The second step was to identify a realistic and achievable goal. A goal of a 20% reduction from our current utilization rate was selected. As our catheter utilization rates were consistently above 90%, we aimed to for a rate of less than 70%. In addition, we sought to reduce our CAUTI standardized infection ratio (number of health care–associated infections observed divided by the national predicted number) from 3.875 to less than 1.0.
In reviewing our current nursing practice and processes, we utilized the CUSP data collection tool and adapted it to meet our institutional needs. Figure 1 shows the original CUSP data collection tool, which is organized around 5 key questions about the catheter (eg, Is catheter present? Where it was placed? Why does the patient has a catheter today?) as well as lists appropriate and inappropriate indications.
To implement the guidelines, we provided education to the nursing staff via emails, placed posters on the unit, and discussed appropriate and inappropriate indications during bedside conversations using the audit tool. As the project continued, these guidelines were reinforced daily when the question “why does your patient have a catheter today?” was posed to the nurses during the audit. Our chief nursing officer supported our implementation efforts by including a CAUTI prevention lecture with her monthly house-wide nursing education series called “lunch and learn.”
We added additional questions to the tool as we learned more about the practices and processes that were currently in use. For example, “accurate measurement of urinary output in the critically ill patient” was the most common reason given by nurses for keeping a catheter in. Upon further questioning, however, the common response was that “the doctor ordered it.” By adding “MD order” to the audit tool, we were able to track actual orders versus nurses falling back on old patterns. This data collection item also provided us the names and groups of physicians to approach and educate on our project goals. Two other helpful items added to the tool related to the catheter seal and stat lock (catheter securement device) placement. The data provided by these questions helped us recognize areas for improvement in nursing practice, supply issues, and the impact of other departments. For example, auditing showed that most of our catheters were placed in the emergency department (ED) and surgery. This gave us an opportunity to reach out to these units to discuss CAUTI reduction strategies. For example, after review of the ED catheter supplies, we discovered that they did not have a closed catheter insertion system with a urometer drainage bag. Therefore, when a patient was transferred to the ICU, the integrity of the urinary collection system had to be broken to place a urometer. Evidence has shown that breaking the integrity of the system increases a patient’s risk for a CAUTI [1]. Once this problem was identified, the ED inventory was changed to include the urometer as part of the closed system urinary insertion kit.