Advertisement

Nurse-driven protocols and the prevention of catheter-associated urinary tract infections: A systematic review

  • Danielle J. Durant
    Correspondence
    Address correspondence to Danielle J. Durant, MBA, MS, Rockefeller College of Public Affairs & Policy, University at Albany, 1400 Washington Ave, Albany, NY 12222. (D.J. Durant).
    Affiliations
    Rockefeller College of Public Affairs & Policy, University at Albany-State University of New York, Albany, NY
    Search for articles by this author
Published:October 02, 2017DOI:https://doi.org/10.1016/j.ajic.2017.07.020

      Highlights

      • A systematic literature review on nurse-driven protocols and catheter-associated urinary tract infections was performed.
      • All included studies demonstrated reductions in clinical predictors of catheter-associated urinary tract infections.
      • A formal quality assessment revealed a high risk of bias in these studies.
      • Health care quality improvement studies could benefit from improved design.
      • Clinical impact could be substantiated through greater scientific rigor.

      Background

      Catheter-associated urinary tract infections (CAUTIs) are one of the most common hospital-acquired conditions and no longer reimbursable from Medicare as of 2008. Nurse-driven protocols (NDPs), which provide a medically approved rubric for professional nurses to make autonomous care decisions, can facilitate appropriate catheter use and timely removal, as advised in the Centers for Disease Control and Prevention's 2009 CAUTI prevention guidelines. However, little attempt has been made to systematically evaluate their effect on clinical outcomes.

      Methods

      A systematic review of studies published in the United States since 2006 was performed, following guidelines from the Institute of Medicine. Sources included CINAHL, Medline, professional agencies, hand-searching, and expert consultation. Clinical predictors and prevalence of CAUTI were examined and synthesized qualitatively; heterogeneity of outcomes made a statistical meta-analysis inappropriate.

      Results

      Twenty-nine studies were found eligible for inclusion. All used a case-control (pre-post) approach, and all reported reductions in clinical predictors of CAUTI, particularly indwelling-urinary catheter utilization and CAUTI rates. However, the number of CAUTIs remained unchanged in 1 study. A formal quality assessment revealed a high risk of bias; included studies met an average of 4.9 out of 11 quality indicators. Specifically, many did not use standardized measures.

      Conclusions

      NDPs appear to have a positive impact on the clinical predictors and prevalence of CAUTI. However, this review identified need for improving the study design of quality improvement projects conducted within the patient care setting.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Infection Control
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Institute for Healthcare Improvement
        Catheter-associated urinary tract infection.
        (Available from)
        • Saint S.
        • Meddings J.A.
        • Calfee D.
        • Kowalski C.P.
        • Krein S.L.
        Catheter-associated urinary tract infection and the Medicare rule changes.
        Ann Intern Med. 2009; 150: 877-884
        • Gould C.V.
        • Umscheid C.A.
        • Agarwal R.K.
        • Kuntz G.
        • Pegues D.A.
        • Healthcare Infection Control Practices Advisory Committee
        Guideline for prevention of catheter-associated urinary tract infections.
        (Available from)
        • The Joint Commission
        Spotlight on success: implementing nurse-driven protocols to reduce CAUTIs.
        Source. 2013; 11 (1+4-6-9)
        • Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine
        The future of nursing: leading change, advancing health.
        National Academies Press, Washington, DC2011
        • Institute of Medicine
        Finding what works in health care: standards for systematic reviews.
        The National Academies Press, Washington, DC2011
        • Melnyk B.M.
        • Fineout-Overholt E.
        Evidence-based practice in nursing and healthcare: a guide to best practice.
        Lippincott, Williams, & Wilkins, Philadelphia (PA)2011
        • Pettengill J.
        • Vertrees J.
        Reliability and validity in hospital case-mix measurement.
        Health Care Financ Rev. 1982; 4: 101-128
        • The Joanna Briggs Institute
        Critical appraisal checklist for case control studies.
        (Available from)
        http://joannabriggs.org/research/critical-appraisal-tools.html
        Date: 2016
        Date accessed: November 19, 2016
        • Hughes R.G.
        Tools and strategies for quality improvement and patient safety.
        in: Patient safety and quality: an evidence-based handbook for nurses. Agency for Healthcare Research and Quality (US), Rockville (MD)2008
        • Burch A.L.
        Implementation of a nurse-driven Foley catheter removal protocol: a patient safety and quality improvement project.
        (Hong Kong, China: STTI-25th International Nursing Research Congress; July 24-28)2014
        • Schultz P.
        • Aljawawdeh A.
        • Hopp T.
        Reducing use of indwelling urinary catheters with a nurse-driven protocol.
        Crit Care Nurse. 2011; : E42
        • Alexaitis I.
        • Broome B.
        Implementation of a nurse-driven protocol to prevent catheter-associated urinary tract infections.
        J Nurs Care Qual. 2014; 29: 245-252
        • Fakih M.G.
        • Rey J.E.
        • Pena M.E.
        • Szpunar S.
        • Saravolatz L.D.
        Sustained reductions in urinary catheter use over 5 years: bedside nurses view themselves responsible for evaluation of catheter necessity.
        Am J Infect Control. 2013; 41: 236-239
        • Purvis S.
        • Gion T.
        • Kennedy G.
        • Rees S.
        • Safdar N.
        • VanDenBergh S.
        • et al.
        Catheter-associated urinary tract infection a successful prevention effort employing a multipronged initiative at an academic medical center.
        J Nurs Care Qual. 2014; 29: 141-148
        • Trovillion E.
        • Skyles J.M.
        • Hopkins-Broyles D.
        • Recktenwald A.
        • Faulkner K.
        • Rogers A.D.
        • et al.
        Development of a nurse-driven protocol to remove urinary catheters.
        (The Society for Healthcare Epidemiology of America; Dallas, TX; Apr 1-4)2011: 59
        • DiRico N.
        • Kosman B.
        From “uh-oh” to “oh-yeah!”: a nurse driven urinary catheter removal protocol.
        (The NICHE Annual Conference)2011
        • Walters L.
        Empowering the clinical bedside nurse: using a nurse-driven protocol to decrease rate of catheter-associated urinary tract infections.
        (Lake Buena Vista, FL: American Nurses Association Annual Conference;; March 9-11)2016
        • Parry M.F.
        • Grant B.
        • Sestovic M.
        Successful reduction in catheter-associated urinary tract infections: focus on nurse-directed catheter removal.
        Am J Infect Control. 2013; 41: 1178-1181
        • Elpern E.H.
        • Killeen K.
        • Ketchem A.
        • Wiley A.
        • Patel G.
        • Lateef O.
        Reducing use of indwelling urinary catheters and associated urinary tract infections.
        Am J Crit Care. 2009; 18: 535-542
        • Fuchs M.A.
        • Sexton D.J.
        • Thornlow D.K.
        • Champagne M.T.
        Evaluation of an evidence-based, nurse-driven checklist to prevent hospital-acquired catheter-associated urinary tract infections in intensive care units.
        J Nurs Care Qual. 2011; 26: 101-109
        • Mori C.
        Avoiding catastrophe: implementing a nurse-driven protocol.
        Medsurg Nurs. 2014; 23: 15-21
        • Reilly L.
        • Sullivan P.
        • Ninni S.
        • Fochesto D.
        • Williams K.
        • Fetherman B.
        Reducing Foley catheter device days in an intensive care unit: using the evidence to change practice.
        AACN Adv Crit Care. 2006; 17: 272-283
        • Thomas K.L.
        Reduction of catheter-associated urinary tract infections through the use of an evidence-based nursing algorithm and the implementation of shift nursing rounds.
        J Wound Ostomy Continence Nurs. 2016; 43: 183-187
        • Voss A.B.
        Incidence and duration of urinary catheters in hospitalized older adults: before and after implementing a geriatric protocol.
        J Gerontol Nurs. 2009; 35: 35-41
        • Gotelli J.M.
        • Merryman P.
        • Carr C.
        • McElveen L.
        • Epperson C.
        • Bynum D.
        A quality improvement project to reduce the complications associated with indwelling urinary catheters.
        Urol Nurs. 2008; 28: 465-467
        • Johnson P.
        • Gilman A.
        • Lintner A.
        • Buckner E.
        Nurse-driven catheter-associated urinary tract infection reduction process and protocol: development through an academic-practice partnership.
        Crit Care Nurs Q. 2016; 39: 352-362
        • Quinn P.
        Chasing zero: a nurse-driven process for catheter-associated urinary tract infection reduction in a community hospital.
        Nurs Econ. 2015; 33: 320-325
        • Timmons B.
        • Vess J.
        • Conner B.
        Nurse-driven protocol to reduce indwelling catheter dwell time: a health care improvement initiative.
        J Nurs Care Qual. 2016;
        • Schneider M.A.
        Prevention of catheter-associated urinary tract infections in patients with hip fractures through education of nurses to specific catheter protocols.
        Orthop Nurs. 2012; 31: 12-18
        • Robinson S.
        • Allen L.
        • Barnes M.R.
        • Berry T.A.
        • Foster T.A.
        • Friedrich L.A.
        • et al.
        Development of an evidence-based protocol for reduction of indwelling urinary catheter usage.
        Medsurg Nurs. 2007; 16: 157-161
        • Ghanem A.
        • Artime C.
        • Moser M.
        • Caceres L.
        • Basconcillo A.
        Holy moley! Take out that Foley! Measuring compliance with a nurse driven protocol for Foley catheter removal to decrease utilization.
        Am J Infect Control. 2015; 43: S51
      1. Utilization of a nurse-driven protocol to decrease catheter-associated urinary tract infections.
        in: Holly C. Scholarly inquiry and the DNP capstone. Springer Publishing Company, New York (NY)2014: 153
        • Gratti M.
        EB73 Infection preCAUTIon: implementation of a nurse-driven protocol for removal of Foley catheters.
        Crit Care Nurse. 2014; 34: e13-4
        • Roser L.
        • Altpeter T.
        • Anderson D.
        • Dougherty M.
        • Walton J.E.
        • Merritt S.
        A nurse driven Foley catheter removal protocol proves clinically effective to reduce the incidents of catheter related urinary tract infections.
        Am J Infect Control. 2012; 40: e92-3
        • Huber K.
        • Sood G.
        • Maygers J.
        Get those Foleys out: successful reduction of catheter utilization through use of a nurse driven Foley discontinuation protocol.
        Am J Infect Control. 2015; 43: S52
        • Fraser D.
        • Dillon M.
        • Danner K.
        • Davis L.
        Implementation of a nurse-driven protocol to reduce catheter-associated urinary tract infections.
        Crit Care Nurse. 2016; : E24-E
        • Newman K.A.
        • Gwynn K.
        • Hubbert C.
        • Nyasende E.
        • Rush E.
        • Martin C.T.
        Use of a nurse driven protocol to remove Foley catheters resulted in a 40% reduction in nosocomial infection markers.
        Am J Infect Control. 2011; 39: E62-3
        • Devine B.S.N.
        Reducing catheter associated urinary tract infections: a nurse-driven urinary catheter removal protocol.
        (Washington, DC: The Oncology Nursing Society Annual Congress; April 25-28)2013
        • Centers for Disease Control and Prevention
        Device-associated module: UTI.
        (Available from)
        https://www.cdc.gov/nhsn/PDFs/pscManual/7pscCAUTIcurrent.pdf
        Date: 2017
        Date accessed: November 12, 2016
        • Institute for Healthcare Improvement
        Science of improvement: establishing measures.
        (Available from)
        • University of Bern
        STROBE checklists.
        (Available from)
        http://strobe-statement.org/index.php?id=available-checklists
        Date: 2007
        Date accessed: November 19, 2016