Prevention Bundle Reduces Urinary Tract Infections

Clinicians and researchers at The Children’s Hospital of Philadelphia are always striving to improve care, which is partly why the institution continues to rank as the No. 1 pediatric hospital in the country. So, when they determined in 2010 that the rate of catheter-associated urinary tract infections (CAUTIs) at CHOP was significantly higher than the national average, they got to work to develop a bundle of strategies aimed at improving care.

Eighty percent of urinary tract infections are associated with an indwelling urinary catheter, which is a tube inserted into the bladder through the urethra to drain urine, according to the Institute for Healthcare Improvement. Symptoms of a urinary tract infection are burning or pain in the lower abdomen, fever, burning during urination, or an increase in the frequency of urination.

Because they are so common and costly, CAUTIs have received national attention as a high-priority, preventable hospital-acquired condition. Yet, most of the research on CAUTI epidemiology and evidence-based prevention guidelines focused on adults, until an observational study was published in the September issue of Pediatrics by the multidisciplinary “Prevent CAUTI” team at CHOP that established a plan to reduce the infection in a pediatric setting.

“We had a huge ‘aha moment’ when we compared ourselves to data in the literature and we had more than two times the CAUTI rate for comparable institutions,” said Katherine Finn Davis, PhD, RN, CPNP, a nurse researcher for CHOP’s Center for Pediatric Nursing Research and Evidence-Based Practice. “That was unacceptable, of course, and we decided that we must do something immediately.”

In July 2010, the team initiated a bundle that focused on placing indwelling urinary catheters only when indicated, using sterile techniques at all points of care, and reviewing catheter necessity daily. A crucial part of the intervention was institution-wide training on proper urinary catheter insertion technique and maintenance practices.

Using an online tutorial and simulation training, four leaders of the quality improvement project who Dr. Davis described as “passionate about CAUTI prevention” — Ann Colebaugh, RN, MSN, CPN; Benjamin Eithun, RN, MSN, CRNP; Natalie Plachter, CRNP; and Allison Thompson, MSN, RD, RN, CCRN, CRNP — trained 200 physicians, advanced practice providers, registered nurses, and radiology technicians in hospital areas with the highest rates of urinary catheter placement and utilization. Once the trainees mastered the insertion checklist, they became qualified observers who were responsible for promoting ongoing education by ensuring that other clinicians on their units completed the online tutorial and then followed the evidence-based practices.

Next, the Prevent CAUTI team rolled out the educational module to other hospital areas that had patients with urinary catheters, including the general medical and surgical units. In all, about 1,500 clinicians over a three-month period received training on the CAUTI prevention bundle.

“It was an incredible example of multidisciplinary work,” Dr. Davis said. “People from different aspects of the clinical world drew on their strengths and worked together toward a common goal to get our rate down.”

The Prevent CAUTI team also conducted a retrospective, observational analysis that compared CHOP’s hospital-wide CAUTI rates before and after implementation of the quality improvement project. Using data from July 2009 to June 2012, they found that the multifaceted intervention was associated with a 50 percent reduction in the hospital’s monthly CAUTI rate.

“That reduction was impressive,” Dr. Davis said. “After analysis, we also determined that the children getting catheters were still the right kids — everyone had an indication. The usage rate of catheters did not decrease during that time period, but we were using them appropriately.”

In addition to understanding better which children are at risk for CAUTIs, Dr. Davis said the study is important because it is one of the first to provide information to healthcare institutions on how to prevent CAUTIs from a pediatric perspective. Other pediatric institutions can assess their CAUTI rates and then use CHOP’s tools, such as taking the insertion checklist to the bedside, to implement similar CAUTI prevention bundles.

In an effort to sustain CHOP’s success and reduce the rate of CAUTIs even further, the Prevent CAUTI team conducts bedside reviews to reinforce standardized care and performs “just in time” training if they identify a lapse that puts the patient at risk. They also continue to identify groups throughout the hospital that benefit from CAUTI prevention training, such as hospital staff who handle the urinary reservoir bag during patient transport. They should check the position of the collection bag and ensure that it is always below the level of the patient’s bladder, Dr. Davis said.

“We want to get our CAUTI rate to zero,” Dr. Davis said. “We’re not there yet, but for any infection that is preventable, we want to get there.”

Other members of the CHOP Prevent CAUTI team who contributed to the Pediatrics paper include Sarah B. Klieger, MPH; Dennis J. Meredith, DVM, CIC, of CHOP’s Department of Infection Prevention and Control; and Julia Shaklee Sammons, MD, MSCE, and Susan E. Coffin, MD, MPH, both of CHOP’s Division of Infectious Diseases and Department of Pediatrics at the Perelman School of Medicine of the University of Pennsylvania.

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