A team of nurses in the medical intensive care unit (MICU) at Abington Hospital-Jefferson Health, in Abington, Pa., identified a problem with indwelling catheterization utilization and catheter-associated urinary tract infections (CAUTIs) in their unit, resulting in the implementation of an evidence-based process improvement plan. The goal was to decrease utilization of indwelling catheters and reduce CAUTI rates, thus improving patient outcomes.
In December 2013, the utilization rate in the MICU was 0.77 urinary catheters per patient day, with an associated CAUTI rate of 2.59 per 1,000 catheter days. In January 2014, the utilization rate was 0.69 and the CAUTI rate had risen to 5.17-well above the benchmark of 0.56, according to a National Healthcare Safety Network (NHSN) data summary.
The CAUTI team began the process improvement plan by designing an educational presentation for all MICU nurses. It reviewed CDC guidelines for appropriate urinary catheter use, evidenced-based insertion techniques, care of indwelling catheters, the pathogenesis of CAUTIs, and CMS reimbursement. The hospital's catheter removal protocols and portable bladder ultrasound guidelines for retention were reviewed, as was the importance of using alternatives.
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The CAUTI team initiated "daily review of necessity" conversations with each nurse caring for patients with indwelling catheters. These conversations reminded nurses of the guidelines for appropriate catheter use and timely removal. In addition, the CAUTI team began reminding primary nurses to remove the catheter on day 3 (to conduct a trial void), then to follow the bladder scanning guidelines and intermittent catheterization, if necessary. Over time, primary nurses were removing catheters on their own-and educating residents and nurses who were pulled from other units to do the same.
L to R: Kelly Purpura, MSN, RN, Dena Lampone, MSN, RN, Tracey Tolchin, RN, CCRN and Lynnann Barker, BSN, RN, CCRN, are members of Abington Hospital-Jefferson Health's CAUTI team. Jeffrey Leeser/thanks to Abington Hospital-Jefferson Health
The CAUTI team kept records of all patients with catheters and communicated face-to-face and via email to ensure that all catheters were appropriate and necessary. This sometimes included initiating conversations and following up with attending physicians. For example, a member of the team might have a conversation with a physician about a catheter that needed to stay in place for an additional 24 hours. At shift's end, one CAUTI team member would inform the next CAUTI team member, so that he or she could have a conversation with the attending physician over the next 24 hours.
CAUTIs were eradicated in the MICU for 12 consecutive months: Zero occurred between September 2014 and August 2015. The MICU experienced one CAUTI in September and one in October 2015; the rate dropped again to zero in November, where it remains as of April 2016.
The process had a substantial impact on the infection rate and strongly influenced utilization rates. From July 2014 to October 2015, utilization rates dropped and remained consistently below the NHSN benchmark of 0.56. Utilization decreased 48% from July 2014 to September 2015. Although utilization jumped slightly above the newly-established benchmark of 0.49 in October and November, MICU utilization decreased below the benchmark again in December, where it has been sustained to the present.
In addition, Abington's department of epidemiology noticed an improvement in CAUTI rates overall. The CAUTI team's timely removal of catheters prior to transfer out of the MICU decreased utilization elsewhere. The hospital's overall utilization rate decreased from 0.17 per patient day in 2014, to 0.13 per patient day in 2015, to 0.12 per patient year-to-date for 2016.
Kelly Purpura is the assistant nurse manager in the MICU at Abington Hospital-Jefferson Health in Abington, Pa.