Running Head: REDUCING CA-UTIS IN THE ICU

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Reducing catheter associated urinary tract infections (CA-UTIs) in the ICU Jennifer Lee ID: 603561269 N204 University of California, Los Angeles

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Phase I: Validation Phase Catheter-associated urinary tract infections (CA-UTIs) are one of the most common hospital acquired infections (Apisarnthanarak et al., 2007). Most of UTIs are associated with an indwelling urinary catheter which is a catheter that is placed in a patients bladder for continuous urine drainage. Centers for Medicare and Medicaid Services (CMS) are no longer reimbursing hospitals for incidences of UTIs (2012). Therefore, it is essential for hospitals to establish a good preventative strategy to reduce CA-UTI rates in a hospital setting to reduce mortality and cost. Several studies have looked at programs implemented at the hospital to reduce CA-UTIs. This pilot study will review the following articles to determine the best practice and intervention to reduce CA-UTIs. Article #1 Rosenthal, V.D., Guzman, S., & Safdar, N. (2004). Effect of education and performance feedback on rates of cathether-associated urinary tract infection in intensive care units in Argentina. Infection Control and Hospital Epidemiology, 25(1), 47- 50. Article #2 Apisarnthanarak, A. et al. (2007). Effectiveness of multifaceted hospitalwide quality improvement programs featuring an intervention to remove unnecessary urinary catheters at a tertiary care center in Thailand. Infection Control And Hospital Epidemiology, 28 (7), 791-798. DOI: 10.1086/518453 Article #3 Oman, K.S, Makic, M.B., Fink, R., Schraeder N., Hulett T., Keech, T., & Wald, H. (2012). Nurse-directed interventions to reduce catheter-associated urinary tract infections. American Journal Of Infection Control, 40, 548-553. Doi:10.1016/j.ajic.2011.07.018

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Rosenthal, V.D. and colleagues conducted a prospective, open trial to determine the effectiveness of education and performance feedback interventions in reducing rates of CA-UTIs (2004). The study was conducted at Colegiales Medical Center in Argentina in which all patients with an indwelling urinary catheter for more than 24 hours in the ICUs was included in both the baseline (N= 1, 779) and intervention periods (N=5.568). Surveillance for CA-UTI was conducted during the baseline period using the methodology of the National Nosocomial Infections Surveillance (NNIS) system of the Centers for Disease Control and Prevention (CDC). After data was collected from the baseline period, an intervention consisted of education and performance feedback was implemented. Education implementation included hand hygiene and urinary catheter care published by the CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). The main education emphasis from the CDC guidelines was compliance with good hand hygiene techniques using antiseptic soap before catheter insertion and avoiding obstruction to urinary flow with the tubing. Performance feedback is another intervention to determine rates of compliance with hand washing and avoiding compressions. Epi-info software was used for data analysis and differences between treatment groups was analyzed using the chi-square analysis for dichotomous variables and the Students t test for continuous variables. Patients from the baseline period were similar to patients in the interventional period in terms of gender, age, severity of illness, presence of diabetes mellitus (DM), cancer, and human immunodeficiency virus (HIV). The results of the study showed that compliance with avoiding compression and hand washing improved significantly (P=0.01 and P < 0.001). CA-UTI rate also reduced significantly from 21.3 to 12.39 per 1,000 patients with indwelling catheters (P = 0.006). A limitation of this study is the lack of randomization and the fact that it was an open trial. Nonetheless, since no other intervention was implemented during

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this period, it is more likely that education and performance feedback reduced CA-UTI in the hospital setting. Apisarnthanarak and colleagues conducted a pre-intervention and post-intervention study to evaluate the efficacy of a multifaceted hospital wide quality improvement program as an intervention to reduce CA-UTIs. The study was conducted in Thammasart University Hospital (Thailand) with a total of 2,412 participants. Patients were consecutively followed for 12 months during the baseline and for another 12 months in the intervention phase. Both the controls had routine infection practice that included use of aseptic technique with catheter insertion, closed urinary catheters, and similar education of urinary catheter care. Nurses were educated on the indication of inappropriate catheterization. Urine and blood samples were only performed when patients displayed signs of infections and a positive test from the urine culture would indicate a UTI. The study design included a team that reviewed the literature and collected baseline data (data on appropriate use of urinary catheters and development of CA-UTI). The intervention team included physicians, epidemiologist, infection control specialist, and nurses. The intervention involves nursing-generated daily reminders to remind physicians about removal of unnecessary urinary catheters. The nurse continued to assess the patient for UTI symptoms every three hours in the ICU. Categorical variables and percentages were compared by use of a chi-square test or the Fisher exact test. A correlation among the variables was used with the SPSS. Participants in the study had no significant conditions; had similar clinical characteristics and demographics. The result of the study found a significant reduction in infections (p<0.001) after the intervention. In addition to reducing CA-UTIs, the study also calculated a 63% reduction in the cost of monthly hospital stay after the intervention. Limitations to the study

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include no randomized trial and the study is subject to bias due to being a quasi-experimental study without a control group. Nonetheless, the study showed a correlation that nursing interventions such as daily reminders to physicians on the removal of unnecessary urinary catheters can reduce rates of CA-UTIs. Oman and colleagues conducted a pre and post-intervention design to determine the impact of nurse-driven interventions based on current evidenced based practice (EBP) to reduce CA-UTIs in the medical/surgical unit (2012). The study used a quality improvement project on both units that recruited a multidisciplinary team (nurses, physicians, rehabilitation therapists, etc..) to examine EBP, identify and understand indwelling urinary catheter (IUC) use, and measure outcomes. The intervention have 3 phases: phase 1, baseline data on IUC duration and CA-UTI rates from both units; phase 2, includes a house-wide education and revision of hospital policy on insertion and care of an IUC based on EBP, 2008 Society for Healthcare Epidemiology of American, Inc/Infectious Disease Society of American practice recommendations, and evaluation of the hospitals IUC products; phase 3, targeted the medical/surgical unit involving the patient, family, and nurse. The Student t test was used to analyze and compare the differences between the baseline and the 2 post-interventions (phase 2 and 3). The healthcare team of RNs, CNAs, and emergency medical technicians (N=947) completed the changes in the IUC policy that highlighted the Health stream (hospital learning management system) module. The results of the study demonstrated a significant decrease in catheter duration (p=0.018) on the surgery unit and a slight reduction (p=0.076) on the medical unit. Limitations in this study include an uncontrolled pre/post intervention study, thus, other factors might impact the results of the study. Another limitation of the study was the fact that CA-UTIs on the

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intervention units were low but the confidence intervals around CA-UTI rates was large. These findings made it very difficult to assess the impact of the interventions. In reviewing the results of all three studies, a possible solution to reduce CA-UTI in the ICU is to implement EBP and re-education of catheter care to the healthcare team, including physical therapist, transporters, and other health personal involved in the patient care. Implementation of education have shown to reduce CA-UTI as evidenced by studies from Apsiarnthanarak et al.(2007) and Rosenthal et al. (2012). Both of these studies implemented the need to educate the staff with reading literature reviews of best practice for catheter care. Both studies showed a significant decrease in CA-UTI and CA-UTI duration. All three studies also show the importance of nursing interventions in catheter care. The studies show that bedside nurses should have good assessment skills for UTIs, insertion skills, as well as good assessment skills for inappropriate urinary catheter use. As a result, the findings reinforce the need for nurses to implement EBP for catheter care to improve patient outcomes in the ICU. Phase II: Comparative Evaluation Phase Fit of Setting I believe that these solutions are appropriate to use in the tertiary acute settings. The role of healthcare professionals such as nurses and physicians are to improve patient outcome and reduce harm. CA-UTI is an infection that is preventable and nurses should implement EBP to reduce rates of infection by assessing for inappropriate urinary catheter usage and communicating with the physicians of these assessments. See TOE attached. Substantiating Evaluation All three studies demonstrated the importance of nursing interventions to reduce CAUTIs in the ICU. Rosenthal el al demonstrated that education and performance feedback

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reduced CA-UTIs. Apisarnthanarak et al. demonstrated the effectiveness of multifaceted hospital wide quality improvement programs featuring nursing interventions to remove unnecessary urinary catheters in the ICU. And although Omans et al. study did not result in a significant CA-UTI reduction, theyre study highlighted interventions that were addressed in the other two studies such as implementing education and working with interdisciplinary teams to evaluate the best practice to implement. Basis for Practice The intervention that I would like to investigate is the implementation of multidisciplinary teams to review literature of EBP to reduce CA-UTIs. I would like to incorporate the Stetlers model of evidence-based practice. During the first phase of the model, the clinical problem of CA-UTIs is identified to be problematic. The multidisciplinary team will gather to find literature reviews to first find prevalence and incidence of the clinical problem. After finding literature reviews to support the clinical problem, the team will read more literature reviews specifically on interventions to reduce CA-UTIs in hospital settings. After finding studies to address the clinical problem, the next step is the validation phase. The interdisciplinary team will gather their resources and critique the literature to determine credibility of the suggested interventions for the clinical problem. The comparative evaluation or decision-making phase would consist of evaluating all of the literature searches. This phase will consist of narrowing the articles to three that deemed fit or appropriate for the clinical problem. The translation or application phase consists of the type of methods use, types of interventions used, such as enforcing hospitals policies or evaluating types of products used for insertion of catheters. This phase is to obtain the most appropriate intervention to implement in the clinical setting by evaluating the benefits and disadvantages of each suggestion in the clinical setting.

Running Head: REDUCING CA-UTIS IN THE ICU

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The last phase is the evaluation phase. This phase will look at research outcomes by comparing the outcomes of the baseline data before the intervention and then the data after the intervention. Feasibility The benefits of using this suggested solution in the ICU setting is to foster collaboration and a good working environment among all of the healthcare professions. This intervention would decrease CA-UTI in ICU patients by educating not only the healthcare professions, but also relaying the EBP to other staff such as transporters to encourage optimal care and improve the patients health outcome. Disadvantage of utilizing multidisciplinary teams to implement EBP to reduce CAUTIs is the lack of time that the team would have to accomplish this task. Bedside nurses and physicians are very busy with their daily task. Finding time to implement such practice would be difficult, but the hospital setting could hire Clinical Nurse Leaders (CNL) to facilitate and organize the multidisciplinary team to advocate for the patients safety. Phase III: Decision-Making Phase The purpose of this pilot study is to implement the best EBP nursing intervention to reduce CA-UTI in the ICU. CA-UTIs in ICUs reduce the patients mortality and are also very costly for the hospital and the patient. As healthcare providers, our role is to do no harm and to improve patients outcome. Therefore, it is our role to work in a multidisciplinary team to identify the best EBP or policy to reduce preventable infections such as CA-UTIs. Participations in this pilot study would be any patient in the ICU with an indwelling urinary catheter (IUC). Sample size was calculated through a power analysis of 80% with an alpha error of 0.05. The sample would be approximately 200 patients in the ICU with an IUC. The method of the study will be based on a pre-intervention and post-intervention design. The pre-intervention design

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will be a surveillance approach for CA-UTI to collect the baseline data using the methodology of the National Nosocomial Infections Surveillance (NNIS) system of the Centers for Disease Control and Prevention (CDC) for a period of 12 months (Rosenthal et al., 2004). At this time, the multidisciplinary team will also identify the best practice to reduce CA-UTI. For example, the team found that having good hand-hygiene is essential to reduce CA-UTI (Rosenthal et al., 2004). The team also found that nursing-generated reminders to remind physicians of inappropriate urinary catheter use is also effective in reducing CA-UTIs according to the study by Apisarnthanarak et al. (2007). To help facilitate and organize the team, the facility should hire more staff to help with the literature review such as CNLs. The interventions will then be communicated and enforced by physicians, nurses, physical therapists, transporters, and other personals taking part of the patients care. They must accept and implement these changes to reduce CA-UTIs and improve patient outcome. The interventions will be implemented for a period of 12 months and will then be reevaluated. Motivation for change in this group includes consolidation and collaborative care and a decrease in cost of services for the hospital and for tax payers. The study conducted by Oman and colleagues showed a significant decrease in hospital cost for nursing interventions at the bedside (2012). Motivation changes for this group would also be to establish a healthier environment by communicating effectively with other colleagues. The barriers to change would be the perception of lack of time to implement these interventions on top of daily tasks. Other barriers would be the struggle to convince older nurse to implement EBP. They might not be receptive of the idea of using research data because of their long experience working in the field.

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A method to overcome the perceived barrier of lack of time to implement interventions is to hire more nurses or to hire CNLs to organize the care of the patient in a more microsystem level to improve patient outcome. Another method is to increase compliance from older nurses is to collect statistical significant data to reinforce that interventions really improve patient outcomes. Communication of Findings Communicating findings of the pilot study to administration of the organization can be facilitated with a power-point presentation. The power-point presentation will have a summary of the pilot studys overall goals, implementation, significant results, and reduced hospital cost. Staff nurses can be informed with these findings by placing posters and good teaching interventions around the staff break rooms/ lounges. Posters will include findings like reduced outcomes of CA-UTI and reduce cost for the hospital and tax payers. Ancillary health care providers can also be given the same power-point presentation as the administration of the organization. The power-point presentation can be presented during conference meetings or by emailing findings to them. The public can be informed of findings by creating posters of outcomes and reduced hospital costs. The posters can be placed in front of elevators or in the hospitals waiting room.

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Reference Apisarnthanarak, A., Thongphubeth, K., Sirinvaravong, S., Kitkangvan, D., Yeukyen, C., Warachan, B., Warren, D. K., and Fraser, V.J. (2007). Effectiveness of multifaceted hospitalwide quality improvement programs featuring an intervention to remove unnecessary urinary catheters at a tertiary care center in Thailand. Infection Control And Hospital Epidemiology, 28 (7), 791-798. DOI: 10.1086/518453 Centers for Medicare & Medicaid Services. (2012) Hospital-acquired conditions (HAC) in acute inpatient prospective payment system (IPPS) hospitals [Data file]. Retrieved from http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HospitalAcqCond/downloads/hacfactsheet.pdf Oman, K.S, Makic, M.B., Fink, R., Schraeder N., Hulett T., Keech, T., & Wald, H. (2012). Nurse-directed interventions to reduce catheter-associated urinary tract infections. American Journal Of Infection Control, 40, 548-553. Doi:10.1016/j.ajic.2011.07.018 Rosenthal, V.D., Guzman, S., & Safdar, N. (2004). Effect of education and performance feedback on rates of cathether-associated urinary tract infection in intensive care units in Argentina. Infection Control and Hospital Epidemiology, 25(1), 47- 50.

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Title

Purpose

Sample /Setting N = 1,779 basline period and N = 5.568 during interventions period of patients with an indwelling urinary catheter for more than 24 hours in the ICUs. The study was conducted in Argentina.

Methods

Results

Discussion & Limitations Education and performance feedback helped reduced CAUTIs in ICUs. Limitation: study was open trial and did not use randomization.

Rosenthal, V.D., Guzman, S., & Safdar, N. (2004). Effect of education and performance feedback on rates of cathether-associated urinary tract infection in intensive care units in Argentina. Infection Control and Hospital Epidemiology, 25(1), 47- 50

To evaluate the effects of education and performance feedback with rates of CAUTI in ICUs.

A prospective, open trial comparing baseline period of surveillance without education and performance feedback with the intervention period.

Compliance with hand washing and performance feedback increased significantly (p=0.01 and p<0.001) after intervention. CA-UTI rates decreased significantly (p=0.006)

Apisarnthanarak, A., et al. (2007). Effectiveness of multifaceted hospitalwide quality improvement programs featuring an intervention to remove unnecessary urinary catheters at a tertiary care center in Thailand. Infection Control And Hospital Epidemiology, 28 (7), 791-798. DOI: 10.1086/518453

To evaluate the intervention of nursing generated reminders to physicians of the removal of unnecessary urinary catheters.

N=2,412 patients for the pre-intervention and postintervention on patients with a urinary catheters. Study conducted in a hospital in Thailand.

A hospitalwide pre-intervention and postintervention study. The intervention consisted of nursing interventions to remind physicians about unnecessary catheters.

After intervention, there was a significant reduction of CAUTI (p<0.001).

Intervention to remind physicians to remove unnecessary urinary catheters can reduce UTIs in hospital settings. Limitation include no randomization trial.

Oman, K.S et al., (2012). Nursedirected interventions to reduce catheterassociated urinary tract infections. American Journal Of Infection Control, 40, 548553. Doi:10.1016/j.ajic. 2011.07.018

To improve patient outcomes by implementingng EBP and reeducating health team about findings to reducing CAUTIs.

N= 150 patients/month with indwelling urinary catheter in the surgical unit. N=947 healthcare team completed the updated IUC modeule.

Pre/post intervention design. Intervention include educating health staff about best EBP to implement.

The results of the study demonstrated a significant decrease in catheter duration (p=0.018) on the surgery unit and a slight reduction (p=0.076) on the medical unit.

Strategies for care management can improve patient outcome. Limitation no randomized or control trials.