Description
Research Poster Discussion
Select from one of the five articles approved for your EBP Project Literature Review section, each group member must select a different article. Using the information from the article you selected, construct a research poster to share with your peers.
You can modify the poster template by adjusting colors, sizes of boxes, and the addition of graphics. However, you should include an introduction, hypothesis, methods, results, implications, conclusion, and reference (boxes are already included in the template). Use brief concise statements in the poster to make it easy to read, paragraphs can be wordy and are not recommended. Also, add pictures/tables/graphs as a way to make it eye-appealing. Be sure to review the research poster rubric.
Here some links for poster templates, you will have to copy and paste the link into the broswer:
https://www.posterpresentations.com/free-poster-templates.html
https://www.genigraphics.com/templates
Examples:
Example Research Poster. Example Research Poster. – Alternative Formats
Attrition Poster (1).ppt
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American Journal of Infection Control 49 (2021) 764−768
Contents lists available at ScienceDirect
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major Article
Implementation of an external female urinary catheter as an alternative
to an indwelling urinary catheter
Curtis Warren MPH, CPH a, Jaclyn D. Fosnacht MPH, CIC b, Elizabeth E. Tremblay MPH, CPH, CIC b,c,*
a
b
c
University of Florida, College of Medicine, Department of Surgery, Gainesville, FL
UF Health Shands Hospital, Infection Prevention and Control, Gainesville, FL
Florida State University, College of Medicine, Tallahassee, FL
Key Words:
Female external urinary catheter
Urinary Tract Infection
Infection prevention
Foley catheter alternative
CAUTI
Background: Until recently, there has been a lack of viable alternative to an indwelling urinary catheter for
female patients that require precise urine output measurements. With the introduction of external female
urinary catheters, we can now substitute this type of device for an indwelling urinary catheter in many
patients, decreasing their risk of catheter-associated urinary tract infections.
Methods: In this retrospective study, we analyzed the impact of a hospital-wide implementation of an external female urinary catheter at a large academic medical center. The study included female patients, greater
than 18 years of age. We compared a 12-month period before and after device implementation to assess the
impact on indwelling urinary catheter utilization and catheter-associated urinary tract infections rate.
Results: Data included over 220,000 patient days, over 10,000 external urinary catheter days and 33,000
indwelling urinary catheter days. We found a statistically significant decrease in indwelling urinary catheter
utilization following the implementation of the external female urinary catheter, but only in intensive care
units.
Conclusions: It is our recommendation that facilities first implement the device in ICUs as this level of care
was where we observed the most significant impact.
© 2020 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All
rights reserved.
A urinary tract infection (UTI) is a potentially serious complication
of inpatient hospital care. When left untreated, UTIs can become life
threatening, progressing to urosepsis and death. UTIs are the most
prevalent healthcare-associated infection; 70%-80% of these infections are attributable to indwelling urinary catheters.1 When a UTI is
caused by an indwelling catheter, the infection is termed a catheterassociated urinary tract infection (CAUTI). By the National Healthcare
Safety Network (NHSN) definition, a CAUTI is a healthcare associated
infection that results from a positive urine culture that was collected
during/after an indwelling urinary catheter was in place for more
than 2 calendar days (NHSN, 2019).2 CAUTIs are caused by bacterial
organisms, most predominantly Escherichia coli (NHSN, 2019).2 The
mean CAUTI rate among inpatients in acute-care hospital settings
ranges from 12% to 16% and the risk increases with each catheter-day
by 3%-7%.2,3 A CAUTI is more common in females than in males in the
* Address correspondence to Elizabeth E. Tremblay, MPH, CPH, CIC, Florida State
University, College of Medicine, 1115 W Call St, Tallahassee, FL 32310.
Conflicts of interest: All authors listed here have no conflicts of interest.
Funding: No funding or support in any form was ever provided by the makers of
PureWick.
hospital setting because an indwelling urinary catheter is usually the
only option to treat female urinary incontinence (UI) and to obtain
accurate urine output measurements. Another risk factor that makes
females more susceptible to CAUTIs is that they have shorter urethras
compared to males.4
Indwelling urinary catheters provide hospital staff with the ability
to accurately measure urine output. This is important in the intensive
care unit (ICU) because a patient’s urine output is a critical component when monitoring their hemodynamic stability. In female
patients, prior to the introduction of external female urinary catheters, the only way to accurately measure urine output was to use an
indwelling urinary catheter. However, assuming the patient is still
capable of urinating on their own, an external female urinary catheter can now be used in place of an indwelling urinary catheter to
measure urine output. In many cases, “need for accurate output” is
the only reason an indwelling urinary catheter is ordered. Now that
external female urinary catheters can provide this functionality, clinicians have a selection of devices to choose from. The only other
proven way to measure urine output without an indwelling urinary
catheter or external female urinary catheter is to use a diaper or
absorbent pad and weigh the product once soiled to gain an
https://doi.org/10.1016/j.ajic.2020.10.023
0196-6553/© 2020 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
C. Warren et al. / American Journal of Infection Control 49 (2021) 764−768
765
Fig 1. Study periods.
approximate output measurement. This is not an exact measurement,
often times is not an acceptable substitute for an indwelling urinary
catheter and can lead to skin breakdown. This method is not a safe
option for patients with sacral decubitus ulcers.5 The general consensus at the time of this study among physicians at this academic medical center was that the external female urinary catheter’s accuracy
was an acceptable replacement for an indwelling urinary catheter
when urine output needed to be measured.
In this study, we sought to determine if the use of an external
female urinary catheter was associated with a reduction in CAUTI
rate in a nonpediatric female inpatient population. We suspect that
an increase in device utilization ratio of the external female urinary
catheter will coincide with a decrease in CAUTI occurrence (reflected
by CAUTI rates). To investigate theses hypotheses the following
methodology was applied.
METHODS
Data were collected from March 1, 2016 to May 31, 2018 via a retrospective chart review. The study period was separated into 3
phases: preimplementation, washout/introduction, and postimplementation (Fig 1). The preimplementation period consisted of the 12
months prior to the implementation of the external female urinary
catheter which served as our baseline period for comparison. The
washout period consisted of 3 months during which the device was
introduced in the hospital and hospital-wide education of staff on the
device took place. The postimplementation period consisted of
12 months after the implementation and education for the external
female urinary catheter. This period was compared to the preimplementation period during pre- and postanalyses. Data were summarized by year-month and by pre- and postimplementation.
The study data were collected from the electronic medical record
(Epic Systems, Madison, WI). The following variables were collected
from the electronic record: patient days, indwelling urinary catheter
days, external catheter days, and CAUTI incidence. Patient days are
defined as the number of days that female inpatients were present in
the acute-care facility during the study period. This count of patients
occurs daily at midnight (eg, if patient A was admitted for 8 days,
spending 7 midnights in the hospital, they would contribute 7 days
to the total patient days for the facility) (NHSN Patient Safety Component Manual, 2019).2 Indwelling urinary catheter days are defined as
the number of days that female inpatients had an indwelling urinary
catheter present. This is also collected once daily at midnight, at the
same time as when patient days are collected (NHSN Patient Safety
Component Manual, 2019).2 External catheter days were defined as
the number of days that female inpatients had an external urinary
catheter present. This is also collected once daily at midnight at the
same time as indwelling urinary catheter days and patient days
(NHSN Patient Safety Component Manual, 2019).2
Figure 2 provides an example of the data collection tool used for
each unit, per month, throughout the study period. Unit name was
derived from the electronic medical record (EMR). Each unit was
then categorized as ICU or non-ICU. This unit classification was determined using NHSN’s 80/20 rule. This rule states that in order to be
called an ICU, the unit must be comprised of at least 80% critically ill
patients. External female urinary catheter purchasing data was also
collected to correlate the volume of devices purchased with the usage
charted by hospital staff in the EMR.
Indwelling urinary catheter days and external catheter days were
collected using an algorithm in the electronic medical record that
looks for nurse documentation of each device instead of collected by
manual count. If a device was not documented, it would not appear
in the electronic count. At this medical center manual-counts compared to the EMR algorithm-counts of indwelling urinary catheter
days were within 5% of one another and therefore not substantially
different.
The total number of CAUTIs per unit per month (in female patients
only) was also included in the dataset. CAUTIs were adjudicated
based on the NHSN criteria for the year in which the CAUTI occurred
(eg, CAUTIs in 2016 were reported using the 2016 NHSN criteria).
To analyze device utilization and infection data per month,
indwelling urinary catheter and external urinary catheter utilization
Fig 2. Example of monthly data collection tool.
C. Warren et al. / American Journal of Infection Control 49 (2021) 764−768
766
This study was approved by the University’s Institutional Review
Board (IRB01) under protocol IRB201802847.
Table 1
Total device days and patient days, for comparison to other studies
Study Total
RESULTS
33,240
10,863
222,819
As seen in Table 1, this was a very large study including over
222,000 patient days. External female urinary catheter and indwelling urinary catheter device days were over 10,000 and 33,000,
respectively. All other data on pre- and postimplementation comparisons rely on standardized ratios and rates to accommodate for
changes in hospital size and occupancy throughout the study period.
In identifying overall trends as depicted in Table 2 the only statistically significant trend was an increase in external female urinary
catheter utilization. Despite an overall decreasing trend in indwelling
urinary catheter utilization and CAUTI rates, both of these were found
to lack statistical significance at the 0.05 level.
Table 2
T test evaluation of pre- and postimplementation periods
Variable
Pre mean
(SD)
Post mean
(SD)
Pvalue
Indwelling urinary catheter utilization ratio
ICU
Non-ICU
External urinary catheter utilization ratio
ICU
Non-ICU
CAUTI rate
ICU
Non-ICU
0.169 (0.182)
0.464 (0.136)
0.083 (0.069)
0.000 (0.001)
0.000 (0.001)
0.000 (0.001)
1.950 (6.856)
4.062 (8.030)
1.342 (6.368)
0.156 (0.175)
0.401 (0.179)
0.077 (0.068)
0.096 (0.085)
0.156 (0.091)
0.077 (0.074)
1.091 (4.905)
1.957 (5.761)
0.810 (4.570)
.3602
.0141
.2629
.0001
.0001
.0001
.0622
.0594
.2776
Utilization ratios and CAUTI rates in all units
Figure 3 shows the indwelling urinary catheter utilization, external female urinary catheter utilization, external female urinary catheter purchasing, and female CAUTI rate over the study period. The
gray area in the figure denotes the washout period which is to be disregarded for analytic purposes as this is when external female urinary catheter educational courses were underway. As seen in the
Figure 3 from preimplementation compared to postimplementation
the overall indwelling urinary catheter utilization ratio decreased
from 0.16 to 0.14, the overall external female urinary catheter utilization ratio increased from 0 to 0.13, overall external female urinary
catheter utilization purchasing in all units increased from 0 to 0.15,
and the overall female CAUTI rate decreased from 2.5 to 1.7.
Note. Bolded value indicates P < 0.05, significant at the 0.05 level.
Utilization ratios and CAUTI rates in ICU locations
From Table 2 the decrease in indwelling urinary catheter utilization ratio was found to be statistically significant (Pvalue = .0141) in
intensive care units only. This significant value also coincided with a
significant increase in the external female urinary catheter utilization
ratio (Pvalue < .0001) for both ICU and non-ICU locations. However,
the decrease in CAUTI rates in all units was found to be insignificant.
In ICUs we observed a significant decrease in indwelling urinary
catheter utilization ratios (Pvalue = .0141), a significant increase in
External Catheter Ulizaon (Medical Record)
Indwelling Urinary Catheter Ulizaon Rao
External Catheter Ulizaon (Purchasing Data)
Female CAUTI Rate (3-Mo Rolling Avg)
Pre
Washout
Period
2018-05
2018-04
2018-03
2018-01
2018-02
2017-12
2017-11
2017-10
2017-09
2017-08
2017-07
2017-06
2017-04
2017-05
2017-03
0.0
2017-02
0.5
0.00
2017-01
1.0
0.02
2016-12
1.5
0.04
2016-10
2.0
0.06
2016-11
2.5
0.08
2016-09
3.0
0.10
2016-08
3.5
0.12
2016-07
4.0
0.14
2016-05
4.5
0.16
2016-06
5.0
0.18
2016-04
0.20
2016-03
Indwelling Urinary Catheter & External
Urinary Catheter Utilization Ratios
ratios and CAUTI rates were calculated. Indwelling urinary catheter
utilization ratios were calculated by dividing the number of indwelling urinary catheter days by the number of female patient days
(NHSN Patient Safety Component Manual, 2019).2 External urinary
catheter device utilization ratios were derived by dividing the number of external urinary catheter days by the number of female patient
days (NHSN Patient Safety Component Manual, 2019).2 CAUTI rates
were adjusted to national standards and calculated by dividing the
number of CAUTIs by the number of indwelling urinary catheter days
and multiplied by 1000 (NHSN Patient Safety Component Manual,
2019).2 A ratio t test was conducted to compare pre- and postimplementation device utilization ratios of indwelling urinary catheters
and external urinary catheters as well as CAUTI rates.
In this study we used the PureWick External Female Catheter by
Bard (C. R. Bard, Inc, Covington, GA), but we would like to remind readers that there are many products of this nature on the market and that
many of the findings in this paper will be applicable to the product
class as a whole and not limited to the PureWick device itself.
CAUTI Rate
Indwelling urinary catheter device days
External urinary catheter device days
Patient days
Post
Fig 3. Graph of indwelling urinary catheter and external urinary catheter utilization ratios against the CAUTI rate over the duration of the study.
Indwelling Urinary Catheter Ulizaon Rao
External Catheter Ulizaon (Purchasing Data)
Female CAUTI Rate (3-Mo Rolling Avg)
Pre
Washout
Period
2018-05
2018-04
2018-02
2018-03
2017-12
2018-01
2017-11
2017-10
2017-08
2017-09
2017-07
2017-06
2017-04
0.0
2017-05
0.0
2017-02
1.0
2017-03
0.1
2016-12
2.0
2017-01
0.2
2016-10
3.0
2016-11
0.3
2016-08
4.0
2016-09
0.4
2016-07
5.0
2016-05
0.5
2016-06
6.0
2016-03
0.6
CAUTI Rate
767
External Catheter Ulizaon (Medical Records)
2016-04
Indwelling Urinary Catheter & External Urinary
Catheter Utilization Ratios
C. Warren et al. / American Journal of Infection Control 49 (2021) 764−768
Post
Fig 4. Graph of indwelling urinary catheter and external female urinary catheter utilization ratios against the CAUTI rate in ICUs.
Utilization ratios and CAUTI rates in non-ICU locations
Indwelling Urinary Catheter Ulizaon Rao
External Catheter Ulizaon (Purchasing Data)
Female CAUTI Rate (3-Mo Rolling Avg)
Pre
Washout
Period
2018-05
2018-03
2018-04
2018-02
2018-01
2017-12
2017-11
2017-10
2017-09
2017-08
2017-07
2017-06
2017-05
0.0
2017-04
0.00
2017-03
1.0
2017-02
0.05
2017-01
2.0
2016-12
0.10
2016-11
3.0
2016-10
0.15
2016-09
4.0
2016-08
0.20
2016-07
5.0
2016-06
0.25
2016-05
6.0
2016-04
0.30
CAUTI Rate
Non-ICU location’s utilization ratios and CAUTI rates were also
graphically expressed in Figure 5. Unlike the indwelling urinary catheter utilization ratios in Figures 3 and 4 the ratio from preimplementation to postimplementation stayed around the same from 0.091 to
0.082. However, like in Figures 3 and 4 the external female urinary
catheter purchasing utilization (0-0.13) and external female urinary
catheter utilization (0-0.11) increased from preimplementation to
postimplementation periods. The female CAUTI rate varied throughout the study period in non-ICU locations.
External Catheter Ulizaon (Medical Records)
2016-03
Indwelling Urinary Catheter & External Urinary
Catheter Utilization Ratios
external female urinary catheter utilization ratios (Pvalue < .0001),
and an insignificant decrease in CAUTI rate (Pvalue = .0594).
Illustrating this finding further Figure 4 shows the overall indwelling urinary catheter utilization ratio, external female urinary catheter
utilization ratio, external female urinary catheter purchasing volumes, and female CAUTI rate. From preimplementation to postimplementation period, the indwelling urinary catheter utilization ratio
decreased from 0.46 to 0.35, external female urinary catheter purchasing utilization ratio increased from 0 to 0.22, external female urinary catheter device utilization increased from 0 to 0.17, and the
female CAUTI rate decreased.
Post
Fig 5. Graph of indwelling urinary catheter and external female urinary catheter utilization ratios against the CAUTI rate in non-ICUs.
768
C. Warren et al. / American Journal of Infection Control 49 (2021) 764−768
In Table 2, it is also seen that the only significant finding in nonICU locations was the increase in external female urinary catheter
utilization from pre- and postimplementation (Pvalue ≤ .0001).
Again, a similar trend as seen in ICU locations was observed. There
was a decrease in indwelling urinary catheter utilization and CAUTI
rate in non-ICU locations however, these trends were found to be
insignificant from pre- and postimplementation.
DISCUSSION
There were several limitations identified in this study. At the start
of the postimplementation phase, there was confusion regarding the
definition of an “external” urinary catheter among nursing staff.
Upon investigation it was determined that bedside staff occasionally
used “external urinary catheter” to indicate an indwelling urinary
catheter that was placed at an outside, or external, facility. These
occurrences were identified and corrected. This type of error only
occurred in the early postimplementation phase and was not an issue
once staff became more familiar with the External female urinary
catheter device.
Another limitation was the ability to track External female urinary
catheter use in the EMR. Traditionally, if a device required a physician
order, we would just track physician order volume as a proxy for utilization. Since an external female urinary catheter is a non-invasive
adjunct to care and requires no order, we had to find new ways to
track device utilization. In the end we used both “purchase volume”
from our hospital stores warehouse combined with EMR documentation of external female urinary catheters from the “Lines/Drains/Airways” data to gain an approximation for utilization.
During the data collection process, some patient charts noted a
patient having both an indwelling urinary catheter as well as an
external female urinary catheter simultaneously. These cases were
individually investigated and resolved as it is clinically inappropriate
to have both an indwelling urinary catheter and external urinary
catheter at the same time. All cases that were charted this way were
reviewed by the infection prevention staff and were determined to
be attributable to documentation errors.
CONCLUSIONS
This is the largest study of its kind, to date, addressing the effectiveness and impact of an external female urinary catheter implementation.6,7 A prior study by Kuzow et al had around 19,000 patient
days, while this study includes >222,000.8 Our large sample size as
well as diverse patient population with hospital-wide implementation allows for better generalizability of our study findings to other
large academic hospitals.
There has been relatively little research conducted on alternative
options for female external urinary catheters to replace the use of
indwelling urinary catheters. Indwelling urinary catheters substantially increase the risk of healthcare-associated UTIs and using an
external female urinary catheter is a way to minimize this risk in
female inpatient populations. Additionally, external female urinary
catheter use eliminates the need to weigh diapers or bed pads to
obtain output measurements. Future research should investigate the
impact of female external urinary catheter use at other facilities for
comparison. Future studies could also assess nursing satisfaction and
improvements in health care efficiency secondary to the device
implementation.
Our study found a statistically significant decrease in indwelling
urinary catheter utilization following the implementation of the
external female urinary catheter, but only in intensive care units.
This was not surprising as ICU locations are where urinary output is
most frequently measured for hemodynamic monitoring making
them high-volume users of indwelling urinary catheters.
An increase in external female urinary catheter utilization coincided with an eventual decrease in the female CAUTI rate. However,
we cannot say for certain that use of the external device was the
direct cause of the decline in CAUTI, but we know that indwelling urinary catheter use is a significant risk factor for CAUTI and implementation of the external female catheter coincided with a significant
decrease in the use of indwelling urinary catheters in ICUs (see
Table 2). Therefore, it is our recommendation that if a hospital wishes
to implement an external female urinary catheter and does not wish
to begin with a house-wide implementation, they should first implement the device in ICUs as this was the area where we observed the
most significant impact.
Last, while we see a decrease in indwelling urinary catheter utilization and an increase in external female urinary catheter utilization,
further research is required to determine if those are a result of one
another or just concurrent data trends. In other words, we assume
the external female urinary catheter accounts for some of the decline
in indwelling urinary catheter use and that the external device is not
just being used for convenience measures in patients who would otherwise have used the patient restroom / bedside commode. The
downstream effects of inappropriate external female urinary catheter
use could include issues like decreased mobility. Further research is
needed to investigate this effect.
Acknowledgments
The authors would like to acknowledge Scott A. Sortino from Decision Support Services, Data Warehousing for his assistance.
References
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7pscCAUTIcurrent.pdf. Accessed November 8, 2020.
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nence-in-bedbound-women-case-studies.html. Accessed November 8, 2020.
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