New Jersey hospital pushing CAUTIs to zero
Catheter use shows steep decline
After expanding a successful initiative to cut catheter-associated urinary tract infections (CAUTI) rates, a New Jersey hospital’s catheter days and CAUTIs were cut in half.
East Orange (NJ) General Hospital had already achieved a zero CAUTI rate on its unit that previously had the highest rate of infections. There have been no CAUTIs on that unit since the project was implemented several years ago.
In late 2013, the hospital expanded the CAUTI prevention program to all med-surg units, producing these results, comparing the first six months of 2013 with the first six months of 2014:
- CAUTIs went from four to two;
- Total catheter days went from 3,609 from January to June, 2013, to 1,783 from January to June, 2014;
- The number of patients receiving catheters dropped from 620 in 2013 to 336 in 2014;
- The number of catheter days per patient declined from 5.82 to 5.31.
The hospital’s CAUTI initiative followed the lead of the Hospital Engagement Network (HEN) and the New Jersey Hospital Association, says Mary Anne Marra, BNP, MSN, RN, vice president and chief nursing officer at East Orange General Hospital.
HEN has promoted the On the CUSP: Stop CAUTI project of the Agency for Healthcare Research and Quality (AHRQ).
The first steps in the project were to form teams, identify team leaders, and select the med-surg unit with the highest CAUTI level for the pilot initiative, Marra says.
"All team members first were educated, and when they implemented the initiative they did a lot of education with the staff on the unit," Marra says.
Other changes included having daily Foley rounds, performed by the clinical coordinator and infection control nurses.
"They would see if patients met the criteria for having a Foley catheter," Marra says. "The hospital also changed policies and procedures to require a urine culture after two weeks, and the Foley catheter was changed at two weeks."
Stickers were put on Foley bags. They listed the reason for having the Foley and the date it was to be changed.
"We changed criteria for insertion of the Foley and for maintenance," Marra says. "We made sure patients who had a Foley needed to have a Foley, and if not, the catheter was discontinued."
The policy changes included recommending that Foley catheters be discontinued within 24 to 48 hours post-surgery. A physician’s order is required to continue the catheter, she says.
The hospital gave nurses the authority to discontinue a Foley catheter without a physician’s order, she adds.
Criteria for inserting and retaining a catheter included:
- If a patient needed strict input and output;
- If a patient had stage 3 or 4 sacral pressure ulcer;
- If the patient’s bladder had an output obstruction;
- If the patient was post-surgery and the surgery required the patient to have a Foley, such as a urological procedure; and
- If the patient was at the end of life care and it was deemed the patient would be more com-fortable with a Foley.
The hospital has not incorporated the CAUTI program policies into an electronic health record, but written reminders are placed on patient charts within 24-48 hours of admission, Marra says.
"We incorporate the written orders in the hand-off of shift so every time nurses change they will know how long the Foley was in," she explains.
"They added Foley care and CAUTI initiatives in the annual nursing competency," she adds.
IP input on cause of CAUTIs
Compliance has improved since the program was initiated, but it requires having an infection preventionist available to answer questions, doing ongoing staff training, engaging support from nurse champions, holding the Foley rounds, and providing compliance follow-up, Marra says.
"Every time we have an infection we do a post-analysis and have a detailed discussion with the infection control committee," Marra says. "It’s reviewed by the infection preventionist, and if it’s not clear to the preventionist what was the cause of the CAUTI, then an infectious disease doctor also will review the case."
One of the lessons learned during the project was that the emergency room needed to be included in the pilot, Marra says.
Also, the new protocol called for having the Foley catheter changed when a new patient arrived from another facility, and this change took a while for staff to adopt, she notes.
There were other issues related to staff adapting to the protocol changes, but over time the behavioral changes took place, she adds.Nurses now are less hesitant to remove catheters without physician orders.
"They know they are supported by the organization, the administration, and by this team," Marra says. "What we’ve achieved in overall numbers in Foley catheter days shows there definitely has been a change here with the nurses: we don’t use as many Foleys, and so there is less opportunity for catheter-associated urinary tract infections."