Urinary catheter use and appropriateness in U.S. emergency departments, 1995-2010

Inappropriate urinary catheterisation: a review of the prevalence, risk factors and measures to reduce incidence

Urinary tract infections (UTIs) comprise the second most common type of healthcare-associated infections, with up to 80% of UTIs caused by indwelling urinary catheters. Current research suggests that the best way to prevent catheter-associated UTIs (CAUTIs) is to reduce unnecessary catheterisation. Few reviews have focused on the prevalence, risk factors and preventive measures for inappropriate catheterisation. This article, consequently, sought to evaluate the current evidence on the prevalence, risk factors and measures that can be taken to prevent inappropriate urinary catheterisation.

Journal club: "Racial disparities in catheter related urinary tract infections among elderly trauma patients in the US"

In this article for Journal Club commentary entitled "Racial Disparities in Catheter Related Urinary Tract Infections Among Elderly Trauma Patients in the US", Keneally et al, conducted a study with the goal of assessing the role of social disparities in catheter associated urinary tract infections (CAUTIs). This cross-sectional study utilized secondary data to determine the possible CAUTI risk in ventilated, older (≥ 65 years of age) trauma patients exploring possible racial structural bias in healthcare. The analysis addressed the following questions in this specific population:While this study does consider race and discusses structural biases, which are important and sparsely researched in healthcare-associated infection (HAI) outcomes, the practice implementations are somewhat limited due to study design and analysis. Therefore, the focus of this Journal Club commentary will be reviewing basic steps Infection Preventionists (IPs) can take to critically appraise the literature for application in their facility's patient population.

Impact of an evidence-based intervention on urinary catheter utilization, associated process indicators, and infectious and non-infectious outcomes

BACKGROUND

Multi-centre intervention studies tackling urinary catheterization and its infectious and non-infectious complications are lacking.

AIM

To decrease urinary catheterization and, consequently, catheter-associated urinary tract infections (CAUTIs) and non-infectious complications.

METHODS

Before/after non-randomized multi-centre intervention study in seven hospitals in Switzerland. Intervention bundle consisting of: (1) a concise list of indications for urinary catheterization; (2) daily evaluation of the need for ongoing catheterization; and (3) education on proper insertion and maintenance of urinary catheters. The primary outcome was urinary catheter utilization. Secondary outcomes were CAUTIs, non-infectious complications and process indicators (proportion of indicated catheters and frequency of catheter evaluation).

FINDINGS

In total, 25,880 patients were included in this study [13,171 at baseline (August-October 2016) and 12,709 post intervention (August-October 2017)]. Catheter utilization decreased from 23.7% to 21.0% (P=0.001), and catheter-days per 100 patient-days decreased from 17.4 to 13.5 (P=0.167). CAUTIs remained stable at a low level with 0.02 infections per 100 patient-days (baseline) and 0.02 infections (post intervention) (P=0.98). Measuring infections per 1000 catheter-days, the rate was 1.02 (baseline) and 1.33 (post intervention) (P=0.60). Non-infectious complications decreased significantly, from 0.79 to 0.56 events per 100 patient-days (P<0.001), and from 39.4 to 35.4 events per 1000 catheter-days (P=0.23). Indicated catheters increased from 74.5% to 90.0% (P<0.001). Re-evaluations increased from 168 to 624 per 1000 catheter-days (P<0.001).

CONCLUSION

A straightforward bundle of three evidence-based measures reduced catheter utilization and non-infectious complications, whereas the proportion of indicated urinary catheters and daily evaluations increased. The CAUTI rate remained unchanged, albeit at a very low level.

Prevalence and risk factors of inappropriate use of intravenous and urinary catheters in surgical and medical patients

BACKGROUND

Previously, the RICAT (Reduction of Inappropriate use of intravenous and urinary CATheters) study had been conducted by ourselves to reduce inappropriate use of intravenous and urinary catheters in medical wards to prevent healthcare-associated infections.

AIM

To compare surgical and medical wards, and to determine risk factors for inappropriate catheter use.

METHODS

A cross-sectional study was performed from October, 2017, to May, 2018, in surgical wards of two university hospitals in the Netherlands. Patients were prospectively observed every other week for seven months. Inappropriate use was compared with non-surgical wards in the RICAT study.

FINDINGS

In all, 409 surgical patients were included, and they were compared with 1781 medical patients. Inappropriate use occurred in 36 (8.5%) out of 425 peripheral intravenous catheters in 373 surgical patients, compared to 400 (22.9%) out of 1747 peripheral intravenous catheters in 1665 medical patients, a difference of 14.4% (95% confidence interval (CI): 11.1-17.8; P < 0.001). Inappropriate use of urinary catheters occurred in 14 (10.4%) out of 134 surgical patients, compared to 105 (32.4%) out of 324 medical patients, a difference of 22.0% (95% CI: 14.7-29.2; P < 0.001). Subgroup analysis in the two university hospitals confirmed these differences. The main risk factor for inappropriate use of peripheral intravenous catheters was admission in medical wards (odds ratio (OR): 3.50; 95% CI: 2.15-5.69), which was also one of the main risk factors for urinary catheters (OR: 2.75; 95% CI: 1.36-5.55).

CONCLUSION

Inappropriate use of catheters is more common in medical wards compared to surgical wards. Prevention strategies to reduce healthcare-associated infections should primarily focus on sites with high prevalence of inappropriate use.

Variations in indwelling urinary catheter use in four Australian acute care hospitals

AIMS AND OBJECTIVES

To identify the point prevalence of indwelling urinary catheters (IDCs) in adult inpatients in acute care hospitals, and to describe the indications for IDC insertion based on patient age, gender, specialty and hospital.

BACKGROUND

Catheter-associated urinary tract infections (CAUTIs) are preventable healthcare-associated infections. IDC duration is the strongest predictor of CAUTI, and little is known about characteristics of patients who receive an IDC.

DESIGN

Two single-day point prevalence surveys collected baseline patient data as part of a larger pre-post control-intervention study.

METHODS

Surveys were conducted at four acute care hospitals in NSW, Australia, for all adult patients. Data collection included IDC presence, insertion details and urine culture collection. Point prevalence data were linked with electronically extracted patient demographic data. This study is presented in line with STROBE checklist (See Supplementary File 1).

RESULT

Data from 1,630 patients were analysed, with 196 patients (12%) identified as having an IDC on the survey dates. IDC prevalence rates were higher in males (13%) than in females (11%). Critical care had the highest rate of patients with IDCs (42%). Urine cultures were collected in 70 patients with an IDC (43%).

CONCLUSIONS

Findings indicated similar rates of IDC use in males and females, and there was no significant difference in age between patients with or without an IDC. However, indication for IDC varied by patient age and gender. High rates of urine culture collection may represent routine collection.

RELEVANCE TO CLINICAL PRACTICE

IDC use is found across genders, all age groups and specialties. Nurses should be aware that any of their patients may have an IDC and be particularly aware of certain indications based on patient age and gender. Routine urine culture collection is not advised, and instead, nurses should be guided by clinical decision-making tools.

Patients knowledge and experience with urinary and peripheral intravenous catheters

Purpose

Inappropriate use of urinary and intravenous catheters is still frequent. The use of catheters is associated with some serious complications, such as health care associated infections (HAIs). An efficient way to reduce HAIs is to avoid inappropriate use of catheters, but the role for patients in quality improvement initiatives is unclear. The aim of this study is to investigate patients knowledge and experience with catheters, to design patient interventions to reduce inappropriate catheter use.

Methods

We assessed patient’s knowledge and experience with catheters using a self report questionnaire, and included patients with a urinary and/or peripheral intravenous catheter (PIVC) during the baseline measurements of a quality improvement project to reduce inappropriate catheters use.

Results

A total number of 82 patients completed the questionnaire, of which 49 had a urinary catheter and 72 a PIVC. Patients were unaware about the indication for their urinary catheter in 20.9% and PIVC in 19.5%. Nevertheless, 65.3% reported symptoms due to urinary catheters and 37.5% for PIVCs. Interestingly, only 25.5% and 22.4% reported that they would ask their doctor if the catheter could be removed.

Conclusions

There is a lack of knowledge about the indication for having a urinary and peripheral intravenous catheter in a substantial part of patients. Although catheters cause symptoms, patients in general do not ask if the catheter could be removed. Doctors should give more information and ask more questions about catheters to their patients. Quality improvement initiatives stimulating patients to actively participate in their treatment are needed.

Electronic supplementary material

The online version of this article (10.1007/s00345-018-02623-4) contains supplementary material, which is available to authorized users.

Antimicrobial Stewardship in the Emergency Department

The emergency department (ED) is the hub of the US health care system. Acute infectious diseases are frequently encountered in the ED setting, making this a critical setting for antimicrobial stewardship efforts. Systems level and behavioral stewardship interventions have demonstrated success in the ED setting but successful implementation depends on institutional support and the presence of a physician champion. Antimicrobial stewardship efforts in the ED should target high-impact areas: antibiotic prescribing for nonindicated respiratory tract conditions, such as bronchitis and sinusitis; overtreatment of asymptomatic bacteriuria; and using two antibiotics (double coverage) for uncomplicated cases of cellulitis or abscess.

Prediction of Acute Kidney Injury With a Machine Learning Algorithm Using Electronic Health Record Data

Background

A major problem in treating acute kidney injury (AKI) is that clinical criteria for recognition are markers of established kidney damage or impaired function; treatment before such damage manifests is desirable. Clinicians could intervene during what may be a crucial stage for preventing permanent kidney injury if patients with incipient AKI and those at high risk of developing AKI could be identified.

Objective

In this study, we evaluate a machine learning algorithm for early detection and prediction of AKI.

Design

We used a machine learning technique, boosted ensembles of decision trees, to train an AKI prediction tool on retrospective data taken from more than 300 000 inpatient encounters.

Setting

Data were collected from inpatient wards at Stanford Medical Center and intensive care unit patients at Beth Israel Deaconess Medical Center.

Patients

Patients older than the age of 18 whose hospital stays lasted between 5 and 1000 hours and who had at least one documented measurement of heart rate, respiratory rate, temperature, serum creatinine (SCr), and Glasgow Coma Scale (GCS).

Measurements

We tested the algorithm's ability to detect AKI at onset and to predict AKI 12, 24, 48, and 72 hours before onset.

Methods

We tested AKI detection and prediction using the National Health Service (NHS) England AKI Algorithm as a gold standard. We additionally tested the algorithm's ability to detect AKI as defined by the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. We compared the algorithm's 3-fold cross-validation performance to the Sequential Organ Failure Assessment (SOFA) score for AKI identification in terms of area under the receiver operating characteristic (AUROC).

Results

The algorithm demonstrated high AUROC for detecting and predicting NHS-defined AKI at all tested time points. The algorithm achieves AUROC of 0.872 (95% confidence interval [CI], 0.867-0.878) for AKI detection at time of onset. For prediction 12 hours before onset, the algorithm achieves an AUROC of 0.800 (95% CI, 0.792-0.809). For 24-hour predictions, the algorithm achieves AUROC of 0.795 (95% CI, 0.785-0.804). For 48-hour and 72-hour predictions, the algorithm achieves AUROC values of 0.761 (95% CI, 0.753-0.768) and 0.728 (95% CI, 0.719-0.737), respectively.

Limitations

Because of the retrospective nature of this study, we cannot draw any conclusions about the impact the algorithm's predictions will have on patient outcomes in a clinical setting.

Conclusions

The results of these experiments suggest that a machine learning-based AKI prediction tool may offer important prognostic capabilities for determining which patients are likely to suffer AKI, potentially allowing clinicians to intervene before kidney damage manifests.

Routine Indwelling Urethral Catheterization in Acute Heart Failure Patients Is Associated With Increased Urinary Tract Complications Without Improved Heart Failure Outcomes

BACKGROUND

Indwelling urethral catheters (IUC) are routinely inserted for the purpose of monitoring urine output in patients with acute heart failure (AHF). The benefit of IUC in patients capable of complying with urine collection protocols is unclear, and IUC carry multiple risks. This study describes the impact of IUC on AHF treatment.Methods and Results:A total of 540 records were retrospectively analyzed. After exclusion criteria were applied, 316 patients were propensity matched to establish groups of 100 AHF patients who either did (IUC(+)) or did not receive an IUC (IUC(-)) upon admission. Hospital length of stay (9 vs. 7 days), in-hospital urinary complications (24 vs. 5%), and 1-year urinary tract infection rate (17 vs. 6%; HR, 3.145; 95% CI: 1.240-7.978) were significantly higher in the IUC(+) group (P<0.05 for all). There were no differences in 30-day rehospitalization (6 vs. 6%; HR, 0.981; 95% CI: 0.318-3.058; P=0.986) or major adverse cardiac/cerebrovascular events at 1 year (37 vs. 32%, HR, 1.070; 95% CI: 0.636-1.799; P=0.798).

CONCLUSIONS

Based on this retrospective analysis, the routine use of IUC may increase length of stay and UTI complications in AHF patients without reducing the risk for major cardiovascular and cerebrovascular events or 30-day rehospitalization rate.

Reducing Inappropriate Urinary Catheter Use in the Emergency Department: Comparing Two Collaborative Structures

BACKGROUND Urinary catheters, many of which are placed in the emergency department (ED) setting, are often inappropriate, and they are associated with infectious and noninfectious complications. Although several studies evaluating the effect of interventions have focused on reducing catheter use in the ED setting, the organizational contexts within which these interventions were implemented have not been compared. METHODS A total of 18 hospitals in the Ascension health system (ie, system-based hospitals) and 16 hospitals in the state of Michigan (ie, state-based hospitals led by the Michigan Health and Hospital Association) implemented ED interventions focused on reducing urinary catheter use. Data on urinary catheter placement in the ED, indications for catheter use, and presence of physician order for catheter placement were collected for interventions in both hospital types. Multilevel negative binomial regression was used to compare the system-based versus state-based interventions. RESULTS A total of 13,215 patients (889 with catheters) from the system-based intervention were compared to 12,104 patients (718 with catheters) from the state-based intervention. Statistically significant and sustainable reductions in urinary catheter placement (incidence rate ratio, 0.79; P=.02) and improvements in appropriate use of urinary catheters (odds ratio [OR], 1.86; P=.004) in the ED were observed in the system-based intervention, compared to the state-based intervention. Differences by collaborative structure in changes in presence of physician order for urinary catheter placement (OR, 1.14; P=.60) were not observed. CONCLUSIONS An ED intervention consisting of establishing institutional guidelines for appropriate catheter placement and identifying clinical champions to promote adherence was associated with reducing unnecessary urinary catheter use under a system-based collaborative structure. Infect Control Hosp Epidemiol 2018;39:77-84.

Addressing overuse in emergency medicine: evidence of a role for greater patient engagement

Overuse of health care refers to tests, treatments, and even health care settings when used in circumstances where they are unlikely to help. Overuse is not only wasteful, it threatens patient safety by exposing patients to a greater chance of harm than benefit. It is a widespread problem and has proved resistant to change. Overuse of diagnostic testing is a particular problem in emergency medicine. Emergency physicians cite fear of missing a diagnosis, fear of law suits, and perceived patient expectations as key contributors. However, physicians' assumptions about what patients expect are often wrong, and overlook two of patients' most consistently voiced priorities: communication and empathy. Evidence indicates that patients who are more fully informed and engaged in their care often opt for less aggressive approaches. Shared decision making refers to (1) providing balanced information so that patients understand their options and the trade-offs involved, (2) encouraging them to voice their preferences and values, and (3) engaging them-to the extent appropriate or desired-in decision making. By adopting this approach to discretionary decision making, physicians are better positioned to address patients' concerns without the use of tests and treatments patients neither need nor value.

Treated-and-released urinary catheterization in the emergency department by sex

BACKGROUND

The prevalence and difference in likely indications of urinary catheterization (UC) in treated-and-released emergency department (ED) visits between men and women are currently unknown.

METHODS

This was a cross-sectional analysis using the 2013 National Emergency Department Sample for all treated-and-released visits in persons aged ≥18 years. The prevalence of conditions associated with UC visits in men and women were identified. A hierarchical ranking was used to categorize diagnosis codes identified during ED visits into clinically meaningful categories to assess conditions for UC.

RESULTS

In 2013, there were 87,797,062 treated-and-released ED visits in adults. The rate of UC in treated-and-released ED visits in adults was 4.3 per 1,000 visits, with 6.5 per 1,000 visits in men and 2.7 per 1,000 visits in women. Using the hierarchal ranking, a higher proportion of UC visits in men were coded for acute urinary retention, and a higher proportion of UC visits in women were coded for neurologic, cognitive, and psychiatric conditions.

CONCLUSIONS

The rate of UC in treated-and-released ED visits was higher in men than women, and UC rate increased with age. The heterogeneity of conditions coded in UC visits in women compared with men may suggest more potentially avoidable UC in women in the treated-and-released ED population. If confirmed, this would suggest opportunities for quality improvement in the ED to prevent overutilization of urinary catheters.

Failed Removal of Indwelling Urinary Catheters in Patients With Acute Stroke: Incidence and Risk Factors

BACKGROUND

Reducing the incidence of indwelling urinary catheter (IUC) use and early removal of the devices that are inserted are appropriate priorities for quality patient care. Just like symptomatic bacteriuria, failed catheter removal as a complication of IUC use is associated with considerable morbidity. In the ideal setting, patients who need IUCs have them, and patients who do not need them will have them removed safely, with the goal of reducing medical complications and facilitating the rehabilitation phase of care.

OBJECTIVE

To determine the incidence of failed removal of IUCs and the factors associated with failed removal in persons hospitalized with acute stroke.

DESIGN

Retrospective review of medical records and associated clinical data collection platforms.

SETTING

Comprehensive stroke center at a tertiary care hospital.

PATIENTS

The study cohort included 175 stroke patients admitted to the hospital and managed with IUCs. Mean age was 66.1 years (standard deviation = 15), 55% were female.

METHODS

Univariable and multiple logistic regression analyses were performed. Variables assessed included age, gender, race, duration of hospital stay, stroke subtype, National Institutes of Health Stroke Scale, and 6-Clicks Scale, which is a measure of functional status.

MAIN OUTCOME MEASUREMENTS

The dependent variable was occurrence of a failed attempt at removal of an IUC, defined as removal followed by a catheter reinsertion.

RESULTS

During the study period, 175 of 432 patients with acute hospital admission for new stroke had an IUC removal event. Of these patients, 46 (26%) experienced a failed catheter removal. On univariate analysis, factors significantly associated with failed removal included presence of a hemorrhagic stroke (P = .005), lower level of physical function (by 6-Clicks and NIHSS scores), hospital length of stay (P < .001), and discharge location (P = .005). Bedside bladder ultrasound testing by nursing staff was used more frequently in the group of patients who had unsuccessful IUC removals (95% confidence interval 4.56-21.67, P < .001). Length of stay (P < .001), white race (P = .001), and hemorrhagic stroke (P = .009) were associated independently with failed catheter removal after adjustment for other clinical variables.

CONCLUSIONS

This single-site study identified a high incidence of failed urinary catheter removal in patients with stroke, along with factors associated with failed removal. This is the first step in developing a predictive model that could reduce the incidence of this adverse event. Policies, penalties, and protocols designed to reduce catheter days must be sensitive to the special situations in which IUCs are medically necessary and equal consideration given to identifying the patients for which catheter removal poses a greater risk than continued catheter use.

LEVEL OF EVIDENCE

III.

Variation in the prevalence of urinary catheters: a profile of National Health Service patients in England

INTRODUCTION

Harm from catheter-associated urinary tract infections is a common, potentially avoidable, healthcare complication. Variation in catheter prevalence may exist and provide opportunity for reducing harm, yet to date is poorly understood. This study aimed to determine variation in the prevalence of urinary catheters between patient groups, settings, specialities and over time.

METHODS

A prospective study (July 2012 to April 2016) of National Health Service (NHS) patients surveyed by healthcare professionals, following a standardised protocol to determine the presence of a urinary catheter and duration of use, on 1 day per month using the NHS Safety Thermometer.

RESULTS

1314 organisations (253 NHS trusts) and 9 266 284 patients were included. Overall, 12.9% of patients were catheterised, but utilisation varied. There was higher utilisation of catheters in males (15.7% vs 10.7% p<0.001) and younger people (18-70 year 14.0% vs >70 year 12.8% p<0.001), utilisation was highest in hospital settings (18.6% p<0.001), particularly in critical care (76.6% p<0.001). Most catheters had been in situ <28 days (72.9% p<0.001). No clinically significant changes were seen over time in any setting or specialty.

CONCLUSION

Catheter prevalence in patients receiving NHS-funded care varies according to gender, age, setting and specialty, being most prevalent in males, younger people, hospitals and critical care. Utilisation has changed only marginally over 46 months, and further guidance is indicated to provide clarity for clinicians on the insertion and removal of catheters to supplement the existing guidance on care.

A Qualitative Study of Factors Facilitating Clinical Nurse Engagement in Emergency Department Catheter-Associated Urinary Tract Infection Prevention

OBJECTIVE

The aim of this study was to explore the actions of nurse leaders that facilitated clinical nurses' active involvement in emergency department (ED) catheter-associated urinary tract infection (CAUTI) prevention programs.

BACKGROUND

Hospitals face increasing financial pressures to reduce CAUTI. Urinary catheters, often inserted in the ED, expose patients to CAUTI risk. Nurses are the principal champions of ED CAUTI prevention programs.

METHODS

This was a qualitative analysis from a multisite, comparative case study project. A total of 52 interviews and 9 focus groups were analyzed across 6 enrolled EDs. Using a conventional content analysis, members of the research team coded data and developed site summaries to describe themes that had emerged across transcripts. Subsequently, all codes and site summaries were reviewed to identify the actions of nurse leaders that facilitated clinical nurses' engagement in CAUTI prevention efforts.

RESULTS

Nurse leaders were the principal champions of CAUTI prevention programs and successfully engaged clinical nurses in CAUTI prevention efforts by (1) reframing urinary catheters as a source of potential patient harm; (2) empowering clinical nurses to identify and address CAUTI improvement opportunities; (3) fostering a culture of teamwork, which facilitated interdisciplinary communication around urinary catheter appropriateness and alternatives; and (4) holding clinical nurses accountable for CAUTI process and outcome measures.

CONCLUSIONS

The prevention of CAUTI is an important opportunity for nurse leaders to engage clinical nurses in meaningful improvement efforts. Clinical nurses are best positioned to examine urinary catheter insertion workflow and to suggest improvements in avoiding use and improving placement and maintenance. To engage clinical nurses in CAUTI prevention, nurse leaders should focus on how urinary catheters expose patients to potential harm, involve nurses in designing and implementing practice changes, and provide local data to show the impact of nursing practices on patient outcomes.

De-implementation strategy to Reduce the Inappropriate use of urinary and intravenous CATheters: study protocol for the RICAT-study

BACKGROUND

Urinary and (peripheral and central) intravenous catheters are widely used in hospitalized patients. However, up to 56% of the catheters do not have an appropriate indication and some serious complications with the use of these catheters can occur. The main objective of our quality improvement project is to reduce the use of catheters without an appropriate indication by 25-50%, and to evaluate the affecting factors of our de-implementation strategy.

METHODS

In a multicenter, prospective interrupted time series analysis, several interventions to avoid inappropriate use of catheters will be conducted in seven hospitals in the Netherlands. Firstly, we will define a list of appropriate indications for urinary and (peripheral and central) intravenous catheters, which will restrict the use of catheters and urge catheter removal when the indication is no longer appropriate. Secondly, after the baseline measurements, the intervention will take place, which consists of a kick-off meeting, including a competitive feedback report of the baseline measurements, and education of healthcare workers and patients. Additional strategies based on the baseline data and local conditions are optional. The primary endpoint is the percentage of catheters with an inappropriate indication on the day of data collection before and after the de-implementation strategy. Secondary endpoints are catheter-related infections or other complications, catheter re-insertion rate, length of hospital (and ICU) stay and mortality. In addition, the cost-effectiveness of the de-implementation strategy will be calculated.

DISCUSSION

This study aims to reduce the use of urinary and intravenous catheters with an inappropriate indication, and as a result reduce the catheter-related complications. If (cost-) effective it provides a tool for a nationwide approach to reduce catheter-related infections and other complications.

TRIAL REGISTRATION

Dutch trial registry: NTR6015 . Registered 9 August 2016.

Emergency Department Catheter-Associated Urinary Tract Infection Prevention: Multisite Qualitative Study of Perceived Risks and Implemented Strategies

BACKGROUND

Existing knowledge of emergency department (ED) catheter-associated urinary tract infection (CAUTI) prevention is limited. We aimed to describe the motivations, perceived risks for CAUTI acquisition, and strategies used to address CAUTI risk among EDs that had existing CAUTI prevention programs.

METHODS

In this qualitative comparative case study, we enrolled early-adopting EDs, that is, those using criteria for urinary catheter placement and tracking the frequency of catheters placed in the ED. At 6 diverse facilities, we conducted 52 semistructured interviews and 9 focus groups with hospital and ED participants.

RESULTS

All ED CAUTI programs originated from a hospitalwide focus on CAUTI prevention. Staff were motivated to address CAUTI because they believed program compliance improved patient care. ED CAUTI prevention was perceived to differ from CAUTI prevention in the inpatient setting. To identify areas of ED CAUTI prevention focus, programs examined ED workflow and identified 4 CAUTI risks: (1) inappropriate reasons for urinary catheter placement; (2) physicians' limited involvement in placement decisions; (3) patterns of urinary catheter overuse; and (4) poor insertion technique. Programs redesigned workflow to address risks by (1) requiring staff to specify the medical reason for catheter at the point of order entry and placement; (2) making physicians responsible for determining catheter use; (3) using catheter alternatives to address patterns of overuse; and (4) modifying urinary catheter insertion practices to ensure proper placement.

CONCLUSIONS

Early-adopting EDs redesigned workflow to minimize catheter use and ensure proper insertion technique. Assessment of ED workflow is necessary to identify and modify local practices that may increase CAUTI risk.

A Novel Clinical Protocol for Placement and Management of Indwelling Urinary Catheters in Older Adults in the Emergency Department

OBJECTIVES

Indwelling urinary catheters (IUCs) are placed frequently in older adults (age ≥ 65 years) in the emergency department (ED) and carry significant risks. The authors developed, implemented, and assessed a novel clinical protocol to assist ED providers with appropriate indications for placement, reassessment, and removal of IUCs in elders in the ED.

METHODS

A comprehensive, evidence-based clinical protocol was built from an extensive literature review and ED provider focus groups. It was implemented at a university-based medical center with a 20-minute scripted slide presentation. Written surveys were administered before, after, and at 6 months to assess providers' baseline practice and the protocol's effects. Surveys included asking providers for IUC management decisions in 25 unique clinical scenarios. Rates of IUC placement and catheter-associated urinary tract infections (CAUTIs) were compared in ED older adult patients admitted to the hospital in the 6 months before and after protocol implementation.

RESULTS

A total of 111 ED providers participated in the all three surveys. Immediately after protocol introduction, providers anticipated that this intervention would reduce rates of IUC use and increase patient safety. At 6-month follow-up, 81% felt the protocol had changed their practice, and 39% reported frequently referencing the protocol. In the clinical vignettes, ED providers correctly identified the appropriate approach for IUC placement in 63% of cases at baseline with an increase of 22% (95% confidence interval [CI] = 19% to 25%) postintervention and an increase of 8% (95% CI = 6% to 12%) between baseline and 6 months. An absolute reduction in the use of IUCs of 3.5% (p < 0.001) for older adults admitted to the hospital was observed after implementation of the protocol. There were three CAUTIs attributable to the ED in the 6 months prior to implementation and none in the 6 months after.

CONCLUSIONS

This comprehensive, evidence-based clinical protocol was well received by participants and was associated with a sustained change in self-reported practice, as supported by a reduction in IUC placement in admitted older adults and a reduction in CAUTIs attributable to the ED for this vulnerable population over the 6-month study period.

Emergency Department Placement and Management of Indwelling Urinary Catheters in Older Adults: Knowledge, Attitudes, and Practice

Indwelling urinary catheters (IUCs) are placed frequently in older adults in the emergency department (ED). Though often a critical intervention, IUCs carry significant risks. Our objective was to examine current knowledge, attitudes, and practice of emergency nurses and other providers regarding IUC placement and management in older adults.

METHODS

We surveyed ED providers at a large, urban, academic medical center. We developed questionnaires using items from previously validated instruments and questions created for this study. We also assessed providers' management of 25 unique clinical scenarios, each representing an established appropriate or inappropriate indication for IUC placement.

RESULTS

129 ED providers participated: 43 nurses and 86 other providers. Ninety-one percent of nurses and 87% of other providers reported comfort with appropriate indications for IUC placement. Despite this, on the clinical vignettes, nurses correctly identified the appropriate approach for IUC placement in only 40% of cases and other providers in only 37%. Practice varied widely between individual providers, with the nurse participants reporting appropriate practice in 16%-64% of clinical scenarios and other providers in 8%-68%. Few nurses or other providers reported reassessing their patients for IUC removal at transfer to the hospital (28% of nurses and 7% of other providers), admission (24% and 14%), or shift change (14% and 8%).

DISCUSSION

Although emergency nurses and other providers report comfort with appropriate indications for IUC placement, reported practice patterns showed inconsistencies with established guidelines. Wide practice variation exists between individual providers. Moreover, nurses and other providers infrequently consider IUC removal after placement.

Provider perspectives on the use of indwelling urinary catheters in older adults in emergency department settings: developing a novel clinical protocol

BACKGROUND

Indwelling urinary catheters (IUCs) are commonly placed in older adult (aged ≥ 65 years) patients in emergency department (ED) settings, often for inappropriate indications. The aim of our qualitative study was to explore ED provider knowledge, attitudes, and practice patterns surrounding use of IUCs in older adult patients in the ED setting, to better guide development of a clinical protocol.

METHODS

We conducted 4 focus groups with 38 participants at a large academic medical center. Each focus group was conducted with a single ED provider type: attending physicians, residents, physician assistants, or nurses. Focus groups used a semistructured format, ranging in duration from 23-33 minutes. The sessions were audiorecorded, fully transcribed, and data were coded and analyzed to identify themes.

RESULTS

Participants reported believing that IUCs are overutilized in ED settings, confirming that IUCs are infrequently removed once placed and often inserted for staff convenience. Participants reported that current clinical decision making about IUC placement varies widely; yet all acknowledged the known risks for patient safety and willingness to adopt a clinical protocol to standardize practice. Focus groups were a critical component for the development of a user-friendly protocol, identifying 10 key elements for successful implementation and 11 potential barriers.

CONCLUSIONS

An evidence-based clinical protocol guiding ED providers in appropriate placement and management of IUCs in older adults would be welcomed.

Introducing the No Preventable Harms campaign: creating the safest health care system in the world, starting with catheter-associated urinary tract infection prevention

BACKGROUND

Endemic health care-associated safety problems, including health care-associated infection, account for substantial morbidity and mortality. We outline a regional No Preventable Harms campaign to reduce these safety problems and describe the initial results from the first initiative focusing on catheter-associated urinary tract infection (CAUTI) prevention.

METHODS

We formed a think tank composed of multidisciplinary experts from within a 7-hospital Midwestern Veterans Affairs network to identify hospital-acquired conditions that had strong evidence on how to prevent the harm and outcome data that could be easily collected to evaluate improvement efforts. The first initiative of this campaign focused on CAUTI prevention. Quantitative data on CAUTI rates and qualitative data from site visit interviews were used to evaluate the initiative.

RESULTS

Quantitative data showed a significant reduction in CAUTI rates per 1,000 catheter days for nonintensive care units across the region (2.4 preinitiative and 0.8 postinitiative; P = .001), but no improvement in the intensive care unit rate (1.4 preinitiative and 2.1 postinitiative; P = .16). Themes that emerged from our qualitative data highlight the need for considering local context and the importance of communication when developing and implementing regional initiatives.

CONCLUSIONS

A regional collaborative can be a valuable strategy for addressing important endemic patient safety problems.