A quality improvement initiative at a Pennsylvania hospital led to a quick turnaround in rates of catheter-associated urinary tract infections (CAUTIs) and a sustained approach to preventing CAUTIs and other healthcare-associated infections, reported the American Association of Critical-Care Nurses (AACN).
Hospital-acquired CAUTIs are the second most common healthcare-associated infection, occurring most frequently in intensive care units (ICUs), according to the Centers for Disease Control and Prevention (CDC). They are preventable events that can lead to poor patient outcomes and higher healthcare costs.
UPMC Williamsport is a 224-bed rural regional medical center in north central Pennsylvania and part of the University of Pittsburgh Medical Center Susquehanna health system. In 2018, the hospital reported 13 CAUTI events, exceeding its benchmark of four or fewer such infections annually. Six of the events occurred in the ICU.
To address the situation, the ICU established a CAUTI reduction task force, which developed a quality improvement initiative with both education and practice-related interventions. The multifaceted approach quickly reduced CAUTI rates and laid the groundwork for hospital-wide implementation with long-term impact. “A Bundle-Based Approach to Prevent Catheter-Associated Urinary Tract Infection in the Intensive Care Unit” reviews the various components of the initiative and simple strategies that helped maximize their impact. The study appears in Critical Care Nurse (CCN).
During the four-month intervention period covered in the study, the ICU had no reported CAUTI events, compared with two CAUTI events during the pre-intervention period. In addition, the CAUTI incident rate decreased by 1.33 per 1,000 catheter days. Of note, total catheter days increased by 10.5% from the pre-intervention period, which may be attributed to higher ICU admissions and a higher device utilization ratio during the intervention period.
Co-author Holly Shadle, DNP, CRNP, FNP-BC, is a nurse practitioner in the neurosurgery department, Neuroscience Center at UPMC Susquehanna. She conducted the study at UPMC Williamsport with colleagues from the hospital and Duke University School of Nursing as part of her doctoral work at Duke.
“One of the strengths of this initiative was the overall simplicity of the interventions,” Shadle said. “These interventions were direct and efficient, with few direct costs or necessary equipment, making the process easily adaptable for hospital-wide use.”
The educational portion of the initiative began with all ICU nurses participating in module-based didactic training, followed by hands-on skill and competency sessions on each component of indwelling catheter care. Another element of the bundle involved indwelling catheter-related documentation and orders, including a daily checklist and a nurse-driven removal protocol for discontinuing catheter use. The seven-item protocol was adapted from practice recommendations from the hospital’s larger umbrella organization. The electronic checklist used drop-down features for all responses, except for the catheter insertion date, to prevent free-text responses and typos. Completing the checklist was required on a nightly basis for every room in the ICU, even those without patients or with patients who didn’t have indwelling urinary catheters.
Overall documentation compliance increased significantly from 50% before the interventions to 83.3% during the interventions. The newly formed CAUTI quality assurance and performance improvement team began adapting the program for hospital-wide implementation. In addition, the informatics department began working to integrate a version of the daily checklist and nurse-driven removal protocol directly into the electronic health record.
