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Engaging health care workers to prevent catheter-associated urinary tract infection and avert patient harm

      Preventing catheter-associated urinary tract infection (CAUTI) remains a significant challenge for US hospitals. The “On the CUSP: Stop CAUTI” initiative represents the single largest national effort (involving >950 hospitals) to mitigate urinary catheter risk. The program brings together key organizations to assist state hospital associations and hospitals by providing education and coaching support, addressing both the technical aspects of preventing CAUTI and CAUTI-specific socio-adaptive challenges. At the local level, engaging health care workers, from physicians and nurses to other ancillary services, is critical. This includes (1) making the importance of addressing CAUTI stakeholder specific, (2) ensuring support from leaders of essential disciplines, (3) underscoring the importance of the collaborative nature of CAUTI prevention, and (4) identifying champions within the organization to lead and be accountable for the work. Sustainability is ensured by integrating the process into the health care worker's daily routine activities.

      Key Words

      Preventing inappropriate urinary catheter use has gained significant focus over the last decade,
      • Meddings J.
      • Rogers M.A.
      • Krein S.L.
      • Fakih M.G.
      • Olmsted R.N.
      • Saint S.
      Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review.
      with growing appreciation of the urinary catheter as a risk to patient safety. The catheter is associated with both mechanical
      • Hollingsworth J.M.
      • Rogers M.A.
      • Krein S.L.
      • Hickner A.
      • Kuhn L.
      • Cheng A.
      • et al.
      Determining the noninfectious complications of indwelling urethral catheters: a systematic review and meta-analysis.
      and infectious complications,
      • Hooton T.M.
      • Bradley S.F.
      • Cardenas D.D.
      • Colgan R.
      • Geerlings S.E.
      • Rice J.C.
      • et al.
      Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 international clinical practice guidelines from the Infectious Diseases Society of America.
      including increased multidrug resistance.
      • Sievert D.M.
      • Ricks P.
      • Edwards J.R.
      • Schneider A.
      • Patel J.
      • Srinivasan A.
      • et al.
      Antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2009-2010.
      • Wang L.
      • Lansing B.
      • Symons K.
      • Flannery E.L.
      • Fisch J.
      • Cherin K.
      • et al.
      Infection rate and colonization with antibiotic-resistant organisms in skilled nursing facility residents with indwelling devices.
      Since October 2008, the Centers for Medicare and Medicaid Services have not reimbursed for hospital-acquired catheter-associated urinary tract infection (CAUTI), considering it to be a reasonably preventable condition.
      • Saint S.
      • Meddings J.A.
      • Calfee D.
      • Kowalski C.P.
      • Krein S.L.
      Catheter-associated urinary tract infection and the Medicare rule changes.
      In addition, the US Department of Health and Human Services' National Action Plan to prevent healthcare-associated infections includes a 25% reduction in CAUTI rates nationwide by 2013.
      • Fakih M.G.
      • George C.M.
      • Edson B.S.
      • Goeschel C.A.
      • Saint S.
      Implementing a national program to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies.
      Among the efforts to meet this goal is the national implementation of Comprehensive Unit-based Safety Program (CUSP) to reduce CAUTI initiative, also known as the initiative—On the CUSP: Stop CAUTI—which is funded by the Agency for Healthcare Research and Quality (AHRQ) and led by several institutions and societies. Specifically, this AHRQ-funded effort, led by the Health Research & Educational Trust (HRET), an affiliate of the American Hospital Association, in collaboration with the Michigan Health & Hospital Association (MHA) Keystone Center for Patient Safety & Quality, St John Hospital and Medical Center, Veterans Affairs/University of Michigan Patient Safety Enhancement Program, and Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, is designed to reduce CAUTI, improve unit safety culture, and reduce CAUTI risk.
      • Fakih M.G.
      • George C.M.
      • Edson B.S.
      • Goeschel C.A.
      • Saint S.
      Implementing a national program to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies.
      In this article, we discuss CAUTI prevention efforts, describe the national collaboration between the different organizations, briefly review the technical and socio-adaptive components of the program, and specifically describe our approach to engaging health care workers (HCWs) as an essential part of CAUTI prevention and averting patient harm. Strategies to ensure sustained improvements are also discussed.

      CAUTI prevention

      Much of the effort to prevent CAUTI has been geared toward reducing device use.
      • Meddings J.
      • Rogers M.A.
      • Krein S.L.
      • Fakih M.G.
      • Olmsted R.N.
      • Saint S.
      Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review.
      • Fakih M.G.
      • Watson S.R.
      • Greene M.T.
      • Kennedy E.H.
      • Olmsted R.N.
      • Krein S.L.
      • et al.
      Reducing inappropriate urinary catheter use: a statewide effort.
      In 2009, the Centers for Disease Control (CDC) Healthcare Infection Control Practices Advisory Committee (HICPAC) issued new guidelines for CAUTI prevention, including consensus-based indications for appropriate use.
      • Gould C.V.
      • Umscheid C.A.
      • Agarwal R.K.
      • Kuntz G.
      • Pegues D.A.
      Guideline for prevention of catheter-associated urinary tract infections 2009.
      Although based on expert opinion, the recommended indications are largely viewed as acceptable indications for catheter use, and hospitals have been encouraged to adopt them. The 6 appropriate indications are as follows: (1) acute urinary retention or bladder outlet obstruction, (2) accurate measurements of urinary output in critically ill patients, (3) perioperative use for selected surgical procedures, (4) to assist in healing of open sacral or perineal wounds in incontinent patients, (5) prolonged immobilization requirement, and (6) improved comfort for end-of-life care. In addition, the HICPAC CAUTI guidelines promote proper aseptic insertion and maintenance techniques.
      • Gould C.V.
      • Umscheid C.A.
      • Agarwal R.K.
      • Kuntz G.
      • Pegues D.A.
      Guideline for prevention of catheter-associated urinary tract infections 2009.
      Nonetheless, unnecessary placement and continued use of urinary catheters remains common in hospitalized patients, especially among vulnerable populations, such as older adults.
      • Apisarnthanarak A.
      • Rutjanawech S.
      • Wichansawakun S.
      • Patanabunjerdkul H.
      • Patthranitima P.
      • Thongphubeth K.
      • et al.
      Initial inappropriate urinary catheters use in a tertiary-care center: incidence, risk factors, and outcomes.
      • Fakih M.G.
      • Shemes S.P.
      • Pena M.E.
      • Dyc N.
      • Rey J.E.
      • Szpunar S.M.
      • et al.
      Urinary catheters in the emergency department: very elderly women are at high risk for unnecessary utilization.
      • Gokula R.R.
      • Hickner J.A.
      • Smith M.A.
      Inappropriate use of urinary catheters in elderly patients at a midwestern community teaching hospital.
      • Hazelett S.E.
      • Tsai M.
      • Gareri M.
      • Allen K.
      The association between indwelling urinary catheter use in the elderly and urinary tract infection in acute care.
      • Jain P.
      • Parada J.P.
      • David A.
      • Smith L.G.
      Overuse of the indwelling urinary tract catheter in hospitalized medical patients.
      • Munasinghe R.L.
      • Yazdani H.
      • Siddique M.
      • Hafeez W.
      Appropriateness of use of indwelling urinary catheters in patients admitted to the medical service.
      The risk exists as soon as the patient reaches the hospital, in the emergency department (ED), on both the intensive care unit (ICU) and the medical surgical floor, or in the operating room (OR). Mitigating the risks associated with catheter use includes addressing both appropriate reasons for use and proper insertion technique and catheter maintenance. The urinary catheter life cycle, described by Meddings and Saint,
      • Meddings J.
      • Saint S.
      Disrupting the life cycle of the urinary catheter.
      provides a useful framework for both identifying and addressing this risk (Fig 1). For example, to reduce catheter harm, the first step is to prevent placement of any urinary catheter that would not be of medical benefit to the patient.
      • Fakih M.G.
      • Pena M.E.
      • Shemes S.
      • Rey J.
      • Berriel-Cass D.
      • Szpunar S.M.
      • et al.
      Effect of establishing guidelines on appropriate urinary catheter placement.
      • Gokula R.M.
      • Smith M.A.
      • Hickner J.
      Emergency room staff education and use of a urinary catheter indication sheet improves appropriate use of foley catheters.
      • Scott R.A.
      • Oman K.S.
      • Makic M.B.
      • Fink R.M.
      • Hulett T.M.
      • Braaten J.S.
      • et al.
      Reducing indwelling urinary catheter use in the emergency department: a successful quality-improvement initiative.
      Avoiding unnecessary catheter placement will not only prevent the risk of infection, but it will also prevent trauma
      • Hollingsworth J.M.
      • Rogers M.A.
      • Krein S.L.
      • Hickner A.
      • Kuhn L.
      • Cheng A.
      • et al.
      Determining the noninfectious complications of indwelling urethral catheters: a systematic review and meta-analysis.
      • Leuck A.M.
      • Wright D.
      • Ellingson L.
      • Kraemer L.
      • Kuskowski M.A.
      • Johnson J.R.
      Complications of Foley catheters–is infection the greatest risk?.
      associated with the catheter and other conditions (eg, impaired mobility).
      • Saint S.
      • Lipsky B.A.
      • Goold S.D.
      Indwelling urinary catheters: a one-point restraint?.
      Step 2, aseptic insertion and proper maintenance, reduces the risk of introducing organisms into the bladder, delaying the occurrence of bacteriuria. Removal of the catheter when it is no longer medically needed (step 3) reduces the risk of noninfectious and infectious complications. Catheter-associated bacteriuria is dependent on duration of use,
      • Tambyah P.A.
      • Maki D.G.
      The relationship between pyuria and infection in patients with indwelling urinary catheters: a prospective study of 761 patients.
      • Garibaldi R.A.
      • Burke J.P.
      • Dickman M.L.
      • Smith C.B.
      Factors predisposing to bacteriuria during indwelling urethral catheterization.
      making removing unnecessary catheters an attractive area for intervention.
      • Meddings J.
      • Rogers M.A.
      • Krein S.L.
      • Fakih M.G.
      • Olmsted R.N.
      • Saint S.
      Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review.
      • Fakih M.G.
      • George C.M.
      • Edson B.S.
      • Goeschel C.A.
      • Saint S.
      Implementing a national program to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies.
      • Fakih M.G.
      • Watson S.R.
      • Greene M.T.
      • Kennedy E.H.
      • Olmsted R.N.
      • Krein S.L.
      • et al.
      Reducing inappropriate urinary catheter use: a statewide effort.
      • Fakih M.G.
      • Dueweke C.
      • Meisner S.
      • Berriel-Cass D.
      • Savoy-Moore R.
      • Brach N.
      • et al.
      Effect of nurse-led multidisciplinary rounds on reducing the unnecessary use of urinary catheterization in hospitalized patients.
      • Knoll B.M.
      • Wright D.
      • Ellingson L.
      • Kraemer L.
      • Patire R.
      • Kustowski M.A.
      • et al.
      Reduction of inappropriate urinary catheter use at a Veterans Affairs hospital through a multifaceted quality improvement project.
      Step 4 of the lifecycle focuses on preventing reinsertion of indwelling urethral catheters, which may involve the use of alternative strategies, such as bladder scanning and intermittent catheterization, as described in the algorithm provided in Figure 2.
      Figure thumbnail gr1
      Fig 1Lifecycle of the urinary catheter, which includes placement, care, removal, and reinsertion.
      (Reproduced with Permission. Meddings and Saint, Clin Infect Dis 2011;52:1291–93.)
      Figure thumbnail gr2
      Fig 2Example of a nurse-driven urinary catheter removal protocol.

      National collaboration between various stakeholders

      Drawing on a successful effort at a hospital,
      • Fakih M.G.
      • Dueweke C.
      • Meisner S.
      • Berriel-Cass D.
      • Savoy-Moore R.
      • Brach N.
      • et al.
      Effect of nurse-led multidisciplinary rounds on reducing the unnecessary use of urinary catheterization in hospitalized patients.
      the MHA Keystone Center implemented a process to reduce inappropriate catheter use in 163 units from 71 acute care hospitals in the state of Michigan. This program resulted in a 25% relative reduction in catheter use and a 30% improvement in appropriate use,
      • Fakih M.G.
      • Watson S.R.
      • Greene M.T.
      • Kennedy E.H.
      • Olmsted R.N.
      • Krein S.L.
      • et al.
      Reducing inappropriate urinary catheter use: a statewide effort.
      which also corresponded with a 25% reduction in CAUTI rates in the state of Michigan during a period in which the nation saw only a 6% decline.
      • Saint S.
      • Greene M.T.
      • Kowalski C.P.
      • Watson S.R.
      • Hofer T.P.
      • Krein S.L.
      Preventing catheter-associated urinary tract infection in the United States: a national comparative study.
      The Michigan work used a bladder bundle that promotes daily evaluation of catheter need, use of tools (eg, bladder ultrasound) to prevent catheterization, and evaluation and feedback on catheter use and appropriateness.
      • Saint S.
      • Olmsted R.N.
      • Fakih M.G.
      • Kowalski C.P.
      • Watson S.R.
      • Sales A.E.
      • et al.
      Translating health care-associated urinary tract infection prevention research into practice via the bladder bundle.
      Building on the Michigan approach and with funding support from the AHRQ, 10 organizations, considered to be important stakeholders in reducing catheter harm, collaborated to plan and implement the On the CUSP: Stop CAUTI project in all 50 states. The HRET leads the project, providing oversight, coordinating the work between the different organizations, and serving as a conduit to state hospital associations and other entities working with hospitals. Since the project's inception in August 2011, a national project team with representatives from the MHA, University of Michigan, St John Hospital and Medical Center, and Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality has been working with the HRET to guide the CAUTI prevention work that is now underway. The roles of the national team members are described in Table 1. In addition to the national team, extended faculty was recruited from the Association for Professionals in Infection Control, Society of Healthcare Epidemiology of America, Society of Hospital Medicine, Emergency Nursing Association, and American College of Emergency Physicians (Table 1). The role of the extended faculty ranges from spreading the educational efforts nationwide, providing insight in their area of expertise, and garnering support for the initiative with their respective members. Finally, representatives from the CDC provide technical assistance and guidance to the national team.
      Table 1Roles of the different entities in the national effort
      EntityExpertiseRole
      HRETAdministration and coordination of initiativesProvide oversight of the national implementation effort; serve as a liaison with the 50 state hospital associations to recruit hospitals, implement education and improvements, and build capacity for sustainability; help coordinate the efforts between the different entities partnering in the project
      MHA Keystone Center for Patient SafetyImplementation of patient safety initiatives, implemented the initial statewide efforts in Michigan that led to significant reduction in urinary catheter useContribute to the development and coordination of project's education and coaching; responsible for data collection and reporting
      University of MichiganFaculty members are leaders in CAUTI research from evaluation to intervention, with technical and socio-adaptive expertise, data evaluation, and readiness assessmentNational faculty responsible for education related to socio-adaptive aspect of reducing CAUTI, data evaluation, expert guidance on the project progress, and suggesting improvements
      St John Hospital and Medical CenterFaculty members are experts in implementation of CAUTI reduction efforts; implemented the initial nurse-driven effort to reduce unnecessary catheter use in addition to efforts to reduce catheter placement in the EDNational faculty responsible for education of the technical component, data evaluation, expert guidance on the project progress, and suggesting improvements
      Johns Hopkins Medicine Armstrong Institute for Patient Safety and QualityExperts in CUSPFaculty for initial CUSP educational sessions; supports the HRET and MHA on content specific to CUSP and its use to prevent CAUTI
      CDCExpertise in CAUTI prevention and the definition of CAUTIProvide technical advice for states to improve their infrastructure to improve readiness for healthcare-associated infection prevention; advice related to CAUTI definition
      Association of Professionals in Infection ControlExpertise in CAUTI prevention, and the CDC CAUTI definitionExtended faculties build capacity for educating facilities, with focus of reducing infection risk and the proper use of the CAUTI definition to measure outcomes
      Emergency Nurses AssociationExpertise in the emergency settingExtended faculties serve as the liaison with the emergency nurses through their society, build capacity for educating emergency nurses with focus on avoiding catheter use unless there is an appropriate indication, and support the interventions in recruited EDs
      Society of Hospital MedicineExpertise in education through a mentoring programExtended faculties serve as a liaison with hospitalists who may play a key role in reducing unnecessary urinary catheter use
      Society of Healthcare Epidemiology of AmericaExpertise in CAUTI prevention and the CDC CAUTI definitionExtended faculties build capacity for educating facilities, with focus of reducing infection risk and the proper use of the CAUTI definition to measure outcomes
      American College of Emergency PhysiciansExpertise in the emergency settingFaculty serves as the liaison with the emergency physicians through their society, builds capacity for educating emergency physicians with focus on avoiding catheter use unless there is an appropriate indication, and supports the interventions in recruited EDs

      Technical and socio-adaptive components

      The On the CUSP: Stop CAUTI effort is initiated for groups of states at a time (or cohorts), beginning with the engagement of the various state leads who serve as a liaison with the hospitals. Interested hospitals are expected to obtain leadership support and identify specific units for their improvement work. Hospitals are also provided with tools to help them assemble their CAUTI prevention teams and resources to support their efforts. The importance of addressing both the technical and socio-adaptive components of CAUTI prevention is stressed throughout program implementation.
      • Saint S.
      • Howell J.D.
      • Krein S.L.
      Implementation science: how to jump-start infection prevention.
      Hospital teams are educated on the epidemiology of urinary catheter use and CAUTIs, CDC HICPAC consensus-based guidelines for urinary catheter use, and evidence-based practices applicable to catheter placement and maintenance.
      • Gould C.V.
      • Umscheid C.A.
      • Agarwal R.K.
      • Kuntz G.
      • Pegues D.A.
      Guideline for prevention of catheter-associated urinary tract infections 2009.
      The technical aspect also includes a focus on evaluating daily necessity for patients with an indwelling urinary catheter.
      Education about the socio-adaptive elements of CAUTI prevention includes strategies to gain the support of all team members. Specifically, the CUSP model is used to help create a culture of safety in the involved hospitals.
      • Pronovost P.
      • Weast B.
      • Rosenstein B.
      • Sexton J.B.
      • Holzmueller C.G.
      • Paine L.
      • et al.
      Implementing and validating a comprehensive unit-based safety program.
      In addition, the socio-adaptive component focuses on providing support to HCWs, addressing challenges to implementation, and offering solutions to overcome possible barriers.
      • Saint S.
      • Kowalski C.P.
      • Banaszak-Holl J.
      • Forman J.
      • Damschroder L.
      • Krein S.L.
      How active resisters and organizational constipators affect health care-acquired infection prevention efforts.
      This focus on socio-adaptive issues is critical because preventing CAUTI is primarily behaviorally focused, requiring engagement, collaboration, and communication across professional disciplines and clinical and administrative boundaries.
      • Damschroder L.J.
      • Banaszak-Holl J.
      • Kowalski C.P.
      • Forman J.
      • Saint S.
      • Krein S.L.
      The role of the champion in infection prevention: results from a multisite qualitative study.
      • Saint S.
      • Kowalski C.P.
      • Banaszak-Holl J.
      • Forman J.
      • Damschroder L.
      • Krein S.L.
      The importance of leadership in preventing healthcare-associated infection: results of a multisite qualitative study.
      • Saint S.
      • Kowalski C.P.
      • Forman J.
      • Damschroder L.
      • Hofer T.P.
      • Kaufman S.R.
      • et al.
      A multicenter qualitative study on preventing hospital-acquired urinary tract infection in US hospitals.
      General approaches for addressing both the technical and socio-adaptive aspects of CAUTI prevention as part of the On the CUSP: Stop CAUTI effort have been previously described.
      • Fakih M.G.
      • George C.M.
      • Edson B.S.
      • Goeschel C.A.
      • Saint S.
      Implementing a national program to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies.
      However, specific strategies, especially those for engaging a diverse range of HCWs have not been well described, despite being a critical element of preventing CAUTI and reducing risk of patient harm.

      Engaging HCWs and the ideal team

      As an important element of socio-adaptive change, HCW engagement at the hospital level is an essential component for successful implementation of the CAUTI prevention work. This includes the range of HCWs and potential stakeholders who provide patient care and are expected to incorporate the implementation of the CAUTI prevention practices into their daily work. The engagement process includes the following: (1) making the case for the importance of addressing CAUTI for different stakeholders, (2) ensuring support of the leaders of essential groups, (3) underscoring the importance of the collaborative nature of the effort, and (4) identifying champions to lead and be accountable for the work.

      Making the case for different stakeholders

      Many stakeholders have an interest in helping to reduce CAUTI. Traditionally, infection prevention has championed the effort to reduce CAUTI, viewing CAUTI as a preventable healthcare-associated infection. More recently, hospital administrative leaders have also recognized and supported many of the initiatives to reduce CAUTI, given that CAUTI is no longer a reimbursable event,
      • Saint S.
      • Meddings J.A.
      • Calfee D.
      • Kowalski C.P.
      • Krein S.L.
      Catheter-associated urinary tract infection and the Medicare rule changes.
      and will be tied to internal quality reporting and value-based purchasing.
      Centers for Medicare and Medicaid Services (CMS), HHS
      Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and Fiscal Year 2014 rates; quality reporting requirements for specific providers; hospital conditions of participation; payment policies related to patient status. Final rules.
      Administrative leadership support may provide a significant incentive for the different hospital disciplines to support the work to reduce CAUTI. However, in focusing on urinary catheter harm more broadly as the principal event to prevent, other disciplines may also be encouraged to help. For example, urinary catheter presence likely leads to more urine cultures and antimicrobial treatment of asymptomatic bacteriuria,
      • Gross P.A.
      • Patel B.
      Reducing antibiotic overuse: a call for a national performance measure for not treating asymptomatic bacteriuria.
      • Cope M.
      • Cevallos M.E.
      • Cadle R.M.
      • Darouiche R.O.
      • Musher D.M.
      • Trautner B.W.
      Inappropriate treatment of catheter-associated asymptomatic bacteriuria in a tertiary care hospital.
      with associated increase in multidrug resistance and Clostridium difficile infection.
      • Sievert D.M.
      • Ricks P.
      • Edwards J.R.
      • Schneider A.
      • Patel J.
      • Srinivasan A.
      • et al.
      Antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2009-2010.
      In addition, urinary catheter use is associated with local trauma, patient discomfort, immobility, and potentially, the risk of pressure ulcers and falls.
      • Hollingsworth J.M.
      • Rogers M.A.
      • Krein S.L.
      • Hickner A.
      • Kuhn L.
      • Cheng A.
      • et al.
      Determining the noninfectious complications of indwelling urethral catheters: a systematic review and meta-analysis.
      • Leuck A.M.
      • Wright D.
      • Ellingson L.
      • Kraemer L.
      • Kuskowski M.A.
      • Johnson J.R.
      Complications of Foley catheters–is infection the greatest risk?.
      • Aaronson D.S.
      • Wu A.K.
      • Blaschko S.D.
      • McAninch J.W.
      • Garcia M.
      National incidence and impact of noninfectious urethral catheter related complications on the surgical care improvement project.
      • Black J.M.
      • Cuddigan J.E.
      • Walko M.A.
      • Didier L.A.
      • Lander M.J.
      • Kelpe M.R.
      Medical device related pressure ulcers in hospitalized patients.
      Engaging the different disciplines and pointing out the reasons why the work is important to them will help gain the support needed to succeed. Table 2 summarizes the potential harm related to the catheter and reasons why different disciplines should be interested in supporting the work.
      Table 2Disciplines and specialties and their incentives to support minimizing urinary catheter harm
      Discipline or specialtyUrinary catheter harm
      Hospital epidemiology, infection prevention, and infectious diseasesInfectious complications: CAUTI, multidrug resistance, C difficile infection, and improve antimicrobial stewardship
      UrologyMechanical complications: hematuria, meatal and urethral injury
      Geriatric medicineInfectious and noninfectious complications: significant proportion of inappropriate catheterization in older adults, leading to increased immobility and deconditioning risk, in addition to infection and trauma
      Hospital medicineInfectious and noninfectious complications: hospitalists care for a large number of patients; their support may significantly improve the appropriate use of urinary catheters resulting also in shorter length of stay
      Rehabilitation medicine and physical therapyUrinary catheter impedes mobility (1-point restraint), and may be associated with an increased risk of falls
      Wound ostomy servicesUrinary catheter use increases immobility, which in turn results in an increased risk of pressure ulcers; wound care nurses may help in advising the bedside nurse on methods to reduce skin breakdown in patients with incontinence without using urinary catheters
      SurgeryAvoid postoperative complications: the surgeons need to comply with the Surgical Care Improvement Project recommendations to remove catheters by postoperative day 1 or 2; inappropriate urinary catheter use postoperatively will negatively affect the surgeon's profile
      Intensive care nurses and physiciansCAUTI is publicly reported in the ICUs; the ICU has the highest prevalence of urinary catheter use compared with other hospital units; opportunities to reduce urinary catheter use exist through daily evaluation of need and on transfer from the ICU to floor
      Emergency medicine nurses and physiciansED represents the point of entry to more than half of the patients admitted to the hospital; unnecessary urinary catheter placement is common in the ED, and promoting appropriate placement will affect use hospital-wide
      Administrative leadersInappropriate urinary catheter use subjects the patient to preventable safety risk; in addition, the Centers for Medicare and Medicaid Services have stopped compensation for hospital-acquired conditions; moreover, CAUTIs are publicly reported and are tied to value-based purchasing and hospital-acquired condition payment penalty
      ED, emergency department; ICU, intensive care unit.
      Specifically, it is helpful to address each discipline's clinical interests and make the case for why this effort is of value to them and their patients. Each group's perception is different; therefore, engaging them needs to take into account their unique priorities. The infection prevention team views reducing urinary catheter use as a critical factor for lowering CAUTI events, antimicrobial use, C difficile infections, and minimizing an important reservoir for multidrug resistant organisms. Urologists are interested in avoiding any mechanical complications related to the catheter (eg, urethral trauma, hematuria). Hospitalists and geriatricians may view the invasive nature of the catheter with its infectious and debilitating effects on already frail patients as important reasons for minimizing catheter use. Physical therapists consider the urinary catheter another barrier that hinders the patient's mobility, therefore delaying the rehabilitation process. Similarly, intensive care nurses and physicians working on early mobility in intubated patients have an incentive to remove the catheter as soon as the patient's critical illness no longer requires hourly output monitoring. In addition, public reporting of CAUTI and linking it to value-based purchasing have increased the pressure placed on intensive care unit teams by administrative leaders. Wound care nurses are concerned about the risk of pressure ulcers and wound deterioration in an incontinent patient, but they also recognize the importance of reducing device-related pressure ulcer risks and risks associated with immobility. Finally, the ED clinicians play a very special role in minimizing avoidable device exposure, supporting all other hospital units and disciplines.

      Ensuring the support of leaders

      After identifying the stakeholders, engaging their leaders is of paramount importance. The leader's involvement may range from being a staunch supporter of the initiative to a barrier to optimal implementation.
      • Saint S.
      • Kowalski C.P.
      • Banaszak-Holl J.
      • Forman J.
      • Damschroder L.
      • Krein S.L.
      How active resisters and organizational constipators affect health care-acquired infection prevention efforts.
      Successful leaders promote a culture of clinical excellence and effectively communicate it to staff, inspire staff to follow their lead, help overcome barriers to adoption of new processes, and “think strategically while acting locally” to move initiatives forward.
      • Saint S.
      • Kowalski C.P.
      • Banaszak-Holl J.
      • Forman J.
      • Damschroder L.
      • Krein S.L.
      The importance of leadership in preventing healthcare-associated infection: results of a multisite qualitative study.
      In contrast, active resisters plainly voice their opposition to the process, whereas organizational constipators may undermine the work without clearly showing their lack of support.
      • Saint S.
      • Kowalski C.P.
      • Banaszak-Holl J.
      • Forman J.
      • Damschroder L.
      • Krein S.L.
      How active resisters and organizational constipators affect health care-acquired infection prevention efforts.
      Engaging active resisters and organizational constipators and including them in discussions to implement changes in the hospital may help obtain their support.

      Understanding the collaborative nature of the effort

      Reducing CAUTI requires both nurse and physician support. Although a physician order has been historically viewed as essential to place or discontinue the catheter, nurses may be empowered to make decisions about removal without a physician order in some settings,
      • Fakih M.G.
      • Pena M.E.
      • Shemes S.
      • Rey J.
      • Berriel-Cass D.
      • Szpunar S.M.
      • et al.
      Effect of establishing guidelines on appropriate urinary catheter placement.
      • Gokula R.M.
      • Smith M.A.
      • Hickner J.
      Emergency room staff education and use of a urinary catheter indication sheet improves appropriate use of foley catheters.
      and they are most affected with respect to workload if the catheter is discontinued.
      • Krein S.L.
      • Kowalski C.P.
      • Harrod M.
      • Forman J.
      • Saint S.
      Barriers to reducing urinary catheter use: a qualitative assessment of a statewide initiative.
      In a recent survey, the vast majority of nurses viewed themselves as responsible for the evaluation and discontinuation of the catheter, but only two-thirds thought it does not affect their workload.
      • Fakih M.
      • Rey J.
      • Pena M.
      • Szpunar S.
      • Saravolatz L.
      Sustained reductions in urinary catheter use over 5 years: bedside nurses view themselves responsible for evaluation of catheter necessity.
      Most of the work to reduce unnecessary urinary catheter use involves a nurse-driven assessment for appropriateness,
      • Meddings J.
      • Rogers M.A.
      • Krein S.L.
      • Fakih M.G.
      • Olmsted R.N.
      • Saint S.
      Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review.
      • Fakih M.G.
      • George C.M.
      • Edson B.S.
      • Goeschel C.A.
      • Saint S.
      Implementing a national program to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies.
      • Fakih M.G.
      • Watson S.R.
      • Greene M.T.
      • Kennedy E.H.
      • Olmsted R.N.
      • Krein S.L.
      • et al.
      Reducing inappropriate urinary catheter use: a statewide effort.
      • Fakih M.G.
      • Dueweke C.
      • Meisner S.
      • Berriel-Cass D.
      • Savoy-Moore R.
      • Brach N.
      • et al.
      Effect of nurse-led multidisciplinary rounds on reducing the unnecessary use of urinary catheterization in hospitalized patients.
      with many requiring physician approval for discontinuation. Even with physician-independent discontinuation protocols, physician support is a key to success. For example, a hospital recently implemented a process for physician-independent discontinuation of urinary catheters based on agreed institutional guidelines. This process included the involvement of nursing leadership, quality improvement, and key administrative physician leaders, but it was not discussed with urology. Early in its implementation, a urinary catheter was removed erroneously in a patient postprostatectomy; this led to strong resistance to the process from urology, and consequently, the program was halted (personal observation, MGF).
      Collaboration between departments is also critical to success. The ED and OR are areas where large numbers of urinary catheters are placed, and the intensive care units represent areas of high prevalence of use.
      • Dudeck M.A.
      • Horan T.C.
      • Peterson K.D.
      • Allen-Bridson K.
      • Morrell G.
      • Anttila A.
      • et al.
      National Healthcare Safety Network report, data summary for 2011, device-associated module.
      Intervening to prevent inappropriate catheter placement in the ED and the OR will help reduce the use of catheters in the nonintensive care units. In addition, removal of no-longer needed catheters in patients on transfer out from the intensive care units will also help lower urinary catheter prevalence in the nonintensive care units.

      Identifying champions to lead and be accountable for the effort

      The recommended champion is a HCW, preferably from the same unit, who is motivated and engaged in improving safety. The champion may be either a physician, a nurse, or in some instances, a member of other supporting services. Successful champions are those who believe in the safety efforts, have the recognition and respect of their coworkers, and are early adopters of change.
      • Damschroder L.J.
      • Banaszak-Holl J.
      • Kowalski C.P.
      • Forman J.
      • Saint S.
      • Krein S.L.
      The role of the champion in infection prevention: results from a multisite qualitative study.
      • Hendy J.
      • Barlow J.
      The role of the organizational champion in achieving health system change.
      • Reinertsen J.L.
      • Gosfield A.G.
      • Rupp W.
      • Whittington J.W.
      Engaging physicians in a shared quality agenda. IHI innovation series white paper.
      The champion's role is to reduce CAUTI risk by promoting best practices. Ensuring that the champion is fully versed on the individual institution's best practices is essential. For example, he/she needs to know the appropriate indications for urinary catheter use and identify the potential barriers and facilitators. The champion acts as a liaison among all HCWs, engaging all of the stakeholders who are involved in patient care. One of the champion's functions is to maintain the focus on reducing urinary catheter risk as a patient safety priority. The champion may share patient stories with HCWs to improve their perception of the potential risk to patients. The champion needs to elucidate significant risks associated with urinary catheters and may share examples of poor patient outcomes related to not following best practices. The champion may promote best practices to others by distributing educational materials, providing presentations, and offering other tools that help HCWs adhere to best practices. The champion will also help identify barriers to implementation and develop solutions with other stakeholders. Finally, a very important role of the champion is providing performance feedback to all stakeholders. For example, the champion may identify a sizable number of patients on a unit without appropriate indications and relay this concern to the nurse manager on the unit. The champion takes on the mantel of striving to improve patient safety and encourages the individual HCW's sense of accountability. Some may even have experience in peer-to-peer coaching and addressing just culture, which recognizes that even competent HCWs may make mistakes and should not be accountable for system failings, but they do not tolerate reckless behavior.

      Marx D. Patient safety and the “just culture”: a primer for health care executives. 2001. Available from: http://www.safer.healthcare.ucla.edu/safer/archive/ahrq/FinalPrimerDoc.pdf. Accessed May 6, 2014.

      Ideal CAUTI prevention team

      We suggest that all hospital teams include nurse and physician champions (Table 3). The nurse champion explains the project details to the team members and ensures that the staff is educated about CAUTI and appropriate indications for catheter use. The nurse champion facilitates the use of teamwork tools and supports the integration of a CUSP into the daily workflow at the unit level. The physician champion is chosen based on an interest in preventing harm related to the urinary catheter. The role of the physician champion is to connect with other physicians, promoting the multidisciplinary support of peers to the project. Infection preventionists play a significant role in supporting the work, highlighting the infectious risks, and helping with data collection related to CAUTI. The team also includes bedside nurses and, in some hospitals, nursing assistants. Daily nursing rounds are used to help identify patients with catheters and trigger the question: “Is the catheter needed?” The unit team learns from each case presented during rounds to incorporate catheter evaluation as a routine daily task. The goal is to have the bedside nurses own the daily process to evaluating the catheter.
      • Fakih M.
      • Rey J.
      • Pena M.
      • Szpunar S.
      • Saravolatz L.
      Sustained reductions in urinary catheter use over 5 years: bedside nurses view themselves responsible for evaluation of catheter necessity.
      Additionally, the team uses process and outcome data to identify areas that require further improvement. For example, the team assesses the frequency of using urinary catheters without appropriate indications and implements solutions. Regular evaluation of CAUTI events and rates help provide the teams with feedback on their performance and highlights that CAUTI prevention is a continuing priority.
      Table 3Key roles of the team members responsible for reducing CAUTI
      Modified from www.catheterout.org.
      Role or responsibilityExamples of personnel to consider
      Project coordinatorInfection preventionist, quality manager, nurse manager, safety officer, nurse educator
      Nurse champion (engage nursing personnel)Bedside nurse, nurse educator, unit manager, charge nurse
      Physician champion (engage medical personnel)Urologist, infectious diseases physician, hospital epidemiologist, hospitalist
      Data collection, monitoring, reportingInfection preventionist, quality manager, utilization manager
      Modified from www.catheterout.org.

      Sustainability

      For successful results, hospital teams need to have a plan to sustain the improvements. Sustainability is achieved if the improvements are maintained or augmented after implementation; for CAUTI prevention, the improvements are reflected in an increase in appropriate catheter use and a reduction in CAUTI events. Sustainability is promoted when the daily evaluation of urinary catheter use and necessity becomes integrated into the HCW's routine, and the hospital has built capacity for continued support.
      • Shediac-Rizkallah M.C.
      • Bone L.R.
      Planning for the sustainability of community-based health programs: conceptual frameworks and future directions for research, practice and policy.
      Integration of urinary catheter assessment into the daily workflow of nurses helps make it a routine task. It also ensures accountability and commitment from the HCW. The program champions continue to play a significant role in reinforcing the importance of appropriate use and care of the catheter, keeping it as a priority. However, reliance only on champions can undermine the sustainability of the processes, either with the loss of the champion or the lack of delegation to other essential members involved in the work.
      • Hendy J.
      • Barlow J.
      The role of the organizational champion in achieving health system change.
      Continued periodic evaluation and feedback are important to identify any gaps and refine the process. Modifications of the program may occur with time, based on new evidence.
      • Wiltsey Stirman S.
      • Kimberly J.
      • Cook N.
      • Calloway A.
      • Castro F.
      • Charns M.
      The sustainability of new programs and innovations: a review of the empirical literature and recommendations for future research.
      Identifying solutions that address data burden through data mining or sharing resources between disciplines may help reduce the perceived difficulties related to the work. Finally, involving different hospital units may reap global benefits. For example, addressing urinary catheter placement in the ED leads to a reduction in urinary catheter use hospital-wide.
      • Fakih M.
      • Rey J.
      • Pena M.
      • Szpunar S.
      • Saravolatz L.
      Sustained reductions in urinary catheter use over 5 years: bedside nurses view themselves responsible for evaluation of catheter necessity.
      Multidisciplinary and multidepartmental efforts may include the ED, intensive care units, and ORs. Because urinary catheters travel with patients from admission in the ED, to their stay in the intensive care unit or during their surgery, and back to their care in the nonintensive care unit areas, collaboration between the different hospital units and disciplines is important to achieve successful results (Fig 3).
      Figure thumbnail gr3
      Fig 3How different interventions affect urinary catheter use on the non-ICUs. Abbreviations: ICU, intensive care unit; PACU, postanesthesia care unit; OR, operating room; ED, emergency department.

      Conclusions

      Although reducing the risk of CAUTI involves a collaborative effort between different stakeholders, engaging HCWs at the hospital and unit level is critical. Although national engagement is helpful, perhaps the most important ingredient of success is engaging HCWs at the unit and hospital level, thereby providing the ability to implement changes that will enhance patient safety.

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