CAUTI is among the most common healthcare-associated infections with an estimated 250,000 cases occurring annually in U.S. hospitals and associated costs of $250-$450 million (Agency for Healthcare Research and Quality [AHRQ], 2015a, 2015b; Clayton, 2017). Seventy-five percent of hospital-acquired UTIs are from a urinary catheter (Gould et al., 2017). Increased length of stay (AHRQ, 2015b; Kaplan & Carter, 2018); patient discomfort (AHRQ, 2015b); increased cost (AHRQ, 2015b); and mortality (AHRQ, 2015b) are common consequences of CAUTI.
A Comprehensive Unit-based Safety Program (CUSP) was developed in the United States as a 4-year national initiative aimed at decreasing CAUTI rates (AHRQ, 2018; Fakih et al., 2014). Current evidence-based interventions include: inserting catheters only if indicated (Gould et al., 2017; Galiczewski & Shurpin, 2017); reducing catheter use or early removal (Gould et al., 2017); using alternatives to indwelling urethral catheters (Gould et al., 2017); and utilizing appropriate strategies for catheter care, maintenance, and removal (Gould et al., 2017).
A quality improvement approach can be used to address CAUTI. Components of this type of approach include: surveillance, supply availability, hand hygiene (Fox et al., 2015; McCalla, Reilly, Thomas, & McSpedon-Rai, 2017), reminders or alerts to assess need (Mauger et al., 2014), nurse-driven protocol for removal, performance feedback (Mauger et al., 2014; Waters et al., 2017), algorithm for perioperative catheter management, protocol for urinary retention, in-service training regarding techniques to use (Mauger et al., 2014), and documentation of catheter insertion date and time.
There were three primary areas of focus for the practice change that was developed as part of this project: 1) focused 1:1 education with NAs by the EBP change champion, 2) discontinuation of routine urinalysis orders unless the patient is symptomatic with suprapubic pain, and 3) a change to twice daily meatal care for patients with an indwelling catheter. The focused 1:1 NA: EBP change champion education was created with a “back to the basics” mindset. Educational sessions were tailored to evidence-based interventions for preventing CAUTIs that were within the scope of NA practice.
The Implementation Strategies for Evidence-Based Practice (Cullen & Adams, 2012; Cullen et al., 2018) were used to create a phased, evidence-based approach to selecting effective implementation strategies. The practice change was initially discussed at unit staff meetings to create awareness and interest. As the project progressed, information was included in unit newsletters to keep it at the forefront. Knowledge and commitment were built via the 1:1 education completed by the EBP change champion with each NA. Select NAs, who were actively involved and engaged in the project, elected to serve as change champions and assisted in restocking the meatal care wipes in patient rooms. During the action and adoption, “go-live” phase of the practice change, NAs demonstrated meatal care competency through return demonstration during annual training. Unit-based efforts to pursue integration and sustained use of the practice change included peer influence, reporting to senior leaders, reporting in the organization’s quality improvement program, and presenting at internal and external educational programs. In addition, documentation audits of meatal cares occurred routinely with actionable and timely data feedback provided to the NAs by unit leaders.
Evaluation of the practice change included NA knowledge, patient outcomes, and improvement of skills and documentation. Seventeen NAs completed training and the seven-question pre- and post-test. The mean pre-test score was 3.29 with the mean post-test score increasing to 6.43. The unit CAUTI rate six months pre-program was 0.78/1000 patient days, which improved to 0.00/1000 patient days six months post-program; the unit actually had no documented CAUTIs from February 2017 through June 2018.
Participation in the EBP Change Champion program empowered this unit-based emerging nurse leader to direct evidence-based improvements that positively impacted patient outcomes. Given the purpose of this project, empowerment and confidence also increased for the unit’s NAs regarding their ability to make an appreciable difference in these very same patient outcomes. Commitment to the project and protected project time for the unit-based EBP change champion was critical for success.
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