Reducing CAUTI through the Houdini Protocol
A. Identification of the Clinical Issue
Catheter associated urinary tract infection (CAUTI) is defined as “a urinary tract infection in a patient who had an indwelling urinary catheter in place at the time of or within 48 hours prior to infection onset” (Amalaradjov & Venkitanarayanan, 2013, p. 357). CAUTI is one of the most common hospital-acquired infections (HAIs) second only to surgical site infections. The most important risk factor to CAUTI is prolonged catheterization. CAUTI is a clinical issue that applies to nursing in the medical-surgical unit as many patients in this setting are catheterized for indications such as surgery, urinary retention, immobilization, and strict urinary output measurements (Bhatia et al., 2010). Estimates show that between 15-25% of in-hospital patients are catheterized during their stay (Amalaradjov & Venkitanarayanan, 2013). Nurses in the frontline of care are optimally positioned to prevent CAUTI and improve the quality of care as they provide routine urinary catheter assessments and care. The issue of CAUTI is also important to the health care environment given that the Centers for Medicare and Medicaid Services (CMS) is no longer reimbursing related costs of care as CAUTI is deemed preventable (Tambyah & Oon, 2012). As such, CAUTI represents a significant financial burden to hospitals if not effectively addressed.
Investigation of the Problem
Urinary tract infection accounts for around 40% of hospital-acquired infections translating to more than a million cases each year (AACN, 2012). At least 80% of such cases are associated with urinary catheterization (CDC, 2015). CAUTI contributes to undue morbidity and may also lead to pyelonephritis, cystitis, bladder stones, chronic kidney inflammation, septic arthritis, bacteremia, and endocarditis among other potential complications (Bhatia et al., 2010; CDC, 2015). Moreover, sepsis arising from CAUTI can result in death. Statistics show that around 13,000 deaths related to UTI occur each year (Amalaradjov & Venkitanarayanan, 2013). Another important concern is the rise in bacterial resistance that makes infection management more challenging. For instance, there have been cases of carbapenem-resistant Klebsiella pneumoniae being isolated from the urethra (Tambyah & Oon, 2012). In the U.S., the costs associated with CAUTI are substantial and range from $340 to $370 million each year (Tambyah & Oon, 2012). The cost per case is estimated to be $758 (Scott, 2009). These figures pertain only to direct medical costs and do not include lost economic productivity and other costs.
The lack of guidelines on acceptable medical indications for catheterization in acute care settings is a factor impacting CAUTI rates. In a hospital-based prospective study by Bhatia et al. (2010), 28.8% of patients with indwelling urinary catheters in medical wards received the intervention based on inappropriate reasons, the most common being urinary incontinence with no evidence of skin breakdown. Other inappropriate reasons were transient incontinence, immobility, and suspected retention while a small number of patients were catheterized with no clear medical indication (Bhatia et al., 2010). Meanwhile, a survey of 406 hospitals across the U.S. conducted by Greene et al. (2014) showed that other inappropriate indications were urinary incontinence despite outlet patency and patient or family request. Furthermore, in a statewide study by Fakih et al. (2012) which involved 163 units situated in 71 acute care hospitals in Michigan, the baseline proportion of patients catheterized for inappropriate medical indications was high at 55.7%.
Prolonged catheterization is considered a key contributory factor to the development of CAUTI. It is estimated that bacteria enter the urinary tract through the contaminated surface of the urinary catheter at a cumulative rate of 3-10% per day leading to bacteriuria in the patient within 30 days (Amalaradjov & Venkitanarayanan, 2013). Biofilms have also been noted on catheter surfaces. A biofilm is a community of bacteria attached to one another and able to stick to a surface enabling their persistence on the device (Amalaradjov & Venkitanarayanan, 2013). Bacteria may also ascend to the urinary tract from a contaminated drainage system or a disrupted tubing junction (Tambyah & Oon, 2012).
Lack of awareness of the impact of prolonged catheterization often causes physicians to “forget” that their patients are catheterized leading to more catheter days that increase the risk of CAUTI unless the physician “remembers” to issue a stop order. In addition, the responsibility of inserting and caring for the urinary catheter falls on nurses after the physician gives an order for the procedure. Thus, if the nurses do not request for a stop order to the urinary catheter once it is no longer needed also results to more catheter days. As such, the lack of coordination in relation to CAUTI prevention between the two disciplines playing different roles in relation to patient’s catheterization contributes to the problem.
The inadequate implementation of effective prevention interventions also translates to the continuing incidence of CAUTI. For instance, increasing CAUTI rates is deemed to be a factor that significantly contributed to the failure of many hospitals from meeting the infection-reduction goal established by the Department of Health and Human Services (DHHS) for the five years spanning 2009 and 2014 (Washington Update, 2015). Inadequate attention to the CAUTI issue is evident in the significantly declining rates of surgical-site infections, ventilator-associated pneumonia, and central-line associated bloodstream infections nationwide but not CAUTI rates.
The HOUDINI protocol is an appropriate strategy in reducing the incidence and rate of CAUTI. HOUDINI is an acronym that stands for 7 medically appropriate reasons for keeping a urinary catheter in place (see Figure 1). The protocol requires nurses to assess the patient on a daily basis in terms of the need for the urinary catheter by referring to the HOUDINI indications for medically necessary catheterization (Adams et al., 2012). All patients with urinary catheters will have a bright yellow tag on their tubing above the urine drainage bag to easily identify them. If the patient’s condition does not fit into any of the indications, the nurse must discontinue the catheter without a stop order unless the physician has expressly stated that such an order must be obtained prior to removal. Post-urinary catheter care with the goal of promoting independent voiding follows (Adams et al., 2012). It includes assessing for urine output, urinary bladder distention or the amount of urine in the bladder determined via a bladder scanner, and the patient’s comfort level. A straight catheter is used to empty the bladder until independent voiding is achieved (Trovillion et al., 2011).
Figure 1. The HOUDINI Acronym (Adams et al., 2012)
Adopting the HOUDINI protocol is justified because it addresses almost all of the practice issues contributing to the development of CAUTI. It builds awareness of the appropriate indications for urinary catheterization and promotes performance of the procedure only when it is necessary. As such, physicians will not order that the patient be catheterized solely on the basis of patient or family preferences. Moreover, the HOUDINI protocol helps prevent prolonged catheterization as the necessity of the urinary catheter is assessed daily and removed if warranted. The implementation of the protocol necessitates the collaboration of physicians and nurses especially with regard to the need for stop orders.
There is evidence supporting the effectiveness of the protocol in reducing the unnecessary use of urinary catheters and thereby the risk of CAUTI. System-wide, nurse-led implementation at BJC Healthcare in Missouri resulted in a 2.8% reduction in the use of urinary catheters (Trovillion et al., 2011). Subsequently, the HOUDINI protocol was adopted by the Missouri University Health Care wherein facility researchers noted a 5% decline in the rate of catheter use in critical care units in addition to a 2% decrease in rate in other units (Tiger Institute, 2014). Protocol adoption by a UK National Health Service trust also reduced catheter utilization by 17% with a lower rate of bacteriuria among patients (Adams et al., 2012). Also, protocol use among hip fracture patients increased the number of catheters discontinued within one week post insertion from 45% at baseline to 82% following implementation (Prayle et al., 2014). While the AACN (2012) categorized the intervention’s current evidence base as Level C, it does not mean ineffectiveness. Rather, it highlights the need for further research to expand knowledge on the topic.
The implementation of the HOUDINI protocol entails human resources, i.e. a nurse educator to develop related educational and skills training activities for the staff, nurse researchers to conduct the study and disseminate it, a statistician to assist in data analysis, information technology experts to integrate the protocol into the electronic health record system, and quality improvement experts to guide issue analysis as well as data collection and monitoring. In addition, trained performance observers are needed in monitoring staff compliance with the protocol. Infection control managers can also assist in collecting CAUTI-related data. Furthermore, nurse leaders and physicians are indispensable members of the project implementation team.
Material resources needed for implementation include indwelling catheter systems, catheter-insertion supplies, a mannequin, and a bladder scanner for use during protocol demonstrations. A venue conducive for learning must also be located for the activity. Online or printed educational materials are also necessary for implementation and need to be made available including the studies supporting the intervention. In addition, posters depicting the protocol in the nurses’ station and patient rooms help sustain the intervention by serving as environmental cues to perform the desired action, i.e. assess the patient of catheter indication and continuing need.
The benefits of implementing the proposed solution far outweigh the costs. With regard to the human resources mentioned, most are already employed in the hospital. Nurses, physicians, infection control personnel, IT personnel, and QI managers are members of the hospital workforce and their responsibilities in the implementation process are part of their job roles. Therefore, there will be minimal costs associated with human resources. There are also demonstration equipment and supplies and a venue to hold the learning activity within hospital premises. Significant cost is associated with the catheter tags and portable bladder scanners, the latter to be used to improve the accuracy of measurements of the amount of urine in the bladder. One scanner can cost as much as $4,700. However, this cost represents an investment that will help prevent CAUTI and related cost throughout the machine’s lifespan. For this reason, each CAUTI prevented translates to savings for the hospital.
Timeline of Implementation
The study will be implemented in 3 phases summarized in Table 2. The first phase will entail formation of a multidisciplinary project team that will spearhead the HOUDINI protocol implementation. The first phase also includes collecting baseline data on catheter utilization, the average number of catheter days, the incidence and/or rate of CAUTI, number of days of CAUTI-related morbidity, and CAUTI-related costs. An analysis of clinical practices when compared with the evidence available in the literature will be conducted by the team to ensure that current practices remain updated and are relevant. The first phase also entails the development of education materials and structured training, data collection and monitoring forms, and reproduction of the protocol. In addition, it is during this phase wherein IT personnel integrate the protocol in the EHR to facilitate nurse documentation of urinary catheter indication. Further, a pilot of the protocol will be conducted to determine the probability of success when implemented full scale.
The second phase of the project entails the full implementation of the protocol. Observers will conduct random and unobtrusive observations of the nursing staff’s performance of the protocol to ascertain the effectiveness of education and training and monitor staff compliance. This phase will also involve educating patients on CAUTI, its consequences, and preventive measures. The third and final phase is post-implementation wherein measurements of the same variables as those collected during the first phase will be conducted and comparisons made. The data will be analyzed and conclusions made over the effectiveness of the HOUDINI protocol in improving the care of patients prior to, during, and after urinary catheterization.
The key stakeholders are nurses and physicians. Both play important roles in CAUTI prevention – the former in prevention after the patient is catheterized and the latter in ensuring appropriate indications for catheterization. Engagement is achieved by eliciting the participation of leaders of each discipline in the project implementation team. The aims of working with them are to build awareness of the issue in both disciplines and foster collaboration on the solution. This approach promotes co-ownership and commitment to the intervention’s success (Borkowski, 2009). At the same time, buy-in at this level enables leaders to champion the intervention in their respective departments generating support and diffusion of the practice until it becomes the new norm consistent with Roger’s theory on the diffusion of innovation (Stanford University, 2010). In the nursing department in particular, compliance with the protocol is an important achievement as it moves the intervention from paper to the enactment of desired behaviors.
Stakeholders also include patients and the organization. Given that one inappropriate reason for catheterization is patient or family members’ preferences, health education must be provided to also build awareness of CAUTI and its prevention as well as safe alternatives to urinary catheterization especially when this intervention is not being given as a comfort measure at the end of life. A brochure can be given to patients and their families on admission to disseminate the information. Adequate assistance will also be given to patients as meeting their needs further promotes the acceptability and effectiveness of alternatives. Educated patients and family members further serve as a check-and-balance mechanism as they can promote protocol compliance among physicians and nurses.
Meanwhile, management support is crucial to project success. A quality improvement (QI) proposal will be written and submitted to senior management and approval secured especially in relation to the human, material, and financial resources needed for implementation. The proposal will highlight the cost-effectiveness analysis that shows the financial losses associated with CAUTI and the potential savings that will be generated by prevention. It will also highlight how the QI project supports the organization’s vision, mission, and strategic goals. Senior management will be updated periodically during the different phases of the project through progress reports.
Implementation of the HOUDINI Protocol
A QI approach will be employed for the implementation. The process involves assessing for aspects of clinical processes and outcomes that need improvement, developing solutions, implementing the solutions, and evaluating the outcomes as well as the need for further quality improvement (Houser & Oman, 2011). An important aspect of QI is the use of quantitative data, i.e. comparing baseline and post-implementation measures, to ascertain improvements and to employ continuous QI to achieve zero cases of adverse patient outcomes. Knowledge of the numbers and current trends increases staff motivation to contribute to improvement especially when scorecards are used to rate the performance of each unit (Houser & Oman, 2011). Units with the best performance serve as benchmarks that drive performance in less performing units.
The HOUDINI protocol represents a change in practice, and hence another aspect of implementation is change management. Participatory change management will be employed as it is associated with higher rates of success (Borkowski, 2009). The features of this approach include open communication with the staff that enables the dissemination of information about CAUTI as a priority clinical issue and the protocol as the proposed solution. Open or two-way communication encourages stakeholder input and feedback, shown in Table 3, both valuable in informing the solution and the manner of implementation. Another feature is stakeholder participation. Feedback and input from frontline care providers in itself constitutes participation and engagement in the change. Moreover, the involvement of different disciplines in the implementation team elicits buy-in and promotes adoption of the new practice by those who need to enact CAUTI prevention practices.
Project implementation must be evaluated for success to determine if the associated goals are met. Quantitative data and comparisons between baseline and post-implementation measurements are direct indicators of success. For instance, reductions in catheter utilization, catheter days, CAUTI incidence, CAUTI rate, duration of hospitalization, and CAUTI-related costs are all evidence of the effectiveness of the practice change promoted through the QI project. In addition, the research component of the project must also involve the collection of qualitative information such as the level of stakeholder engagement, satisfaction with the manner of communication used, the nature of interdisciplinary collaboration, and adequacy of organizational support. The insights gained from qualitative data will assist in evaluating the processes that occurred during implementation and will help improve future QI projects and change management.
B. Fulfillment of the Different Nursing Roles
Nurse as Detective
This role was fulfilled in the process of identifying an important practice issue within the organization as the focus of this paper. The nurse as detective is not complacent with the status quo but rather is an active participant in improving the quality of care. Detection of CAUTI as a significant threat to patient safety stimulates the development of solutions to ensure prevention.
Nurse as Scientist
This role was fulfilled through the use of research evidence in analyzing the issue and crafting a solution to the CAUTI issue. Knowing the state of the problem and contributory factors leads to the appropriate selection of interventions that are likely to result in successful resolution of the issue. The search and utilization of evidence-based practices is also consistent with the role of the nurse as scientist as is the conduct of QI and research to generate new knowledge on effectiveness in the selected setting.
Nurse as Manager of the Healing Environment
Fulfillment of this role was through leadership in the identification and resolution of CAUTI as an urgent clinical issue. Leadership entailed building awareness of the issue, promoting teamwork in issue analysis and protocol implementation, and the use of different strategies (QI, research, participatory change management) in project planning and implementation.
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