The purpose of this study was to measure the clinical impact of an evidence-based educational strategy on urinary tract infection (UTI) rates in a 900+ bed acute care facility located in a southwestern state. The research team sought to answer the question, “Will a focus on staff education in the intensive care unit (ICU) on the proper placement techniques, care, and early removal of urinary retention catheters reduce incidences of catheter-associated urinary tract infections (CAUTIs) in an ICU setting?” Indwelling urinary catheters are frequently used in critically-ill patients worldwide. Hospital-acquired infections from indwelling urinary catheters are associated with increased morbidity, length of stay, and healthcare costs (World Health Organization [WHO], 2016). Urinary tract infections acquired during a hospitalization account for 40% of all hospital-acquired infections (HAIs) with 80% of UTIs being associated with use of urinary retention catheters (Quinn, 2015). HAIs from indwelling urinary catheters are associated with more than 113,000 deaths annually in the United States (Ternavasio-de la Vega et al., 2016). Review of peer reviewed literature demonstrated various strategies to decrease CAUTIs, including computer reminders and evidence-based guidelines for urinary catheter care and maintenance. One 301-bed non-academic hospital in the northeastern United States demonstrated a 50% reduction in CAUTIs one year after introducing a nurse-driven process designed to daily question the need for a urinary catheter through use of nursing assessment and targeted clinician education (Quinn, 2015). Hospital acquired infection rates have declined in the United States except for CAUTIs, which rose 3% from 2009 to 2012 (Knudson, 2014). Clinicians in this study sought to implement specific opportunities for improvement in CAUTI rates in an ICU unit through reduction of urinary catheters used, implementation of urinary catheter insertion and maintenance best practices, and timely nursing assessment for need leading to urinary catheter removal if indicated through a structured educational strategy. Additionally, this study measured the impact on CAUTI incidence after implementation of the project intervention. Knudson (2014) reported analyzed data from 1,653 ICUs found that CAUTI prevention strategies were followed 27-67% of the time, thus informing the need for implementation and adherence measures for CAUTI prevention in this ICU. Evidence-based protocols designed to decrease urinary catheter associated infections may not capture point of care practices contributing to this significant problem. In response to this significant issue for critically ill patients, a targeted education intervention was developed and implemented by the infection prevention CAUTI team and the cardiac intensive care unit (CICU) nursing staff.
Methods: The intervention of a targeted, evidence-based educational program was implemented to raise nursing staff awareness and uptake of evidence-based protocol and point of care practices designed to decrease risks of catheter-associated urinary tract infections (CAUTI) in CICU patients. A descriptive design was used. Sampling was made at the unit and not the individual level. The CICU was selected by infection prevention CAUTI team members to implement specific nursing staff education focused on urinary catheter insertion hands-on training using low fidelity simulation, daily catheter care best practices, and timely nursing assessment of early urinary catheter removal. Targeted education and training was initiated December 2015. One hundred percent of CICU staff nurses (N = 76) received hands on training for insertion and care of urinary retention catheters. Periodic rounding in CICU by infection prevention CAUTI team members was performed to assess 100% of patients with an indwelling urinary catheter. The infection prevention team checked for daily care compliance by nursing staff, nurse assessment for necessity of continued urinary catheter placement, proper urinary catheter securement devices in use, and appropriate positioning of closed drainage units. “Just in time” coaching and recognition was provided by the assessment team as needed.
Results: Catheter induced infection rates dropped significantly after training was initiated for the CICU staff. For FY2015, a total of 16 CAUTIs were recorded for the CICU with a rate of 3.91 per 1,000 device days and 2.22 per 1,000 patient days. For FY2016, the current total for CAUTIs reported in CICU is 4, reflecting a 75% reduction in the number of CAUTIs for CICU. The infection rate per 1,000 device days is currently at 1.15 and the rate per 1,000 patient days is 0.69. The incidence of improper care was reduced significantly with the periodic rounding by the infection prevention CAUTI team nurses.
Conclusion: With regular use of urinary retention catheters in ICU settings, patients are at increased risk for developing a CAUTI. Working in partnership with experts outside nursing units improved collaboration across disciplines in this CICU. Use of an infection prevention CAUTI team aided in increasing staff education and awareness of CAUTI nurse-led prevention strategies in this ICU. With targeted evidence-based education for the nursing staff and routine rounding by the infection prevention CAUTI team, a reduction in the number of CAUTIs have resulted in this ICU setting. The significance of this project to nursing practice and patient clinical outcomes is demonstrated in the reduction of CAUTIs through nurse-driven monitoring and processes. Further research is recommended to fully demonstrate the impact of targeted evidence-based clinician education and nurse-led protocols on CAUTI rates in the CICU setting.