Effectiveness of an External Urinary Device for Female Anatomy and Trends in Catheter-Associated Urinary Tract Infections.

PURPOSE: The purpose of this study was to examine the effectiveness of an external female urinary management system (external urinary device for female anatomy [EUDFA]) in critically ill women unable to self-toilet and to identify rates of indwelling catheter use, catheter-associated urinary tract infections (CAUTIs), urinary incontinence (UI), and incontinence-associated dermatitis (IAD) before and after the introduction of the EUDFA. DESIGN: Prospective, observational, and quasi-experimental design. SUBJECTS AND SETTING: The sample comprised 50 adult female patients in 4 critical/progressive care units using an EUDFA at a large academic hospital in the Midwestern United States. All adult patients in these units were included in the aggregate data. METHODS: Prospective data collected from the adult female patients over 7 days included urine diverted from the device to a canister and total leakage. Aggregate unit rates of indwelling catheter use, CAUTIs, UI, and IAD were retrospectively examined during 2016, 2018, and 2019. Means and percentages were compared using t tests or chi-square tests. RESULTS: The EUDFA successfully diverted 85.5% of patients' urine. Indwelling urinary catheter use was significantly lower in 2018 (40.6%) and 2019 (36.6%) compared with 2016 (43.9%) (P < .01). The rate of CAUTIs was lower in 2019 than in 2016, but not significantly (1.34 per 1000 catheter-days vs 0.50, P = .08). The percentage of incontinent patients with IAD was 69.2% in 2016 and 39.5% in 2018-2019 (P = .06). CONCLUSIONS: The EUDFA was effective in diverting urine from critically ill female incontinent patients and indwelling catheter utilization.

Hospital-Acquired Pressure Injuries and Acute Skin Failure in Critical Care: A Case-Control Study.

PURPOSE: The purpose of this study was to examine clinical characteristics and risk factors for critically ill patients who develop pressure injuries and identify the proportion of validated unavoidable pressure injuries associated with the proposed risk factors for acute skin failure (ASF). DESIGN: Retrospective case-control comparative study. SUBJECTS AND SETTING: The sample comprised adult critically ill participants hospitalized in critical care units such as surgical, trauma, cardiovascular surgical, cardiac, neuro, and medical intensive care and corresponding progressive care units in 5 acute care hospitals within a large Midwestern academic/teaching healthcare system. Participants who developed hospital-acquired pressure injuries (HAPIs) and patients without HAPIs (controls) were included. METHODS: A secondary analysis of data from a previous study with HAPIs and matching data for the control sample without HAPIs were obtained from the electronic health record. Descriptive and multivariate logistic regression analyses were conducted. RESULTS: The sample comprised 475 participants; 165 experienced a HAPI and acted as cases, whereas the remaining 310 acted as controls. Acute Physiology and Chronic Health Evaluation (APACHE II) mean score (23.8, 8.7%; P < .001), mortality (n = 45, 27.3%; P = .002), history of liver disease (n = 28, 17%; P < .001), and unintentional loss of 10 lb or more in 1 month (n = 20, 12%; P = .002) were higher in the HAPI group. Multivariate logistic regression analysis identified participants with respiratory failure (odds ratio [OR] = 3.00; 95% confidence interval [CI], 1.27-7.08; P = .012), renal failure (OR = 7.48; 95% CI, 3.49-16.01; P < .001), cardiac failure (OR = 4.50; 95% CI, 1.76-11.51; P = .002), severe anemia (OR = 10.89; 95% CI, 3.59-33.00; P < .001), any type of sepsis (OR = 3.15; 95% CI, 1.44-6.90; P = .004), and moisture documentation (OR = 11.89; 95% CI, 5.27-26.81; P <.001) were more likely to develop a HAPI. No differences between unavoidable HAPI, avoidable HAPI, or the control group were identified based on the proposed ASF risk factors. CONCLUSION: This study provides important information regarding avoidable and unavoidable HAPIs and ASF. Key clinical characteristics and risk factors, such as patient acuity, organ failure, tissue perfusion, sepsis, and history of prior pressure injury, are associated with avoidable and unavoidable HAPI development. In addition, we were unable to support a relationship between unavoidable HAPIs and the proposed risk factors for ASF. Unavoidability of HAPIs rests with the documentation of appropriate interventions and not necessarily with the identification of clinical risk factors.

Pressure Injury Prevention for Complex Cardiovascular Patients in the Operating Room and Intensive Care Unit: A Quality Improvement Project.

PURPOSE: The purpose of our project was to examine the effect of an alternating pressure (AP) overlay on hospital-acquired pressure injury (HAPI) in high-risk cardiovascular surgical patients. PARTICIPANTS AND SETTING: This quality improvement (QI) initiative was conducted in a core group of 8 cardiovascular operating room (OR) suites and 1 cardiovascular surgical critical intensive care unit (ICU) in a large Indiana-based academic hospital. The sample comprised adult patients who underwent complex cardiovascular surgical procedures and those in the cardiovascular surgical ICU with extracorporeal membrane oxygenation (ECMO), ventricular assistive device (VAD), and undergoing heart and/or lung transplant, or open chest procedures. APPROACH: The AP overlay was placed on OR cardiovascular foam surfaces and on selected ICU support surfaces for patients who met inclusion criteria. We used a pre/postcomparative QI design to assess outcomes including OR-related HAPI rates, ICU aggregate unit HAPI data, related costs, and staff satisfaction during the 3-month project period. OUTCOMES: Operating room-related HAPIs were reduced from 8/71 (11%) preintervention to 0/147 (0%) postintervention (P = .008), resulting in a cost avoidance of $323,048 and positive staff satisfaction (mean = 3.85; 1- to 4-point Likert scale). No adverse outcomes occurred. Although not significant, ICU HAPI rates decreased from 10 to 7 pre/postintervention (P = .29), demonstrating a 14% HAPI reduction with a cost avoidance of $121,143. The ICU incidence density decreased from 3.57 to 3.24; however, there was no decrease in ICU monthly unit prevalence. Critical care staff satisfaction was positive (mean = 2.95; 1- to 4-point Likert scale) with most staff members preferring the AP overlay to a fluid immersion surface. A cost savings of 48% (AP overlay vs fluid immersion rental) was identified in the ICU. IMPLICATIONS FOR PRACTICE: We achieved fewer HAPIs and reduced costs and observed positive staff satisfaction, along with no adverse events with the use of the AP overlay. Further research is needed to determine the safety and efficacy of this device for this pressure injury prevention option for immobile patients in both the OR and the ICU.

Pressure Injury Prevention and Wound Management for the Patient Who Is Actively Dying: Evidence-Based Recommendations to Guide Care.

Preventing pressure injuries and wound deterioration can be challenging for the patient at the end of life. Pressure injuries are often deemed unavoidable when a patient is actively dying; however, the time frame for this process is variable. As the skin fails in an actively dying patient, interventions should align with the patient and family's goals. This integrative literature review defines essential concepts to pressure injury and wound management during this final stage of life including (1) actively dying, (2) end of life, (3) palliative care, and (4) comfort measures. We also provide clinically relevant, evidence-based recommendations for pressure injury prevention and wound management of the patient who is actively dying.

Interventions Post Catheter Removal (iPCaRe) in the Acute Care Setting: An Evidence- and Consensus-Based Algorithm.

Despite advances in the prevention of catheter-acquired urinary tract infections achieved by programs that include removal of the indwelling urinary catheter at the earliest possible time, evidence guiding bladder and incontinence management strategies following discontinuation of a catheter is sparse. To address this gap and guide best practice, the WOCN Society appointed a Task Force to develop an evidence- and consensus-based algorithm guiding clinical decision-making for effective bladder and incontinence management strategies after indwelling urinary catheter removal. This article describes the design and development of the algorithm, consensus-based statements used to guide best practice in this area, and its content validation.

Urinary Management With an External Female Collection Device.

BACKGROUND: Strategies to decrease use of female indwelling urinary catheters and catheter-associated urinary tract infections are challenging due to the limited availability of proper fitting external collection devices. Female urinary incontinence predisposes the skin to potential pain, itching, burning, infection, or pressure injuries. CASE STUDIES: This article discusses 3 patients' trajectory of care with use of an external female urinary collection device. All of these females were incontinent of urine after the indwelling urinary catheter was removed and managed with an external female urinary collection device. CONCLUSIONS: The use of an external female urinary collection device is a feasible alternative to an indwelling urinary catheter as well as managing urinary incontinence.

Do Intra-anal Bowel Management Devices Reduce Incontinence-Associated Dermatitis and/or Pressure Injuries?

PURPOSE: The purpose of this article was to examine the evidence and provide recommendations related to the effectiveness of intra-anal bowel management systems including intra-anal bowel catheters and rectal trumpets in reducing incontinence-associated dermatitis and pressure injuries. QUESTION: Does the use of an intra-anal bowel management system (intra-anal bowel catheter or rectal trumpet) reduce incontinence-associated skin damage and/or hospital-acquired pressure injuries in the acute care adult patient population? SEARCH STRATEGY: A search of the literature was performed by a trained university librarian, which resulted in 133 articles that examined intra-anal bowel management systems (intra-anal bowel catheter and rectal trumpet), incontinence-associated dermatitis, and pressure injuries. A systematic approach was used to review titles, abstracts, and text yielding 6 studies that met inclusion criteria. Strength of the evidence was rated using rating methodology from Essential Evidence Plus: Levels of evidence and Oxford Center for Evidence-based Medicine, adapted by Gray and colleagues. FINDINGS: Five of the 6 studies reported positive results concerning the effectiveness of intra-anal bowel management systems to reduce incontinence-associated dermatitis and/or pressure injuries. One randomized control trial found no improvement in incontinence-associated dermatitis in the intra-anal bowel management system (intra-anal bowel catheter or rectal trumpet) groups or pressure injuries as compared to usual care. The strength of the evidence for the identified studies was moderate (2 level A, 3 level B, and 1 level C). An important finding in 2 of the studies was the safety of the intra-anal bowel management systems-both intra-anal bowel catheter and rectal trumpet. CONCLUSION/RECOMMENDATION: Evidence indicates intra-anal bowel management system (intra-anal bowel catheters and rectal trumpet) provides a viable option for fecal incontinence management and these devices reduce incontinence-associated dermatitis and/or pressure injuries.

Unavoidable Pressure Ulcers: Development and Testing of the Indiana University Health Pressure Ulcer Prevention Inventory.

PURPOSE: Despite prevention strategies, hospital-acquired pressure ulcers (HAPUs) continue to occur in the acute care setting. The purpose of this study was to develop an operational definition of and an instrument for identifying avoidable/unavoidable HAPUs in the acute care setting. METHODS: The Indiana University Health Pressure Ulcer Prevention Inventory (PUPI) was developed and psychometric testing was performed. A retrospective pilot study of 31 adult hospitalized patients with an HAPU was conducted using the PUPI. RESULTS: Overall content validity index of 0.99 and individual item content validity index scores (0.9-1.0) demonstrated excellent content validity. Acceptable PUPI criterion validity was demonstrated with no statistically significant differences between wound specialists' and other panel experts' scoring. Construct validity findings were acceptable with no statistically significant differences among avoidable or unavoidable HAPU patients and their Braden Scale total scores. Interrater reliability was acceptable with perfect agreement on the total PUPI score between raters (κ = 1.0; P = .025). Raters were in total agreement 93% (242/260) of the time on all 12 individual PUPI items. No risk factors were found to be significantly associated with unavoidable HAPUs. CONCLUSION: An operational definition of and an instrument for identifying avoidable/unavoidable HAPUs in the acute care setting were developed and tested. The instrument provides an objective and structured method for identifying avoidable/unavoidable HAPUs. The PUPI provides an additional method that could be used in root-cause analyses and when reporting adverse pressure ulcer events.

Implementation of a Bowel Management Program in Critical Care.

PURPOSE: The purpose of this study was to examine the effectiveness of a unit-based, educational program on implementation of a sustainable bowel management program in a critical care setting. SUBJECTS AND SETTING: Two hundred thirty nurses in 6 critical care units within a 750-bed level I trauma hospital and 400-bed university academic teaching hospital participated in the study. METHODS: Data collection and analysis were guided by a quasi-experimental pre-/postdesign. An evidence-based, interactive Web-based education program was developed. The education program consisted of 3 components: (1) knowledge acquisition (Web-based education module), (2) skill acquisition (unit-based skill session performance and competency), and (3) mastery experiences (self-efficacy). Data collected included pre- and posteducation module test scores, skill-acquisition competency, and self-efficacy scores. RESULTS: The Web-based education module pre- and posttest scores for 225 participants showed significant (P < .001) improvement in knowledge scores. All participants (100%) completed the skill acquisition sessions successfully during the unit-based performance session. Nurses' self-efficacy scores significantly improved (P < .001) over the course of this study period. Eighty-six percent (n = 125) of critical care nurses reported enhanced collaboration with the WOC nurses and clinical nurse specialists. CONCLUSION: Study findings support the use of a structured, evidence-based educational program incorporating a multimethod approach to implement practice change for critical care.

Medical device-related hospital-acquired pressure ulcers: development of an evidence-based position statement.

Hospital-acquired pressure ulcers (HAPUs) are a problem in the acute care setting causing pain, loss of function, infection, extended hospital stay, and increased costs. In spite of best practice strategies, occurrences of pressure ulcers continue. Many of these HAPUs are related to a medical device. Correct assessment and reporting of device-related HAPUs were identified as an important issue in our organization. Following the Iowa Model for Evidence-Based Practice to Promote Quality Care, a task force was created, a thorough review of current evidence and clinical practice recommendations was performed, and a definition for medical device-related HAPU and an evidence-based position statement were developed. Content of the statement was reviewed by experts and appropriate revisions were made. This position statement provides guidance and structure to accurately identify and report device-related HAPU across our 18 healthcare facilities. Through the intentional focus on pressure ulcer prevention and evidence-based practice in our organization and the use of this position statement, identification and reporting of device-related HAPUs have improved with a decrease in overall HAPU rates of 33% from 2011 and 2012. This article describes the development and implementation of this device-related HAPU position statement within our organization.

Methods of bowel management in critical care: a randomized controlled trial.

PURPOSE: The purpose of this study was to compare 3 methods of bowel management to control fecal incontinence in adult critical care patients and their effect on incontinence-associated dermatitis, pressure ulcer prevalence, and clinician satisfaction. SUBJECTS AND SETTING: Fifty-nine adult patients in critical care with liquid fecal incontinence were recruited from 6 critical care units in a large Midwest healthcare system. METHODS: Subjects were randomly assigned to 1 of 3 groups: bowel management system catheter, rectal/nasopharyngeal trumpet, or usual care. Subjects were assessed daily for incontinence-associated dermatitis, pressure ulcer prevalence, and other clinical data. Direct care nurse satisfaction with each method was evaluated by self-administered survey. RESULTS: Incontinence-associated dermatitis severity and pressure ulcer prevalence did not differ across groups at baseline. Over time, the change in incontinence-associated dermatitis severity score was significantly different across groups (P < .001). There were no significant differences in proportion of patients experiencing pressure ulcers during the study among groups. Clinicians reported significantly greater satisfaction with the bowel management system (P = .007) and rectal trumpet (P = .001) as compared to usual care. In addition, economic and safety benefits were identified with use of internal fecal devices. Specifically, an economic savings of $3100 to $3400 per 29 days of care was identified. Subjects experienced no adverse side effects when internal devices were used. CONCLUSION: Results of this randomized controlled trial provide new information for the care of patients with fecal incontinence in the critical care setting. Incontinence-associated dermatitis severity scores differed across groups over time, pressure ulcer prevalence did not differ across groups over time, use of an internal device or bowel management system improved clinician satisfaction, and the use of internal fecal methods was more cost-effective than usual care.

Real world utilization of nurse-driven urinary catheter removal protocol in patients with epidural pain catheters.

BACKGROUND: Surgeons use indwelling bladder catheters (IBCs) to avoid urinary retention in patients with epidural analgesic catheters. Reduction of IBC-days is associated with improved catheter-associated urinary tract infection rates (CAUTI). This study investigates real world application of a Nurse-Driven Catheter Removal Protocol (NDCRP) to reduce IBC-days in this patient population. METHODS: Patients with epidural catheters and IBC were targeted for IBC removal on post-operative day 1 (POD1). Patients were followed for application of the NDCRP, catheterization need, IBC re-anchoring, and complications. RESULTS: One hundred and thirty-three patients had IBCs removed on POD1 (Protocol Group) and 50 patients did not (Non-Protocol Group). There was a reduction in IBC-days in the Protocol Group despite incomplete adherence to the NDCRP (1.55 days vs 4.64 days; P < .001). Ninety-three patients (70%) were able to spontaneously void after early IBC removal. Fourteen patients (11%) were able to spontaneously void after serial in-and-out catheterization (I/O). No significant difference in re-anchoring was found between the protocol and non-protocol groups (26 vs 4 patients; P = .09). CONCLUSIONS: Early removal of IBCs (POD1) in patients with epidural catheters with the assistance of an NDCRP is a safe and successful strategy to reduce IBC-days in the hospital.

Hospital-Acquired Pressure Injuries in Critical and Progressive Care: Avoidable Versus Unavoidable.

BACKGROUND: Despite prevention strategies, hospital-acquired pressure injuries (HAPIs) continue to occur, especially in critical care, raising the question whether some pressure injuries are unavoidable. OBJECTIVES: To determine the proportion of HAPIs among patients in critical and progressive care units that are unavoidable, and to identify risk factors that differentiate avoidable from unavoidable HAPIs. METHODS: This study used a descriptive retrospective design. Data collected included demographic information, Braden Scale scores, clinical risk factors, and preventive interventions. The Pressure Ulcer Prevention Inventory was used to categorize HAPIs as avoidable or unavoidable. RESULTS: A total of 165 patients participated in the study. Sixty-seven HAPIs (41%) were unavoidable. Participants who had congestive heart failure (odds ratio [OR], 0.22; 95% CI, 0.06-0.76; P = .02), were chemically sedated (OR, 0.38; 95% CI, 0.20-0.72; P = .003), had systolic blood pressure below 90 mm Hg (OR, 0.52; 95% CI, 0.27-0.99; P = .047), and received at least 1 vasopressor (OR, 0.44; 95% CI, 0.23-0.86; P = .01) were less likely to have an unavoidable HAPI. Those with bowel management devices were more likely to have an unavoidable HAPI (OR, 2.19; 95% CI, 1.02-4.71; P = .04). When length of stay was incorporated into the regression model, for each 1-day increase in stay, the odds of an unavoidable pressure injury developing increased by 4% (OR, 1.04; 95% CI, 1.002-1.08; P = .04). Participants who had a previous pressure injury were 5 times more likely to have an unavoidable HAPI (OR, 5.27; 95% CI, 1.20-23.15; P = .03). CONCLUSIONS: Unavoidable HAPIs do occur; moreover, when preventive interventions are not documented and implemented appropriately, avoidable HAPIs occur.

Nosocomial pressure ulcer rates in critical care: performance improvement project.

Assessment, monitoring, and prevention of pressure ulcers in the hospitalized patient are required standards of care. The annual nosocomial pressure ulcer (NPU) rates for the adult intensive care units at our facility had trended up to 33% from 14% over a 13-month period. Our performance improvement team decided to track 5 variables that may have contributed to the increased incidence of NPU. Weekly skin care rounds were conducted to collect data, educate staff, and reinforce skin care policy and standards of care. Data analysis revealed 3 areas that required further emphasis with nursing staff: daily assessment with the Braden Scale, prevention of NPU beginning on the day of hospital admission, and the effect of sedation on patient mobility. Implementation of appropriate interventions targeted to specific Braden subscales needs to be included in the plan of care.