Wednesday, December 05, 2007

Abstract with Commentary

Abstract and Commentary

Robinson, S. et al. (2007). Development of an evidence-based protocol for reduction of indwelling urinary catheter usage. MEDSURG Nursing, 16, 157-161.

Author’s Abstract

Studies indicate 40% of indwelling urinary catheters are unnecessary in hospitalized patients (Gardam, Amihod, Orenstein, Consolacion, & Miller, 1998; Gokula, Hickner, & Smith, 2004). The results of a protocol developed to limit catheter use are described.

Commentary by Dana Rutledge, RN, PhD, Nursing Research Facilitator

The project was framed in the Iowa Model of Evidence-Based Practice (EBP; Titler et al., 2001), the same model adopted at St. Joseph Hospital. Nurses at a large tertiary care center identified a potential problem: inappropriate use of indwelling urinary catheters. The trigger to action was guidelines developed by the Nurses Improving Care to Health System Elderly (NICHE). The guidelines recommend limiting catheters to elders with very specific problems such as urinary retention.

Chart audits of patients with indwelling catheters found 17% with documented urinary tract infections (UTI). A team was formed to develop a protocol to encourage more appropriate use of indwelling catheters. This group reviewed 32 articles on the topic, about half of which were rated as strong evidence sources. Based upon the evidence, they determined when urinary catheters are appropriate in hospitalized patients.[1]

A pre-protocol chart audit indicated that 35% of patients had a urinary catheter at some time during hospitalization. Of these, 42% had no appropriate reason for catheter use. Only 70% had an order for insertion. Almost 40% were inserted in the emergency department. Almost 2/3 were not removed until day of discharge. Symptoms of UTI developed in 38% of patients.

A 2-week pilot test was done with nurses requesting an order for removal of the catheter unless it was used for one of the criteria in the footnote below, along with use in patients 48 hours post surgery. Afterwards, mean days that catheters were in place dropped from 8.6 to 4.5 days, orders to remove increased (43% to 93%), documentation of removal increased (57% to 87%), and only 7% of patients had catheters in on discharge day. In the pilot group, only13% had UTI symptoms.

To institute this change in practice (nurses asking for catheter removal), a multi-method educational effort ensued. Pilot outcomes were disseminated, along with findings from the literature. Physicians were educated at several formal gatherings. This manuscript does not describe outcomes from the full scale implementation.

Can you think of which patients at SJH may have inappropriate urinary catheters? What methods could be used to decrease their use? What resources would be needed to implement these methods?

Titler, M.G. et al. (2001). The Iowa Model of Evidence-Based Practice to Promote Quality Care.
Critical Care Nursing Clinics of North America, 13, 497-509.

[1] For bladder irrigation or instillation of medication; to provide relief of urinary tract obstruction; to permit drainage in persons with neurogenic bladder dysfunction or urinary retention not manageable by other means; to obtain accurate intake and output in critically ill patients; to aid in urologic or related surgery; to manage urinary incontinence in persons with stage 3 or 4 pressure ulcers; and to promote comfort care in the terminally ill

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