Clinical
Reducing Indwelling Urinary Catheter Use in the Emergency Department: A Successful Quality-Improvement Initiative

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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.

Section snippets

Methods

A multidisciplinary strategy was used to examine ED practice related to IUC utilization and determine best-practice interventions. The entire project lasted more than 1 year (Figure 1).

Results

The intervention was associated with a 2.49% absolute reduction of catheterizations in admitted patients (95% confidence interval, 2.46%-2.52%), which represents a 33% relative decrease in the proportion of patients admitted to inpatient status with IUCs placed in the emergency department (9.05% ± 0.49% before intervention vs 6.1% ± 1.1% after intervention). These results appeared to be partially attenuated over the 6 months of follow-up (Figure 4).

A 9-item survey to understand the impact of

Discussion

This QI project made major strides in changing the ED culture regarding IUC insertion. We found that the use of focus groups was a key strategy to the success of this project because the participants provided a deeper understanding of the decision making behind placing an IUC. Our interventions were then targeted to the specific needs of our emergency department. By use of multiple approaches of dissemination, providers were introduced to the concept of using urinary management alternatives in

Conclusion

The insertion of IUCs in the ED setting is a common occurrence in the patient facing hospital admission, and the clinical appropriateness for initial insertion is often unjustified. Delayed complications such as CAUTIs are often underappreciated by the ED personnel, perhaps contributing to a “minor procedure” status without perceived morbidity and mortality. Our interdisciplinary team was able to define the problem of inappropriate IUC insertion in our institution, create an educational tool

Robin A. Scott, Member, Colorado Chapter, is Clinical Nurse Specialist, University of Colorado Hospital, Aurora, CO.

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Robin A. Scott, Member, Colorado Chapter, is Clinical Nurse Specialist, University of Colorado Hospital, Aurora, CO.

Kathleen S. Oman, Member, Colorado Chapter, is Research Nurse Scientist, University of Colorado Hospital, and Associate Professor, College of Nursing, University of Colorado Denver, Aurora, CO.

MaryBeth Flynn Makic is Research Nurse Scientist, University of Colorado Hospital, and Associate Professor, College of Nursing, University of Colorado Denver, Aurora, CO.

Regina M. Fink is Research Nurse Scientist, University of Colorado Hospital, Aurora, CO.

Teri M. Hulett is Infection Preventionist, University of Colorado Hospital, Aurora, CO.

Jane S. Braaten is PhD Student, College of Nursing, University of Colorado Denver, Aurora, CO.

Fred Severyn is Associate Professor, School of Medicine, University of Colorado Denver, Aurora, CO.

Heidi L. Wald is Assistant Professor, School of Medicine, University of Colorado Denver, Aurora, CO.

Earn Up to 9.5 CE Hours. See page 293.

This project was funded by a University of Colorado Hospital/School of Medicine QI (Quality-Improvement) Small Grant.

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