Running head: CAUTI
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INDWELLING URINARY CATHETERS: PREVENTION OF CATHETER-ASSOCIATED
URINARY TRACT INFECTIONS (CAUTIs)
April Beresford, Benjamin Kasper, and Kara Elkins
Ferris State University
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Abstract
Catheter-associated urinary tract infections (CAUTI) are of big concern today. They can
leave patients with increased amount of unnecessary pain and discomfort, lead to
increased length of stay in hospitals, and large amounts of money that could be better
used elsewhere. We will review and critique three articles relating to CAUTI and the
steps that are being researched to decrease the incidence of it, while also discovering if
the research itself is strong enough or too weak to make a case for change in practice.
Keywords: Urinary tract infection (UTI), foley catheter, straight catheter, hospital
acquired, healthcare acquired, cystitis, CAUTI
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Indwelling Urinary Catheters: Prevention of Catheter Associated Urinary Tract
Infections (CAUTIs)
Catheter associated urinary tract infections (CAUTI) are the cause of many
hospital acquired infections. According to Andreessen et al. (2012), “CAUTIs are the
most common type of nosocomial infection, accounting for 40% of all infections in the
hospital per year” (p. 209). Because of the increase in these numbers, nurses,
physicians, and others in the medical field, have decided to come together to research
the issue.
In this document, we will discuss three different studies that have been
conducted to find the root cause of this problem, and to come up with plans to reduce
the cause, and therefore decrease the incidence of CAUTI.
Description of Research Articles
Article One
This first article written by Andreessen et al. (2012), focuses primarily on
changing the current practice of nurses and doctors by giving them a tool to help
prevent catheter associated urinary tract infections (CAUTI). The researchers have
developed a bundle plan that will aid the nurses in insertion techniques and
maintenance of urinary catheters. This plan will also include daily assessment of need
by both the nurse and physician, and will require a q24 hour order to continue use of
catheter in a patient. By changing practice, adding meticulous computer
documentation, and reducing use and duration of catheters, these researchers hope in
the long run to reduce the percentage of CAUTIs experienced by patients. This is
proven to be an important study because it has been noted that “CAUTIs are the most
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common type of nosocomial infection.” This causes increased pain and discomfort felt
by the patient, and also increases healthcare costs for both the patient and the medical
facility (Andressen et al., 2012, p. 209). Medicare and Medicaid are no longer paying
for treatment of CAUTI because it is something that the hospital is unnecessarily
causing the patient to have (Andressen et al., 2012, p. 209). Because of this, hospitals
are now required to pay out of pocket for the additional expenses related to CAUTI,
which include but are not limited to antibiotic treatment and increased length of stay.
Article Two
Oman et al conducted a primary research study in 2011 to establish the
effectiveness of nursing initiated interventions in regards to the incidence rate of
catheter associated urinary tract infections (CAUTI). Because bladder catheterization is
common in the hospital setting, and nursing professionals are utilized to manage these
urinary drainage systems, Oman et al studied the effectiveness of specific nursinginitiated interventions in relations to urine elimination management within a hospital
system. This study was conducted on two adjacent medical/surgical units at a Colorado
hospital using a formally constructed nursing education program and measured CAUTI
rates in a daily average census of 18 patients for a period of over one year. The goal of
this study, which was carried out by five registered nurses and a physician, was to
“decrease CAUTI rates through implementation of hospital-wide nursing interventions
that emphasized education for inpatient nurses and specific unit-based nursing practice
actions on a pulmonary medical and a general surgical inpatient unit” (Oman et al,
2011, p. 4).
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Article Three
While indwelling catheter use remains a necessity on the medical intensive care
unit (MICU), catheter associated urinary tract infections (CAUTIs) continue to be an
ongoing battle. This study has shown that with use of guidelines for indwelling catheter
use CAUTIs can be reduced or eliminated in MICU inpatients (Elpern et al., 2009, p.
535).
A vast majority of the data presented in the article, “Reducing use of indwelling
urinary catheters and associated urinary tract infections,” written by Elpern et al. (2009),
was obtained from quality improvement indicators which were used to determine CAUTI
rates in inpatients of the MICU which was studied. Other data collected during this
study was duration of catheterization, appropriateness of catheterization and reason for
inappropriate catheter use. This study focuses on appropriate indwelling catheter
usage and CAUTI rates within a 6 month focus range in a 21 bed MICU.
Critical Appraisal
Article One
Review of literature
The authors of this research article spent two months before beginning the study
reviewing the literature for procedures and policies that would assist them in decreasing
CAUTI incidence (Andreessen et al., 2012, p. 211). The several sources that are
referenced are current and relevant to the study and the goals of the study. In this area,
they did not provide much of the information that they gathered from their review, but it
is considered strong in that their sources are up to date, and the information used was
shown to be a strong background for beginning the study. The “bundle” that they
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created to decrease percentage of CAUTI was put together based on the information
gathered in the review of literature, and this bundle was the basis for the study. This
would show that the researchers were very thorough and confident with the review.
Hypothesis
Andreessen et al. (2012) did not actually make a problem/purpose or a
hypothesis statement that was recorded in the article. They did however ask the
question “is a urinary catheter bundle with computerized documentation and ordering
templates (including the daily assessment of continued need for a catheter) effective in
reducing the use and duration of indwelling urinary catheterization in acute hospitalized
patients” (Andreessen et al., 2012, p. 211). They also made a statement earlier in the
article saying “The strongest predictor for CAUTI is the duration of catheterization, and
catheterization lasting more than six days increases the risk for CAUTI seven times”
(Andreessen et al. 2012, p. 210).
Framework
In this question they did introduce the following variables dependent variable:
duration of urinary catheterization, and independent variables: urinary catheter bundle,
which included proper insertion and assessment techniques to be utilized, computerized
documentation, and ordering templates. The population was also defined which in this
case is “acutely hospitalized patients” (Andreessen et al., 2012, p. 211). This is a strong
hypothesis because all of the variables were defined and the question asked is relevant
to the goals for the study.
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Research design/data collection
This article is out to prove that the independent variables named (urinary catheter
bundle, computerized documentation, and ordering templates) have a direct relationship
with the dependent variable of catheter duration, which they feel, will influence the longterm research goal of decreasing CAUTI incidence. Because of the cause and effect
noted in the relationship of these variables, The researchers have used causality in their
research design for this study. The study that they performed was an experimental
using the pretest and posttest design. According to Burns and Grove 2011),
experimental pretest and posttest design focus on the study of causality between
variables and look at the relationship before and after the manipulation of variables (p.
276). Andreessen et al. did an evaluation before and after the introduction of the
urinary catheter bundle.
The total amount of time it took these researchers to complete their project was
eight months. During this time, they were collecting data daily from computerized
charts. The initial three weeks included evaluation of 1,200 charts to collect baseline
data, followed by many months of collecting data after the urinary catheter bundle and
other policies were put into place. They ended with another three-week post program
evaluation process that required the review of 1,385 computerized medical charts to
collect the outcome data (Andreessen et al., 2012, p. 211). These charts were
reviewed many times to find all patients with indwelling urinary catheters. They would
then follow these patients to make sure the bundle and new policies were being
adhered to with the hopes of the catheter duration for these patients would be
decreased, and in turn resulting in less incidence of catheter acquired urinary tract
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infections Andreessen et al., 2012, p. 211). Registered nurses, physicians, and
infection control nurses, along with the others that were involved in the research team,
reviewed the documentation (Andreessen et al., 2012, p. 211).
The research team put a lot of effort into their data collection process. This area
of the research was strong, but could have been better with more detailed information
as to what they were recording in their data collection and not just that they were
looking for patients with indwelling catheters.
Sample/setting
“The research project took place at a VA (veterans affairs) medical center, and
included patients with acute placement (less than thirty days) of an indwelling urinary
catheter” (Andreessen et al., 2012, p. 211). Only male patients were included because
the majority of the patient population at this center was male. All charts were reviewed
for those male, and eighteen and older (Andreessen et al., 2012, p. 211). Those
patients who needed long-term catheterization, or were diagnosed with a urinary tract
infection within 24 hours of admission were excluded from the study to protect from
misinformation in the data collected (Andreessen et al., 2012, p. 211).
This sample a convenience sample. Burns and Groves (2011) define
convenience sampling as “choosing subjects because they happen to be in the right
place at the right time” (p. 305). The researchers chose the location of the study to be
the VA hospital, and then chose the target population out of those who were admitted to
the hospital during the time of the study. They didn’t have full control over those who
were available when they were collecting data.
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The researchers did what they could to control outside variables that may
construe the data, and therefore made this a strong sample for their research. Their
choice to only include male patients also decreased the amount of bias in their study as
well since there were not many female patients available for study. They will have to
conduct another study with female patients to see if in fact the same the same results
are achieved, or if different tools need to be utilized.
Limitations
This study was conducted at a single site which causes limitation in that the
results may be limited to hospitals of similar size and type to the VA medical center
where the study took place. “The project also lacked CAUTI rates for comparison
because the hospital had not collected this rate before this project began” (Andreessen
et al., 2012, p. 211). Even though this study contained these limitations, the
researchers did everything they could to control biases and chose their target
population the best they could.
Analysis/results
A total of 90 charts were used in this study after all ineligible patients were
removed. “In the pre-intervention stage of the study 2% of the charts had complete
documentation on urinary catheter insertion dates, removal dates, and catheter
maintenance, and in the post-intervention stage, the nurses had documented
appropriately 98% of the time” (Andreessen et al., 2012, p. 214,). “The new catheter
bundle template was being used 40% of the time, the new order template was being
used 35% of the time, and only 2% of the charts were missing a documented order”
(Andreessen et al., 2012, p. 211). The nurses were also following CDC guidelines
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regarding appropriate catheter size more frequently after the catheter bundle was
introduced.
Discussion
According to Andreessen et al. (2012), “the most important criteria was the daily
questioning of the continuing need for catheterization (p. 215). This portion was
included in the ordering criteria. After the post-intervention data was gathered, it
showed that the use of the guidelines from the care plan bundle along with the need for
daily assessment and order for a urinary catheter, assisted in reducing catheter use
(Andreessen et al., 2012, p. 215). Proper education was given to the staff and residents
regarding proper use of urinary catheters, including care when inserting and
maintenance, proper assessment and appropriate uses, and detailed documentation.
The researchers made it so that even after the data was collected, the staff would have
the appropriate tools and knowledge to continue to work towards the goal of CAUTI
rates decreasing. This proves that this study is important to them and they wish to see
the rates continue to decrease.
Conclusion
It was discovered at the end of the study that “the implementation of a set of
guidelines (the urinary catheter bundle) for catheter use and care resulted in a reduction
of catheter use by 57% and a significant decrease in catheter duration by 70%”
(Andreessen et al., 2012, p. 216). The researchers that conducted this study felt that in
the long-term, if this new plan of care continued, would contribute to the reduction of
CAUTI, but in order to really research the reduction of incidence of CAUTI, the
researchers would have to continue to watch and collect the data from the medical
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center. The effort lies with the staff and practitioners to keep up the newly introduced
protocols, and then the researchers are confident that this will lead to decrease in
CAUTI (Andreessen et al., 2012, p. 216).
The researchers in this case did an excellent job with their study. The study was
well thought out and the interventions were simple changes that nurses were able to
execute easily. Even though there were limitations, and the information wasn’t able to
be compared to previously recorded percentages of CAUTI, the conclusions validated in
this study could be used in broader settings to assist in the prevention of CAUTI.
Article Two
Problem and Purpose
Oman et al began by describing the background and history of catheter
associated urinary tract infections (CAUTIs). “Cather-associated urinary tract infections
are common, morbid, and costly. Nearly 25% of hospitalized patients are catheterized
yearly, and 10% develop urinary tract infections” (Oman et al, 2011, p. 1). They also
state that CAUTIs create a financial burden, and attribute to hospital-acquired
bacteremia on a large scale and point out that significant populations at risk are
postoperative patients and inambulatory patients who “do not have a clear indication for
indwelling urinary catheters” (Oman et al, 2011, p. 1). After building a strong concern
for addressing the problem of CAUTI in the patient population, they state “Catheters
may be inappropriately retained for days because of convenience, misunderstanding of
their necessity/appropriateness, or lack of clear orders for removal. Therefore, efforts to
reduce CAUTI prevalence must focus on evidence-based use of IUCs during insertion,
maintenance, and removal” (Oman et al, 2011, p. 1). This can be considered as the
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problem statement, as it reflects the concerns regarding CAUTI that were reflected in
the background review. The purpose statement is clearly identified on page two, and
states “The purpose of this quality improvement process study was to develop and
implement evidence-based, multifaceted, nurse-driven interventions to improve urine
elimination management in hospitalized patients and to measure the impact of these
interventions on the duration of indwelling urinary catheterization (dwell time) and the
CAUTI incidence among patients on the target inpatient units” (Oman et al, 2011, p. 2).
This accurately reflects the reason for the study. It is clear and concise and easy to
understand, and clearly includes ties to nursing practice and builds on existing nursing
research.
Review of Literature
Oman et al did not do a formal presentation of the literature reviewed in
preparation for or in process of their study. Instead, they used facts and other
information during the study to assist in explaining or conceptualizing their data. The
literature cited and the information included was all current with the exception for only
four of their 23 sources cited, and for those citations it was framed that the data was
historical. None of the literature presented was thoroughly or critically appraised, nor
was there a method to determine which research mentioned was primary or secondary
research. No quotations were utilized but information stated from outside sources was
properly cited. There was no contradictory theory or information presented. All of the
sources cited were appropriately listed at the end of the study with no citation errors
found.
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Study Framework
Oman et al were very clear in their description of this study framework.
Relatively early in the study description, they state “This project used the following
framework for implementation: Recruit a multidisciplinary team; Examine the evidence;
Identify and understand product(s); Measure outcomes” (2011, p.2). The concepts
contained within the framework were all clearly stated, and included “A pre/post
intervention design….to test the impact of nurse-driven interventions based on current
evidence to reduce CAUTIs in hospitalized patients on 2 medical/surgical units” (Oman
et al, 2011, p.1). Variables in this study were numerous. The dependant variables in
this study were incidence rates of CAUTI, catheter duration, LOS, bladder scanner
usage, and product streamlining. The independent variable was solidified as “nursing
interventions” but was broken down into a series of interventional options presented to
nurses who were participating in the study. Oman et al also described additional
technology provided to the unit, such as bladder scanners, as well as numerous
methods of educational support provided to nurses and nursing assistants on the
sample unit. Because there were multiple variables at work within the sample unit
simultaneously, it was it was impossible within this framework to identify which nursing
intervention was most effective or which were not highly effective, nor was the
educational component of the study evaluated from the standpoint of effective education
of the nursing staff. Although there were several variables to consider in this study, each
was clearly outlined and identified by the researchers. The relationships between the
concepts were presented in very clear terms.
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Hypothesis and Research Questions
This study was based on a quality improvement approach, and Oman et al
describe a gap between the evidence-based nursing practices current to our nursing
practice and the availability of these concepts to disseminate within the nursing
population. “The goal of this quality improvement study was to decrease CAUTI rates
through implementation of hospital-wide nursing interventions that emphasized
education for inpatient nurses and specific unit-based nursing practice actions on a
pulmonary medical and a general surgical inpatient unit” (Oman et al, 2011, p. 4-5).
The hypothesis was not written in a single declarative sentence, but can be derived
indirectly by referencing the framework and assessing the reflection at the end of the
study, which state that “The findings of this project support the effectiveness of
implementation of a CAUTI program that encompasses nursing education, competency
training, products, and surveillance to positively impact patient outcomes. Reexamining a common nursing procedure resulted in improved practice with IUC care
and improved patient outcomes” (2011, p. 5).
Quantitative Design
The Oman et al study was a quantitative study, which sought to systematically
describe variables, test their relationships, and examine the cause-and-effect of nursing
interventions on CAUTIs in hospitalized patients. Oman et al used a quasi-experimental
pretest/posttest design which was specifically identified as their chosen method, and
further subdivided this study into three phases (baseline data collection; house-wide
intervention; second data collection) which were all critically evaluated. This was a
quasi-experimental and not a true experimental study because complete control over all
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of the variables was possible. The design of the study was very effective in examining
the results of the study because the variables were clearly identified and the
relationships between those variables was clearly constructed. Threats to the internal
validity of the study were controlled by explaining in detail each of the nursing
interventions encouraged in the intervention group, and how each one correlated to a
reduction in the use of or the infection rates of urinary catheters. One threat that could
not be controlled was the sample population; although two units were utilized (one
medical and one surgical) the population diversity among the patients was minimally
described, and the nursing staff was not described, including but not limited to years of
experience within the nursing staff. This study was conducted using only that single trial
at a single hospital which creates a study bias. Definition of the ‘Student T’ test was not
cited and not explained or summarized which left a gap in the study instrumentation
which is important also to internal validity.
Sampling Procedure
The target population is identified several times throughout the study, including
an introduction to this population in the very first sentence of the study which reads
“Hospital-acquired, catheter-associated urinary tract infections (CAUTIs) are a common
and costly health care concern” (2011, p.1). The target population is later clarified in the
purpose statement, which was “The purpose of this quality improvement process study
was to develop and implement evidence-based, multifaceted, nurse-driven interventions
to improve urine elimination management in hospitalized patients…” (2011, p. 2). The
population included within the selected nursing units was not adequately described
within the study: ages, backgrounds, comorbidities, etc. Although it is necessary to
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acknowledge that Oman et al did include a table to identify the mean age and the
breakdown of the male/female proportions on each unit, no correlation between that
data and the context of the study was made. The sampling procedure was not
descriptively identified, and it was only briefly mentioned that the average daily census
of each nursing unit was 18 patients per day for a sum of approximately 150 patients
per month. It was not specified whether or not all of part of the patient population on
these units was included in the study, and the reader was left to assume that this was a
convenience sampling of the accessible population. A convenience sampling is a weak
approach to enforcing the internal validity of a study because it “provides little
opportunity to control for biases; subjects are included in the study merely because they
happen to be in the right place at the right time” (Burns & Grove, 2011, p. 305). This
accounts for both the population of the patients as well as the population of the nurses
who were included in this study. Because this study was only conducted in two nursing
units at a single hospital, the potential biases are numerous and it is too narrow to
consider it a complete and accurate representation of both the nursing and the patient
populations at large. “Our assessment of the focused interventions within 2 units may
have provided only a snapshot of the overall effectiveness of the education, policy and
product changes implemented in this study as a more comprehensive assessment of
the impact of the intervention were not undertaken” (Oman et al, 2011, p. 5). The issue
of subject dropout was completely omitted.
Data Collection
Data collection and measurement was explored extensively in this study.
“Demographic patient data, CAUTI rates, and IUC duration were collected at baseline
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(phase 1) and after the two intervention phases” (Oman et al, 2011, p. 3). Oman et al
describe the data collection intervals for the incidence rate of CAUTI, and indicate that
demographic data was compiled but the group fails to include any of that information in
the study. Catheter duration, length of stay (LOS), bladder scanner usage, and product
streamlining were also measured and correlated as part of the study outcome (Oman et
al, 2011, p. 4). The descriptions of these, as well as the instruments of measurement
used to evaluate each variable was included and adequately described each so that the
effectiveness of the interventions as a whole could be validated. There were no
extensive analytical models presented as a component of any of the variables; instead
“All variables were summarized using descriptive statistics appropriate for the level of
measurement. Statistical analyses were conducted to compare the differences between
the baseline and the 2 post-intervention catheter-days… CAUTI rates were not
compared because of the low numbers of incidences and rates” (Oman et al, 2011, p.
3). This statement is a bit confusing, and does not precisely identify which rates were
compared (or not compared) at the conclusion of the study to validate the effectiveness
of the nursing interventions as an independent variable. Thorough attention was paid to
describing the educational methods used to train nursing staff including attendance
rates, defining characteristics of catheters used, variances in the LOS among the
patient population, and bladder scanner usage. The data collection component of this
study was thorough and only minimally biased, but would have benefitted from a
definition of the Student t test (Oman et al, 2011, p. 3), a population description of the
nursing staff including years of experience.
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Study Findings
The study findings at the end of the research study report directly reflect the
problem and the purpose statements at the beginning. “The findings of this project
support the effectiveness of implementation of a CAUTI program that encompasses
nursing education, competency training, products, and surveillance to positively impact
patient outcomes” (Oman et al, 2011, p. 5). Because of the study framework and the
methods of data collection, it was not determined which of the nursing interventions
included in the study (education of patients and families, questioning physician orders,
education of nurses and supportive care staff, bladder scanner use, alterations in
catheter equipment, charge nurse catheter rounds, and increased availability of bedside
commodes) were most effective. Determining which interventions were most effective
were not a part of the hypothesis or scope of this study. “It was beyond the scope of
this quality improvement project to determine which of the individual components of this
comprehensive intervention were the most effective in changing practice. However, our
results suggest an important impact of the house-wide intervention on catheter duration
apart from the focused intervention” (Oman et al, 2011, p. 5). Additional limitations
within this study were disclosed, and included a concern regarding external validity. “In
addition, the number of CAUTIs on the intervention units during the study period was
low, and the confidence intervals around the CAUTI rates were relatively large, making
it difficult to assess the impact of the intervention on the outcome of interest” (Oman et
al, 2011, p. 5). Table 3 on page 4 describes per-patient catheter duration measured in
days, and shows an improvement on both the pulmonary and the general surgery units
by indicating a decrease in the number of days patients remain with an indwelling
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urinary catheter. The researchers also individually address each of the primary patient
outcomes: catheter duration (per table 3), incidence of CAUTI (decreased from 3.4
patient days to 2.2 in the third period), length of stay (from 6.91 to 6.55 days on the
surgical unit and from 7.39 to 6.72 on the pulmonary unit), bladder scanner usage (50
recorded uses total with only 2 patients out of those 50 who required a catheter
reinsertion), and product streamlining (removal of silver alloy indwelling catheters in a
cost-savings effort did not negatively affect the CAUTI rates). After reviewing the
evidence presented in an objective manner, it seems logical to conclude that these
interventions did have a positive effect on decreasing the CAUTI rates.
Implications for Practice
Because this study was directly aimed at assessing the effectiveness of nursing
interactions within the population of hospitalized patients who require an indwelling
urinary catheter, assimilation of the results of this study are relatively simple. “Focusing
on nursing-driven interventions to improve the nursing care of ICUs was found to
positively impact CAUTI rates. Re-educating on the importance of a perceived ‘basic’
skill and infusing best evidence into current practice were important to raise awareness
of simple interventions that positively impacted patient outcomes” (Oman et al, 2011, p.
5). It is not possible to select which intervention was the most successful or effective,
but to provide emphasis on a larger scale that best practice methods in nursing do have
positive effects on patient outcomes. The researchers caution, though, that nurses are
not completely independent. “To effectively change practice, multifaceted efforts are
necessary to reduce CAUTI in hospitalized patients. IUCs are often indicated in the
management of patients in acute care hospital facilities, and efforts that re-examine
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practice and strategies for care management based on best evidence are needed and
must be continuously revisited” (Oman et al, 2011, p. 5).
Article Three
Review of Literature
Elpern et al. did not include literature review in their study. Greater than 50% of
their sources are current; however, there was no indication of databases used for
acquisition of sources. They also did not include a critical appraisal of their sources.
No quotations were used in the article, however, the sources which were used
appeared to have proper citation throughout.
Study framework/theory
Elpern et al. did not identify a specific framework used for this study. However, the
authors appear to have used intervention theory. According to Burns & Grove, “Such
theories direct the implementation of a specific nursing intervention and provide
theoretical explanations of how and why the intervention is effective in addressing a
particular patient problem” (Burns & Grove, 2011, p. 238). In the case of this study, the
intervention is removal of inappropriate catheters, assessment for need of catheters and
early removal of indwelling catheters.
Hypothesis
The hypothesis used was, “days of use of urinary catheters and number of
CAUTIs would decrease during the intervention months compared with the 11 months
before the intervention. Total days of use of catheters and monthly CAUTI rates before
and during the intervention were compared using unpaired t tests. Significance was set
at P <.05” (Elpern et al., 2009, p. 537).
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Elpern et al. defined a CAUTI as “an infection in a patient with a urinary catheter
who met National Healthcare Safety Network definition of a urinary tract infection”
(Elpern et al., 2009, p. 537). The authors also used a formula to calculate CAUTI rates.
CAUTI rates were defined as, “the number of CAUTIs divided by the number of urinary
catheter device days multiplied by 1000. CAUTI rates were computed monthly” (Elpern
et al., 2009, p. 537).
Research design/data collection
Elpern et al. (2009) state that, “this study was a before-and-after evaluation of a
low-technology intervention to reduce duration of urinary catheterization and occurrence
of CAUTIs in an MICU.” Subjects included in the research study consisted of all MICU
patients admitted from December 1, 2007 to May 31, 2008 who had indwelling catheters
as part of their unit stay (Elpern et al., 2009). The data collected during the intervention
phase of this study was duration of catheterization, appropriateness of catheterization,
and reasons for inappropriate catheter use. Surveillance for CAUTIs was completed by
nurse epidemiologists from the medical center’s infection control department (Elpern et
al., 2009, p. 537).
There are many threats to the external validity of this study. Some of the threats
are discussed by the authors, such as the subjectivity which was involved in daily
evaluations, appropriate catheter use was consensus based and not evidence based,
and differences of opinion on catheter use were deferred to the judgment of the nurses
providing direct patient care.
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Study Findings
Elpern et al. provided detailed statistical information to support their research
findings. The data analysis is included with the results of the study. It is reported that,
“during the 6-month intervention, 337 patients had indwelling urinary catheters for a total
of 1,432 days. Before the intervention, the mean number of urinary catheter days was
311.7 device days per month (d/mo)”(Elpern et al., 2009, p. 538). Continuing on with
the data analysis, Elpern et al. stated that the comparison of data pre and post
intervention has demonstrated a decrease in the mean catheter days to 238.6 d/mo, for
a total reduction of 73.1 d/mo. “In the 11 months before the intervention, 15 CAUTIs
occurred during 3,429 device days or 4.7 per 1000 days. In the intervention phase,
zero CAUTIs occurred in 1,432 device days” (Elpern et al., 2009, p. 538). The stated
statistical findings are significant.
Implications for Practice
It is very apparent that by assessing the actual need for indwelling urinary
catheters and using guidelines which allow catheter use for specific purposes only, the
CAUTI rates had been completely eliminated in this study. It is not a feasible idea for
complete elimination of CAUTIs due to the nature of the invasiveness. Elpern et al.
stated that, “despite strict adherence to indicators, some CAUTIs will inevitably occur.
Reasonable goals are to avoid overuse of indwelling urinary catheters and reduce
CAUTI rates” (Elpern et al., 2009, p. 540).
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Recommendations
Urinary catheterization is a necessary component of patient care in many
different types of patient situations, yet overuse of catheters has been demonstrated in
all three articles to be a significant contributor to high infection rates. In addition to
possessing a questioning attitude with catheter use, there are other actions that can be
taken by a nurse to assist in the reduction of CAUTI for those that do require prolonged
catheterization: daily reassessment of the need for the catheter, intentional catheter
selection based on individual patients and not nurse preference, detailed patient care
documentation, charge nurse rounds on every shift, education of patients and family
members about proper catheter care, and ongoing competency training for both nurses
and nursing assistants. Because CAUTI can become a significant comorbidity, and is
not a reimbursable medical condition for some major insurance payers, careful attention
to this condition is vital. As a group, we recommend careful consideration of the need
for each and every indwelling catheter that is placed, and for hospitals to develop
practice policies that reflect the recommendations listed above.
Conclusion
Each of these three articles was chosen because they appeared to be strong
studies that directly reflected the potential for nurse-specific interventions related to
CATUI. Although each quasi-experimental study had its own challenges and areas of
bias, each was constructed differently enough from one another to cover those gaps, at
least in part. There is enough evidence included within the three studies to make a
strong recommendation for changes in nursing practice and to validate the importance
of doing so.
CAUTI
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References
Andreessen, L., Wilde, M., Herendeen, P.,(2012). Preventing Catheter-Associated
Urinary Tract Infections in Acute Care. Journal of Nursing Care Quality. 27(3),
209-217. Retrieved from
http://www.nursingcenter.com/lnc/JournalArticle?Article_ID=1355891
Burns, N. & Grove S. K. (2011) Understanding nursing research: Building an evidencebased practice. Maryland Heights, MO: Elsevier Saunders.
Elpern, E.H., Killeen, K., Ketchem, A., Wiley, A., Patel, G., & Lateef, O. (2009).
Reducing use of indwelling catheters and associated urinary tract infections.
American Journal of Critical Care, 18(6), 535-541. doi:10.4037/ajcc2009938
Oman, K., Makic, M.B., Fink, R., Schraeder, N., Hulett, T., Keech, T., & Wald, H. (2011).
Nurse-directed interventions to reduce catheter-associated urinary tract
infections. American Journal of Infection Control. doi:10.1016/j.ajic,2011.07.018
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Paper #1 Evidence-Based Group Project Paper
Grading Criteria
30% of grade for paper can be deducted for APA errors including Spelling and grammar after
paper graded.
Headings
Possible
Points
Comments
points
Earned
Abstract and Title Page
10
Introduction
(What is the problem or
question; Provide support for
relevance of the question;
Clearly describe the aim of
the project & paper)
A descriptive summary of
the most relevant & best
evidence to answer the
research question (there is
not analysis here, just a
description of what you
found in the literature)
An analysis of the
evidence (this is a critical
appraisal of the evidence
and what you feel as a group
the evidence suggests and
whether there is strong or
weak evidence to support
the suggested findings)
Describe how the evidence
is affected by your
experiences as nurses,
patient preferences,
nursing's or other's values
and how these factors
would influence your
decision to utilize the
evidence in practice
Make a recommendation
as to whether or not to
utilize the evidence
(support your
recommendation with
rationale)
APA spelling and
Grammar Deductions
Total points
10
20
20
20
20
100