PDSA cycles in the design and implementation of an intervention to reduce unnecessary urinary catheters on general medical wards*
| Cycle | Prediction | Do | Study | Act | Time required |
|---|---|---|---|---|---|
| 1 | There is unnecessary catheter use on medical wards. | Point prevalence of catheter use on medical wards (null hypothesis: 80% or more catheters are appropriate). | 54/278, including 17 (31%, 95% CI 21% to 45%) with appropriate clinical indication→null hypothesis refuted (p<0.001). | There is a problem worth investing time to improve. Staff on the ward feel the ED inserts majority of unnecessary catheters. | 1 day |
| 2 | Catheter insertions in the ED are the main contributor of unnecessary use. | Interview of staff and chart review to identify whether the unnecessary use was driven by inappropriate insertions as opposed to appropriately inserted urinary catheters that were simply left in too long. | Chart review showed roughly equal contributions from unnecessary insertion and prolonged maintenance. Interviews revealed residents hesitant to remove because they are unsure of initial indication in ED; ward nurses often asking residents to reassess. | Catheters left in place are just as frequent contributors to problem and improving documentation in the ED would facilitate reassessment on the ward. | 2 days |
| 3 | Improving awareness of initial catheter indication in the ED will facilitate early removal. | Meeting with ED to add catheter indication to ‘transfer of accountability’ form for patients admitted to the ward from the ED. | The ‘transfer of accountability’ form is not a chart copy. Emergency staff perceive adding catheter will increase workload. | Because of inability to measure fidelity and lack of engagement, this intervention will not successfully address the problem. | 2 weeks |
| 4 | Admission order sets that promote catheter insertion lead to overuse. | Pareto diagram of unnecessary catheter insertions to identify whether admission order set was checked off for the majority of cases. | On stroke unit, 89% (8/9) unnecessary catheter insertions are associated with order set. | The stroke unit order set should be revised through the forms committee. Because this will take time, another intervention should be developed first. | 2 days |
| 5 | Medicine physicians can achieve consensus regarding indications for catheters on the ward to create medical directive for nurses. | Propose idea at medicine division meeting and discuss indications for catheter use. | Consensus on catheter indications achieved but concerns raised regarding ability of nurses to apply criteria appropriately. | Medical directive will need to be operationalised for nurses to recognise and apply criteria appropriately. | 3 weeks |
| 6 | Nurses can apply criteria of medical directive. | Usability testing of medical directive among convenience sample of nurses. | After six tests, multiple problems in usability identified in postcatheter care algorithm. | Medical directive is now operational from nursing standpoint and ready to be piloted. | 1 month |
| 7 | The medical directive is being used by front-line nurses on the ward (fidelity of >80%). | Audit of consecutive patients with urinary catheter present on transfer to the ward. | 18 consecutive patients had their catheter removed within 24 hours (fidelity of >80%). Better adherence may be achieved by standardising timing of medical directive at beginning of shift. | Nurse managers will help standardise timing of medical directive on their units. | 1 week |
| 8 | The medical directive will result in decreased catheter use without inappropriate removals. | Electronic trigger tool of catheter reinsertions within 48 hours to confirm whether reason for initial catheter removal was appropriate. | Catheter utilisation on intervention wards decreased to 7.9%, significantly below control wards (12.6%) (p<0.001) and no inappropriate removals identified. | The medical directive is being followed correctly and the pilot will be extended for 3 months. | 1 month |
*An online supplementary appendix describes each of the PDSA cycles in greater detail. As stated in the text, the formal evaluation of the impact of this improvement projects has been published separately.5
ED, emergency department; PDSA, plan–do–study–act.