Transcript What impact does a nurse training program designed to

What Impact Does a Nurse Training Program
Designed to Decrease Urinary Catheter Use
Have on Bacteruria Rates in the Community
Hospital Setting?
Jamie Bartley DO, Diane Lenk MSN, RN, Janet Moody BSN, RN, Amy Brode DO.
From the Division of Urology, Wound Care Nursing, and The Infectious Disease
Department.
Botsford Hospital, Farmington Hills, MI
Introduction

Urinary catheters are one of the most common
causes of nosocomial infections in the
hospitalized patient



Patients with an indwelling foley catheter have a risk
of bacteruria at 5% per day
Symptomatic urinary tract infection has been shown
to occur in 20% of patients with bacteruria
Urinary catheters are often placed without a clear
indication for need
Hypothesis


We believe that a nursing education
program through the “Keystone Project”
will decrease non-indicated catheter use in
hospitalized patients
Secondary analysis: We suspect this will
decrease the prevalence of positive urine
cultures
“Indicated vs. Non-Indicated Foley”
Nursing Inservice

Beginning fall 2007, nurses were
inserviced on indications and nonindications for foley catheters
Urinary tract obstruction
Neurogenic bladder
Urologic study/urologic surgery
Stage 3 or 4 pressure ulcer
Hospice, comfort care
or palliative care only
Figure 1: Indications for Urinary Catheter Use
Nephrology
Transferred from ICU
Patient requests
Confused
Incontinence
Other
Figure 2: Non-Indications for urinary catheter use
Collection of Catheter Data

Catheter use was documented for one week (MondayFriday) and recorded on two units according to the dates
below.
5 South Data Collection Dates
Weeks 1-3 October 8-26, 2007  Pre-education data
Week 8 November 26 - 30, 2007
1st Quarterly March 3 - 7, 2008
2nd Quarterly July 14 - 18, 2008
3rd Quarterly October 27 -31, 2008
Post-education data
PCU Data Collection Dates
Week 1-3 Feb 18 - March 7, 2008  Pre-education data
Week 8 April 7 - 11, 2008
1st Quarterly July 28 - August 1, 2008
Post-education data
2nd Quarterly September 22 - 26, 2008
3rd Quarterly December 8 -12, 2008
Collection of Urine Culture Data

Information on patients with bacteruria was
obtained from the Infectious Disease
Department


Bacteruria= >10^2 CFUs
A retrospective chart review

Did patients with bacteruria had a foley catheter and
if so, was it was indicated according to the above
criteria?
Study Population


Pre-intervention- n = 1223 (378 and 845)
Post Intervention- n = 1737 (608 and
879)
RESULTS

Logistic regression analysis and Odds
Ratios (95% confidence limits) were
performed to determine if there was a
statistically significant decrease (a=0.05)
in non-indicated foley catheter use
PCU Catheter Results
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Pre-Pilot
Week 8
1st Qtr-08
2nd Qtr-08
3rd Qtr-08
% Patients w/ Foleys
30%
34%
20%
19%
15%
% Indicated Foleys
34%
40%
59%
37%
34%
% Non-Indicated Foleys
66%
60%
41%
63%
66%
PCU Catheter Results
Odds Ratios
(95% confidence limits)
Time
Week 8
P-values
0.75 (0.46 , 1.23)
0.2551
0.36 (0.20 , 0.64)
0.0005*
0.85 (0.47 , 1.53)
0.5902
0.97 (0.47 , 2.00)
0.9402
(compared to pre-intervention)
Quarter 1
(compared to pre-intervention)
Quarter 2
(compared to pre-intervention)
Quarter 3
(compared to pre-intervention)
Contrast
Pre-education Mean Post- education
P-value
< 0.0001*
* statistically significant for α=0.05
5 South Catheter Results
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Pre-Pilot
Week 8
1st Qtr-08
2nd Qtr-08
3rd Qtr-08
% Patients w/ Foleys
35%
36%
40%
33%
27%
% Indicated Foleys
60%
76%
83%
78%
90%
% Non-Indicated Foleys
40%
24%
17%
22%
10%
5S Catheter Results
Table 3: Outcome – Non-indicated foley use
Odds Ratios
(95% confidence limits)
Time
Week 8
P-values
0.49 (0.24 , 0.99)
0.0466*
0.32 (0.15 , 0.66)
0.0022*
0.43 (0.20 , 0.92)
0.0286*
0.18 (0.06 , 0.52)
0.0017*
(compared to pre-intervention)
Quarter 1
(compared to pre-intervention)
Quarter 2
(compared to pre-intervention)
Quarter 3
(compared to pre-intervention)
Contrast
Pre-education Mean Post- education
P-value
< 0.0001*
* statistically significant for α=0.05
Does the decrease in catheter
use we see lead to a decrease in
bacteruria?
Our ultimate Goal Prevention of
CAUTI
5S and PCU Urine Culture Data
100%
3.0%
90%
2.5%
80%
%
P
a
2.0%
60%
50%
1.5%
T
I
40%
E
n
30%
T
s
1.0%
20%
0.5%
10%
0%
Pre-Pilot
Post-Pilot
% Patients w/ Foleys
32%
26%
% Urine Cultures with Indicated or
no Foley
90.3%
77.4%
% Urine Cultures with Non-Indicated
Foley
9.7%
22.6%
% + Urine Cultures
2.5%
1.8%
0.0%
% Positive Urine Cultures
70%
Can Decreasing Catheter Use
Decrease Bacteruria?


Urine culture data was analyzed using Fisher’s exact test to
determine if there was a decrease in the incidence of positive
urine cultures after the foley education program was
instituted
A decrease in percentage of positive urine cultures* was
seen but it did not reach statistical significance (2.5%, 1.8%)
Fisher's Exact Test
Two-sided Pr <= P
0.1921
*Note: This was determined by the number of positive urine cultures per total
patient population, not total number of urine cultures. Since data was provided
only on positive urine cultures, it is assumed that the other patients without
cultures taken were either not indicated or were negative (this may represent a
sample bias)
Results

Of interest (though not significant)

Most of the positive urine cultures in our data
were seen in patients with an indicated
catheter in both the pre-education and posteducation periods (90.32% and 77.42%)
Discussion



Decreasing hospital acquired infections is
necessary to decrease patient morbidity and
mortality
Financial incentive to hospital due to no
reimbursement for “reasonably preventable
infections (including CAUTI)
Certain factors such as patient population will
greatly influence the success of such a program

PCU, compared to 5S, was 4 times more likely to have
a non-indicated foley (p<0.001).
Conclusion



A nurse training program can be successful in
decreasing foley catheter use when it may not
be appropriate
The effect on decreasing bacteruria by
decreasing catheter use was not proven in this
study
The majority of positive urine cultures still occur
in patients who have a medical reason to have a
foley in place. Improved infection control
techniques are needed for this high-risk
population
References
1.Cravens, DD., Zweig, S. Urinary catheter management. American Family
Physician. 61 (2): 369-76, 2000 Jan 15
2. Hart, S. Urinary catheterization. Nursing Standard. 22(27): 44-8, 2008 Mar
12-18
3. Hashmi, S., Kelly, E. Rogers, SO. Urinary tract infection in surgical patients.
American Journal of Surgery. 186(1) 53-6, 2003, Jul
4. Lo, E., Nicolle, L., et al. Strategies to prevent catheter-associated urinary tract
infections in acute care hospitals. Infection Control and Hospital
Epidemiology. 29(1), 2008, Oct
5. Maki, DG., Tambyah, PA. Engineering out the risk for infection with urinary
catheters. Emerging Infectious Diseases. 7(2), 2001 Mar-Apr
6. Saint, S., Chenoweth, CE. Biofilms and catheter-associated urinary tract
infections. Infectious Disease Clinics of North America. 17(2): 411-31, 2003
Jun
7. Saint, S., Lipsky BA. Preventing catheter-related bacteriuria: should we? Can
we? How? Archives of Internal Medicine. 159(8): 800-8, 1999 Apr 26
8. Sedor J., Mulholland, SG. Hospital Acquired urinary tract infections
associated with the indwelling catheter. Urologic Clinics of North America.
26(4): 821-8, 1999 Nov
9. Trautner, B.W., Darouiche, R.O. Catheter-associated infections: pathogenesis
affects prevention. Archives of Internal Medicine. 164(8): 842-50, 2004 Apr
26