Running head: EBP PART II ANALYSIS 1

EBP Part II Analysis

Savannah C. Dillender

James Madison University

EBP PART II ANALYSIS 2

EBP Part II Analysis

As nurses, providing education to our hospitalized patients and staff regarding their own

catheter care is an essential part of preventing catheter associated urinary tract infections

(CAUTI). Staff should also be educated with the most current best practice catheter care

recommendations. Many patients and healthcare staff do not comply or are unsure of the correct

techniques for handling foley catheters. The aim of my PICO question is to discover if educating

our staff will help decrease CAUTI rates. In hospitalized medical surgical patients with Foley

catheters increasing the risk for CAUTI, how do current catheter care techniques compared to

using existing hospital protocol (catheter care) reduce risk of CAUTI infections (O)?

Upon reviewing eight research articles related to catheter care, and ways to decrease

CAUTI occurrence, I have found that education is the key to eliminating CAUTIs in the hospital

setting. Educating nurses is not enough, we need to educate patients, families, and doctors on the

use, need, and how to properly clean and maintain a foley catheter. Nurses need to understand

that CAUTIs do not only affect the patients health, but also length of stay, and cost the hospital

reimbursement from health insurances.

To decrease or eliminate CAUTIs, first nurses must understand what a CAUTI is.

According to the CDC a CAUTI is, a UTI where an indwelling urinary catheter was in place for

>2 calendar days on the date of event, with day of device placement being Day 1, and an

indwelling urinary catheter was in place on the date of event or the day before (CDC, 2017).

The CDC goes on to say, that about 12-16% of adults that stay impatient in the hospital will end

up having a catheter at some point in their hospital stay (CDC, 2017). CAUTIs and UTIs alike

are preventable if we as healthcare professionals learn the correct technique on how to take care

of foleys. A common theme among CAUTI research is education. CAUTIs are preventable if
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we just educate our staff, including doctors. Education includes but is not limited to, how to

insert/remove, how to maintain, reasons to maintain a foley catheter, and removing them in a

timely manor.

Once a CAUTI is discovered the hospital pays for all the care of the CAUTI. The cost of

a CAUTI is approximately $6,913.00. A study that was done at Swedish Medical Center First

Hill Campus in Seattle Washington, proved that nurses can be the first to help educate other

nurses. This study started with only four nurses, two on day shift and two on night shift. They

not only wanted to educate nurses but also family, and other staff. By making posters, holding

information sessions, and educating this hospital decreased their CAUTI rate. These group of

nurses were able to meet their goal of cutting CAUTI rates to 50% in nine months, they

surpassed that goal of only having one. This was compared to their previous 12 in the same

period the pervious year (Gattis, 2016).

Within review of Henrico Doctors Hospital protocol, foley catheters are only to be left in

place if: they were ordered or placed by a urologist, ordered by a surgeon, palliative care for

hospice or end- of- life comfort care patients, management of incontinent patients with stage III

or IV pressure ulcer of the perineal/sacral area, urinary retention (enlarged prostate, edematous

scrotum/penis, new onset neurologic disease or medication effect) unresolved by other

interventions, strict I&O in cases where patient cannot participate in collection and measurement,

and patient requires immobilization as part of acute therapeutic plan of care (Headen 2014).

Nurses have the responsibility to question the continueation of a foley catheter. If a patient

hospitalized at Henrico Doctors Hospital does not meet the foley continuation criteria listed

above, by 11 am to keep the foley catheter then the foley must be removed.

Secondly, regarding education on the correct and serile techniquie for indwelling catheter
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insertion, Henrico Doctors Hospital has a protocol. First and foremost, always maintain a sterile

field. Once you have the patient prepped with clean gloves on, open the foley catheter container

making sure the table you are opening it on is at waist level or higher. Then, proceed to open the

sterile container with the last flap opening toward you. With every hospitals kits looking slightly

different, the sterile gloves should be next. Once the sterile gloves are on, nothing should be

touched that is not in the sterile kit, due to breaking the sterile field. You would then drape the

patient with the white draping cloth. At this point you would be getting the lubricant syringe

emptied in the correct square, attach the water syringe to the foley catheter hub. Depending on

the kit, wither iodine swabs or iodine liquid are used to cleanse the patients perineal area. Using

your non-dominant hand place the hand on the patient and from there it does not move off the

patient. That is now considered your dirty hand. With the dominant hand, cleanse one side of the

perineal are, second swab with the other the other side, and finally with the third straight down

the middle. Finally you dip the tip of the catheter into the lubricant and insert (Headen, 2014).

During my research, I have found this to be the most correct and sterile way to insert an

indwelling catheter.

Preventative measures for CAUTI such as catheter avoidance strategies, hand hygiene,

perineal care, and daily necessity review to limit catheter days have been associated with

decreased CAUTI rates in ICU, (Galiczewski & Shurpin, 2017). This particular study

completed in the medical intensive care unit by Galiczewski and Shurpin, showed positive

results while having direct observation during the insertion of a foley catheter. There were two

phases of this study, phase I was looking at the charts and research, while phase II focused on the

direct observation of the insertion technique. For this study, the direct observer had a checklist

with yes/no answers in accordance with their policy. The monthly rate of a CAUTI can range
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anywhere from 0-3.26 per 1000 catheter days, phase I mean was 2.24. The overall mean monthly

rate of CAUTI in the medical ICU decreased from 2.24 to 0 per 1000 catheter days in phase II.

Reducing the incidents of CAUTI not only improves patient outcomes, but can also decrease

medical costs. One of the checklist elements required the observer to choose a reason for catheter

use from a list of 10 hospital-approved indications for catheter insertion. Greatly helps the

number of foley insertions and helps to decrease potential CAUTIs.

For males, the use of a urinary catheter should be avoided if they have an enlarged

prostate. The use of a foley catheter could cause urinary retention. However, there are specialty

catheters that urologist can use if they are needed or the physician orders they foley to be placed.

The use of latex verses silicone catheters are also being researched. In a study that was published

within a Pennsylvania hospital showed that latex catheters should be avoided due to stricture

formation. Silicone catheters cause less strictures and less bladder irritation; they are also less

prone to obstruction by encrustation. Whether there is an added benefit to using silver-coated

silicone catheter is unclear, but it appears that their use could decrease CAUTI rates (Cabrera-

Cancio, 2012).

Finally, when discussing ethical or legal issues throughout the research process, there

were none found. Most of the issues in the studies I examined were the fact that most of the

research that has been done, has been on intensive care units. For my own personal practice I

would like to adapt the direct observer into my practice. Having someone else in the room will

help hold you accountable within your own actions.

In conclusion, education is the key to preventing CAUTIs. While these different research

articles can tell you different way to decrease CAUTIs, the biggest thing is to just stay on top of

education. In hospitalized medical surgical patients with Foley catheters increasing the risk for
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CAUTI, how do current catheter care techniques compared to using existing hospital protocol

(catheters care) reduce risk of CAUTI infections (O)? One take away that I will be

implementing in my current practice will be direct observation. When there is someone there that

can hold you accountable to every move and every action in that time, that makes us want to do

better.
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References

CDC (2017, January ). Urinary Tract Infection (Catheter-Associated Urinary Tract Infection

[CAUTI] and Non-Catheter-Associated Urinary Tract Infection [UTI]) and Other Urinary

System Infection [USI]) Events. , 1-17. Retrieved from

https://www.cdc.gov/hai/ca_uti/uti.html

Cabrera-Cancio, M. R. (2012, June). Infections and the Compromised Immune Status in the

ChronicallyCritically Ill Patient: Prevention Strategies. , 57(6), 979-991.

Fletcher, K. E., Tyszka, J. T., Harrod, M., Fowler, K. E., Saint, S., & Krein, S. L. (2016, October

1). Qualitative validation of the CAUTI Guide to Patient Safety assessment tool. , 44(10),

1102-1109. http://dx.doi.org/10.1016/j.ajic.2016.03.051

Fonseca Andrade, V. L., & Veludo Fernandes, F. A. (2015, November 07). Prevention of

catheter-associated urinary tract infection:implementation strategies of international

guidelines. , 1-8. http://dx.doi.org/10.1590/1518-8345.0963.2678

Galiczewski, J. M., & Shurpin, K. M. (2017). An intervention to improve the catheter associated

urinary tractinfection rate in a medical intensive care unit: Direct observation of catheter

insertion procedure. , 1-9. Retrieved from http://dx.doi.org/10.1016/j.iccn.2016.12.003

Gattis, S. (2016, May 17). CAUTI Nearly Eliminated, Major Savings from Nursing Project. ,

41(6), 1-3.

Gittlen, S. (2016, March). Slashing CAUTI Rates. , 48-51.

Halperin, J. J., Moran, S., Prasek, D., Richards, A., Maund, C., & Ruggiero, C. (2016, June 27).

Reducing Hospital-Aquired Infectinos Among the Neurologically Critically Ill. , 170-

177. http://dx.doi.org/10.1007/s12028-016-0286-2

Headen, B. (2014, August ). Foley Catheter Removal and Insertion Policy and Protocol. , 1-2.
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Lo, E., Nicolle, L. E., Coffin, S. E., Gould, C., Maragakis, L. L., Meddings, J., ... Yokoe, D. S.

(2014, May). Strategies to Prevent Catheter-Associated Urinary Tract Infectionsin Acute

Care Hospitals: 2014 Update. , 35, 464-478. Retrieved from

http://www.jstor.org/stable/10.1086/675718

Meddings, J., Saint, S., Fowler, K. E., Gaies, E., Hickner, A., Krein, S. L., & Bernstein, S. J.

(2015, May 5). The Ann Arbor Criteria for Appropriate Urinary Catheter Use

inHospitalized Medical Patients: Results Obtained by Using theRAND/UCLA

Appropriateness Method. , 162(9), 1-30. http://dx.doi.org/10.7326/M14-1304

Smith, A., Fitzpatrick, T., & Kruger, P. (2017, March). Measuring CAUTI in ICU: Urine for

dissapointment. , 30(2), 130. Retrieved from http://dx.doi.org/10.1016/j.aucc.2017.02.057

Tedja, R., Wentink, J., OHoro, J. C., & Thompson, R. (2015, July 20). Catheter-Associated

Urinary Tract Infections in Intensive Care Unit Patients. , 36(11), 1330-1334.

http://dx.doi.org/10.1017/ice.2015.172