The industry-wide focus on reducing hospital-acquired infections (HAIs) and the growing movement for nurses to practice more autonomously have intersected in an interesting way: emerging evidence supports the idea that a simple nurse-directed intervention can reduce rates of catheter-associated urinary tract infections (CAUTIs).
Urinary tract infections are the most common type of hospital-acquired infection, accounting for between 30 and 40 percent of the HAIs reported by hospitals. Because of this high incidence, the overall costs to the healthcare system are staggering, with an estimated $451 million spent annually in the United States to manage these infections. And up to 80 percent of these hospital-acquired UTIs are correlated with the use of an in-dwelling urinary catheter.
In 2008, Medicare deemed CAUTIs to be a preventable adverse event and stopped reimbursing hospitals for treating these infections. And ever since then, hospitals have been diligently reviewing policies and implementing strategies designed to prevent CAUTIs. Nurses who manage in-dwelling urinary catheters in medical units, surgical units, and the intensive care unit (ICU) should always adhere to the core prevention strategies outlined by the CDC. The primary goal is to minimize catheter use in all patients—and to avoid using catheters for the convenience of the nursing staff (e.g. as a way to prevent falls or manage incontinence).
Studies suggest that as many as half of all catheterized patients have no clear indication for their in-dwelling catheters. On surgical units, nearly 50 percent of patients remain catheterized beyond the recommended 48-hour post-operative period. Many of these are “forgotten catheters” that remain in place because of a lack of clear orders for their removal. Because of this, some hospitals are now writing protocols for nurse-directed catheter assessment and removal, which allows nurses to initiate an intervention without a physician’s order.
While protocols vary between hospitals, the process generally works something like this:
- On a daily basis, nurses assess all catheterized patients for conditions that indicate continued catheter use. They may use a standardized checklist to help them review all of the relevant factors, like how much time has passed since a post-op catheter was placed.
- If indications for continued use are present, nurses will monitor and manage the catheter according to infection control guidelines—and continue to assess the need for the catheter on a daily basis.
- If there are no indications that warrant continued use, nurses remove the catheter and assess the need for follow-up care. This may be hourly rounding to assist the patient with toileting, or contacting the physician for further orders if the patient is retaining urine and is unable to eliminate.
- Nurses document their assessments and catheter removals in the patient record, and continue the re-evaluate the patient daily to assess the outcome of the intervention.
In a study published in the American Journal of Infection Control, researchers used an interventional study to measure the effects of a nurse-directed catheter removal protocol. They reported that:
We achieved a 50% hospital-wide reduction in catheter use and a 70% reduction in CAUTIs over a 36-month period, although there was wide variation from unit to unit in catheter reduction efforts, ranging from 4% (maternity) to 74% (telemetry).
Since nurses are the frontline caregivers and patient advocates, it only makes sense for hospitals to empower them to perform autonomous assessments and interventions. In ways like this, nursing practice is becoming more complex, more evidence-based, and more in need of nurses with excellent critical thinking skills.
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