Results
During the pre-intervention period (April–December 2014) there were 10 infections and 1450 catheters inserted, which equates to an insertion-related CAUTI rate of 6.9/1,000 catheters. In the post-intervention period (April–December 2015), there were 2 infections and 1180 catheters placed, or an insertion-related CAUTI rate of 1.7/1000 catheters (Table 1)—a 75% decrease from the pre-intervention rate (P = 0.05).
Additionally, the utilization ratio was calculated for 2014 and 2015 based on the number of catheter insertions per total patient ED visits in each year (Table 2). In 2014 the utilization ratio was 2.2 and in 2015 the utilization ratio was 1.7, representing a 23% reduction (P < 0.01).
Following the post-intervention period, insertion-related rates and device utilization were also monitored in 2016. There were a total of 97,004 patient visits to the ED in 2016 with 1530 catheters inserted and 3 insertion-related CAUTIs attributed to the ED. The insertion-related CAUTI rate was 2.0/1000 catheters, which is statistically no different from the post-intervention period rate. The utilization ratio was 1.6, which is less than the post-intervention period (P < 0.01).
Discussion
As highlighted in the AHRQ toolkit [5], the project confirmed that using both technical and socioadaptive methodologies yielded a significant and sustainable impact on CAUTIs and utilization of indwelling urinary catheters. Prior to initiating the project, a review of the literature did not show any previous studies involving the insertion of urinary catheters by 2 licensed personnel. Since then, an acute care facility published data demonstrating a sustainable 39% reduction of CAUTI rates in an inpatient post-surgical unit within 6 months after the implementation of 2-person urinary catheter insertion [9]. The facility had also done extensive education and training on the CAUTI prevention best-practices prior to implementing the new insertion practices.
A key measure of success in regards to implementing cultural and technical changes is the sustainability of the results yielded after implementation. According to the AHRQ CAUTI toolkit, several specific strategies are necessary to successfully sustain prevention efforts. Implementing changes in the ED at our hospital in alignment with the goal of creating a culture of safety, incorporating the changes into daily work flow, employing both technical and socioadaptive interventions, empowering staff to stop the procedure if there are any concerns, and monitoring and communicating outcomes all ensure that the changes in practice will be sustained. Additionally, there is an engaged interdisciplinary CAUTI committee that continues to meet regularly as well as required yearly computer-based education for all frontline staff, and a “Safety Day” education session for all newly hired nurses where competency is assessed and validated for proper insertion and maintenance of a urinary catheter.
Initially, barriers for implementation included limited staff to ensure the presence of 2 licensed personnel for every urinary catheter insertion, lack of ability to collect checklist data in the electronic medical record and run compliance reports, and availability of the checklists at the onset of implementation. The staffing limitation seemed to work in favor of meeting the goals of the project, as staff were less likely to insert indwelling urinary catheters for inappropriate indications. In regards to the checklists, the barriers identified via the PDSA rapid cycles included inadequate locations to obtain checklists for use during insertion and drop-off locations for checklists after use. To increase availability and convenience, brightly colored folders labeled “FOLEY!” containing the checklists were placed both on the outside of the supply management stations and on the doors exiting the supply rooms where indwelling urinary catheter kits were located. Rounds were made on these folders approximately 1 to 2 times per week to be sure they remained full. In addition, more locations for dropping off completed forms were placed at all nursing stations as opposed to a single drop off location.
A limitation of the project is that there are not established metrics for infection rates in any outpatient setting nor are there established criteria to differentiate between insertion- and maintenance-related infections. While the metrics were created for the purposes of the project, they are easily reproducible within other health care facilities to track infection rates associated with outpatient areas. Additionally, by ensuring indications are met and proper insertion occurs in ED patients, the overall hospital’s CAUTI infection rate and standardized infection ratio are impacted, which are comparable across facilities. The criteria for differentiating between insertion and maintenance related infections was established in an attempt to define where the biggest vulnerabilities were with insertion versus maintenance. Days from insertion to infection were tracked for all infections, and arbitrarily a 7-day cutoff was used to consider the infection potentially insertion-related, as no evidence has been published to define this previously.
The lessons learned both during implementation of the changes in practice and the impact it can have on infection rates are valuable. Moving forward, Tampa General Hospital plans to spread dual personnel indwelling urinary catheter insertion as a best practice, first targeting inpatient units identified with the highest number of insertion-related infections as well as high device utilization ratios.