906
Brett E. Youngerman et al
Fig. 3. Catheters remaining and by duration. P<.001 was calculated using Kruskal- Wallis one-way analysis of variance.
Fig. 2. Outcomes by month. NOTE. I, phase 1; IIA, group A phase 2; IIB, group B phase 2; T, transition phase; IIIA, group A phase 3; IIIB, group B phase 3; IV, phase 4.
alternatives increased dramatically, including 1,704% for straight catheterization and 607% for absorbent underpads (Table S3).
Discussion
In this longitudinal study, we demonstrated a significant reduc- tion in IUC and CAUTI rates through the phased introduction of CDS across a multicampus academic medical center. Through an iterative process and EMR-centered implementation, the interventions progressively engaged a wide audience of nurses and physicians in their workflow to incrementally change practice habits and outcomes. Collectively, the tools targeted the complete life cycle of IUCs.
Nurse training in best practices and documentation
Efforts to standardize and train nurses in best practices around catheter placement and maintenance care techniques are a proven component of CAUTI reduction initiatives11,18,19; however, a
natural limit likely applies to the gains that can be achieved without a reduction in catheter use.2 Our training initiative was associated with a dramatic decline in CAUTIs, which leveled off after ~12months, and withminimal changes in overall catheter use. Our approach was unique in that the training initiative also
engaged nurses in the standardized documentation of catheters in the EMR, thus enabling real-time tracking and laying the groundwork for subsequent electronic CDS interventions. The overwhelming majority of prior catheter reduction efforts relied on dedicated personnel to track catheter use, limiting the opportunity to scale the intervention hospital-wide.6 By engaging all nurses at the level of their routine documentation practices, administrators employed the latest approaches to crowdsourcing hospital data,20 and they were able to distribute the burden of measuring the key outcome in this quality improvement initiative.
Reducing catheter placement
The most surprising observation in our study was the dramatic and sustained decrease in new catheter placements shortly fol- lowing the release of real-time catheter tracking in phase 2. The decline occurred after ~18 months of relatively stable rates in phase 1. Real-time tracking was intended to increase clinician awareness of existing catheters, and we hypothesized that it would lead to decreased catheter duration.21 We hypothesize that the tool raised clinician awareness of the hospital’s monitoring efforts, lead- ing to a difference in clinician behavior by means of the Hawthorne
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