Why So Many Foleys?Posted on by
Guest Author: Wendy Kaler, MPH, CIC
Dignity Health Clinical Lead for CAUTI Prevention
At Dignity Health, our goal is to reduce the rate of hospital-acquired infections (HAI) by 40 percent and readmissions by 20 percent before 2015, and we are well on our way. We have introduced specific evidence-based practices and bedside intervention activities to evaluate full adoption of safe preventive practices and assure coordination of care at the bedside with clinicians, including physicians. When I am provided the opportunity to share my experiences with Dignity Health’s “No Harm Campaign” to prevent catheter-associated urinary tract infection (CAUTI), I am often asked “why is it so difficult to get Foleys discontinued?”
Weighing the Benefits and Risks of Using a Foley
During training, physicians and nurses are made aware of the advantages of indwelling urinary catheters indwelling urinary catheters, but oftentimes the instructors do not focus on the associated risks of these devices. With competing priorities and time constraints, health care providers do not prioritize indwelling urinary catheters as a device that should be assessed daily for need, especially in the critical care units. Historically, the intensive care unit (ICU) staff believed that all critical care unit patients need a Foley. Lack of good alternatives available to provide bladder management and output measurement have contributed to this practice. Bedside nurses are ultimately managing the Foley and the advantages for them are understandable, including reducing the amount of time they must spend managing the bladders of their patients and keeping their patients skin dry. However, bedside nurses need to be aware that the risks to the patient are greater than the advantage to themselves. For example, if a patient develops a UTI and is treated with antibiotics, they are at an increased risk to develop multi-drug resistant organisms or C. difficile infection.
In the past, Infection Preventionists have implemented evidenced-based bundles, including Central Line Insertion Practices (CLIP) and Surgical Care Infection Prevention (SCIP) to reduce risk of HAIs. Training is always provided to support use of new bundles, but it is difficult to ensure that the elements in these bundles have been adopted. If CAUTI rates are low, hospitals assume staff members are following the bundles. However, if processes are not in place, the good outcomes are only temporary. Oftentimes, further inspection is required only when infection rates increase and patients are harmed, most likely identifying that the bundles were not consistently being followed.
A Multipronged Approach is Required to See Improved Foley Use Results
In order to ensure the best practices are in place to manage Foley use and reduce risk of CAUTI, there needs to be accountability by bedside staff. This requires resources focused at the bedside on an ongoing basis to assess compliance with bundle elements. This needs to continue on a regular basis until there is a visible change in the culture surrounding Foley use. Otherwise, as has happened so often in the past, the bedside nurse sees initiatives like “Get the Foleys Out” as an “initiative du jour” — just another program that they can survive by remaining quiet and passive in the hopes that it will surely pass. The following recommendations may help hospital facilities better manage Foley Use:
- Designate a CAUTI Clinical Lead
A performance improvement campaign to reduce CAUTI can only be successful with a dedicated CAUTI Clinical Lead in the facility. This CAUTI lead might be a nurse or an Infection Preventionist who has working relationships with key individuals that support bedside nursing care, including central supply staff, Materials Managers, and Therapies staff. Education needs to be provided to all stakeholders and alternative products to indwelling urinary catheters must be trialed, purchased and then consistently made available on supply carts in all nursing units. Ongoing verification and feedback of failures to Central Supply staff is needed as space limitations for products are common. Challenges to achieving 100 percent compliance with any bundle must be identified and feedback provided to Quality/Performance Improvement Committees, which will then put measures in place to foster accountability for compliance with bundle elements.
• Utilize Bedside Coaches
Bedside coaches can show bedside nurses other options to indwelling urinary catheters for a specific patient, provide feedback that can help overcome resistance to change, and verify the adherence to bundles. An optimal bedside coach is a nurse who knows the culture of that nursing unit and provides options that are realistic for that patient. Utilizing a “moonlighting” nurse-model as the bedside coach is ideal because the benefits extend beyond their bedside coaching role. Once nurses support performance improvement strategies, they naturally incorporate this mindset into their clinical role when they are working a regular shift.
- Engage Champions
The more champions who support the early removal of indwelling urinary catheters, the better the chances are to successfully reduce Foley use. Physical and Occupational Therapists can be educated and encouraged to advocate for early indwelling urinary catheter removal. They are well aware of their patient’s mobility and capabilities, and can make recommendations to their patient’s nurses and physicians. Additionally, physicians who do daily rounds or participate in rounding teams can raise the question of whether each indwelling urinary catheter is essential, and Infection Preventionists can round on the ICUs and Telemetry units (alone or as part of a team) to review with the bedside nurse each patient with a indwelling urinary catheters to determine if it remains truly essential.
- Leverage the Electronic Health Record
EHRs can be programmed to monitor indwelling urinary catheters orders and require physicians to provide documentation of a valid criteria for them. Additionally, EHRs can send daily reminders or alerts to physicians to justify continuation of indwelling urinary catheters .This creates fields for nurses or physicians to document a justification for continuation of any indwelling urinary catheters so that compliance can be audited and non-compliance can be reviewed with the individual.
- Implement Nurse Driven Protocols
Protocols place optimal approaches to patient-specific bladder management in the hands of the bedside nurse. These protocols allow the nurse to discontinue a non-essential indwelling urinary catheter and follow approved procedures for bladder management post catheter discontinuation. This will decrease the common practice of reflex orders for indwelling urinary catheter re-insertion until it is accurately assessed to have urinary retention. Success requires ongoing education to nurses and a physician-champion to provide education to physicians to ensure that they address bladder function issues in nursing communications as well as daily assessments and plans.