Monday, 18 November 2019
Background: Catheter urinary tract infection (CAUTI) is the fourth most common healthcare-associated infection reported in the United States (CDC, 2018). The major risk factor of CAUTI is the presence of an indwelling urinary catheter (IUC) and the duration that it is in place (Lo et al., 2014). Purpose: The purpose of this project was to determine if the implementation of a criteria-based screening protocol and on-screen computer reminder can improve unnecessary urinary catheter-use among patients in the intensive care unit (ICU). Methods: A criteria-based screening protocol was used to screen patients in the ICU daily for the presence of IUCs. In addition, an on-screen computer reminder was used to remind nurses to remove IUCs if the order has reached the stop date. Implementation/Procedure: The quality improvement project was conducted in a Catholic, community, academic medical center with 25-bed critical care units. All patients in the ICU are screened daily. An algorithm and reminder embedded in the ICU flowsheet guided the nurses to make decisions in removing IUCs. The interventions were implemented for eight weeks. The CUR was compared from pre-implementation (Aug 2018) to post-implementation period (Oct 2018). The interventions implemented for this change project were two-folds; the criteria-based screening protocol and an on-screen computer reminder. The criteria-based screening protocol was embedded in the ICU flowsheet of the medical center’s EHR. All patients in the ICU must be screened for the presence of IUC. If the nurse selected that the patient has no IUC, the nurse will get an alert to screen the patient again tomorrow. If the nurse selected that patient has IUC, the nurse received an alert to assess the appropriateness of the IUC. The nurse selects from a list of indications based on CDC. Each selection contains a specific criteria based on the Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients to guide the nurse’s clinical decision making. If the nurse selected that there is no criteria met, the nurse received an alert to remove the IUC immediately. The nurse received an alert containing guidelines based on the hospital policy, such as the use of bladder scan, external catheters, intermittent catheterization, and ensuring that the IUC insertion and removal dates are documented in the patient’s EHR. If the nurse selected a criterion, the nurse received an alert to discuss plan of care with the physician that can lead to the removal of the catheter. IUCs inserted by the urologist, the nurse will get an alert not to remove the catheter and discuss plan of care with the physician. Monitoring the adherence of the nurses in the daily screening for the presence of IUC is critical to ensure that no IUCs are left inserted without the nurse or the physician knowing. Documentation of screening in the EHR will provide the nurse the opportunity to assess the appropriateness of the IUC using evidence-based criteria and the hospital’s policy in the removal of the catheters. According to the medical center’s policy, a physician’s order for an indwelling urinary catheter will have a default stop date of either 24 or 48 hours unless the IUC was inserted by the urologist. The intervention implemented was an on-screen computer reminder, that was triggered when an existing indwelling urinary catheter order has a default stop order date of 24 or 48 hours. Once the default stop order date has been reached, the nurses were prompted with a reminder. The reminder appeared during the nurses’ documentation in the electronic health record, when the nurse clicked on the “save” button to save the charting for indwelling urinary catheter assessment. The message informed the nurses to remove the indwelling urinary catheter and that the default stop date for the indwelling urinary catheter of 24 hours had expired. There is currently no existing on-screen reminder for this purpose at the academic medical center. If the indwelling urinary catheters are removed within the prescribed time, the lesser the risk for infection to develop. Results: IBM SPSS Statistics v.25 was used to analyze the data. Poisson exact test revealed a p-value of 0.593. There is not a statistically significant change in the catheter use rates from pre to post-implementation. Conclusion: Although, the CUR was slightly higher following post implementation, there was 92.8% of patients were screened, which resulted to 4.5% of catheters removed within the same day screening was performed.