NOSOCOMIAL infections continue to plague our healthcare system in spite of the decades of documented warnings. Unlike in the past, deaths from nosocomial infections now appear as headlines in newspapers and magazines as well as interest stories on local and national news broadcasts. Nearly 2 million patients are affected each year in the United States, resulting in approximately 90,000 deaths.1 It is estimated that 4.5 to 5.7 billion dollars are added to the cost of patient care every year.
Urinary tract infections (UTIs) account for approximately 35% of nosocomial infections but are the lowest in mortality and cost.1 Patients with UTIs as a secondary diagnosis have an average length of stay (LOS) of 9.1 days versus those without a urinary catheter of 4.7 days. As individuals live longer, the probability of them being hospitalized and requiring specialized care services is increased.2 Hospitalization of any aged person increases the risk for them to have a urinary indwelling catheter, which predisposes them to a nosocomial urinary tract infection.3
Nurses are responsible for placing and maintaining the urinary catheter system, including cleaning and other tasks. Routine care of the catheter is often delegated to nonlicensed personnel. Inadequate placement and care from the beginning may contribute to increased infection rates. Standardizing the education, training, and orientation of new nursing staff on proper urinary catheter placement and care can have an impact on patient outcomes. Assessment of current staff competency and reeducation is a timeconsuming and costly venture but is essential to ensure continuing skill of nurses in urinary catheter care.
DEVELOPMENT OF PROJECT
This project was done at the third largest rural health system in the Unites States. It consists of a 6 hospital system with a total of 856 acute care beds located in the south. The main unit is a 650 bed level II trauma center.
In 2001, the manager of staff development and nursing education was approached by urologists about the nursing staff's clinical competency in placement of indwelling urinary catheters in men. There were a few incidents of a urinary catheter balloon being inflated prior to entering the bladder, causing bleeding, balloon rupture, and patient complaints of pain. Daneshgari and colleagues4 reported a series of incidents related to male catheterizations, which were similar to what was reported by local urologists.
A urinary project team was established in a manner similar to that of Doyle and associates,5 which included a clinical nurse specialist (CNS) for medical/surgical nursing, manager of staff development and nursing education, pharmacist, physician hospitalist, urologist, infection control physician, infection control nurse, home health nurse, and outcomes manager.
The outcomes manager used CareScience's Care Management System (CareScience Philadelphia, Pa) to identify outcome profiles of top-volume diagnostic related groups (DRGs) with and without UTIs to ascertain whether UTIs were a significant issue. Between January 1 and December 31, 2000, UTI was #3 (n = 499) or 1.8% of all discharge complications.
There were multiple recommendations by the UTI project team after discussing this information. These recommendations were as follows:
1. Discontinue indwelling catheter in recovery room if possible.
2. Develop prompts in the charting system for nursing staff to request the physician to remove catheter if not medically necessary.
3. Produce a training video on catheter insertion and continuous bladder irrigation for mandatory nursing inservice.
4. Develop a continuous bladder irrigation charting system protocol.
5. Develop an education program for nursing and medical staff about medications associated with urinary retention.
6. Develop a competency for bladder scan usage.
7. Encourage individual use versus standing orders.
8. Target staff education based on variance reports and patient, nurse, and physician concerns.
It was decided to examine not only the issues identified by the UTI project team but to investigate all issues regarding indwelling urinary catheters based on UTI incidents and policies and procedures for catheter care and placement, usage of indwelling urinary catheters, competencies associated with placement and care, and documentation as well. Careminder protocols were reviewed to address documentation issues concerning nephrostomy, external catheters, and foley catheters. Because of this project, a continuous bladder irrigation protocol was also developed and implemented into the charting system for nurses to document care given.
REVIEW OF THE LITERATURE
A plethora of articles have been written about nosocomial urinary catheter-related infections,1,5-8 management of the catheter,9-11 and proper placement of the indwelling catheter in the male patient 4 but little about the impact of nursing education on outcomes related to decreasing UTIs and usage of indwelling urinary catheters. Many articles include recommendations about care, treatment, and recognition of UTIs; use of stabilizing devices; closed systems versus open systems; mortality rates; and misuse of urinary catheters for convenience of nursing care.
DEVELOPMENT AND REVIEW OF POLICY AND PROCEDURE
Because urinary retention is the only justifiable criterion for use of a urinary catheter, a policy needed to be developed and implemented as a priority. Currently, there was little guidance from a policy standpoint for the nursing and medical staff to follow, other than to obtain an order from a physician to place a catheter. The urinary project team developed definitions and guidelines for the nursing staff related to (a) urinary retention, (b) when to perform a bladder scan, (c) results of the bladder scan and notifying the physician, and (d) exceptions to the policy.
The goal became to change theS "traditional" nursing and physician practice of obtaining a written or verbal order regarding use of a bladder scanner of an indwelling urinary catheter into "cutting edge" practice. The goal was to empower the nursing staff to use the bladder scanner for evaluating the need for indwelling urinary catheters without first obtaining an order to do so. It was necessary to review long-standing preprinted physician orders and delete them of routine urinary catheter insertions.
The nurses routinely called for an order to use a bladder scanner. The bladder scanner policy was reviewed, and a new policy was written for the nursing staff to use the scanner before placement of a urinary catheter especially for urinary retention after surgical procedures and once a catheter is removed before replacement. The clinical educators were taught to use the bladder scanner and then educated nursing staff on proper use of it.
The CNS developed a competency for the use of the bladder scanner, and then clinical educators focused on the top 4 clinical areas where catheters were placed. Overall, the nursing units combined placed 45.6% of urinary catheters while the single area with the highest percentage was the emergency department (ED) (27.8%) followed by the operating room (OR) (16.7%). Select target units and eventually all inpatient nursing units and the ED were skill validated.
The computerized charting system had established foley catheter, nephrostomy, and external catheter protocols as part of it. Even though a continuous bladder irrigation policy was in place, the need was identified to develop a computerized protocol for charting. The urology department also agreed for the nursing department to add a prompt for the nursing staff to approach the physician daily on all nonurological patients for the catheter to be removed. The CNS for medical/surgical nursing made rounds during nursing report and discharge planning rounds, reiterating early discontinuation of the urinary catheters. Because of this project, the OR evaluated its procedures, and urinary catheters were removed for procedures of 2 hours or less on all nonurological cases. If a catheter is used in the OR, the PACU attempts to discontinue it before the patient is transported to the general surgical units.
DEVELOPMENT OF POSTER AND VIDEO FOR NURSING STAFF
The challenge was to transfer the knowledge gained at the UTI team level to each nurse in this large rural healthcare system. To educate all staff on the consequences of using indwelling urinary catheters and importance of proper insertion on male patients, an eye-catching educational poster was developed and migrated through the nursing units of the main hospital. The poster remained on each nursing unit for a 7-day period. Additional posters and videos were developed for each community hospital as well as for behavioral and women's hospitals.
The poster showcased definitions of urinary retention and uses of a bladder scanner and also included the essential points of proper catheterization of a male patient. Accompanying each poster was a videotape developed by an urologist with an introduction by the CNS as to the issues and why this information was important. The poster was accredited for CEUs so a posttest and an evaluation were required.
At the close of fiscal year 2002, when staff compliance was evaluated, it was clear by many of the nursing units' low participation that the staff did not see the importance of this poster and videotape (Fig 1). At this point in time, there was a range of 4% compliance on a nursing unit up to 100% compliance on 2 of the nursing units. Because of the low compliance of some units, the poster and videotape were immediately recirculated onto the units and were made mandatory for the entire nursing staff to complete including the posttest. In addition, as part of the annual skills review, the clinical educators made available a male model that all licensed staff were to catheterize under the direction of the educators or the CNS. At the end of 2003, there was a range of 93% compliance of a single nursing unit to 100% compliance by 10 of the 14 nursing units (Fig 2).
DISCUSSION
This project has demonstrated that a concerted effort through education and staff development can improve care of patients with indwelling catheters and prevent urinary tract infections. There were 548 fewer UTIs reported for FY03 than for FY02. Incident reports related to indwelling urinary catheters decreased to 1, which occurred in a trauma patient who was being catheterized prior to being sent to the OR from the ED.
By investigating issues related to urinary catheter placement, many other areas of nursing practice were improved on, especially those dealing with proper urinary catheterization of men. This project at first appeared uncomplicated. However, once the team assembled, multiple issues were identified, including the need to change policies and procedures, documentation, and orientation of staff. To sustain the outcomes, practice changes were integrated into general nursing orientation, and skills checklists were updated.
Throughout the summer of 2004, our nursing education and staff development department continued use of the UTI poster with new graduates and nursing staff, with required practice using the male model as part of the nursing skills laboratory. The CNS presented to the nearly one hundred 2004 graduates about the project.
This project demonstrates that one must have long-term goals and processes in place to sustain the changes to clinical practice. Orientation, policies and procedures, and documentation issues must all be linked in a congruent process for long-term positive patient outcomes to be sustained.
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