Effectiveness of an External Urinary Device for Female Anatomy and Trends in Catheter-Associated Urinary Tract Infections

PURPOSE

The purpose of this study was to examine the effectiveness of an external female urinary management system (external urinary device for female anatomy [EUDFA]) in critically ill women unable to self-toilet and to identify rates of indwelling catheter use, catheter-associated urinary tract infections (CAUTIs), urinary incontinence (UI), and incontinence-associated dermatitis (IAD) before and after the introduction of the EUDFA.

DESIGN

Prospective, observational, and quasi-experimental design.

SUBJECTS AND SETTING

The sample comprised 50 adult female patients in 4 critical/progressive care units using an EUDFA at a large academic hospital in the Midwestern United States. All adult patients in these units were included in the aggregate data.

METHODS

Prospective data collected from the adult female patients over 7 days included urine diverted from the device to a canister and total leakage. Aggregate unit rates of indwelling catheter use, CAUTIs, UI, and IAD were retrospectively examined during 2016, 2018, and 2019. Means and percentages were compared using t tests or chi-square tests.

RESULTS

The EUDFA successfully diverted 85.5% of patients' urine. Indwelling urinary catheter use was significantly lower in 2018 (40.6%) and 2019 (36.6%) compared with 2016 (43.9%) (P < .01). The rate of CAUTIs was lower in 2019 than in 2016, but not significantly (1.34 per 1000 catheter-days vs 0.50, P = .08). The percentage of incontinent patients with IAD was 69.2% in 2016 and 39.5% in 2018-2019 (P = .06).

CONCLUSIONS

The EUDFA was effective in diverting urine from critically ill female incontinent patients and indwelling catheter utilization.

Real world utilization of nurse-driven urinary catheter removal protocol in patients with epidural pain catheters

BACKGROUND

Surgeons use indwelling bladder catheters (IBCs) to avoid urinary retention in patients with epidural analgesic catheters. Reduction of IBC-days is associated with improved catheter-associated urinary tract infection rates (CAUTI). This study investigates real world application of a Nurse-Driven Catheter Removal Protocol (NDCRP) to reduce IBC-days in this patient population.

METHODS

Patients with epidural catheters and IBC were targeted for IBC removal on post-operative day 1 (POD1). Patients were followed for application of the NDCRP, catheterization need, IBC re-anchoring, and complications.

RESULTS

One hundred and thirty-three patients had IBCs removed on POD1 (Protocol Group) and 50 patients did not (Non-Protocol Group). There was a reduction in IBC-days in the Protocol Group despite incomplete adherence to the NDCRP (1.55 days vs 4.64 days; P < .001). Ninety-three patients (70%) were able to spontaneously void after early IBC removal. Fourteen patients (11%) were able to spontaneously void after serial in-and-out catheterization (I/O). No significant difference in re-anchoring was found between the protocol and non-protocol groups (26 vs 4 patients; P = .09).

CONCLUSIONS

Early removal of IBCs (POD1) in patients with epidural catheters with the assistance of an NDCRP is a safe and successful strategy to reduce IBC-days in the hospital.

Pressure Injury Prevention for Complex Cardiovascular Patients in the Operating Room and Intensive Care Unit: A Quality Improvement Project

PURPOSE

The purpose of our project was to examine the effect of an alternating pressure (AP) overlay on hospital-acquired pressure injury (HAPI) in high-risk cardiovascular surgical patients.

PARTICIPANTS AND SETTING

This quality improvement (QI) initiative was conducted in a core group of 8 cardiovascular operating room (OR) suites and 1 cardiovascular surgical critical intensive care unit (ICU) in a large Indiana-based academic hospital. The sample comprised adult patients who underwent complex cardiovascular surgical procedures and those in the cardiovascular surgical ICU with extracorporeal membrane oxygenation (ECMO), ventricular assistive device (VAD), and undergoing heart and/or lung transplant, or open chest procedures.

APPROACH

The AP overlay was placed on OR cardiovascular foam surfaces and on selected ICU support surfaces for patients who met inclusion criteria. We used a pre/postcomparative QI design to assess outcomes including OR-related HAPI rates, ICU aggregate unit HAPI data, related costs, and staff satisfaction during the 3-month project period.

OUTCOMES

Operating room-related HAPIs were reduced from 8/71 (11%) preintervention to 0/147 (0%) postintervention (P = .008), resulting in a cost avoidance of $323,048 and positive staff satisfaction (mean = 3.85; 1- to 4-point Likert scale). No adverse outcomes occurred. Although not significant, ICU HAPI rates decreased from 10 to 7 pre/postintervention (P = .29), demonstrating a 14% HAPI reduction with a cost avoidance of $121,143. The ICU incidence density decreased from 3.57 to 3.24; however, there was no decrease in ICU monthly unit prevalence. Critical care staff satisfaction was positive (mean = 2.95; 1- to 4-point Likert scale) with most staff members preferring the AP overlay to a fluid immersion surface. A cost savings of 48% (AP overlay vs fluid immersion rental) was identified in the ICU.

IMPLICATIONS FOR PRACTICE

We achieved fewer HAPIs and reduced costs and observed positive staff satisfaction, along with no adverse events with the use of the AP overlay. Further research is needed to determine the safety and efficacy of this device for this pressure injury prevention option for immobile patients in both the OR and the ICU.

Hospital-Acquired Pressure Injuries and Acute Skin Failure in Critical Care: A Case-Control Study

PURPOSE

The purpose of this study was to examine clinical characteristics and risk factors for critically ill patients who develop pressure injuries and identify the proportion of validated unavoidable pressure injuries associated with the proposed risk factors for acute skin failure (ASF).

DESIGN

Retrospective case-control comparative study.

SUBJECTS AND SETTING

The sample comprised adult critically ill participants hospitalized in critical care units such as surgical, trauma, cardiovascular surgical, cardiac, neuro, and medical intensive care and corresponding progressive care units in 5 acute care hospitals within a large Midwestern academic/teaching healthcare system. Participants who developed hospital-acquired pressure injuries (HAPIs) and patients without HAPIs (controls) were included.

METHODS

A secondary analysis of data from a previous study with HAPIs and matching data for the control sample without HAPIs were obtained from the electronic health record. Descriptive and multivariate logistic regression analyses were conducted.

RESULTS

The sample comprised 475 participants; 165 experienced a HAPI and acted as cases, whereas the remaining 310 acted as controls. Acute Physiology and Chronic Health Evaluation (APACHE II) mean score (23.8, 8.7%; P < .001), mortality (n = 45, 27.3%; P = .002), history of liver disease (n = 28, 17%; P < .001), and unintentional loss of 10 lb or more in 1 month (n = 20, 12%; P = .002) were higher in the HAPI group. Multivariate logistic regression analysis identified participants with respiratory failure (odds ratio [OR] = 3.00; 95% confidence interval [CI], 1.27-7.08; P = .012), renal failure (OR = 7.48; 95% CI, 3.49-16.01; P < .001), cardiac failure (OR = 4.50; 95% CI, 1.76-11.51; P = .002), severe anemia (OR = 10.89; 95% CI, 3.59-33.00; P < .001), any type of sepsis (OR = 3.15; 95% CI, 1.44-6.90; P = .004), and moisture documentation (OR = 11.89; 95% CI, 5.27-26.81; P <.001) were more likely to develop a HAPI. No differences between unavoidable HAPI, avoidable HAPI, or the control group were identified based on the proposed ASF risk factors.

CONCLUSION

This study provides important information regarding avoidable and unavoidable HAPIs and ASF. Key clinical characteristics and risk factors, such as patient acuity, organ failure, tissue perfusion, sepsis, and history of prior pressure injury, are associated with avoidable and unavoidable HAPI development. In addition, we were unable to support a relationship between unavoidable HAPIs and the proposed risk factors for ASF. Unavoidability of HAPIs rests with the documentation of appropriate interventions and not necessarily with the identification of clinical risk factors.

Hospital-Acquired Pressure Injuries in Critical and Progressive Care: Avoidable Versus Unavoidable

BACKGROUND

Despite prevention strategies, hospital-acquired pressure injuries (HAPIs) continue to occur, especially in critical care, raising the question whether some pressure injuries are unavoidable.

OBJECTIVES

To determine the proportion of HAPIs among patients in critical and progressive care units that are unavoidable, and to identify risk factors that differentiate avoidable from unavoidable HAPIs.

METHODS

This study used a descriptive retrospective design. Data collected included demographic information, Braden Scale scores, clinical risk factors, and preventive interventions. The Pressure Ulcer Prevention Inventory was used to categorize HAPIs as avoidable or unavoidable.

RESULTS

A total of 165 patients participated in the study. Sixty-seven HAPIs (41%) were unavoidable. Participants who had congestive heart failure (odds ratio [OR], 0.22; 95% CI, 0.06-0.76; P = .02), were chemically sedated (OR, 0.38; 95% CI, 0.20-0.72; P = .003), had systolic blood pressure below 90 mm Hg (OR, 0.52; 95% CI, 0.27-0.99; P = .047), and received at least 1 vasopressor (OR, 0.44; 95% CI, 0.23-0.86; P = .01) were less likely to have an unavoidable HAPI. Those with bowel management devices were more likely to have an unavoidable HAPI (OR, 2.19; 95% CI, 1.02-4.71; P = .04). When length of stay was incorporated into the regression model, for each 1-day increase in stay, the odds of an unavoidable pressure injury developing increased by 4% (OR, 1.04; 95% CI, 1.002-1.08; P = .04). Participants who had a previous pressure injury were 5 times more likely to have an unavoidable HAPI (OR, 5.27; 95% CI, 1.20-23.15; P = .03).

CONCLUSIONS

Unavoidable HAPIs do occur; moreover, when preventive interventions are not documented and implemented appropriately, avoidable HAPIs occur.

Nosocomial pressure ulcer rates in critical care: performance improvement project

Assessment, monitoring, and prevention of pressure ulcers in the hospitalized patient are required standards of care. The annual nosocomial pressure ulcer (NPU) rates for the adult intensive care units at our facility had trended up to 33% from 14% over a 13-month period. Our performance improvement team decided to track 5 variables that may have contributed to the increased incidence of NPU. Weekly skin care rounds were conducted to collect data, educate staff, and reinforce skin care policy and standards of care. Data analysis revealed 3 areas that required further emphasis with nursing staff: daily assessment with the Braden Scale, prevention of NPU beginning on the day of hospital admission, and the effect of sedation on patient mobility. Implementation of appropriate interventions targeted to specific Braden subscales needs to be included in the plan of care.