Presented By: April Beresford, Benjamin Kasper, and Kara Elkins

1. Presented By: April Beresford, Benjamin Kasper, and Kara Elkins Indwelling Urinary Catheters: Prevention of catheter-associated urinary tract infections (CautiS)

2. Catheter associated urinary tract infections (CAUTI) are the cause of many hospital acquired infections. Nearly 25% of hospitalized patients are catheterized annually, and 10% of these patients develop infections (Oman et al. 2011, p. 1). 40% of all nosocomial infections are due to CAUTIs (Andreessen et al., 2012, p. 209). Problem

3. Patients have increased pain and discomfort due to CAUTIs. CAUTIs are an unnecessary added expense to healthcare costs. Problem

4. Article One Preventing Catheter-Associated Urinary Tract Infections in Acute Care Conducted by Andreessen et al. Development of bundle plan to assist nurses in insertion techniques and maintenance or urinary catheters Daily assessment of need by nurse and physician Requirement of orders q24 hours to continue catheter use Changing practice and adding meticulous computer documentation Reducing use and duration of catheters Percentage of CAUTIs experienced by patients should decrease Evidence

5. Article One – Literature Review The “bundle” that they created to decrease percentage of CAUTI was put together based on the information gathered in the review of literature “The strongest predictor for CAUTI is the duration of catheterization, and catheterization lasting more than six days increases the risk for CAUTI seven times” (Andreessen et al. 2012, p. 210). EVIDENCE

6. Article One – Hypothesis Dependent variable: duration of urinary catheterization Independent variables: urinary catheter bundle, which included proper insertion and assessment techniques to be utilized, computerized documentation, and ordering templates. The population defined in this case is “acutely hospitalized patients” (Andreessen et al., 2012, p. 211). The study was performed using an experimental pretest and posttest design. Andreessen et al. performed an evaluation before and after the introduction of the urinary catheter bundle. EVIDENCE

7. Article One – Data Collection Evaluation of 1,200 charts to collect baseline data over three weeks Months of collecting data after the urinary catheter bundle and other policies were put into place Ended with another three-week post program evaluation and review of 1,385 computerized medical charts to collect the outcome data (Andreessen et al., 2012, p. 211). Documentation review was performed by registered nurses, physicians, and infection control nurses, along with the other members of the research team (Andreessen et al., 2012, p. 211). EVIDENCE

8. Article One – Sample “The research project took place at a VA (veterans affairs) medical center, and included patients with acute placement (less than thirty days) of an indwelling urinary catheter” (Andreessen et al., 2012, p. 211). Only male patients were included due to patient majority being male at this VA facility. EVIDENCE

9. Article One – Sample All charts were reviewed for those male, and eighteen and older (Andreessen et al., 2012, p. 211). Patients who needed long-term catheterization, or were diagnosed with a urinary tract infection within 24 hours of admission were excluded from the study to protect from misinformation in the data collected (Andreessen et al., 2012, p. 211). EVIDENCE

10. Article One – Limitations Conducted at a single site which causes limitation in the results “The project also lacked CAUTI rates for comparison because the hospital had not collected this rate before this project began” (Andreessen et al., 2012, p. 211). EVIDENCE

11. Article One – Conclusion It was discovered at the end of the study that “the implementation of a set of guidelines (the urinary catheter bundle) for catheter use and care resulted in a reduction of catheter use by 57% and a significant decrease in catheter duration by 70%” (Andreessen et al., 2012, p. 216). EVIDENCE

12. Article Two Nurse-directed interventions to reduce catheter-associated urinary tract infections Conducted by Oman et al. Oman et al directed a study at the University of Colorado in 2011 to evaluate the effectiveness of nursing interventions at avoiding CAUTI. “Catheters may be inappropriately retained for days because of convenience, misunderstanding of their necessity, or lack of clear orders for removal. Therefore, efforts to reduce CAUTI prevalence must focus on evidence-based use of IUCs during insertion, maintenance and removal” (Oman et al, 2011, p. 1). EVIDENCE

13. Article Two – Purpose / Framework • Oman et al used a pre/post quasi-experimental design to test incidence rates of CAUTI in a pulmonary and a general medical surgical unit at a Colorado hospital, using nurses as champions of change. • Dependent variables: incidence rates of CAUTI, catheter duration, LOS, bladder scanner usage, and product streamlining. • Independent variables: solidified as “nursing interventions” but was broken down into a series of interventional options presented to nurses who were participating in the study • charge nurse rounds • patient-related catheter selections, not nursing preference • daily evaluations of the need for continued catheter use • use of bladder scanners • continuing education for nurses and nurses aids (Oman et al, 2011, p. 2-3) EVIDENCE

14. Article Two – Framework / Data Collection • Study was divided into three phases • PHASE ONE: baseline data on IUC duration and CAUTI rates was obtained • PHASE TWO: intervention begins hospital-wide, including new protocols, updated training for staff, and product evaluation was performed. • PHASE THREE: interventions targeted the targeted units, including: more education and journal review with staff nurses, purchase of 2 new bladder scanners and additional bedside commodes, charge nurse catheter rounds, and posting of flyers throughout the department outlining facets of evidence based best practice techniques and interventions. (Oman et al, 2011, p. 2-3) EVIDENCE

15. Article Two – Framework / Data Collection • Electronic patient records were used to identify patients with CAUTI and to determine the length of catheterizations. CAUTIs were reported as an absolute number and a number of infections per 1,000 catheter-days for eligible patients. (Oman et al, 2011, p. 2-3) EVIDENCE

16. Article Two – Results It was found that nursing based interventions did result in a decrease of CAUTI within the designated units, although it was beyond the scope of the study to determine which interventions were most and least effective. “This project suggests that a focused unit intervention may be indicated when there is inadequate response to hospital-wide strategies” (Oman et al, 2011, p. 5) EVIDENCE

17. Article Three Reducing use of indwelling catheters and associated urinary tract infections Conducted by Eplern et al. CAUTIs remain an ongoing battle Guidelines for indwelling catheter use can reduce CAUTIs (Elpern et al. 2009). Quality improvement indicators determine CAUTI rates EVIDENCE

18. Article Three – Purpose/Framework • Intervention theory which consisted of the following • Removal of inappropriate catheters • Assessment for need for catheters • Early removal of indwelling catheters • “This study was a before-and-after evaluation of a low-technology intervention to reduce duration of urinary catheterization and occurrence of CAUTIs in an MICU” (Elpern et al. 2009 p. 537). EVIDENCE

19. Article Three – Data Collection • Subjects included in this study consisted of all MICU patients during a six month period • Data collected during intervention phase • Duration of catheterization • Appropriateness of catheterization • Reasons for inappropriate catheter use • CAUTI rates based upon surveillance by nurse epidemiologists Elpern et al. (2009) EVIDENCE

20. Article Three – Findings • Pre – Post intervention data analysis showed a decrease in catheter use • Eleven months previous to intervention, 15 CAUTIs occurred during 3,429 device days • During the intervention phase, zero CAUTIs occurred in 1,432 device days. EVIDENCE

21. Urinary catheterization is necessary in many patient situations • Overuse has been demonstrated to be a significant contributor to increased infection rates • Questioning attitudes about catheter use assist in CAUTI reduction • Daily reassessment for catheter need • Catheter use based on patient need not nurse preference • Education for proper catheter care • Development of practice policies Implications for practice / recommendations

22. Andreessen, L., Wilde, M., Herendeen, P.,(2012). Preventing Catheter-Associated Urinary Tract Infections in Acute Care. Journal of Nursing Care Quality. 27(3), 209-217. Retrieved from http://www.nursingcenter.com/lnc/JournalArticle?Article_ID=1355891 Burns, N. & Grove S. K. (2011) Understanding nursing research: Building an evidence- basedpractice.Maryland Heights, MO: Elsevier Saunders. Elpern, E.H., Killeen, K., Ketchem, A., Wiley, A., Patel, G., & Lateef, O. (2009). Reducing use of indwelling catheters and associated urinary tract infections. American Journal of Critical Care, 18(6), 535-541. doi:10.4037/ajcc2009938 Oman, K., Makic, M.B., Fink, R., Schraeder, N., Hulett, T., Keech, T., & Wald, H. (2011). Nurse-directed interventions to reduce catheter-associated urinary tract infections. American Journal of Infection Control. doi:10.1016/j.ajic,2011.07.018 References