Implementation of a multifaceted nurse-led intervention to reduce indwelling urinary catheter use in four Australian hospitals: A pre- and postintervention study

Nurse-Sensitive Indicators as Predictors of Trauma Patient Discharge Disposition

BACKGROUND

About 3.5 million trauma patients are hospitalized every year, but 35%-40% require further care after discharge. Nurses' ability to affect discharge disposition by minimizing the occurrence of nurse-sensitive indicators (catheter-associated urinary tract infection [CAUTI], central line-associated bloodstream infection [CLABSI], and hospital-acquired pressure injury [HAPI]) is unknown. These indicators may serve as surrogate measures of quality nursing care.

OBJECTIVE

The purpose of this study was to determine whether nursing care, as represented by three nurse-sensitive indicators (CAUTI, CLABSI, and HAPI), predicts discharge disposition in trauma patients.

METHODS

This study was a secondary analysis of the 2021 National Trauma Data Bank. We performed logistic regression analyses to determine the predictive effects of CAUTI, CLABSI, and HAPI on discharge disposition, controlling for participant characteristics.

RESULTS

A total of n = 29,642 patients were included, of which n = 21,469 (72%) were male, n = 16,404 (64%) were White, with a mean (SD) age of 44 (14.5) and mean (SD) Injury Severity Score of 23.2 (12.5). We created four models to test nurse-sensitive indicators, both individually and compositely, as predictors. While CAUTI and HAPI increased the odds of discharge to further care by 1.4-1.5 and 2.1 times, respectively, CLABSI was not a statistically significant predictor.

CONCLUSIONS

Both CAUTI and HAPI are statistically significant predictors of discharge to further care for patients after traumatic injury. High-quality nursing care to prevent iatrogenic complications can improve trauma patients' long-term outcomes.

The effectiveness of high-fidelity simulation methods to gain Foley catheterization knowledge, skills, satisfaction and self-confidence among novice nursing students: A randomized controlled trial

BACKGROUND

The use of high-fidelity simulation (HFS) methods provides probable benefits and advantages for nursing students to retain knowledge, acquire skills, improve satisfaction, and gain self-confidence in a safe, realistic and supportive environment.

OBJECTIVES

To evaluate the effect of HFS methods to develop Foley catheterization knowledge, skills, satisfaction and self-confidence among novice nursing students when compared to low-fidelity simulation (LFS). The specific aim was to examine the effects of outcome variables between the intervention group and the control group, through multi-group path analysis.

DESIGN

A randomized controlled trial was designed.

SETTINGS AND PARTICIPANTS

80 nursing students were randomly assigned to the HFS group (high-fidelity manikin and scenario) and the LFS group (female catheterization simulator) at a nursing faculty between May and July 2019 in Türkiye.

METHODS

The intervention group experienced HFS and the control group experienced LFS in order to learn Foley catheterization. Students' knowledge was evaluated before and after the intervention, while affective and psychomotor skills, and satisfaction and self-confidence in learning were evaluated after the intervention.

RESULTS

The HFS group had better skill performance and significantly higher self-confidence in learning than the LFS group. While each group had a high level of knowledge, affective skills and satisfaction, there was no significant difference between the groups' mean scores.

CONCLUSIONS

The HFS and scenario improved the knowledge, affective and psychomotor skills, satisfaction and self-confidence of novice nursing students on Foley catheterization. When compared to LFS, HFS had more advantages for the development of psychomotor skills and self-confidence in learning.

Pragmatic review of interventions to prevent catheter-associated urinary tract infections (CAUTIs) in adult inpatients

BACKGROUND

Urinary tract infections (UTIs) are one of the most common hospital-acquired complications. Insertion of a urinary catheter and the duration of catheterization are the main risk factors, with catheter-associated UTIs (CAUTIs) accounting for 70-80% of hospital-acquired UTIs. Guidance is available regarding the prevention of hospital-acquired CAUTIs; however, how best to operationalize this guidance remains a challenge.

AIM

To map and summarize the peer-reviewed literature on model-of-care interventions for the prevention of CAUTIs in adult inpatients.

METHODS

PubMed, CINAHL and SCOPUS were searched for articles that reported UTI, CAUTI or urinary catheter outcomes. Articles were screened systematically, data were extracted systematically, and interventions were classified by intervention type.

FINDINGS

This review included 70 articles. Interventions were classified as single component (N=19) or multi-component (N=51). Single component interventions included: daily rounds or activities (N=4), protocols and procedure changes (N=6), reminders and order sets (N=5), audit and feedback interventions (N=3), and education with simulation (N=1). Overall, daily catheter reviews and protocol and procedure changes demonstrated the most consistent effects on catheter and CAUTI outcomes. The components of multi-component interventions were categorized to map common elements and identify novel ideas.

CONCLUSION

A range of potential intervention options with evidence of a positive effect on catheter and CAUTI outcomes was identified. This is intended to provide a 'menu' of intervention options for local decision makers, enabling them to identify interventions that are relevant and feasible in their local setting.

Reducing urinary catheter use in geriatric patients - results of a single-center champion-led intervention

BACKGROUND

Indwelling urinary tract catheters (UTC) are a well-known risk factor for urinary tract infections (UTI). Because geriatric patients are at high risk of infection, an intervention with a focus on appropriate and minimal UTC use was introduced in 4 acute care geriatric wards.

METHODS

Between 11/2018 and 1/2020, unit-based data on UTC use and nosocomial UTI was collected in accordance with the methods of the German national surveillance system KISS. From 6/2019 to 1/2020, a champion-led intervention was implemented which focused on: (i) feedback of surveillance data, (ii) education and training in aseptic UTC insertion and maintenance, (iii) HCW's daily assessment of UTC necessity based on a checklist and (iv) timely removal of unnecessary UTCs. UTC use, incidence, and incidence densities for catheter-associated UTI (CAUTI) were calculated before and during the intervention. In addition, we analyzed adherence to a scheduled daily assessment of UTC necessity. Rate ratios (RR) with 95% confidence intervals (95%CI) were calculated. Differences based on the quality of checklist completion were evaluated using the Kruskal Wallis test.

RESULTS

We analyzed the data of 3,564 patients with a total 53,954 patient days, 9,208 UTC days, and 61 CAUTI. Surveillance data showed a significant decrease in the pooled UTC utilization rate from 19.1/100 patient days to 15.2/100 patient days (RR = 0.80, 95%CI 0.77-0.83, p < 0.001). CAUTI per 100 patients dropped from 2.07 to 1.40 (RR = 0.68, 95%CI 0.41-1.12, p = 0.1279). Overall, 373 patients received a UTC during the intervention. Of those patients 351 patients had an UTC ≥ 2 days. The analysis of these patients showed that 186 patients (53%) received a checklist as part of their chart for daily evaluation of UTC necessity. 43 (23.1%) of the completed checklists were of good quality; 143 (76.9%) were of poor quality. Patients in the group whose checklists were of good quality had fewer UTC days (median 7 UTC days IQR (3-11)) than patients whose checklists were of poor quality (11 UTC days IQR (6-16), p = 0.001).

CONCLUSION

We conclude that a champion-led, surveillance-based intervention reduces the use of UTC among geriatric patients. Further research is needed to determine to what extent the use of checklists in daily medical UTC assessment affects the prevention of CAUTI. The fact that patients whose checklists were completed well had fewer UTC days should encourage a conscientious and thorough daily review of the need for UTC.

Barriers and enablers to nurses' use of harm prevention strategies for older patients in hospital: A cross-sectional survey

BACKGROUND

Preventable harms during hospitalization pose a major challenge for health systems globally. Nurse-led strategies provide comprehensive harm prevention to keep the most vulnerable patients safe in hospital, but gaps in care are common. Nursing roles and activities to prevent harm to patients during acute hospitalization are poorly understood.

AIM

The aim of this study was to identify nurses' perceived enablers and barriers to the implementation of comprehensive harm prevention for older people admitted to an acute hospital setting.

DESIGN

Anonymous, online, cross-sectional survey.

METHODS

The adapted Influences on Patient Safety Behaviours Questionnaire (IPSBQ) was used to collect data from nurses working on five general medicine wards across three hospitals of a single tertiary health service in Australia in 2019. Participants also rated their perceptions of overall quality of care, missed care and awareness of strategies for an eight-factor framework for comprehensive harm prevention. The STROBE reporting checklist was used.

RESULTS

Ward response rates between 35% and 58% resulted in 132 complete questionnaires for analyses. High mean scores for behavioural regulation (3.28), beliefs about capabilities (2.96) and environmental context and resources (2.73) indicated these domains were perceived by nurses as enablers. Low mean scores for the domains of intentions (1.65), beliefs about consequences (1.69), optimism (1.72) and professional role and identity (1.85) indicated these were barriers to comprehensive harm prevention by nurses. High perceived quality of care (scored 9-10/10) (p = .024), and awareness of strategies for the eight-factor framework (p = .019) were significant enablers of comprehensive harm prevention.

CONCLUSION

Targeted evidence-based strategies that include education, persuasion, incentivization, coercion and modelling would be most useful for promoting comprehensive harm prevention by nurses. However, to be most effective the harm prevention strategy may need to be tailored for each ward.

Budget impact analysis of a multifaceted nurse-led intervention to reduce indwelling urinary catheter use in New South Wales Hospitals

BACKGROUND

In hospitals, catheter acquired urinary tract infection causes significant resource waste and discomfort among admitted patients. An intervention for reducing indwelling catheterisations - No-CAUTI - was trialled across four hospitals in New South Wales, Australia. No-CAUTI includes: train-the-trainer workshops, site champions, compliance audits, and point prevalence surveys. The trial showed reductions on usual care catheterisation rates at 4- and 9-month post-intervention. This result was statistically non-significant; and post-intervention catheterisation rates rebounded between 4 and 9 months. However, No-CAUTI showed statistically significant catheterisation decreases for medical wards, female patients and for short-term catheterisations. This study presents a budget impact analysis of a projected five year No-CAUTI roll out across New South Wales public hospitals, from the cost perspective of the New South Wales Ministry of Health.

METHODS

Budget forecasts were made for five year roll outs of: i) No-CAUTI; and ii) usual care, among all public hospitals in New South Wales hosting overnight stays (n=180). The roll out design maintains intervention effectiveness with ongoing workshops, quality audits, and hospital surveys. Forecasts of catheterisations, procedures and treatments were modelled on No-CAUTI trial observations. Costs were sourced from trial records, the Medical Benefits Scheme, the Pharmaceutical Benefits Scheme and public wage awards. Cost and parameter uncertainties were considered with sensitivity scenarios.

RESULTS

The estimated five-year No-CAUTI roll-out cost was $1.5 million. It had an overall budget saving of $640,000 due to reductions of 100,100 catheterisations, 33,300 urine tests and 6,700 antibiotics administrations. Non-Metropolitan hospitals had a net saving of $1.2 million, while Metropolitan hospitals had a net cost of $0.54 million.

CONCLUSIONS

Compared to usual care, NO-CAUTI is expected to realise overall budget savings and decreases in catheterisations over five years. These findings allow a consideration of the affordability of a wide implementation.

TRIAL REGISTRATION

Registered with the Australian New Zealand Clinical Trials Registry ( ACTRN12617000090314 ). First registered 17 January 2017, retrospectively. First enrolment, 15/11/2016.

I-DECIDED®-a decision tool for assessment and management of invasive devices in the hospital setting

Indwelling medical devices, including vascular access and urinary catheters, pose a risk for infection, and therefore daily assessment and consideration of their continued need is a patient safety priority. The I-DECIDED® device assessment and decision tool is an evidence-based checklist, designed to improve the assessment, care and timely removal of invasive devices in acute hospitalized patients. This paper explains each step of the tool, with rationale for inclusion.

Effect of Cluster Nursing Based on Risk Management Strategy on Urinary Tract Infection in Patients With Severe Craniocerebral Injury

Objective

To observe the effect of cluster nursing based on risk management strategy in the management of urinary tract infection in patients with severe craniocerebral injury.

Methods

A total of 116 patients with severe craniocerebral injury who were admitted to our hospital from March 2019 to March 2021 were included. They were divided into the control group (58 patients) and the observation group (58 patients). The control group received routine nursing care and the observation group received cluster nursing based on risk management strategy. The incidence of catheter-associated urinary tract infection (CAUTI), the results of bacterial culture on the surface of the urinary catheter, the incidence of nursing risk events, the duration of placing the urinary catheter, the length of hospital stay, and hospital costs as well as the patient satisfaction score were compared between the two groups. The knowledge, attitude, and practice scale for prevention of catheter infection and the competence evaluation scale of nurses were used to evaluate the sense-control ability and core competence of the interveners.

Results

The total incidence of CAUTI in the observation group was (6.90%) lower than that in the control group (20.69%) (p < 0.05). The bacterial culture results on the catheter surface of patients in the observation group before and after 6 and 12 h of catheter cleaning were better than those of patients in the control group (p < 0.05). The duration of indwelling urinary catheter, hospitalization time, and hospitalization expenses of patients in the observation group were lower than those of patients in the control group (p < 0.05). The incidence rate of nursing risk events in the observation group was (1.72%) lower than that in the control group (11.86%) (p < 0.05). The overall satisfaction score of patients and the control and core ability scores of nursing staff in the observation group were higher than those in the control group (p < 0.05).

Conclusion

Cluster nursing based on risk management strategy can effectively reduce the incidence of nursing risk events and the probability of UTI in patients with severe craniocerebral injury, shorten the duration of indwelling urinary catheter and hospitalization.

Administration of indwelling urinary catheters in four Australian Hospitals: cost-effectiveness analysis of a multifaceted nurse-led intervention

BACKGROUND

Urinary catheters are useful among hospital patients for allowing urinary flows and preparing patients for surgery. However, urinary infections associated with catheters cause significant patient discomfort and burden hospital resources. A nurse led intervention aiming to reduce inpatient catheterisation rates was recently trialled among adult overnight patients in four New South Wales hospitals. It included: 'train-the trainer' workshops, site champions, compliance audits and promotional materials. This study is the 'in-trial' cost-effectiveness analysis, conducted from the perspective of the New South Wales Ministry of Health.

METHODS

The primary outcome variable was catheterisation rates. Catheterisation and procedure/treatment data were collected in three point prevalence patient surveys: pre-intervention (n = 1630), 4-months (n = 1677), and 9-months post-intervention (n = 1551). Intervention costs were based on trial records while labour costs were gathered from wage awards. Incremental cost effectiveness ratios were calculated for 4- and 9-months post-intervention and tested with non-parametric bootstrapping. Sensitivity scenarios recalculated results after adjusting costs and parameters.

RESULTS

The trial found reductions in catheterisations across the four hospitals between preintervention (12.0 % (10.4 - 13.5 %), n = 195) and the 4- (9.9 % (8.5 - 11.3 %), n = 166 ) and 9- months (10.2 % (8.7 - 11.7 %) n = 158) post-intervention points. The trend was statistically non-significant (p = 0.1). Only one diagnosed CAUTI case was observed across the surveys. However, statistically and clinically significant decreases in catheterisation rates occurred for medical and critical care wards, and among female patients and short-term catheterisations. Incremental cost effectiveness ratios at 4-months and 9-months post-intervention were $188 and $264. Bootstrapping found reductions in catheterisations at positive costs over at least 72 % of iterations. Sensitivity scenarios showed that cost effectiveness was most responsive to changes in catheterisation rates.

CONCLUSIONS

Analysis showed that the association between the intervention and changes in catheterisation rates was not statistically significant. However, the intervention resulted in statistically significant reductions for subgroups including among short-term catheterisations and female patients. Cost-effectiveness analysis showed that reductions in catheterisations were most likely achieved at positive cost.

TRIAL REGISTRATION

Registered with the Australian New Zealand Clinical Trials Registry (ACTRN12617000090314). First hospital enrolment, 15/11/2016; last hospital enrolment, 8/12/2016.

Effectiveness of a Multifaceted Educational Intervention to Enhance Therapeutic Regimen Adherence and Quality of Life Amongst Iranian Hemodialysis Patients: A Randomized Controlled Trial (MEITRA Study)

Purpose

A multimodal intervention designed and executed to improve therapeutic regimen adherence and quality of life in a sample of Iranian hemodialysis patients. Its feasibility and impact was assessed post intervention.

Patients and Methods

This randomized controlled trial (RCT) study was conducted at two hemodialysis wards of the Shahrvand hospital located in Sari, the capital city of the Mazandaran province, north of Iran. The study sample included patients with end-stage renal disease (ESRD) receiving outpatient hemodialysis treatment. Considering 10% attrition, 70 registered patients were randomly categorized into intervention and control groups. The proposed intervention included playing of relevant educational video tracks, conducting eight cognitive behavioral therapy (CBT) group sessions, and telephone-based peer support. Data were collected applying a set of questionnaires including sociodemographic, Beck Depression Inventory (BDI-SF), Multidimensional Scale of Perceived Social Support (MSPSS), Patient Satisfaction with Nursing Care Quality Questionnaire (PSNCQQ), End-Stage Renal Disease Adherence Questionnaire (ESRD-AQ) and the World Health Organization Quality of Life (WHOQOL-SF) scale. Sociodemographic and clinical data were collected at baseline in both groups and the postintervention assessment was performed in the intervention and nonintervention groups after one month and three months.

Results

A significant change in the self-reported depression symptoms (P=0.001), mean social support score (P=0.001), nursing care satisfaction score (P=0.001), quality of life score (P=0.001) and interdialytic weight gain (IDWG) (P=0.001) was observed among the participants in the intervention group compared to the baseline measures. The highest rise in the ESRD-AQ scores within the intervention group was observed after one month of intervention (mean difference=131.88) compared to the baseline values. Same pattern of statistically significant changes in mean scores of the intervention group’s attendants in all subscales of the ESRD-AQ were also ascertained.

Conclusion

This interventional study revealed that inaugurating of a feasible low-cost intervention without need to add major logistic or financial inputs into existing health-care systems, especially in resource limited contexts, is achievable. Findings of this study could provide insights into scientific basis of evidence-informed interventions applicable in the realm of health-care delivery.