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James Cook University, Centre for Nursing and Midwifery Research, 1 James Cook Drive, Townsville, QLD, AustraliaRoyal Melbourne Hospital, 300 Grattan St, Parkville, Vic, Australia
James Cook University, Centre for Nursing and Midwifery Research, 1 James Cook Drive, Townsville, QLD, AustraliaTownsville Hospital and Health Service, Townsville Institute of Health Research and Innovation, 100 Angus Smith Drive, Douglas QLD, Australia
James Cook University, Centre for Nursing and Midwifery Research, 1 James Cook Drive, Townsville, QLD, AustraliaTownsville Hospital and Health Service, Townsville Institute of Health Research and Innovation, 100 Angus Smith Drive, Douglas QLD, Australia
Catheter-associated urinary tract infections significantly contribute to hospital acquired complications globally, with adverse implications for patient outcomes, healthcare, and fiscal resources. Nurse-led protocols for early removal of urinary catheters to reduce the incidence of catheter-associated urinary tract infections have been trialled.
Aim
To report the evidence for nurse-led practices of removing urinary catheters within the acute healthcare setting.
Methods
Five databases (CINAHL, MEDLINE, SCOPUS, EMCARE, and INFORMIT) were systematically searched in a scoping review of all peer reviewed publications up to 12/03/2021.
Findings
Thirteen studies met the inclusion criteria. Eleven studies described a reduction in catheter-associated urinary tract infections regardless of the type of intervention, one study did not demonstrate a change and one study reported an increase in catheter-associated urinary tract infections. Settings, study duration and sample size varied substantially between the included studies. Interventions were exclusive nurse-led protocol for removal of urinary catheters, computerised reminder systems, bundle approaches or comprehensive packages. Outcome measures and definitions of catheter-associated urinary tract infections were varied or absent.
Discussion
The quality of evidence of included studies in this review was low, attributed to by a number of methodological issues related to sample size and statistical analyses. Whilst the introduction of nurse-led protocols showed some improvements, the methodological inconsistencies make it difficult to highlight a specific protocol.
Conclusion
Given the quality of existing evidence, caution is required in translating these findings to policy and practice.
Catheter-associated urinary tract infections are avoidable and contribute to poor patient outcomes in hospitalised adults. Since 2010, an up-to-date systematic review for nurse-led protocols for removal of urinary catheters has not yet been conducted.
What is already known
Several interventions have been reported to reduce incidence of catheter-associated urinary tract infections in hospitalised adults.
What this paper adds
New evidence showed that a reduction in catheter-associated urinary tract infection incidence could be achieved by utilising nurse-led protocols for removal of urinary catheters. Interventions that could reduce catheter-associated urinary tract infection incidence are exclusive nurse-led protocols, electronic reminder systems, bundle packages, and comprehensive care packages.
1. Background
Catheter-associated urinary tract infections (CAUTI) place a significant burden on healthcare systems globally and can lead to significant patient morbidity as well as having resource and fiscal implications for health services. In the United States of America (USA), hospital acquired infections have been estimated to cost up to $45 billion (USD) annually and account for approximately 100,000 deaths per year (
). Approximately one-third of those hospital acquired infections are CAUTIs, with an estimated 15%–25% of patients in hospitals catheterised during their admission (
). In Australian hospitals during the financial year of 2018–2019, 13.90% of hospital separations (the process by which an episode of care for an admitted patient ceases) had a hospital acquired complication, of which 9.96% were urinary tract infections (UTI) (
Australian Institute of Health and Welfare [AIHW]. (2022). Separation: identifying and definitional attributes. Australian Government. accessed 11 May 2022 Available from: https://meteor.aihw.gov.au/content/327268.
Most UTIs are preventable and urinary catheters (UC) have long been regarded as a significant contributor to the development of a hospital acquired UTI (
Systematic review and meta-analysis: reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients.
The scientific evidence for a potential link between confusion and urinary tract infection in the elderly is still confusing - a systematic literature review.
). The use of antimicrobial agents to treat CAUTIs contributes to the ongoing global problem of antimicrobial resistance, further burdening the poor outcomes of patients, making infections more difficult to treat by narrowing the spectrum of antibiotics able to be used (
Frequency and antimicrobial resistance patterns of bacteria implicated in community urinary tract infections: a ten-year surveillance study (2000-2009).
). Because of the impact of CAUTIs on healthcare, some governments have ceased providing funding for CAUTIs in an attempt to incentivise hospitals to proactively reduce the incidence of this infection (
Australian Commission on Safety and Quality in Health Care. (2019). Australian Commission on Safety and Quality in Health Care: about us. Australian Government. accessed 26 January 2021 Available from: https://www.safetyandquality.gov.au/about-us.
). As a part of the National Safety and Quality Health Service Standards Standard 3: Preventing and Controlling Healthcare Associated Infections, the prevalence of CAUTIs must by audit by hospitals and data made available to governing bodies (
). Organisations have the potential to experience additional financial penalties from the mismatch between reported data from coding systems compared to actual CAUTI events (
Many initiatives have been developed with an aim of reducing the incidence of CAUTIs and improving patient outcomes. The objectives underpinning these initiatives include: reducing the number of insertions of UCs by determining the appropriateness of the intervention; identifying the ongoing need for the UC; alerts to remind clinicians of the presence of a UC; electronic reminders to review the UC; and protocols for the early removal of UCs by clinicians (
An examination of the barriers to and facilitators of implementing nurse-driven protocols to remove indwelling urinary catheters in acute care hospitals.
Implementation of a multifaceted nurse-led intervention to reduce indwelling urinary catheter use in four Australian hospitals: apre- and postintervention study.
Systematic review and meta-analysis: reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients.
). Nurse-led removal of UC protocols allows nurses to have the autonomy to make the clinical decision to remove the UC according to a predetermined list of criteria (
An examination of the barriers to and facilitators of implementing nurse-driven protocols to remove indwelling urinary catheters in acute care hospitals.
The evidence underpinning nurse-led removal of UC protocols needs to be collated, tabulated and summarised to describe best practice. To this end, a scoping review protocol was developed to guide the synthesis of evidence for nurse-led practices in removing UCs within an acute healthcare setting.
2. Aim
The aim of this scoping review was to report the evidence for nurse-led practices of removing UCs within the acute healthcare setting.
3. Methods
A scoping review provides a rigorous and transparent method for mapping areas of research (
). The five stages of the framework are: developing a research question; identifying relevant studies; study selection; charting the data; and collating, summarising and reporting the results (
The research question for this scoping review was, ‘What is the evidence for nurse-led removal of urinary catheters in adults within the acute hospital setting?’ A search strategy was developed using key words and, where relevant, controlled vocabulary for each of the databases: CINAHL; MEDLINE; SCOPUS; EMCARE and INFORMIT (Supplementary 1). Boolean operators ‘AND’ and ‘OR’ were used to combine terms (Supplementary 2). Alternative sources of articles included a manual search of the reference lists of included studies and the table of contents of key journals.
3.1 Selection criteria
Eligibility criteria were articles that specified a nurse-led practice for urinary catheter removal in an acute hospital setting with reference to the impact on CAUTI rates. All peer reviewed publications published up to 12/03/2021 were included with no restrictions for year of publication, language or study design and therefore quality improvement projects were also included. Articles were excluded if full text was not available. Letters to the editor, commentaries, reviews and editorials were excluded. Studies involving the following contexts were also excluded: aged care facilities; community settings; physician-led; paediatrics; suprapubic and long-term urinary catheters.
3.2 Data extraction
Results were collated using reference software (EndNote X9.3) and duplicates were removed. Titles and abstracts were screened for eligibility independently by one team member. The second screening involved a full text read conducted independently by two team members. A third team member was available and required to resolve one discrepancy relating to selection. Data extraction was conducted by one team member and reviewed by three other team members. Data extracted were author, year, study type, setting and country, sample size, aims, intervention type, study duration, outcome measure, definition of CAUTI, self-evaluation tool, and key findings. The extracted data was recorded and summarised using Microsoft Excel and was reviewed by all team members.
) for inclusion in this scoping review (Fig. 1) and are described in the data extraction table (Table 1). Twelve studies were classified as research studies and one study was a quality improvement project (
Demonstrate the collaborative relationship between academic nurses and clinical nurses in implementing evidence-based nurse-led protocol for decreasing the rate of CAUTIs
Nurse-led orders for UC discontinuation, UC care, education of staff; 16-months
CAUTIs/month, catheter days/month
Nil; ICARE
28% reduction in CAUTIs for all ICUs. CAUTIs reduction 36%, rates of catheter days 11% reduction. CAUTI rates 0.60% pre-intervention, 0.43% post-intervention. CAUTIs detected at 8.9 days pre to 16.5 days post
4.7 CAUTIs/1000 catheter days pre-intervention, O during intervention phase 6 months (p < 0.001). Reduction of 73.1 catheter days per month. (p = 0.01)
Cardiovascular thoracic stepdown unit, urban academic medical centre, USA; 54 with UCs, 31 met algorithm criteria
Implement a nurse-led, evidence-based CAUTI reduction algorithm for 6 weeks to decrease the risk of CAUTIs and reduce the CAUTI rate by 50% from 4.80 to 2.40 per 1000 catheter days
59 patients with CAUTI pre-intervention, 16 patients with CAUTI post-intervention, UC utilisation decreased from 0.78 to 0.70 (p < 0.05, risk ratio post vs pre 0.89, 95% confidence interval [CI]: 0.86–0.91). CAUTI reduced from 5.1/1000 catheter days to 2.0/1000 catheter days (p < 0.01, risk ratio: 0.38 with 95% CI: 0.21–0.65)
Catheter days, UC utilisation (catheter days/patient days), number of CAUTIs, CAUTIs/1000 catheter days
CDC CAUTI surveillance criteria / Nil
14% decrease in catheter days (p = 0.001), UC utilisation decreased 14% (89% pre to 75% post intervention) (p = 0.001), 21 CAUTIs pre to 17 CAUTIs post (19% decrease although not significantly different, p = 0.95), CAUTIs/1,000 catheter days (7.6 vs 7.2) (p = 0.84) remained unchanged
The primary objective of all studies was to reduce incidence of CAUTIs. Secondary objectives were to reduce UC usage and/or to reduce duration UC in situ, to assess nurses’ perceptions and behaviours for UC removal, and to measure uptake of a nurse-led protocol. All studies took place in the United States, with the exception of two, one from the United Kingdom (
) participants and the majority of studies described sample size in terms of total patient days or total catheter days. In seven studies, no sample size was reported. Six articles included a post-study self-evaluation tool for their studies and 11 studies presented the definition of CAUTI they used.
Interventions varied across studies. The intervention for eight articles was exclusively a nurse-led protocol for removal of urinary catheters (
) and two presented a comprehensive care package for all aspects of urinary catheter care including insertion, catheter care, urinary drainage bag, specimen collection, and removal (
Outcome measures and definitions of CAUTIs also varied across studies. Nine articles used CAUTI per 1000 catheter days as an outcome measure; of these, eight used the Center for Disease Control and Prevention (CDC) definition for CAUTIs and one utilised the presence of Escherichia coli or Enterococcus spp. as the definition of CAUTI. One study utilised CAUTIs/catheter day and CAUTIs/patient days as percentages as the outcome measures and also used the CDC definition of CAUTI (
); neither of those studies included a definition of CAUTI. Eleven articles described a reduction in CAUTI incidence regardless of the type of intervention however only three studies had results that were statistically significant (
The aim of this study was to report the evidence for nurse-led practices of removing UCs within the acute healthcare setting and findings from a combination of research studies and a quality improvement project found limitations in methodologies with varied results. There was unclear evidence for use of a particular protocol as results varied depending on differing settings, patient groups, clinicians’ behaviours, perceptions, and culture. Twelve studies were classified as research studies based on the definition of research as the systematic investigation aimed at the discovery into and study of materials and sources in order to establish facts and reach new conclusions (
) and after some consideration the team decided against conducting this assessment.
A critical review of each included study identified methodological concerns related to sample size and statistical analyses. Whilst 11 studies displayed a reduction in CAUTI rates, small sample sizes in combination with small incidence rates of CAUTIs per population indicates that due diligence needs to be taken before implementing policy and procedural changes based on the available evidence. While several parameters need to be considered when calculating sample size, justification of sample size is required to determine the level of confidence in sample estimates (
). No studies included how sample sizes were calculated and the implications of having an inadequate sample size are increasing the margin of error, less conclusive results, increasing the risk of developing a Type II error, falsely confirming a hypothesis when in fact the alternative hypothesis is true and decreasing the power of the study (
). From the included studies in this scoping review, the number of participants required to capture an adequate number of CAUTIs to determine the effectiveness of the intervention would be high given the low rate of CAUTI occurrence in the population. The duration of some studies was quite short, or point prevalence data collection utilised, which perhaps did not allow enough time to capture CAUTI events to demonstrate statistical significance.
To gain an adequate sample size, given the frequency of CAUTI events, the duration of a study might be so long as to make it not feasible in the clinical context subject to research fatigue, conflicting priorities and loss of interest in the impact of the study (
). Likewise, if a study proposed is of considerable length, approval might not be granted by the organisation if the cost of the study begins to outweigh the cost benefits of the intervention (
). In order to capture a larger sample size, multiple sites may be required, but this relies on cooperation and collaboration between different organisations, which may be difficult to coordinate and it would require consistent practices at each participating site.
Of the included studies, it was noted that no randomised controlled trials or metanalyses existed for the research question. This lack of hierarchical evidence has implications for the robustness of the studies as they can be susceptible to bias and affects the validity of results (
), prospective cohort observational studies may be the best study type to address the research objective as randomised controlled trials may not be clinically or ethically appropriate. For this reason, control data groups may need to be retrospective as having a control and intervention group concurrent may be subject to external influences and bias. Randomised controlled trials may also be considered unethical given the evidence that UCs contribute to the development of CAUTIs.
The use of a specific definition of CAUTI is an important point as six studies did not offer a definition. The use of one definition may capture more or less CAUTI events compared to another definition, which may result in reported CAUTI events differing from actual CAUTI events. This may influence the effectiveness of an intervention that had success based on one definition to a context that utilises a different definition. Depending on the geographical context and the governing bodies responsible for accreditation and funding, the definition may impact the reporting rates to these bodies, which can result in over reporting in surveillance indicators which may be an overestimation of the actual numbers occurring (
). The majority of the studies were conducted in the United States and this is likely due to the long-standing existence of penalties for organisations for CAUTIs as they are considered a preventable condition (
). There were no studies undertaken in Australia, which may limit the generalisability of protocols used overseas to an Australian healthcare context.
The variation in settings may have an impact on the use of the interventions in settings that are different to where the studies were conducted. Intensive care units tend to have 1:1 or 1:2 nurse to patient ratios compared to acute wards which can range from 1:4 to 8 patients depending on public or private setting, workforce enterprise bargaining agreements and legislation (Safe Patient Care (
). The net result of these variations in ratios and settings is the nursing time spent for involvement in each patient's care. The specialised training of nurses in these different settings will vary and potentially influence the knowledge and expertise of the nurse caring for the patient and may result in a greater awareness of symptoms and complications associated with UCs (
). Busier work environments combined with higher patient to nurse ratios, patients at different stages of their care, patients who can advocate for themselves or patients who rely on staff to advocate on their behalf, the clinical condition of the patient, and cognitive ability of patients, can all affect the timing of when a UC is removed. These factors, combined with the environment, experience and focus of nurses, may affect confidence and autonomy, behaviours and knowledge, which all are contributing factors to the effectiveness of an intervention being introduced (
Reducing catheter-associated urinary tract infections: a systematic review of barriers and facilitators and strategic behavioural analysis of interventions.
While most of the studies displayed results with a reduction in CAUTI rates, there were no convincing results that favoured any particular intervention type. There were no discernible differences between comprehensive bundles or nurse-led protocol by itself in terms of reduction of CAUTIs, although given the methods of implementation of the nurse-led protocol, it is possible that bringing the focus of UC to the forefront of nurses’ practice might mean that the other aspects of UC care and maintenance are also improved indirectly. Likewise, the analysis of this review was not able to distinguish which components of the comprehensive bundles had the most significant impact. Therefore, if policy makers were to adopt a comprehensive approach, the bundle would likely have to be implemented in its entirety to ensure the best possible outcomes. Given there were no statistically significant results, this poses difficulty choosing which strategy to implement.
The final observation of this review was the absence of qualitative data and the experience of the consumers. While some articles included an evaluation post intervention (
), most did not present follow-up data. Evaluation of a study allows for reflection on possible changes to future interventions, allows for policies to be fine-tuned and changed to allow for problems noted during the intervention period (
Reducing catheter-associated urinary tract infections: a systematic review of barriers and facilitators and strategic behavioural analysis of interventions.
). Utilising evaluation tools presents an opportunity to take into consideration the human aspects of nurses’ behaviour and perceptions and whether the intervention is something that can be maintained in the long term. It is not uncommon for performance and key performance indicators to slip when not under the scrutiny of direct observation; evaluation tools can assist in developing recommendations to ensure that compliance continues to occur after the observers have left.
6. Limitations
While the initial screening may have the potential for the inclusion of selection bias as titles and abstracts were screened by one author and thus a limitation of this review, however, it was conducted under the supervision of the other experienced team members. The inclusion of quality improvement projects, while accepted in scoping reviews, may limit the outcomes to specific clinical settings and may not be generalisable to a broader context. Only one of the 13 studies included was conducted over multiple sites, the others were at a single site and this is a limitation of those studies.
7. Conclusion
There is limited quality evidence for a nurse-led catheter removal protocol associated with reducing incidence of CAUTIs, however noting the methodological limitations identified, caution needs to be taken in the interpretation of these results to inform practice. Results can vary substantially depending on the setting, patient groups, clinicians’ behaviours, perceptions, and culture. The definition of CAUTI used may affect the results by over or under reporting CAUTI events, which may have a substantial impact if the reported data leads to financial penalties to organisations, therefore it is important to choose the protocol carefully that is in line with an evidence based standardised definition. The significance of CAUTIs cannot be underestimated, as the impacts reach patients, consumers, organisations, and governments.
Authorship contribution statement
All authors reviewed and approved the manuscript.
Ethical statement
An ethical statement is not applicable as no human or animal research was undertaken.
Conflict of interest
None.
Acknowledgements
Acknowledgements for the William Buckland Foundation that awarded the primary author with the $10,000 Lynly S Aitken Travelling Fellowship. The foundation was not involved in study design, collection of data, analysis, interpretation nor publication.
Reducing catheter-associated urinary tract infections: a systematic review of barriers and facilitators and strategic behavioural analysis of interventions.
Australian Commission on Safety and Quality in Health Care. (2019). Australian Commission on Safety and Quality in Health Care: about us. Australian Government. accessed 26 January 2021 Available from: https://www.safetyandquality.gov.au/about-us.
Australian Institute of Health and Welfare [AIHW]. (2022). Separation: identifying and definitional attributes. Australian Government. accessed 11 May 2022 Available from: https://meteor.aihw.gov.au/content/327268.
An examination of the barriers to and facilitators of implementing nurse-driven protocols to remove indwelling urinary catheters in acute care hospitals.
Implementation of a multifaceted nurse-led intervention to reduce indwelling urinary catheter use in four Australian hospitals: apre- and postintervention study.
Frequency and antimicrobial resistance patterns of bacteria implicated in community urinary tract infections: a ten-year surveillance study (2000-2009).
The scientific evidence for a potential link between confusion and urinary tract infection in the elderly is still confusing - a systematic literature review.
Systematic review and meta-analysis: reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients.
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