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Implementing a CAUTI Prevention Program in an Acute Care Hospital Setting.

Healthcare-associated infections are the most common complication of an inpatient hospitalization (Agency for Healthcare Research and Quality, 2015). Catheter-associated urinary tract infections (CAUTIs) are the fourth leading cause of healthcare-associated infections in acute care hospitals in the United States (Magill et al., 2014). A CAUTI is a urinary tract infection that occurs in a patient who has (or had) an indwelling urinary catheter in place at the time of or within 48 hours prior to the onset of infection. According to the Centers for Disease Control and Prevention (CDC) (2012), 15% to 25% of patients who are admitted to the hospital will have a urinary catheter inserted at some point during their stay, placing them at risk of developing a CAUTI. Annually, an estimated 13,000 deaths are attributed to CAUTIs. In addition, they are the leading cause of secondary bloodstream infections, with a mortality rate of approximately 10% (CDC, 2012).

The impact of CAUTIs to the patient and the healthcare system include patient discomfort, increased mortality, longer length of hospital stay, and higher healthcare costs. The average cost to treat a single patient with a CAUTI is estimated to be $758 with an annual cost of over $340 billion in the United States (Centers for Medicare and Medicaid Services [CMS], 2016). Currently, no costs associated with the treatment of a CAUTI are reimbursable; they must be absorbed by the healthcare entity. This practice dates back to 2008, when CMS identified CAUTI as a hospital-acquired condition, thus prompting hospitals across the country to implement CAUTI prevention programs. A healthcare organization that continues to experience CAUTIs may be penalized through a reduction in Medicare payments. Robust, cost-effective interventions designed to reduce the negative outcomes and burden of CAUTIs are imperative.

A CAUTI can occur in multiple ways during urinary catheterization and may include the migration of bacteria from the urethra, rectum, or vagina; contamination from healthcare provider hands; a break in the sterile field during catheter insertion; or from manipulation of the collection system (CDC, 2012). The risk of bacteriuria (bacteria in the urine) from an indwelling urinary catheter is 3% to 10% per day and reaches 100% after 30 days (Seckel, 2013). Therefore, one major risk factor for a CAUTI is having an indwelling urinary catheter in place for an extended period. Additional risk factors include a disconnection of the drainage system and having lesser-trained professionals insert urinary catheters (CDC, 2012). Nurses can play a key role in preventing CAUTIs among hospitalized patients, and subsequently, impact the outcomes and burden of CAUTIs by adhering to evidence-based practice guidelines.

Purpose

The purpose of this quality improvement (QI) project was to implement an interactive CAUTI prevention educational program in two units of an acute care hospital, selected based on having experienced the highest CAUTI rates among all hospital units. Specifically, this project aimed to enhance nurses' knowledge of appropriate indwelling urinary catheter care, and reduce the incidence of CAUTIs on the units.

Review of Relevant Literature

To identify the body of evidence to guide the development of a CAUTI prevention educational program for this project, a literature search was conducted utilizing the PubMed, Cochrane Collaborative, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Key search terms included catheter-associated urinary tract infections, CAUTI, urinary tract infections, staff education, nurses' knowledge, and infection prevention. Articles published in English and after 2012 were retrieved and reviewed. Literature on nurses' knowledge related to catheter care and on multifaceted CAUTI prevention educational programs were deemed particularly important to this project and are discussed here.

Nurses' Knowledge

Overall, nurses' and other healthcare providers' knowledge of evidence-based practices for indwelling urinary catheter care is limited. Jain, Dogra, Mishra, Thakur, and Loomba (2015) assessed the knowledge and attitudes of a sample of healthcare providers (i.e., nurses and physicians) regarding indications for catheterization and methods of preventing CAUTIs, and only 57% could identify all measures for the prevention of a CAUTI correctly. The finding suggests healthcare providers need reinforcing education on CAUTI prevention methods.

Viswanathan and colleagues (2015) utilized survey methodology to examine the current knowledge, attitudes, and practices regarding indwelling urinary catheter placement and management among a sample of various healthcare providers that included emergency nurses, attending physicians, nurse practitioners, physician assistants, and resident physicians. Ninety-one percent of nurses (and 87% of other providers) reported comfort with the appropriate indications for catheter placement. However, despite their self-report of comfort, nurses could correctly identify the appropriate indications for placement in only 40% of the cases presented and the remaining provider sample in only 37% of cases. In addition, the authors found few nurses (or other providers) reported they reassessed their patients for indications for the removal of an indwelling catheter after insertion, subsequently increasing each patient's risk of developing a CAUTI. While data indicate nurses and other providers reported comfort with the appropriate indications of catheter placement, their reported practice behaviors were inconsistent with their knowledge.

Gesmundo (2016) utilized a mixed-method approach to evaluate the impact of a multi-faceted CAUTI education package on nurses' attitudes towards, knowledge of, and barriers to indwelling catheter management. Quantitatively, there was a significant increase in nurses' knowledge of catheter care following the education intervention. Qualitative analysis of focus group data revealed several themes, including nurses felt the decision to insert, re-insert, and/or remove a catheter relied heavily on physicians; the existence of post-operative protocols made nurses feel empowered to remove catheters; and nurses were aware of the existence of organizational policies yet were unsure where to find the information. Inconsistencies between the evidence base and actual practice behaviors were identified and included the use of saline solution to inflate the balloon, type of dressing used to secure the catheter, and placing the catheter drainage bag on the floor.

Multifaceted CAUTI Prevention Programs

In addition to enhancing nurses' knowledge of guideline-concordant indwelling urinary catheter care, the literature supports the use of multifaceted educational programs in decreasing CAUTI rates and duration of catheter use, and improving healthcare workers' adherence to guideline recommendations.

Singh, Kumar, Sundaram, Kanjilal, and Nair (2012) implemented a modular training program on healthcare-associated infections (including CAUTIs) to surgeons, anesthesiologists, perfusion technologists, nurses, operating room technicians, and housekeeping staff on a cardiovascular unit of a tertiary care hospital. The program included didactic sessions, videos, quizzes, role plays, and tests. Results showed a reduction in CAUTI rates from 37% to 3.48% and improvement in subjects' performance of catheter care. In a QI project conducted in the general medical-surgical and general surgical units of an academic medical center, Purvis and colleagues (2014) demonstrated a reduction in CAUTI rates (from 4.2 to 2.4 per 1,000 catheter days) along with a downward trend for catheter utilization days (from 8 to 3) through a multifaceted CAUTI prevention program that included protocols, an educational workshop, CAUTI champions, and daily rounding.

Andrioli, Furtado, and Medeiros (2016) implemented a multifaceted intervention and assessed its impact on the incidence of CAUTIs, urinary catheter utilization ratios, and adherence to recommendations for indwelling urinary catheters use among nurses in a cardiac intensive care unit. Overall, the incidence of CAUTIs decreased by 61.7% during the study period, and the nurses' ability to correctly answer questions related to indwelling urinary catheter protocol management increased significantly. An improvement in practice behaviors was also observed. Specifically, the nurses' performance of hand hygiene prior to the insertion of an indwelling urinary catheter increased from a baseline of 9% to 100% adherence.

The CAUTI rate decreased to zero (from 30.4%) among adult patients admitted to medical wards following a multifaceted intervention, implemented for nurses and clinical officer interns, that included a lecture series, education videos, reminder signs, and weekly infection prevention rounds in a study by Tillekeratne and colleagues (2014). In addition to meeting the study goals of reducing inappropriate urinary catheter use and CAUTI rates, findings revealed an improvement in nurses' knowledge regarding appropriate vs. inappropriate indications for urinary catheterization and an increase in the number of catheters that were placed to gravity drainage.

Rosenthal and colleagues (2012) studied over 56,000 hospitalized patients across 57 intensive care units in 15 countries to evaluate the impact of a multidimensional infection control strategy to reduce the incidence of CAUTIs among adults hospitalized in intensive care units. Utilizing a bundle of infection control interventions that consisted of education and training on the insertion and maintenance care of urinary catheters, alternatives to indwelling catheters, and procedures for catheter insertion and removal, CAUTI rates decreased from 7.86 to 4.95 per 1,000 catheter days (p=0.00), a 37% reduction across the study sites. Compliance with the urinary catheter care protocol among healthcare workers increased to 97%.

In summary, the studies reviewed here indicate nurses' knowledge of indwelling urinary catheter care and CAUTI prevention methods is suboptimal (Andrioli et al., 2016; Gesmundo, 2016; Jain et al., 2015) and that CAUTI prevention interventions that include staff education and training on indwelling urinary catheter care and maintenance have a positive impact on decreasing the number of CAUTIs in the hospital setting (Andrioli et al., 2016; Purvis et al., 2014; Rosenthal et al., 2012; Singh et al., 2012; Tillekeratne et al., 2014).

Multifaceted prevention programs are effective in decreasing the incidence of CAUTI rates and for enhancing nurses' knowledge of CAUTI prevention strategies and indwelling urinary catheter care (Andrioli et al., 2016; Gesmundo, 2016; Purvis et al., 2014; Rosenthal et al., 2012; Singh et al., 2012; Tillekeratne et al., 2014). Successful interventions include educational training sessions/workshops, catheter removal protocols, nurse champions, daily rounding, competency training, and electronic health record reminders. In addition, several different teaching strategies, including face-to-face instruction, videos, self-assessment, computer modules, and hands-on skills demonstration, have demonstrated success in enhancing nurses' knowledge of indwelling urinary catheter care.

Educational Program Intervention

A review of the evidence-based literature guided the development of an interactive CAUTI prevention educational program for this QI project. The program employed a multifaceted approach to education and included face-to-face instruction utilizing a PowerPoint[R] slide presentation with video clips, knowledge assessment, and skill acquisition and competency demonstration with feedback.

Program content was developed from evidence-based practice guidelines on indwelling urinary catheter care (Association for Professionals in Infection Control and Epidemiology, 2014; CDC, 2012; Gould et al., 2009) and included the definition of CAUTI, risks and complications of CAUTIs, appropriate (and inappropriate) indications for an indwelling urinary catheter, strategies for CAUTI prevention, and a review of the hospital's indwelling urinary catheter policy. Video clips on proper indwelling urinary catheter insertion technique and maintenance were utilized. Urologists affiliated with the hospital and the Director of Infection Control reviewed and approved the educational program.

Method

A pre/post-survey design was used to examine the effect of the one-time educational program on nurses' knowledge of appropriate indwelling urinary catheter care and incidence of CAUTIs. Exempt status was granted by the Institutional Review Boards of the hospital and the associated university.

Setting and Sample

Two units within a 393-bed acute care hospital in the Southeastern region of the United States were selected for this project based on their high rates of CAUTIs for the first quarter of 2016. The two units included neurotrauma intensive care (4.12 per 1,000 catheter days) and telemetry (7.49 per 1,000 catheter days). All nurses (RNs and LPNs) on the units were required to attend the one-hour educational program.

Measures

Nurses' knowledge. A 14 item self-report survey was used to assess nurses' knowledge of appropriate indwelling urinary catheter care (see Table 1). The items were selected from an 18-item survey originally developed by Drekonja, Kuskowski, and Johnson (2010) to measure nurses' knowledge of indications for urinary catheter placement and the prevention of CAUTIs. Specifically, the 14 items selected represented three of the four subscales of the original 18-item survey and were used with the author's permission.

The knowledge of institutional policies subscale consisted of three items that asked participants for a yes/no response to questions regarding their knowledge of current facility policies. Responses were scored "1" for yes and "0" for no.

A second subscale, indications for Foley catheter use, consisted of five items presented in 5-point Likert format (1 = not indicated; 5 = always indicated) that assessed knowledge regarding catheter indications in specific clinical situations. The third subscale, methods to prevent catheter related infections (CAUTIs), included six items presented in 5-point Likert format (1 = not effective at all; 5 = very effective) and measured knowledge regarding CAUTI prevention. Items on the latter two subscales were scored as "correct" or "incorrect" based on published evidence and expert opinion on urinary catheter care. Appropriate indications for catheterization (scored "correct") included critical illness/unstable volume status and post-bladder urinary obstruction. Urinary incontinence, inability to stand to void, and increased diuretic dose were scored as "incorrect." For methods to prevent CAUTI, all items except one (i.e., antimicrobial agents added to drainage bag) were "correct." Each "correct" response was scored 1 and each "incorrect" response scored 0. Scores for each subscale were obtained by summing the items for the subscale. A knowledge summary score was obtained by summing the responses of all 14 items. For the summary and subscale scores, higher scores reflected a higher level of knowledge.

CAUTI rates. CAUTI rates were determined according to CDC criteria for CAUTIs (CDC, 2017), and by dividing the number of infections by the number of urinary catheter line days, multiplied by 1,000. CAUTI rates were reported per 1,000 catheter days. Data were collected by the Director of Infection Control on a weekly basis for each of the two units for the quarter (three-month period) preceding, and again for the quarter following completion of the educational intervention.

Procedure

Over a three-month period, the educational program was delivered by the project leader to the nurses. Each session was limited to five participants to facilitate instruction and discussion time. Participants were asked to voluntarily complete the 14-item knowledge survey at the start of the session. All nurses then received face-to-face instruction with PowerPoint presentation and video clips. At the end of the session, they voluntarily completed the knowledge survey once again. The nurses were then asked to demonstrate skills competency. The nurses' use of proper technique was observed and assessed by the project leader who observed each nurse insert an indwelling urinary catheter on a manikin. A checklist, developed in collaboration with the hospital's nurse specialist, was used as an educational tool to facilitate skill acquisition and competency (see Table 2). Each nurse received immediate feedback from the project leader during the skills demonstration. Proper technique was reinforced to each nurse upon the observation of incorrect technique by the project leader, as indicated.

During the quarter immediately following implementation of the educational program, each bedside nurse caring for a patient with an indwelling urinary catheter was responsible for assessing daily the patient for signs and/or symptoms of a urinary tract infection, and if suspected, to notify the patient's primary care provider and collect a urine specimen for culture testing. Urine cultures were evaluated according to CDC criteria, with no more than two species of organisms present, and at least one of which was a bacterium of [greater than or equal to] 105 CFU/ml (CDC, 2017).

Data Analysis

Statistical analysis was conducted using SPSS Version 22.0 (IBM Corp., Armonk, NY). Descriptive statistics were used to assess nurses' knowledge and CAUTI rates. Paired sample t tests were used to examine differences in pre/post-knowledge summary and subscale scores. An alpha level of 0.05 was used for all statistical analysis.

Results

A total of 67 nurses worked on the two units. Of these, 59 (88%) participated in the educational program and completed the voluntary pre/post-knowledge survey. No identifying or demographic data were collected. Results presented below reflect data from the combined total sample of nurses (N=59).

The nurses' knowledge summary and subscale scores pre/ post-educational program are presented in Table 3. Mean knowledge summary scores ranged from 6 to 13 (pre) and 9 to 14 following the program. A paired t test revealed a significant increase in the nurses' overall knowledge following the program (p=0.00). The mean increase in summary score was 2.59, 95% CI [-0.31, -2.06].

Paired t tests were used to assess for differences in the three pre/post-knowledge subscale scores. A significant increase in scores (all p=0.00) was observed in each of the three subscales following the educational program. Descriptive analysis of the individual items included in each of the knowledge subscales is displayed in Table 4. Nurses' knowledge increased for 13 of the 14 survey items. Fewer nurses (10.2% fewer) correctly identified antimicrobial-coated catheter as a method to prevent catheter related infections following the educational program on this survey item.

The greatest change from "incorrect" to "correct" responses following the education program was found among items of the indications for Foley catheter use subscale. In particular, for inappropriate indications for Foley catheter placement, there was a 49% increase among nurses who recognized incontinence without skin breakdown, 39% increase in recognizing a new prescription for or change in diuretic dose, 34% increase in recognizing post-bladder obstruction, and 27% increase in recognizing an inability to stand to void.

Table 4 also shows most nurses reported having knowledge about the institution's policies on indwelling urinary catheter care (i.e., standardized orders, formalized system, standardized monitoring) before completing the educational program, and data revealed an increase of knowledge about each of these policies following the education program. Most notably, there was a 22% increase in knowledge about the institution's formalized system of guidance on when to insert or remove a Foley catheter.

CAUTI rates were measured pre/post-educational program, and declines were observed in both units. For the quarter preceding the intervention, the mean CAUTI rate on the telemetry unit was 7.49 per 1,000 catheter days. The rate decreased to 0 per 1,000 catheter days in the quarter following the intervention. A reduction in CAUTI rate from a mean of 4.12 to 1.56 per 1,000 catheter days was observed in the neurotrauma intensive care unit during the same quarterly time point.

Discussion

The purpose of this QI project was to implement an interactive CAUTI prevention educational program in two units of an acute care hospital to enhance nurses' knowledge of appropriate indwelling urinary catheter care and reduce the incidence of CAUTIs on the units. Findings demonstrate both aims were met.

Consistent with the evidence-based literature, this project demonstrated a multifaceted, interactive CAUTI prevention educational program can enhance nurses' knowledge of appropriate indwelling urinary catheter care. Significant increases in knowledge were observed across the knowledge summary and three knowledge subscale scores following participation in the educational program. Further, frequencies of correct responses increased for 13 of the 14 items included in the knowledge survey. However, 10% fewer nurses correctly identified antimicrobial-coated catheter as a method to prevent catheter related infections following the educational program. A possible explanation for this finding may be in how the information was presented during the educational session. The CDC recommends that if CAUTI rates do not decrease after implementing a comprehensive CAUTI prevention program, a hospital should then consider using antimicrobial-coated catheters. It is possible the nurses may have inaccurately interpreted this CDC recommendation as antimicrobial-coated catheters are not an effective method for CAUTI prevention.

The second aim of this QI project was to reduce the incidence of CAUTIs on the two units that experienced the highest CAUTI rates across the hospital's units during the quarter prior to project implementation. To this end, CAUTI rates declined in both the neurotrauma intensive care and telemetry units in the quarter following the educational program. This finding is also consistent with the evidence-based literature and demonstrated that a multifaceted, interactive CAUTI prevention educational program can effectively decrease the incidence of CAUTI among hospitalized patients.

There are a few limitations of this project worth noting. At the time this project was conducted, no reliability data were available for the survey used to measure nurses' knowledge of appropriate indwelling urinary catheter care. The need exists for the development of an appropriate knowledge survey tool with demonstrated reliability. Several efforts were made by the project leader to enable all units' nurses to attend an educational session (such as scheduling additional days and times, communication with the unit nurse managers, and letters and flyers posted throughout the units to remind nurses of the educational sessions). While most nurses on the two units participated, the 12% who did not attend the educational program may have differed from those who did attend, and therefore, findings may not be reflective of the entire population of nurses on the two hospital units. Further, generalizability cannot be extended to nurses on the other units of the hospital or to other hospitals because they may also differ from the cohort of nurses who participated in this project.

Performance Improvement Model

The Evidence-Based Change Model was utilized to develop this QI project by identifying the clinical problem; linking the problem with interventions and outcomes based on research; synthesizing the best practices; developing, implementing, and evaluating the program; and finally, by expanding and maintaining the change in practice (Rosswurm & Larrabee, 1999). The first step involved identifying unit-specific CAUTI rates that were high when compared to the other hospital units. The second and third steps involved a rigorous review of the evidence base related to interventions to increase nurses' knowledge of urinary catheter care and the reduction of CAUTIs in the acute care hospital setting. Each study was critically appraised in terms of its feasibility, benefits and risks, and strength of evidence. The fourth and fifth steps involved the development and implementation of the educational program on the two specific units with an evaluation of the outcomes. Based on the success of this project, the sixth step involved the dissemination of the educational program hospital-wide through the subsequent development of an online learning module.

Implications for Nursing

Nurses' knowledge of indwelling urinary catheter care improved after implementation of the educational program and the nurses were very supportive of the program. Anecdotal comments made by the nurses to the project leader included: "This information was a great update", "I was unaware of the appropriate indications for urinary catheters;" "I didn't know how to secure the catheter;" and "I didn't know the drainage system needed to stay closed." This program allowed the project leader to clarify any misunderstandings of nursing staff regarding catheter care in a non-threatening learning environment.

Based on the demonstrated success of this project, the Director of Infection Control subsequently wanted the hospital's entire nursing staff to receive this CAUTI prevention educational program. Considering the hospital employs over 1,800 nurses, the decision was made to develop an online learning module that could be delivered to the hospital's nursing staff in an easy, cost-effective way. The project leader worked in collaboration with the hospital's information technology staff to develop an online module that was then disseminated to the entire nursing staff.

The resources and costs needed to implement this project were minimal compared to the cost of treating a single patient with a CAUTI. The overall cost of the project was less than $200 for the printed materials and handouts. The project leader volunteered her time to educate the nurses. The mannequin used to facilitate skill acquisition and demonstration of skill competency was supplied by the hospital. The feasibility and sustainability of this QI project was demonstrated by the request and subsequent dissemination of the educational program to the hospital's entire nursing staff, enabling many nurses to complete the online training module in a time-efficient manner, with minimal cost to the hospital. This CAUTI prevention program could easily be adapted to meet the needs of other nurses and healthcare workers across a wide variety of institutions, ranging from the small, rural hospital to the large, multispecialty institution, across geographic areas.

Conclusion

The impact of CAUTIs to the patient and the healthcare system includes patient discomfort, increased mortality, longer length of hospital stay, and higher healthcare costs. Fortunately, most CAUTIs can be prevented if evidence-based practice guidelines for indwelling urinary catheter care are followed. This QI project was implemented on two units of an acute care hospital that experienced the highest CAUTI rates across the hospital's units. The project focused on decreasing the incidence of CAUTIs by educating the nursing staff on evidence-based practices for indwelling urinary catheter care. Findings demonstrated a statistically significant increase in nurses' knowledge of indwelling urinary catheter care and a decrease in CAUTI rates in both units. This project was a cost-effective method to improve quality of care in the acute care hospital setting.

Research Summary

Introduction

Catheter-associated urinary tract infections (CAUTIs) are the fourth leading cause of healthcare-associated infections in acute care hospitals in the United States. Nurses can play a key role in preventing CAUTIs among hospitalized patients, and subsequently, impact the outcomes and burden of CAUTIs by adhering to evidence-based practice guidelines.

Purpose

The purpose of this quality improvement (QI) project was to implement an interactive CAUTI prevention educational program in two units of an acute care hospital to enhance nurses' knowledge of appropriate indwelling urinary catheter care and reduce the incidence of CAUTIs experienced among patients on the units.

Methods

Two units within a 393-bed acute care hospital were selected based on their high rates of CAUTIs. The units' nurses participated in a one-hour multifaceted, interactive CAUTI prevention educational program that included faceto-face instruction, knowledge assessment, and skill acquisition with competency demonstration. A pre/post-design was used to assess nurses' knowledge of indwelling urinary catheter care and CAUTI incidence for each unit.

Results

A total of 59 nurses completed the educational program over a three-month period. Paired /'tests revealed significant increases in the nurses' knowledge summary score and across all three knowledge subscale scores (all p=0.00). A reduction in CAUTI rates was observed in both hospital units. CAUTI rates declined to zero (from 7.49) and to 1.56 (from 4.12) per 1,000 catheter days, respectively, in the quarter following implementation of the educational program.

Conclusion

Consistent with the evidence-based literature, this QI project demonstrated a multifaceted, interactive CAUTI prevention educational program can increase nurses' knowledge of appropriate indwelling urinary catheter care and decrease the incidence of CAUTI among hospitalized patients. It was a feasible and sustainable, cost-effective method to improve quality of care in the acute care hospital setting.

Level of Evidence--V-B

Source: Johns Hopkins Hospital/Johns Hopkins University, 2016.

Instructions for Continuing Nursing Education Contact Hours

Implementing a CAUTI Prevention Program in an Acute Care Hospital Setting

Deadline for Submission: December 31, 2020 UNJ 1806

To Obtain CNE Contact Hours

1. For those wishing to obtain CNE contact hours, you must read the article and complete the evaluation through SUNA's Online Library. Complete your evaluation online and print your CNE certificate immediately, or later. Simply go to www.suna.org/library.

2. Evaluations must be completed online by December 31, 2020. Upon completion of the evaluation, a certificate for 1.4 contact hour(s) may be printed.

Learning Outcome

After completing this learning activity, the learner will be able to identify best practice related to indications for catheter insertion and appropriate indwelling catheter care in hospitalized patients to reduce the incidence of CAUTI.

Learning Engagement Activity

1. Review Table 2. Compare your facility's policy/procedure for Foley catheter insertion to the one in the table. Does your procedure reflect best practice?

2. Visit the Agency for Healthcare Research and Quality (AHRQ) website (https://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/cautihospitals/index.html) to access the "Toolkit for Reducing CAUTI in Hospitals."

Articles in the SUNA Online Library are FREE for SUNA Members. / CNE Evaluation Fee--$15

The author(s), editor, editorial board, content reviewers, and education director reported no actual or potential conflict of interest in relation to this continuing nursing education article.

This educational activity is provided by the Society of Urologic Nurses and Associates (SUNA).

SUNA is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

SUNA is a provider approved by the California Board of Registered Nursing, provider number CEP 5556. Licensees in the state of California must retain this certificate for four years after the CNE activity is completed.

This article was reviewed and formatted for contact hour credit by Michele Boyd, MSN, RN-BC, SUNA Education Director.

References

Agency for Healthcare Research and Quality (AHRQ). (2015). Toolkit for reducing CAUTI in hospitals. Retrieved from https://www.ahrq. gov/professionals/quality-patientsafety/hais/tools/cauti-hospitals/ index.html

Andrioli, E.R., Furtado, G.H., & Medeiros, E.A. (2016). Catheter-associated urinary tract infection after cardiovascular surgery: Impact of a multifaceted intervention. American Journal of Infection Control, 44(3), 289-293. doi:10.1016/j.ajic.2015.09.030

Association for Professionals in Infection Control and Epidemiology. (2014). APIC implementation guide: Guide to preventing catheter-associated urinary tract infections. Retrieved from http://apic.org/Resource_/EliminationGuideForm/0ff6ae59-0a3a-464097b5-eee38b8bed5b/File/CAUTI_06.pdf

Centers for Disease Control and Prevention (CDC). (2012). Catheter-associated urinary tract infection (CAUTI) toolkit. Retrieved from https://www.cdc.gov/hai/pdfs/tool kits/cautitoolkit_3_10.pdf

Centers for Disease Control and Prevention (CDC). (2017). Urinary tract infection (catheter-associated urinary tract infection [CAUTI] and non-catheter associated-urinary infection [UTI]) and other urinary system infections [USI] events. Retrieved from: https:// www.cdc.gov/nhsn/pdfs/pscmanual/ 7psccauticurrent.pdf

Centers for Medicare and Medicaid Services (CMS). (2016). Hospital-Acquired Condition Reduction Program (HACRP). Retrieved from https://www.cms.gov/ Medicare/Medicare-Fee-for-Service Payment/AcuteInpatientPPS/HACReduction-Program.html

Drekonja, D.M., Kuskowski, M.A., & Johnson, J.R. (2010). Internet survey of Foley catheter practices and knowledge among Minnesota nurses. American Journal of Infection Control 38(1), 31-37. doi:10.1016/j. ajic.2009.05.005

Gesmundo, M. (2016). Enhancing nurses' knowledge on catheter-associated urinary tract infection (CAUTI) prevention. Kai Tiaki Nursing Research, 7(1), 32-40.

Gould, C.V., Umscheid, C.A., Agarwal, R.K., Kuntz, G., Pegues, D.A., & the Healthcare Infection Control Practices Advisory Committee. (2009) Guideline for prevention of catheter-associated urinary tract infections. Retrieved from https://www.cdc. gov/infectioncontrol/pdf/guidelines/cauti-guidelines.pdf

Jain, M., Dogra, V., Mishra, B., Thakur, A., & Loomba, P.S. (2015). Knowledge and attitude of doctors and nurses regarding indications for catheterization and prevention of catheter-associated urinary tract infection in a tertiary care hospital. Indian Journal of Critical Care Medicine 19(2), 76-81. doi:10.4103/0972-5229.151014

Johns Hopkins Hospital/Johns Hopkins University. (2016). Johns Hopkins Nursing Evidence-Based Practice Model--Appendix C: Evidence level and quality guide. Retrieved from http://www.hopkinsmedicine.org/ evidence-based-practice/jhn_ebp.html

Magill, S.S., Edwards, JR., Bamberg, W., Beldavs, Z.G., Dumyati, G., Kainer, M.A., ... Fridkin, S.K. (2014). Multistate point-prevalence survey of health care-associated infections, New England Journal of Medicine. 370, 1198-1208. doi:10.1056/NEJMoa1306801

Purvis, S., Gion, T., Kennedy, G., Rees, S., Safdar, N., VanDenBergh, S., & Weber, J. (2014). Catheter-associated urinary tract infection: a successful prevention effort employing a multipronged initiative at an academic medical center. Journal Nursing Care Quality, 29(2); 141-148. doi:10.1097/NCQ.0000000000000037

Rosenthal, V.D., Todi, S.K., Alvarez-Moreno, C., Pawar, M., Kariekar, A., Zeggwagh, A.A., ... Ulusoy, S. (2012). Impact of a multidimensional infection control strategy on catheter-associated urinary tract infection rates in the adult intensive care units of 15 developing countries: Findings of the International Nosocomial Infection Control Consortium (INICC). Infection, 40(5), 517-526. doi:10.1007/ s15010-012-0278-x

Rosswurm, M.A., & Larrabee, J.H. (1999). A model for change to evidence based practice. Image: The Journal of Nursing Scholarship, 31(4), 317-322. doi:10.1111/j.1547-5069.1999.tb00510.x

Seckel, M. (2013). Maintaining urinary catheters: What does the evidence say? Nursin, 43(2), 63-65. doi:10.1097/ 01.NURSE.0000425872.18314.db

Singh, S., Kumar, R.K., Sundaram, K.R., Kanjilal, B. & Nair, P. (2012). Improving outcomes and reducing cost by modular training in infection control in a resource-limited setting. International Journal for Quality Health Care, 24(6), 641-648. doi:10. 1093/intqhc/mzs059

Tillekeratne, L.G., Linkin, D.R., Obino, M., Omar, A., Wanjiku, M., Holtzman, D., & Cohn, J. (2014). A multifaceted intervention to reduce rates of catheter-associated urinary tract infections in a resource-limited setting. American Journal of Infection Control, 42(1), 12-16. doi:10.1016/j.ajic.2013.07.007

Viswanathan, K., Rosen T., Mulcare, M.R., Clark, S., Hayes J., Lachs, M.S., & Flomenbaum, N.E. (2015). Emergency department placement and management of indwelling urinary catheters in older adults: Knowledge, attitudes, and practice. Journal of Emergency Nursing, 41(5) 414-422. doi:10.1016/j.jen.2015.02.013

doi: 10.7257/1053816X.2018.38.6.273

Annette Ferguson, DNP, MSN, RN, CNE, is an Associate Professor, Marshall University School of Nursing, Huntington, WV.
Table 1.

Nurses' Knowledge Survey Items

Knowledge of Institutional Policies (3 items)

Response options = Yes or No

* Does the facility you currently work in have a standardized order
set (protocol) that gives guidance on when to insert or remove a
Foley catheter?

* Does your facility have any other formalized system of guidance
on when to insert or remove Foley catheters (examples include
scheduled in-service on Foley catheters, educational posters,
guidelines, etc.)?

* Does the facility have a standardized method to monitor which
patients have a Foley catheter?

Indications for Foley Catheter Use (5 items)

Response options = Never indicated, Sometimes indicated, Unsure,
Usually indicated, Always indicated

* Is a Foley catheter indicated in a patient with critical illness
and unstable volume status?

* Is a Foley catheter indicated for a patient with post-bladder
urinary obstruction?

* Is a Foley catheter indicated for urinary incontinence (in a
patient without skin breakdown)?

* Is a Foley indicated in a patient who is unable to stand to void?

* If a patient has been newly prescribed furosemide, or has been
prescribed an increased dose of this or another diuretic, is it
reasonable to place a Foley catheter?

Methods to Prevent Catheter Related Infections (6 items)

Response options = Not effective at all, Possibly effective, No
effect or unknown, Moderately effective, Very effective

How effective do you think the each of the listed interventions is
in preventing catheter-associated urinary tract infections?

* Removing catheters as early as possible.

* Using a condom catheter instead of a Foley catheter, if possible.

* Using intermittent (straight) catheterization instead of a Foley
catheter.

* Using catheters coated with antimicrobial substances.

* Using antimicrobial agents in the drainage bag.

* Using automated reminders to discontinue/renew the order for
catheter.

Table 2.

Indwelling Urinary Catheter Skills Competencies

* Verifies physician's order for indwelling catheter.

* Verifies correct patient using 2 identifiers.

* Explains procedure to patient.

* Provides privacy.

* Opens catheter kit using aseptic technique.

* Prepares patient for insertion.

* Performs proper hand hygiene. **

* Places sterile drape under buttocks by touching only two corners.

* Dons sterile gloves. **

* Maintains sterile technique during procedure (or verbalizes
breaks in sterile technique immediately). **

* Prepares tray for insertion and places tray and contents to
maintain sterility.

* Cleanses patient with antiseptic using proper technique based on
gender. **

* Applies lubricant to catheter to appropriate length based on
gender.

* Inserts catheter, verbalizes visualization of urine return, and
continues catheter advancement based on gender.

* Inflates balloon and gently withdraws catheter until resistance
is met.

* Secures catheter using stabilization device.

* Properly positions urine collection bag and tubing.

* Documents procedure in patient record.

** Failure to correctly perform this skill requires remediation.

Table 3.

Nurses' Knowledge of Appropriate Indwelling Urinary Catheter
Care (N=59)

                                                   Pre-Intervention
                                                        M (SD)

Summary score (a)                                     9.71 (1.87)
Subscales (b)
  Knowledge of institutional policies                 2.59 (0.65)
  Indications for Foley catheter use                  2.53 (1.34)
  Methods to prevent catheter-related infections      4.59 (0.79)

                                                   Post-Intervention
                                                        M (SD)

Summary score (a)                                    12.30 (1.38)
Subscales (b)
  Knowledge of institutional policies                 2.92 (0.34)
  Indications for Foley catheter use                  4.15 (1.10)
  Methods to prevent catheter-related infections      5.24 (0.77)

                                                   Test Statistic

Summary score (a)                                  t (58) = -9.89
Subscales (b)
  Knowledge of institutional policies              t (58) = -3.94
  Indications for Foley catheter use               t (58) = -9.43
  Methods to prevent catheter-related infections   t (58) = -4.39

                                                   p

Summary score (a)                                  0.00
Subscales (b)
  Knowledge of institutional policies              0.00
  Indications for Foley catheter use               0.00
  Methods to prevent catheter-related infections   0.00

(a) Possible score range 0 to 14; higher score reflects higher
level of knowledge.

(b) Possible score range 0 to 5; higher score reflects higher level
of knowledge.

Table 4.

Pre/Post-Intervention Nurses' Knowledge Survey Subscale Item
"Correct" Scores (a) (N=59)

                                                    Pre-Intervention
                                                          n (%)
Knowledge of institutional policies
  Facility has standardized orders?                     54 (91.5)
  Facility has formalized system?                       44 (74.6)
  Facility has standardized monitoring?                 54 (91.5)

Indications for Foley catheter use
  Critical illness and unstable volume status (b)       44 (74.6)
  Post-bladder obstruction (b)                          36 (61.0)
  Incontinence without breakdown                        22 (37.3)
  Unable to stand to void                               28 (47.5)
  New/change in diuretic dose                           19 (32.2)

Methods to prevent catheter related infections
  Remove catheter early                                 58 (98.3)
  Use condom catheter                                   52 (88.1)
  Intermittent straight catheterization                 42 (71.2)
  Antimicrobial-coated catheter                         46 (78.0)
  Antimicrobial agents in drainage bag (c)              20 (33.9)
  Automated reminders                                   53 (89.8)

                                                    Post-Intervention
                                                          n (%
Knowledge of institutional policies
  Facility has standardized orders?                     58 (98.3)
  Facility has formalized system?                       57 (96.6)
  Facility has standardized monitoring?                 57 (96.6)

Indications for Foley catheter use
  Critical illness and unstable volume status (b)       52 (88.1)
  Post-bladder obstruction (b)                          56 (94.9)
  Incontinence without breakdown                        51 (86.4)
  Unable to stand to void                               44 (74.6)
  New/change in diuretic dose                           42 (71.2)

Methods to prevent catheter related infections
  Remove catheter early                                 58 (98.3)
  Use condom catheter                                   58 (98.3)
  Intermittent straight catheterization                 54 (91.5)
  Antimicrobial-coated catheter                         40 (67.8)
  Antimicrobial agents in drainage bag (c)              44 (74.6)
  Automated reminders                                   55 (93.2)

(a) Possible score range 0 to 5 "correct" responses; higher score
reflects higher level of knowledge.

(b) Appropriate indication for catheterization.

(c) Incorrect response.
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Title Annotation:catheter-associated urinary tract infections
Author:Ferguson, Annette
Publication:Urologic Nursing
Article Type:Report
Geographic Code:1USA
Date:Nov 1, 2018
Words:6327
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