Catheter-associated urinary tract infections are the second most common health care–associated infections, occurring most frequently in intensive care units. These infections negatively affect patient outcomes and health care costs.
The targeted institution for this improvement project reported 13 catheter-associated urinary tract infections in 2018, exceeding the hospital’s benchmark of 4 or fewer such events annually. Six of the events occurred in the intensive care unit. Project objectives included a 30% reduction in reported catheter-associated urinary tract infections, 20% reduction in urinary catheter days, and 75% compliance rating in catheter-related documentation in the intensive care unit during the intervention phase.
This project used a pre-post design over 2 consecutive 4-month periods. The targeted population was critically ill patients aged 18 and older who were admitted to the intensive care unit. A set of bundled interventions was implemented, including staff education, an electronic daily checklist, and a nurse-driven removal protocol for indwelling urinary catheters. Data were analyzed using mixed statistics, including independent samples t tests and Fisher exact tests.
No catheter-associated urinary tract infections were reported during the intervention period, reducing the rate by 1.33 per 1000 catheter days. There was a 10.5% increase in catheter days, which was not statistically significant (P = .12). Documentation compliance increased significantly from 50.0% before to 83.3% during the intervention (P = .01).
This bundled approach shows promise for reducing catheter-associated urinary tract infections in critical care settings. The concept could be adapted for other health care–associated infections.
Health care–associated infections (HAIs) have become a widespread concern. Nationally, these avoidable events contribute to higher health care costs and excess mortality rates.1 Data from the Centers for Disease Control and Prevention (CDC) revealed that catheter-associated urinary tract infections (CAUTIs) were the second most commonly observed HAI from 2015 through 2017.2 Further analysis found that CAUTIs accounted for approximately 15% of reported HAI events annually.2 To combat this issue, the National Healthcare Safety Network (NHSN) made CAUTI reduction a national outcome measure.3 All health care–acquired CAUTIs in the inpatient setting, excluding level II/III neonatal intensive care units (ICU), must be reported to the NHSN.3 A summary measure known as the standardized infection ratio (SIR) was created to help hospitals track reported events and measure against local, state, and national benchmarks over time.4 The SIR compares the number of infections observed at an institution with the number of infections predicted.4 Predicted values are individualized for each institution through standardized algorithms that adjust for population, size, and other risk factors.4 In interpretation of the SIR, values less than 1.0 indicate that reported CAUTIs fell below predicted values, whereas values higher than 1.0 indicate that observed events exceeded predicted values.4 The benchmark SIRs for observed CAUTIs in the acute hospital setting are 1.050 in Pennsylvania and 0.993 nationally.5
Given the projected SIR and expected patient volumes, the institution targeted for this improvement study should have reported no more than 4 CAUTIs per year. Instead, hospital data revealed a total of 13 reportable CAUTI events in 2018, of which 6 were reported by the ICU. These findings prompted a quality improvement initiative that focused on reducing CAUTI rates in the ICU.
Background and Relevance to Critical Care Nurses
Hospital-acquired CAUTIs are preventable events that can lead to poor patient outcomes and higher health care costs. Approximately 75% of hospital-acquired urinary tract infections are attributed to indwelling urinary catheter use, and 15% to 25% of all inpatient populations undergo catheterization at some point during an acute hospitalization.6 The Agency for Healthcare Research and Quality (AHRQ) National Scorecard on Hospital-Acquired Conditions reported approximately 161 000 CAUTIs in 2017,7 with a projected excess mortality rate of 0.036 per CAUTI event.1 Additional CAUTI-related costs were estimated to be approximately $14 000 per hospital-acquired condition event, with a range from $4694 to $29 743.1 Another study found that per-patient costs range from approximately $500 in the case of an uncomplicated CAUTI to as high as $3000 when secondary complications such as bacteremia develop.8 There are also indirect consequences that may result in additional costs. The Centers for Medicare and Medicaid Services (CMS) is currently conducting a program called the Hospital-Acquired Condition Reduction Program, which collects data on patient safety events and certain HAIs, including CAUTIs.9 Hospitals are ranked on the basis of this information, and results are released to the public. This information can also lead to CMS penalties and reductions in reimbursement.9
Approximately 75% of hospital-acquired urinary tract infections are attributed to indwelling urinary catheter use.
Annual data demonstrate that CAUTI incidence rates are consistently higher in ICU settings. Data from the CDC’s 2018 National and State HAI Progress Report for acute care hospitals showed that 45% of the observed CAUTIs were reported by ICUs.10 Additional data indicated that the pooled mean CAUTI rate per 1000 catheter days in non-ICU inpatient wards ranged from 0.1 to 3.1, compared with 1.2 to 5.3 in critical care units.11
A urinary catheter is a foreign device that alters the body’s internal milieu. This change in environment allows an influx of microorganisms through the urinary tract and into the bladder. Indwelling urinary catheters facilitate this process by altering the normal micturition process and promoting biofilm growth. These factors promote the migration of common gastrointestinal and perineal flora into the urinary tract, leading to CAUTIs. Depending on the severity and duration of the infection, additional complications such as pyelonephritis, bacteremia, and even death can occur. Intensive care unit patients are at increased risk for complications related to indwelling urinary catheters for a variety of reasons, including prolonged use, immunocompromised status, immobility, bowel incontinence, dietary insufficiency, presence of severe underlying acute illnesses, and poorly controlled comorbidities such as diabetes mellitus and renal insufficiency.12
Several evidence-based practices have been successful in reducing the incidence of CAUTI in the critical care population. Multiple studies evaluated the use of single interventions on CAUTI reduction. One observational study indicated that the use of clinical support tools in the electronic health record (EHR) was highly effective in reducing CAUTI rates and overall catheter days.13 Regarding equipment-based interventions, a literature review indicated that “simple impregnation of antimicrobial agents in catheters with sterile conditions is not sufficient for the prevention of CAUTI.”14(p36) Using daily checklists and algorithm-based nurse-driven protocols for catheter removal reduced CAUTI rates by 1.42 per 1000 catheter days.15 Staff education also played an important role in CAUTI reduction.
Using daily checklists and algorithm-based nurse-driven protocols for catheter removal has been found to reduce CAUTI rates.
Evidence from several literature reviews indicated that using a bundled intervention approach encompassing multiple evidence-based interventions simultaneously was very effective in CAUTI reduction.15–17 One quality improvement project implemented a bundled approach involving 5 separate interventions.18 These interventions consisted of a bedside reminder tool, an educational campaign, improved EHR orders with related clinical support tools, an automated catheter removal order, and a protocol outlining specific care after catheter removal. The entire project occurred over a 3-year period, and results revealed a 35% reduction in catheter use and a decreased overall CAUTI rate.18 A recent quasi-experimental study also used a bundled approach.19 This long-term study took place in an ICU over a 12-year period from 2005 to 2016. A daily checklist and biannual routine trainings on CAUTI prevention were implemented at the institution. CAUTI incidence rates decreased from 14.9 to 1.1 per 1000 catheter days, and the rate of urinary catheter use decreased from 73.1% to 45.6%.19 The AHRQ also has suggested that using a bundled intervention model is the best approach for CAUTI reduction.20 Given these findings and recommendations, this improvement project was also designed using a bundled approach.
The chief objective of the improvement project was to reduce the number of CAUTIs in a local ICU using a multifaceted approach that combined education and practice-related interventions. Specific aims were as follows: (1) a 30% reduction in total reported CAUTIs in the ICU during the 4-month intervention period as compared with the preintervention phase, (2) a 20% reduction in total urinary catheter days in the ICU during the 4-month intervention period as compared with the preintervention phase, and (3) a 75% compliance rating with indwelling catheter–related EHR documentation during the intervention period.
Organizational Setting and Sample
The primary setting for this project was a 28-bed ICU in a rural regional medical center with a county population of approximately 116 000. The hospital is a 224-bed nonprofit licensed acute care community hospital and the main campus for a larger system. In total, the system encompassed 6 campuses across a 12-county area with approximately 16 521 inpatient admissions in 2017. The targeted service population consisted of critically ill medical-surgical, trauma, neurological, and cardiothoracic surgical patients aged 18 years or older who were admitted to the ICU.
Inclusion and Exclusion Criteria
All reported CAUTIs had to meet the NHSN definition and symptomatic urinary tract infection (UTI) criteria.21 Per the infection control department’s UTI policy (2015) and the NHSN,21(p7-2) that definition is as follows:
Catheter-associated urinary tract infection is defined as a UTI where an indwelling urinary catheter was in place for more than 2 calendar days on the day of event, with day of device placement being Day 1, and indwelling urinary catheter was in place on the date of the event or the day before.
Per the CDC’s definition of CAUTI, all patients using straight or external catheters, or any patients with ileo-conduits, nephrostomy tubes, a urostomy, or suprapubic catheters, except when there is documented evidence of an indwelling urethral catheter as well, were excluded from CAUTI-related data.21
This improvement project had a typical pre-post design. Preintervention data were collected and compared with data collected throughout the intervention phase. This process occurred over 2 consecutive 4-month periods. Data were then statistically analyzed and interpreted to determine efficacy.
The AHRQ’s implementation guide Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units describes 3 primary components that can help foster success in CAUTI reduction programs in clinical settings: suitable catheter use, proper insertion and removal, and appropriate maintenance.20 The interventions in this project were based on the inclusion of each of the AHRQ recommendations.
The educational portion of this improvement project was provided by the CAUTI-reduction task force and critical care staff development team during the final month of the preintervention period. A detailed description of both the didactic and hands-on components that were used is provided in Table 1. All related training was adapted from recommendations in a best practice guide released by the institution’s larger umbrella organization. This reference included general catheter education as well as directions and resources for hands-on learning, including recommended skills and related evaluation checklists.
The module-based didactic portion included CAUTI definition and related information (ie, criteria, symptomatic versus asymptomatic UTIs), appropriate urine specimen testing and collection techniques, and care-based education. Education related to direct care included indications and contraindications for indwelling urinary catheter use, alternative catheter options such as external catheters and timed voiding, proper insertion and removal, and appropriate maintenance and care. Basic but essential topics were reviewed, including sterile technique for insertion, catheter and drainage bag positioning, and techniques for proper catheter care. Appropriate catheter care included use of a washcloth, bar soap, and water. Examples of improper care and related contraindications, including use of the system’s perineal spray for indwelling urinary catheter care, were also incorporated into the education.
Once the didactic element was complete, staff members were required to attend a hands-on skills and competency session held in the ICU. All ICU nurses were required to complete skills evaluations on each component of indwelling catheter care, including insertion, removal, daily care, and specimen collection. These skills evaluations were held at various intervals over a 1-month period to accommodate all staff and shifts and promote maximum compliance. The skills sessions were designed to be short and efficient. Individual testing was also offered by shift supervisors or elected “superusers” for those who were unable to attend scheduled sessions. As an attempt to minimize any costs incurred related to the improvement project, nurses were encouraged to complete all education during a scheduled shift. An online tracking tool was used to ensure that everyone completed the learning modules, and sign-in sheets were used during skill sessions. Permanent ICU staff achieved 100% completion for both didactic and hands-on education, but because of design flaws, float pool nurses, travel nurses, and new hires were not accurately tracked.
Three primary components can help foster success in CAUTI reduction programs: suitable catheter use, proper insertion and removal, and appropriate maintenance.
The second important component of the project involved indwelling catheter–related documentation and orders. An updated nurse-driven protocol for discontinuation of indwelling urinary catheter use was implemented. The protocol was adapted from practice recommendations by the institution’s larger umbrella organization. Protocol specifics are shown in Table 2. An electronic daily checklist for indwelling urinary catheters was also implemented. The checklist included documenting the urinary catheter insertion date, whether a urinary catheter order was present, reason for continued use, whether patient education was documented, and whether daily catheter care was documented. Staff members were required to complete the checklist once daily between 7 pm and 11:59 pm, and email reminders were sent nightly. The daily list was created using Microsoft Excel and adapted into a secure electronic format (Microsoft SharePoint) that was easily accessible by all nurses.
Study of the Interventions
Several approaches were used to maximize the impact of the interventions. Steps were also taken to increase the probability that observed outcomes were a result of the interventions. To strengthen the educational component, ICU nurses were required to complete all education before participating in catheter-related patient care during the intervention period.
Additional methods were used to strengthen the other projection interventions. The daily checklist for indwelling urinary catheters was created using an electronic format instead of a traditional paper-based design. Transitioning to the electronic format was intended to help increase staff compliance through ease of use, decrease the supervisor workload, and improve accuracy of the collected data. Eliminating paper-based audits helped limit the potential for human error, including missing paper documents, illegibility, and improper, time-consuming hand calculations. A drop-down feature was used for all checklist responses except catheter insertion date. This feature prevented free-text responses and limited typographical errors. Completing this checklist was required for every room in the ICU on a nightly basis.
Selections for empty bed assignments or non– indwelling urinary catheter patients were also built into the checklist; nurses would select the appropriate drop-down response under each assigned room and move to the next. The goal was to maximize completion by creating habit, but also to increase accountability and compliance. Also, because this format provides real-time data, a supervisor could access the list every night and offer staff reminders where needed. The time frame for completing the daily checklist was also standardized to increase the reliability of the instrument.
Measures and Methods for Associated Data Collection
To achieve the project aims, specific data were required to measure efficacy and overall success of the project. Selected approaches included measures for both fidelity and outcome. To address all objectives, necessary outcome measures included (1) monthly reported CAUTI rate for the ICU, (2) monthly indwelling catheter days in the ICU, and (3) compliance rates for indwelling catheter–related EHR documentation for the ICU.
Applicable data points were compiled monthly. The data were drawn from the census, EHR-generated data, and preintervention and postintervention random record audits. At the end of the intervention period, all data were analyzed using the appropriate descriptive statistics or statistical tests applicable to each outcome measure. A detailed explanation of each measure’s operational definition and associated data collection plan is provided in Table 3.
For the first aim, the goal was to reduce the number of CAUTIs reported in the ICU during the intervention period by 30%. Analysis for this aim involved a percent change calculation.
The second aim targeted a 20% reduction in total urinary catheter days at the end of the intervention period as compared with the preintervention phase. To analyze this objective, an independent t test was performed. Weekly counts of total catheter days were collected over the entire 8-month period, producing a total of 16 data points for each 4-month interval. Using these data, the independent t test was used to compare the overall mean total catheter days for each time frame and evaluate the results for statistical significance. Additional measurements for this aim included a percent change calculation between the intervals to analyze the overall efficacy of the project interventions.
For the final aim, the goal was to achieve a 75% compliance rating for related documentation during the intervention phase. To evaluate this aim, 30 patient records were audited from each 4-month interval. Samples were randomly selected using a systematic method to increase generalizability to the population. Three computer-generated random dates were selected from each time interval, and then the first 10 records on each of the daily lists were selected, generating a total of 30 records for each 4-month period, or 60 in total. Documentation from each record was assessed using a checklist that included insertion date, presence of an order, reason for use, patient education, and catheter care. Compliance for overall completion was defined as proper documentation of all 5 elements. Each individual component of the documentation was analyzed as well. Analyzing each element separately was essential for determining trends in reasons for use and identifying specific areas that might require improvement or revision. Compliance rates for both overall and individual element completion for the 2 intervals were compared using Fisher exact tests.
This quality improvement project was formally evaluated using a quality improvement checklist and determined not to be human participants research. Therefore, institutional review board approval was not required.
All data were analyzed through a mix of descriptive and quantitative statistics and then interpreted to evaluate the overall efficacy and success of the project. IBM SPSS Statistics, version 25, was used for all statistical analysis, with the α set to .05.
Implementation of this bundled intervention model was correlated with a reduction in the ICU’s CAUTI rate. In the preintervention period, there were 4 CAUTI events reported hospital-wide, with 2 occurring in the ICU. During the intervention period the ICU had no reported CAUTI events. Postintervention calculations revealed a percentage change of 100%. In addition, the CAUTI incidence rate decreased by 1.33 per 1000 catheter days. These results are comparable to the 1.42 reduction documented in similar studies.15
Indwelling Urinary Catheter Days
Postintervention analysis revealed that total catheter days increased by 10.5% (P = .12; see Figure). The mean number of catheter days during the intervention period was 103.56, compared with 93.75 in the preintervention period.
Overall documentation compliance increased significantly from before (50.0%) to during the intervention (83.3%) (P = .01). The postintervention compliance exceeded the initial target goal of 75%. Individual element analyses revealed increases in education documentation (P = .06) and documented catheter care (P = .08). There was 100% compliance for presence of indwelling catheter orders at both time points; thus, comparative tests could not be performed.
Reducing the CAUTI rate was the primary goal of this improvement initiative. National estimates suggest that each reported CAUTI is associated with an average of $14 000 in additional costs.1 On the basis of these numbers, this improvement project may have avoided nearly $28 000 in additional costs.
This improvement initiative did not result in a decrease in total urinary catheter days. This finding was not consistent with those of longer 3-year18 and 12-year19 studies, in which use of bundled interventions reduced total catheter days by as much as 27.5%19 to 35.0%.18 These results prompted additional review. Retrospective data for the number of ICU patient admissions, total patient days, and reason for use were analyzed for each time period. Admission data revealed that ICU admissions were 3.68% higher during the intervention period. The device utilization ratio was also higher during the intervention (0.63) compared with the preintervention period (0.57), indicating higher overall use throughout the intervention phase. The device utilization ratio (number of catheter days divided by number of patient days) helps track urinary catheter use over time while accounting for census variations. Reason for use data were also compared during documentation compliance audits. Postintervention analysis revealed a larger percentage of patients requiring ongoing urinary catheter use owing to intravenous sedation, mechanical ventilation, and use of intravenous inotropic agents compared with the preintervention period. Prompt removal of urinary catheters can be more challenging in these higher-acuity patients.
Findings regarding indwelling urinary catheter–related documentation were also positive. Postintervention results exceeded the initial aim of 75% overall documentation compliance. There was also a significant 33.3% improvement during the intervention period. A review of individual elements also demonstrated increased compliance with documenting catheter-related patient education and catheter care. Despite all-around improvement in compliance, documentation of catheter care was still identified as the weakest individual element during both time periods. Presence of an order for the indwelling urinary catheter was not identified as an issue in the ICU, as both time frames demonstrated 100% compliance.
One of the strengths of this improvement project was the simplicity of the interventions. These interventions were direct and efficient, with few direct costs or necessary equipment. This process could be easily adapted for hospital-wide use.
Implications for Nursing Practice
We underestimated the relevance of the education-based elements of this improvement initiative. Postintervention feedback from both staff and management indicated that this aspect was especially helpful. Intensive care unit nurses have been equipped to care for complex patients, but the basic aspects of care remain essential despite acuity. This feedback mirrors the results of a recent quasi-experimental study in which biannual CAUTI training sessions were highly effective in CAUTI reduction.19
Most CAUTIs are avoidable events. Nurse-driven interventions can play a major role in CAUTI reduction. Important tasks such as using strict aseptic techniques during insertion and maintaining a closed system can limit biofilm formation. Performing proper perineal care in patients with indwelling urinary catheters can also limit migration of common gastrointestinal microorganisms into the urinary tract. In the vulnerable critical care population, each of these important skills can help reduce CAUTI rates. Nursing leaders can promote continued education through annual skills fairs that focus on current and emerging evidence-based nursing practices.
Nurse-driven interventions can play a major role in CAUTI reduction, including using strict aseptic techniques during insertion.
Several precautions were taken during the project’s design to improve overall strength of the study, but the generalizability of the findings is limited. Sample sizes were small, and the study duration was short. Use of the nurse-driven removal protocol was not tracked throughout the intervention period. Accurate tracking was difficult because the protocol was not built into the EHR. The missing data made it difficult to determine the true impact of the removal protocol on the project. This imprecision in the design may have weakened the project’s internal validity. Once the removal protocol is incorporated into the new EHR, total catheter days should be reevaluated. The AHRQ recommendations also suggest adding more clinical support tools, such as hard stops for urinary catheter insertion and urine specimen collections, a urinary catheter “time-out,” and/or pop-up reminders.20
Another unintended problem was not accounting for float pool nurses, agency nurses, and new hires throughout the education and intervention period. Staff included in these populations were able to complete the daily checklists and use the removal protocol, but adequate tracking for the educational component was not done for these subpopulations. This population was small but still posed a risk to the overall efficacy of the study.
Although the overall project showed significant promise, the analysis also revealed areas for improvement. Before hospital-wide implementation, there should be a period of revision and improvement based on project results and administrative and staff feedback. This review process could also expose additional strengths and weaknesses. Once implemented hospital-wide, a sustainability team should be formed to help prevent failure of the interventions and maintain competency and compliance. Biannual reviews of the bundled interventions will allow for revisions and updates to the program based on hospital trends and any evidence-based changes.
This improvement initiative proved successful and led to a significant reduction in CAUTIs in the ICU and throughout the hospital. Owing to the overall success of the project, a newly formed CAUTI quality assurance and performance improvement team embarked on revising and adapting the program for hospital-wide implementation. In addition, the informatics department began to work toward integrating a version of the daily checklist and nurse-driven removal protocol directly into the EHR.
In conclusion, using this bundled intervention model shows significant promise for quality improvement in the intensive care setting. This same multifaceted approach could be used to implement improvement programs for the reduction of other CMS-targeted HAIs such as central catheter–associated bloodstream infections, ventilator-associated pneumonia, surgical site infections, and hospital-acquired Clostridioides difficile infections. Ultimately, large-scale practice improvements in these problem areas could result in significant improvement in patient outcomes, decreased hospital stays, and reduction in overall health care costs.
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To learn more about preventing catheter-associated urinary tract infections, read “Zeroing in on Safety: A Pediatric Approach to Preventing Catheter-Associated Urinary Tract Infections” by Williams in AACN Advanced Critical Care, 2016;27(4):372–378. Available at www.aacnacconline.org.