Clinical Evidence Review A regular feature of the American Journal of Critical Care, Clinical Evidence Review unveils available scientific evidence to answer questions faced in contemporary clinical practice. It is intended to support, refute, or shed light on health care practices where little evidence exists. To send an eLetter or to contribute to an online discussion about this article, visit www.ajcconline.org and click “Respond to This Article” on either the full-text or PDF view of the article. We welcome letters regarding this feature and encourage the submission of questions for future review.

DO SYSTEM-BASED INTERVENTIONS AFFECT CATHETER-ASSOCIATED URINARY TRACT INFECTION? By Margo A. Halm, RN, PhD, ACNS-BC and Nancy O’Connor, RN, BSN, MSBA, CIC

I

ntroduced in the 1930s by American urologist Dr Fredrick Foley, urinary catheters have become a mainstay in clinical care.1 An estimated 30 million urinary catheters are used annually in the United States. Prevalence of catheter use among hospitalized patients ranges from 16% to 33%2,3 and is even higher (67%-76%) in critically ill patients.4,5 But up to onethird of patients may not have an appropriate indication for a catheter to be used.3,6-8 Inappropriate catheter use occurs because of convenience, misunderstanding of necessity, and lack of clear orders for catheter removal9 or the physician's lack of awareness of the catheter's presence.8 More than 500 000 catheter-associated urinary tract infections (CAUTIs) occur each year in the United States alone. As the single largest source of bacteremia in hospitalized patients, CAUTIs account for 30% to 40% of all hospital-acquired infections.10,11 Prolonged catheterization is the principal risk factor for CAUTI.1215 CAUTI is associated with increases in morbidity and mortality, resource utilization, and health care costs. CAUTIs may lead to unnecessary use of antibiotics and antimicrobial resistance and longer hospital stays,1,10,11,16 with a cumulative additional 90 000 hospital days per year.17 The cost of a single CAUTI episode varies from $980 to $2900 (depending on presence of bacteremia),18 with a collective annual US cost of $424 million to $451 million.19 Other potential complications of catheterization such as mechanical trauma, urethral strictures, and restricted mobility also affect morbidity, further affecting length of stay and costs.1,20 The Centers for Disease Control and Prevention estimated that 20% to 70% of all CAUTI events could © 2014 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ajcc2014689

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be eliminated by universal implementation of evidence-based prevention practices.11 One guideline involves minimizing catheter use and limiting duration in all patients, but especially those at higher risk (ie, women, elderly patients, critically ill patients, patients with impaired immune function).11,21 The focus of this review is the following PICO (problem or population, intervention, comparison, outcome) question: What is the effectiveness of system interventions, such as daily reminders, on catheter use and CAUTI rates in hospitalized patients?

Method A search of the MEDLINE and CINAHL databases, limited to the past 5 to 7 years, was conducted by using these terms: urinary tract infection, catheter-associated urinary tract infection (CAUTI), daily reminders, and nurse-driven protocols.

Results Eight research or quality improvement projects were retrieved (Table 1). These reports tested the effects of single or multifaceted interventions on catheterrelated and cost variables. Educational interventions focused on evidence-based bundles/policies and competency assessment. Reminder systems involved (1) initial electronic catheter orders with embedded indications for selection from a drop-down box, or stop orders that prompt the user to either discontinue or renew a catheter order; (2) prewritten stop orders that specify criteria according to which nurses should remove catheters; and (3) daily review of catheter indications by nurses, who then would remind physicians to discontinue unnecessary catheters during multidisciplinary rounds. Product interventions involved replacing catheters coated with silver alloy

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Table 1 Matrix of evidence (P < .05) Reference

Intervention and results

Evidence level

Educational Yoon et al22

Hospitalwide education: catheter tagging Catheter insertion date tagging increased from 46.2% (baseline) to 84.6% (after education)

Meddings et al20

Catheter reminders or stop orders (N = 14 studies) Catheter days declined 2.61 days per patient in intervention group (mean duration decreased 37%) Pooled standardized mean difference for duration of catheterization was -1.11 days overall, including significant decrease when stop orders were used (but not reminders) Catheter-associated urinary tract infection (CAUTI) rate (per 1000 catheter days) decreased by 52% with either intervention

A

Fuchs et al23

Daily checklist for catheter initiation/continuation Catheter days declined from 402 (baseline) to 380 (after intervention)

C

Elpern et al24

Nurse-driven daily evaluation of catheter indication Catheter days (mean) declined from 311.7 to 238.6 days per month Inappropriate catheter use = 32% (common reasons included incontinence, skin integrity concerns, obesity, diuresis, perceived discomfort, patient's request for comfort) CAUTI rate (mean) decreased from 4.7 to 0 per month during 6-month intervention period

C

Fakih et al7

Daily review of catheter indication Catheter days declined from 203 (before intervention) to 162 per 1000 patient days (after intervention) Unnecessary catheters decreased from 102 (before intervention) to 64 catheter days per 1000 patient days (during intervention) but increased to 91 catheter days after the intervention Inappropriate catheter use decreased from 50.4% (at baseline) to 39.6% (during the intervention) and 48.7% (after the intervention)

B

Apisarnthanarak et al25

Multidisciplinary daily review of catheter indication Catheter days declined from a mean of 11 (SD, 2.5) to a mean of 3.0 (SD, 0.7) days Inappropriate catheter use decreased from 20.4% to 11% CAUTI rates decreased from 21.5 to 5.2 per 1000 catheter days Antibiotic costs decreased 63%, from $3739 (SD, $1422) to $1378 (SD, $651) Hospitalization costs decreased 58%, from $366 (SD, $62) to $154 (SD, $34)

C

Knoll et al1

Multifaceted education with system redesign/rewards/feedback Catheter prevalence decreased from 15.2% to 9.3% (intervention phase I), 13.6% (phase II) and 12% (phase III) Nonordered catheters decreased from 17% to 5.1%, and nonindicated catheters decreased from 15% to 1.2%

C

Oman et al26

Multifaceted education, charge nurse catheter rounds, product review/standardization Catheter days declined on surgical unit from 3.01 (phase 1) to 2.2 (phase 3) CAUTI rates maintained at 0 per 1000 catheter days from baseline to after the intervention (pulmonary unit) Length of stay (mean) decreased from 7.39 to 7.21 and 6.72 days in 3 phases (pulmonary unit) Product removal of silver alloy catheters had annual cost savings of $52 000; no adverse effect on CAUTI rates

C

C

Daily Checklist or Reminder System

Multifaceted

About the Authors Margo A. Halm is the director of nursing research, professional practice, and Magnet at Salem Hospital in Salem, Oregon. Nancy O’Connor is the infection prevention and employee health manager at Salem Hospital. Corresponding author: Margo A. Halm, RN, PhD, ACNS-BC, Salem Hospital, Salem, OR 97301 (e-mail: margo.halm@ salemhealth.org).

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with latex and nonlatex catheters, standardizing securement devices and metered drainage bags in insertion kits, and increasing availability of commodes and bladder scanners. Finally, multifaceted interventions often incorporated audits and feedback.

Recommendations for Practice CAUTI is a nurse-sensitive indicator of the quality of care. Nurses are responsible for using evi-

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dence-based guidelines from start to finish (ie, inserting, managing, and removing catheters).22 Existing evidence for the interventions reviewed ranged from level A (daily reminder systems) to level C (education and product review/standardization; Table 2). Table 3 summarizes key impacts of these interventions. Urinary catheters should be used only for approved indications (Table 4). Global catheter education, as part of multifaceted interventions, reduced overall prevalence of catheter use,1,26 and the prevalence of nonordered or nonindicated catheters.1 Nurses have a pivotal role in collaborating with their physician colleagues to ensure that catheter use is aligned with these guidelines, even in settings like the emergency department. If patients are admitted from outside facilities with catheters, nurses should assess the need for the catheter and communicate with physicians if a physician is not present for prompt removal of the catheter.11 Another option involves embedding approved indications into electronic order sets so that physicians must

Table 2 American Association of Critical-Care Nurses evidence-leveling systema Level

Description

A

Meta-analysis of multiple controlled studies or metasynthesis of qualitative studies with results that consistently support a specific action, intervention, or treatment

B

Well-designed controlled studies, both randomized and nonrandomized, with results that consistently support a specific action, intervention, or treatment

C

Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results

D

Peer-reviewed professional organizational standards, with clinical studies to support recommendations

E

Theory-based evidence from expert opinion or multiple case reports

M

Manufacturer’s recommendation only

a

From Armola et al,27 with permission.

Table 3 Summary of results Intervention Remindera

Multifacetedb

Inappropriate catheter use (% or rate)

Decreased

Decreased

Catheter prevalence (% or rate per patient days)

Decreased

Decreased

Catheter-associated urinary tract infection rate

Decreased

Decreased

No. of urine cultures

No change

Recatheterization rates

No change

Result

Educational

Catheter tagging (date of Insertion)

Increased

Length of stay

Decreased

Cost savings (antibiotics, overall costs) a b

Increased

Increased

Daily checklists, daily catheter review, initial catheter orders, and stop orders. Education about the bundle for catheter-associated urinary tract infections, catheter insertion competencies, catheter reminders, feedback and rewards, product streamlining, and equipment availability.

Table 4 Approved evidence-based indications for urinary cathetersa Bladder outlet obstruction (severe prostatic enlargement, blood clots, urethral compression) Acute urinary retention (need to straighten catheter >2 times because of anesthesia, opioids, paralytics, nerve injury) Perioperative uses (large volume infusions/diuretics, prolonged stay in operating room, intraoperative output monitoring, urological procedures) Strict monitoring of output in critically ill patients (neurogenic bladder, use of paralytic agents, vasopressors, or inotropic agents) Prolonged immobilization (potentially unstable thoracic/lumbar spine, multiple traumatic injuries such as pelvic fractures) Healing of sacral or perineal wounds in incontinent patients Promotion of comfort at the end of life, if needed Long-term indwelling urinary catheter on admission a

Based on information from Gould et al.11

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Table 5 Catheter do’s and don’tsa Do

Don’t

Use aseptic technique to insert catheter

Clean periurethral area with antiseptics

Secure catheter to prevent movement and traction

Let drainage bag touch floor

Perform routine meatal cleansing

Disconnect drainage system

Always keep drainage bag below level of bladder

Routinely irrigate bladder

Maintain free urine flow by keeping catheter and tubing free of kinks

Routinely change catheters or drainage bags

Empty bag regularly by using a separate clean container

Clamp tubing during transport

Disinfect port before and after urine sampling

Clamp catheter before removal

Replace catheter and system if a break in aseptic technique, disconnection, or leakage occurs Consider closed continuous irrigation if obstruction is anticipated Consider alternatives (external catheters or intermittent catheterization) Use bladder ultrasound to evaluate urinary retention a

Based on information from Gould et al,11 Fink et al,28 and Blodgett.29

select the indication before inserting the catheter.1 Yoon et al22 trained staff to tag/date the catheter at the time of insertion. This visual reminder tells the health care team when the catheter was placed, obviating having to look up this information during daily review and bedside rounding. Once a catheter is inserted, use of evidence-based CAUTI bundles (Table 5) is critical; however, catheters should be removed as soon as possible.11 The studies in this review suggest that system interventions aid nurses in regular evaluation of the need for a catheter. Embedding daily checklists and catheter reviews into unit processes (eg, huddles, charge nurse or interdisciplinary rounds), or stop orders into the electronic record are system changes that can reduce inappropriate catheter use and the overall prevalence of catheter use. Education on such reminder systems is critical to ensure that implementation is consistent so that gains are sustained. Next to evidence-based care of urinary catheters, the biggest step you can take to prevent CAUTIs in your patients is addressing each patient’s catheter every day: “Does this patient have an approved indication for a urinary catheter? If so, what indication is present?” When an indication is not present, call the physician to obtain an order to discontinue the catheter. This simple task can have a huge impact. FINANCIAL DISCLOSURES None reported.

eLetters Now that you’ve read the article, create or contribute to an online discussion on this topic. Visit www.ajcconline.org and click “Responses” in the second column of either the full-text or PDF view of the article.

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REFERENCES 1. Knoll B, Wright, Ellingson L, et al. Reduction of inappropriate urinary catheter use at a veteran affairs hospital through a multifaceted quality improvement project. Clin Infect Dis. 2011; 52(1):1283-1290. 2. Junkin J, Selekof J. Prevalence of incontinence and associated skin injury in the acute care inpatient. J Wound Ostomy Continence Nurs. 2007;34(3):260-269. 3. Weinstein JW, Mazon D, Pantelick E, Reagan-Cirincione P, Dembry LM, Hierholzer WJ Jr. A decade of prevalence surveys in a tertiary-care center: trends in nosocomial infection rates, device utilization, and patient acuity. Infect Control Hosp Epidemiol. 1999;2:543-548. 4. Charles P, Dalle D, Aube F, et al. Candida spp. colonization significance in critically ill medical patients: a prospective study. Intensive Care Med. 2005;31(3):393-400. 5. Rosser C, Blare R, Meredith J. Urinary tract infections in the critically ill patient with a urinary catheter. Am J Surg. 1999;177 (4):287-290. 6. Apisarnthanarak A, Rutjanawech S, Wichansawakun S, et al. Initial inappropriate urinary catheters used in a tertiary-care center: incidence, risk factors, and outcomes. Am J Infect Control. 2007;35(9):594-599. 7. Fakih M, Dueweke C, Meisner S, et al. Effect of nurse-led multidisciplinary rounds on reducing the unnecessary use of urinary catheterization in hospitalized patients. Infect Control Hosp Epidemiol. 2008;29(9):815-819. 8. Saint S, Wiese J, Amory J, et al. Are physicians aware of which of their patients have indwelling urinary catheters? Am J Med. 2000;109(6):476-480. 9. Loeb M, Hunt D, O’Halloran K, Carusone SC, Dafoe N, Walter SD. Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized controlled trial. J Gen Intern Med. 2008;21:816-820. 10. Centers for Disease Control and Prevention (CDC). CAUTI Guidelines Fast Facts. Atlanta, GA: CDC; 2010. 11. Gould C, Umscheid C, Agarwal R, et al. HICPAC guideline for prevention of catheter-associated urinary tract infections, 2009. Infect Control Hosp Epidemiol. 2010;31(4):319-326. 12. Foxman B. Epidemiology of urinary tract infections: incidence, morbidity, and economic costs. Am J Med. 2002; 113(Suppl 1A): 5S-13S. 13. Kumin C. Nosocomial urinary tract infections and the indwelling catheter: what is new and what is true? Chest. 2001;120:10-12. 14. Maki D, Tambyah P. Engineering out the risk for infection with urinary catheters. Emerg Infec Dis. 2001;7(2):342-347. 15. Saint S, Chenoweth C. Biofilms and catheter-associated urinary tract infections. Infect Dis Clin North Am. 2003;17: 411-432. 16. Appelgren P, Hellström I, Weitzberg E, Söderlund V, Bindslev L, Ransjö U. Risk factors for nosocomial intensive care infections: a long-term prospective analysis. Acta Anesthe-

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siol Scand. 2001;45(6):710-719. 17. Gokula R, Hickner J, Smith M. Inappropriate use of indwelling urinary catheters at a Midwestern community teaching hospital. Am J Infect Control. 2004;32:196-199. 18. Saint S. Clinical and economic consequences of nosocomial catheter-related bacteriuria. Am J Infect Control. 2000;28: 68-75. 19. Jacobsen S, Schaeffer E. Infections of the urinary tract. In: Wein A, Kavoussi L, Novick A, Partin A, Peters C, eds. Campbell-Walsh Urology. Philadelphia, PA: Saunders; 2007:223-303. 20. Meddings J, Rogers MA, Macy M, Saint S. Systematic review and meta-analysis: reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients. Clin Infect Dis. 2010; 51(5):550-560. 21. Gray M. Reducing catheter-associated urinary tract infection in the critical care unit. AACN Adv Crit Care. 2010;21:247-257. 22. Yoon B, McIntosh SD, Rodriguez L, Holley A, Faselis CJ, Liappis AP. Changing behavior among nurses to track indwelling urinary catheters in hospitalized patients. Interdisc Perspect Infect Dis. 2013. http://www.ncbi.nlm.nih.gov /pmc/articles/PMC3606769/. Accessed August 21, 2014.

23. Fuchs MA, Sexton DJ, Thornlow DK, Champagne MT. Evaluation of an evidence-based nurse-driven checklist to prevent hospitalacquired catheter-associated urinary tract infections in intensive care units. J Nurs Qual. 2011;26(2):101-109. 24. Elpern EH, Killeen K, Ketchem A, Wiley A, Patel G, Lateef O. Reducing use of indwelling urinary catheters and associated urinary tract infections. Am J Crit Care. 2009;18(6):535-541. 25. Apisarnthanarak A, Thongphubeth K, Sirinvaravong S, et al. Effectiveness of multifaceted hospital wide quality improvement programs featuring an intervention to remove unnecessary urinary catheters at a tertiary care center in Thailand. Infect Control Hosp Epidemiol. 2007;28(7):791-798. 26. Oman K, Makic M, Fink R, et al. Nurse-directed interventions to reduce catheter-associated urinary tract infections. Am J Infect Control. 2012;40:548-553. 27. Armola R, Bourgault A, Halm M, et al. Upgrading AACN’s evidence leveling hierarchy. Am J Crit Care. 2009;18:405-409. 28. Fink R, Gilmartin H, Richard A, Capezuti E, Boltz M, Wald H. Indwelling urinary catheter management and catheter-associated urinary tract infection prevention practices in nurses improving care for Healthsystem Elders hospitals. Am J Infect Control. 2012;40(8):715-720. 29. Blodgett T. Reminder systems to reduce the duration of indwelling urinary catheters: a narrative review. Urol Nurs. 2009;29(5):369-379.

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Do System-Based Interventions Affect Catheter-Associated Urinary Tract Infection? Margo A. Halm and Nancy O'Connor Am J Crit Care 2014;23:505-509 doi: 10.4037/ajcc2014689 © 2014 American Association of Critical-Care Nurses Published online http://www.ajcconline.org Personal use only. For copyright permission information: http://ajcc.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT

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AJCC, the American Journal of Critical Care, is the official peer-reviewed research journal of the American Association of Critical-Care Nurses (AACN), published bimonthly by The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright © 2014 by AACN. All rights reserved.

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Do system-based interventions affect catheter-associated urinary tract infection?

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