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Abstract
Catheter-associated urinary tract infection (CAUTI) remains one of the most prevalent, but preventable, health care-associated infections and predominantly occurs in patients with indwelling urinary catheters. Duration of urinary catheterization is the most important modifiable risk factor for development of CAUTI. Alternatives to indwelling catheters should be considered in appropriate patients. If indwelling catheterization is necessary, proper aseptic practices for catheter insertion and maintenance and use of a closed catheter collection system are essential for preventing CAUTI. The use of intervention bundles and collaboratives helps in the effective implementation of CAUTI prevention measures.
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Affiliation(s)
- Carol E Chenoweth
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, F4141 South University Hospital, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5226, USA.
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Goldman J, Kuper A, Whitehead C, Baker GR, Bulmer B, Coffey M, Shea C, Jeffs L, Shojania K, Wong B. Interprofessional and multiprofessional approaches in quality improvement education. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2021; 26:615-636. [PMID: 33113055 DOI: 10.1007/s10459-020-10004-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 10/21/2020] [Indexed: 06/11/2023]
Abstract
The imperative for all healthcare professionals to partake in quality improvement (QI) has resulted in the development of QI education programs with participants from different professional backgrounds. However, there is limited empirical and theoretical examination as to why, when and how interprofessional and multiprofessional education occurs in QI and the outcomes of these approaches. This paper reports on a qualitative collective case study of interprofessional and multiprofessional education in three longitudinal QI education programs. We conducted 58 interviews with learners, QI project coaches, program directors and institutional leads and 135 h of observations of in-class education sessions, and collected relevant documents such as course syllabi and handouts. We used an interpretive thematic analysis using a conventional and directed content analysis approach. In the directed content approach, we used sociology of professions theory with particular attention to professional socialization, hierarchies and boundaries in QI, to understand the ways in which individuals' professional backgrounds informed the planning and experiences of the QI education programs. Findings demonstrated that both interprofessional and multiprofessional education approaches were being used to achieve different education objectives. While each approach demonstrated positive learning and practice outcomes, tensions related to the different ways in which professional groups are engaging in QI, power dynamics between professional groups, and disconnects between curricula and practice existed. Further conceptual clarity is essential for a more informed discussion about interprofessional and multiprofessional education approaches in QI and explicit attention is needed to professional processes and tensions, to optimize the impact of education on practice.
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Affiliation(s)
- Joanne Goldman
- Centre for Quality Improvement and Patient Safety, University of Toronto, 525 University Ave., Suite 630, Toronto, ON, M5G 2L3, Canada.
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada.
- Wilson Centre for Research in Education, University of Toronto, Toronto, Canada.
| | - Ayelet Kuper
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
- Wilson Centre for Research in Education, University of Toronto, Toronto, Canada
- Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Cynthia Whitehead
- Wilson Centre for Research in Education, University of Toronto, Toronto, Canada
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
- Women's College Hospital, Toronto, Canada
| | - G Ross Baker
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Beverly Bulmer
- St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
- Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Maitreya Coffey
- Department of Paediatrics, University of Toronto, Toronto, Canada
- The Hospital for Sick Children, Toronto, Canada
- Children's Hospitals Solutions for Patient Safety, Cincinnati, OH, USA
| | - Christine Shea
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Lianne Jeffs
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Kaveh Shojania
- Centre for Quality Improvement and Patient Safety, University of Toronto, 525 University Ave., Suite 630, Toronto, ON, M5G 2L3, Canada
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
- Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Brian Wong
- Centre for Quality Improvement and Patient Safety, University of Toronto, 525 University Ave., Suite 630, Toronto, ON, M5G 2L3, Canada
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
- Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
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Swoboda NL, Dahlke S, Hunter KF. Nurses' perceptions of their role in functional focused care in hospitalised older people: An integrated review. Int J Older People Nurs 2020; 15:e12337. [PMID: 32790240 DOI: 10.1111/opn.12337] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 07/01/2020] [Accepted: 07/20/2020] [Indexed: 12/01/2022]
Abstract
AIM The aim of this integrative review was to identify nurses' perspectives of their role in influencing the functional status of hospitalised older people. METHODS An integrative review using Whittemore and Knafls' method was conducted using EBSCOhost CINAHL, Ovid MEDLINE(R), EBSCOhost, Social Gerontology, Cochrane Database of Systematic Reviews and ProQuest Dissertations & Theses data bases. Only studies with nurses' perspectives, or beliefs about their role in function-focused care were included. Content analysis was used to develop the themes nurses' role in function-focused care and barriers to functional care. RESULTS The review found 12 relevant articles. Nurses believed that they were responsible for function-focused care, yet functional care tasks were often missed. Organisational contexts created many barriers to providing function-focused care for patients. Nurses felt powerless to address these overarching problems in their organisations. CONCLUSION Nurses understand the importance of functional care yet often fail to carry out functional care interventions. Lack of organisational support creates a workplace that is short on staff, time and equipment and does not prioritise functional care needs. Nurse leaders and healthcare organisations need to reprioritise function-focused care for the good of patients, families and healthcare budgets.
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Affiliation(s)
| | - Sherry Dahlke
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
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Schweiger A, Kuster SP, Maag J, Züllig S, Bertschy S, Bortolin E, John G, Sax H, Limacher A, Atkinson A, Schwappach D, Marschall J. Impact of an evidence-based intervention on urinary catheter utilization, associated process indicators, and infectious and non-infectious outcomes. J Hosp Infect 2020; 106:364-371. [PMID: 32653433 DOI: 10.1016/j.jhin.2020.07.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 07/02/2020] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- A Schweiger
- Swissnoso, National Centre for Infection Control, Bern, Switzerland; Department of Infectious Diseases and Hospital Epidemiology, Basel University Hospital, Basel, Switzerland; Zug Cantonal Hospital, Zug, Switzerland
| | - S P Kuster
- Swissnoso, National Centre for Infection Control, Bern, Switzerland; Division of Infectious Diseases and Hospital Epidemiology, University and University Hospital Zurich, Zurich, Switzerland
| | - J Maag
- Swissnoso, National Centre for Infection Control, Bern, Switzerland
| | - S Züllig
- Swiss Patient Safety Foundation, Zurich, Switzerland
| | - S Bertschy
- Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - E Bortolin
- Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - G John
- Department of Internal Medicine, Hôpital Neuchâtelois, Neuchâtel, Switzerland; University of Geneva, Geneva, Switzerland
| | - H Sax
- Swissnoso, National Centre for Infection Control, Bern, Switzerland; Division of Infectious Diseases and Hospital Epidemiology, University and University Hospital Zurich, Zurich, Switzerland
| | - A Limacher
- CTU Bern, University of Bern, Bern, Switzerland
| | - A Atkinson
- Department of Infectious Diseases, Inselspital, Bern University Hospital, Bern, Switzerland
| | - D Schwappach
- Swiss Patient Safety Foundation, Zurich, Switzerland; Institute for Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - J Marschall
- Swissnoso, National Centre for Infection Control, Bern, Switzerland; Department of Infectious Diseases, Inselspital, Bern University Hospital, Bern, Switzerland.
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Atkins L, Sallis A, Chadborn T, Shaw K, Schneider A, Hopkins S, Bunten A, Michie S, Lorencatto F. Reducing catheter-associated urinary tract infections: a systematic review of barriers and facilitators and strategic behavioural analysis of interventions. Implement Sci 2020; 15:44. [PMID: 32624002 PMCID: PMC7336619 DOI: 10.1186/s13012-020-01001-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 05/18/2020] [Indexed: 11/18/2022] Open
Abstract
Background Reducing the need for antibiotics is crucial in addressing the global threat of antimicrobial resistance. Catheter-associated urinary tract infection (CAUTI) is one of the most frequent device-related infections that may be amenable to prevention. Interventions implemented nationally in England target behaviours related to catheter insertion, maintenance and removal, but the extent to which they target barriers to and facilitators of these behaviours is unclear. This strategic behavioural analysis applied behavioural science frameworks to (i) identify barriers to and facilitators of behaviours that lead to CAUTI (CAUTI-related behaviours) in primary, community and secondary care and nursing homes; (ii) describe the content of nationally adopted interventions; and (iii) assess the extent to which intervention content is theoretically congruent with barriers and facilitators. Methods A mixed-methods, three-phased study: (1) systematic review of 25 studies to identify (i) behaviours relevant to CAUTI and (ii) barriers to and facilitators of CAUTI-related behaviours, classified using the COM-B model and Theoretical Domains Framework (TDF); (2) content analysis of nationally adopted CAUTI interventions in England identified through stakeholder consultation, classified using the Behaviour Change Wheel (BCW) and Behaviour Change Techniques Taxonomy (BCTTv1); and (3) findings from 1 and 2 were linked using matrices linking COM-B and TDF to BCW/BCTTv1 in order to signpost to intervention design and refinement. Results The most frequently reported barriers to and facilitators of CAUTI-related behaviours related to ‘environmental context and resources’; ‘knowledge’; ‘beliefs about consequences’; ‘social influences’; ‘memory, attention and decision processes’; and ‘social professional role and identity.’ Eleven interventions aiming to reduce CAUTI were identifed. Interventions were primarily guidelines and included on average 2.3 intervention functions (1–5) and six BCTs (2–11), most frequently ‘education’, ‘training’ and ‘enablement.’ The most frequently used BCT was ‘information about health consequences’ which was used in almost all interventions. Social professional role and identity and environmental context and resources were targeted least frequently with potentially relevant BCTs. Conclusions Interventions incorporated half the potentially relevant content to target identifed barriers to and facilitators of CAUTI-related behaviours. There were missed opportunities for intervention as most focus on shaping knowledge rather than addressing motivational, social and environmental influences. This study suggests that targeting motivational, social and environmental influences may lead to more effective intervention design and refinement.
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Affiliation(s)
- Lou Atkins
- Centre for Behaviour Change, University College London, Alexandra House, 7-19 Queens Square, London, WC1N 3AZ, UK.
| | - Anna Sallis
- Public Health England, Wellington House, 133-155 Waterloo Road, London, SE1 8UG, UK
| | - Tim Chadborn
- Public Health England, Wellington House, 133-155 Waterloo Road, London, SE1 8UG, UK
| | - Karen Shaw
- Public Health England, Wellington House, 133-155 Waterloo Road, London, SE1 8UG, UK
| | - Annegret Schneider
- Centre for Behaviour Change, University College London, Alexandra House, 7-19 Queens Square, London, WC1N 3AZ, UK
| | - Susan Hopkins
- Public Health England, Wellington House, 133-155 Waterloo Road, London, SE1 8UG, UK
| | - Amanda Bunten
- Public Health England, Wellington House, 133-155 Waterloo Road, London, SE1 8UG, UK
| | - Susan Michie
- Centre for Behaviour Change, University College London, Alexandra House, 7-19 Queens Square, London, WC1N 3AZ, UK
| | - Fabiana Lorencatto
- Centre for Behaviour Change, University College London, Alexandra House, 7-19 Queens Square, London, WC1N 3AZ, UK
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Quinn M, Ameling JM, Forman J, Krein SL, Manojlovich M, Fowler KE, King EA, Meddings J. Persistent Barriers to Timely Catheter Removal Identified from Clinical Observations and Interviews. Jt Comm J Qual Patient Saf 2019; 46:99-108. [PMID: 31879072 DOI: 10.1016/j.jcjq.2019.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 09/23/2019] [Accepted: 10/15/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Indwelling urinary and vascular catheters are valuable devices in patient care, but prolonged or unnecessary use increases the risk of infectious and noninfectious catheter harms. METHODS To understand persistent barriers to detecting and removing unnecessary catheters, researchers conducted a multimethod qualitative study that included observations and in-person interviews with clinicians working on a progressive care unit of a large hospital. Observations consisted of shadowing nurses during shift change and while admitting patients, and observing physicians during morning rounds. Observational data were gathered using unstructured field notes. Interviews were conducted using a semistructured guide, audio-recorded, and transcribed. Qualitative content analysis was conducted to identify main themes. RESULTS Barriers to timely removal identified during 19 interviews with clinicians and 133 hours of field observations included physicians not routinely reviewing catheter necessity during rounds, catheters going unnoticed or hidden under clothing, common use of "Do Not Remove" orders, and little or no discussion of catheters among clinicians. Five overall themes emerged: (1) Catheter data are hard to find, not accurate, or not available; (2) Catheter removal is not a priority; (3) Confusion exists about who has authority to remove catheters; (4) There is a lack of agreement on, and awareness of, standard protocols and indications for removal; and (5) Communication barriers among clinicians create challenges. CONCLUSION To address barriers and facilitate detection and timely removal, clinicians need ready access to accurate catheter data, more clearly delineated clinician roles for prompting removal, effective tools to facilitate discussions about catheter use, and standardized catheter removal protocols.
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Pinto IB, dos Santos Machado L, Meneguetti BT, Nogueira ML, Espínola Carvalho CM, Roel AR, Franco OL. Utilization of antimicrobial peptides, analogues and mimics in creating antimicrobial surfaces and bio-materials. Biochem Eng J 2019. [DOI: 10.1016/j.bej.2019.107237] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Saint S, Greene MT, Fowler KE, Ratz D, Patel PK, Meddings J, Krein SL. What US hospitals are currently doing to prevent common device-associated infections: results from a national survey. BMJ Qual Saf 2019; 28:741-749. [PMID: 31015378 PMCID: PMC6820292 DOI: 10.1136/bmjqs-2018-009111] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 03/18/2019] [Accepted: 03/27/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Despite focused initiatives to reduce device-associated infection among hospitalised patients, the practices US hospitals are currently using are unknown. We thus used a national survey to ascertain the use of several established and novel practices to prevent device-associated infections. METHODS We mailed surveys to infection preventionists in a random sample of nearly 900 US acute care hospitals in 2017. Our survey asked about the use of practices to prevent three common device-associated infections: catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI) and ventilator-associated pneumonia (VAP). Using sample weights, we estimated the percentage of hospitals reporting regular use of each practice. We also conducted multivariable regression to determine associations between selected hospital characteristics (eg, perceived support from leadership) and use of CAUTI, CLABSI and VAP prevention practices. RESULTS The response rate was 59%. Several practices are reportedly used in over 90% of US hospitals: aseptic technique during indwelling urethral catheter insertion and maintenance (to prevent CAUTI); maximum sterile barrier precautions during central catheter insertion and alcohol-containing chlorhexidine gluconate for insertion site antisepsis (to prevent CLABSI); and semirecumbent positioning of the patient (to prevent VAP). Antimicrobial devices are used in the minority of hospitals for these three device-associated infections. CONCLUSIONS We provide an updated snapshot of the practices US hospitals are currently using to prevent device-associated infections. Compared with previous studies using a similar design and questions, we found that the use of recommended practices increased in US hospitals, especially for CAUTI prevention.
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Affiliation(s)
- Sanjay Saint
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael Todd Greene
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Karen E Fowler
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - David Ratz
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Payal K Patel
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Division of Infectious Diseases, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jennifer Meddings
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Sarah L Krein
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
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Dahlke SA, Hunter KF, Negrin K. Nursing practice with hospitalised older people: Safety and harm. Int J Older People Nurs 2019; 14:e12220. [PMID: 30628753 DOI: 10.1111/opn.12220] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 11/26/2018] [Accepted: 11/28/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Nursing teams work with hospitalised older people in institutions, which prioritise a biomedical model of care. This model does not fit the needs of older people because it emphasises efficacy and a narrow definition of patient safety, but does not prioritise functional needs. Nursing care is provided around the clock within the context of fiscal restraints as well as negative societal and nursing perspectives about ageing and old people. Yet, nursing perceptions of managing safety and potential harms to older patients within these hospital institutions are not well understood. METHODS An integrative review was conducted to examine nursing perspectives of safety and harm related to hospitalised older people. RESULTS The majority of included papers focused on restraint use. Findings reveal that nurses are using restraints and limiting mobility as strategies to manage their key priority of keeping older patients safe, reflecting a narrow conceptualisation of safety. Policy, administrative support and individual nurse characteristics influence restraint use. Safety policies that nurses interpret as preventing falls can encourage the use of restraints and limiting mobility, both of which result in functional losses to older people. CONCLUSIONS This complex issue requires attention from clinical nurses, leaders, policy makers and researchers to shift the focus of care to preservation and restoration of function for older people in hospital as a safety priority. IMPLICATIONS FOR PRACTICE Clinical leaders and nursing teams should engage in developing processes of care that incorporate maintaining and restoring older people's function.
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Affiliation(s)
- Sherry Ann Dahlke
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Kathleen F Hunter
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Kelly Negrin
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
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Gupta A, Harrod M, Quinn M, Manojlovich M, Fowler KE, Singh H, Saint S, Chopra V. Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors. ACTA ACUST UNITED AC 2018; 5:151-156. [PMID: 30007056 DOI: 10.1515/dx-2018-0014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 06/18/2018] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Traditionally, research has examined systems- and cognitive-based sources of diagnostic error as individual entities. However, half of all errors have origins in both domains.
Methods
We conducted a focused ethnography of inpatient physicians at two academic institutions to understand how systems-based problems contribute to cognitive errors in diagnosis. Medicine teams were observed on rounds and during post-round work after which interviews were conducted. Field notes related to the diagnostic process and the work system were recorded, and findings were organized into themes. Using deductive content analysis, themes were categorized based on a published taxonomy to link systems-based contributions and cognitive errors such as faulty data gathering, information processing, data verification and errors associated with multiple domains.
Results
Observations, focus groups and interviews of 10 teams were conducted between January 2016 and April 2017. The following themes were identified: (1) challenges with interdisciplinary communication and communication within the electronic medical record (EMR) contributed to faulty data gathering; (2) organizational structures such as the operation of consulting services in silos promoted faulty information processing; (3) care handoffs led to faulty data verification and (4) interruptions, time constraints and a cluttered physical environment negatively influenced multiple cognitive domains.
Conclusions
Systems-based factors often facilitate and promote cognitive problems in diagnosis. Linking systems-based contributions to downstream cognitive impacts and intervening on both in tandem may help prevent diagnostic errors.
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Affiliation(s)
- Ashwin Gupta
- Division of Hospital Medicine, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105-2303, USA.,University of Michigan Medical School, Ann Arbor, MI 48109-0624, USA
| | - Molly Harrod
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Martha Quinn
- University of Michigan School of Public Health, Ann Arbor, MI, USA
| | | | | | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.,Baylor College of Medicine, Houston, TX, USA
| | - Sanjay Saint
- Division of Hospital Medicine, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,University of Michigan Medical School, Ann Arbor, MI, USA
| | - Vineet Chopra
- Division of Hospital Medicine, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,University of Michigan Medical School, Ann Arbor, MI, USA
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Trudel K, Zavalkoff S, Winters N, Quach C, Lacroix J, Fontela PS. Determinants of urinary catheter removal practices in the pediatric intensive care unit: A survey. Am J Infect Control 2018. [PMID: 29519651 DOI: 10.1016/j.ajic.2017.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Prolonged use of indwelling catheters is associated with hospital-acquired urinary tract infections (UTIs). Literature is scarce about the factors influencing urinary catheter removal and maintenance in children. This study aims to describe the determinants of urinary catheter removal in pediatric intensive care unit (PICU) patients. METHODS Cross-sectional survey of 171 physicians and nurses working at 2 tertiary PICUs in Montreal, Canada. We used focus groups and literature review to design the survey questions and 3 clinical scenarios. We analyzed our results using descriptive statistics and multivariate multinomial regression. RESULTS There were 131 (77%) participants who answered the survey. Factors prompting urinary catheter removal (P < .01) included recent extubation, superficial sedation level, fever, and history of previous UTI. Presence of shock (P < .01) and fluid overload (P < .05) were associated with maintenance of catheters. Physicians were more likely to remove urinary catheters than nurses in all scenarios. CONCLUSIONS We identified a consistent set of variables that drive the removal of indwelling catheters in PICUs. Studies are needed to determine whether incorporating these determinants into infection control interventions will reduce urinary catheter use and catheter-associated UTIs in critically ill children.
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Nurses’ and Physicians’ Perceptions of Indwelling Urinary Catheter Practices and Culture in Their Institutions. J Patient Saf 2018; 16:e82-e89. [DOI: 10.1097/pts.0000000000000502] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Factors Associated With Removal of Urinary Catheters After Surgery. J Nurs Care Qual 2017; 33:29-37. [PMID: 29176442 DOI: 10.1097/ncq.0000000000000287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Publicly available data from the Centers for Medicaid & Medicare Services were used to analyze factors associated with removal of the urinary catheter within 48 hours after surgery in 59 Massachusetts hospitals. Three factors explained 36% of the variance in postoperative urinary catheter removal: fewer falls per 1000 discharges, better nurse-patient communication, and higher percentage of Medicare patients. Timely urinary catheter removal was significantly greater in hospitals with more licensed nursing hours per patient day.
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Abstract
Catheter-associated urinary tract infection (CAUTI) remains one of the most prevalent, yet preventable, health care-associated infections and predominantly occurs in patients with indwelling urinary catheters. Targeted strategies for prevention of CAUTI include limiting urinary catheter use; physician reminder systems, nurse-initiated discontinuation protocols, and automatic stop orders have successfully decreased catheter duration. Alternatives to indwelling catheters should be considered in appropriate patients. If indwelling catheterization is necessary, proper aseptic practices for catheter insertion and maintenance and closed catheter collection system is essential for preventing CAUTI. The use of "bladder bundles" and collaboratives aids in the effective implementation of CAUTI prevention measures.
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Affiliation(s)
- Carol E Chenoweth
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA.
| | - Sanjay Saint
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA; Division of General Medicine, Department of Internal Medicine, University of Michigan Health System, 2800 Plymouth Road, Building 16, Room 430 West, Ann Arbor, MI 48109-2800, USA; Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Understanding risk perceptions and responses of the public and health care professionals toward Clostridium difficile: A qualitative interpretive description study. Am J Infect Control 2017; 45:133-138. [PMID: 27789069 DOI: 10.1016/j.ajic.2016.07.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 07/05/2016] [Accepted: 07/06/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND The occurrence of Clostridium difficile infection is a major health-related risk. How the public and health care professionals perceive and respond to a health-related risk is shaped by socially and contextually structured evaluations and interpretations. Risk perceptions and responses are context dependent and therefore need to be understood within the context in which they are perceived and experienced. METHODS This interpretive description study used 8 public focus groups (39 participants) and 7 health care professional focus groups (29 participants) in 2 geographic areas (an area that had experienced a C difficile outbreak and an area that had not). RESULTS Both the public and health care professionals expressed varying concerns about the perceived consequences of C difficile occurring and the potential influence on emotional and physical health and well-being. In doing so, they drew upon a range of direct and indirect experiences and accounts from the media. Conceptual factors found to be important in influencing risk perceptions and responses included feelings of vulnerability, attribution of responsibility, judgments about competence, and evaluations of risk communicators. CONCLUSIONS If risk management and communication strategies are to achieve desired responses toward C difficile and wider risks, those responsible for managing risk must consider already established risk perceptions in addition to factors that have influenced them.
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Samraj RS, Stalets E, Butcher J, Deck T, Frebis J, Helpling A, Wheeler DS. The Impact of Catheter-Associated Urinary Tract Infection (CA-UTI) in Critically Ill Children in the Pediatric Intensive Care Unit. J Pediatr Intensive Care 2015; 5:7-11. [PMID: 31110876 DOI: 10.1055/s-0035-1568148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 07/12/2015] [Indexed: 10/22/2022] Open
Abstract
Objective Catheter-associated urinary tract infections (CA-UTIs) comprise a significant proportion of hospital-acquired infections. However, the impact of CA-UTIs on important outcome measures, such as length of stay (LOS) and hospital charges, has not been examined in the pediatric intensive care unit (PICU) setting. Design Single-center, retrospective, case-matched, cohort study and financial analysis. Setting PICU in a tertiary-care children's medical center. Patients A total of 41 critically ill children with CA-UTIs and 73 critically ill children without CA-UTI, matched for age, gender, severity of illness, and primary admission diagnosis. Interventions None. Measurements and Main Results We compared the length of hospital stay (LOS in PICU and in hospital), mortality, and hospital costs in critically ill children with CA-UTIs and their matched controls. Critically ill children experiencing CA-UTI had significantly longer PICU LOS, hospital LOS, duration of mechanical ventilation, and mortality compared with matched controls without CA-UTI. The longer LOS resulted in higher PICU and hospital charges in this group. Conclusion Critically ill children with CA-UTI experience worse outcomes in the PICU compared with those without CA-UTI. Further studies on the impact of CA-UTI in the PICU are warranted.
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Affiliation(s)
- Ravi S Samraj
- Division of Critical Care Medicine and Pediatric Intensive Care Unit, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Erika Stalets
- Division of Critical Care Medicine and Pediatric Intensive Care Unit, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - John Butcher
- Division of Critical Care Medicine and Pediatric Intensive Care Unit, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Theresa Deck
- Division of Critical Care Medicine and Pediatric Intensive Care Unit, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - James Frebis
- Division of Critical Care Medicine and Pediatric Intensive Care Unit, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Alma Helpling
- Division of Critical Care Medicine and Pediatric Intensive Care Unit, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Derek S Wheeler
- Division of Critical Care Medicine and Pediatric Intensive Care Unit, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
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Taleschian-Tabrizi N, Farhadi F, Madani N, Mokhtarkhani M, Kolahdouzan K, Hajebrahimi S. Compliance With Guideline Statements for Urethral Catheterization in an Iranian Teaching Hospital. Int J Health Policy Manag 2015; 4:805-11. [PMID: 26673464 DOI: 10.15171/ijhpm.2015.128] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 07/09/2015] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND It is believed that healthcare staff play an important role in minimizing complications related to urethral catheterization. The purpose of this study was to determine whether or not healthcare staff complied with the standards for urethral catheterization. METHODS This study was conducted in Imam Reza teaching hospital, Tabriz, Iran, from July to September 2013. A total of 109 catheterized patients were selected randomly from surgical and medical wards and intensive care units (ICUs). A questionnaire was completed by healthcare staff for each patient to assess quality of care provided for catheter insertion, while catheter in situ, draining and changing catheter bags. Items of the questionnaire were obtained from guidelines for the prevention of infection. Data analysis was performed with SPSS 16. RESULTS The mean age of the patients was 50.54±22.13. Of the 109 patients, 56.88% were admitted to ICUs. The mean duration of catheter use was 15.86 days. Among the 25 patients who had a urinalysis test documented in their hospital records, 11 were positive for urinary tract infection (UTI). The lowest rate of hand-washing was reported before bag drainage (49.52%). The closed drainage catheter system was not available at all. Among the cases who had a daily genital area cleansing, in 27.63% cases, the patients or their family members performed the washing. In 66.35% of cases, multiple-use lubricant gel was applied; single-use gel was not available. The rate of documentation for bag change was 79%. CONCLUSION The majority of the guideline statements was adhered to; however, some essential issues, such as hand hygiene were neglected. And some patients were catheterized routinely without proper indication. Limiting catheter use to mandatory situations and encouraging compliance with guidelines are recommended.
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Affiliation(s)
- Negar Taleschian-Tabrizi
- Students' Research Committee, Iranian Evidence-Based Medicine Center of Excellence, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fereshteh Farhadi
- Students' Research Committee, Iranian Evidence-Based Medicine Center of Excellence, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Neda Madani
- Students' Research Committee, Iranian Evidence-Based Medicine Center of Excellence, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohaddeseh Mokhtarkhani
- Students' Research Committee, Iranian Evidence-Based Medicine Center of Excellence, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Kasra Kolahdouzan
- Students' Research Committee, Iranian Evidence-Based Medicine Center of Excellence, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sakineh Hajebrahimi
- Iranian Evidence-Based Medicine Center of Excellence, Department of Urology, Tabriz University of Medical Sciences, Tabriz, Iran
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Murphy C, Prieto J, Fader M. "It's easier to stick a tube in": a qualitative study to understand clinicians' individual decisions to place urinary catheters in acute medical care. BMJ Qual Saf 2015; 24:444-50. [PMID: 26065467 DOI: 10.1136/bmjqs-2015-004114] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 04/30/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Indwelling urinary catheters (IUCs) placed in acute care are a leading cause of healthcare-associated urinary tract infection. Despite initiatives to minimise the placement of IUCs, levels of inappropriate use are still considered unacceptable. IUC practice is difficult to change, and factors influencing clinicians' decisions need to be better understood. OBJECTIVE To explore why clinicians decide to place IUCs in acute medical care. METHODS We conducted a qualitative study in the emergency department and acute medical wards of a 1200+ bed hospital, undertaking 30 retrospective think aloud and 20 semistructured interviews with nurses and physicians who made the decision to place an IUC. A purposive sample and thematic analysis were used. RESULTS Opinions on when an IUC was warranted varied considerably. Inconsistency in decision-making was caused by differing beliefs on when an IUC was appropriate for each clinical indication. Numerous patient and non-patient factors, including clinical setting, resources, patient age and gender and staff workload, also impacted on each decision. Assessing when the benefit of an IUC outweighed the risk could be problematic due to conflicting goals. CONCLUSIONS These findings help to explain why clinicians sometimes deviate from IUC best practice guidance and resist interventions to modify practice. In order to engage nurses and physicians in change, interventions to reduce IUC use should acknowledge and respond to the complexity and lack of clarity often faced by clinicians making the decision to place an IUC. However, it is equally important that inconsistencies in IUC-related beliefs are recognised, investigated and, where appropriate, challenged.
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Affiliation(s)
- Catherine Murphy
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Jacqui Prieto
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Mandy Fader
- Faculty of Health Sciences, University of Southampton, Southampton, UK
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Krein SL, Saint S. What's your excuse for Foley use? BMJ Qual Saf 2015; 24:412-3. [PMID: 26031559 DOI: 10.1136/bmjqs-2015-004376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2015] [Indexed: 11/04/2022]
Affiliation(s)
- Sarah L Krein
- VA Ann Arbor Healthcare System, Center for Clinical Management Research, Ann Arbor, Michigan, USA Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Sanjay Saint
- VA Ann Arbor Healthcare System, Center for Clinical Management Research, Ann Arbor, Michigan, USA Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Chenoweth CE, Gould CV, Saint S. Diagnosis, Management, and Prevention of Catheter-Associated Urinary Tract Infections. Infect Dis Clin North Am 2014; 28:105-19. [DOI: 10.1016/j.idc.2013.09.002] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Krein SL, Saint S. Preventing catheter-associated urinary tract infection: a happy marriage between implementation and healthier patients. ACTA ACUST UNITED AC 2014. [DOI: 10.1071/hi13047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Mishra B, Basu A, Chua RRY, Saravanan R, Tambyah PA, Ho B, Chang MW, Leong SSJ. Site specific immobilization of a potent antimicrobial peptide onto silicone catheters: evaluation against urinary tract infection pathogens. J Mater Chem B 2014; 2:1706-1716. [PMID: 32261400 DOI: 10.1039/c3tb21300e] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Bacterial colonization of urinary catheters is a common problem leading to Catheter Associated Urinary Tract Infections (CAUTIs) in patients, which result in high treatment costs and associated complications. Due to the advantages of antimicrobial peptides (AMPs) compared to most other antimicrobial molecules, an increasing number of AMP-coated surfaces is being developed but their efficacy is hindered by suboptimal coating methods and loss of peptide activity upon surface tethering. This study aims to address this issue by employing a methodic approach that combines a simple selective chemical immobilization platform developed on a silicone catheter with the choice of a potent AMP, Lasioglossin-III (Lasio-III), to allow site specific immobilization of Lasio-III at an effective surface concentration. The Lasio-III peptide was chemically modified at the N-terminal with a cysteine residue to facilitate cysteine-directed immobilization of the peptide onto a commercial silicone catheter surface via a combination of an allyl glycidyl ether (AGE) brush and polyethylene glycol (PEG) based chemical coupling. The amount of immobilized peptide was determined to be 6.59 ± 0.89 μg cm-2 by Sulfo-SDTB assay. The AMP-coated catheter showed good antimicrobial activity against both Gram positive and negative bacteria. The antimicrobial properties of the AMP-coated catheter were sustained for at least 4 days post-incubation in a physiologically relevant environment and artificial urine and prevented the biofilm growth of E. coli and E. faecalis. Adenosine tri-phosphate leakage and propidium iodide fluorescence studies further confirmed the membranolytic mode of action of the immobilized peptide. To the best of our knowledge, this is the first proof-of-concept study that reports the efficacy of AMP immobilization by sulfhydryl coupling on a real catheter surface.
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Affiliation(s)
- Biswajit Mishra
- School of Chemical and Biomedical Engineering, Nanyang Technological University, 62 Nanyang Drive, 637459 Singapore
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