Not everyone was pleased with the provocative acronym, but an infection preventionist’s “Why the Foley?” campaign captured attention and dramatically reduced catheter-associated urinary tract infections (CAUTIs).

Cassandra Mueller, MSN, RN, CNL, an IP at Boone Hospital Center in Columbia, MO, described the findings recently in Minneapolis at the annual conference of the Association for Professionals in Infection Control and Epidemiology.

“Most of the UTIs in the hospital are caused by a Foley catheter,” she said.

“Prolonged use of a urinary catheter is the most important risk for developing a UTI, and for every day a patient has a catheter the risk increases.”

CAUTI prolongs the patient length of stay, adding about 2.5 days before discharge. The average increased cost is about $800 a patient, she said.

Mueller reminded attendees that while once considered benign or nuisance infections, CAUTIs have a 2% mortality rate, with approximately 13,000 patient deaths annually.

CAUTIs increased at Boone Hospital in 2015, resulting in “financial penalties across multiple pay-for-performance programs,” she said.

A CAUTI Task Force was formed that included IPs, quality, leadership, nurses, and physicians. The goal was to reduce the CAUTI rate through a series of interventions.

Interventions

The first step was conducting a hospitalwide assessment of urinary catheter insertion and maintenance, she said. A common finding was some break in the insertion process, usually due to a failure to maintain aseptic technique.

To address these problems and standardize the process, a checklist was created for catheter insertion, which one nurse checked down while another was inserting the catheter.

“When a nurse was inserting a catheter, another nurse was in the room with them and following a standardized checklist,” Mueller said.

“That was to make sure no one missed a step during insertion. We kind of held everybody accountable.”

Likewise, infection preventionists became involved in the training of new nurses. “Another IP and I went to the nurse preceptor and the nurse resident classes and did hands-on catheter insertion and maintenance training,” she says.

The IPs also participated in multidisciplinary rounds in the ICU to raise awareness of the CAUTI prevention program. The WTF term was rolled out, encouraging staff, through posters and messaging from a task force, to daily question the need for a Foley.

“Not everyone embraced the WTF concept — I can’t imagine why,” Mueller said. “But it got their attention.”

For example, Mueller sent out email updates on the campaign, putting “WTF” in the subject line in communications that included hospital administration.

“People were like, ‘what?’ she said. “But they paid attention to my emails, and that’s what we wanted. We wanted people to think about this, and it worked. We called it ‘WTF’ to get attention.”

Patient brochures on preventing CAUTIs were included in all admissions packages. There were activities to promote compliance, including a reward system for appropriate removal of a catheter.

“They would call me every time they took one out,” Mueller said. “I confirmed it was documented and then they would get a ticket. When they got four tickets, they got a gift card.”

An 80% Drop

As the program set in, positive results followed, including four months without a CAUTI at one point.

That called for a celebration, so Mueller’s team ordered 450 cookies, telling the baker to put “WTF” on every one of them. Thinking that must be a mistake, the bakery put “WTS” on the cookies instead.

“We thought it was funny when we went to pick them up,” she said. “But the bakery scraped off the ‘S’ and put the ‘F’ on the cookies. The staff got a kick out of that and loved the cookies.”

In another attention-grabber that drew some strange looks, Mueller and colleagues made hanging art “mobiles” out of bed pans and urinals and hung them from the ceiling in a physician dining area.

“All of these were things we did to promote catheter utilization and CAUTI prevention,” Mueller said.

As a result, the Standardized Infection Ratio for CAUTI fell by 80% from the preimplementation period (January 2016 - September 2016) to the postimplementation (October 2016 - September 2017).

In the category of obstacles and lessons learned, nurses were hesitant to remove catheters without alerting physicians, Mueller said. They were empowered to do so if the Foley met certain criteria, but that aspect remains a work in progress.

“That wasn’t new,” she said. “Nurses sometime just don’t feel comfortable taking out the catheter without asking the physicians. This is a constant hurdle we are trying to overcome. It was difficult to change established beliefs and behaviors.”

Some experienced NICU nurses balked at the requirement to have an observer present when inserting a catheter.

“I get it — I’m a nurse,” Mueller said. “They said, ‘We know how to put in a catheter; we don’t need someone watching us.’ We just tried to reiterate that it was because we want to standardize how we do it. It’s not that you don’t know how to do it.”