In 2010, the rate of catheter-associated urinary tract infections (CA-UTI) at The Children’s Hospital of Philadelphia was significantly higher than the national average. Recognizing that CA-UTI could lead to significant morbidity and mortality, we convened a multidisciplinary team to evaluate this problem and subsequently developed and implemented strategies to reduce CA-UTI within our institution.
At the onset of our work, our team partnered with the Institute for Healthcare Improvement (IHI), which recommended that teams combating hospital-acquired infections assess their individual hospital’s needs and develop a bundle of activities aimed at improving care and reducing the infection. Our team developed a bundle focusing on 2 basic principles: using catheters only when indicated, and the use of aseptic technique at all points of care.
When we were finished, our full bundle consisted of these elements:
- Place indwelling urinary catheters only when team-approved recommendations for indwelling catheter usage are met:
- OR cases lasting > 4 hours
- Continuous monitoring of urine output in critically ill patients
- Management of acute urinary retention and/or urinary obstruction
- Assistance in pressure ulcer healing for the incontinent patient
- Improved comfort in end-of-life care
- Patients with abnormal genitourinary (GU) systems
- Oncologic-specific indications to assist in prevention of potential radiologic contamination, to promote bladder emptying, and to prevent harm to bladder lining during certain chemotherapy protocols
- Insert urinary catheters using aseptic technique
- Maintain urinary catheters based on principles of asepsis, and position patient and collection device to assist in urine drainage.
- Review urinary catheter necessity daily, and remove promptly when indications are no longer met.
We implemented small tests of change and vigorously monitored our outcomes. Our first test of change was to evaluate catheter necessity on a small group of patients in one high-risk unit. When it was shown that this was linked to a reduction in catheter days in 1 area, this was rolled out sequentially to all high Foley catheter utilization care delivery areas.
The next thing we evaluated was compliance with aseptic technique with catheter insertion. We supported this intervention by the development and implementation of intensive training for all providers on Foley catheter insertion. Working as a team, we trained close to 1,500 clinicians in 3 months, and we have moved that same training into new nurse onboarding and nurse preceptor education.
This work was innovative as it was not localized to one professional group, department, or unit. The team that generated and implemented the recommendations was composed of a cross section of the hospital at large; the team involved supply chain analysts, researchers, infection prevention specialists, radiology technicians, nurses, and physicians. Our goal was to reduce our CA-UTI rate by 50% in 1 year. Reduction of total indwelling catheter days by 25% was the secondary outcome measure based on our team’s hypothesis that the duration of catheter placement was the most important risk factor in the development of CA-UTI.
Following re-education of both nurses and physician providers on proper insertion of Foley catheters and on the CA-UTI prevention bundle, there was a 51% reduction in the median monthly CA-UTI rate within the first 12 months, and a 71% reduction by the end of 36 months. We believe that our success was a result of a multidisciplinary team approach to this problem. We needed research staff to help us evaluate our institution as compared with our peers.
We needed supply chain analysts to help determine if changes in our Foley catheter kits would improve aseptic technique. We needed to educate ordering providers on the indications for ordering a Foley catheter, and we needed to educate nurses on the care and maintenance of these devices. Focusing on one group may have impeded our progress initially. Instead, the multidisciplinary approach allowed us to touch groups throughout the institution, allowing us to make notable, sustainable change.
In an effort to sustain our goals and reduce our rate of CA-UTI further, our group conducts bedside reviews on patients with CA-UTI. Each review is evaluated for a lapse that may have put the patient at risk and, if identified “just in time,” training is implemented. We continue to work as a team, and through this partnership we hope to provide the best care to our patients.