NURS 8114 Blog: Observation of Evidence-Based Practice

NURS 8114 Blog: Observation of Evidence-Based Practice

NURS 8114 Blog: Observation of Evidence-Based Practice

Evidence-based practice is the key to improving healthcare quality and patient outcomes.  Evidence-based practice utilizes the best evidence as to the basis of nursing practice while nursing research is conducting research to generate new knowledge (Chien, 2019).

One specific example of evidence-based practice in my hospital that is improving patient outcomes is reducing catheter-associated urinary tract infections (CAUTIs).  I know this topic is often used as an example, but I am developing a passion for preventing and using foley catheters. It is essential because CAUTIs are the most frequent type of healthcare-acquired infection.  They can lengthen hospital stays, increase morbidity and mortality, and raise healthcare costs.  The Centers for Medicare and Medicaid Services will no longer reimburse hospitals for additional costs related to CAUTIs (Connor, 2018).

Typically there are protocols that hospitals develop and follow.  My hospital does not use protocols, which is frustrating.  There are guidelines that my hospital and other facilities observe.  Some examples are to use the smallest catheter size possible and the daily monitoring of patients with catheters (type, size, duration).  Also, documenting daily assessments of catheter condition, the securement method, the potential for catheter removal, and a reminder system for physicians to evaluate the need for indwelling catheters (Connor, 2018).

We must document and assess some particular things at my hospital: catheter securement, having the catheter bag and tubing hang below the insertion, and using special wipes for foley care.  In light of everything written, I believe my hospital has reduced CAUTIs, especially in the intensive care unit.  However, there are some problems that we see due to removing catheters too soon.  More patients are developing urinary retention and requiring a single-use straight catheterization or placement of another indwelling foley catheter, increasing the risk for CAUTIs.

Since my hospital does not have many protocols, the ICU nurses developed a nurse-driven ICU protocol after

NURS 8114 Blog Observation of Evidence-Based Practice
NURS 8114 Blog Observation of Evidence-Based Practice

removing foley catheters.  Briefly, it states that if a patient has not voided within eight hours of catheter removal, nurses are to bladder scan the patient.  If the bladder scan reveals a number greater than 400ml, the nurse performs a straight catheterization. If the patient still has not voided in another eight hours, the nurse conducts a second bladder scan.  Nurses complete the same bladder scanning process and perform a straight catheterization if the urine in the bladder is greater than 400ml. Nurses can perform a straight catheterization two times, and if the patient continues to have urinary retention, then an indwelling catheter is inserted.  This process has reduced our overall foley days.  However, some may see this process as traumatic for the patient if they require three additional foley insertions.

Evidence shows that most CAUTIs are related to catheter placement (during or after), where bacteria that originates in the perineal or colonic flora transfers to the patient during insertion via the hands.  Therefore, sterile technique is essential.  Nurses are vital to the maintenance and proper insertion of foley catheters.  They are the key to the prevention of CAUTIs (McNeil, 2017).

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I would like to become more involved with the development of foley catheter protocols in my hospital.  First, I would need to do more research regarding the insertion and removal of catheters.  In some cases, catheters with removing catheters too soon show an increase in urinary retention.  Nurses should monitor closely.  Implementing foley care into everyday practice is necessary for CAUTI reduction.  In other cases, catheters are used unnecessarily.  There is still much to be learned from CAUTIs and the insertion and removal process.

The general application of evidenced-based practice is received well since I work in a teaching hospital.  My hospital is always looking for innovative ways to take care of patients and improve overall outcomes and satisfaction.

Chien, L.Y. (2019). Evidenced-based practice and nursing research. The Journal of Nursing

               Research, 27(4), e29. https://doi.org.10.1097/jnr.0000000000000346

Connor, B. (2018). Best practices: CAUTI prevention. American nurse today.

Retrieved from https://www.myamericannurse.com/wp-content/uploads/2018/02/ANT_BestPractices_CautiPrevention.pdf

McNeill, L. (2017). Back to Basics: How Evidence-Based Nursing Practice Can Prevent

Catheter-Associated Urinary Tract Infections. Urologic Nursing37(4), 204–206. https://doi-org.ezp.waldenulibrary.org/10.7257/1053-816X.2017.37.4.204

CAUTI prevention is an area of focus at my facility as well. Earlier this year, a new bladder management protocol was implemented for non-urologic patients. Most of the elements were already in practice, but there were a few additions. The whole protocol is very comprehensive, so I will just give you some highlights. Before inserting an indwelling catheter, a “Foley Time Out” must be completed. This requires the nurse to ensure an order for the Foley has been entered and includes documentation of an appropriate indication for the indwelling catheter. Once the catheter has been inserted, nursing has to document whether the two-person insertion method was used. Fletcher-Gutowski and Cecil (2019) identified the two-person insertion method as influential in CAUTI reduction as it draws more attention to the use of aseptic technique. The bladder management protocol also includes a nurse-driven Foley removal protocol. Each shift, indications for the Foley are reviewed and if the patient no longer meets indication requirements, the Foley is removed. Nurse-driven protocols for removal have been shown to decrease CAUTI rates (Durant, 2017). This is largely due to the timely removal of the indwelling catheter since it is not necessary to call a physician for a removal order. McNeill (2017) identified the duration of indwelling catheter placement as the greatest predictor of CAUTI. One could infer the “early” catheter removal noted in your post is related to the desire to remove the indwelling catheter as quickly as possible in order to avoid CAUTI.

Similar to what you mentioned is happening in your ICU, we also complete bladder scanning post-removal if patients have been unable to void. The timing of the repeat scan depends on the amount of urine in the bladder. If the bladder contains less than 400 ml, the patient is rescanned in two hours if they have not yet voided. If the bladder contains more than 400 ml, it is emptied via straight catheterization and the patient is rechecked with a bladder scan in four hours. After three straight catheterizations are required, an indwelling is reinserted. Overall, implementation of this protocol has gone well; although, I have not yet seen a comparison of pre-implementation CAUTI rates to post-implementation rates.

 

References

Durant, D. (2017). Nurse-driven protocols and the prevention of catheter-associated urinary tract infections: A systematic review. American Journal of Infection Control, 45(2017), 1331-1341. https://doi.org/10.1016/j.ajic.2017.07.020

Fletcher-Gutowski, S., & Cecil, J. (2019). Is 2-person urinary catheter insertion effective in reducing CAUTI? American Journal of Infection Control, 47(2019), 1508-1509. https://doi.org/10.1016/j.ajic.2019.05.014

McNeill, L. (2017). Back to basics: How evidence-based nursing practice can prevent catheter-associated urinary tract infections. Urologic Nursing, 37(4), 204-206. https://doi.org/10.7257/1053-816X.2017.37.4.204