2019 Research Forum

Rebecca Babb RN, Rosalba Cadena BRN, Trishawana Gonzalez RN, Cynthia Murillo RN & Melisa Palos RN Catheter Associated Urinary Tract Infection-CAUTI Project Med-Surgical Unit, ICU, & Psychiatric Unit. CAUTI Prevention Using an Audit Tool to Encourage a Nurse-Driven Protocol

Introduction

Each patient with an indwelling urinary catheter is evaluated by the bedside RN at each shift using the IC CAUTI Prevention Audit Tool. The RN must answer nine Yes or No type questions inspired by the current CAUTI prevention policy in order to evaluate continued need for indwelling catheter and also monitor if the indwelling catheter is being properly cared for by used catheter wipes, etc. The goal was by using a tool to help decide if continued indwelling urinary catheter use in each patient was necessary, more indwelling urinary catheters would be removed in a more timely manner that without the use of a tool. The audit tool was iplemented during the months of February 2018 through April 2018. Quarter 1 data for 2018 was then interpreted and compared to Quarter 4 2017. Methods

Conclusions Although CAUTI did not disappear completely, the use of an audit tool to encourage a nurse-driven protocol was a successful intervention to decrease CAUTI development in the ICU/DOU setting. According to interviews with the ICU/DOU RN staff involved in using the IC CAUTI Prevention Audit Tool, the tool was helpful, though difficult to complete on top of the already heavy work load that is expected within this critical care departments. Nearly all of the RNs interviewed were aware of the current standardized procedure protocol; however, many believed that indwelling catheter removal was not a top priority in caring for these very ill patients. Nurses recommended the use of an alternative person in charge of completing the audit tool would be more beneficial. Recommendations : • Consider use of alternatives to female catherization such as Purewick external urine collection device • Update current policy for “CAUTI Prevention” to match the “Standardized Procedure for Urinary Catheter Removal” (the policy sates that there needs to be a doctor’s order for removal) • Create a CAUTI champion team composed of physician, nurses, and leadership as recommended by the Minnesota Hospital Association. • Create short and long-term goals between patients and nursing staff to achieve positive outcomes • Campaign nurse driven protocol each month or each week PRN. Promote usage of the protocol it works. • Utilizing experts outside the unit to communicate and collaborate across disciplines improves patient outcomes. The infection control preventionist at Kern Medical can communicate with staff on the unit and communicate ways to improve patient outcomes case specifically. • Celebrations of sustained results, reinforcement of protocols by the bed side nurse and physicians can decrease CAUTI rates (Quinn, P. 2015). • Review all cases and talk about ways that CAUTI could have been handled differently/better or even prevented. Be as case specific as possible as a unit. (Gavin P). • Alternative use of PurWick, condom catheter, straight catheters, bladder scanner, or urinal at the bedside. Take leadership role as the bedside nurse. Promote usage of these alternatives. • Talk about catheters in hand-off communication from one nurse to the next. Ask questions each time. Why is this Foley still in place? Make this discussion part of SBAR hand-off each time. References • Chenoweth, C., & Saint, S., (2018). Preventing Catheter-Associated Urinary Tract Infections in the Intensive Care Unit. Crt Care Clinic. (1) 19-32. • Centers for Disease Control and Prevention (CDC) (2018). Urinary Tract Infection (Catheter Associated Urinary Tract Infection (UTI) and Other Urinary System Infection. Retrieved from www.cdc.gov on 4-16-2018. • Davis, P., Daley, M., & Hect, J., (2017). Effectiveness of a Bundled Approach to Reduce Urinary Catheters and Infection Rates in Trauma Patients. American Journal of Infection Control. Retrieved from online sources on 4-15-2018. • Durant, D., (2017). Nurse-Driven Protocols and the Prevention of Catheter Associated Urinary Tract Infection: A System Review. American Journal of Infection Control. Retrieved from online sources on 4-15-20198. • Dy, S., (2016). A Nurse-Driven Protocol for Removal of Indwelling Urinary Catheters across a Multi-Hospital Academic Healthcare System. Urologic Nursing, 36(5). 243-249. Doi:10.7257/1053-816X2016.36.5.243 • Kern Medical Center, (2018). IC- CAUTI Prevention Audit Tool-Observation Each Shift in ICU & DOU • Kern Medical Center., (2016-2018). Indwelling Urinary Catheters. CAUTI Prevention. Standard Policy. PCS-IC-135. • Mori, C., (2014). A-Voiding Catastrophe: Implementing a Nurse-Driven Protocol. Medsurg Nursing, 23 (1), 15-28. • Quinn, P., (2015). Chasing Zero: A Nurse-Driven Process For Catheter-Associated Urinary Tract Infection Reduction in Community Hospital Nursing Economic$ 33 (6), 320-325. • Scanlon, K. A., (2017). Saving Lives and Reducing Harm : A CAUTI Reduction Program. Nursing Economics, 35 (3), 134-141. • Tuttle, J.C., (2017). Cutting CAUTIs in Critical Care. Journey of Clinical Outcomes Management, 24 (6), 267-272. Acknowledgements We want to thank the nurses on ICU & DOU for taking the time of completing the survey of CAUTI audit tool, and we will share the results with you of the development of the CAUTI Prevention Adult Tool based on evidence-based practice to promote patients and family satisfaction. • Pam Gavin RN- NRP Coordinator • Cindy Norville- Clinical Director ICU & DOU • Kathleen Kearney- Clinical Supervisor • Kristi Brownfield- RN- BSN-Infection Preventionist

Due to an increase of catheter associated urinary tract infections (UTI) in the Kern Medical Center ICU/DOU, as RNs of the Residency Program Cohort 3 2017, we created this project in order to decrease CAUTI occurrence and encouraging RNs of the early removal of indwelling urinary catheter to patients in these units to decrease urinary tract infection (UTI) and promote positive outcomes. According to Quinn, P., (2015), the author states “Catheter Associated Urinary tract infection (CAUTI) continue to challenge community hospitals. Hospitals acquired urinary tract infections account for 40% of hospital-acquired infections, which 80% of those infections related to use a urinary, or Foley catheter”. It is important to promote Foley catheter removal in ICU/DOU units within 48 hours according to the hospital policy to decrease catheter associated urinary tract infections to promote patient wellness and satisfaction. The inspiration to decrease CAUTI occurrence led us to the following PICO question: “In patients with indwelling urinary catheter in the intensive care, and direct observation unit setting, does use of an audit tool to encourage a nurse-driven protocol compared to not using an audit tool or nurse-driven protocol, improve incidence of statistics by decreasing CAUTI occurrence during hospital staying?” Using search engines such as EPSCO, Elsevier, CDC, and in-home resource center the group was able to obtain fifteen resources applicable to CAUTI prevention. Most of the journals recommended: • Early removal of indwelling urinary catheter • Evaluation of indwelling urinary catheter necessity • And the use of nursing-driven protocol A research was obtained, and we created a PICO question; as a result, we develop nursing interventions to implement in the ICU &DOU critical care units. Goals : Implement use of IC CAUTI Prevention Audit Tool from February-April 2018 • Obtain research consistent with decreasing CAUTI development • Early removal of indwelling urinary catheters • Implement or improve upon current nurse-driven protocol • Educate staff of CAUTI risk factors Material Used Included • IC CAUTI Prevention Audit Tool • Current Standardized procedure for removal of indwelling urinary catheter policy • Bedside nurse and MD collaboration • Staff feedback

ICU&DOUCAUTIPreventionAudit Tool Observationseach shift in ICU&DOU

Kern MedicalCAUTI Occurrence 2016-2018

Reviewedby :____________________ DATE:_________________________

Shift MAR# Unit/Room# Admitting Service NurseAssigned CatheterDay

4.5

4

Yes No N/A Yes No N/A Yes No N/A Yes

No N/A Yes

No N/A

1.MedicalNecessarydocumentedby MD 2.MedicalNecessary(seebelow)

3.5

“Other”justification(Explain) 3.Collectionbag labeledwith insertiondate 4. SecuredProperly to thigh 5.CollectionBag isbelowBladder 6.CollectionBag isoffof floor 7.Pericareprovided this shiftusing readycleansewipes 8.Patient information record is current 9.Catheter removed ifmedical necessarynomet. Note recommendationsof staff: Clinical SupervisorReview: Actions: Submit toClinicalDirector forReview KMCApproved FoleyMedicalNecessary: 1.

3

2.5

2

Need foraccuratemeasurementofurinaryoutput inahemodynamicallyunstablepatient (Hemodynamic instability isdefinedas: SBP<90or40mmHgvariance from thepatient’sbaseline,MAP<65or theuseofoneor morevasopressors, inotropes,antiarrhythmics for supportofcardiacoutput/bloodpressure. Peripheralcyanosis and/ormottling inconjunctionwithchanges inbloodpressureor lactate> 4. 2. Urinary tractobstructionorurinary retention 3. Stage3or4 sacralorcoccyxpressure injury in incontinentpatients 4. Peri-operativeuse for surgicalproceduresonlywhennecessarywith removalwithin48hrs 5. Requiresprolonged immobilization (e.g.,unstable spineorpelvisorepidural inplace). 6. Hospital,Palliativecare 7. Perioperativeuseof surgicalprocedureswith removalwithin48hours 8. GU surgeryoracuteGUwound 9. Ohers:Mustexplain CAUTIBandle: Indwellingcatheter isusedonlywhennecessary Aseptic techniqueusedupon insertionandUAC/SGM staincollectedat timeof insertion Maintainclosed system Secure the system-anchor to thigh Maintainunobstructed flow Maintaincollectionbagbelow the levelofbladder-includesduringpatient transferoff theunit-donotplacebagon bed Perinealcareeach shiftandprn

1.5

1

0.5

0

2016Q4

2017Q1

2017Q2

2017Q3

2017Q4

2018Q1

2018Q2

ICU DOU

According to literature research, the use of a nurse-driven protocol is effective in reducing incidence and duration of indwelling urinary catheter, decrease CAUTI incidence, and improve the quality of care in patients in the hospital setting (Mori, 15). While we were unable to accurately develop data for number of indwelling urinary catheters removed due to use of the IC CAUTI Prevention Audit Tool. The CAUTI rate in ICU/DOU decreased significantly during the implementation of the daily audit tool used according to the statistics show below. Results

Objectives

Kern Medical CAUTI Occurrence 2016-2018

4.5

2018Q 2 15%

2016Q 4 15%

4

ICU

DOU

2017Q1 0%

3.5

2018Q 1 5%

2017Q2 2 10%

3

2.5

2

1.5

# of Patients with CAUTI

2017Q 4 30%

1

2017Q3 25%

0.5

0

2016 Q4 2017 Q1 2017 Q2 2017 Q3 2017 Q4 2018 Q1 2018 Q2

2016Q4 2017Q1 2017Q2 2017Q3 2017Q4 2018Q1 2018Q2

• Christina Elizondo- NRP Facilitator • Valerie Cantorna- NRP Facilitator • Joan Buddeeke RN-BSN-Kern Health Science Library

Q4 2016 – Q2 2018

133