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The Impact of Two-Person Indwelling Urinary Catheter Insertion in the Emergency Department Using Technical and Socioadaptive

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The Impact of Two-Person Indwelling Urinary Catheter Insertion in the Emergency Department Using Technical and Socioadaptive REPORTS FROM THE FIELD The Impact of Two-Person Indwelling Urinary Catheter Insertion in the Emergency Department Using Technical and Socioadaptive Interventions Chaz Rhone, MPH, CIC, Yonatan Breiter, MSN, RN, CNL, Linda Benson, DNP, ACNP-BC, CPHQ, Heather Petri, MOS, Peggy Thompson, RN, BSN, CIC, FAPIC, and Carmen Murphy, RN, BSN, CIC ABSTRACT ach year an estimated 721,800 health care– • Objective: To decrease insertion-related catheter- associated infections occur in U.S. acute care associated urinary tract infections (CAUTIs) attrib- E hospitals, resulting in approximately 75,000 uted to the emergency department (ED) as well as deaths [1]. Catheter-associated urinary tract infections facility-wide within a large teaching hospital. (CAUTIs) account for an estimated 449,334 of health • Methods: Recommendations from the Agency for care–associated infections s annually [2]. The direct Healthcare Research and Quality (AHRQ) toolkit for medical cost per CAUTI ranges from $749 to $1007, reducing CAUTIs in hospital units were used to im- resulting in direct costs to U.S. facilities of over $340 plement both technical and socioadaptive changes million annually [2]. Although CAUTIs are one of focused on prevention of insertion-related CAUTIs in the most common health care–associated infections, the ED through a trial that required 2 licensed person- the literature has shown that following well established nel for insertion of all urinary catheters. The process prevention guidelines can greatly reduce their incidence. would include a safety time-out to confirm catheter Since most health care–associated infections are appropriateness and review of the proper steps for preventable and cause unnecessary patient harm, there insertion as a means to encompass and hardwire is pressure from regulatory bodies to prevent such both the technical and socioadaptive aspects of the events during a patient’s hospitalization. Prevention of Comprehensive Unit-based Safety Project methodol- CAUTIs is a Joint Commission National Patient Safety ogy into ED practice. Goal, and as of 2008 the Centers for Medicare and • Results: There was a 75% decrease in CAUTI rates Medicaid Services (CMS) does not reimburse hospitals following the intervention (P = 0.05). This reduction for the cost of additional care as a result of a CAUTI. was sustained for at least 1 year following implemen- Additionally, facility CAUTI data is included in the tation. CMS value-based purchasing program, which can with- • Conclusion: Using AHRQ recommendations to imple- hold payments to hospitals based on performance, as ment socioadaptive and technical changes through well as the inpatient quality reporting program, which 2-person insertion of urinary catheters yielded a sig- requires public reporting of CAUTI to receive a higher nificant and sustainable decrease in insertion-related annual payment. CAUTI rates and utilization of indwelling urinary cath- Even before the external pressures of regulatory eters in the ED at Tampa General Hospital. bodies, Tampa General Hospital has strived to protect patients by preventing infections through implementing Key words: catheter-associated urinary tract infections; infec- best practices via multidisciplinary committees to maxi- tion prevention; quality improvement; change model. mize impact. Tampa General Hospital, a private not-for- From Tampa General Hospital, Tampa, FL. www.jcomjournal.com Vol. 24, No. 10 October 2017 JCOM 451 CAUTI PREVENTION profit level 1 trauma center located in downtown Tampa, tices Advisory Committee’s (HICPAC) guideline for Florida, is a teaching facility affiliated with the University prevention of CAUTIs [3], the committee focused its ef- of South Florida Morsani College of Medicine. It is li- forts on appropriate indications for insertion and timely censed for more than 1000 beds and serves 12 surround- removal, aseptic insertion, and proper maintenance of ing counties with a population in excess of 4 million. indwelling urinary catheters. The key accomplishments of the CAUTI committee Background during 2014 included development of a comprehensive CAUTI data had been collected in all of the intensive genitourinary management policy, incorporation of care units at the hospital for several years, benchmarked CAUTI prevention into new employee orientation for against national unit-specific rates, with feedback pro- all patient care staff, aseptic indwelling urinary catheter vided to committees and the hospital board. However, in insertion competency check-off with return demonstra- 2006, a multidisciplinary committee chaired by the chief tion (teachback methodology) for all nursing staff, and operating officer known as Committee Targeting Zero reinforcement of insertion criteria and daily assessment (CTZ) was formed to review best practices and analyze for necessity with documentation of indications, and all device-associated infection rates in an effort to reduce removal via nurse-driven protocol when necessary. Ad- hospital-acquired infections. To target reduction of the ditionally, a requirement to document indications for CAUTI rate, a Foley stabilization device and renewed ordering urine cultures and a pop-up reminder in the focus on hand hygiene were implemented, and CAUTI electronic medical record for patients with an indwell- rates were reduced by over 50% by the end of 2007. ing urinary catheter requiring indications to continue, When CAUTI rates began to climb in 2008, ad- both targeted towards physicians and advanced practice ditional interventions were implemented under the providers, were implemented. direction of CTZ, including a literature review for In conjunction with the technical changes, ad- CAUTI prevention for any new or novel prevention ditional strategies were executed with the intent of strategies, reporting of each CAUTI to leadership of facilitating a culture of patient safety and reinforcing the attributed unit at the time of identification, ongoing the aforementioned technical changes. In 2014, the surveillance of the appropriateness of indwelling urinary hospital implemented Franklin Covey’s “The Speed of catheters at the unit level with feedback to CTZ, and Trust” methodology [4] and its associated 13 behaviors mandatory education focused on infection of CAUTI hospital-wide. Additionally, several of the inpatient units and proper insertion for all staff inserting indwelling participated in a quality improvement project with either urinary catheters. Additionally, in 2009 an evaluation the Florida Hospital Engagement Network (HEN) [5] of an antibiotic-coated Foley catheter was implemented or the Agency for Healthcare Research and Quality to further decrease rates, resulting in a statistically sig- (AHRQ) Comprehensive Unit-based Safety Program nificant 42% reduction in the CAUTI rate as compared (CUSP) [6] national project. Physician engagement and to 2008. Other prevention strategies instituted between education was accomplished through a white paper writ- 2010 and 2012 included increased availability of con- ten by the infection prevention department, summariz- dom catheters, a closed system urine culture collection ing the current state of CAUTI within the facility and kit, and computer-based learning module for all staff highlighting strategies to reduce infection, including inserting indwelling urinary catheters. evidence-based guidelines on ordering urine cultures. In 2013, the hospital included CAUTI prevention In an attempt to target ongoing improvement as part of a facility-wide initiative to decrease patient strategies, CAUTIs were categorized as either inser- harm. A CAUTI committee led by senior leadership tion-related, occurring within 7 days of insertion, or was convened to address CAUTI rates that exceeded maintenance-related, occurring greater than 7 days of national benchmarks. The multidisciplinary team began insertion; the date of insertion was considered day 1. A as a subcommittee of CTZ and was chaired by the chief review of the facility CAUTI data demonstrated that an nursing officer with the support of the chief operations opportunity to reduce insertion-related CAUTIs existed officer and included representation from the infection and a high volume of urinary catheters were inserted prevention department and nursing unit leadership. in the emergency department (ED). Therefore, ED After reviewing the Healthcare Infection Control Prac- leadership agreed to participate in the CUSP initiative 452 JCOM October 2017 Vol. 24, No. 10 www.jcomjournal.com REPORTS FROM THE FIELD for EDs beginning April 2014. The goals of the CUSP and the proper steps for insertion per hospital policy. The initiative include using best practices for CAUTI preven- catheter was then inserted by one person while the second tion through the implementation of both technical and was solely responsible to assure compliance with proper socioadaptive changes. aseptic technique. The procedure was stopped if aseptic technique was compromised. The indications for inser- Methods tion and/or maintaining the urinary catheter are based CUSP Initiative on the HICPAC guidelines [3] and include the following: The CUSP initiative focuses specifically on improving processes for determining catheter appropriateness and • Acute urinary retention/obstruction promoting proper insertion techniques in addition to • Urologic, urethral or extensive abdominal surgi- changes in culture to facilitate teamwork and commu- cal procedure nication amongst frontline staff and improve collabora- • Critically ill patient with
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