Kachare, S.D., Sanders, C., Myatt, K., Fitzgerald, T.L., & Zervos, E.E. (2014). Toward eliminating catheter-associated urinary tract infections in an academic health center. The Journal of Surgical Research, 192, 280–285. 

To determine if implementing two interventions would cause a reduction in catheter-associated urinary tract infections (CAUTIs) in an inpatient surgical oncology unit (The first intervention was designed to decrease the use of Foley catheters, and the second intervention was designed to initiate early removal while preventing reinsertion of the Foley catheter.)

The first intervention was the development of a hospital-wide guideline outlining the indications for Foley catheter use. There were six defined reasons for the use of a Foley catheter in a patient. If the patient did not meet one of these criteria, then Foley catheter use was not recommended. The second intervention included two measures. The first was aimed at the early removal of the catheter by designing a daily electronic query sent to the attending physician regarding continuing use of the Foley catheter, and the second was direct personal contact with the primary medical team to determine the medical necessity of continued Foley catheter use. They also focused on the prevention of catheter reinsertion by following a developed algorithm for the healthcare team.

• N = 2,843
• KEY DISEASE CHARACTERISTICS: Cancer of the liver, pancreas, colon, head and neck, urologic, or gynecologic organs requiring inpatient surgery
• OTHER KEY SAMPLE CHARACTERISTICS: CAUTIs were defined as the presence of symptomatic urinary tract infection (UTI) or asymptomatic bacteremic UTI in patients with an indwelling catheter in place for greater than 48 hours.

• SITE: Single site    
• SETTING TYPE: Inpatient    
• LOCATION: Vidant Medical Center, Greenville, NC

• PHASE OF CARE: Active antitumor treatment

This study design was a pre/post design with preintervention data obtained in a retrospective manner followed by the authors obtaining postintervention data.

• The authors used total device days for Foley catheters, utilization rate, total number of CAUTI’s, and hand hygiene compliance pre- and postintervention as measurement instruments to determine the effectiveness of their interventions.

There was a significant reduction in the use of Foley catheters after the interventions were put in place (P < 0.0001). There also was a significant reduction in CAUTI rates for patients who did require a Foley catheter after interventions were put into place, from 4.6 to 0 (P = 0.03). For patients who required a Foley catheter and had a diagnosed CAUTI during the postintervention time period, none of the Foley catheters were reinserted. The preintervention group had four patients with positive CAUTIs who had a Foley reinserted.

Even though the study was limited to one inpatient surgical oncology unit, the findings support other similar studies of best practice indicating use of Foley catheter insertion criteria as well as algorithm guidelines for care after catheter removal. Because infections can be detrimental in the oncology population, healthcare teams working with these patients should explore the literature surrounding the prevention of CAUTIs and ways of implementing best practices.

• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Other limitations/explanation: Retrospective study; self-reporting of hand hygiene compliance; single-unit study

Oncology nurses need to be diligent with hand hygiene, not only among themselves but with other members of the healthcare team. They also need to adhere to Foley catheter bundles, including the daily verification of continuing need for the catheter, the use of catheter securement devices, keeping tubing below the level of the bladder, keeping the bag off of the floor, and providing perineal care at least twice per day. If the institution does not have a catheter bundle, nurses need to lead the initiative to implement one. This study demonstrated successful institutional approaches for protocol implementation and ongoing auditing and interventions with care providers.