Nursing discussion board

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C ATHETER-ASSOCIATED urinary tract infections (CAUTI) continue to challenge com- munity hospitals. Hospital-

acquired urinary tract infections account for 40% of hospital-ac quir - ed infections, with 80% of those in - fections related to use of a urinary, or Foley, catheter (Gokula, Smolen, Gaspar, Hensley, Benninghoff, & Smith, 2012; Hanchett, 2012). Given the rising cost of treating CAUTI, the Centers for Medicare & Medicaid Services (CMS) identi- fied hospital-acquired CAUTI as one of eight conditions for which hospitals would no longer receive reimbursement as of October 1, 2008 (Milstein, 2009). Community hospitals, therefore, are charged with implementing innovative strategies that will reduce the inci- dence of hospital-acquired CAUTI.

A variety of strategies have been explored in nursing and other scientific literature for decreasing the incidence of CAUTI. Practical suggestions, such as stickers on pa - tients’ medical records or comput- er-generated reminders, along with implementation of evidence-bas - ed guidelines for Foley cathe ter maintenance, have been offer ed as potential solutions (Bruminhent, Keegan, Lakhani, Roberts & Passalacqua, 2010; Gokula et al., 2012; Wilson et al., 2009). The majority of literature, however,

has been focused on tertiary or academic medical centers and long-term care facilities

White Plains Hospital is a 301-bed non-academic communi- ty hospital in the suburbs of New York City that has implemented a nurse-driven process that reduced the incidence of CAUTI 50% within 1 year of implementation. The incidence of CAUTI contin- ues to decline to date with the goal of eventually having zero hospital- acquired CAUTI events. Further, with the decline in the incidence of CAUTI, costs decreased sub- stantially. White Plains Hospital’s nurse-driven, cost-effective pro - cess for reducing CAUTI is des - cribed. The ideas and steps taken to implement and sustain the process are outlined, along with suggestions for how nurse leaders in similar clinical settings can replicate the process.

Background In 2007, White Plains Hospital

experienced a transition in its sen- ior nursing leadership that reor- ganized the roles and responsibil- ities of the directors of nursing. The incoming chief nursing offi- cer launched the nursing division on its Magnet® journey and creat- ed an innovative role for the organization: the director of nurs- ing quality. This senior nursing

EXECUTIVE SUMMARY Due to treatment costs and lack of reimbursement, community hospitals are charged with imple- menting innovative strategies that will reduce the incidence of hos- pital-acquired catheter-associated urinary tract infections (CAUTI).

A nurse-driven system for decreasing the number of hospi- tal-acquired CAUTI is effective and useful for a community hos- pital.

One nurse with accountability for implementing a simple evidence- based protocol can dramatically decrease the total incidence of hospital-acquired CAUTI.

The basis for the success of this initiative relied heavily on the ease of using the eight-point Question the Foley criteria, the availability of the electronic med- ical record, interdisciplinary col- laboration, and support from nursing and physician administra- tion.

With collaboration and support from nursing leadership, the goals for patient safety by reduc- ing hospital-acquired CAUTI can become a reality in a short period of time.

Paul Quinn

Chasing Zero: A Nurse-Driven Process For Catheter-Associated Urinary Tract

Infection Reduction in a Community Hospital

PAUL QUINN, PhD, CNM, RN-BC, NEA- BC, CEN, CCRN, is Director of Nursing, White Plains Hospital, White Plains, NY.

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leadership role had direct respon- sibility for all nursing-sensitive indicators, performance improve- ment, nursing research, evidence- based practice, and dissemination of quality data within the nursing division. Specifically, the director of nursing quality was charged with identifying trends in health care that could affect the nursing division, performing gap analyses, and reporting the findings to the chief nursing officer so that action plans could be created and imple- mented.

The author, in the role of direc- tor of nursing quality, utilizing cod- ing data and a retrospective chart audit, found White Plains Hospital had an astonishing 110 incidences of CAUTI for the period of 2007 and the first two quarters of 2008. Current estimates for an organiza- tion to treat each incidence of hos- pital-ac quired CAUTI range from $1,200 to $2,400 (Palmer, Lee, Dutta-Linn, Wroe, & Hartmann, 2013; Rebmann & Greene, 2010). Since treating a hospital-acquired CAUTI was costly, with the poten- tial for those costs to increase over time, the chief nursing officer made reducing the incidence of CAUTI a key initiative in her strate- gic plan.

The Question the Foley pro - cess (see Figure 1), an evidence- based criteria that utilized existing resources within the organization, was implemented. Adopted from a best practice described in a long- term care setting in Illinois, the criteria provided a framework for nurses to use daily to assess the need for continuing a Foley cath - eter (Robinson et al., 2007). This successful initiative, however, relied on the usefulness of eight- point criteria, physician support, informatics collaboration, targeted education, daily monitoring, and dissemination of results through- out the organization (see Table 1).

Question the Foley To minimize the incidence of

hospital-acquired CAUTI, nurses needed a way to evaluate which

Figure 1. Question the Foley Criteria

Ask Daily if the Foley Catheter Is Being Used to:

1. Provide bladder irrigation and/or instill medication? 2. Provide relief from urinary tract obstruction not manageable by other means? 3. Permit urine drainage in a patient with neurogenic bladder dysfunction,

hydronephrosis, or urinary retention not manageable by other means? 4. Obtain accurate intake and output in critically ill patients? 5. Aid in urologic surgery or other surgery in the contiguous area (GYN or lower

GI surgery)? 6. Manage urinary issues or special purposes/circumstances such as a difficult

insertion per the urologist? 7. Manage urinary incontinence in patients with Stage III or Stage IV pressure

ulcers? 8. Provide comfort care in terminally ill or hospice patients?

If the patient meets NONE of the above criteria, the RN will contact the physician and discuss the possibility of catheter removal.

Table 1. Tactics for CAUTI Reduction

Tactic Comments

Question the Foley criteria

• Evidence based • Daily assessment for Foley catheter need; done on the day

shift only • Nurse pursues an order to discontinue Foley catheter if the

patient no longer meets the criteria

Physician support

• Support from the chief medical officer crucial • Physician champion helpful (e.g., chief of infectious diseases) • Physician assisted with review of medical records • Enforced process with fellow physicians

Informatics collaboration

• Designed nursing documentation in electronic medical record to include 8-point criteria

• Designed physician documentation and ordering to reflect the criteria

• Created customized reports for tracking and monitoring

Targeted education

• Created diverse education sessions for nurses and physicians • Varied hours and shifts • Case presentation, explanation of process and eight-point

criteria

Daily monitoring

• One RN responsible only • Track physician orders, insertions, use of criteria • Report outliers and statistics • Identify CAUTI from microbiology report • Identify all staff involved in the care of a patient with CAUTI;

letters sent to all involved

urinary catheters should be con- tinued and which ones were no longer being used for a specific purpose and should thus be dis- continued. A long-term care cen- ter in Illinois had tackled this issue and, through its work with

implementing an evidence-based practice, created criteria based on the literature that would provide nurses with situations to assess whether a Foley catheter should be continued (Robinson et al., 2007). These criteria, evaluated for

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their applicability to the inpatient setting of a community hospital, addressed similar patient popula- tions. White Plains Hospital’s adaptation of the criteria was called Question the Foley, and it provided decision points for nurs- es to use daily to assess whether continuation of a Foley catheter was appropriate (see Figure 1).

In addition to establishing the eight-point criteria, the hospital put into place an algorithm for nurses to use for specific patient circumstances. There is no auto- matic stop order or discontinua- tion of a urinary catheter without a physician’s order. Therefore, the daily assessment of Foley catheter continuation was done on the day shift to eliminate unnecessary phone calls to physicians during off-hours. Furthermore, if the nurse was uncertain about the need to continue a Foley catheter, it allowed the nurse a chance to either speak to the physician directly during his or her rounds or have a detailed conversation with the physician by phone dur- ing normal office hours. If a nurse reviewed the criteria and the patient was assessed as needing to have the Foley catheter continued, then the nurse would document his or her assessment in the elec- tronic medical record and remind the physician to renew the order daily. If a nurse reviewed the crite- ria and the patient was assessed as no longer requiring the Foley catheter, the nurse would speak directly to the physician and secure an order to discontinue the Foley catheter and monitor the patient accordingly.

Physician Support Physician support and com-

mitment were crucial to the suc- cess of this initiative. A report was created by the author for the chief medical officer (CMO) highlight- ing the incidence of hospital- acquired CAUTI and the proposed Question the Foley criteria. The CMO approved the plan and agreed to be a liaison between

nursing and the medical staff for physicians who were not willing to comply with the process. Additionally, the section chief of infectious diseases became aware of the proposed initiative and vol- unteered to be a physician cham- pion. In this role, he would edu- cate physicians about the need to reduce hospital-acquired CAUTI, and he would advertise the useful- ness of the Question the Foley ini- tiative. This physician also assist- ed with reviewing medical re- cords as needed.

Informatics Collaboration White Plains Hospital con-

verted to an electronic medical record (EMR), MEDITECH, in 2006 and has maximized many of the capabilities an EMR offers. The chief nursing officer identi- fied internal experts with profi- ciency in the use and functionali- ty of the MEDITECH system and created two distinct roles to man- age the informatics needs: the clinical informaticist for nursing and the clinical informaticist for physician services. Each role is designed to assist either nursing or physicians with documentation, data mining, and the generation of customizable user reports. The clinical informaticist for nursing changed the nursing documenta- tion and included the eight-point Question the Foley criteria. A cus- tomized report was created that lists all patients with a Foley catheter (room number, name, and medical record number) along with the date and time of the first documentation by a nurse within a 24-hour period. This report would be invaluable for tracking patients on a daily basis and assessing compliance with the ini- tiative.

The clinical informaticist for physician services created two orders for physicians for Foley catheters: one for the initial inser- tion of a Foley catheter and one for an ongoing Foley catheter. Phy - sicians were instructed to use the insertion order for any new Foley

catheter placed. Once completed, this order remains active for 48 hours before an electronic remind - er message is generated to the physician through the Physician Desktop. If a physician and a nurse concur the Foley catheter should remain in place past 48 hours, then an ongoing continua- tion order is given. An ongoing order will generate an electronic reminder message to the physi- cian every 24 hours. The expecta- tion, then, is the need for a Foley catheter will be evaluated daily past 48 hours of insertion and that a daily reorder is required for each day a Foley catheter remains in place.

Targeted Education Educating nurses and physi-

cians was required. In the past, Foley catheters remained in place, and the need to continue them was not addressed on a daily basis. The director of nursing quality created diverse education sessions for the nurses. Some ses- sions were offered in large group settings, such as the hospital audi- torium, while others were done with small groups of nurses on the nursing units at staff meetings or daily staff briefing sessions (“hud- dles”). Huddles, for example, were opportunities for the nurses to identify patients with a Foley catheter on the unit and review one or two key strategies for CAUTI reduction. In contrast, the content of the larger education session focused on the high inci- dence of hospital-acquired CAUTI and introduced the Question the Foley criteria as a process change. Case presentations were given to demonstrate the process of assess- ing a patient daily, and allowed role playing of the conversation a nurse might have with a physician to pursue a maintenance or dis- continuation order. These larger education sessions were offered on day, evening, and night shifts, and incorporated the assistance of clinical nurse specialists and staff development educators. During a

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2-month period, over 400 nurses (approximately 75% of the nurs- ing staff) attended an educational session.

Physician education proved to be a challenge. White Plains Hos - pi tal has more than 800 physi- cians on staff, including a robust hospitalist program, and reaching key members was difficult. Phy - sicians rely heavily on the hospi- tal’s email system as their pre- ferred method of communication, so an email was generated by the CMO to the physicians outlining the Question the Foley initiative, the reasons behind it, and what was expected from the physicians. A printed mailing was created and distributed to all physicians through a monthly mailing sent to their homes or offices. Hospitalists have their offices on-site, so in-ser- vice education was created for them and provided during lunch hours or at their monthly staff meetings. More than 90% of the active hospitalist physicians were educated about the Question the Foley initiative.

Daily Monitoring Monitoring the Question the

Foley initiative was left to the director of nursing quality, who was primarily accountable for sus- taining the process. Each morning, the director of nursing quality generates the customized report from the previous day of all catheterized patients in the organ- ization. Patients from the materni- ty unit are excluded first, due to standard orders that allow Foley catheter discontinuation within 24 hours of delivery. Using a checklist, the author identifies and tracks which patients have had a Foley catheter inserted or have an ongoing catheter. Cath - eterized patients on all other units are reviewed daily, including five medical-surgical units, an eight- bed intensive care unit, an eight- bed coronary care unit, and two telemetry/critical care step-down units. Through the EMR, the director of nursing quality can

quickly scan the patient’s record for an existing physician’s order and review nursing documenta- tion simultaneously. If a physician order is missing, a log is main- tained that is shared daily with the CMO, the hospitalist program directors, and the individual nurse manager and assistant nurse manager. If nursing documenta- tion needs to be addressed, an email is sent to the nurse manager and assistant nurse manager, and the nurse is counseled according- ly. From this report, monthly totals are tabulated, including total patients, total catheter days, average catheter dwell time per unit, catheter utilization rates, and total number of missing orders.

A concurrent report is gener- ated daily from the microbiology department that identifies all pos- itive urine cultures, and it is sent via email every morning to the director of nursing quality. This report is reviewed in collaboration with the infection control preven- tionist to confirm any suspected hospital-acquired CAUTI. A thor- ough chart audit follows to identi- fy when and where the infection was contracted. Each nurse in - volved in the care of that patient then receives a letter from the director of nursing quality identi- fying that a patient has contracted a hospital-acquired CAUTI and inviting the nurse to participate in a root cause analysis of the events surrounding the hospital-acquired CAUTI. During the analysis, each nurse is encouraged to identify any barriers in or breaks to the prevention initiative. Letters sent to nurses, and the need to perform analyses, have decreased over the past 4 years.

Additional Measures Other evidence-based prac-

tices have been identified as valu- able in combating the incidence of CAUTI since the introduction of the Question the Foley initiative. For example, the use of silver alloy Foley catheters, implement- ing the use of securement devices

to limit Foley catheter movement after insertion, strict adherence to proper drainage tube placement to avoid touching contaminated sur- faces, and incorporating the removal of Foley catheters by day 1 or 2 for most postoperative patients were additional strategies that demonstrated efficacy in the overall reduction of hospital- acquired CAUTI (Trautner, 2010). These measures were implement- ed progressively between 2008 and 2011. The infection control department and nursing division developed a combined, ongoing education plan for infection pre- vention incorporating these strate- gies in conjunction with the Question the Foley initiative.

Results Dramatic reduction in the

incidence of hospital-acquired CAUTI occurred within the first year of the Question the Foley ini- tiative (see Figure 2). By 2009, the total number of hospital-acquired CAUTI decreased. Specifically, the CAUTI rate decreased dramat- ically from 4.9/1,000 catheter days in 2008 to 3.9/1,000 catheter days in 2009. Further, the rate contin- ued to decrease from 2009 to the first quarter of 2013 where the rate was only 0.2/1,000 catheter days. The number of catheter days also decreased over the same time peri- od, signifying a direct correlation between catheter utilization and CAUTI rates.

White Plains Hospital had a surge in its annual inpatient cen- sus since 2010; despite the increased number of patients catheterized per month, the time Foley catheters remained in place, or dwell time, decreased. In 2008, Foley catheters remained in place for an average of 5.6 days, and by the end of 2009, that number dropped to 3.7 days. No benchmark was known to compare our dwell time, but a goal was to mimic the emerging data for postoperative patients that catheters should be in no longer than 48 hours. Since 2009, the average dwell times for all

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2008 2009 2010 2011 2012 Q1 & 2 2013

Total catheterized patients 5,561 4,174 3,995 3,904 3,022 2,256

Total catheter days 22,212 15,513 13,659 13,523 13,249 6,833

Average catheter dwell days 5.6 3.7 3.4 3.2 3.1 2.4

Total acquired CAUTI 110 56 13 11 5 2

CAUTI incidence rate 4.9% 3.7% 3.4% 3.2% 3.1% 0.30%

ability of the EMR, interdiscipli- nary collaboration, and support from nursing and physician ad - ministration.

The Question the Foley crite- ria satisfied the hospital’s need to change practice on the basis of the latest scientific evidence. The pro- tocol is simple to compile and implement, and it contains nor- mal clinical situations not foreign to nurses practicing in community hospitals. The practice change that followed was not difficult for the nurses, and hardwiring the change occurred within a short amount of time. New nurses will require time to become familiar with the process, but skilled pre- ceptors can be an asset for role- modeling the behavior.

The EMR has multiple capa- bilities, but the role of clinical and technologic experts within the organization who are accessible to the nursing division and who have time allotted to dedicate to new projects is essential. The clin- ical informaticists played a key role in creating customized re - ports, working through revisions of those reports, and evaluating ways to enhance those reports during system upgrades. White Plains Hospital, recently designat- ed as a Magnet organization, creat- ed a nursing informatics council, which works closely with the clin- ical informaticists to not only gain expertise and knowledge of the MEDITECH system, but also con- tributes its clinical expertise when new documentation or reports are created. The clinical experts, as the end users of the technology, are in a key role to ensure adher- ence to documentation. The com-

Figure 2. Total Acquired CAUTI and Incidence Rate, 2008 to Quarter 2, 2013

To ta

l A c q

u ir

e d

C A

U T

I

120

100

80

60

40

20

0

4.9%

3.7%

3.4% 3.2% 3.1% 0.3%

2008 2009 2010 2011 2012 Q1 & 2, 2013

Table 2. Cost Savings Over Time for Implementing a Nurse-Driven Process for CAUTI Reduction

2008 2009 2010 2011 2012 2013

Number of CAUTI cases 110 59 13 11 5 2

Treatment @ $1,200/case $132,000 $70,800 $15,600 $13,200 $6,000 $2,400

Savings compared to previous fiscal year $61,200 $55,200 $2,400 $7,200 $3,600

Cost with inflation adjusted (nurse salary to lead initiative) $75,000 $77,625 $80,341 $83,152 $86,062

Cost savings $4,200 $62,025 $67,141 $77,152 $83,662

units, excluding the maternity unit, has been sustained between 3.1 to 2.4 days. Further, the overall total cost to the organization to treat CAUTI decreased (see Table 2). For example, using the current lowest cost estimate (e.g., $1,200 per hospi- tal-acquired CAUTI), costs to treat hospital-acquired CAUTI de - creased from $132,000 in 2008 to $2,400 in the first quarter of 2013. Additionally, for making one nurse accountable for the success of the quality monitoring process, there was an overall cost savings and return on investment to the organ- ization of $83,662 (see Figure 3). Results were printed in tables dis- played on each nursing unit and discussed during unit council meetings. The results continue to

be formally presented to both the hospital’s performance improve- ment committee and the board of trustees on a quarterly basis.

Recommendations for Nurse Leaders

A nurse-driven system for decreasing the number of hospi- tal-acquired CAUTI is effective and useful for a community hospi- tal. One nurse with accountability for implementing a simple evi- dence-based protocol can dramat- ically decrease the total incidence of hospital-acquired CAUTI. The basis for the success of this initia- tive at White Plains Hospital therefore relied heavily on the ease of using the eight-point Ques - tion the Foley criteria, the avail-

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bination of clinical experts with technological experts helps expe- dite projects to completion and decreases turnaround time for special requests.

Utilizing experts outside the nursing division improves collab- oration and communication across disciplines. Having a physician champion such as the section chief of infectious disease and the support of the CMO helped gain support for the initiative among the multiple physicians within the organization. The infection control preventionists were essen- tial by identifying the presence of infection, confirming which ones were present on admission or acquired during hospitalization, and suggesting strategies for con- tainment and treatment. The col- laboration of nursing, medicine, and infection control presented a united force to physicians and nurses alike and conveyed the import of the project. Recognition from the chief executive officer and the chief nursing officer,

along with celebration of sus- tained results, reinforced the efforts of the bedside nurses and physicians and fostered the col- laboration and communication between the disciplines.

A nurse leader with the ability to critically analyze each clinical scenario, make pertinent recom- mendations, and demonstrate leader - ship savvy to correct inconsisten- cies can pioneer a similar project and ensure success for a commu- nity hospital. With collaboration and support from nursing leader- ship, the goals for patient safety by re ducing hospital-ac quired CAUTI can become a reality in a short period of time. $

REFERENCES Bruminhent, J., Keegan, M., Lakhani, A.,

Roberts, I., & Passalacqua, J. (2010). Effectiveness of a simple intervention for prevention of catheter-associated urinary tract infections in a communi- ty teaching hospital. American Jour - nal of Infection Control, 38, 689-693.

Gokula, M., Smolen, D., Gaspar, P.M., Hensley, S.J., Benninghoff, M.C., & Smith, M. (2012). Designing a proto-

col to reduce catheter-associated uri- nary tract infections among hospital- ized patients. American Journal of Infection Control, 40(10), 1002-1004.

Hanchett, M. (2012). Preventing CAUTI: A patient-centered approach. Preven - tion, 43, 42-50.

Milstein, A. (2009). Ending extra payment for “never events”: Stronger incen- tives for patient safety. New England Journal of Medicine, 360, 2388-2390.

Palmer, J.A., Lee, G.M., Dutta-Linn, M., Wroe, P., & Hartmann, C.W. (2013). In - cluding catheter-associated urinary tract infections in the 2008 CMS pay- ment policy: A qualitative analysis. Urologic Nursing, 33(1), 1-9.

Rebmann, T., & Greene, L.R. (2010). Pre - venting catheter-associated urinary tract infections: An executive summa- ry of the Association for Professionals in Infection Control and Epidemi - ology, Inc., elimination guide. Ameri - can Journal of Infection Control, 38, 644-646.

Robinson, S., Allen, L., Barnes, M.R., Berry, T.A., Foster, T.A., Friedrich L. A., ... Weitzel, T. (2007). Development of an evidence-based protocol for reduction of indwelling urinary catheter usage. MEDSURG Nursing, 16(3), 157-161.

Trautner, B. (2010). Management of cath - eter-associated urinary tract infection (CAUTI). NIH Public Access, 23, 76- 82.

Wilson, M., Wilde, M., Webb, M.I, Thompson, D., Parker, D., & Harwood, J. (2009). Nursing interventions to reduce the risk of catheter-associated urinary tract infections: Part II. Staff educa- tion, monitoring and care techniques. Journal of Wound Ostomy & Conti - nence Nursing, 36, 137-154.

Figure 3. Return on Investment for Implementing a Nurse-Driven Process for

CAUTI Reduction

$140,000

$120,000

$100,000

$80,000

$60,000

$40,000

$20,000

$

120

100

80

60

40

20

0

N u

m b

e r o

f C a s e s

2008 2009 2010 2011 2012 2013

Treatment @ $1,200/Case

Cost with Inflation Adjusted (nurse salary to lead initiative)

Number of CAUTI Cases

Savings Compared to Previous Fiscal Year

Cost Savings

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