication for catheter use or the criteria for removal are not accurately assessed and acted upon. It is likely that factors other than the implementation of the NDRP contributed to some differences in device utilization, including changes in case-mix index, staffing ratios, length of stay, and admission volumes over time. In addition, when we examined specific units, we found that twice daily electronic documentation of IUC indication use was substantially higher in the intensive care units compared to acute-care unit locations, suggesting that staffing ratios may be an additional factor impacting NDRP implementation (Olson-Sitki, Kirkbride, & Forbes, 2015).
The NDRP was associated with a non-significant 19% reduction in overall CAUTI rates, with 21 fewer CAUTIs observed compared to the baseline period. This overall reduction was due exclusively to the 28% reduction in CAUTI rates per 1,000 IUC days at hospital #1, where there were 30 fewer CAUTIs compared to baseline (61 vs. 91). Given the very low burden of CAUTIs at hospital #2, with only two CAUTIs reported during the baseline period, the four-fold increase in CAUTI rates observed during the NDRP implementation period may reflect regression to the mean or be due to other factors, including increased device utilization. Use of device days as a denominator may underestimate reductions in CAUTI risk associated with earlier catheter removal if the intervention results in only sicker patients at greater risk of CAUTI still having catheters (Wright et al., 2011). Therefore, we used a patient days denominator in addition to the IUC device days denominator to risk adjust CAUTI rates; we observed a slightly greater 21% reduction CAUTI rates across the health system and 32% reduction at hospital #1.
To facilitate comparison over time, we adjusted our CAUTI data for changes in the National Healthcare Safety Network CAUTI surveillance definitions that took effect in January 2015 (CDC, 2015). These changes included exclusion of low colony count urine cultures and Candida species from CAUTI criteria, and were implemented to account for differences in microbiology laboratory practices across the U.S. and evidence of limited clinical significance of Candiduria, respectively. Without this adjustment, there were approximately 45% more CAUTI cases during the baseline period, and it is possible that the impact of the NDRP may have been greater than that reported herein.
This performance improvement project highlights important steps in developing and implementing a NDRP for IUCs across a multi-hospital healthcare system. Our study has several important limitations. We focused our educational efforts on the pre-implementation phase and did not formally assess provider barriers to the use of the NDRP or other active IUC removal options once the order set was implemented. This approach may have contributed to suboptimal selection of and adherence to the NDRP over time. We were also not able to assess other human and systems factors that potentially impact the decision to leave an IUC in place or to assess differences in patient characteristics or other care practices that may have influenced the risk of CAUTI. Despite inclusion of three acute care hospitals across a large healthcare system, results may not be generalizable to other settings or healthcare systems. Nevertheless, our study provides an important contribution to the literature on CAUTIs and specific nursing interventions to optimize care and address prevention strategies.
Summary and Conclusions
Keys to the success of this project included 1) a solid multidisciplinary team, including nursing, physician providers, information systems staff, system education teams, infection preventionists, evidence analysts, and data scientists; 2) strong support of executive leadership; and 3) engagement of physicians, nursing staff, and others involved in patient care on individual care units. Next steps include expanding this initiative to include additional acute care hospitals that have more recently joined our healthcare system and exploring barriers to early adoption of the NDRP.
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Sitha Dy, MSN, RN-BC, CNS, CCNS, is a Clinical Nurse Specialist, Hospital of the University of Pennsylvania, Philadelphia, PA.
Bridget Major-Joynes, MSN, RN, CNS, is a Clinical Nurse Specialist, Hospital of the University of Pennsylvania, Philadelphia, PA.
David Pegues, MD, is a Professor of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA.
Christine Bradway, PhD, RN, FAAN, is an Associate Professor of Gerontological Nursing/University of Pennsylvania School of Nursing and Hospital of the University of Pennsylvania, Philadelphia, PA.
Acknowledgements: The authors gratefully acknowledge our colleagues: Diane Newman, DNP, ANP-BC, FAAN, BCB-PMD; Penn Medicine's Center for Evidence-Based Practice; Joanne Resnic, MBA, BSN, RN, Associate Clinical Informatics Officer; and all of the nurses and interprofessional staff within our healthcare system who work every day to provide excellence in patient care.
Table 1. Project Timeline for Indwelling Urinary Catheter (IUC) Nurse Directed Removal Protocol (NDRP) January- June-July February March Activity 2013 2014 2014 Center for Evidenced-Based Practice X report completion Clinical decision support development X X of project team, policy, protocols and build elements Create online education X X materials--nursing staff Standard protocol and policies across X X healthcare system IUC order set clean up (N = 191 order X X sets) Identification of "NDRP Default On" X units Create clinician awareness and X information materials Active provider education X Finalize build elements and testing X Determine evaluation criteria Launch Evaluate with focus on units with NDRP as Default Deploy "NDRP as Default" system-wide April May June Activity 2014 2014 2014 Center for Evidenced-Based Practice report completion Clinical decision support development X of project team, policy, protocols and build elements Create online education materials--nursing staff Standard protocol and policies across healthcare system IUC order set clean up (N = 191 order X sets) Identification of "NDRP Default On" X units Create clinician awareness and X information materials Active provider education X Finalize build elements and testing X Determine evaluation criteria X Launch April 28 Evaluate with focus on units with X X X NDRP as Default Deploy "NDRP as Default" system-wide June 2 Table 2. Indwelling Urinary Catheter (IUC) Use by Hospital and Overall Healthcare System (HCS) Device IUC Patient Utilization Hospital Period Days Days Ratio #1 Baseline period 40,442 216,668 0.187 Performance period 37,440 213,663 0.175 #2 Baseline period 11,646 61,959 0.187 Performance period 14,984 67,732 0.221 #3 Baseline period 13,144 85,525 0.154 Performance period 12,709 84,019 0.151 HCS Baseline period 65,232 364,152 0.179 Performance period 65,133 365,414 0.178 Rate Ratio Hospital Period (95% Confidence Interval) p-Value #1 Baseline period 0.94 (0.93-0.95) < 0.001 Performance period #2 Baseline period 1.18 (1.15-1.20) < 0.001 Performance period #3 Baseline period 0.98 (0.96-1.01) 0.16 Performance period HCS Baseline period 0.995 (0.98-1.05) 0.32 Performance period Note: Baseline Period, May 2013-April 2014; Performance period, June 2014-May 2015 Table 3. Catheter-Associated Urinary Tract Infection (CAUTI) Rates per 1,000 Indwelling Urinary Catheter (IUC) Device Days and 1,000 Patient Days by Hospital and Overall Healthcare System (HCS) CAUTI CAUTI Rate/1,000 Hospital Period Count IUC Days Device Days #1 Baseline period 91 40,442 2.25 Performance period 61 37,440 1.63 #2 Baseline period 2 11,646 0.17 Performance period 11 14,984 0.73 #3 Baseline period 15 13,144 1.14 Performance period 15 12,709 1.18 HCS total Baseline period 108 65,232 1.65 Performance period 65,133 1.33 Rate Ratio (95% Hospital Confidence Interval) p-Value #1 0.72 (0.52-1.00) 0.05 #2 4.27 (0.95-19.28) 0.04 #3 1.03 (0.51-2.11) 0.92 HCS total 0.81 (0.61-1.07) 0.13 CAUTI CAUTI Patient Rate/1,000 Hospital Period Count Days Patient Days #1 Baseline period 91 216,668 0.42 Performance period 61 213,663 0.28 #2 Baseline period 2 61,959 0.032 Performance period 11 67,732 0.16 #3 Baseline period 15 85,525 0.18 Performance period 15 84,019 0.18 HCS total Baseline period 108 364,152 0.30 Performance period 87 365,414 0.24 Rate Ratio Hospital (95% confidence Interval) p-Value #1 0.68 (0.49-0.94) 0.02 #2 5.03 (1.12-22.70) 0.02 #3 1.02 (0.50-2.08) 0.96 HCS total 0.80 (0.61-1.06) 0.13 Note: Baseline Period, May 2013-April 2014; Performance period, June 2014-May 2015
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|Title Annotation:||Research/Quality Improvement Project|
|Author:||Dy, Sitha; Major-Joynes, Bridget; Pegues, David; Bradway, Christine|
|Date:||Sep 1, 2016|
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