The North Dakota Nurse - July 2022

Page 14 The North Dakota Nurse July, August, September 2022
CAUTI’s and External Catheterization
Appraised by:
Brenna Hoger SN, Patricia Shepard SN, Kaylie
Wilson SN, Ashley Wanner SN, Emily Russell SN,
Morgane Inangorore SN
Allison Sadowsky MSN RN Assistant Professor
of Practice (Faculty)
(NDSU School of Nursing at Sanford Bismarck)
Clinical Question:
For women in need of urinary catheterization,
does the use of external catheterization reduce
the risk for urinary tract infections compared to
indwelling foley catheters?
List of Articles:
Eckert, L., Mattia, L., Patel, S., Okumura, R., Reynolds,
P., & Stuiver, I. (2020). Reducing the risk of
indwelling catheter-associated urinary tract
infection in female patients by implementing
and alternative female external urinary
collection device: A quality improvement
project. Journal of wound, ostomy, and
continence nursing: official publication of The
Wound, Ostomy, and Continence Nurses Society,
47(1), 50-53.
Leontie, S.L., & Delawder, J.M. (2021). Utilizing a ‘Fight
the Foley’ bundle to reduce device utilization
rates and catheter-associated urinary tract
infections. Urologic Nursing, 41 (4), 208-213.
Rearigh, L., Gillett, G., Sy, A., Micheels, T., Evans, L.,
Goetschkes, K., Van Schooneveld, T.C., Lyden, E.,
& Rupp, M.E. (2021). Effect of an external urinary
collection device for women on institutional
catheter utilization and catheter-associated
urinary tract infections. Infection control and
hospital epidemiology, 42(5), 619-621. https://doi.
org/10.1017/ice.2020.1259
Van Decker SG., Bosch N., Murphy J. (2021). Catheter
associated urinary tract infection reduction
in critical care units: a bundled care model.
BMJ Open Quality, 10(e001534) Doi: 10.1136/
bmjoq-2021-001534
Warren, C., Fosnacht, J. D., & Tremblay, E. E. (2021).
Implementation of an external female urinary
catheter as an alternative to an indwelling
urinary catheter. American journal of infection
control, 49(6), 764–768. https://doi.org/10.1016/j.
ajic.2020.10.023
Zavodnick, J., Harley, C., Zabriskie, K., & Brahmbhatt,
Y. (2020). Effect of a female external urinary
catheter on incidence of catheter-associated
urinary tract infection. Cureus. https://doi.
org/10.7759/cureus.11113
Synthesis of Evidence:
Six articles were reviewed as evidence
in this report, including three retrospective
observational studies and three quasiexperimental
quality improvement project
studies. Rearigh et al (2021) stated “catheterassociated
urinary tract infections (CAUTIs) are
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a common hospital-acquired infection resulting
in excess morbidity, mortality, and cost.” Urine
management, for women in particular, has
been challenging due to the limited options
for control of urinary incontinence and the
anatomy of the female body. The external
catheter allows for urine management in a
manner that is still easily measurable and
accurate and avoids an indwelling catheter.
Eckert et al (2020) conducted a quasiexperimental
“quality improvement project.”
This project entailed the use of a “test run”
in one unit utilizing a female external urinary
collection device in an effort to reduce the
number of CAUTI rates in female patients
needing urinary management. The trial run
included a 60-bed telemetry unit for 30 female
patients requiring urinary management. At
the end of the trial period, each nurse on the
unit who used the female external urinary
collection device was given a survey, and the
nursing usage reports were positive. After the
trial run and survey analysis, the experiment
was expanded to other units in the hospital.
The amount of CAUTI rates with the use of a
foley catheter were compared to CAUTI rates
with the use of the female external urinary
collection (FEUC) device. Before implementing
the use of a FEUC device, the female CAUTI
rate were eight cases per 7,181 indwelling
catheter device days, so approximately 0.11%.
After implementation of the FEUC device,
CAUTI rates were approximately 0% in 2016,
and 0.09% in 2017. It was found that the use
of a female urinary collection device may
reduce both indwelling catheter utilization and
CAUTI rates if a consistent, comprehensive, and
interdisciplinary approach is used to assess
CAUTI bundle compliance that included a FEUC
device.
Leontie and Delawder (2021) conducted
a quasi-experimental “quality improvement
project” (QI). This QI was conducted to
determine if implementing a ‘fight the Foley’
bundle would reduce the device utilization
rates of indwelling catheters and reduce the
rates of CAUTI. This study included anyone
with an indwelling catheter on a critical care,
intermediate care, or medical surgical unit in a
238 bed Not-for-profit hospital. Pre-intervention
data was collected from July 2017 to August
2018 and post intervention data was collected
from October 2018 to September 2019. The
intervention developed an implementation
of a daily ‘Fight the Foley’ line huddle for unit
leaders, developed and implemented a Foley
stop huddle prior to insertion and increased
available alternative devices (Pure Wick). The
major finding of this study found that there
was a downward trend in CAUTIs, but no
clinical significance was noted. There were 16
CAUTIs captured pre-intervention and eight
in the post-intervention timeframe. There was
statistical significance in alternative device
usage which increased with a 105% increase
in condom catheter use, 16% with intermittent
catheterization, and 409% increase in female
urinary incontinence device usage such as Pure
Wick.
Rearigh et al (2021) conducted a
retrospective quasi-experimental study to
determine whether external urinary catheter
devices, in comparison to indwelling catheters,
decreased the amount of catheter usage days,
catheter associated urinary tract infections in
females, and adverse events associated with
urinary catheterization. The study included
2,347 adult inpatient women in need of urinary
catheterization during the experimental period
(14 months) and other female patients (number
not stated) in the control comparison period
(14 months). The intervention in this study was to
initiate the external collection device, otherwise
known as the “PureWick.” The study found that
there was a significant decrease in catheter
utilization (71.49 to 56.15), the rate of CAUTI
decreased (0.15-0.09), and there were only five
reported adverse events in the 14 months of the
experimental period related to malposition of
the “PureWick” and patient allergies.
Van Decker SG., Bosch N., Murphy J. (2021)
conducted a quasi-experimental quality
improvement project utilizing the Plan/Do/
Study/Act (PDSA) Framework at a Boston
Medical Center (BMC) hospital in Boston,
Massachusetts starting in Spring 2013 and
spanning five years. The CAUTI taskforce
implemented the PDSA cycle and used CAUTI
rates per 1000 patient days as measurement,
which aimed at testing the effect of Purewick
external catheter use among female ICU
patients and resulted in a significant downward
shift from 5.86 to 1.62 mean CAUTI rate post
intervention.
Warren et al (2021) conducted a quasiexperimental
retrospective study. The purpose
of this study was to analyze “the impact of a
hospital-wide implementation of an external
female urinary catheter at a large academic
medical center.” This study compared predevice
implementation and post-device
implementation to see if there was a reduction
of CAUTIs. This study took place in a large
academic center in Madison, WI. Data was
collected from March 1, 2016, until May 31,
2018. This study compared CAUTI rates per unit
month, indwelling urinary catheter utilization
rate, and external urinary catheter utilization
rate in a retrospective chart review from EPIC.
The major findings of this study were that the
overall female CAUTI rate went from 5.5 to
1.7, indwelling urinary catheter utilization ratio
decreased from 0.46 to 0.35, and external
female urinary catheter device utilization
increased from 0 to 0.17.
Zavodnick, Zabriskie, and Brahmbhatt (2020)
conducted a retrospective observational study.
This study was conducted to investigate the
effect of female external urinary catheters
(FEUCs) on indwelling catheter use and female
CAUTIs. The study focused on female ICU
patients at Thomas Jefferson University Hospital.
The study included ICU patients during the
preintervention time period of Jan 1, 2017 to
December 31, 2017 and then the intervention
period of Jan 1, 2018 to December 31, 2019
when the FEUC became available. The major
findings were that female CAUTI rates were
3.14 per 1000 catheter days and 1.42 after the
FEUC was introduced. CAUTI rates decreased
by over 50% after the FEUC was introduced.
Device-associated pressure injury (DAPI)
increased after the FEUC was introduced. The
DAPI was 0.49% for preintervention and 0.61%
during intervention. Overall, after the FEUC
was introduced, CAUTI rates had a significant
decrease.
Conclusions: Brief Summary of the Evidence
All six articles indicated a downward
trend in catheter associated urinary tract
infections after implementing an external
catheter device in females in comparison to
indwelling catheters. Also, all articles showed
a decrease in overall catheter usage days
after the implementation of the external
female collection device. However, Zavodnick,
Zabriskie, and Brahmbhatt (2020) found that
there was an increase in adverse events after
the implementation of the external device due
to device associated pressure injuries.
Implications for Nursing Practice:
(Recommendations for Practice)
According to this research, there is evidence
to suggest that implementing an external
urinary collection device will reduce catheter
associated urinary infections and reduce the
number of catheter usage days in female
patients. Warren et al (2021) recommended
that facilities first implement the device in
the ICU as this level of care was where they
observed the most significant impact, before
facilities implement the device on every floor.
This external female collection device provides
a non-invasive method to manage female
urinary incontinence, measure urinary output
and reduce skin breakdown from urinary
incontinence, which overall improves patient
outcomes and associated costs.