1012
Table 1. Duration of Catheterization and Insertion Rates of Devices Placed in the Emergency Department
Preintervention (n=1,001)
Duration of catheterization, median h (IQR) All devices (n=1,346)
Intervention (n=345)
P Valuea 57.5 (27.2–116.3) 48.2 (24.1–107.4) .11
Urinary catheter (n=771) 70.5 (36.7–140.3) 67.1 (32.0–127.1) .18 Arterial line (n=528) CVC (n=47)
39.3 (20.3–74.1) 41.9 (22.6–86.0)
Insertion rates, no. (% of all hospitalized patients) Hospitalized ED patients 9,884 (100) All devices
Urinary catheter Arterial line CVC
1,001 (10.1) 596 (6.0) 372 (3.8) 33 (0.3)
.51 99.8 (48.1–169.6) 36.9 (24.1–108.5) .15
3,250 (100) 345 (10.6) 175 (5.4) 156 (4.8) 14 (0.4)
NOTE. CVC, central venous catheter; ED, emergency department. aWilcoxon or χ2 test.
action plan was 73.0 hours and did not differ significantly between these periods (P=.45). A sensitivity analysis with 2 preintervention periods (period 1: July–December 2016; period 2: January–March 2017) did not reveal seasonality, and its results did not differ substantially from the primary analysis (data not shown). In this intervention study aimed to reduce duration of cathe-
tion rates are in agreement with previously published results.1,6,7 The low uptake of documentation, a limitation of this study, might reflect difficulties implementing preventive measures in
terization through improved documentation, just one-third of all devices were mentioned in the ED discharge reports, and action plans were present in only 10% of cases. We observed no decrease in the duration of catheterization or insertion rates after our intervention, even if we analyzed only those devices with an action plan. Unexpectedly, we noted increased use of arterial lines over time, suggesting some variation in severity of illness between the 2 periods. The documentation rate achieved in this study was similar to the 22% reported in another study on urinary catheters in the ED.2 In addition, both duration of urinary catheterization and inser-
Bernard Surial et al
the ED. Emergency physicians act in busy environments with multiple shifts and patient handovers where infection prevention efforts are not necessarily a priority. Additionally, awareness of device-associated complications may be low because they usually develop after discharge from the ED. Incorporating mandatory fields into the electronic medical record specifying indication and estimated duration might have improved the intervention uptake, but this option was not available. In our institution, ED discharge reports remain the most
important form of communication between the ED and admitting hospital floors. Although improved documentation neither reduced utilization nor duration of catheterization in this study, it reinforces physician involvement in placement decisions and should therefore be promoted. In conclusion, recommending an action plan in the ED dis-
.45 .19 .01 .53
charge report appears insufficient for reducing device utilization. Implementing other measures, such as mandatory device plans or daily device rounds, may be more promising.
Acknowledgments. The authors thank Caspar Breitenstein and Barbara Schärer for their assistance with data extraction.
Financial support. No financial support was provided relevant to this article.
Potential conflicts of interest. All authors report no conflicts of interest relevant to this article.
References
1. Schuur JD, Chambers JG, Hou PC. Urinary catheter use and appropriate- ness in US emergency departments, 1995–2010. Acad Emerg Med 2014; 21:292–300.
2. Gokula RM, Smith MA, Hickner J. Emergency room staff education and use of a urinary catheter indication sheet improves appropriate use of foley catheters. Am J Infect Control 2007;35:589–593.
3. Saint S, Wiese J, Amory JK, et al. Are physicians aware of which of their patients have indwelling urinary catheters? Am J Med 2000;109:476–480.
4. progress! Sicherheit bei Blasenkathetern, Patient Safety Switzerland website.
http://www.patientensicherheit.ch/dms/Progress-Programme/progress-_Blasen katheter/Synopsis_20160426.pdf. Published 2016. Accessed April 28, 2018.
5. R Studio software website.
https://www.rstudio.com. Accessed April 28, 2018. 6. Gokula RR, Hickner JA, Smith MA. Inappropriate use of urinary catheters in elderly patients at a midwestern community teaching hospital. Am J Infect Control 2004;32:196–199.
7. Greene MT, Fakih MG, Watson SR, Ratz D, Saint S. Reducing inappropriate urinary catheter use in the emergency department: compar- ing two collaborative structures. Infect Control Hosp Epidemiol 2017:1–8.
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