Nurse-Driven Quality Improvements Cut ICU CAUTI Rates

UPMC Williamsport used a bundled approach to prevent catheter-associated urinary tract infections.

A Pennsylvania hospital's quality improvement initiative led to a rapid turnaround in catheter-associated urinary tract infections (CAUTIs) and a sustained approach to preventing healthcare-associated infections.

Hospital-acquired CAUTIs are the second most common healthcare-associated infection, according to the U.S. Centers for Disease Control and Prevention (CDC), occurring most frequently in intensive care units (ICUs). They are preventable events that can lead to poor patient outcomes and higher healthcare costs.

UPMC Williamsport, part of the University of Pittsburgh Medical Center (UPMC) Susquehanna health system, reported 13 CAUTI events in 2018, far exceeding its benchmark of four or fewer such infections annually. Six of the infections occurred in the ICU of the 224-bed rural regional medical center in north central Pennsylvania.

UPMC Williamsport responded by establishing a CAUTI reduction task force, which developed a quality improvement initiative with both education and practice-related interventions.

The multifaceted approach quickly reduced CAUTI rates and paved the way for hospital-wide implementation with long-term impact.

A Bundle-Based Approach to Prevent Catheter-Associated Urinary Tract Infection in the Intensive Care Unit, which appears in April's issue of Critical Care Nurse, reviews the components of the initiative and simple strategies that helped maximize their impact.

'Direct and efficient' interventions

During the four-month intervention period covered in the study, the ICU had no reported CAUTI events, compared with two CAUTI events during the pre-intervention period. In addition, the CAUTI incident rate decreased by 1.33 per 1,000 catheter days. Total catheter days increased by 10.5% from the pre-intervention period, which may be attributed to higher ICU admissions and a higher device utilization ratio during the intervention period, according to the study.

"One of the strengths of this initiative was the overall simplicity of the interventions," co-author Holly Shadle, DNP, CRNP, FNP-BC, a nurse practitioner in the neurosurgery department, Neuroscience Center at UPMC Susquehanna, said in a press release. "These interventions were direct and efficient, with few direct costs or necessary equipment, making the process easily adaptable for hospital-wide use."

The educational portion of the initiative began with all ICU nurses participating in module-based didactic training on each component of indwelling catheter care, followed by hands-on skill and competency sessions.

Another element of the bundle involved indwelling catheter-related documentation and orders, including a daily checklist and a nurse-driven removal protocol for discontinuing catheter use, according to the release.

The electronic checklist used drop-down features for all responses, except for the catheter insertion date, to prevent free-text responses and typos. A completed checklist was required each night for every room in the ICU—even those without patients or with patients who didn't have indwelling urinary catheters.

Program adapted hospital-wide

Documentation compliance increased significantly, from 50% before the interventions to 83.3% during the interventions, the study says.

Because of the project's success, the newly formed CAUTI quality assurance and performance improvement team began adapting the program for hospital-wide implementation.

Additionally, the informatics department began integrating a version of the daily checklist into the electronic health record.