The prolonged use of indwelling urinary catheters in the hospital-setting can lead to many complications. In an effort to decrease Foley catheter related urinary tract infections (UTI's), this critical care unit focused on reducing the number of foley catheter device days in the critical care setting.

Type of evidence – methods to obtain and review:

Nursing, Medical, and Infection Control journal articles were utilized as well as Center for Disease Control (CDC) guidelines.

A literature search to find published research studies focused on urinary catheters and/or the reduction and prevention of UTI's. The databases used to search were Medline (1996 - November 2004) and Cinahl (Cumulative Index to Nursing and Allied Health Literature; 1982 - December 2004). Key words for searches were urinary catheters, urinary tract infections, and critical care.

Summary of literature findings was discussed at various project team meetings as well as interdisciplinary team meetings such as the ICU Interdisciplinary Quality Improvement Meetings, and Infection Control meetings.

Planned strategy:

The setting for this Six Sigma project was a 22-bed mixed medical/surgical/trauma adult intensive care unit. A critical care nurse and infection control nurse were chosen as project leads by the Chief Nursing Officer, ICU Manager, and Infection Control Manager. Further team members were chosen, a stakeholder analysis was initiated, and strategies were developed to create buy-in for change. A collaborative approach was important in order to create positive change with interdisciplinary support.

Six Sigma techniques were used to isolate the root causes, measure capability, define variable factors, and drive the improvement.

The measurement metric utilized was Foley catheter device days (DD). A device day began when a patient was admitted to the intensive care unit (ICU) with an indwelling Foley catheter intact or one was placed in the ICU. A DD ended when the patient was discharged from the ICU with the Foley catheter intact or the Foley catheter was discontinued in the ICU. After conducting a sample size calculation it was determined that 123 data points (patient charts) would be needed for pre-intervention data. Exclusion criteria included patients that expired in the ICU, and patients with no Foley catheter. The pre-intervention mean was 4.72 (N=124) and the pre-intervention standard deviation was 7.67 (N=124). After analyzing multiple factors that may have contributed to prolonged DD, a regression analysis determined that 71.9% (p = 0) of our process variation was due to the fact that the catheters were not being removed once criteria for removal was met.

Implementation of Strategy: After multiple brainstorming sessions with team members as well as ICU staff, it was decided to implement nurse-driven surveillance of Criteria-Based Foley Catheter Guidelines (CFCG).

From the CFCG an algorithm for foley catheter decision-making and a Criteria-Based Foley Catheter Checklist was developed. The plan was presented at the ICU Committee meeting as well as the Infection Control meeting. Internal Review Board approval was obtained and an intense educational program was instituted. An educational binder was created and utilized to educate ICU staff (nurses, residents, and physicians) during multiple one-on-one in-services over a 2-week period. Education included risks associated with prolonged catheterization including UTI, urosepsis, and mortality rates associated with urosepsis.

Upon completion of staff education the pilot was instituted. A daily checklist for every patient with an indwelling Foley catheter was completed by the nurses. The checklist functioned as a trigger to determine the necessity of the catheter. If the patient did not fall into one of the criteria categories, the nurse contacted the physician to request an order for discontinuation of the catheter. The charge nurse was responsible for distribution and collection of the daily checklists.

Method of Evaluation. After implementation of the pilot, another sample size calculation was conducted and it was determined that 52 patient charts were needed for 95% confidence. A random convenience sample of 83 charts was reviewed retrospectively in the same manner as the pre-intervention data.

The after data mean was DD = 2.98, and standard deviation was 3.17 (N= 83).

Outcomes/Results. A 2-sample T-test was conducted on the pre and post intervention means, and a Test for Equal Variance was completed for the pre and post intervention standard deviations. The data showed a statistically significant decrease in the means (N=83, p=.03) and 94% confidence that the intervention decreased the standard deviation (N= 83, p=.06). The pre-intervention UTI infection rate for this units 4th quarter 2003 data was 6.4 (UTI's per 1000 device days). Post-intervention the 4th quarter 2004 UTI rates decreased by almost 70% to 1.9 (UTI's per 1000 device days. Pre-intervention only 6% of the Foley catheters were removed before the patient was transferred out of the ICU and post-intervention 20% of the Foley catheters were removed prior to ICU transfer. When a patient leaves the ICU without the Foley catheter, chances are the Foley catheter will not be reinserted on the general hospital floor and the potential to decrease hospital-wide Foley catheter related UTI's is very probable as well.

Lessons Learned: There was some skeptism by staff when this project was initiated. Staff felt it was unlikely that this patient population could tolerate the removal of many Foley catheters. Although a large percentage of our patients did meet the criteria for continued Foley catheter use, there was a subcategory that, prior to intervention, had a continued use of Foley catheters when they weren't warranted. Both physicians and nurses have an increased awareness as to what constitutes appropriate indications for Foley catheters and the importance of removing those catheters that are not needed.

In addition to the nurse-driven CFCG an additional line has been added to the ICU Admission Order Set used by this unit. The additional line asks the “reason” for the Foley catheter in hopes that physicians will question the necessity of the catheter before writing the order.

This Six Sigma approach can be replicated to decrease other interventions that may be used unnecessarily (eg. central lines) in the critical care setting as well as on general medical and surgical floors.