Urinary tract infections are among the most common hospital acquired infections

Urinary tract infections are among the most common hospital acquired infections. Over 75% of hospital acquired UTI’s are associated with an indwelling urinary catheter (IUC) (CDC, 2009). In many cases, catheters are placed for inappropriate indications, and healthcare providers are often unaware that their patients have catheters, leading to prolonged, unnecessary use (CDC, 2009).
There are many health risks associated with the development of a catheter acquired urinary tract infection. The occurrence of a UTI often results in a longer hospital stay, compromising the patient’s safety and placing them at increased risk for developing additional health care acquired illnesses. CAUTI is the leading cause of secondary nosocomial bloodstream infections, with a reported mortality of about 10% (CDC, 2009). The most frequent pathogens associated with CAUTIs in hospitals are Escherichia coli (21.4%), Candida spp (21.0%), Enterococcus spp (14.9%), and Pseudomonas aeruginosa (10.0%) (CDC, 2009). Additionally, there has been an increasing prevalence of bacterial antibiotic resistance. The Centers for Disease Prevention and Control (CDC) (2009) reported “About a quarter of E. coli isolates and one third of P. aeruginosa isolates from CAUTI cases were fluoroquinolone-resistant” (p. 24).
Many issues can arise from a physician driven urinary catheter removal protocol. A majority of these issues stem from leaving a Foley catheter in place for longer than medically necessary. Since nurses insert most indwelling urinary catheters, physicians are not as likely to consider removing a catheter because their interaction with them is quite limited (Johnson, Gilman, Lintner, & Buckner, 2016). The longer an IUC is in place, the greater the risk of infection becomes for a patient (CDC, 2009). CAUTIs can often be prevented using thorough evaluation and evidence-based practice.
The objective of this study is to examine research that has been conducted with the implementation of a nurse driven Foley catheter removal protocol to propose a quantitative research proposal for future research.
Nursing Research/PICOT Question
For patients with Foley catheter placement, will the use of a nurse driven removal protocol reduce the incidence of catheter acquired urinary tract infections, when compared with that of physician ordered removal?
Importance to Nursing
Part of a nurse’s role is to serve as the patients advocate. Not only does this include providing resources needed but also helping to discontinue those no longer needed, such as urinary catheters. CAUTIs are one of the most common hospital-acquired infections in the United States, leading to additional expenses, longer hospital stays, and increased patient morbidity (Durant, 2017). Reduction in the incidence of CAUTI will provide many benefits to both the patient population and health care facilities. In October 2008, the Centers for Medicare ; Medicaid Services ceased reimbursements for the costs of increased care resulting from a hospital-acquired CAUTI (Durant, 2017). Decreasing the incidence of CAUTIs is vitally important in reducing healthcare costs. These reductions seen in CAUTI can help to cause a subsequent decline in hospital stay times. Additionally, antibiotic resistance has become an increasingly more prevalent problem since the recent rise seen in CAUTIs. The Centers for Disease Prevention and Control (CDC) (2009) report “urinary drainage systems are often reservoirs for multidrug resistant bacteria and a source of transmission to other patients” (p. 22). A reduction in HAI’s will help to decrease and prevent the development of additional resistant bacterial strains.
Review of Literature
A literature review was conducted using the following key words: catheter acquired urinary tract infection, nurse-driven protocols, incidence of UTIs, UTI prevention, and evidence-based practice. The search yielded a wide variety of information regarding studies that had been conducted that investigated the use of nurse-driven protocols in a variety of different settings. Included among these settings was the implementation of nurse-driven protocols in intensive care units, oncology, and teaching hospitals. Topics discussed included proper insertion of indwelling urinary catheters, aseptic technique, and infection control.
Johnson et al (2016) conducted a study that investigated, implemented, and examined an evidence-based nurse-driven protocol for reducing rates of CAUTI. This study took place in four intensive care units and involved the implementation of nurse-driven orders for catheter removal. Additionally, education was provided to staff on the appropriate care and maintenance of urinary catheters. Data was collected for a period of 8 months for both pre- and post-implementation. A 28% reduction was seen in the incidence of CAUTI when compared with that of pre-implementation (p. 352).
A study conducted in a southern California hospital focused on the incidence of CAUTI in immunosuppressed patients that were admitted to an oncology unit (McCoy, Paredes, Allen, Blackey, Nielsen, Paluzzi, & … Radovich, 2017). Creators of this study reviewed CAUTI prevention measures and compared them with current research. They then developed a standardized protocol to implement for patients with IUC on the oncology unit. These changes were supported by evidenced-based practice and involved the implementation of a nurse driven protocol. As part of this study nurses were required to complete an IUC documentation. Included in this documentation was a list of IUC catheter indications and patient-family caregiver education regarding the indwelling catheter. Additional interventions put in place included a “keep me low” sticker for IUC bags, photographs depicting optimal placement of the urinary collection bag, and procedural emptying of the collection bag before the patient left the unit. All these implications were aimed at reducing the occurrence of urinary reflux, a common cause of CAUTI. Evaluation of this study included review of CAUTI incidence, number of IUC days, and nursing adherence. Nursing adherence to this newly implemented protocol showed an improvement of 90% from the original 66% within only two months (p. 463). Additionally, pericare documentation increased to 90% by the seventh month of the study. An evaluation of data from 2014 to 2016 showed a reduction in CAUTIs from 14.32 in 2014 to 11.79 in 2016 per 1,000 catheter days (p. 463).
The use of nurse-driven removal protocol system appears to be successful in reducing the incidence of CAUTIs. Equally important, is a nurse’s perception of this potential protocol. One study evaluated nurse perceptions of a nurse-driven urinary catheter removal protocol at a teaching hospital (Olson-Sitki, Kirkbride, ; Forbes, 2015). A survey was conducted four months following the implementation of a nurse driven protocol. The study included a survey that evaluated nurses’ perceptions on the influence of an IUC nurse-removal protocol on job satisfaction, job ease, empowerment, patient feedback, and physician feedback. Each category measured was rated using terms “better”, “worse”, and “no impact”. Of the individuals who completed the survey, 71% reported better job ease and 80% reported a greater sense of empowerment (p. 96-97). Data regarding physician feedback and job satisfaction remained unchanged. However, patient feedback experienced a large increase to 95% (p. 98). Additional feedback provided included a reported increase in nurse-physician feedback and communication regarding IUCs.