Purpose: This quality improvement project aimed to achieve and sustain a significant reduction in the incidence of catheter-associated urinary tract infections (CAUTIs) in a surgical population.
Background/significance: CAUTI is a preventable harm. In fiscal year (FY) 2017, a 26-bed high-acuity surgical unit in a large academic medical center had a total of 12 CAUTIs, the highest in the health system. Our leadership team and unit practice council (UPC) conducted a comprehensive evaluation of current practices and find ways to decrease CAUTIs.
Methods: The UPC and unit leaders partnered to perform iterative problem-solving and process improvements using plan-do-study-act (PDSA) cycle. CAUTI incidents were analyzed through mini-root cause analyses to identify causal trends (e.g., high indwelling catheter days, inconsistent or missed hygiene, inappropriate urine culture practices, and other system-level challenges). A comprehensive synthesis of the best available evidence and subject matter expert consultation was completed to determine best practice recommendations. Staff received UPC-led education, and accountability systems were implemented to ensure consistent practice, including active daily management and chart audits.
The PDSA cycle was engaged with each relapse of CAUTIs, and during the last cycle, a CAUTI prevention education bundle was designed and implemented as an effective, cost-efficient intervention that addressed knowledge-practice gaps and improved care quality [1,2] while consolidating and building upon interventions from prior cycles. Ten-minute one-on-one education using teach-back methods was completed with each registered nurse (RN) in April 2021 and care partner (CP) in July 2021.
The education bundle addressed catheter insertion and removal, clinical indications for urine culture and proper specimen collection, timely catheter removal, the use of external urinary devices, and catheter care. Unit leaders performed active daily management to ensure ongoing compliance with CAUTI prevention practices. The UPC
reviewed data each month using descriptive statistics, and milestones were recognized during pre-shift huddles and staff meetings.
Results: The unit achieved a 9-month (March 2018 – November 2018), 8-month (May 2019 through January 2020), and ultimately 12-month period since July 2021, with zero CAUTIs. The unit also had a significant decrease in average monthly catheter days, from 262 in FY17 to 189 in FY22. Active daily management and chart audits continued to be done and deviations from best practice were promptly addressed.
Conclusions/implications: The UPC and unit leadership used a structured quality improvement tool, PDSA, and then applied resulting multimodal interventions to reduce CAUTIs. These included clarifying and educating on best practices, creating multi-layered audit and accountability systems, and electronic health record improvement.
By periodically returning to the PDSA cycle, and continuing to identify gaps and solutions, the unit was able to sustain a significant reduction in CAUTIs. Some barriers identified were periodic staffing level fluctuations and the use of temporary staff, as well as variations in physician practices in catheter discontinuation. This continuous quality improvement approach is an effective, evidence-based process that sustainably reduced CAUTIs in a high-acuity surgical population and translates well for any institution facing challenges with CAUTI to identify root causes that threatens the quality and safety of care.
Evidence-based references
1. Ferguson, A. (2018). Implementing A CAUTI prevention program in an acute care hospital setting. Urologic Nursing, 38(6), 273. https://doi.org/10.7257/1053-816x.2018.38.6.273
2. Gesmundo, M. (2016). Enhancing Nurses’ Knowledge On Catheter-Associated Urinary Tract Infection (CAUTI) Prevention. Kai Tiaki Nursing Research, 7(1).