Empowering the Clinical Bedside Nurse: Using a Nurse-Driven Protocol to Decrease Rate of Catheter-Associated Urinary Tract Infections

Purpose:
In 2012, despite a 3 year, multi-modal, interdepartmental effort to decrease indwelling urinary catheter associated urinary tract infections (CAUTIs), initial improvements threatened to stagnate without Nursing empowerment & ownership. The goal was to decrease CAUTIs by 50% over prior years.

Relevance/Significance:
Hospital acquired urinary tract infections account for approximately 30% of all hospital acquired infections with >75% associated with instrumentation of the urinary tract i.e. indwelling catheters. These infections can lead to complications such as prostatitis, cystitis, pyelonephritis, bacteremia, endocarditis, & meningitis. These complications are associated with discomfort to the patient, increased morbidity, mortality, prolonged length of hospital stay and increased cost.

Strategy and Implementation:
Using the Plan, Do, Study, Act methodology, a multi-disciplinary team researched criteria for insertion, maintenance and removal based upon recommendations from professional organizations (SHEA & Agency for Healthcare Research & Quality-AHRQ). A process flow was developed to guide the clinical RN in the needs assessment for an indwelling urinary catheter. The use of physician order sets including an order to remove the catheter within 48 hours of insertion empowered the RN to remove the catheter in a timely fashion. The success of implementation was monitored through concurrent review by a clinical RN which provided supportive “Just in Time” education for both the nursing and physician staff. After protocol implementation, the data was reviewed which revealed that a process flow for the use of bladder scanner to reduce catheter reinsertion would be beneficial. The focus on catheter removal was identified as a clinical priority in the organization's Performance Improvement plan.

Evaluation:
The data showed over the course of 24 months that a nurse driven indwelling urinary catheter discontinuation protocol was successful in decreasing the incidence of CAUTI by >97% with a concomitent reduction in Urinary Catheter Utilization >40%.

Implications for Practice:
The empowerment of the clinical bedside nurse is pivotal to the success of this initiative. The implementation of a concurrent review process conducted by an RN ensured ongoing compliance & a process to monitor for the inevitable “drift” that occurs after time and changes in staff members.