...up to 50% of hospitalized patients who receive an indwelling catheter lack documentation of evidence-based criterion regarding the decision to insert a catheter. The increased pace of care, along with staffing shortages, challenges health care providers in terms of fully documenting care that is provided. Gould et al. (2010) have reported reviews of hospital records indicate that up to 50% of hospitalized patients who receive an indwelling catheter lack documentation of evidence-based criterion regarding the decision to insert a catheter. Failure to adequately document care places the institution at risk, as federal entities no longer assume that appropriate care was provided in the absence of documentation.

Although we have had, for the past 30 years, both guidelines to address the prevention and care of patients with an indwelling urinary catheter infection (Gould et al., 2010) and technological advancements in urinary catheters, catheter-associated urinary tract infections (CAUTIs) remained among the most common of the hospital-acquired infections (Nicolle, 2010). However, recent research and systematic reviews of the literature have led to revisions of the original guidelines.

One of the major, evidence-based, conceptual changes has been to minimize both the initiation and the duration of urinary catheter use... One of the major, evidence-based, conceptual changes in the revised guidelines has been to minimize both the initiation and the duration of urinary catheter use, in contrast to a continued focus on prevention through use of recommended techniques of catheterization and care (Nicolle, 2010). This newer focus is based on the well-known fact that bacterial colonization increases with time (Wald, 2007). This increased bacterial colonization can result in a hospital-acquired infection (HAI), which is an infection that the patient did not have on admission and that may have been preventable by following generally accepted guidelines. A CAUTI is a common HAI, one that involves patient discomfort, fever, increased length of stay, increased costs, and other adverse effects. Thus, when a CAUTI occurs, and there is no documentation of the rationale for the catheter use or its duration, it is no longer assumed that appropriate care was provided. The additional cost of care associated with a hospital-acquired CAUTI has been targeted by the Centers for Medicare and Medicaid Services (CMS) for nonpayment (CMS, 2010). This additional cost of a CAUTI can range from $676 to $2836, thus adding an unnecessary half billion dollar increase to the cost of health care in the United States (US) per year.

In 2009, a CAUTI-preventive, quality improvement (QI) project at a Midwestern, multi-campus, 505-bed hospital was developed over a four-month period and implemented simultaneously with the institution of an electronic health record (EHR) system. The objective of the QI project was to develop a strategy to sustain CAUTI-prevention care practices and prevent CAUTIs through documentation in the EHR, as recommended by the Centers for Disease Control and Prevention (CDC). To meet this objective, an electronic infrastructure related to urinary catheter usage was integrated into the daily electronic workflow of the nurse. Our hospital Information Systems (IS) Department helped us to incorporate components of the CAUTI project into the EHR.

...when a CAUTI occurs, and there is no documentation of the rationale for the catheter use or its duration, it is no longer assumed that appropriate care was provided. The purpose of this article is to describe how our QI team utilized the EHR in a meaningful manner to support, drive, sustain, and demonstrate evidence-based practices (EBPs) in CAUTI prevention care. In this article, I will both describe our QI project that used the EHR to drive catheter-related, evidence-based care and also share our results demonstrating a significant decrease in positive urine cultures, improved catheter care practices, and documentation of evidence-based criterion for catheter utilization. I will conclude by discussing the benefits of using the EHR to decrease urinary catheter usage.

Literature Review

The first step in this QI project was to address the question: Can the EHR assist in driving evidence-based, foley-catheter-care practices?  Multiple search engines were used to search the literature, including the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, and OVID. Urologic nursing periodicals were also searched manually. Websites accessed included the Association for Professionals in Infection Control and Epidemiology (APIC), CDC, and CMS. Articles selected for inclusion in our project included systematic reviews, meta-analyses, and case studies published in the US within the previous five years. Key terms used in the search included: electronic health record (EHR), catheter-associated, urinary tract infection (CAUTI), evidence-based practice (EBP), and clinical decision support (CDS). Appraisal of this current literature noted a greater emphasis on limiting the insertion of foley catheters and minimizing the duration of use. This emphasis was grounded in evidence-based criteria for catheter insertion and recognition that the duration of catheter placement is a risk factor for bacteriuria and a subsequent CAUTI.

The literature search also confirmed that standardized clinical content and clinical decision support offered through the EHR are needed to strengthen EBP within the care delivery area. Hebda and Czar (2009) observed that the EHR is transforming the way health information is managed because the traditional paper medical record is no longer efficient in meeting the needs of health care. El-Kareh et al. (2009) added that “the electronic health records offer the potential to provide clinical decision support and increased access to information that can ultimately result in safer, more effective and efficient care (p. 464).”

...the EHR serves both as a catalyst to augment and drive evidence-based practice and as a source of clinical decision support. Clinical decision support, defined by Brokel (2009) as an aid that supplies providers with evidence-based resources to guide the care and documentation of patient care activities through a point and click response requiring minimal typing.  To provide CDS, it is imperative that clinical content be clearly articulated so that all users consistently document and provide care with the same understanding (Watkins et al., 2009). Clinical content is the terminology that defines and guides practice. It is derived from multiple nursing, medical, and governmental sources, and it entails words and phrases that describe the assessments and interventions providers need to document care (Watkins et al., 2009). Our team derived the terminology to develop our evidence-based guidelines for insertion and continuation criteria of an indwelling urinary catheter from the CDC and APIC. We integrated the terminology into the electronic, nursing flow sheet as a drop down menu that requires staff to assess the need to either insert or continue the catheter. In this way, the EHR serves both as a catalyst to augment and drive evidence-based practice and as a source of clinical decision support.

Our literature review noted the absence of any reported electronic processes to assist in CAUTI prevention practices, and the absence of reports describing the implementation of a QI process within a large health care system. The CAUTI-prevention strategies reported in the literature included only manually processed prevention strategies that were implemented on a small, or in a single, nursing area. Thus our review identified the need to restructure health care to improve the quality of care delivery and reduce health care costs related to CAUTI; it stimulated us to develop an EHR to meet this need, as suggested by Hebda and Czar (2009).

Method

Prior to forming a QI team for CAUTI prevention, we sent a voluntary survey to staff on all in-patient nursing units to determine attitudes and behaviors related to indwelling-urinary-catheter care practices. Information gleaned from the survey indicated a general lack of knowledge about evidence-based criteria for the insertion of an indwelling urinary catheter. This lack of knowledge served as the basis to incorporate catheter insertion criteria into the EHR. Simultaneously, our Clinical Nurse Specialist (CNS) conducted a literature search, benchmarked CAUTI practices with other facilities, and consulted internal staff with expertise in urological policy and procedures to guide the development of our QI project. We divided the project into the following five phases: Organization and Coordination, Data Collection and Analysis, Project Development, Implementation, and Evaluation.

Phase I: Project Organization and Coordination

The CAUTI Core Team, formed to organize and coordinate the project, consisted of a CNS, nurse educator, infection control nurse, urology technician, and QI nurse, along with staff nurses. Team members received an array of evidence-based periodicals and educational resources on the components of a CAUTI bundle (a group of policies or guidelines relating to a specific health issue, such as a CAUTI). After developing an action plan and timeline, the core team divided into sub-teams with specific responsibilities, such as education, equipment, and prevalence (i.e. care practices and documentation of these practices), to ensure all components of the project were in place.

A nursing informatics nurse from the Clinical Support Section of the IS Department helped develop the clinical content integrated into the EHR. Core team. The Core Team, chaired by the CNS, supervised the project and developed the policy in collaboration with other educators, urologists, and hospital-employed physicians. The Core Team also obtained support from the Nursing Shared Governance (NSG), Nursing Practice, and Nursing Education Councils, and our Chief Nurse Officer. The team then coordinated baseline data collection and activities, which were used to assess current practices and develop audit tools for monitoring. A nursing informatics nurse from the Clinical Support Section of the IS Department helped develop the clinical content integrated into the EHR. A member of the Core Team was selected to chair each sub-team and report progress regularly.

Education sub-team. The Education Sub-Team was responsible for developing the CAUTI prevention policy, providing house-wide education on the policy, and establishing CAUTI-related documentation in the EHR. Educational flyers were utilized to depict electronic screen shots and instructions. Additional education on the use of a catheter stabilizer device was also conducted.

Equipment sub-team. The Equipment Sub-Team was responsible for identifying equipment issues related to the external urinary catheter system and barriers that would hinder the institution of our CAUTI bundle. Barriers included foley catheter packs without a stabilizing device, low patient beds with the potential for allowing the urinary bag to touch the floor, and wheel chair challenges related to correct urinary bag placement. Collaboration with the Clinical Support Team, Sterile Supply Department, and Engineering Maintenance Department enabled swift resolution of these barriers.

Prevalence sub-team. The Prevalence Sub-Team devised a monthly prevalence study (a standardized tool/audit to identify targets for quality improvement of specific, care-related behaviors or performances) which started six weeks after implementation of the revised CAUTI prevention care practices. The prevalence study included monthly audit tools that were developed using information from the baseline data. The 2009 CDC recommendations regarding documentation and care practices were also incorporated into the audit tool.

Phase II: Data Collection and Analysis

Chart auditing revealed actual care and documentation practices. We conducted retrospective chart audits on 42 charts randomly selected from the 420 charts of ICU patients cared for during June of 2009.  Chart auditing revealed actual care and documentation practices. During these chart reviews we identified whether the need (criteria) for the insertion of an indwelling catheter was documented.

A house-wide, baseline prevalence study was performed before staff members were educated on the CAUTI project. Baseline data collected from the prevalence study revealed foley catheter utilization at our hospital to be 30% of all inpatients assessed on a single day. Of those patients, 96% met the criterion of documenting the need for catheter insertion. However, the four selected catheter care practices (assessing whether the catheter was secure, the seal had not been tampered, the tubing was in the correct position, and the bag was not touching the floor) were documented in only 47% of the cases. As a result, the prevalence study supported the implementation of a process to assist staff to both to document the criteria for catheter insertion and to assess care practices recommended by the CDC guidelines for prevention of CAUTI. The criteria for insertion of an indwelling urinary catheter was built into the EHR as a drop-down menu that prompted staff to point and click from the criteria list, and thereby, document the specific criterion as it related to the respective patient. A second drop down menu included documentation of the required daily care practices that align with our policy on the care and maintenance of a urinary catheter.

Phase III: Project Development

After data were collected, team members and volunteers gathered for an update to review the results and identify issues, brainstorm, and develop a plan of action. Members were given results from the survey, chart reviews, and prevalence study; they were led through exercises to identify issues. During this process the project start date was revised to coincide with the pending ‘Go Live’ implementation date of the new EHR. This afforded time to go back to the Nursing Shared Governance Councils to provide a detailed presentation of the complete project. The Education Sub-Team provided hospital-wide education the month prior to implementation of our QI project and new EHR.

Phase IV: Implementation

We worked with the IS Department to incorporate the CAUTI components into the EHR so that we could integrate evidence-based CAUTI care practices with the EHR before the ‘Go-Live’ date. Because our EHR was in the very early stages of development, we could include only a limited amount of information. Hence, evidence-based criteria for meeting the need for a urinary catheter were embedded in the EHR as criteria on the Continue-to-Meet drop-down menu, from which the nurse selected the appropriate reason(s) to continue with the catheter. The criteria were later revised (Figure 1) to include surgical patients who required either that the catheter be removed by the end of post-op-day two or a physician’s order with a documented reason to continue the catheter. If the patient did not meet the criteria to continue the catheter, the nurse was to notify the physician in person or by electronic request (“sticky note”) for possible removal as dictated per our hospital policy.

Figure 1. An electronic health record screen shot of the drop down menu, Criteria to Continue Met, where the indwelling urethral catheter is documented. Adapted for use in OJIN with permission from Epic Systems Corporation © 2011 Epic Systems Corporation.

Phase V: Evaluation

To measure the effectiveness of the QI process, an audit tool was developed using baseline data and CDC recommendations for CAUTI performance measures. Six weeks after implementation, staff began a monthly prevalence review on all inpatients with an indwelling urinary catheter between the hours of 3 am to 9 am. The daily census count was used to calculate the results. The following components were audited: (a) the criteria for appropriateness of the catheter (electronic chart audit); (b) documentation of the criteria and assessment (electronic chart audit); and (c) compliance on four selected catheter care practices (visual audit).

Results

The improvement resulting from the CAUTI project was measured and reported using several different approaches during the first two years. Initially, bar graphs indicative of global performance were disseminated to all nursing leaders. Subsequently, unit scorecards were developed and displayed for staff review. The year following project implementation, percentages from respective scorecards were entered into statistical a software package (SPSS) for analysis. Finally, in 2012, the improvement was measured for sustainability by plotting four consecutive, 7-month periods, beginning with the initial 7-month project.

A color-coded score card enabled nurse managers and staff to assess their respective unit’s performance over time. Within the first six months post implementation, and after use of bar chart to disseminate global performance, it was determined that use of score cards would be a more effective format to display performance. A color-coded score card, reflective of all inpatient nursing units, and individual unit score cards enabled nurse managers and staff to assess their respective unit’s performance over time. The Figure 2 score card reports the collective performance of inpatient nursing units with the average percentage of each type of documentation and each direct observation component taken from the CAUTI audit. To determine changes (e.g., progress reflected in specific categories of the audit form), each unit was assigned a range in which they were either below (red colored), approaching (yellow colored), or had met (green colored) their compliance goal . For example, most non-ICU units were assigned a goal to reduce catheter use to 20% of inpatients. If this goal was met in a particular month, the block was color coded green. If catheter use was above 20% or above 25%, the block was color coded yellow or red, respectively. On the other hand, if an ICU unit had a goal to reduce catheter use to 80% or below (green) and if the census of catheter use was greater than 80%, the block was coded yellow or red, based on the extent of use above 80%. As a preliminary analysis, the system allowed all stakeholders to easily compare unit compliance (meeting unit goals) and progress with this visual audit method.

Figure 2. A score card of all inpatient nursing units demonstrates performances of CAUTI-related documentation and direct observation of CAUTI preventive care practices.

Within the first six months of implementation... improvement in care practices [and] catheter insertions showed a downward trend... To evaluate improvement in total care practices, the mean value for the four selected practices (catheter security, seal intact, tubing position, and bag off the floor) was determined by summing the score of all care practices and dividing by four. Within the first six months of implementation, process improvement in care practices increased from 47% (prior to CAUTI education) to 93%. The number of catheter insertions showed a downward trend from 30% of patients using a catheter at baseline to 25% six months post implementation. Furthermore, sustained decrease has continued into 2012 reaching 19-20% in overall catheter insertions.

Both ICU and non-ICU units demonstrated significant improvement in foley catheter care practices and documentation... As result of this preliminary analysis using SPSS, we wanted to determine the types of units on which the greatest impact of the process occurred. We then compared non-ICU units with ICU units to avoid potential confounding factors from differences in patient populations and the typical census of catheter use between these two types of units. Mean score card values for each care practice category was determined for non-ICU and ICU units. One-way analysis of variance and post hoc Fisher’s least significant difference (LSD) was used to determine significance between mean values that were calculated for each quarter (90 calendar days) for one year. Significant improvement in documentation practice for both ICU and non-ICU units (Figures 3C and 3D and Figures 4C and 4D) were evident. non-ICU units demonstrated the greatest improvement by the third quarter of the study. It was not expected that the census of patients with Foley catheters and patient-met criteria would improve on the ICU units (Figure 3A and 3B); however, significant improvement in census with catheters and criteria met were clearly evident on non-ICU units (Figure 4A and 4B). Both ICU and non-ICU units demonstrated significant improvement in foley catheter care practices and documentation due to the CAUTI process improvement project.

Figure 3. Analysis of ICU patient assessment and documentation. For one year, (A) the census with foley catheter, (B) percent of patients that met criteria for catheterization, (C) percent of criteria to continue was met, and (D) documentation of patient assessment completed were tabulated and the mean values determined for each quarter (90 days). One way analysis of variance and post hoc Fisher’s least significant difference (LSD) was used to determine significance between quarters, * p<0.05, **p<0.01, ***p<0.001.

Figure 4. Analysis of non-ICU patient assessment and documentation. (A) Census with foley catheter, (B) percent of patients that met criteria for catheterization, (C) percent of criteria to continue met, and (D) documentation of patient assessment completed were tabulated and analyzed in a similar manner as Figure 3.

As indicated, the focus of the CAUTI improvement process was to incorporate an infrastructure within the EHR to drive and sustain practice. In 2012, this was analyzed using one-way analysis of variance (ANOVA) in statistical software (MiniTab-16) when four consecutive 7-month periods were compared. After the first 7-month period post implementation, analysis demonstrated a significant (p <0.05) difference from the pre-implementation period. This improvement was sustained through the next three measurement periods with sustainability of CAUTI patient care practices having tighter variances in practice (Figure 5; * p<0.05, **p<0.01; and ***p<0.001).

Figure 5. Four 7-month periods were compared using a one-way ANOVA. After the first 7-month period, analysis demonstrated sustainability of CAUTI patient care practices with a tighter variance in practice.

Discussion

The primary purpose of implementing the CAUTI bundle was to eliminate adverse outcomes associated with an indwelling urethral catheter in situ. As Wald (2007) has noted, a longer duration of catheter use directly correlates with an increased risk for developing an infection. Using the EHR to drive both use of the CAUTI-bundle and the required documentation of a daily assessment to determine the necessity for continuing the catheter led to an overall decrease in the number of patients with a catheter.

A major goal of the QI project was to sustain CAUTI care practices by instituting mechanisms within the daily workflow of the EHR to prompt staff to question the need for insertion and/or continued duration of the catheter. In support of the literature, our findings indicated that use of the EHR to drive the improvement of CAUTI care practices, and subsequent decrease in number of catheter insertions (census) correlated with decreased positive urine cultures per total patient days, particularly on non-ICU units.

...the greatest change in practice and outcomes was evident after we implemented the unit score cards... We reasoned that a constant visual, one that showed respective unit performance and was posted in a manner that improved staff awareness, would promote unit ownership and result in better performance. Hence, we replaced global graphs and tables of data that were not easy to interpret with color-coded unit score cards to improve visual assessment of performance by nursing units. Indeed, the greatest change in practice and outcomes was evident after we implemented the unit score cards at the end of the second quarter. During monthly audits, opportunities for improvement were ongoing; nursing units took ownership of the QI project and used their CAUTI representative to educate staff on deficiencies.

Implementing the CAUTI project at the same time the entire hospital went ‘live’ with the electronic health record elicited unexpected challenges. A major limitation of our project was the prolonged learning curve that staff had with electronic documentation. This barrier had an overall impact not only on documentation related to CAUTI but on all core measures across campuses. In an attempt to correct this, all nursing staff were required to attend a Patient Safety Fair. Soon afterwards, we began to see a steady drop in the positive urine cultures, as evidenced by epidemiology reports.

Since monthly prevalence studies were performed on a single day of the month, another limitation of our project was the inability to audit 100% of patients with an indwelling urethral catheter in situ and obtain the total number of catheter days. Therefore, the monthly prevalence data were normalized to total patient days.

Several change requests to augment performance and outcome measurements have been submitted since the completion of our QI project. For instance, the creation of a “best practice alert” reminds physicians of the catheter and asks if it should be continued. Secondly, “automated CAUTI reports” have been developed to facilitate evaluation of CAUTIs by the Infection Preventionist, and automated reports are now used to demonstrate staff performance in documentation and care practice assessments. Thirdly, a “catheter to continue order” with criteria to meet for continuing the catheter has been created, specifically for the Surgical Care Infection Project (SCIP) foley catheter measure, and is working well for staff and physicians. Lastly, “Foley catheter reports,” built into the My Reports section of the EHR, provide staff a concurrent identification of patients with a catheter and enable performance monitoring and outcome measurements on all patients as part of our QI process.

Conclusion

The U.S. healthcare system faces many challenges as efforts are made to improve the quality and safety patient care. The EHR was proposed by the Institute of Medicine in 2001 as a catalyst to improve safety, quality, and efficiency in the healthcare system (Stoten, 2009). Consequently, in 2004, U.S. President George W. Bush outlined a plan to move the health care, paper-record system to an EHR by 2014. This mandate has afforded the opportunity for healthcare providers and quality improvement teams to strive to prevent hospital-acquired infections by integrating evidence-based guidelines or standards of care into the EHR to document evidence of delivering safe, high quality patient care. Members of QI teams are encouraged to use EHRs in a meaningful manner, integrating applicable functions that drive the sustainability of documentation related to patient care practice, and to consult clinical informatics staff early in the planning process to assure feasibility of the project.

Ownership at the unit level continues to elicit a steady increase in compliance...in CAUTI preventive care and documentation. In summary, the primary goals of the CAUTI project were to implement foley catheter practices based on CDC Guidelines and best practices and to embed an electronic infrastructure that would drive and sustain these care practices. In 2012, sustainability of the CAUTI process was analyzed via one-way ANOVA as four 7-month periods were compared (Figure 5). Compared to the first seven months of the project, the post-implementation data demonstrated that CAUTI patient care practices continue to reflect that sustainability of the process has been integrated into our patient care delivery system. Sustainability of these practices is further substantiated by a reduction in the variability of CAUTI practices, thus demonstrating foley catheter practices are being ingrained into the daily patient care. Ownership at the unit level continues to elicit a steady increase in compliance; and staff members recognize the EHR as a fundamental catalyst that supports, drives, and sustains EBP in CAUTI preventive care and documentation.

Acknowledgement: This article is the result of a quality improvement project with resources and administrative support at Deaconess Hospital in Evansville, Indiana. Special thanks go to staff employees who participated in the development, implementation, and continual coordination of the project. In addition, the following staff contributed to the manuscript: Catherine A. Seuell, BSN, RN, CRRN, Black Belt, Lean Six Sigma for Deaconess Hospital, developed an extensive CAUTI database and the respective unit scorecards. Monica Corcoran, MLIS, Medical Librarian of the Deaconess Hospital Health Science Library provided editorial advice. Jonathan D. Stallings, PhD, a research scientist, calculated mean scorecard values for each quarter and normalized actual CAUTIs to patient days, compared ICU versus non-ICU units, and then conducted ANOVA to determine significance between quarters. The views expressed in this article do not necessarily represent the views of Deaconess Hospital.

Author

Lois M. Welden, MSN, RN
Email: lois.welden@deaconess.com

Lois M. Welden has worked at Deaconess Hospital in Evansville, IN for 31 years.  She is currently serves as a Clinical Nurse Specialist in a multi-faceted role in Nursing Administration for a multi-campus hospital system serving the Tristate area of southwestern Indiana. She has extensive experience in critical care bedside nursing, management, and leadership.  Lois coordinates various quality improvement projects and oversees specific clinical outcomes. Her primary focus is to assist in the establishment of a culture of nursing excellence characterized by strong leadership and inspired professional practice to promote caring, compassionate, individualized, and safe care delivery utilizing evidence-based practice to achieve best outcomes. She received her Master of Science in Nursing degree in 2001 and her Bachelor of Science in Nursing degree in 1994, both from the Southern University of Indiana in Evansville, IN. She received her Associate of Science in Nursing degree in 1983 from the University of Evansville in Evansville, IN.

© 2013 OJIN: The Online Journal of Issues in Nursing
Article published August 6, 2013