Physician Engagement
Indwelling urinary catheters lead to both infectious and non-infectious complications. Despite these potential harms, studies have found that initial catheterization was inappropriate 21% to 50% of the time, and that continued catheter use was inappropriate almost half of the days that patients are catheterized.
A common reason for inappropriate continued catheter use is that physicians forget, or are never aware of, the presence of the catheter. In one multi-center evaluation, inpatient physicians at 4 hospitals were asked whether or not each patient on their service had a urinary catheter in place. Incorrect negative responses were recorded for over one-third of attending physicians and more than a quarter of resident physicians. For inappropriately catheterized patients, the proportion of physicians unaware of the presence of a catheter was even higher (over 50% for attending physicians and over 40% of senior residents). These "forgotten” catheters often remain in the patient until either a catheter-related complication occurs or the patient’s discharge is imminent.
Below, we provide specific strategies for engaging physicians in CAUTI prevention.
Physicians should assess daily whether or not their catheterized patient still requires the catheter. While nursing involvement in catheter insertion, care, and removal is paramount, physicians also play an important role in prevention efforts. The physician champion—often an infectious diseases specialist, hospital epidemiologist, urologist, or hospitalist—can inform physicians about the planned prevention program, encourage support for the program, be available to answer questions, and help educate other physicians about the appropriate indications for catheter use.
Nurse Engagement
What do we mean by nurse engagement? Nurse engagement refers to a persistent, positive state of fulfillment experienced by nurses at work. When nurses are engaged they feel energetic and dedicated to their work. They become immersed in work activities. Engagement has also often been described as the opposite of burnout. However nurse engagement is defined, it refers to buy-in, and in our case buy-in by nurses for the catheter-associated urinary tract infection (CAUTI) prevention program.
Getting nurses to buy in to any new initiative can be challenging, but especially an initiative aimed at changing nursing practice. The question answered in this section is: how can nurses break their bond with the catheter?
In this section we offer numerous activities for bolstering nursing engagement. Many of the activities can be used throughout the hospital. Other activities may need to be tailored to specific nursing units, since local customs and traditions may help shape the CAUTI prevention program on a particular unit. A final group of activities are more comprehensive and may take longer to get under way, but we offer them as well, so that your organization has the full range of activities needed to get nurses excited about saying: “Let’s get that catheter out!”
Below, we provide specific strategies for engaging nurses in CAUTI prevention.
Barriers & Possible Solutions
Implementing a change in a clinical practice or process often requires overcoming certain barriers or challenges. This section describes several common barriers encountered by other hospitals when instituting changes related to the insertion and care of indwelling urinary catheters as well as the strategies they used to overcome those barriers (PDF).
While the situation may not be exactly the same at your hospital, both the barriers described and the suggestions provided may be helpful in identifying potential solutions when challenges arise or for anticipating issues that may need to be addressed.
The literature on implementing evidence-based practices and practice guidelines may also provide valuable guidance. For example, Francke and colleagues (2008) examined 12 systematic reviews and identified the following categories as influencing guideline adherence: guideline characteristics, implementation strategies, professional autonomy, and patient and environment characteristics. In addition, De Vos et al. (2009) reviewed 21 studies and identified perceived barriers for quality initiatives including unawareness, lack of credible data, lack of management support for physicians, and lack of resources. Facilitating factors included supportive or collaborative management, administration support, and use of detailed and credible feedback data.
Lastly, theoretical perspectives may also be valuable in implementing evidence-based practice and practice guidelines (Gurses 2010, Grol and Wensing 2004). Some of the useful frameworks and models are:
Theories of diffusion of innovation, complex adaptive systems (alternate link), and planned behavior
PRECEDE-PROCEED (Predisposing, Reinforcing, and Enabling Constructs in Ecosystem Diagnosis and Evaluation for Policy, Regulation or Resourcing, and Organizing for Educational and Environmental Development)
TRIP (Translating Research Into Practice)
RE-AIM (Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance)
PRISM (Practical, Robust Implementation and Sustainability Model)
PARIHS (Promoting Action on Research Implementation in Health Services)
CFIR (Consolidated Framework For Implementation Research)
Leadership & Policy Implications
Increasingly, healthcare leaders are focusing their attention on preventing healthcare-associated infection. Indeed, empiric work from 2010 demonstrates that certain characteristics of leaders (the term “leader” was applied broadly) were used by those perceived as being effective in implementing evidence-based infection prevention recommendations. Specifically, successful leaders tended to insist on a culture of clinical excellence which they instill through effective communication, thinking strategically while acting locally, inspiring staff, and taking a solutions-oriented approach to overcoming barriers. Importantly, some of the most important leaders in infection prevention activities are not senior executives. Examples abound of infection prevention personnel—hospital epidemiologists and infection preventionists—who play crucial leadership roles in their hospital’s patient safety activities.
One important way to engage healthcare leaders—especially those in senior positions—in the topic of healthcare-associated infection prevention is through familiarity with the policy changes from 2009 by the Center for Medicare and Medicaid Services (CMS) that affect hospital reimbursement if adverse events occur during hospitalization. In brief, since October 2008, hospitals are no longer eligible for additional payment from CMS to treat several common and/or high morbidity hospital-acquired complications, such as catheter-associated urinary tract infections and pressure ulcers. This same policy has also facilitated and encouraged public reporting of hospital-acquired condition events—another topic of high interest to healthcare leaders. Therefore, this single policy regarding non-payment of hospital-acquired conditions may engage the interest of healthcare leaders along the lines of financial implications, patient safety, and public reporting.