Operationalizing the ANA CAUTI prevention€¦ · The ANA CAUTI prevention tool has helped change the culture around IUC insertion at St. Francis. Our nurses now have a better understanding

NOTE FROM THE EDITOR: TheAmerican Nurses Association(ANA) led an initiative in collabo-ration with the Centers forMedicare & Medicaid Services’Partnership for Patients to developa unique tool to prevent catheter-associated urinary tract infections(CAUTIs). Developed through atechnical expert panel of nurses,the tool is available in this SpecialReport.

If you work in a medical-sur-gical unit, an intensive careunit, or an operating room,

you need to understand your vi-tal role in preventing CAUTIs.

ANA has developed an evi-dence-based CAUTI preventiontool to aid bedside clinicians inpreventing UTIs during every-day clinical practice. Expectedoutcomes from using this toolare preventing harm, savinglives, and lowering costs.

Implementing the tool intopractice helps bedside nursesmake sound clinical decisionsrelated to indwelling urinarycatheter (IUC) use. Consistentuse of the tool highlights appro-priate clinical questions andprevents inappropriate short-term IUC use. The tool promptsnurse-driven timely catheter re-moval and promotes best prac-tices for catheter insertion,maintenance, and removal. Italso guides nurses through keycomponents of complete blad-der assessment. Differentiatingand prioritizing interventionsbased on individualized assess-ment findings related to com-

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Operationalizing the ANA CAUTI preventiontool in acute-care settings

By Chenel Trevellini, MSN, RN, CWOCN

This easy-to-use toolcan help prevent

patient suffering fromCAUTI. —

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6 American Nurse Today Volume 10, Number 9 www.AmericanNurseToday.com

plete bladder emptying, urinaryretention, and incontinence areimportant in preventingCAUTIs.

How one hospitaloperationalized the tool This article shares strategies usedto operationalize the CAUTI pre-vention tool into nursing prac-tice through the nursing educa-tion’s skin champion program atSt. Francis Hospital, The HeartCenter®, in Ro slyn, New York—part of Catholic Health Services LongIsland (CHSLI). In 2012, thisaward- winning, 300+-bed,acute-care hospital was recog-nized as a top-performing Na-tional Database of NursingQuality Indicators® hospital.

St. Francis had tried manystrategies to decrease IUC usebefore serving as a pilot hospi-tal to review the ANA CAUTIprevention tool. Its infectionprevention team invited thewound, ostomy, and continencenurse (WOCN) to join the CAU-TI prevention team and offersuggestions and alternatives tocurrent strategies. Leading theinitiative, this team included aninfection prevention nurse fromeach of CHSLI’s acute- andlong-term care hospitals. Theteam also invited WOCNs andnurse educators from all CHSLIhospitals. Over a 6-week period,two face-to-face meetings andthree conference calls were held.The result was an updated IUCpolicy and protocol to promoteearly IUC removal, subsequent-ly approved by chief nursing of-ficers and then medical execu-tive committees (MECs) at theindividual CHSLI hospitals.

In addition, CHSLI made sev-eral catheter-related productchanges. All catheter insertionkits were converted to includeurometers instead of drainagebags, to decrease incidence ofbroken systems. Also, the maleexternal catheter was convertedto a new product with silicone

adhesive (available in multiplesizes) as an alternative to inap-propriate IUC insertion.

As these changes were imple-mented, the skin championprogram was updated to in-clude didactics related to CAUTIprevention. Data-collectionmetrics related to IUC use dur-ing the skin champion’s month-ly pressure-ulcer point-preva-lence study were added. Educa-tion focused on stabilizing thecatheter, maintaining a closedsystem, following manufacturerguidelines for insertion tech-niques, ensuring the tubing waskink-free, and maintaining theurometer below bladder leveland off the floor. When theseefforts successfully reduced IUCinsertion rates, the hospital’scatheter-use rates began to

decrease.

Developing the ANA CAUTIprevention tool In the first quarter of 2014, St.Francis’ WOCN specialist (theauthor of this article) was re-cruited to be part of ANA’s tech-nical expert panel (TEP) for de-veloping an evidence-basedCAUTI prevention tool. (SeeTechnical expert panel members.)The TEP was charged with gath-ering evidence for tool develop-ment, which included guidelinesfrom the Centers for DiseaseControl and Prevention (CDC),a literature review, and expertconsensus. The expert consensuswas carried out by independentTEP online input, teleconfer-

ences, face-to-face interactions,and meetings. The process in-volved a split-panel expertanalysis, a clinical pilot, and re-visions. The clinical pilot in-cluded evaluation from threehospitals in the Hospital En-gagement Network, 14 otherhospitals, and three clinical liai -sons; the liaisons served in theroles of WOCN, infection pre-vention RN, and quality-im-provement manager. St. Fran-cis’s WOCN was one of the clin-ical liaisons, helping to bringtool evaluation in the clinicalsetting to her hospital.

The evaluation strategy forthe tool’s pilot program was tohave a nursing education groupuse the tool when IUC insertionwas ordered. If the patient’sclinical criteria met CDC inser-tion recommendations, the clin-ical nurse specialist or nurse ed-ucator buddied with anotherclinical RN to insert thecatheter using the ANA inser-tion checklist. For each inser-tion, they completed a ques-tionnaire to evaluate the tool’seffectiveness and documentfeedback for the TEP.

At that point, the CAUTI pre-vention tool was fully integrat-ed into the skin champion pro-gram at St. Francis. The skinchampions expanded their per-sonal knowledge base on howto assess for complete bladderemptying when an IUC is re-moved. They also gained a bet-ter understanding of the ration-ale for straight catheteriza-tion—specifically how thisprocedure can be used short-term to retrain the flaccid blad-der and help improve urinaryfunction. Nurses found the maleexternal cathe ters useful for pa-tients who had urinary inconti-nence without underlying reten-tion issues. They also requestednew products, such as femaleurinals and more bladder scan-ners.

Clearly, St. Francis’ skin

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The ANA CAUTIprevention tool hashelped change theculture around IUC

insertion at St.Francis.

champion program was evolv-ing and the hospital culture waschanging. Nurses began to un-derstand that IUCs are neededonly in specific clinical situa-tions, as outlined by the CDC.

Developing a policy forsystem-wide use After the CAUTI prevention toolwas released publicly at the2015 ANA Quality Conferencein Orlando, it was used to devel-op a policy for use across theCHSLI system. Infection preven-tion RNs and WOCNs from allCHSLI hospitals collaborated todevelop a system policy and pro-cedure for IUC insertion, mainte-nance, and removal. The policyis complete and currently is be-ing presented to the MEC for ap-proval. Order sets are being builtinto the electronic health record(EHR) and an education strategyis in development. The policywill be integrated into the EHR,establishing an order set for IUCinsertion, maintenance, and removal.

At St. Francis, outcomes for

hospital-acquired CAUTI rates,IUC use rates, and compliancewith evidence-based IUC inser-tion and maintenance are monitored through severalmechanisms.• The infection prevention

nurse team monitors all CAUTI incidence rates.

• The WOCN asks the skinchampion team to collect da-ta on IUC use and tracks andtrends rates during monthlypoint-prevalence studies.

• The nursing education andinfection prevention depart-ments collaborate with theIUC vendor to conduct annu-al point-prevalence and in-sertion assessments. Thisdeeper examination of all in-dwelling catheters, types ofmaintenance performed, andwhich units are insertingIUCs yields greater insight in-to the effectiveness of CAUTIprevention education.

Changing the culture The ANA CAUTI prevention toolhas helped change the culturearound IUC insertion at St.Francis. Our nurses now have abetter understanding of whyCAUTI prevention is so impor-tant—and how they can helpimprove patient outcomes byalways asking “Why is this IUCbeing inserted?” �

Selected referenceAmerican Nurses Association. ANA CAUTIPrevention Tool. 2015. http://nursingworld.org/ANA-CAUTI-Prevention-Tool

Chenel Trevellini is a Certified Wound Ostomy Conti-

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Technical expert panel members The technical expert panel that developed the ANA catheter-associated urinary tract infection prevention tool includednurse-members of the following organizations:

• Academy of Medical-Surgical Nurses

• American Geriatrics Society

• American Hospital Association Health Research & Educational Trust

• American Nurses Association

• Association for Professionals in Infection Control

• Association of periOperative Registered Nurses

• Association of Rehabilitation Nurses

• Centers for Disease Control and Prevention

• Centers for Medicare & Medicaid Services’ Part-nership for Patients

• National Database of Nursing Quality Indicators(NDNQI) Award-Winning Hospitals Robert Wood Johnson and St. Francis Hospital

• Society of Urologic Nurses and Associates

• Wound, Ostomy and Continence Nurses Society.

Several recognized content experts also served as members of the panel, which was chaired by Maureen Dailey, PhD, RN, CWOCN,Senior Policy Fellow for Health Policy at ANA. Access a list of members at http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/Improving-Your-Practice/ANA-CAUTI-Prevention-Tool/ANA-Technical-Expert-Panel.pdf

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All catheter insertionkits were converted to

include urometersinstead of drainagebags, to decrease

incidence of brokensystems.