Infection Control & Hospital Epidemiology
that demonstrated an association between a reminder system and a reduction in catheter use in some, but not all, clinical wards within a hospital environment.9 Similarly, a notable national prevention CAUTI program in the United States was also associated with a reduction in catheter use and CAUTI in non-ICUs.4 The mixed-methods approach we used provides further impor-
tant contextual information that facilitates understanding of the results. There were notable differences between ICU and non- ICU staff regarding their experiences with the CATH TAG. Non-ICU staff appeared to have a positive experience and regarded it as more useful and effective than ICU staff. In the non-ICU set- ting, staff reported in both the survey and focus group that the CATH TAG was easy to use and to implement into clinical care. We assessed our study for pragmatism, using the PRagmatic-
Explanatory Continuum Indicator (PRECIS-2) tool.10 This tool could be implemented into hospital care relatively easily, especially if it were incorporated into a urinary catheter bag. When we designed the study, we were interested to know whether the device would engage patients in catheter care, particularly when the device flashed red. There did not appear to be much patient involvement or ownership with the CATH TAG, perhaps because the device was largely unnoticed by participants. No negative com- ments were made by patients or reported to the researchers via the survey or focus group. We did not identify a reduction in bacteriuria in our study.
However, bacteriuria was a secondary outcome, and a larger sam- ple size would be needed for a definitive conclusion. The need to preserve antibiotic effectiveness is an important healthcare issue.11 Avoiding treatment of asymptomatic bacteriuria should reduce the risk of developing antibiotic resistance.12 Thus, strategies that reduce catheter use, and therefore bacteriuria, may be of value and could be included as part of a wider strategy to reduce CAUTIs and antimicrobial resistance. The cluster randomized design has the advantage of address-
ing many potential confounders because wards (clusters) act as their own control. A Hawthorne effect may have occurred as a result of study awareness and impending rollout. To reduce this potential bias, educational events and training on the use of the CATHTAGwere staggered,were focused on the use of the device only andwere delivered to wards individually in the week prior to implementation of the intervention. Our study was limited to a single hospital. We undertook a pragmatic clinical trial and identified the
potential benefits of using an electronic reminder system at the point of care to reduce catheterization duration and hence CAUTI risk. Although our overall results were negative, we iden- tified a potential reduction in catheterization duration in the non- ICU setting. These results, coupled with largely positive survey and focus group feedback from nursing staff, suggest that the CATH TAGmay be a useful device to aid prompt removal of urinary cath- eters in the non-ICU hospital setting.
431
Supplementary material. To view supplementary material for this article, please visit
https://doi.org/10.1017/ice.2019.31.
Author ORCIDs. Brett G. Mitchell, 0000-0003-4220-8291
Acknowledgements. The authors acknowledge the support of the participat- ing hospital and specifically the infection prevention and control team. Senver, the company that owns CATH TAG and who was awarded the Accelerating Commercialisation grant played no role in the study design, conduct, collection, or analysis of data.
Financial support. This study was supported by an Accelerating Commercialisation grant from the Australian Commonwealth Government.
Conflicts of interest. All authors report no conflicts of interest relevant to this article.
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3. Fasugba O, Cheng AC, Russo PL, Northcote M, Rosebrock H, Mitchell BG. Reducing urinary catheter use: a protocol for a mixed methods evaluation of an electronic reminder system in hospitalised patients in Australia. BMJ Open 2018;8:e020469.
4. Saint S, GreeneMT, Krein SL, et al.Aprogramto prevent catheter-associated urinary tract infection in acute care. N Engl J Med 2016;374:2111–2119.
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