Approximately 30% of all hospital reported infections are of the urinary tract (Joint commission: New year will usher in new CACTI prevention requirements, 2011). The Joint Commission estimates the annual cost of CACTI care is in excess of $400 million; Rutherford, CACTI care is targeted by Medicaid and Medicare services as a non- reimbursable infection. For years, postoperative urinary catheter utilization has been contested regarding the appropriate criteria required for its application, maintenance, and discontinuation.
Patients hospitalized for short term postoperative care, specifically, orthopedic patients, are often categorized due to their limited immobility. The goal of therapy with surgical orthopedic procedures is to improve mobility, not render the patient immobile. Urinary catheters are often viewed as cumbersome, inconvenient instruments of immobility by the patient. Conversely, nurses have often viewed urinary catheters as an instrument of convenience and standard of care for hospitalized patients.
The use of short term urinary catheter use, whether indwelling or intermittent, in orthopedic patients has been surveyed through multiple studies, resulting in evolutionary changes in the standard of care of postoperative orthopedic patients. The contrasts in patient outcomes utilizing indwelling categorization, intermittent straight categorization, and non-use of categorization will be reviewed. In postoperative orthopedic patients, how does the discontinuation of an indwelling urinary catheter compare to non-categorization in relation to the prevention of urinary tract infection?
PATTI .NET 3 Population: Postoperative orthopedic patients Intervention: Discontinuation of an indwelling catheter Comparison: Non-categorization of postoperative orthopedic patients Outcome: The patient will not exhibit any symptom’s of a urinary tract infection Evidenced Based Practice Models The Johns Hopkins Nursing Evidence Based Practice Conceptual Model MOONBEAM) can be utilized in this area of focus as it comprises the foundations of nursing: practice, education, and research. There are three phases to this model known as the PET process: Practice question, Evidence, and Translation.
The practice question identifies a problem with a current practice. Evidentially support to answer the practice question is produced through the utilization and evaluation of research and non-research evidence. The outcome of the implemented research is then translated into practice change, the measurement of those outcomes, and the dissemination the new research (Buck & Robinson, 2012). The Iowa Model of Evidenced Based Practice (IMBIBE) is appropriate for use in this area of focus. It allows for the entire healthcare system to be utilized in determining the need for change in the delivery of care.
Employing this model allows the researcher to elect to choose between a current problem and new research as the basis for change in patient care. Once the trigger has been substantiated as a priority, a team is put in place to assemble, critique, and determine if enough research has been presented to pilot a change in current practices. If there is sufficient evidence for change and the pilot program is successful, a change in practice will occur. Once a change has been made, the ATA obtained from the practice change can be further 4 developed utilizing this model and continuing the evolutionary cycle of improving standard of care practices.
Otherwise, if there is not enough evidence, further research may be conducted to provide enough of a base to continue toward obtaining a practice change (Donate, 2007). The differences between the CHEYENNE and the IMBIBE are minor. They both provide a common goal: to change current practices by employing evidenced based research to foster the evolution of healthcare practices. Both models use a question or a trigger to initiate a change in practice. The minor difference between the CHEYENNE and the IMBIBE is the CHEYENNE validates its change of practice question with the application of non-research data in addition to its research data.
In this way, the CHEYENNE can consider patient preference as an indicator to best practices. Determining the Question The National Patient Safety Guidelines, as determined by the Joint Commission, include the prevention of indwelling CACTI, emphasizing the prompt removal of these instruments and the observation for subsequent infection (Joint commission: New year will usher in new CACTI prevention requirements, 2011). The initial question was, “In admitted orthopedic surgical patients, does prompt removal of an indwelling Foley catheter within 48 hours of surgery reduce the incidence of catheter associated urinary tract infection? In order to have a broader result list in searching for articles, the PICO parameters were refined. The population parameter was reduced to “postoperative orthopedic patients. ” The intervention parameter was refined to “discontinuation of an indwelling catheter. ” This removed the time constraint from the initial PICO question. Using “non-categorization,” employed the comparison tool to serve as the basis or improved practice. The outcome parameter, “prevention of urinary tract infection” aligns .NET 5 with the Joint Commission’s National Patient Safety Guidelines to preventing CACTI, ensuring better patient care by eliminating infections.
Search of Evidence Pumped was the first database searched for postoperative urinary catheter indications and subsequent infections. The key terms, “indwelling urinary catheter AND urinary tract infection AND surgery,” were entered into the search bar, yielding 320 results. Accordingly, a second search using the key terms, “orthopedic surgery AND catheter associated urinary tract infection,” resulted n eight articles. Of those eight, two articles were chosen for review due to their specificity to joint surgery and urinary categorization.
The Cumulated Index of Nursing and Allied Health (CINCH) database was the second database searched. The key terms, “surgical patients and urinary tract infection,” produced 14 articles, of which two retrospective cohort studies were chosen for review based on the PICO criteria of urinary catheter use in the postoperative period. Additionally, a search for the key terms, “orthopedic surgery and catheter associated urinary tract infection” resulted in zero hits. The third database searched was Science Direct.
The key terms searched for in this database were, “surgical patients, indwelling catheter, sterile field, and urinary tract infection. ” This search resulted in 845 articles in which they were further limited to, “infection control,” which yielded 27 articles. Of those 27 articles, two were chosen for further review; a prospective observational study with descriptive and comparative design and a randomized control trial with cost- effectiveness analysis. 6 Evidence Review The first, and oldest, article reviewed was discouraging.
Knight and Peeling’s 1996) randomized control trial determined utilization of indwelling catheters for urinary retention in postoperative total hip arthroscopy (THAT) or total knee arthroscopy (TEAK) procedures was beneficial for the patient. It was also determined urinary tract infections were not a consequence of indwelling catheter usage. The level of evidence met level one criteria, yet the grade of recommendation was D due to the weak recommendations with alternative approaches likely to better suit a different group of patients, those requiring urinary categorization for urinary retention.
The next study, a retrospective cohort study, sampled 35,904 patients who underwent major cardiac, vascular, orthopedic, or gastrointestinal surgery. A urinary catheter was placed interpretatively, resulting in the development of a urinary tract infection if left in for more than two days; these patients were twice as likely to develop a urinary tract infection compared to patients whose catheters were removed within 48 hours of surgery (Wald, Allen, Barrater, & Kramer, 2008).
That same year, another retrospective cohort study by two of the previous authors along with two additional researchers, concluded postoperative tenants admitted to skilled nursing facilities where their indwelling urinary catheters were maintained over the course of their care were associated with poorer outcomes. This study was restricted to the patients in skilled nursing facilities where direct patient care was limited and ongoing surveillance was minimal (Wald, Epstein, Radcliff, & Kramer, 2008).
Both of these studies level of evidence met two-b criteria, grade of recommendation A and B respectively; the first study could apply to most patients in most circumstances, while the second study could apply to most circumstances. 7 The final review of Many, et. L, (2013), resulted in a one-a level of evidence with an A for grade of recommendation. This randomized control trial concluded the employment of indwelling catheters and intermittent straight categorization during the postoperative period for hip surgery patients had both benefits and disadvantages, yet non-categorization was best for postoperative patient outcomes.
This study was the most recent on record and aligned with the Joint Commission’s National Patient Safety Guidelines. Summary Evidence based practices have become the cornerstone for the standard of care in healthcare facilities. Over the course of the past 20 years, healthcare providers have provided the research necessary to remove indwelling urinary catheters as the standard of care in postoperative orthopedic patients; from advocating of their use for urinary retention in the late 1 ass’s to limiting their utilization today.
The higher incidence of CACTI has provided Medicaid and Medicare programs support in rejecting reimbursement measures to facilities for these types of uneconomical infections. New nurse directed protocols supported by evidenced based research have decreased the incidence of CACTI, although, if these raciest are to continue to be successful, a physician culture change must be embraced. The entire healthcare team must continue to participate in an active role to eliminate unnecessary and preventable infections, specifically Cactus’s.
