Janet Bell, the Clinical Practice Leader at Trident Hospital Medical Center, is a little obsessed with Foley catheters.
Yes, those internal flexible tubes that allow urine to drain from the bladder and are used when patients need assistance after surgery, to monitor accurate outputs, or to provide relief from obstruction. Inserting an indwelling urinary catheter has become a standard practice in the intensive care units, where treating critical patients requires urine output to be strictly monitored or the patient is unable to void due to obstruction, retention or sedation issues.
The result of this practice is that catheter-associated urinary tract infections, also known as CAUTIs, are common in intensive care units. The immediate effects of this infection can be fever, chills, and pain, and, if improperly treated, a CAUTI can spread to the bloodstream and kidneys, possibly leading to death. They have also long been considered an inevitable risk of being treated in a hospital.
But not anymore.
“I’m one of those determined people that, when assigned a project, I make it happen,” says Bell with a laugh.
Bell is the leader of Trident Medical Center’s CAUTI Prevention Committee, a group established as an outgrowth of South Carolina Hospital Association’s Comprehensive Unit-based Safety Program (CUSP). CUSP is geared specifically at eliminating CAUTIs. The biggest challenge facing the program is that standard catheter practices are ingrained in the clinical settings, almost to the point of ritualism. As the leader of Trident’s committee, Bell knew that to make a difference, she would have to be relentless in her push for a culture change.
“I understand how it is… I was one of those nurses that were overworked in the ICU,” she points out. “All nurses want to do the right thing for their patients. They are fierce advocates for their patients. Change will only occur when the nurses understand the reasons behind taking the catheter out. Just telling a nurse to take it out will not get buy-in for the change and sustain it.”
One of the strategies Bell promoted was the daily “eyes on the catheter and discussing its need.” In most ICUs, a daily multidisciplinary round occurs on each patient. The team usually consists of the nurse, physician, nutritionists, pharmacist, respiratory therapist, chaplain and any discipline that has a part in the patient’s care. As the team moves from patient to patient, care is discussed. During these rounds, Bell makes a point of questioning the reason for the catheter, noting the insertion date, and, if appropriate, suggesting a possible alternative. If one of the team members believes the patient needs to keep the catheter, they must provide one of the CDC reasons to keep it.
Bell saw immediate results with this approach. Catheters went from staying in for weeks to being removed promptly. She also made sure that the date of the insertion was not only on the foley bag, but also on the whiteboard in the patient’s room. This ensured that the date is seen by the physician, nurse, family and the patient as a constant reminder of the length of time the catheter has been in which would place the patient at risk.
She also did not stop there, though. Through the use of simulation, Bell requires every nurse who practices in the ICU to go through her class on how to insert a foley catheter using sterile techniques. No matter how experienced they are, they are required to go through this lab, thus validating their aseptic technique and reviewing the latest evidence-based practices.
As Bell sees it, her challenge was to change the framing of catheters from a menial, rote task to one of heightened importance.
“I wanted them to see how important it was. Because we're working with smart women. These--—these women are all college graduates,” she points out. “They need to understand why I'm asking them to do it, and how much power they have to do it. And as a nurse you can only do four things within your scope of practice that are invasive, and one of them is a Foley. Another is an IV. And those are the two biggest infections in the hospital.”
Bell acknowledges she can come across like a broken record, but she believes that repetition is essential.
“I’m kind of the ‘Foley Nazi,’ people truly refer to me as that,” she laughs, noting that she has occasionally butted heads with physicians and other staff on her insistence about timely catheter removal. “But I truly believe that you have to have eyes on it every day. If I can hardwire it for the nurses, then it becomes the default [approach].”
It’s hard to argue with her when you look at the numbers. When she arrived at the hospital in 2014, they were averaging 12 CAUTIs a year in the unit, the number dropped by 50% in 2015, and they’ve had only one so far this year.
While her success is obvious, Bell remains quite driven on the subject. She has introduced several alternatives to catheters, everything from biodegradable female urinals to ultra-absorbent pads that wick away moisture. She is particularly interested in new approaches for females, since they are disproportionally affected by CAUTIs, and is currently looking to trial a female product that is used externally as a substitute for an indwelling urinary catheter.
“I don't think about this when I leave the hospital, I promise,” Bell laughs. “But I love doing something that we can show success in.”