(Article 1) Tyson et al. (2020)(2323 Tyson AF, Campbell EF, Spangler LR, Ross SW, Reinke CE, Passaretti CL, et al. Implementation of a nurse-driven protocol for catheter removal to decrease catheter-associated urinary tract infection rate in a surgical trauma ICU. J Intensive Care Med. 2020;35(8):738-44. https://doi.org/10.1177/0885066618781304
https://doi.org/10.1177/0885066618781304...
) |
The nursing intervention to reduce UTI by IUC is characterized in a bundle structured in three instruments managed by nurses (A, B and C):
A. Care and maintenance of Long-Term IUC
1. Perform hand hygiene immediately before and after any handling of the catheter or associated equipment;
2. Keep the internal catheter properly protected, with stabilization device to avoid movement and traction/urethral trauma;
3. Keep the drainage system continuously closed;
4. Do not disconnect catheter and drainage tubes unless irrigation is required or drainage bag leakage occurs;
5. Empty the drainage bag regularly to prevent overflow, taking care that the faucet does not touch the sides of the urine collection container;
6. Keep a clean and labeled urine collection container for each patient, rinsing it with running water and storing it in a way to facilitate drying after each use;
7. Keep the catheter and drainage tube patency for the bag without folds;
8. Keep the urinary drainage bag below bladder level permanently;
9. Prevent the urine-collecting bag from touching the floor;
10. Avoid catheter exchanges at arbitrary fixed intervals;
11. Change the urinary catheter only with clinical indications, such as infection, obstruction, leakage or kidney/ureteral stones;
12. Sanitize the urinary meatus with soap and water daily and as needed, as in the case of fecal incontinence;
13. Replace catheter and urinary bag if accidentally disconnected, i.e., with compromised closed system. |
Resultados/desfechos
Catheter utilization decreased significantly with the implementation of the protocol conducted by nurses, from 0.78 in the pre-intervention period to 0.70 in the post-intervention period (p < 0.05). As a result of the bundle, the catheter-associated UTI rate decreased significantly, from 5.1 to 2.0 infections per 1,000 catheter-days, in the pre- and post-implementation period (Incident rate [IRR]: 0.38, 95% confidence interval.
Conclusions
Implementing a protocol/bundle for early IUC removal by nurses, as part of a multimodal intervention strategy for UTI, can result in measurable measures of reduction, both in the period of catheter use, and in the rates of this type of infection. |
(Article 1) Tyson et al. (2020)(2323 Tyson AF, Campbell EF, Spangler LR, Ross SW, Reinke CE, Passaretti CL, et al. Implementation of a nurse-driven protocol for catheter removal to decrease catheter-associated urinary tract infection rate in a surgical trauma ICU. J Intensive Care Med. 2020;35(8):738-44. https://doi.org/10.1177/0885066618781304
https://doi.org/10.1177/0885066618781304...
) |
B. Flowchart for decision-making in IUC daily assessment
C. Indications for continuous IUC use
1. Patients with a urinary catheter passed by a urologist;
2. Urologist as responsible physician of a patient or this awaiting consultation with a specialist;
3. In the immediate postoperative period (not more than 24 hours);
4. Bladder outlet obstruction;
5. Urological/perineal procedures;
6. Continuous bladder irrigation;
7. Movement intolerance due to severe disability (severe contractures, pelvic or hip fractures)
8. On-site epidural;
9. Deep sacral/gluteal tissue injury and incontinent;
10. Stage III/IV/Unstable sacral/perineal pressure ulcer and incontinent;
11. Critically ill patients requiring urine output monitoring every 1 to 2 hours;
12. Patients chemically paralyzed or seeded and on mechanical ventilation;
13. Prolonged deep sedation (> 2 hours);
14. Comfort care at the end of life;
15. Urinary retention: Bladder with residual volume > 100 mL of urine after urination;
Bladder with residual volume > 300 mL of urine at any time;
Intermittent catheterization in 2 weeks, with volume > 300 mL of urine. 
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Article 2 (Major-Joynes, Pegues, Bradway, 2016)(2424 Major-Joynes B, Pegues D, Bradway C. A nurse-driven protocol for removal of indwelling urinary catheters across a multi-hospital academic healthcare system. Urol Nurs. 2016;36(5):243-9. https://doi.org/10.1177/0885066618781304
https://doi.org/10.1177/0885066618781304...
)/A nurse-driven protocol for removal of indwelling urinary catheters across a multi-hospital academic healthcare system/ Urologic nursing/ MEDLINE |
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Results/outcomes
With the adoption of the protocol, considering the ICUs of the three hospitals, there was a 19% reduction in UTI rates related to urinary catheterization per 1,000 catheterization days, compared to the baseline period (p = 0.13). However, the impacts on hospitals were different when analyzed separately. In Hospital 1, it was 28%, and it was associated with team compliance with the protocol, but in Hospital 2 the infection rate increased, despite the fact that the team used the protocol, while, in Hospital 3, it remained unchanged, but justified by low compliance of participants.
Conclusions
The project’s success included: 1) a cohesive multidisciplinary team (nursing, medical, information systems, education, statisticians, among others); 2) executive leadership support; and 3) engagement of medical, nursing and other teams involved in patient care in the units. To expand the initiative, it is necessary to explore the barriers to early adoption of an IUC Removal Protocol managed by nurses. |
Article 3 (Thomas, 2016)(2525 Thomas KL. Reduction of catheter-associated urinary tract infections through the use of an evidence-based nursing algorithm and the implementation of shift nursing rounds: a quality improvement project. J Wound Ostomy Continence Nurs. 2016;43(2):183-7. https://doi.org/10.1097/WON.0000000000000206
https://doi.org/10.1097/WON.000000000000...
)/ Reduction of catheter-associated urinary tract infections through the use of an evidence-based nursing algorithm and the implementation of shift nursing rounds/ Journal of Wound, Ostomy and Continence Nursing/Scopus |
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Results/outcomes
There was a statistically significant change in the number of UTIs by IUC (p = 0.009) and occurrences (p = 0.005) after the intervention. The pre-intervention median went from 10.31 to 0.00 after nine months. The number of days of indwelling catheter and its use did not differ significantly after implementation. Nurses’ compliance with the intervention was calculated for each month, with a mean rate of 91%. The results indicate that an evidence-based practice project, managed by nurses, positively influenced the reduction of UTI by IUC.
Conclusions
The nursing protocol promoted evidence-based, nurse-led practice change to reduce catheter-associated UTI. Success was due to the change in nursing care culture. |
Article 3 (Thomas, 2016)(2525 Thomas KL. Reduction of catheter-associated urinary tract infections through the use of an evidence-based nursing algorithm and the implementation of shift nursing rounds: a quality improvement project. J Wound Ostomy Continence Nurs. 2016;43(2):183-7. https://doi.org/10.1097/WON.0000000000000206
https://doi.org/10.1097/WON.000000000000...
)/ Reduction of catheter-associated urinary tract infections through the use of an evidence-based nursing algorithm and the implementation of shift nursing rounds/Journal of Wound, Ostomy and Continence Nursing/Scopus |
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Article 3 (Thomas, 2016)(2525 Thomas KL. Reduction of catheter-associated urinary tract infections through the use of an evidence-based nursing algorithm and the implementation of shift nursing rounds: a quality improvement project. J Wound Ostomy Continence Nurs. 2016;43(2):183-7. https://doi.org/10.1097/WON.0000000000000206
https://doi.org/10.1097/WON.000000000000...
)/ Reduction of catheter-associated urinary tract infections through the use of an evidence-based nursing algorithm and the implementation of shift nursing rounds/ Journal of Wound, Ostomy and Continence Nursing/ Scopus |
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