Professional Nursing Practice Beyond the Toolkit: How enculturating human factors influences sustained CAUTI reduction

Purpose:
Application of nurse-driven catheter-care and catheter-removal protocols have transformed care practices related to catheter-associated urinary tract infections (CAUTIs). The purpose of this initiative was moving beyond protocols to enculturate human factors to sustain/further improve CAUTI rates.

Relevance/Significance:
Urinary tract infection (UTI) is the most common healthcare-associated infection with an estimated 13,000 associated deaths and cost of $1,000/occurrence. More than a quarter of patients who have an indwelling urinary catheter for 2-10 days will develop bacteriuria, and 25% of these will develop a CAUTI. This project describes the impact of enculturating human factors in evidence-based, interprofessional, patient-centered care for sustained CAUTI reduction.

Strategy and Implementation:
After eliminating ICU CAUTIs for 399 days, in 2014 quarter 1, CAUTI clusters were noted in Surgical/Transplant and ICU - units sharing a high-risk population with extended catheter use. Analysis identified characteristics influencing CAUTI risk: obesity, immobility, incontinence, and liver encephalopathy. New interventions cued staff to high-risk patients with specific whiteboard notes. Crucial to successful sustained CAUTI reduction were human factors: personal interaction and structured conversation. The catheter-removal protocol was used as a foundation to direct interventions: intentional assessment of catheter need and pursuit of catheter removal. Nurse awareness was enculturated through implementation of daily CNS rounding, deliberate direct nurse conversations, and collegial provider dialogues. Trusting physician partnerships were enhanced with interdisciplinary rounds, checklist-scripted collaborative conversations, and adjusted EMR documentation to support catheter removal.

Evaluation:
Catheter days have remained stable for the past 15 months. In 2014 quarter 1, the Surgical/Transplant unit had a spike of 3 CAUTIs. Following initiative interventions CAUTIs were reduced to 0 for the next 10 months (to Feb 2015). Surgical/Transplant CAUTI rate was reduced from 7.85 to 0/1,000 catheter days. ICU CAUTI rate decreased from 3.36 to .93/1,000 catheter days.

Implications for Practice:
In this era of computerized documentation & standardized care, nurse-driven protocols & patient outcomes are enhanced by purposeful use of human factors: intentional conversations, awareness, & collaboration. The value of these interventions is through enculturation of professional nursing autonomy.