1. What Impact Does a Nurse Training Program Designed to Decrease Urinary Catheter Use Have on Bacteruria Rates in the Community Hospital Setting? Jamie Bartley DO, Diane Lenk MSN, RN, Janet Moody BSN, RN, Amy Brode DO. From the Division of Urology, Wound Care Nursing, and The Infectious Disease Department. Botsford Hospital, Farmington Hills, MI Botsford Hospital, Farmington Hills, MI

2. Introduction Urinary catheters are one of the most common causes of nosocomial infections in the hospitalized patient Urinary catheters are one of the most common causes of nosocomial infections in the hospitalized patient Patients with an indwelling foley catheter have a risk of bacteruria at 5% per day Patients with an indwelling foley catheter have a risk of bacteruria at 5% per day Symptomatic urinary tract infection has been shown to occur in 20% of patients with bacteruria Symptomatic urinary tract infection has been shown to occur in 20% of patients with bacteruria Urinary catheters are often placed without a clear indication for need Urinary catheters are often placed without a clear indication for need

3. Hypothesis We believe that a nursing education program through the “Keystone Project” will decrease non-indicated catheter use in hospitalized patients We believe that a nursing education program through the “Keystone Project” will decrease non-indicated catheter use in hospitalized patients Secondary analysis: We suspect this will decrease the prevalence of positive urine cultures Secondary analysis: We suspect this will decrease the prevalence of positive urine cultures

4. “Indicated vs. Non-Indicated Foley” Nursing Inservice Beginning fall 2007, nurses were inserviced on indications and non- indications for foley catheters Beginning fall 2007, nurses were inserviced on indications and non- indications for foley catheters Urinary tract obstruction Neurogenic bladder Urologic study/urologic surgery Stage 3 or 4 pressure ulcer Hospice, comfort care or palliative care only Figure 1: Indications for Urinary Catheter Use Nephrology Transferred from ICU Patient requests Confused Incontinence Other Figure 2: Non-Indications for urinary catheter use

5. Collection of Catheter Data Catheter use was documented for one week (Monday- Friday) and recorded on two units according to the dates below. Catheter use was documented for one week (Monday- Friday) and recorded on two units according to the dates below. 5 South Data Collection Dates Weeks 1-3 October 8-26, 2007  Pre-education data Week 8 November 26 - 30, 2007 1 st Quarterly March 3 - 7, 2008 2 nd Quarterly July 14 - 18, 2008 3 rd Quarterly October 27 -31, 2008 PCU Data Collection Dates Week 1-3 Feb 18 - March 7, 2008  Pre-education data Week 8 April 7 - 11, 2008 1 st Quarterly July 28 - August 1, 2008 2 nd Quarterly September 22 - 26, 2008 3 rd Quarterly December 8 -12, 2008 Post-education data

6. Collection of Urine Culture Data Information on patients with bacteruria was obtained from the Infectious Disease Department Information on patients with bacteruria was obtained from the Infectious Disease Department Bacteruria= >10^2 CFUs Bacteruria= >10^2 CFUs A retrospective chart review A retrospective chart review Did patients with bacteruria had a foley catheter and if so, was it was indicated according to the above criteria? Did patients with bacteruria had a foley catheter and if so, was it was indicated according to the above criteria?

7. Study Population Pre-intervention- n = 1223 (378 and 845) Pre-intervention- n = 1223 (378 and 845) Post Intervention- n = 1737 (608 and 879) Post Intervention- n = 1737 (608 and 879)

8. RESULTS Logistic regression analysis and Odds Ratios (95% confidence limits) were performed to determine if there was a statistically significant decrease (  =0.05) in non-indicated foley catheter use Logistic regression analysis and Odds Ratios (95% confidence limits) were performed to determine if there was a statistically significant decrease (  =0.05) in non-indicated foley catheter use

10. PCU Catheter Results Contrast P-value Pre-education Mean Post- education< 0.0001* Time Odds Ratios (95% confidence limits) P-values Week 8 (compared to pre-intervention) 0.75 (0.46, 1.23)0.2551 Quarter 1 (compared to pre-intervention) 0.36 (0.20, 0.64)0.0005* Quarter 2 (compared to pre-intervention) 0.85 (0.47, 1.53)0.5902 Quarter 3 (compared to pre-intervention) 0.97 (0.47, 2.00)0.9402 * statistically significant for α=0.05

12. 5S Catheter Results Time Odds Ratios (95% confidence limits) P-values Week 8 (compared to pre-intervention) 0.49 (0.24, 0.99)0.0466* Quarter 1 (compared to pre-intervention) 0.32 (0.15, 0.66)0.0022* Quarter 2 (compared to pre-intervention) 0.43 (0.20, 0.92)0.0286* Quarter 3 (compared to pre-intervention) 0.18 (0.06, 0.52)0.0017* Table 3: Outcome – Non-indicated foley use Contrast P-value Pre-education Mean Post- education< 0.0001* * statistically significant for α=0.05

13. Does the decrease in catheter use we see lead to a decrease in bacteruria? Our ultimate Goal  Prevention of CAUTI

14. % P a T I E n T s

15. Can Decreasing Catheter Use Decrease Bacteruria? Urine culture data was analyzed using Fisher’s exact test to determine if there was a decrease in the incidence of positive urine cultures after the foley education program was instituted Urine culture data was analyzed using Fisher’s exact test to determine if there was a decrease in the incidence of positive urine cultures after the foley education program was instituted A decrease in percentage of positive urine cultures* was seen but it did not reach statistical significance (2.5%, 1.8%) A decrease in percentage of positive urine cultures* was seen but it did not reach statistical significance (2.5%, 1.8%) *Note: This was determined by the number of positive urine cultures per total patient population, not total number of urine cultures. Since data was provided only on positive urine cultures, it is assumed that the other patients without cultures taken were either not indicated or were negative (this may represent a sample bias)

16. Results Of interest (though not significant) Of interest (though not significant) Most of the positive urine cultures in our data were seen in patients with an indicated catheter in both the pre-education and post- education periods (90.32% and 77.42%) Most of the positive urine cultures in our data were seen in patients with an indicated catheter in both the pre-education and post- education periods (90.32% and 77.42%)

17. Discussion Decreasing hospital acquired infections is necessary to decrease patient morbidity and mortality Decreasing hospital acquired infections is necessary to decrease patient morbidity and mortality Financial incentive to hospital due to no reimbursement for “reasonably preventable infections (including CAUTI) Financial incentive to hospital due to no reimbursement for “reasonably preventable infections (including CAUTI) Certain factors such as patient population will greatly influence the success of such a program Certain factors such as patient population will greatly influence the success of such a program PCU, compared to 5S, was 4 times more likely to have a non-indicated foley (p<0.001). PCU, compared to 5S, was 4 times more likely to have a non-indicated foley (p<0.001).

18. Conclusion A nurse training program can be successful in decreasing foley catheter use when it may not be appropriate A nurse training program can be successful in decreasing foley catheter use when it may not be appropriate The effect on decreasing bacteruria by decreasing catheter use was not proven in this study The effect on decreasing bacteruria by decreasing catheter use was not proven in this study The majority of positive urine cultures still occur in patients who have a medical reason to have a foley in place. Improved infection control techniques are needed for this high-risk population The majority of positive urine cultures still occur in patients who have a medical reason to have a foley in place. Improved infection control techniques are needed for this high-risk population

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