Nurse-Driven Catheter-Associated Urinary Tract Infection Reduction Process and Protocol:

Question Answered step-by-step Nurse-Driven Catheter-Associated Urinary Tract Infection ReductionProcess and Protocol: Development Through an Academic-Practice PartnershipJohnson, Pamela DNP, RN; Gilman, Anna BSN, RN; Lintner, Alicia MSN, CRNP-BC, CCRN; Buckner, Ellen PhD, RN, CNE, AE-CAuthor InformationAdult Health Nursing Department, University of South Alabama College of Nursing, Mobile (Drs Johnson and Buckner); Staff Development, University of South Alabama Medical Center, Mobile (Ms Gilman); and Arnold Luterman Regional Burn Center, University of South Alabama Medical Center, Mobile (Ms Lintner).Correspondence: Pamela Johnson DNP, RN, Adult Health Nursing Department, University of South Alabama College of Nursing, 5721 USA Dr North, HAHN 4068, Mobile, AL 36688 (..n@southalabama.edu).The authors are grateful to the University of South Alabama Medical Center for its support and participation in development and successful implementation of this protocol, especially: the CAUTI prevention action team; evidence-based practice committee members, and physicians and nurses in the medical surgical ICU, progressive care unit, surgical trauma ICU, and Burn ICU.There is no actual or potential conflict of interest including financial, personal, or other relationships with organizations and companies that could inappropriately influence this article.The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this study.AbstractTranslating evidence-based practices to the bedside can be facilitated by an active academic-practice partnership between nursing faculty and frontline nursing staff. A collaborative effort between the university’s academic nurses and the medical center’s clinical nurses explored, created, implemented, and evaluated an evidence-based nurse-driven protocol for decreasing the rate of catheter-associated urinary tract infections. The nurse-driven protocol was piloted in 4 intensive care units and included nurse-driven orders for catheter discontinuation, utilization of smaller bore urinary catheters, addition of silver-based cleansing products for urinary catheter care, and education of staff on routine catheter care and maintenance. Data were collected for more than 8 months pre- and postimplementation of the nurse-driven protocol. Postimplementation data revealed a 28% reduction in catheter-associated urinary tract infections in the intensive care units as compared with preimplementation. Secondary benefits of this academic-practice partnership included strengthening the legitimacy of classroom content as lessons learned were integrated into courses in the nursing curriculum. The result of the partnership was a stronger sense of collaboration and collegiality between hospital staff and the university faculty. Transformative leadership engaged numerous stakeholders through collaborative efforts to realize best practices. An academic-practice partnership facilitates transformative change and provides structural stability and sustainability.THE Institute of Medicine report on The Future of Nursing1 highlighted the critical need for nurses to be prepared to advance science that benefits patients and the capacity of health professionals to deliver safe, quality patient-centered care. An academic-practice partnership has been defined as a relationship between a nursing education program and a care setting, with a unified purpose of improving health care delivery systems.2 Partnerships may vary in purpose and structure. Partnerships are key in fostering care settings that are able to respond and thrive in a US health care system that is continuously growing and adapting to changes. Health care is also influenced by requirements of credentialing agencies, public monitoring and reporting, and governmental policies.1 The fast pace of technological and scientific advances creates an enormous mass of evidence supporting practices that improve the safety and effectiveness of patient care; however, a lag time of approximately 17 years has been noted in the implementation of best practices at the bedside.3,4 There are numerous reasons for this delay in implementing best practices at the bedside, one of which is the lack of collaboration between the producers of evidence-based practice (EBP) approaches and those who implement these. The purpose of this academic-practice partnership description is to report on how the collaborative relationship facilitated change in the practice setting to reduce catheter-associated urinary tract infections (CAUTIs). In addition, benefits to the academic curriculum resulted from the frontline implementation, and improved curricular content is an outcome of the active relationship.Back to TopBACKGROUND: ACADEMIC-PRACTICE PARTNERSHIPSBack to TopEvidence-based practiceEvidence-based practice has been defined as a decision-making process for patient care that uses best evidence available combined with practice experience and the patient’s own values and preferences to guide patient care.5 Evidence-based nursing is the process in which nurses make clinical decisions on the basis of evidence, nursing expertise, and values and/or preferences of individuals, families, and communities.6,7 Nursing policies, procedures, and guidelines are expected to be founded on evidence. Translating research findings into clinical practice is a complex undertaking. It has been estimated that 30% to 40% of patients do not receive treatment on the basis of the best available evidence.8 The complexity of translating research findings is created by several factors including the sheer amount of information that is continually generated, the ability of the practitioner to evaluate and translate the findings into practice at the bedside. In the United States, an educational objective for baccalaureate, master’s, and doctoral education includes the ability of graduates to integrate evidence-based interventions into practice in order to provide care that is of high quality and centered on safety.9,10,11 The Institutes of Medicine report 1 reinforced the importance of competency in EBP as a responsibility for health care providers to develop and maintain throughout their careers. Despite academic emphasis on the use of EBP and institutionally established competencies for EBP, studies have found that recent graduates and seasoned nurses continue to report low rates of research utilization in their clinical practice.8,12 Challenges that have been cited by bedside nurses include being too busy with clinical care, having insufficient research skills or exposure to EBP, lack of interest in research, and limited time and resources.7,13 Sadly, the most common sources to guide clinical practice at the bedside include personal judgment based on past experiences, and opinions of colleagues.8 The complexity and perceived barriers of discovering and implementing best practice elucidate the importance of academic involvement in guiding clinicians in developing their awareness and competency in engaging in EBP. An academic-practice partnership is a relationship that supports the implementation of EBP and should continue long past a nurse’s academic preparation.Back to TopCollaboration and the academic-practice partnershipMany words are associated with the term collaboration. It is common to think of terms such as “cooperative work,” “shared responsibility,” “making decisions” and “solving problems” as being associated with collaboration. Traditionally, collaboration in the hospital setting is thought of as an ongoing, interdisciplinary process in which nurses, physicians, and other professionals work together to maximize delivery of care to the patients they serve. Collaboration is a process and an outcome where individuals work together to solve complex problems.14 Six characteristics of collaboration identified by Springer et al 7 include (1) voluntary participation, (2) mutual valuing, (3) mutual goals, (4) shared responsibility, (5) shared resources, and (6) shared accountability. Frontline nurses at the University of South Alabama Medical Center (USAMC) are currently engaged with faculty from the University of South Alabama College of Nursing (USACON) in an academic-practice partnership in a collaborative effort to focus on enhancing the quality of patient care through the implementation of EBP. In the academic-practice partnership, both groups contribute their perspectives to better understand how to approach a specific area in health care delivery that requires a performance improvement initiative. Each party has a mutual respect for each other’s knowledge, expertise, and skills and values their mutual interdependency.7,15Back to TopBackground of the partnershipThe USAMC is an acute care hospital located in Mobile, Alabama, serving as the area’s only level 1 trauma center and regional burn center. It also provides care for the majority of the indigent population in the city, who often use the medical center as their primary care resource. During the time of this study, the USAMC was recognized as caring for a high-acuity population. The USA Medical Center is ranked 44th of 3200 hospitals nationwide in “acuity index” measuring the severity of patients’ illnesses.16 As a result of these characteristics, the patients served by the medical center have high-complexity illnesses. The USAMC serves as a multidisciplinary teaching and research facility.Formal relationships are established at the senior leadership level and practiced at multiple levels throughout the organization. The USAMC and the USACON have had a long-standing relationship based primarily on clinical placement for students and faculty appointment to hospital committees including the EBP Committee and Nurse Practice Congress. The USAMC and the USACON share related visions, missions, goals, and values that center on providing the highest level of care to our patients and educating the next generation of health care providers.Back to TopEvidence-based improvement processesIn the last 8 years, academic nurses and frontline nurses at the USAMC and the USACON have participated in national studies as part of Transforming Care at the Bedside and the Improvement Science Research Network.17,18 These experiences have further developed the ability of frontline staff to lead change initiatives. Nursing staff have implemented “tests of change” and contributed to quality improvement processes leading to many successful initiatives. Faculty have collaborated through major studies and engaged students at undergraduate and graduate levels in conducting unit-based studies. These collaborations further developed the relationships between practice and academic nursing.To ensure that provision of patient care is based on evidence, the facility established an EBP committee in July 2010. The EBP committee is a nursing led, multidisciplinary committee that uses evidence-based research to positively impact changes in patient care, safety, and satisfaction. The EBP committee partnered with the USACON faculty and the Biomedical Library. Members of this committee include multiple disciplines as appropriate for the clinical topic being explored. The EBP committee meets on a monthly basis to promote meaningful engagement in ongoing improvement projects.The academic-practice partnership has opened many doors for collaboration. The following exemplar was a multiyear process that resulted in quality improvements in practice and educational improvements in the academic setting. Research skills capacity grew across the partnering organizations with stronger bridges between the producers of research evidence and that evidence being applied to practice.Back to TopEVIDENCE-BASED PRACTICE PARTNERSHIP EXEMPLAR: DEVELOPMENT OF THE NURSE-DRIVEN CAUTI REDUCTION PROTOCOLBack to TopPurposeThe purpose of this exemplar is to demonstrate the collaborative relationship between the University’s academic nurses and the frontline nurses in exploring, creating, implementing, and evaluating an evidence-based nurse-driven protocol for decreasing the rate of CAUTIs. Furthermore, the exemplar listed later describes how the EBP process resulted in a positive impact on patient care. In working together toward a common goal of implementing evidence-based interventions to decrease rates of CAUTIs, both institutions contributed to developing a collaborative process more effective than either could alone.Back to TopSteps in EBP and improvement methodologyThe former USAMC performance improvement methodology, “ICARE,” was utilized to organize and complete the project. Members of the EBP committee undertook a process improvement approach to reduce CAUTI rates in the hospital, especially in the intensive care units (ICUs). The I stands for “Identify,” an opportunity for improvement. In this stage, the idea for improvement was identified, and the CAUTI Action Team was formed. The next step “Clarify” involved evaluating the current process and practice for indwelling urinary catheter insertion, maintenance, and discontinuation. Several factors involving insertion, maintenance, and discontinuation of indwelling catheters were identified. During the “Analysis” step of the process, drilled down de-identified data collected from charts of ICU patients who developed CAUTIs over a specific period of time were collected and evaluated and contributing factors were considered. Evidence-based practices for CAUTI reduction from the literature and other sources were evaluated and compared with current practices. “Revision” of the action plan was the next step. During this phase, the nurse-driven protocol was developed and the pilot was implemented. The final steps are “Evaluate/Educate.” This is where the pilot project for CAUTI reduction in the ICUs was evaluated. It was during this phase when exciting results were realized, as outlined in more detail in the following paragraphs.Back to TopPartnership for improvementThe CAUTI reduction project began when infection control staff reported baseline data regarding CAUTIs to the EBP committee. Data included infection rates per 1000 catheter days, number of CAUTIs, and number of catheter days. After a review of the CAUTI rates at the medical center in comparison to national averages, the EBP committee identified a need for improvement in this area. To focus on the revision of current practice at USAMC, a subcommittee of the EBP committee, the CAUTI Action Team, was formed. This multidisciplinary team consisted of USAMC staff particularly intensive care support (ICU nurses, nurse practitioner, nurse manager, trauma surgeon, and nurse educators), CON faculty, and infection control. The CAUTI Action Team was tasked to investigate current policies, procedures, and practices regarding care of patients who require an indwelling urinary catheter and to propose changes that would lead to the ultimate goal of reducing CAUTIs at the USAMC. For this pilot project, the ICUs were primarily the area of focus due to higher CAUTI rates and catheter utilization. Institutional review board approval was obtained.Back to TopBaseline dataThe initial step in this CAUTI focus included assessment of current CAUTI reduction measures and unit surveillance. A CON faculty member conducted a site visit and through direct observation of intensive care patients who had urinary catheters in place identified areas for improvement in routine daily maintenance and infection control measures.To determine whether there were specific clinical factors that contributed to the development of CAUTIs in the ICUs, baseline surveillance data were collected in 1 particular unit. The initial data were reviewed and a “drill down” was done on every CAUTI for 12 months. Clinical factors that were evaluated included obesity, incontinence, specific infection, number of catheter days, temperature, blood glucose control, urine output, ventilator status and settings, indications for catheter, and documentation of compliance with current CAUTI reduction measures during patient transport (emptying the drainage bag before transport and maintaining the catheter below the level of the bladder). In addition, a retrospective review of baseline data (number of CAUTIs and number of catheter days) across multiple units revealed that the CAUTI rate for the combined units was 0.60% (25 CAUTIs per 4154 catheter days).Back to TopCAUTI Action Team processesThrough a series of focused meetings, the CAUTI Action Team reviewed current literature related to best practices for indwelling urinary catheter insertion, maintenance, and CAUTI reduction, as well as evaluation of several shared protocols solicited from similar level 1 trauma centers in the region. The team determined that delays in discontinuation of catheters (increased number of catheter days) were occurring because nurses were required to obtain a physician’s order for removal of an indwelling urinary catheter. The team’s physician champion explained that nurses insert indwelling urinary catheters and unless there was a specific issue, physicians are more prone not to consider removing a catheter because the physician’s interaction with it was limited. Increased number of catheter days is known to be a major contributor to higher CAUTI rates.19 With this in mind, the team developed an order set that included the nurse-driven protocol (see Figure 1). The order set included an option for nurse-driven protocol in the majority of cases unless specific exemptions were met (an opt out process). Changes in policies and procedures included utilization of smaller bore urinary catheters, addition of silver-based cleansing products for urinary catheter care, and education of staff on routine catheter care and maintenance. The newly developed order set with the nurse-driven protocol and revised policies and procedures were reviewed and approved by the appropriate hospital committees and administrators for use in a pilot study to be conducted in the units at the USAMC.The main focus of the nurse-driven protocol was timely removal of indwelling urinary catheters when clinically indicated, without requiring an additional physician’s order. The order set allows the physician to decide whether the patient will be included or excluded in the nurse-driven protocol. If the physician places the patient on the protocol, once the patient no longer meets the criteria for an indwelling urinary catheter, the nurse may remove the catheter. If the physician excludes the patient from the protocol, a reason from the exemption criteria (listed on the order set) must be documented. For patients excluded from the protocol, a separate physician’s order is required to discontinue the catheter. The need for the catheter is assessed daily during multidisciplinary ICU daily rounds, where it is determined whether the patient meets criteria for an indwelling urinary catheter and documents the indication for the catheter (see Figure 2).Back to TopInitiation of new protocol roll outThe next step involved education of all nursing staff in the involved units, the chief residents, and surgery/medicine physician teams. The education included current CAUTI statistics for the USAMC and the specific units, an introduction of the nurse driven protocol and the evidence that guided its development, and a review of routine catheter care and maintenance. A laminated copy of the order set was posted in each unit. The revised orders, policies, and procedures were implemented with an 8-month surveillance pilot to evaluate effectiveness. Indwelling urinary catheters per unit, as well as the number of patients who were placed on the nurse driven protocol were tracked. Infection control continued to monitor and report data including number of CAUTIs and number of catheter days for combined units.Back to TopRESULTSThe institutional review board at the University of South Alabama approved the study as a secondary analysis of de-identified clinical data. Data from the units were collected from all units and reviewed. Unit-specific data included number of CAUTIs per month and catheter days per month. Data were available from nightly unit reports and additional data collected by unit managers/educators.Data covering 8 months pre- and postimplementation of the nurse-driven protocol revealed a 28% reduction in CAUTIs for the combined ICUs. The improvements were reflected in postimplementation lower rates of CAUTIs (actual, 36% reduction), lower number of catheter days (actual, 11% reduction), and lower CAUTI rates (0.43% at postimplementation compared with 0.60% at preimplementation).De-identified data regarding CAUTIs in specific ICUs both pre- and postimplementation, including number of catheter days, if patient was on the nurse-driven protocol or not, and average day to CAUTI revealed a reduction in actual number patients with catheters, number of CAUTIs, and number of catheter days from pre- to postimplementation. Two patients repeated with a second CAUTI and 2 other patients postimplementation met criteria for exemption. The average day to CAUTI increased from 8.9 to 16.5. This was probably a reflection of 2 factors. One is that with longer days, there is an increase in CAUTI risk and actual number of CAUTIs, and with the nurse-driven protocol, more catheters were being discontinued earlier, resulting in fewer CAUTIs. When CAUTIs did develop, they occurred at a later date, resulting in a later average day to CAUTI.Back to TopClosing the loopBased on the effectiveness of the protocol, change occurred in the practice setting. The order set is still in use with continued trends in CAUTI reduction. One step remained and that was bringing the evidence-based protocol to the academic setting. Faculty who served on the CAUTI Action Team collaborated with the course faculty for the undergraduate-level clinical nursing skills course to include information about the evidence-based CAUTI reduction protocol at the USAMC in the course. For the skills course, the order set for the nurse-driven protocol for catheter removal was included in the simulated patient charts used for skills checkoffs. The process of the nurse-driven protocol was also embedded into the skills checkoff sheet that is used by students as they learn how to insert, maintain, and discontinue an indwelling urinary catheter, and it is used by faculty to evaluate student mastery of this skill.Back to TopDISCUSSIONThis academic-practice partnership has proven beneficial to both systems as needs of patients, nurses, facility, faculty, and students are being met. Academics often find themselves isolated in some ways, teaching what is considered to be best practices and processes, but often lack follow through in making sure that our graduates enter a practice environment where best practices and processes are part of the culture. As participants in the EBP committee, academics are able to evaluate frontline nurses’ knowledge of best practices, resources to improve practice, and processes to improve practice at the bedside. The academic membership of the EBP committee serves to enhance committee members’ and frontline nurses’ research skills, aid in evaluating current policies and processes, and act as mentors for nurses as they evaluate current practices and lead change to advance the quality of care.Another benefit that faculty have realized through this partnership is keeping touch with the complexities of providing patient care in a highly acute hospital setting. A secondary strength of this academic-practice partnership lies in the ability of nursing students, from undergraduate to graduate levels, to apply classroom knowledge and develop skills as they actively participate in the EBP process through research assignments and capstone project completion in their scholarly endeavors. The partnership has expanded to include academic and clinical partners collaborating in professional roles as they jointly disseminate successes through scholarly works including publications and presentations at local, state, regional, and national venues.Faculty are also able to bring examples of actual EBP initiatives to the classroom, thus strengthening the link to real clinical practice and the legitimacy of classroom content.Lessons learned from this collaborative partnership are integrated across the curriculum at the USACON. For example, in a senior-level EBP course, students evaluate policies and protocols from the USAMC and offer input for updates/improvement based on EBP. Students share their experiences in utilizing the EBP process to critique current policies through presentations to the EBP committee and hospital staff. This also enables the students to gain experience in presenting their findings to an audience and starts them out with something worthy of including in their CV as they pursue employment. Information about evidence-based practices is incorporated into a first semester skills class. The lesson in which students learn to insert and maintain indwelling urinary catheters contains a focus on preventing CAUTI.Through this collaborative academic-practice partnership, a stronger sense of collegiality between hospital staff and university academics has developed, knowledge and skills have been strengthened, and care based on the best current evidence has been implemented.Back to TopPractice empowermentMeasuring the number of indwelling urinary catheters per month served as positive feedback to the nurses. When the health care team saw the results of lower catheter days, lower CAUTI rates, they realized that their care made a difference and were inspired to continue providing care that was based on the best evidence in order to achieve the best outcomes for their patients.Practice partners feel empowered as they realize that they have support of academics and are able to improve their skills in implementing changes to patient care that are based on EBP. The partnership has ignited the passion and vision it takes to achieve lofty goals of improving patient care and outcomes. This academic-practice partnership acts as a way to close the loop in improving patient care in a timely manner. The benefits of the partnership are reciprocal.From the academic standpoint, participants in the EBP committee were able to evaluate staff member’s knowledge of best practices, resources, and processes to improve practice. Academics were able to increase staff members’ skills, knowledge, and attitudes in their ability to formulate, implement, and evaluate practice changes. We “talk the talk” in the classroom; this partnership allows us to “walk the walk” in supporting EBP implementation in practice.Back to TopEvidence-informed educationThere are no limits in education in the nursing profession. The emphasis on education is not only in the classroom but also in all aspects of health care. Nurses are teachers. The main goal of nursing educators and frontline nurses is to provide the best care to patients. Evidence-informed education makes each aspect of nursing more caring than ever before, because our care is based on the best evidence leading to better outcomes and healthier patients.Back to TopInterprofessional perspectivesThe team’s physician champion, a seasoned trauma surgeon, board certified in critical care, agreed that a nurse-led initiative to remove catheters was the best option. He noted that nurses insert the catheters and unless there was a specific issue, physicians do not place or handle the catheter. He explained that he was more prone not to consider removing an indwelling urinary catheter because other than ordering it, the physician interaction with the device was limited, unlike a central line that he placed and maintained when issues arose. Following the successful implementation in reducing CAUTIs, he noted that the nurse-driven protocol removed this unnecessary delay in indwelling urinary catheter discontinuation. He went on to advocate that the protocol incorporates the bedside nurse into our multidisciplinary method of ICU patient care.The multidisciplinary collaboration of the team produced efficient and detailed plans for achieving each step of project implementation. Health information technology was engaged to prepare the new order set for electronic implementation. Each individual’s perspective and expertise fueled engagement, innovation, and an overall strong, thoughtful protocol. Creating improvement strategies together is a win for everyone with the patient in the center.Back to TopOngoing collaboration for improvementThe plan do study act model (PDSA model) of EBP has since been adopted as the model that guides improvement at the USAMC. Processes are in place to ensure that new members of the EBP committee are provided with an orientation to EBP. Students (honors undergraduate, and doctoral level) are involved in improvement projects so that they can model the collaborative partnerships, as well as investigate specific topics. The Nursing Practice Congress actively identifies issues from the frontline that affect care and create teams to address them. The concept of collaborative practice in an academic-practice partnership is stronger through the formalizing of the process and integration across settings and personnel. 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