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In the Hospitalized Population of the Acute Setting, Do Nurse Driven, Catheter Removal Protocols Decrease Catheter Associated Urinary Tract Infections, Over a 5 Year Review.

Crystal J. Rogers

Department of Nursing, Houston Baptist University

NURSE5301 Advanced Nursing Research

Dr. Antonea’ Jackson

April 2, 2022

Approximately 1 in every 25-person hospitalized in the United States (US) will experience a Healthcare-Associated Infection (HAI). (“Healthcare-Associated Infection,”2017) Catheter Associated Urinary Tract Infections (CAUTI), are among the top HAI reported worldwide, accounting for 36-40% of all nosocomial infections in hospitals. (Mong et al., 2021) According to the Center for Disease Control and Prevention (CDC), HAIs are complications of healthcare and linked with high morbidity and mortality. Over 13,000 deaths each year are associated with healthcare-associated urinary tract infections. (Letica-Kriegel et al., 2019) The estimated total U.S. cost per year for CAUTI is $400–$500 million dollars. (Russell et al., 2019) This literature review focused on looking at hospitals that have developed a nurse driven, catheter removal protocol, to decrease Catheter Associated Urinary Tract Infections, in an acute care setting.

While the CDC does report decreasing numbers of CAUTIs over the last 5 years, these results are not universal across the country. In some sates the Standardized Infection Ratio (SIR) for CAUTI rates are as low as 0.55, while in others the SIR is as high as 1.56. This is believed to be related to the different hospital preventive protocols that are in place. (“Catheter-Associated Urinary Tract Infections,”2020) This literature review focused on the statistical reports given by the CDC for the last 5 years, the department of Health and Human Services as well as scholarly based journal articles, published within the last 5 years.

A literature search was conducted focusing on scholarly based journals, with search term variations including the words, “urinary tract infections,” “Catheter associated Urinary Tract Infections,” “Foley catheter usage in hospitals, ” ” Nurse Driven protocols for catheter removals,” “Nurse Driven Catheter Removal Protocols in Rule hospitals,” and CAUTIs in the title. Approximately 14 scholarly based journal articles were utilized.

The articles used were both quantitative, qualitative, and retrospective as well as methodological. Chosen articles focused on both male and female patients of all ages, in acute care hospitals, post-surgical, Intensive care, long term Acute Care Hospitals and Tertiary facilities. This study was conducted to evaluate the effectiveness of nurse driven catheter removal protocols.  It also examined the different variances in results noted at facilities with CAUTI protocols in place, and how they were affected by nurse interactions and interventions, or lack thereof.

In 1981, the CDC updated the guidelines for CAUTI, and recommended that quality improvement programs be implemented, to address them. (Russell et al., 2019) It seems that whatever specific improvements were to be implemented was left to each individual healthcare entity, resulting in healthcare facilities interpreting these guidelines and each implementing quality improvements differently.  In 2008, the health care delivery model was changed by Medicare, allowing them to charge hospitals penalties when a patient acquires preventable conditions including CAUTI. (Russell et al., 2019) Hospitals with a total hospital acquired condition, (HAC), Score greater than the 75th percentile of all Total HAC Scores will receive a 1% percent payment reduction. (CMS, 2020) 1% seems small, but in reality, it can coast hospitals hundreds of thousands of dollars.

Several risk factors for developing a CAUTI include being a female, the length of time the IUC is in place, having diabetes mellitus, anatomical abnormalities of the urinary tract, and poor catheter care and lack of aseptic technique upon insertion, or breaks in the drainage system. When planning to initiate an IUC, patients that have any risk factors, should be closely monitored and IUC should be avoided is possible. The most common uropathogen found as the source of CAUTI is Escherichida Coli. (Chuang & Tambyah, 2021) The insertion of, maintenance, monitoring, and removal of IUC is within the scope of practice for nurses, and it has been found that nurses can play a key role in causing or preventing CAUTI. (Mong et al., 2021)

In the US, it is reported that approximately 13,088 deaths per year are related to CAUTI. Studies indicate that 21% to 55% of all IUC placed, are being utilized inappropriately and are not indicated. (Schiessler et al., 2019) CAUTI can be prevented by avoiding unnecessary utilization of IUC. (Mong et al., 2021) When a IUC is required, it is vital that the nurse uses proper aseptic technique when inserting the IUC. (Chuang & Tambyah, 2021) Propper aseptic technique with administration of the IUC, and proficient hand hygiene with soap and water, before and after touching the catheter will reduce the number of pathogens that are introduced to the urinary tract. (Assadi, 2018) For example, if a nursing professional is administering an IUC, and properly uses aseptic technique, they are helping to prevent the contamination and transfer of pathogens from the nurse’s hands, the surrounding surfaces, and equipment to the patient’s urinary tract. The definition of Aseptic, means to be free from pathogenic microorganisms (Libretexts, 2022)

Under the guidelines of the CDC, for a urinary tract infection to be classified as a CAUTI, the indwelling unary catheter (IUC), must be inserted into the bladder for more than 2 days, at time of diagnosis. (Letica-Kriegel et al., 2019) While using this definition as a baseline, a retrospective cohort study was performed of patients admitted to an Urban academic health system of the USA, of 2500 beds, who were catheterized from January 2012 to March 2016. There were a total number of 148,631 catheterizations, resulting in CAUTI rate of 1.64 per 1000 catheter-days. This study showed that the longer a IUC is left in place, the higher the chance of developing a CAUTI. It also proved that females are at a higher risk of developing CAUTI. (Letica-Kriegel et al., 2019)

Another comparative study with similar results was conducted in a pediatric intensive care unit (PICU) here in the US.  They implemented a nurse driven, IUC removal protocol. One month post implementation of the protocol, the use of IUC, decreased in days by 60%. After 2 months, the PICU had zero CAUTI. (Schiessler et al., 2019) But it was noted that the nurses did not have complete autonomy with catheter removal decisions. They still had to consult with urology and pediatric surgery, prior to removal of the IUC.  While a PICU, may be more guarded in allowing their nursing staff the autonomy to remove IUC, some research has proven this can be very beneficial to the patient’s and the facilities, yet many facilities continue to control this in some degree.

A surgical group in a US facility investigated application of a nurse-driven catheter removal protocol, to reduce the number of days the IUC are in place. They hoped to decrease the number of patients experiencing urinary retention post IUC placement and removal and CAUTI.   They implemented a NDCRP, that allowed the nurses to remove IUC, but it was still not completely autonomous. The nurse was directed on when to remove the IUC. Approximately 130 patients had there IUC removed post-operatively on day one (POD1), while 50 patients with IUC, had the catheter left in place for 4 days or greater.

The NDCRP was a success, with patients that had their IUC removed POD1, (70%) Ninety-three patients, were able to urinate spontaneously, had no urinary retention or CAUTI. Of the 50 patients that the IUC was left in place greater than 4 days, only (11%), or 14 patients were able to spontaneously urinate. While this study did conclude that Nurse Driven Catheter Removal Protocols (NDCRP) are safe and effective to reduce urinary retention, CAUTI, and prolonged hospital stays, (Beeler et al., 2021) it did not allow the nurses to decide when to remove the IUC. So, it questions, how much of the NDCRP, was truly nurse driven.

In comparison, to the facilities that did not allow the nurses complete autonomy with the decision on when to remove the IUC, some facilities have implemented NDCRP that are in fact, nurse driven, and completely autonomous. A few of such facilities include a surgical trauma intensive care unit (SICU) in a large tertiary care center, an Urban academic medical center, and a Long-Term Acute Care Hospital (LTACH).

After educating their staff and implementing the NDCRP, the SICU found their Cather utilization overall decreased significantly from 0.78 to 0.70. (Tyson et al., 2018) After implementation of the NDCRP, the Urban academic medical center reported a decrease in the utilization of IUC usage, (Russell et al., 2019) and the LTACH  showed a decrease in their overall catheter usage by approximately 10%. (Zurmehly, 2018)

All three facilities proved that the NDCRP were successful in decreasing CAUTI. The SICU, CAUTI rate declined from 5.1 to 2.0 per 1000 catheter days. (Tyson et al., 2018) The Urban academic medical centers CAUTI rate decreased from 3.04 to 2.40 per 1000 catheter days. (Russell et al., 2019) While the LTACH, CAUTI rate decreased by 74%, with 4.82 CAUTI noted per 1000 patients. (Zurmehly, 2018)

The Urban academic medical centers started the project with a goal of empower nurses and promote autonomy, with a goal of decreasing their CAUTI by 50%, or 1.9 per 1000 catheters. The facility did not reach their goal of a 50% reduction in CAUTI. They report having increased nurse empowerment and autonomy and seeing a decline in CAUTI of 36%. Post refection they realized they needed to reevaluate their protocols to address post removal urinary retention. (Russell et al., 2019)

Even when healthcare facilities do not reach their goal of decreased CAUTI, it seems they do show a decrease in occurrences. This leads one to wonder why NDCRP are not implemented universally in healthcare facilities.  One main reason is medical communities are not in agreement that NDCRP should be implemented or even recommended. (Durant, 2017) The American Medical Association has voiced disagreement with giving medical professionals who are not physicians, the autonomy required to implement a true NDCRP. It has been argued that the implementation of these protocols could lead to adverse patient outcomes, and the decisions to use or remove IUC should be left to physicians. (Durant, 2017) Finding that the American Medical Association disagrees with giving nurses more autonomy, for a NDCRP prompted a search for failures resulting from the implementation of NDCRP.

A project was initiated at 3, large hospitals with 1,604 beds. Their initial goal mirrored many others and wanted to decrease CAUTI. A NDCRP was developed and initiated in October 2020, but after 14 months, the results were shocking. The utilization of IUC had increased from 0.1707 to 0.1767 (measured by the number of IUC used per patient days). And with that, the CAUTI rate also increased from 0.1678 to 0.204, per 1000 patient days. (Reynolds et al., 2022) These results were in direct conflict with most of the published research findings on IUC, NDCRP and CAUTI.

It was noted that the NDCRP did not integrate with the facilities electronic health record (EHR) well. Within the EHR, when the initial orders were placed for the IUC, the physician could select if they wanted to allow the NDCRP to be used or not. It is also noted that this 14-month project was conducted and analyzed during the height of the COVID-19 pandemic, with staff shortages, patient surges and increased travel nurses, it is unknown how these variances, may have affected the overall project results.  (Reynolds et al., 2022)

The published conclusion from this project was that NDCRP can potentially decrease the number of CAUTI, yet their own evidence did not support this. It did prove that NDCRP alone will not decrease CAUTI. Proficient training and consistency are needed as well as more cohesive EHR, collaboration, and less push-back form medical staff. (Reynolds et al., 2022)

Medical personnel’s, attitude and knowledge base seems to be significant in relation to the success of a NDCRP and CAUTI. The nurse’s knowledge and understanding of CAUTI and attitude about prevention can make the difference in a NDCRP being a success or failure. (Mong et al., 2021) The extent of the nurse’s enthusiasm and involvement in the monitoring of IUC, providing reminders about IUC being in place, performing bladder ultrasounds or scans, has proven to decrease CAUTI. Even with the nurses performing these invaluable tasks, it is reported that there is a nursing knowledge-practice gap where IUC are involved. (Mong et al., 2021) The lack of knowledge in preventing CAUTI, is also attributed to the attitude that nurses seem to have in relation to basic infection control protocols. (Mong et al., 2021)

A mixed-method study was performed at a US acute care hospital to examine the actual usage of their NDCRP, and how well the policy was accepted by nurses in each hospital department. After a total of 13 questioners with approximately 50% of the nurses participating, the results were reviewed. The NDCRP were well perceived in every department except medical-surgical units. While the nurses showed a good knowledge base and felt that NDCRP could decrease CAUTI, they showed a lack of education in the clinical aspects of a CAUTI, and the possible effects it can have on the patients. The nurses did not feel that the risk for a CAUTI, was serious enough for them to implement the NDCRP. Leaving IUC in place for longer time frames than were warranted per the policies. (Blodgett & Sheets, 2021)

It is suggested that this knowledge gap can be closed with encouragement, empowerment, and education. A positive nursing attitude, in relation to nurse driven protocols, increases productivity, patient safety and generally have positive results. The relationship between a nurses practice and attitude is considered essential. (Mong et al., 2021) When comparing different hospitals and the results of implementing NDCRP, the nurse’s attitudes toward success and with the amount of autonomy allowed, seems to differ by facility, setting and geographic location.

NDCRP have been implemented in many different large acute care settings, LTACH, ICU, nursing homes, but what about those areas that are considered small, hometowns, the rule acute care hospitals. In 2017, a small rule, acute care hospital decided to implement NDCRP in the hopes, like all the others, to decrease CAUTI. The steps the Rule hospital implemented were thorough and based in evidence. The NDCRP allowed the nurses the autonomy to remove the IUC per their nursing judgment. The Rule facility made it standard practice to included aseptic techniques for removal and insertion of catheters, maintaining closed catheter drainage system, sterile technique for collecting urine for culture, precautions to prevent urine backflow, and it encouraged removal of the IUC as soon as possible. After 2 years, the facility reported a 60.2% reeducation in their CAUTI. (Potugari et al., 2020) Proving that NDCRP, even in a rule acute care setting, can be successful in reducing CAUTI.

The evidence found during this literature review showed unanimously, that the best way to prevent a CAUTI is, to not use IUC. When it is necessary to use an IUC, removal at the earliest possible opportunity is recommended in prevention against CAUTI. (Chuang & Tambyah, 2021) It was found that facilities that implemented a nurse driven, catheter removal protocol showed a decrease in CAUTIs, or the potential for decreased CAUTI. This conclusion was based on the evidenced based results reported prior to implementation of the NDCRP and the results reported post implementation of the protocols.

In some studies, it was found that there is a need for further research with more a cohesive NDCRP. It was noted that in facilities with nursing staff that are less educated, and have a less cooperative attitude, the CAUTIs did not decrease as much as other facilities, as the protocols set in place were not consecutively followed as intended. When care is not evidenced based and the IUC is not consistently assessed for continued need, there is a risk of CAUTI to develop by 5% every 24 hours that the IUC is left in place. (Russell et al., 2019) Leading one to believe that Nurse driven catheter removal protocols, in well-educated facilities, with cooperative medical professionals, will lead to decreased CAUTIs.

References

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