The title of the article is “Electronic Health Record: Driving Evidence-Based Catheter-Associated Urinary Tract Infections (CAUTI) Care Practices.” The lone author is a master’s prepared nurse who participated in the implementation of the quality improvement (QI) project. The article was published in the Online Journal of Issues in Nursing (OJIN) of the American Nurses Association. The ANA states that the OJIN is a peer-reviewed and scholarly publication.
The problem addressed by the article is the incidence of CAUTI coupled with the lack of documentation of the clinical evidence that served as basis for urinary catheter insertion despite the availability of best practices guiding the prevention of nosocomial UTI. There was also a lack of consistent documentation of catheter care. With the lack of documentation, there is no certainty that the patient received appropriate care in relation to urinary catheterization. As the electronic health record (EHR) system is used in documenting patient care, the research question addressed was how meaningful use of the EHR can be employed to “support, drive, sustain, and demonstrate evidence-based practices (EBPs) in CAUTI prevention care” (Welden, 2013).
The article can be categorized as a descriptive simple before-after study as it describes how the QI project was planned, implemented, and evaluated as well as compares the situation before and after project implementation to gauge project impact. Unlike descriptive correlational studies or randomized controlled trials (RCTs), associations or causality between independent and dependent variables leading to generalizations cannot be established in a QI activity. The limitations include the very specific context in which the project is implemented, the lack of or inadequate control over bias, and absence of statistical analysis to establish confidence in the relationship between variables. Rather, the article contributes to knowledge on the translation of EBPs in practice and the conduct of QI.
A survey was conducted of the nursing staff to determine gaps in knowledge, skills, and attitudes in relation to CAUTI prevention practices that would validate the need to related criteria in the EHR. Benchmarking of facility practices against those employed by other organizations with better urinary catheterization outcomes was done to determine how far the facility is from best practices. This activity enabled the setting of quantitative targets of the QI. New policies and guidelines were developed as well using the input of in-house urology experts. The project consisted of five phases: “organization and coordination, data collection and analysis, project development, implementation, and evaluation” (Welden, 2013).
Project organization and coordination involved the formation of the core team and sub-teams to address staff education needs, barriers and needs related to equipment, and data management to enable monthly CAUTI prevalence monitoring. Data collection and analysis included chart audits to ascertain whether there was use of established criteria when assessing the need to insert a catheter or continue urinary catheterization was made and if the use of such criteria was documented (Welden, 2013). In addition, the audits determined whether daily urinary catheter care was documented. The data also included baseline inpatient catheterization rates.
Project development entailed collaboration with the IT department in order to add a menu in the EHR from which nurses can choose the criteria that the patient meets on that day warranting catheterization or continued catheterization (Welden, 2013). Another menu was also added for documenting catheter care on a daily basis. Activities during implementation included communicating the project to the staff and providing education to fill the gaps in knowledge and skills before going live. Units defined their goals in relation to the proportion of catheterized patients, fulfillment of criteria for catheterization, documentation of need, documentation of assessment, and observed performance of four catheter care interventions. Scorecards were created for each unit to permit the monthly tracking of goal attainment. In the final phase, a CDC-recommended audit tool was used to compare baseline and post-project implementation measures on CAUTI performance (Welden, 2013). Additional measures included the appropriateness of catheterization and staff compliance with evidence-based catheter care practices.
Because the project was intended for improving the quality of care related to urinary catheterization, types of data collected and sampling decisions were not based on a study design but most likely on what were needed to measure whether there was truly quality improvement. For instance, validating and measuring the baseline extent of the problem – lack of documentation of the use of criteria and the performance of catheter care – could be quantitatively measured through a survey done on a voluntary basis. As such, the method can be regarded as convenience sampling. Retrospective chart audit was another measurement method and was done randomly yielding a sample size of 42 or 10% of patients admitted in the ICU within the prior year (Welden, 2013). The ICU was selected because majority of patients in this unit are catheterized.
The survey and audits revealed a general inadequacy in knowledge of evidence-based catheter insertion criteria. Baseline data also showed that around 30% of patients in the facility were catheterized on any given day. Further, the audits showed that while the documentation of the need for urinary catheterization was met in 96% of patients, the documentation of daily catheter care was met in only 47% of patients (Welden, 2013). Six months after project implementation, compliance with catheter care and documentation rose to 93%. The proportion of catheterized patients also declined to 25% after six months except in the ICU. The reduction was sustained and further went down to 19-20% two years after (Welden, 2013). There was also significant improvement in adherence to catheter care and related documentation in the ICU and other units. Statistical analysis showed that the improvement in practice was significant in relation to the baseline and that this was sustained for at least two years.
Based on the improvements in CAUTI measures, the author concludes that the use of the EHR to promote the daily assessment and documentation of the need for inserting a catheter or continuing catheterization was successful in reducing the proportion of patients with urinary catheters and thus the length of time that they were catheterized (Welden, 2013). Catheterization, especially for long periods of time, is a major risk factor for CAUTI. The addition of drop-down menus pertaining to assessment and documentation in the EHR, and thus the work flow, was seen as a contributory factor to sustaining the improvements. At the same time, the EHR supported practice changes in conjunction with staff education and the use of scorecards. Thus, the conclusion relates to the purpose of the study which was to determine whether meaningful use of the EHR can support, motivate, and sustain quality improvement in CAUTI prevention.
While the author did not offer explicit recommendations, the discussion showed that the use of colorful scorecards as a visual and easy-to-understand indicator of targets and monthly goal attainment was more effective in motivating staff compliance with EBPs than tables and graphs. In change implementation, the author also highlights the need for ownership of the QI process at the unit level to ensure continued adherence. The need to consider the sustainability of improvements was also emphasized as was inter- and intradisciplinary collaboration.
The findings imply that EBPs can be translated into practice within the framework of QI processes and that the practice of QI also employs research but for the purpose of establishing whether there is improvement or not. Quality improvement is a process that nurses must be adept at initiating as they are in the best position to lead collaborative practice changes. Moreover, there will be no improvement without the use of EBP. For this reason, nurses must be aware of and are able to utilize EBP. The findings further imply that meaningful use of the EHR as part of a QI initiative should be optimized as a catalyst for practice change. The integration of guidelines and policies in the workflow, such as in electronic documentation, ensures adherence.
The information from the article improved my understanding of how QI and EBP are implemented to address clinical issues and improve patient outcomes. The article also prompted reflection on my own practice and my facility’s policies and guidelines in caring for patients with urinary catheters. It has encouraged me to adhere to evidence-based CAUTI prevention. The article also prompted a comparison with how my organization is approaching the problem of CAUTI and, again, reflection on whether it should be done differently and if the author’s recommendations are applicable in our context.
Reference
Welden, L. (2013). Electronic health record: Driving evidence-based catheter-associated urinary tract infections (CAUTI) care practices. Online Journal of Issues in Nursing, 18(3). Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodica ls/OJIN/TableofContents/Vol-18-2013/No3-Sept-2013/Articles-Previous- Topics/Electronic-Health-Record-CAUTI-Care-Practices.html?css=print
