clinical updates Associate Editors: Elaine L. Smith, EdD, MSN, MBA, NEA-BC, ANEF Karen L. Rice, DNS, APRN, ACNS-BC, ANP Authors: Launette Woolforde, EdD, DNP, RN-BC, and Emily Castro, MSN, RN, CCRN
A Nursing Education Strategic Plan for Conquering Catheter-Associated Urinary Tract Infections
abstract Catheter-associated urinary tract infections (CAUTIs) intercept opportunities for hospitals to achieve quality patient care outcomes, maintain sound financial performance, and ensure a positive health care experience. Nurse educators play a key role in designing effective strategies and establishing important partnerships aimed at reducing CAUTIs in hospitalized patients. J Contin Educ Nurs. 2013;44(12):531532.
A
pproximately 75% of the urinary tract infections (UTIs) acquired in hospitals are catheterassociated UTIs (CAUTIs) (Centers for Disease Control and Prevention [CDC], 2013). CAUTIs contribute to patient discomfort, unnecessary antimicrobial use, a perception of poor quality of care, increased morbidity and mortality (up to 13,000 attributable deaths annually), an unnecessary increase in hospital length of stay averaging 2 to 4 days, and increased health care costs (up to $500 million per year nationally). More than half of these infections are preventable (CDC & National Healthcare Safety Network [NHSN], 2013). Committed to excellence, nurse educators at
an academic medical center took on the challenge of eradicating CAUTIs. BACKGROUND An early 2013 review of hospitalwide CAUTIs revealed that our facility was far from its goal of a CAUTI standardized infection ratio (SIR) of less than 1 within and outside of the intensive care units (ICUs). The SIR is calculated by dividing the number of observed infections by the number of expected infections (CDC & NHSN, 2013). At the end of 2012, the ICU CAUTI SIR was 1.54 and the non-ICU CAUTI SIR was 1.32. As part of a larger, multiphase, CAUTI prevention model, nurse educators developed a six-step comprehensive strategic plan to help conquer CAUTIs. 1. Establishment and identification of CAUTI goals and allowances Understanding that overarching goals may be more readily achieved through identification of smaller, discrete steps, nursing education implemented a “goals and allowance” framework for units to follow. Through collaboration with the infection prevention team, both the 2012 unit-specific CAUTI rate and the 2013 year-to-date (YTD) unit-specific CAUTI rate were identified. A goal of a 25% reduction from the 2012 rate was established. The target goal was
Dr. Woolforde is Director and Ms. Castro is Critical Care Nurse Educator, Nursing Education and Professional Development, North Shore University Hospital, Manhasset, New York. The authors have disclosed no potential conflicts of interest, financial or otherwise. Address correspondence to Launette Woolforde, EdD, DNP, RN-BC, Director, Nursing Education and Professional Development, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030; e-mail: [email protected]. doi:10.3928/00220124-20131121-12
The Journal of Continuing Education in Nursing · Vol 44, No 12, 2013
identified for each unit, subtracted from the actual unit-specific YTD CAUTI rate, and an allowance of CAUTIs for the remainder of the year for the unit was established. Progress toward unit-specific goals is reviewed routinely at nursing patient care services and nursing quality meetings. 2. Strategic partnerships with nursing operations and the urinary catheter product vendor team One key partnership for nurse educators was with the director of nursing for critical care services and the critical care nurse managers. The critical areas were experiencing the majority of CAUTIs, so close alignment, open communication, and team spirit were essential. Another key partnership was with the urinary catheter product vendor team. This close partnership expanded the reach of nursing education through inclusion of the vendor team nurse educators in unitbased rounding, education on best practices, scheduling and delivery of classes, and access to evidence-based CAUTI prevention resources. 3. Development of a CAUTI Prevention Task Force It was well-known that an interdisciplinary approach would be necessary to conquer CAUTIs. Thus, nurse educators helped establish the CAUTI Prevention Task Force, composed of staff from nursing education, nursing critical care, nursing quality, and nurse practitioner and physician assistant mid-level providers. The Task Force meets as needed to close the loop on CAUTI ambassador feedback and to integrate other components of CAUTI prevention, such as the straight catheterization 531
protocol and urinary residual algorithm. Additionally, the Task Force performs unit rounds to assess, support, and reinforce CAUTI prevention standards of care. 4. Comprehensive education program on indwelling urinary catheter (IUC) insertion and care A comprehensive program of education was developed to disseminate best practice on CAUTI prevention and catheter care. A priority ranking methodology was used to organize the implementation of the education plan. The 10 units with the highest SIRs and incidences of CAUTIs through 2013 were targeted. The Emergency Department, Operating Room, and Post Anesthesia Care Unit rounded out the 13 priority areas. Unit-based education for these targeted areas was organized and provided through the partnership with the IUC vendor nurse educator. Mutually agreeable times were established in cooperation with the unit nurse managers. Education sessions usually occurred during the prescheduled “huddle” times on the unit. This methodology fostered smooth delivery of the in-service, decreased the time needed to assemble staff, and fostered a partnership because the nurse manager helped establish the time and structure for the session. 5. Competency validation process for IUC insertion and care IUC insertion was adopted as a house-wide core competency for 2013. An improved insertion competency was developed using the existing competency, best practice recommendations from the CDC, a local federally designated quality improvement organization, internal infection prevention, hospital policy, and CAUTI collaborative guidelines established within the parent health care system. The competency went beyond the usual basic insertion steps and included CDC guidelines on when an IUC should be inserted and maintenance steps to reduce infection. 532
6. Implementation of the CAUTI prevention ambassador model The CAUTI prevention ambassador model focused on identification of a minimum of six registered nurse (RN) CAUTI prevention ambassadors per unit: three on the day shift and three on the night shift. The CAUTI prevention ambassador is a resource person on the unit, represents the unit, reports CAUTI performance data at the hospital nursing quality council, performs or assists with oversight of the CAUTI prevention and IUC care practices, and, through peer review, serves as the IUC insertion validator for other RN staff on the unit. Dates and times of preparation sessions for ambassadors were based on the work schedules of the identified ambassadors. Ambassadors were assigned to a particular session. The targeted scheduling plan allowed for accurate anticipation of the number of attendees, assurance that return demonstration time and manikin availability would be sufficient, and prevention of “waiting in line” to perform return demonstrations. During each session, the ambassadors received comprehensive education on the implications of CAUTIs and best practices for CAUTI prevention, including a demonstration of the new IUC product being introduced to the hospital. Ambassadors were then validated by the nurse educator on IUC insertion using manikins. Finally, for ambassadors in select areas where bladder scanning would be performed by staff RNs, competency on bladder scanning was validated during the session. OUTCOMES One hundred eighty-eight CAUTI ambassadors have been trained since the inception of the program. CAUTI prevention ambassadors have helped identify concerns, including whether a new insertion kit should be used
each time if IUC insertion is unsuccessful, how often an order is required after the initial 48-hour postinsertion order, and, because breaking the closed system is highly undesirable, how Emergency Department nurses should manage patients who arrive with an IUC already in place. From January to July 2013, the hospital had an average of 15 CAUTIs per month. In August, the house-wide CAUTI rate dropped to 7. Several units have been free of CAUTIs for 2 or more consecutive months, including the Medical ICU, the Respiratory Care Unit, and the Neuroscience Unit. The quarterly ICU CAUTI incidence is trending downward, decreasing from 28 (Q1) to 22 (Q2) to 16 (Q3). The non-ICU CAUTI incidence is following a similar pattern, decreasing from 18 (Q1) to 11 (Q2) to 8 (Q3). The quarterly ICU SIR is steadily decreasing—2.313 (Q1) to 1.984 (Q2) to 1.02 (Q3). Similarly, the quarterly non-ICU SIR has exceeded organizational goals, decreasing from 1.562 (Q1) to 1.121 (Q2) to 0.53 (Q3). SUMMARY Although many factors contribute to these and other successful quality outcomes, nursing education plays a critical role in meeting organizational goals related to quality and nursesensitive indicators. Through education, knowledge and skills validation, and the integration of data, measurement, goals, and outcomes, nursing education can realize true partnership and leadership in the achievement of positive patient care outcomes. REFERENCES Centers for Disease Control and Prevention. (2013). Catheter-associated urinary tract infections (CAUTI). Retrieved from http:// www.cdc.gov/HAI/ca_uti/uti.html Centers for Disease Control and Prevention & National Healthcare Safety Network. (2013). Device associated module: CAUTI. Retrieved from http://www.cdc.gov/nhsn/ pdfs/pscmanual/7psccauticurrent.pdf
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A Nursing Education Strategic Plan for Conquering Catheter-Associated Urinary Tract Infections
abstract Catheter-associated urinary tract infections (CAUTIs) intercept opportunities for hospitals to achieve quality patient care outcomes, maintain sound financial performance, and ensure a positive health care experience. Nurse educators play a key role in designing effective strategies and establishing important partnerships aimed at reducing CAUTIs in hospitalized patients. J Contin Educ Nurs. 2013;44(12):531532.
A
pproximately 75% of the urinary tract infections (UTIs) acquired in hospitals are catheterassociated UTIs (CAUTIs) (Centers for Disease Control and Prevention [CDC], 2013). CAUTIs contribute to patient discomfort, unnecessary antimicrobial use, a perception of poor quality of care, increased morbidity and mortality (up to 13,000 attributable deaths annually), an unnecessary increase in hospital length of stay averaging 2 to 4 days, and increased health care costs (up to $500 million per year nationally). More than half of these infections are preventable (CDC & National Healthcare Safety Network [NHSN], 2013). Committed to excellence, nurse educators at
an academic medical center took on the challenge of eradicating CAUTIs. BACKGROUND An early 2013 review of hospitalwide CAUTIs revealed that our facility was far from its goal of a CAUTI standardized infection ratio (SIR) of less than 1 within and outside of the intensive care units (ICUs). The SIR is calculated by dividing the number of observed infections by the number of expected infections (CDC & NHSN, 2013). At the end of 2012, the ICU CAUTI SIR was 1.54 and the non-ICU CAUTI SIR was 1.32. As part of a larger, multiphase, CAUTI prevention model, nurse educators developed a six-step comprehensive strategic plan to help conquer CAUTIs. 1. Establishment and identification of CAUTI goals and allowances Understanding that overarching goals may be more readily achieved through identification of smaller, discrete steps, nursing education implemented a “goals and allowance” framework for units to follow. Through collaboration with the infection prevention team, both the 2012 unit-specific CAUTI rate and the 2013 year-to-date (YTD) unit-specific CAUTI rate were identified. A goal of a 25% reduction from the 2012 rate was established. The target goal was
Dr. Woolforde is Director and Ms. Castro is Critical Care Nurse Educator, Nursing Education and Professional Development, North Shore University Hospital, Manhasset, New York. The authors have disclosed no potential conflicts of interest, financial or otherwise. Address correspondence to Launette Woolforde, EdD, DNP, RN-BC, Director, Nursing Education and Professional Development, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030; e-mail: [email protected]. doi:10.3928/00220124-20131121-12
The Journal of Continuing Education in Nursing · Vol 44, No 12, 2013
identified for each unit, subtracted from the actual unit-specific YTD CAUTI rate, and an allowance of CAUTIs for the remainder of the year for the unit was established. Progress toward unit-specific goals is reviewed routinely at nursing patient care services and nursing quality meetings. 2. Strategic partnerships with nursing operations and the urinary catheter product vendor team One key partnership for nurse educators was with the director of nursing for critical care services and the critical care nurse managers. The critical areas were experiencing the majority of CAUTIs, so close alignment, open communication, and team spirit were essential. Another key partnership was with the urinary catheter product vendor team. This close partnership expanded the reach of nursing education through inclusion of the vendor team nurse educators in unitbased rounding, education on best practices, scheduling and delivery of classes, and access to evidence-based CAUTI prevention resources. 3. Development of a CAUTI Prevention Task Force It was well-known that an interdisciplinary approach would be necessary to conquer CAUTIs. Thus, nurse educators helped establish the CAUTI Prevention Task Force, composed of staff from nursing education, nursing critical care, nursing quality, and nurse practitioner and physician assistant mid-level providers. The Task Force meets as needed to close the loop on CAUTI ambassador feedback and to integrate other components of CAUTI prevention, such as the straight catheterization 531
protocol and urinary residual algorithm. Additionally, the Task Force performs unit rounds to assess, support, and reinforce CAUTI prevention standards of care. 4. Comprehensive education program on indwelling urinary catheter (IUC) insertion and care A comprehensive program of education was developed to disseminate best practice on CAUTI prevention and catheter care. A priority ranking methodology was used to organize the implementation of the education plan. The 10 units with the highest SIRs and incidences of CAUTIs through 2013 were targeted. The Emergency Department, Operating Room, and Post Anesthesia Care Unit rounded out the 13 priority areas. Unit-based education for these targeted areas was organized and provided through the partnership with the IUC vendor nurse educator. Mutually agreeable times were established in cooperation with the unit nurse managers. Education sessions usually occurred during the prescheduled “huddle” times on the unit. This methodology fostered smooth delivery of the in-service, decreased the time needed to assemble staff, and fostered a partnership because the nurse manager helped establish the time and structure for the session. 5. Competency validation process for IUC insertion and care IUC insertion was adopted as a house-wide core competency for 2013. An improved insertion competency was developed using the existing competency, best practice recommendations from the CDC, a local federally designated quality improvement organization, internal infection prevention, hospital policy, and CAUTI collaborative guidelines established within the parent health care system. The competency went beyond the usual basic insertion steps and included CDC guidelines on when an IUC should be inserted and maintenance steps to reduce infection. 532
6. Implementation of the CAUTI prevention ambassador model The CAUTI prevention ambassador model focused on identification of a minimum of six registered nurse (RN) CAUTI prevention ambassadors per unit: three on the day shift and three on the night shift. The CAUTI prevention ambassador is a resource person on the unit, represents the unit, reports CAUTI performance data at the hospital nursing quality council, performs or assists with oversight of the CAUTI prevention and IUC care practices, and, through peer review, serves as the IUC insertion validator for other RN staff on the unit. Dates and times of preparation sessions for ambassadors were based on the work schedules of the identified ambassadors. Ambassadors were assigned to a particular session. The targeted scheduling plan allowed for accurate anticipation of the number of attendees, assurance that return demonstration time and manikin availability would be sufficient, and prevention of “waiting in line” to perform return demonstrations. During each session, the ambassadors received comprehensive education on the implications of CAUTIs and best practices for CAUTI prevention, including a demonstration of the new IUC product being introduced to the hospital. Ambassadors were then validated by the nurse educator on IUC insertion using manikins. Finally, for ambassadors in select areas where bladder scanning would be performed by staff RNs, competency on bladder scanning was validated during the session. OUTCOMES One hundred eighty-eight CAUTI ambassadors have been trained since the inception of the program. CAUTI prevention ambassadors have helped identify concerns, including whether a new insertion kit should be used
each time if IUC insertion is unsuccessful, how often an order is required after the initial 48-hour postinsertion order, and, because breaking the closed system is highly undesirable, how Emergency Department nurses should manage patients who arrive with an IUC already in place. From January to July 2013, the hospital had an average of 15 CAUTIs per month. In August, the house-wide CAUTI rate dropped to 7. Several units have been free of CAUTIs for 2 or more consecutive months, including the Medical ICU, the Respiratory Care Unit, and the Neuroscience Unit. The quarterly ICU CAUTI incidence is trending downward, decreasing from 28 (Q1) to 22 (Q2) to 16 (Q3). The non-ICU CAUTI incidence is following a similar pattern, decreasing from 18 (Q1) to 11 (Q2) to 8 (Q3). The quarterly ICU SIR is steadily decreasing—2.313 (Q1) to 1.984 (Q2) to 1.02 (Q3). Similarly, the quarterly non-ICU SIR has exceeded organizational goals, decreasing from 1.562 (Q1) to 1.121 (Q2) to 0.53 (Q3). SUMMARY Although many factors contribute to these and other successful quality outcomes, nursing education plays a critical role in meeting organizational goals related to quality and nursesensitive indicators. Through education, knowledge and skills validation, and the integration of data, measurement, goals, and outcomes, nursing education can realize true partnership and leadership in the achievement of positive patient care outcomes. REFERENCES Centers for Disease Control and Prevention. (2013). Catheter-associated urinary tract infections (CAUTI). Retrieved from http:// www.cdc.gov/HAI/ca_uti/uti.html Centers for Disease Control and Prevention & National Healthcare Safety Network. (2013). Device associated module: CAUTI. Retrieved from http://www.cdc.gov/nhsn/ pdfs/pscmanual/7psccauticurrent.pdf
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