DO SYSTEM-BASED INTERVENTIONS AFFECT CATHETER-ASSOCIATED URINARY TRACT INFECTION? Clinical Evidence Review By Margo A. Halm, RN, PhD, ACNS-BC and Nancy O’Connor, RN, BSN, MSBA, CIC I ntroduced in the 1930s by American urologist Dr Fredrick Foley, urinary catheters have become a mainstay in clinical care. 1 An estimated 30 mil- lion urinary catheters are used annually in the United States. Prevalence of catheter use among hospitalized patients ranges from 16% to 33% 2,3 and is even higher (67%-76%) in critically ill patients. 4,5 But up to one- third of patients may not have an appropriate indica- tion for a catheter to be used. 3,6-8 Inappropriate catheter use occurs because of convenience, misunderstanding of necessity, and lack of clear orders for catheter removal 9 or the physician's lack of awareness of the catheter's presence. 8 More than 500 000 catheter-associated urinary tract infections (CAUTIs) occur each year in the United States alone. As the single largest source of bacteremia in hospitalized patients, CAUTIs account for 30% to 40% of all hospital-acquired infections. 10,11 Prolonged catheterization is the principal risk factor for CAUTI. 12- 15 CAUTI is associated with increases in morbidity and mortality, resource utilization, and health care costs. CAUTIs may lead to unnecessary use of antibi- otics and antimicrobial resistance and longer hospital stays, 1,10,11,16 with a cumulative additional 90 000 hos- pital days per year. 17 The cost of a single CAUTI episode varies from $980 to $2900 (depending on presence of bacteremia), 18 with a collective annual US cost of $424 million to $451 million. 19 Other potential com- plications of catheterization such as mechanical trauma, urethral strictures, and restricted mobility also affect morbidity, further affecting length of stay and costs. 1,20 The Centers for Disease Control and Prevention estimated that 20% to 70% of all CAUTI events could A regular feature of the American Journal of Critical Care, Clinical Evidence Review unveils available scientific evidence to answer questions faced in contemporary clinical practice. It is intended to support, refute, or shed light on health care practices where little evidence exists. To send an eLetter or to contribute to an online discussion about this article, visit www.ajcconline.org and click “Respond to This Article” on either the full-text or PDF view of the article. We welcome letters regarding this feature and encourage the submission of questions for future review. be eliminated by universal implementation of evi- dence-based prevention practices. 11 One guideline involves minimizing catheter use and limiting dura- tion in all patients, but especially those at higher risk (ie, women, elderly patients, critically ill patients, patients with impaired immune function). 11,21 The focus of this review is the following PICO (problem or population, intervention, comparison, outcome) question: What is the effectiveness of system inter- ventions, such as daily reminders, on catheter use and CAUTI rates in hospitalized patients? Method A search of the MEDLINE and CINAHL databases, limited to the past 5 to 7 years, was conducted by using these terms: urinary tract infection, catheter-associated urinary tract infection (CAUTI), daily reminders, and nurse-driven protocols. Results Eight research or quality improvement projects were retrieved (Table 1). These reports tested the effects of single or multifaceted interventions on catheter- related and cost variables. Educational interventions focused on evidence-based bundles/policies and competency assessment. Reminder systems involved (1) initial electronic catheter orders with embedded indications for selection from a drop-down box, or stop orders that prompt the user to either discontinue or renew a catheter order; (2) prewritten stop orders that specify criteria according to which nurses should remove catheters; and (3) daily review of catheter indications by nurses, who then would remind physi- cians to discontinue unnecessary catheters during multidisciplinary rounds. Product interventions involved replacing catheters coated with silver alloy © 2014 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ajcc2014689 www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2014, Volume 23, No. 6 505 by AACN on December 16, 2016 http://ajcc.aacnjournals.org/ Downloaded from