Spotlight on Success

Implementing Nurse-Driven Protocols to Reduce CAUTIs

any hospitals today are increasingly allowing nurses to make decisions regarding patients care, treatment, and services without consulting a physician or other licensed independent practitioner. Giving nurses more decisionmaking power typically comes in the form of nurse-driven protocols, which provide a rubric for nurses to make these decisions on their own, describe the circumstances in which the protocols may be used, and detail the procedures involved. According to Jane Schetter, RN, senior consultant at Joint Commission Resources, any nurse-driven protocols must be written so there is no doubt as to the requirements needed in order to implement, and should take nationally recognized and evidence-based guidelines into consideration. They need to be developed and reviewed by the medical staff,
(continued on page 4)

Page 1

Copyright 2013 The Joint Commission The Source, April 2013, Volume 11, Issue 4

Spotlight on Success
(continued from page 1)

nursing leadership, or other discipline affected by the protocol, and be in accordance with any state of federal laws or regulations such as state boards of nursing, pharmacy, and medicine.

Benefits to Patients
When granted greater decision-making power under these guidelines, nurses can have a tremendous impact on safety and care in a hospital because they can administer services and medication to patients in a more timely fashion, whether it involves standard procedures, emergencies, or urgent situations. In some cases, the timeliness prevents death or significant complications of the patients condition, Schetter says. Timeliness is one of the key advantages that nurse-driven protocols provide for a variety of patient care policies at hospitals, from sedation to weaning patients off mechanical ventilation. A vital area of care for patients is the removal of indwelling urinary catheters. The longer an indwelling catheter is used, the greater the risk of infection for patients. Developing a nurse driven-protocol for catheter removal (under certain conditions determined by the organization) can enable nurses to remove catheters much sooner than if they had to wait for physician approval. This practice has

become particularly important due to the risk of catheterassociated urinary tract infections (CAUTIs), which is the most frequently occurring type of health careassociated infection (HAI) in US hospitals. The Institute for Healthcare Improvement estimates that 40% of all HAIs are urinary tract infections (UTIs) and at least 80% of UTIs in hospitals are caused by indwelling urinary catheters.1 Complications associated with CAUTIs can also lead to more serious afflictions such as cystitis, pyelonephritis, prostatitis, endocarditis, sepsis and septic shock, and menengitis.2 CAUTIs are associated with increased morbidity, mortality, hospital cost, and length of stay, Schetter says. In addition, the Centers for Medicare & Medicaid Services [CMS] will not pay for CAUTIs that develop during hospitalization. Although most important is eliminating CAUTIs as part of high-quality patient care, and the elimination of CAUTIs decreases the potential for a major financial burden on the hospital and increases the potential for appropriate use of its resources. To minimize CAUTIs, clinical practice guidelines such as the Guideline for Prevention of Catheter-Associated Urinary Tract Infections 20093 by the Healthcare Infection Control Practices Advisory Committee (HICPAC) offer assistance in developing, implementing, and evaluating infection prevention and control programs. The Joint Commission supports

Related Requirements
NPSG.07.06.01 Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTIs). Note: This NPSG is not applicable to pediatric populations. Research resulting in evidence-based practices was conducted with adults, and there is no consensus that these practices apply to children. Elements of Performance for NPSG.07.06.01 1. Insert indwelling urinary catheters according to established evidence-based guidelines that address the following: Limiting use and duration to situations necessary for patient care Using aseptic techniques for site preparation, equipment, and supplies Ensuring that supplies are sterile 2. Manage indwelling urinary catheters according to established evidence-based guidelines that address the following: Securing catheters for unobstructed urine flow and drainage Maintaining the sterility of the urine collection system Replacing the urine collection system when required Collecting urine samples Measure and monitor catheter-associated urinary tract infection prevention processes and outcomes in high-volume areas by doing the following: Selecting measures using evidence-based guidelines or best practices Monitoring compliance with evidence-based guidelines or best practices Evaluating the effectiveness of prevention efforts

3.

Note: Surveillance may be targeted to areas with a high volume of patients using indwelling catheters. Highvolume areas are identified through the hospitals risk assessment as required in IC.01.03.01, EP 2.

Page 4

Copyright 2013 The Joint Commission The Source, April 2013, Volume 11, Issue 4

this effort through its National Patient Safety Goal (NPSG) Requirement NPSG.07.06.01, Element of Performance 1, which specifically requires that organizations limit use and duration of catheters to situations necessary for patient care. (See Related Requirements on page 4.)

Figure 1. Nursing Foley Removal Protocol

Norman Regionals Experience

Preventing CAUTIs and reducing catheter use is a mission for many hospitals in the United States, such as Norman Regional Hospital in Norman, Oklahoma, which put together a multidisciplinary team in 2008 to review its processes and implement a CAUTI prevention program after noticing an unsafe trend. It was determined that many catheters were being placed in the emergency department [ED] and left in patients who did not meet criteria for a Foley [catheter], says Jenny Anderson RN, BSN, clinical outcomes specialist at Norman. Part of Normans initial program was to define which patients actually did meet criteria for catheter placement. Anderson says the hospital used the Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals developed by Source: Norman Regional Hospital. Used with permission. the Society for Healthcare Epidemiology of America (SHEA), The Joint Commission, and other Chemically paralyzed or sedated (ICU/CVU) stakeholders as a guide. The compendium highlights basic Inability to void HAI prevention strategies, offers advanced approaches for Incontinent with perineal/sacral skin breakdown outbreak management, and recommends performance and Large doses of diuretics accountability measures to apply to individuals and groups Post-op period 2448 hours working to implement infection prevention practices.4 Based on the compendium recommendations, Anderson Procedure scheduled within 24 hours says the team at Norman Regional first came up with a list Comfort measures for the terminally ill of criteria for Foley use5: Urology/gynecology patient Hourly intake and output (I&O) as ordered by physician After the criteria was determined, the team was able to Hemodynamically unstable (Intensive Care create its Nursing Foley Removal Protocol (Figure 1, above), Unit/Cardiovascular Unit [ICU/CVU] or Progressive Care which includes the criteria listed, along with other docuUnit) ments used in catheter removal and care. (These documents
(continued on page 6)

Page 5

Copyright 2013 The Joint Commission The Source, April 2013, Volume 11, Issue 4

Spotlight on Success
(continued from page 5)

are available as Figures 2 and 3 on pages 7 and 8 and a bonus figure in the online version of this newsletter.) To get buy-in from the staff on the development of these new procedures, Anderson says all inpatient units were given representation on the team. A physician champion for the changes also assisted in the approval from medical staff of the catheter removal protocol. Creating and implementing the protocol was not without obstacles, however. Change was hard to accept for some of the staff. It has always been a standard in nursing care to leave the Foley inserted until there was a physician order to remove, Anderson says. There was some physician pushback on the protocol in the beginning, but with the help of the physician champion, these were resolved. Educating nurses and nurse assistants on CAUTI awareness, the importance of removing the catheter, and proper insertion and care of catheters was also a challenge. A skills fair was held to facilitate the educational components. Anderson said the education included specific ways to help prevent CAUTIs in patients, such as proper placement of the catheter bag at end of the bed, emptying the bag prior to transport, maintaining a closed system to reduce the risk of bacteria entry, keeping bags below the patients bladder at all times, using the smallest French catheter size to decrease chances of urethral trauma, and the importance of sterile technique for insertion. Classes also covered the impact HAI has on the patient stay, increased morbidity/mortality, and increased cost. Norman Regional made education available to other disciplines as well. Anyone who came in contact with a patient requiring a catheter, such as the distribution/transportation, physical therapy/occupational therapy, and radiology departments, was offered training. Now five years after Norman Regional implemented its nurse-driven protocol for catheter removal, Anderson says the hospital has seen a reduction in the number of days patients use catheters and in the catheter utilization rate. Current statistics, recorded on a monthly basis, show a drop from 0.32 days in 2010 to 0.28 days in 2012 (see Figures 4 and 5, page 9). With a current CAUTI incidence rate at 1.06%, Anderson says she also believes the hospital has seen a reduction in the infections; however, the data does not support this at this time due to the continuing changes in the [CAUTI] definition, she says.

Evaluate Your Results

According to Schetter, measuring the results of a protocol, like Norman Regional has, is important. She says organiza-

tions should monitor progress on a frequent basis. Monthly monitoring is a good way to start. Schetter also suggests organizations measure the effectiveness of their nurse-driven protocols by verifying that the practice is consistent with organization policies and procedures. According to Schetter, processes an organization could use include the following: Investigating how the standing order was developed Reviewing evidence-based practice guidelines or applicable literature Verifying that the protocol or standing order was approved by the medical staff and the hospitals nursing and pharmacy leadership, and that this approval is documented Verifying that the order was authenticated by the physician or practitioners responsible for the care of the patient Authenticating within the time frame established by the organization Reporting the findings of the monitoring or performance improvement activities Regular review of the standing orders and/or protocols Practice consistent with policies Understanding of the circumstances for the use of nursinginitiated protocols/standing orders Evidence of orientation and training related to the use of standing order or protocol At Norman Regional, Anderson says the policies and protocols for catheter use are evaluated on a one- to two-year year basis, or as needed, should changes in best practice occur. We have a Policy and Procedures Committee that reviews all policies and protocols. It is multidisciplinary and includes members of the medical staff. It will send the policy to nursing, performance improvement, and infection prevention to review and evaluate, she says. When determining whether to continue with the policies or change them, Anderson says that Norman Regional takes all information it has gathered into consideration. Currently, the infection prevention department at the hospital is evaluating the program to see if any changes to the protocol are warranted. The majority of our catheters are placed in the ED, so more ED involvement in following the Foley criteria is in discussion, Anderson says. According to Schetter, this type of ongoing evaluation is essential to complying with Joint Commission standards and ensuring patient safety under any nurse-driven protocols. While developing the standing orders or protocols, there should be a consistent and ongoing review of applicable nationally recognized and evidence-based guidelines, review of any state or federal laws related to the scope of practice, and input from the various disciplines of their own
(continued on page 9)

Page 6

Copyright 2013 The Joint Commission The Source, April 2013, Volume 11, Issue 4

Figure 2. Foley Catheter Insertion Instructions

Source: Norman Regional Hospital. Used with permission.

Page 7

Copyright 2013 The Joint Commission The Source, April 2013, Volume 11, Issue 4

Figure 3. Foley Catheter Care Instructions

Source: Norman Regional Hospital. Used with permission.

Page 8

Copyright 2013 The Joint Commission The Source, April 2013, Volume 11, Issue 4

Spotlight on Success
(continued from page 6)

Figure 4. Device UtilizationUrinary Catheters

thoughts and previous experience with protocols, Schetter says. The protocols should define inclusions, exclusions, and potential indicators for monitoring the effectiveness of the process and outcomes of using the protocol. TS
References
1. Institute for Healthcare Improvement. Catheter-Associated Urinary Tract Infection. Accessed Mar 15, 2013. http://www.ihi.org/explore/CAUTI /Pages/default.aspx. 2. Conemaugh Memorial Medical Center. Foley Catheters and the Risk for Infection. Fesko C, Waronek S. Accessed Mar 15, 2013. http://tinyurl.com/bglqfoa. 3. Healthcare Infection Control Practices Advisory Committee. Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009. Gould C., et al. 2009. Accessed Mar 15, 2013. http://www.cdc.gov/hicpac/pdf/CAUTI /CAUTIguideline2009final.pdf. 4. Society for Healthcare Epidemiology of America. Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals. Accessed Feb 24, 2013. http://www.shea-online.org /HAITopics/CompendiumofStrategiesto PreventHAIs.aspx. 5. Norman Regional Health System. Nursing Foley Removal Protocol. Document provided by Norman Regional Hospital.
Source: Norman Regional Hospital. Used with permission. Source: Norman Regional Hospital. Used with permission.

Figure 5. Device Utilization

Page 9

Copyright 2013 The Joint Commission The Source, April 2013, Volume 11, Issue 4