Clinical

A Collaborative, Nurse-driven Initiative to Reduce Hospital-acquired Urinary Tract Infections

The prevalence and difference in likely indications of urinary catheterization (UC) in treated-and-released emergency department (ED) visits between men and women are currently unknown.

This was a cross-sectional analysis using the 2013 National Emergency Department Sample for all treated-and-released visits in persons aged ≥18 years. The prevalence of conditions associated with UC visits in men and women were identified. A hierarchical ranking was used to categorize diagnosis codes identified during ED visits into clinically meaningful categories to assess conditions for UC.

In 2013, there were 87,797,062 treated-and-released ED visits in adults. The rate of UC in treated-and-released ED visits in adults was 4.3 per 1,000 visits, with 6.5 per 1,000 visits in men and 2.7 per 1,000 visits in women. Using the hierarchal ranking, a higher proportion of UC visits in men were coded for acute urinary retention, and a higher proportion of UC visits in women were coded for neurologic, cognitive, and psychiatric conditions.

The rate of UC in treated-and-released ED visits was higher in men than women, and UC rate increased with age. The heterogeneity of conditions coded in UC visits in women compared with men may suggest more potentially avoidable UC in women in the treated-and-released ED population. If confirmed, this would suggest opportunities for quality improvement in the ED to prevent overutilization of urinary catheters.

Indwelling urinary catheters (IUCs) are placed frequently in older adults in the emergency department (ED). Though often a critical intervention, IUCs carry significant risks. Our objective was to examine current knowledge, attitudes, and practice of emergency nurses and other providers regarding IUC placement and management in older adults.

We surveyed ED providers at a large, urban, academic medical center. We developed questionnaires using items from previously validated instruments and questions created for this study. We also assessed providers’ management of 25 unique clinical scenarios, each representing an established appropriate or inappropriate indication for IUC placement.

129 ED providers participated: 43 nurses and 86 other providers. Ninety-one percent of nurses and 87% of other providers reported comfort with appropriate indications for IUC placement. Despite this, on the clinical vignettes, nurses correctly identified the appropriate approach for IUC placement in only 40% of cases and other providers in only 37%. Practice varied widely between individual providers, with the nurse participants reporting appropriate practice in 16%-64% of clinical scenarios and other providers in 8%-68%. Few nurses or other providers reported reassessing their patients for IUC removal at transfer to the hospital (28% of nurses and 7% of other providers), admission (24% and 14%), or shift change (14% and 8%).

Although emergency nurses and other providers report comfort with appropriate indications for IUC placement, reported practice patterns showed inconsistencies with established guidelines. Wide practice variation exists between individual providers. Moreover, nurses and other providers infrequently consider IUC removal after placement.

Introduction: This quality-improvement project aimed to evaluate the effectiveness of implementing multidisciplinary education and deploying utilization tools aimed at reducing the inappropriate insertion of indwelling urinary catheters (IUCs) in the emergency department. Literature supports the use of decision support tools and education as proven techniques to reduce IUC use. Few studies have implemented a multidisciplinary approach involving the use of focus groups to understand the thought processes behind deciding to place an IUC.

Methods: Focus groups were used to understand the current practice for inserting an IUC in the emergency department. These data were then used to create a nursing-based IUC decision support tool and educational presentation regarding appropriate uses for IUCs. Live, in-person education sessions were given to emergency nurses, emergency medical technicians, physicians, and residents; in addition, electronic education was assigned to all emergency nurses and technicians. Seventy-eight percent of ED staff received some form of education regarding appropriate IUC insertion criteria. Physicians and residents also received an in-person presentation on the topic. A survey was sent to all emergency nurses and emergency medical technicians to assess actual practice changes. In addition, an IUC utilization and appropriateness audit was completed before and immediately after the interventions.

Results: The project resulted in a 25% decrease in the proportion of patients admitted to inpatient status with IUCs placed in the emergency department and a 9% decrease in the inappropriate use of IUCs. Staff surveys after education showed that staff members were more likely to document the reason for placing an IUC and to use alternatives to IUCs.

Conclusions: The potential risks associated with IUCs often go overlooked by direct-care staff members. Educating staff and creating new standards and utilization tools have often been used to decrease the initial insertion of IUCs and to improve recognition of appropriate removal of IUCs. Using direct feedback from staff to develop the interventions led to a reduction in IUC insertions in the emergency department in the short-term, but long-term changes were not seen. The project results suggest that incorporating staff into the decision making and implementation will lead to long-term acquisition of knowledge and longer-term results. Ongoing regularly scheduled education refreshers need to be assessed for their potential to affect long-term change.

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were originally commissioned by the Department of Health and developed during 1998–2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were first published in January 2001¹ and updated in 2007.² A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective for the prevention of HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority.

The Department of Health commissioned a review of new evidence and we have updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the epic2 guidelines published in 2007 remain robust, relevant and appropriate, but some guideline recommendations required adjustments to enhance clarity and a number of new recommendations were required. These have been clearly identified in the text. In addition, the synopses of evidence underpinning the guideline recommendations have been updated.

These guidelines (epic3) provide comprehensive recommendations for preventing HCAI in hospital and other acute care settings based on the best currently available evidence. National evidence-based guidelines are broad principles of best practice that need to be integrated into local practice guidelines and audited to reduce variation in practice and maintain patient safety.

Clinically effective infection prevention and control practice is an essential feature of patient protection. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of health care in NHS hospitals in England can be minimised.

Indwelling urinary catheters (IUC) are the primary cause of urinary tract infection in acute care. Current research aimed at reducing the use of IUCs in acute care has focused on the prompt removal of catheters already placed. This paper evaluates attempts to minimise the initial placement of IUCs.

To evaluate systematically the evidence of the effectiveness of interventions to minimise the initial placement of IUCs in adults in acute care.

Studies incorporating an intervention to reduce the initial placement of IUCs in an acute care environment in patients aged 18 and over that reported on the incidence of IUC placement were included in the review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist has been used as a tool to guide the structure of the review.

MEDLINE, CINAHL, EMBASE, National Health Service Centre for Review and Dissemination and Cochrane Library.

A systematic review to identify and synthesise research reporting on the impact on interventions to minimise the use of IUCs in acute care published up to July 2011.

2689 studies were scanned for eligibility. Only eight studies were found that reported any change (increase or decrease) in the level of initial placement of IUCs as a result of an intervention in acute care. Of the eight, six had an uncontrolled before–after design. Seven demonstrated a reduction in the initial use of IUCs post-intervention. There was insufficient evidence to support or rule out the effectiveness of interventions due to the small number of studies, limitations in study design and variation in clinical environments. Notably, each study listed the indications considered to be acceptable uses of an IUC and there was substantial variation between the lists of indications.

More work is needed to establish when the initial placement of an IUC is appropriate in order to better understand when IUCs are overused and inform the development of methodologically robust research on the potential of interventions to minimise the initial placement of IUCs.