Risk management
Rounding to reduce CAUTI By Kim Flanders, MBA, MSN, RN, NEA-BC
C
atheter-associated urinary tract infection (CAUTI) is a significant concern throughout the acute healthcare setting. CAUTI is the most common healthcare-associated infection (HAI). Worldwide it’s responsible for 40% of all HAIs annually.1,2 The duration of an indwelling catheter is directly related to the occurrence of CAUTI, with the risk of CAUTI rising 3% to 7% each day, culminating at 100% risk of bacteriuria at 1-month catheter duration.1,2 The most effective way to eliminate CAUTI is with the reduction of the indwelling catheter.2 The How-to Guide published by the Institute for Healthcare Improvement in 2011 provides a comprehensive strategy identifying best practices, and explains how to form a team, set aims, measure, and get started; yet many organizations continue to struggle with impacting the utilization rate attributing to over 93,000 cases of CAUTI in 2011.2,3 HAIs contribute to the financial burden and adverse patient outcomes associated with CAUTI result in an estimated increase of 2 to 4 days length of stay and an annual cost of $0.4 to $0.5 billion per year, nationally.1 Bacteremia, secondary to CAUTI, is estimated to increase cost up to $3,000 per case in unreimbursable expenses, making managing cost to reimbursement a significant challenge.2 In 2009, our organization implemented a CAUTI reduction program. Despite house-wide implementation through an electronic learning module, our organization didn’t have the desired impact of reducing indwelling catheter utilization. Noticeable variation in the level of comprehension and interpretation of the indications for use among healthcare providers was realized www.nursingmanagement.com
during the project and contributed to the lack of change in the indwelling catheter utilization rate. Specific organizational barriers to achieving the desired outcomes included the reluctance to embrace the indications for use and to fully acknowledge the CAUTI project at the bedside. (See Tables 1 and 2.) Trying again After the unsuccessful attempt at reducing CAUTI rates in 2009, we employed a new method. In July 2012, a traditional approach to educating RNs was implemented with the creation and distribution of a slide presentation created by a workgroup utilizing the evidence-based practice solutions found in the literature. Education materials were distributed by unit-based educators throughout the organization and included basic facts about catheters and CAUTI, indications for use, and the CAUTI bundle. Educators used a variety of methods to provide education through an online learning module, staff meetings, huddles, and e-mail. In November 2012, a 54-bed surgical unit was selected to pilot an approach utilizing a unit-based RN leader, referred to as a rounder, to ensure daily review of catheter necessity, catheter care, and the perineal care portion of the CAUTI bundle were in place and staff members fully comprehended the material by applying procedure to practice. The rounder reviewed an electronic report Monday through Friday that displayed patients on the unit with an indwelling catheter then reviewed the electronic medical record for appropriate documentation of the indication for use, perineal care, and catheter care. On weekends, during the initial 60 days, the rounder performed an online review from home then telephoned the unit staff members. Unit-based charge nurses assumed this duty after completion of the pilot study. Follow-up from the rounder with the clinical nurse helped the unit identify opportunity for improvement, determine barriers, and realize positive outcomes. The rounder’s feedback was escalated to the project lead daily and additional Nursing Management • November 2014 21
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Risk management information and/or education was disseminated, as needed, to further drive practice change. Staff members were provided feedback on utilization rates each month and were acknowledged for their efforts through e-mail, huddles, and rounds.
Embracing the accurate indications for use and being held accountable helped drive the needed culture and practice change to reduce CAUTI rates. Don’t dwell on it A statistics program was used to analyze data regarding the proportion of patient days in which an indwelling catheter was used in the last two quarters of fiscal year 2012 and the first two quarters of fiscal year 2013 after implementing a rounder in October 2012. The results indicated that in the last two quarters of FY12, there were 8,801 patient days on the surgical unit, 1,883 (21.4%) of which were classified as indwelling catheter days. (See Table 3.) Following the intervention in November 2012, there were 7,990 patient days, 1,174 (14.7%) of which were classified as indwelling catheter days. This indicates a 6.7% decrease in catheter days following the intervention, which was found to be statistically significant. Providing proof Evidence shows that the most effective intervention to reduce CAUTI is to reduce the utilization
rate by restricting use to patients that meet the evidence-based indication criteria.1-6 Challenges during the intervention stemmed primarily from the interpretation of the indication criteria with the inappropriate use for accurate intake and output and urinary retention. Emphasis on the ability to manage urinary retention through intermittent catheterization was initially met with resistance. Healthcare providers disagreed with removing an indwelling catheter because they thought that intermittent catheterization posed an increased risk of urinary tract infection over an indwelling catheter. Distribution of literature demonstrating the effects of duration of catheterization on urinary retention and urinary tract infection to clinical staff members prompted an impetus to begin critically assessing the need for early catheter removal. This then provided the momentum to carry the rounder methodology across the organization.7,8 Reduce and maintain Driving practice and culture change remains a challenge
Table 1: Indications for use • Perioperative use for selected surgical patients • Postprocedural management following major gynecologic, urologic, or abdominal surgeries or epidural catheter in place • Management of acute urinary retention and urinary obstruction • Comfort during end-of-life care • Incontinent patients with a stage 3 or 4 pressure ulcer or an extensive wound in the sacral or groin area • Hemodynamically unstable patients requiring strict measurement of intake and output of fluids, or I.V. vasopressors/ fluid resuscitations/paralytics • Prolonged immobilization needs such as unstable spinal cords, hip fractures, pelvic fractures, or multiple traumatic injuries
22 November 2014 • Nursing Management
Table 2: CAUTI bundles • Avoid unnecessary urinary catheters. • Insert urinary catheters using sterile technique. • Maintain urinary catheters based on recommended guidelines: – maintain a sterile continuously closed drainage system – keep catheter properly secured to prevent movement and traction – keep collection bag below the level of the bladder at all times – maintain unobstructed urine flow (for example, avoid dependent loops) – empty collection bag regularly using a separate collecting container for each patient and avoid allowing the drainage spigot to touch the collecting container. • Review urinary catheter necessity daily and remove promptly, when indicated. • Consider alternatives to an indwelling catheter: – bladder scanning – intermittent catheterization – external male catheter – warm water perineal stimulation – incontinence pad.
throughout many organizations. In the climate of cost containment and improved outcomes, the importance of a leader with passion for driving change may be underestimated. The original attempt to decrease CAUTI began in 2009 with a renewed attempt in July 2012. Our number of CAUTI and the catheter utilization rate remained stagnant until we found a unit-based leader who embraced the initiative and made educating the staff a priority. Embracing the accurate indications for use and being held accountable helped drive the needed culture and practice change to decrease the utilization rate, ultimately reducing the CAUTI rate. Failure to reduce HAIs is a costly risk that can be mitigated by engaging frontline staff to understand the rationale for change. The rounder model was cost neutral as the leader incorporated the duties www.nursingmanagement.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Risk management into daily work. Indwelling catheter utilization on the 54-bed surgical unit decreased from a rate of 21.4% to 14.7% over 60 days and has maintained a rate of 12% to 13% consistently over the past year. The unit reduced the CAUTI rate from 2.97 (and 11 HAIs) in FY12 to a CAUTI rate of 1.22 (and 2 HAIs) after the intervention. It’s important to note that the CAUTI rate is heavily influenced by the overall utilization rate. Much-needed leaders Results of this project created the impetus to spread the intervention throughout the organization. Our organization chose to use a unit-based rounder rather than a dedicated rounder for all units based on the premise that unit-level ownership would prove valuable for buy-in and sustained results while maintaining alignment with the organizations cost-containment efforts. A prospective quasi-experimental study would be valuable in determining the correlation of leader and interventional outcomes.
Table 3: Catheter days cross tabulation Indwelling catheter days
Intervention
Pre
Post
Total
Without
With
Total
Count
6,918
1,883
8,801
Percent within intervention
78.6%
21.4%
100%
Count
6,816
1,174
7,990
Percent within intervention
85.3%
14.7%
100%
Count
13,734
3,057
16,791
Percent within intervention
81.8%
18.2%
100%
Producing the best outcomes Limitations of this study include the retrospective assessment of the intervention and lack of a controlled intervention. An increased overall awareness and education of CAUTI was introduced before and during this intervention, which produced a heightened awareness for all staff members. Knowledge gaps were evaluated daily and addressed through e-mail, huddles, and sharing literature to reinforce the evidence supporting the early removal of catheters. This additional support
Leadership and ownership of change management are the key drivers to reducing CAUTI. This project wasn’t without bias—the author and primary investigator is the nursing director for the intervention unit and the project lead for the organization. Staff and unit leadership may have been more inclined to produce the needed outcomes due to this reporting structure. This potential bias does, however, lend credibility to the importance of leadership buy-in and establishing priorities as a driving factor in producing change and outcomes. www.nursingmanagement.com
makes it difficult to isolate the rounder approach as the sole successful intervention, yet does support the theory that leadership and ownership of change management are the key drivers to producing desirable outcomes. NM
2. Lo E, Nicolle LE, Coffin SE, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(5):464-479. 3. CDC. Catheter-associated urinary tract infection. http://www.cdc.gov/HAI/ca_uti/uti.html. 4. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, Healthcare Infection Control Practices Advisory Committee. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010;31(4): 319-326. 5. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 international clinical practice guideline from the Infectious Diseases Society of America. Clin Infect Dis. 2010; 50(5):625-663. 6. Sauter J. Preventing catheter-associated UTIs. Nursing Critical Care. 2012;7(1): 17-21. 7. Newman DK, Willson MM. Review of intermittent catheterization and current best practices. Urol Nurs. 2011;31(1):12-48. 8. Willson M, Wilde M, Webb ML, et al. Nursing interventions to reduce the risk of catheter-associated urinary tract infections: part 2: staff education, monitoring, and care techniques. J Wound Ostomy Continence Nurs. 2009;36(2): 137-154. Kim Flanders is a clinical director at OSF Saint Francis Medical Center in Peoria, Ill.
REFERENCES 1. Institute for Healthcare Improvement. How-to guide: prevent catheter-associated urinary tract infections. http://www.ihi. org/resources/Pages/Tools/Howto GuidePreventCatheterAssociatedUrinary TractInfection.aspx.
The author has disclosed that she has no financial relationships related to this article. DOI-10.1097/01.NUMA.0000455738.86743.6f
Nursing Management • November 2014 23
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Rounding to reduce CAUTI By Kim Flanders, MBA, MSN, RN, NEA-BC
C
atheter-associated urinary tract infection (CAUTI) is a significant concern throughout the acute healthcare setting. CAUTI is the most common healthcare-associated infection (HAI). Worldwide it’s responsible for 40% of all HAIs annually.1,2 The duration of an indwelling catheter is directly related to the occurrence of CAUTI, with the risk of CAUTI rising 3% to 7% each day, culminating at 100% risk of bacteriuria at 1-month catheter duration.1,2 The most effective way to eliminate CAUTI is with the reduction of the indwelling catheter.2 The How-to Guide published by the Institute for Healthcare Improvement in 2011 provides a comprehensive strategy identifying best practices, and explains how to form a team, set aims, measure, and get started; yet many organizations continue to struggle with impacting the utilization rate attributing to over 93,000 cases of CAUTI in 2011.2,3 HAIs contribute to the financial burden and adverse patient outcomes associated with CAUTI result in an estimated increase of 2 to 4 days length of stay and an annual cost of $0.4 to $0.5 billion per year, nationally.1 Bacteremia, secondary to CAUTI, is estimated to increase cost up to $3,000 per case in unreimbursable expenses, making managing cost to reimbursement a significant challenge.2 In 2009, our organization implemented a CAUTI reduction program. Despite house-wide implementation through an electronic learning module, our organization didn’t have the desired impact of reducing indwelling catheter utilization. Noticeable variation in the level of comprehension and interpretation of the indications for use among healthcare providers was realized www.nursingmanagement.com
during the project and contributed to the lack of change in the indwelling catheter utilization rate. Specific organizational barriers to achieving the desired outcomes included the reluctance to embrace the indications for use and to fully acknowledge the CAUTI project at the bedside. (See Tables 1 and 2.) Trying again After the unsuccessful attempt at reducing CAUTI rates in 2009, we employed a new method. In July 2012, a traditional approach to educating RNs was implemented with the creation and distribution of a slide presentation created by a workgroup utilizing the evidence-based practice solutions found in the literature. Education materials were distributed by unit-based educators throughout the organization and included basic facts about catheters and CAUTI, indications for use, and the CAUTI bundle. Educators used a variety of methods to provide education through an online learning module, staff meetings, huddles, and e-mail. In November 2012, a 54-bed surgical unit was selected to pilot an approach utilizing a unit-based RN leader, referred to as a rounder, to ensure daily review of catheter necessity, catheter care, and the perineal care portion of the CAUTI bundle were in place and staff members fully comprehended the material by applying procedure to practice. The rounder reviewed an electronic report Monday through Friday that displayed patients on the unit with an indwelling catheter then reviewed the electronic medical record for appropriate documentation of the indication for use, perineal care, and catheter care. On weekends, during the initial 60 days, the rounder performed an online review from home then telephoned the unit staff members. Unit-based charge nurses assumed this duty after completion of the pilot study. Follow-up from the rounder with the clinical nurse helped the unit identify opportunity for improvement, determine barriers, and realize positive outcomes. The rounder’s feedback was escalated to the project lead daily and additional Nursing Management • November 2014 21
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Risk management information and/or education was disseminated, as needed, to further drive practice change. Staff members were provided feedback on utilization rates each month and were acknowledged for their efforts through e-mail, huddles, and rounds.
Embracing the accurate indications for use and being held accountable helped drive the needed culture and practice change to reduce CAUTI rates. Don’t dwell on it A statistics program was used to analyze data regarding the proportion of patient days in which an indwelling catheter was used in the last two quarters of fiscal year 2012 and the first two quarters of fiscal year 2013 after implementing a rounder in October 2012. The results indicated that in the last two quarters of FY12, there were 8,801 patient days on the surgical unit, 1,883 (21.4%) of which were classified as indwelling catheter days. (See Table 3.) Following the intervention in November 2012, there were 7,990 patient days, 1,174 (14.7%) of which were classified as indwelling catheter days. This indicates a 6.7% decrease in catheter days following the intervention, which was found to be statistically significant. Providing proof Evidence shows that the most effective intervention to reduce CAUTI is to reduce the utilization
rate by restricting use to patients that meet the evidence-based indication criteria.1-6 Challenges during the intervention stemmed primarily from the interpretation of the indication criteria with the inappropriate use for accurate intake and output and urinary retention. Emphasis on the ability to manage urinary retention through intermittent catheterization was initially met with resistance. Healthcare providers disagreed with removing an indwelling catheter because they thought that intermittent catheterization posed an increased risk of urinary tract infection over an indwelling catheter. Distribution of literature demonstrating the effects of duration of catheterization on urinary retention and urinary tract infection to clinical staff members prompted an impetus to begin critically assessing the need for early catheter removal. This then provided the momentum to carry the rounder methodology across the organization.7,8 Reduce and maintain Driving practice and culture change remains a challenge
Table 1: Indications for use • Perioperative use for selected surgical patients • Postprocedural management following major gynecologic, urologic, or abdominal surgeries or epidural catheter in place • Management of acute urinary retention and urinary obstruction • Comfort during end-of-life care • Incontinent patients with a stage 3 or 4 pressure ulcer or an extensive wound in the sacral or groin area • Hemodynamically unstable patients requiring strict measurement of intake and output of fluids, or I.V. vasopressors/ fluid resuscitations/paralytics • Prolonged immobilization needs such as unstable spinal cords, hip fractures, pelvic fractures, or multiple traumatic injuries
22 November 2014 • Nursing Management
Table 2: CAUTI bundles • Avoid unnecessary urinary catheters. • Insert urinary catheters using sterile technique. • Maintain urinary catheters based on recommended guidelines: – maintain a sterile continuously closed drainage system – keep catheter properly secured to prevent movement and traction – keep collection bag below the level of the bladder at all times – maintain unobstructed urine flow (for example, avoid dependent loops) – empty collection bag regularly using a separate collecting container for each patient and avoid allowing the drainage spigot to touch the collecting container. • Review urinary catheter necessity daily and remove promptly, when indicated. • Consider alternatives to an indwelling catheter: – bladder scanning – intermittent catheterization – external male catheter – warm water perineal stimulation – incontinence pad.
throughout many organizations. In the climate of cost containment and improved outcomes, the importance of a leader with passion for driving change may be underestimated. The original attempt to decrease CAUTI began in 2009 with a renewed attempt in July 2012. Our number of CAUTI and the catheter utilization rate remained stagnant until we found a unit-based leader who embraced the initiative and made educating the staff a priority. Embracing the accurate indications for use and being held accountable helped drive the needed culture and practice change to decrease the utilization rate, ultimately reducing the CAUTI rate. Failure to reduce HAIs is a costly risk that can be mitigated by engaging frontline staff to understand the rationale for change. The rounder model was cost neutral as the leader incorporated the duties www.nursingmanagement.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Risk management into daily work. Indwelling catheter utilization on the 54-bed surgical unit decreased from a rate of 21.4% to 14.7% over 60 days and has maintained a rate of 12% to 13% consistently over the past year. The unit reduced the CAUTI rate from 2.97 (and 11 HAIs) in FY12 to a CAUTI rate of 1.22 (and 2 HAIs) after the intervention. It’s important to note that the CAUTI rate is heavily influenced by the overall utilization rate. Much-needed leaders Results of this project created the impetus to spread the intervention throughout the organization. Our organization chose to use a unit-based rounder rather than a dedicated rounder for all units based on the premise that unit-level ownership would prove valuable for buy-in and sustained results while maintaining alignment with the organizations cost-containment efforts. A prospective quasi-experimental study would be valuable in determining the correlation of leader and interventional outcomes.
Table 3: Catheter days cross tabulation Indwelling catheter days
Intervention
Pre
Post
Total
Without
With
Total
Count
6,918
1,883
8,801
Percent within intervention
78.6%
21.4%
100%
Count
6,816
1,174
7,990
Percent within intervention
85.3%
14.7%
100%
Count
13,734
3,057
16,791
Percent within intervention
81.8%
18.2%
100%
Producing the best outcomes Limitations of this study include the retrospective assessment of the intervention and lack of a controlled intervention. An increased overall awareness and education of CAUTI was introduced before and during this intervention, which produced a heightened awareness for all staff members. Knowledge gaps were evaluated daily and addressed through e-mail, huddles, and sharing literature to reinforce the evidence supporting the early removal of catheters. This additional support
Leadership and ownership of change management are the key drivers to reducing CAUTI. This project wasn’t without bias—the author and primary investigator is the nursing director for the intervention unit and the project lead for the organization. Staff and unit leadership may have been more inclined to produce the needed outcomes due to this reporting structure. This potential bias does, however, lend credibility to the importance of leadership buy-in and establishing priorities as a driving factor in producing change and outcomes. www.nursingmanagement.com
makes it difficult to isolate the rounder approach as the sole successful intervention, yet does support the theory that leadership and ownership of change management are the key drivers to producing desirable outcomes. NM
2. Lo E, Nicolle LE, Coffin SE, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(5):464-479. 3. CDC. Catheter-associated urinary tract infection. http://www.cdc.gov/HAI/ca_uti/uti.html. 4. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, Healthcare Infection Control Practices Advisory Committee. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010;31(4): 319-326. 5. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 international clinical practice guideline from the Infectious Diseases Society of America. Clin Infect Dis. 2010; 50(5):625-663. 6. Sauter J. Preventing catheter-associated UTIs. Nursing Critical Care. 2012;7(1): 17-21. 7. Newman DK, Willson MM. Review of intermittent catheterization and current best practices. Urol Nurs. 2011;31(1):12-48. 8. Willson M, Wilde M, Webb ML, et al. Nursing interventions to reduce the risk of catheter-associated urinary tract infections: part 2: staff education, monitoring, and care techniques. J Wound Ostomy Continence Nurs. 2009;36(2): 137-154. Kim Flanders is a clinical director at OSF Saint Francis Medical Center in Peoria, Ill.
REFERENCES 1. Institute for Healthcare Improvement. How-to guide: prevent catheter-associated urinary tract infections. http://www.ihi. org/resources/Pages/Tools/Howto GuidePreventCatheterAssociatedUrinary TractInfection.aspx.
The author has disclosed that she has no financial relationships related to this article. DOI-10.1097/01.NUMA.0000455738.86743.6f
Nursing Management • November 2014 23
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
