By Dyana C. Williams, MBA, MSN, RN, CNOR
The reporting of any type of healthcare-associated infection (HAI) is difficult. First, it indicates our patients have experienced a complication. Second, for an acute-care facility, we consistently have a low denominator; therefore any HAI has a significant impact on an infection rate that is publically reportable. This hospital was pleased to report an infection rate of zero for catheter associated urinary tract infections (CAUTIs) for more than two years. Unfortunately, in 2015, three of our patients experienced a CAUTI which dramatically increased the reported infection rate and raised important concerns. Urinary tract infections are the most common type of HAI reported to the National Healthcare Safety Network, with more than 75 percent of those UTIs being catheter associated. The literature tells us that the impact of these infections includes increased length of stay, increased costs, unnecessary antimicrobial use, and is the leading cause of secondary bloodstream infections which results in increased mortality rates. Determining the cause for the increase in infections experienced at this facility and developing strategies to decrease these HAIs became a priority.
The infection preventionist (IP) and leadership decided to take a deeper look into the increase of CAUTIs by examining current practices of the nursing staff and evaluating their knowledge of care and maintenance of catheters, proper insertion techniques, and prevention of CAUTI. In order to maximize resources, the IP partnered with a large vendor to conduct several assessments. First, we completed a gap analysis on all in-patient units as well as in the emergency room and outpatient areas to obtain an understanding of the current practices. Utilizing a data collection tool provide by the vendor, the IP performed the gap analysis by rounding on every patient with an indwelling catheter. Components examined included type of catheter used, placement of the Foley bag (below level of the bladder and not touching the floor), documentation of date and time of insertion noted on collection bag, use of a securement device and location of that device, integrity of the tamper evidence seal, and for any evidence of looping.
Continuing to partner with the vendor, the team conducted a house-wide insertion assessment in a simulation environment in order to evaluate practice techniques and to determine if any variations existed. Using anatomically correct models, two to three nurses from all nursing units were observed performing an insertion task and were evaluated in areas such as hand hygiene prior to insertion, aseptic technique, maintaining a sterile field, performing peri-care, prep of patient, and steps needed to perform insertion. Upon collection of these data, the information was shared with the vendor who prepared a customized report based on the gap analysis and insertion assessment. Next, materials management and the IP completed an inventory of the catheter trays and supplies available to the nursing staff.
During the gap analysis, the team examined our catheter line days and insertion location. Forty-three percent of the indwelling catheters present at our facility have a duration of four to six days. We did discover that a high percentage of catheters, 29 percent, have a duration of ten days or greater. The greatest risk factor for developing a CAUTI is prolonged duration of the urinary catheter and we knew this was a finding that needed attention. Insertion location was evenly distributed with 29 percent of catheters being placed in the emergency department, med/surg unit and critical care. Fourteen percent of catheters at this facility are present on admission. The gap analysis also revealed that there was excellent compliance with maintaining the integrity of the tamper evidence seal with 100 percent of the seals intact on the day of observation. Other findings included that securement devices were only utilized 57 percent of the time; 86 percent of the catheters in place that day had a loop or kink present in the drainage tubing; and only 14 percent of the drainage bags were dated and timed.
The insertion assessment revealed many opportunities for improvement as well. Out of 110 aseptic opportunities, 45 breaks in aseptic technique were observed. Other results revealed that 80 percent of the time peri-care was omitted, the integrity of the sterile field was contaminated 70 per-cent of the time, and 20 percent of the time contamination occurred with donning of sterile gloves. When evaluating how well the nurses per-formed the catheterization procedure as specified by the directions for use (DFU), 30 percent either omitted or incorrectly performed the steps.
Regarding standardization of the catheter supplies, we identified that multiple products were available for use house-wide.
Armed with the results of gap analysis and insertion assessment as well as the product examination, the IP assembled the chief nursing officer, unit directors and all the co-chairs of the shared governance councils to the table for dissemination of our results. Understanding multiple opportunities for improvement existed; an action plan was developed and immediately implemented. CAUTI champions were designated on each unit with the help of the shared governance councils. Utilizing the time set aside for council meetings one month, the champions were provided extensive education on care, maintenance, insertion, and prevention. Return demonstration for proper insertion was required of the champions who were then tasked with educating and determining competency of the remaining nurses on their respective units. All nurses completed a combination of didactic and hands on education. Feedback from nursing staff and surveillance and reporting of any infections remains ongoing. In addition, we completed a clean-up and conversion to one product to ensure standardization and to remove some gaps in practice.
It was important to this facility’s IP and leadership to capture the nursing staffs’ attention regarding the rising infection rate. Determining how to engage the staff in learning and in valuing personal practice was needed in order to overcome the complacency observed in the reporting of the few CAUTIs experienced. Reiterating that one infection is too many and re-enforcing the aim for zero goal was critical to maintaining a culture focused on prevention. An in-depth evaluation into the nursing staff's skills and practice allowed leadership to identify what education and tools they needed in order to provide safe and efficient care. The nursing staff welcomed the assessments and is fully invested in prevention strategies. Since the product conversion, extensive education and skills demonstrations, no CAUTIs have been reported.
Dyana C. Williams, MBA, MSN, RN, CNOR, is an infection preventionist at LewisGale Hospital Montgomery.