Posted on January 8, 2014
The translation of evidence-based practices to the bedside requires flexibility to change traditional ways of practice. The paradigm shift of responsibility for reducing healthcare-associated infections (HAIs) from infection control professionals to multidisciplinary patient care teams has facilitated the adoption of interventions with evidence suggesting a clinical benefit.
Shifting accountability to the clinicians has led to implementation of timely, sustainable and successful HAI prevention strategies. A recent publication on reducing unnecessary urinary catheter use illustrates the impact that team-led initiatives can achieve by leveraging the use of technology.
Parry and colleagues  describe the implementation of a nurse-directed catheter removal protocol on urinary catheter use and CAUTI rates at a 300-bed community teaching hospital. Despite extensive education regarding best practices for insertion and maintenance of urinary catheters, CAUTIs represented 28% of all HAI cases, consistent with nationally reported data. As virtually all healthcare-associated UTIs are caused by instrumentation of the urinary tract, the initiative aimed to reduce both indwelling urinary catheter use and CAUTIs on all patient care units.
The informatics team used an electronic medical record (EMR) system with physician order entry and nursing documentation to build charting modules, which reinforced the appropriateness of catheter use. Parameters for catheter removal by nursing staff were based on 2009 Healthcare Infection Control Practices Advisory Committee recommendations  and were approved by clinical and administrative leadership.
A physician order for a catheter requires criteria for catheter insertion mapped to the nursing checklist, which triggers a “foley maintenance protocol.” A device-specific charting module provides for nursing documentation of patient voiding method and serves as a physician reminder of the catheter’s presence. During the intervention period, infection preventionists using NHSN definitions performed CAUTI surveillance. Over a 36-month period, the team achieved a 50% hospital-wide reduction in catheter use and a 70% reduction in CAUTIs.
This interventional study is a notable example of a team-led performance improvement initiative focused on the translation of evidence-based practices to the bedside. A key operational strategy was the use of technology to assist with “hardwiring” the required work redesign and modifying the well-established habits of the clinicians.
The use of informatics tools should also be considered to decrease the effort and resources required for the monitoring of process and outcome metrics aimed at HAI reduction.