Can use of catheter alternatives decrease use of urinary catheters? Amy Lucas, MSN, RN, CCNS, CCRN K

Can use of catheter alternatives decrease use of urinary catheters?

Amy Lucas, MSN, RN, CCNS, CCRN-K - Clinical Nurse Specialist, Nursing Quality & Safety

The purpose of this project was to reduce urinary catheter use at CRMH by providing appropriate products to manage urine in hospitalized patients. Reduction of catheter use should not only decrease risk of urinary tract infection, but also of other complications, such as meatal trauma and bacterial resistance or clostridioides difficile (formerly known as clostridium difficile) infection related to antibiotic overuse1 .

Literature Review

CAUTI (catheter-associated urinary tract infection), the most common healthcare acquired infection in adults in acute care facilities, is associated with higher mortality and longer lengths of stay2. Recommendations to prevent CAUTI, commonly known as the ‘foley bundle’, are to: only place catheters for specific indications, remove them as soon as possible, and maintain them appropriately while in place1,3,4. No guidelines advocate inserting a urinary catheter solely to manage urinary incontinence or to measure output when another method can be used3,4,5 . Despite the recommendations and the evidence that reducing catheter days does reduce CAUTI6 , between 21-50% of urinary catheters may be placed for inappropriate reasons7 .

The Association for Professionals in Infection Control and Epidemiology (APIC) 2014 guidelines list several factors that contribute to the delayed removal of catheters, including a lack of supplies to manage incontinence. Scott et al.8 considered this in a project to decrease urinary catheter placement in the Emergency Department (ED). They used focus groups to understand practice related to placing catheters and then created education, a decision support tool, and improved the availability of catheter alternatives for their staff. These interventions lead to fewer catheters being placed in their ED as well as an increase in the use of catheter alternatives. Interventions such as these can ultimately prevent CAUTI by reducing urinary catheter placements and decreasing catheter dwell times.

IRB Determination

The Carilion Clinic IRB determined that this study did not meet the regulatory definition of human subjects research as outline in the Department of Health and Human Services (DHHS) regulations.

Methods and Procedures

The project took place in several stages starting in late 2016. First, nursing and medical staff were surveyed about catheter alternatives and their perceived needs for other products. This survey indicated a need for better products for both men and for incontinent and immobile women. Next, products were found to fill these needs. The first products searched for based on the survey were a new device for incontinent women and a better version of male condom catheter. Later, as more needs were identified, a pouch for men who could not wear a condom catheter was also found. These products were piloted and implemented. Finally, champions were recruited from nursing units and educated about the new products, acceptable reasons for a urinary catheter, and current policy. They helped to advocate for and educate about the new products. The clinical nurse specialist also rounded in areas with catheters of long duration to identify opportunities for removal and further needs for different products.

Outcome Measures and Data Collection

The main outcome measure for this project was catheter use. This was monitored using Infection Control reports of catheter duration that included utilization ratio as well as catheter hours and

number of catheters used. The numbers were compared between the baseline year (2016), the implementation year (2017), and a follow up year (2018).

Results

• There was a statistically significant decrease in the number of catheters used in 2017 and 2018 compared to 2016 (p=0.0001). There was also a statistically significant decrease (p=0.0003) in the number of hours a catheter dwelled in the patients over the three-year period (see figure 2). • For the years 2016, 2017, and 2018, there was a statistically significant positive association (p=0.015) between catheter duration in hours and CAUTIs. However, the decrease in CAUTIs over the three years was not statistically significant (p=0.1213).

Additionally, this association between catheter duration in hours and CAUTIs did not sustain, and infection rates increased in 2019.

Practice Implications

While the cause of the decrease in CAUTI cannot be unequivocally attributed to this project due to other initiatives, such as enhanced unit director accountability and better reporting of documentation that occurred during the same time, the decrease in CAUTI in 2017 did seem to coincide with the introduction of the new products. Use of the new products was associated with a decrease in catheter use at CRMH, and this decrease in catheter use was associated with a decrease in the number of CAUTI; however, despite often having lower catheter use than our peers, CRMH continues to have a higher CAUTI rate, indicating that we still have work to do. Avoiding or decreasing duration of catheters is only one part of the bundle. In addition to continuing to assess and address needs for products to manage urine, we must ensure that all parts of the foley bundle are being followed.

References

1. Lo, E., Nicolle, L., Coffin, S., Gould, C., Maragakis, L., Meddings, J., et al. (2014). Strategies to Prevent

Catheter-Associated Urinary Tract Infections in Acute Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology, 35(5), 464-479. 2. Centers for Disease Control and Prevention. (2010, April 26). CAUTI FastFacts. Retrieved November 7, 2016, from cdc.gov: http://www.cdc.gov/hicpac/CAUTI_fastFacts.html 3. Association for Professionals in Infection Control and Epidemiology (APIC). (2014). Guide to preventing catheter-associated urinary tract infections. Retrieved from APIC Implementation Guides: http:// www.apic.org/Professional-Practice/Implementation-guides 4. Gould, C., Umscheid, C., Agarwal, R., Kuntz, G., Pegues, D., & Committee, H. I. (2009). Guideline for

Prevention of Catheter-Associated Urinary Tract Infections 2009. Retrieved April 24, 2014, from Centers for Disease Control and Prevention: http://www.cdc.gov/hicpac/pdf/CAUTI/

CAUTIguideline2009final.pdf 5. Meddings, J., Saint, S., Fowler, K. E., Gaies, E., Hickner, A., Krein, S. L., & Bernstein, S. J. (2015). The

Ann Arbor Criteria for Appropriate Urinary Catheter Use in Hospitalized Medical Patients: Results

Obtained by Using the RAND/UCLA Appropriateness Method. Annals of Internal Medicine, 162(9), S1–

S34. https://doi.org/10.7326/M14-1304 6. Bernard, M., Hunter, K., & Moore, K. (2012). A review of strategies to decrease the duration of indwelling urethral catheters and potentially reduce the incidence of catheter-associated urinary tract infections. Urologic Nursing, 32(1), 29-37. 7. Chenowith, C., & Saint, S. (2011). Urinary Tract Infections. Infectious Disease Clinics of North America, 25, 103-115. 8. Scott, R., Oman, K., Makic, M., Fink, R., Hulett, T., Braaten,

J., et al. (2014). Reducing indwelling urinary catheter use in the Emergency Department: A successful quality-improvement initiative. Journal of Emergency Nursing, 40(3), 237-244.

Figure 1. Foley Catheter Use from 2016 to 2018 at Carilion Roanoke Memorial Hospital.

Note: The Kruskal-Wallis test results (Chi-Square = 18.31, DF = 2, p=0.001) indicate that there is a statistically significant difference for Foley Count over the three years. The Dwass, Steel, Critchlow-Fligner (DSCF) multiple comparison post-hoc analysis indicates a statistically significant difference for Foley Count for 2016 compared to the counts in 2017 and 2018. However, there is no statistically significant difference in Foley Count comparing 2017 to 2018.

Figure 2. Number of Hours a Catheter Dwelled in a Carilion Roanoke Memorial Hospital Patient from 2016-2018.

Note: Over these three years there was a statistically significant decrease (p=0.0003) every year in the hours that Foleys have been used.