Off the Charts

By Christine Moffa, MS, RN, AJN clinical editor

Ever since we started the Cultivating Quality column at AJN, manuscripts featuring evidence-based quality improvement projects have been pouring in. There is a lot of great work being done at the bedside by practicing nurses, and this column provides the opportunity to share their ideas with others.

Lancaster General's CAUTI rates, fiscal yrs 2007-2009 (click to enlarge)

This month’s Cultivating Quality installment, Reducing Rates of Catheter-Associated Urinary Tract Infection, comes from Joyce Wenger, MS, RN, the infection control performance improvement coordinator at Lancaster General Hospital, Lancaster, PA. According to the CDC, urinary tract infections (UTIs) account for more than 30% of hospital-associated infections, and almost all are “caused by instrumentation of the urinary tract.” Nursing staff were able to reduce catheter-associated urinary tract infection (CAUTI) rates using a three-pronged approach “beginning with education, progressing to tests of new and better products, and ending with the nurse-driven protocol for catheter removal.”

That last part is my favorite. In most facilities a doctor or nurse practitioner has to write an order before a Foley catheter can be removed from a patient. Patients may end up spending several days at increased risk for UTI because of an unnecessary urinary catheter in place. This hospital came up with a plan to give nurses the autonomy to remove them—which makes sense, since they’re the ones checking the patient daily. The team at Lancaster General created the following list of criteria that patients need to meet in order to maintain a Foley catheter. If not, then the nurse can remove it.

A nurse keeps the Foley catheter in place if

• a urologist is on the case; the catheter cannot be removed without the urologist’s approval.
• a physician has ordered that the catheter not be removed (the medical reason to continue or criteria for removal should be documented).
• a physician has documented “medical necessity” within the last 24 hours.
• the patient is unresponsive or comatose.
• the patient is receiving palliative or hospice care.
• the patient has received IV sedation within the last 12 hours.
• the patient has received IV inotropic agents within the last 24 hours.
• there is an order for IV diuretics to be given every six or fewer hours.
• the patient is undergoing ultrafiltration.
• acute or worsening renal failure is evident (that is, there has been a creatinine level increase of 1 mg/dL or more above the admission or baseline level).
• surgery has been performed within the last 24 hours.
• a pressure ulcer might be soiled if the catheter is removed and the patient is incontinent.

But I’d recommend reading the entire article and seeing how these interventions compare to those at your facility. We’d love to hear what you think about it.