Children’s Hospital of Philadelphia (CHOP) has achieved a rate of zero catheter-associated urinary tract infections (CAUTIs) through the use of daily targeted rounds. The hospital has maintained that zero rate for more than one year.
An interdisciplinary team took a proactive approach to identify and address barriers to CAUTI prevention in its 55-bed pediatric ICU (PICU), says Megan Snyder, MSN, RN, ACCNS-P, CCRN, director of nursing professional practice at CHOP. The PICU was one of the highest CAUTI risks in the hospital, she says.
The CAUTI work group included an attending physician, nurse practitioner, unit-based clinical nurse specialist, unit-based safety quality specialist, clinical nurse leader, staff nurse, infection control specialist, a data analyst, and an executive sponsor. They met once or twice a month.
CHOP deployed five specific CAUTI prevention elements, achieving a compliance rate of 84% in the PICU and an overall rate of 2.7 infections per 1,000 catheter-days. All patients in the PICU had appropriate indications for catheter placement, Snyder reports.
Targeted rounds provided a systematic approach to rounding only for patients with an indwelling urinary catheter, Snyder explains.
Originally, the PICU CAUTI team leader conducted these daily targeted rounds, but the task proved to be too much for one person. CHOP assigned each clinical member a day to conduct rounds each week.
“One of the biggest things we noticed from our data was that those patients at some of the highest risk for CAUTI were those who had had a catheter, and then we removed it but then they weren’t voiding on their own, so we replaced the catheter,” Snyder says. “They made up half of the CAUTIs. We would round and talk to the nurses about all the patients who had catheters. If they thought the catheter was coming out, we would talk about tips and things they could do to keep the catheter out.” Those options include medications, straight catheters, and bladder scanning.
Rounding for Bundle Compliance
During rounds, the team member checks for bundle compliance. The team member also can conduct real-time training to address any issues immediately, Snyder says.
The CAUTI team also developed a data review dashboard with information from the electronic health record and other sources to track bundle compliance and access bedside review data. Anyone in the facility can review compliance data, identify trends, and see harm metrics in real time.
Bundle compliance in the PICU increased steadily, but avoiding dependent loops in the drainage tubing was consistently identified as an area for improvement. The CAUTI team focused more on compliance; with that element, overall compliance rates improved.
The unit’s overall CAUTI rate had been 2.7 infections per 1,000 catheter-days, but the daily targeted rounds sustained a rate of zero CAUTIs for longer than a year, Snyder says. “Often, the nurses were busy in the PICU, so we would take the conversation to the bedside where the nurse was caring for the patient rather than expecting that nurse to come to where we were meeting with other nurses,” Snyder says. “Sometimes, taking little things off the plate made it easier to get the results we wanted. Our team approach gave us enough team members to be able to take that kind of approach.”
Snyder notes the team benefited from significant buy-in from physician leaders. One of the medical directors for the PICU sat on the CAUTI work group and participated with rounds, along with a nurse provider. “We had good cross representation from the provider side and the nursing side, which really helped move the needle. If we had any issues, we could use our team to navigate from both of those angles,” Snyder says.
Pics Help With Loop Issue
One of the biggest challenges involved the dependent loop, in which the drainage tubing creates a U shape that leads to urine stasis and can promote urinary infection. Snyder says the team had to focus specifically on that issue because it had not been addressed well in previous CAUTI prevention efforts.
“They didn’t know what we meant until we showed them pictures of what it normally looks like and how to fix it. That was a gamechanger when we illustrated it like that and it clicked for them,” Snyder says. “For our pediatric patients, we usually keep their beds in the lowest position. A lot of the urinary catheter drainage bags are made to accommodate the adult population, so we had to look at altering the way we did things to better suit our patients.”
Snyder notes that after the year of zero CAUTIs, there was an uptick. An investigation revealed the hospital had brought in a trial product to manage catheterization in a different way. The increase in CAUTIs directly correlated with that trial. The hospital stopped using the trial product, and the CAUTI rate fell again.
There was another blip in infection rates when Snyder left her role in the PICU for her current position at the hospital. Staff were less diligent about rounding without her leadership, but infections declined when the rounding was reinforced.
In fiscal 2020, which started Oct. 1, 2019, the PICU has logged three months without an infection and two months so far with one infection per month, Snyder reports.
“We’ve had stumbles but no spikes like we’ve had in the past. We’re trying to keep those numbers as low as possible. The good news is that even when we have a small increase, we can trace it to a specific deficiency, which just reconfirms that our practices work,” Snyder says. “Reinvigorating the staff by reminding them what good results we achieved with such little effort and low cost makes them want to sustain that progress.”
- Snyder MD, Priestley MA, Weiss M, et al. Preventing catheter-associated urinary tract infections in the pediatric intensive care unit. Crit Care Nurse 2020;40:e12-e17.
- Megan Snyder, MSN, RN, ACCNS-P, CCRN, Director, Nursing Professional Practice, Critical Care Nursing, Children’s Hospital of Philadelphia. Phone: (267) 426-5968. Email: firstname.lastname@example.org.