The North Dakota Nurse - July 2022

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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 EARN YOUR RN TO BSN 100% ONLINE Admit Fall, Spring, and Summer Semesters Key program features: • Study at your own pace • Program completion in two, three, or four semester plans • Earn college credit for current NCLEX-RN licensure • Affordable tuition and scholarships available • Exception support and 1:1 advising Contact Melissa at: 800-777-0750 ext. 3101 Melissa.Fettig@MinotStateU.edu MinotStateU.edu/nursing Be seen. Be heard. Be empowered. Flexibility to achieve your goals! 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.
July, August, September 2022 The North Dakota Nurse Page 15 Ozone Compared to 02 Appraised By: Amanda Hanson, RN, Mayville State University RN-to-BSN Student; Ashley Locken, RN, Mayville State University RN-to-BSN Student; Brandon Ferguson, RN, Mayville State University RN-to- BSN Student. Clinical Question: In patients hospitalized for COVID-19, how does integrating ozone treatment compared to O2 alone affect prognosis? Articles: Hernández, A., Viñals, M., Pablos, A., Vilás, F., Papadakos, P. J., Wijeysundera, D. N., Bergese, S. D., & Vives, M. (2020, December 5). Ozone therapy for patients with COVID-19 pneumonia: Preliminary report of a prospective case-control study. International immunopharmacology. Retrieved April 12, 2022, from https://www.ncbi. nlm.nih.gov/pmc/articles/PMC7833586/ Hernández, Viñals, M., Isidoro, T., & Vilás, F. (2020). Potential Role of Oxygen-Ozone Therapy in Treatment of COVID-19 Pneumonia. The American Journal of Case Reports, 21, e925849– e925849–6. https://doi.org/10.12659/AJCR.925849 Orscelik, A., Karaaslan, B., Agiragac, B., Solmaz, I., & Parpucu, M. (2020). Could the minor autohemotherapy be a complementary therapy for healthcare professionals to prevent COVID-19 infection? Annals of Medical Research, 28(10), 1863–1869. https://doi.org/10.5455/ annalsmedres.2020.11.1133 Synthesis of Evidence: Ozone therapy is considered a nonpharmacologic method which can be used as a complementary therapy when paired with pharmacologic interventions in the treatment of COVID-19. The treatment method depends on the severity of the infection and what stage of the infection the patient is currently experiencing. Ozone therapy is used in conjunction with standard treatment for COVID-19 to improve patient outcomes and provide for a better prognosis than using O2 therapy alone. “Ozone therapy acts as an auto-vaccine which can induce the oxidation of the viral components” and is administered as a minor hemotherapy (Orscelik, et al, 2020, g 1863). The treatment method depends on the severity of the infection and what stage of the infection the patient is currently in. It also depends on if the patient is receiving pharmacological treatment for the infection. The research for this study was a random sample study that was obtained from a group of people that had tested positive for COVID-19 and were symptomatic. The research that was conduced was used to determine the benefits of the use of ozone therapy for patients that tested positive for COVID-19 and were experiencing symptoms. A randomized controlled group that consists of three covid positive individuals that acquired covid induced pneumonia, gave informed consent to receive ozone oxygenated treatment. These three individuals that presented with respiratory distress was a 49-year-old male, 61-year-old male, and 64-year-old female. Each patient received four to six sessions of the ozone autohemotherapy. The outcomes were that each patient was able to discharge from the hospital on day two through four after ozone treatment. Laboratory tests and chest x-rays obtained before, during and after treatment and shown significant improvements throughout the study. None of these three patients needed invasive measures for breathing assistance, oxygenation, or mechanical ventilation. Each patient had an overall rapid clinical improvement after ozone therapy. Bottom Line: COVID-19 was a rapid outbreak that spread from person to person through airborne and droplets causing a global pandemic in March of 2020. This pandemic continued on through early 2022. Guidelines were put in place that instructed people to isolate in their homes and wear masks when they were out in public to hopefully stop the spread of this new infection. Treatment options were limited due to the unknowns of the infection transmission, cause, and barriers. When the infection first surfaced in the United States, standard treatment was supplemental oxygen therapy and occasional antibiotic treatment. Through research and trial and error, new standards for infection treatment have surfaced. One of the new treatments was ozone therapy. Ozone treatment is an alternative medical therapy that introduces ozone to the body. For the treatment of COVID-19, ozone is mixed with a patient’s blood and reinjected into the patient’s body. This process is known as autohemotherapy. “Ozone therapy can be giving in multiple treatments; it improves oxygenation through attaching to the blood cells and it consider to be ‘10 times more soluble than oxygen’” (Hernadez et. al. 2020). This therapy is shown to improve the overall immune system response. Studies have shown that ozone therapy combined with supplemental oxygen have significantly decreased COVID-19 symptoms and prevented the need for mechanical ventilation or intubation. Ozone therapy was trialed in some areas and was found to be successful in COVID treatment, however, there is not enough studied evidence to consider it a true treatment for COVID-19 symptoms. Ozone therapy can be used in the treatment of COVID-19 infection in addition to traditional treatment of the infection. There is not enough evidence to determine if using ozone therapy alone would provide better outcomes for the patient, so it is determined that using it in addition to oxygen therapy and pharmacologic treatment provides better outcomes for the patient. There is still more research available, and all studies are shortterm with moderate-small sample sizes. Implications for Nursing Practice: Ozone therapy cannot be said to provide sufficient protection alone but can be used with other treatments to provide better results in protection and therapy for COVID-19 infection. Using ozone as an adjuvant therapy in the treatment of COVID-19 associated pneumonia is shown to be beneficial to the patient. Determining what patients can receive ozone therapy and which patients are candidate for other forms of therapy is imperative to ensure the patient is getting the highest quality of care/treatment for the best results. Early results show that ozone therapy does benefit patients affected by the COVID-19 virus. Nurses should continue to educate themselves on potential treatment options for patients with COVID-19 infection. Many people are rather skeptical about the infection and the presented treatment options. Staying up to date by reading current studies can go a long way when talking to people about treatment options for COVID-19 infection, including Ozone therapy.
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