Preventing Catheter-Associated UTIs in Acute Care Hospitals

Section 6: Examples of Implementation Strategies

Accountability is an essential principle for preventing HAIs. It provides the necessary translational link between science and implementation. Without clear accountability, scientifically based implementation strategies will be used in an inconsistent and fragmented way, decreasing their effectiveness in preventing HAIs. Accountability begins with the chief executive officer and other senior leaders who provide the imperative for HAI prevention, thereby making HAI prevention an organizational priority. Senior leadership is accountable for providing adequate resources needed for effective implementation of an HAI prevention program. These resources include necessary personnel (clinical and nonclinical), education, and equipment ( Table 3 ).

Interventions to assist with program implementation that have been reported to be associated with improved outcomes are provided in this section. The references provided are published studies of CAUTI quality improvement projects that specifically describe outcomes. These programs are normally multifactorial and include elements of most or all of the 4 categories of implementation approaches. Practical approaches for problem solving of potential barriers to implementation are provided in Table 4 .

I. Engage

Quality improvement projects directed toward improving compliance with CAUTI guidelines have used various techniques to engage the hospital staff to raise awareness of the issue and increase buy-in.

A. Develop a multidisciplinary team

1. 
   Physician-led team
   
2. 
   Nursing-led team
   
3. 
   Leadership of team not specified
   

B. Involve local champions to promote the program

C. Utilize peer networking

II. Educate

Education of the hospital staff can include in-person sessions or educational material available in paper format or electronically. The educational sessions may outline the evidence behind the guidelines, indicate the goals of the program, and target specific aspects of CAUTI prevention.

1. 
   Provide educational sessions
   
   1. 
      Appropriate catheter care
      
   2. 
      Appropriate indications for catheter insertion
      
   3. 
      Insertion technique
      
   4. 
      Hand hygiene education
      
   5. 
      Physician-directed education
      
   6. 
      Alternatives for indwelling catheters
      
   
   
   
2. 
   Provide educational materials
   
   1. 
      Indications for urinary catheter utilization
      
   2. 
      Decision-making algorithim
      
   3. 
      Bedside binders
      
   4. 
      Unit-based educational materials
      
   5. 
      Online learning materials
      
   6. 
      Patient/family educational materials
      
   
   
   

III. Execute

The process for making quality improvement changes employs new protocols and algorithms. Interventions may be grouped into "bundles" of practices to be implemented simultaneously. Computer order entry is also increasingly being used to prompt change.

1. 
   Standardize care processes
   
   1. 
      Provide daily nursing reminders to physicians to remove unnecessary catheters
      
   2. 
      Standardize indications for urinary catheter placement
      
   3. 
      Utilize bladder bundle
      
   4. 
      Develop a nurse-driven protocol to discontinue catheter if no longer meeting criteria
      
   5. 
      Employ computerized order entry
      
      1. 
         Admitting physician alert requiring confirmation of continued indication for previously placed catheters
         
      2. 
         Change of physician order set from "insert Foley catheter" to patient-initiated "void on call" for appropriate procedures
         
      3. 
         Mandatory order to remove catheter at 5 days
         
      4. 
         Best-practice order sets
         
      
      
      
   6. 
      Use prewritten stop orders
      
   7. 
      Utilize bladder scanners to measure urine volume
      
   8. 
      Standardize products
      
   9. 
      Increase availability of bedside commodes
      
   10. 
       Conduct individual case reviews
       
   11. 
       Create redundancy of educational materials
       
       1. 
          Posters in units
          
       2. 
          Pocket cards
          
       
       
       
   
   
   

IV. Evaluate

The success of a CAUTI quality improvement program can be measured by decreased rates of CAUTI, by decreased catheter-days, and by uptake of a new intervention. Most programs have found that providing feedback to the hospital or unit increases awareness.

1. 
   Measure performance
   
   1. 
      Compliance with bundle
      
   2. 
      Compliance with hand hygiene
      
   
   
   
2. 
   Provide feedback to staff
   
   1. 
      CAUTI rates by ward
      
   2. 
      CAUTI rate by hospital
      
   3. 
      Hand hygiene rate
      
   4. 
      Catheter care compliance
      
   5. 
      Costs of UTI