Driving Patient Outcomes through Clinical Decision Support Systems and Nurse-Directed Protocols

Background: Nurse-directed catheter removal protocols (NDCRPs) are a recommended strategy to promote prompt removal of unnecessary urinary catheters, thus reducing patient risk for catheter associated urinary tract infection (CAUTI).  However, implementation of NDCRPs has not been widespread, and adoption of protocol recommendations is even lower.  Clinical decision support systems (CDSSs) have the potential to improve patient outcomes by delivering evidence-based guidance to frontline nurses in the course of their workflow.  This study explored the effect of a CDSS promoting NDCR on the rates of NDCR, CAUTI, and urinary catheter utilization at a mid-sized community hospital.  Additionally, data from open-ended questionnaires and individual interviews were analyzed to understand why nurses might not remove a urinary catheter despite meeting NDCRP criteria, and factors limiting the impact of the CDSS. 

Sample: patients with urinary catheters eligible for NDCR for 4 months before and 4 months after implementation of a CDSS linked to the protocol for NDCR (Phase 1 n=103, Phase 2 n=100); Nurses on inpatient units who responded to an open-ended questionnaire (n=30) and participated in validation of the analysis (n=7). Data Collection/Analysis: 1)Retrospective comparison of NDCR (chi-square analysis), CAUTI, and urinary catheter utilization rates (comparison of rates) before and after implementation of a CDSS linked to the NDCR protocol 2)Thematic analysis of open-ended questionnaire responses describing nurses' experiences with the protocol for NDCR, and CDSS.

Results: Implementation of the CDSS resulted in significantly increased NDCR (Phase 1=42%, Phase 2=76%, X²=19.6; df=1, p<.001) but no significant difference in catheter utilization rate (Phase 1=.26/patient day, Phase 2=.26/patient day; p=.953) or CAUTI rate (Phase 1=.69/1,000 catheter days, Phase 2=.25/1,000 catheter days; p=.362). Analysis of the open-ended responses resulted in identification of 3 main themes which both enhance and detract from the capacity of a NDCR protocol and CDSS to impact patient outcomes: (a) professional values with the subthemes of autonomy, accountability, and high-quality care; (b) avoidance of conflict in professional relationships; and (c) ease of workflow.

Discussion: This presentation will be concentrated on findings of the qualitative component of this study offering insight into why the protocol and CDSS did not result in improved patient outcomes. Specifically, discussion will focus on nurses’ comfort with autonomy granted by nurse-directed protocols and how this may limit the efficacy of such protocols.  In this qualitative sample, half of respondents commented that they were not comfortable to remove the catheter without minimally consulting with the provider, or even having a provider order.  The discomfort seemed to stem from the overriding belief that nurses need an order for everything, despite knowledge of the standing protocol.  Additionally, there was fear that a catheter would have to be re-inserted in which case the patient or physician might be angry with them.  While other research has indicated that discomfort with autonomy may be a limiting factor in nurse-directed protocols, this study generates an understanding of the underlying issues.  The discussion will offer recommendations for addressing the culture of safety to promote nurse autonomy in order to increase adoption of evidence-based practice and improve patient outcomes.