2021 Annual Conference

CNS Improving Outcomes

Purpose

The use of indwelling urinary catheters predisposes a patient to a catheter associated urinary infection (CAUTI). The estimated average excess cost for care is $13,793. From January – June of 2019, the NSICU had a total of 7 patients harmed with a CAUTI. Historically, the unit has seen an average of 1 CAUTI per month. Compared with other critical care units within the organization, NSICU had a significantly higher rate of infection and catheter utilization. The purpose of this quality improvement project was to develop evidence-based practice strategies to decrease the utilization of urinary catheters by 10% and reduce the rate of CAUTI by 50% within 3 months.

PICO Question/Aim Statement

In adult neuroscience intensive care unit patients, does use of a ‘mindfulness’ guideline for indwelling urinary catheters, compared to standard of practice, result in a reduction of utilization of urinary catheters and rate of CAUTI?

Evaluation of the Literature

Analysis of all infections found urinary catheters were utilized without clinical need, urine cultures were being ordered frequently for isolated fevers, cultures were being obtained from catheters that had been indwelling for several days, and frequent occurrence of fecal incontinence which could lead to contamination of the catheter.

A review of the literature was done to search for recent evidence. The Agency of Healthcare Research and Quality (AHRQ) evidence-based guidelines and toolkit was used to guide practice change. Recommendations from these guidelines include reducing unnecessary insertion, avoidance of random urine culturing, and recommendations for care and maintenance.

 Methodology/Implementation

A team was established that included Advanced Practice Registered Nurses and bedside clinical nurses. A new guideline was developed that included “mindfulness” prior to ordering insertion, avoiding reactive urine cultures for isolated fevers, alcohol caps on sampling ports, and increased catheter care to every 4 hours using hospital supplied castile soap wipes. Urine cultures were no longer obtained from any catheter that was > 48 hours due to the increased risk of biofilm.

 Evaluation Measures

Infection Prevention reports for catheter utilization and CAUTI were monitored monthly. Bedside audits were done by the leadership team daily on all patients with a urinary catheter to provide real time coaching.

 Outcome

The unit met the goal for utilization within 3 months and has maintained utilization below the national mean. There has been 100% reduction in CAUTI since implementation with an estimated cost saving of $165,516. A zero CAUTI rate has been sustained for over 300 consecutive days.

Discussion

Reducing utilization and CAUTI is a mission that requires collaborative work with providers who prescribe urinary catheters and clinical nurses who care for them. In NSICU, a team of Nurse Practitioners manages patients under supervision of the Intensivist. The role of the Clinical Nurse Specialist leading collaborative efforts between these two nursing roles, reviewing the literature and implementing new standards has led to a successful quality improvement project and improved patient outcomes.