WSU REPOSITORY MSN/DNP Educating ICU Nurses On External Catheter Usage to Prevent CAUTIs Project Title by Maylyn Larson Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, UT 04/26/24 Date Maylyn Larson, BSN, RN, MSN Student 4/26/24 Student Name, Credentials Date (electronic signature) Jamie Wankier EdD(c), MSN, RN 04/26/2024 MSN Project Faculty Date (electronic signature) 4/26/2024 Anne Kendrick (electronic signature) DNP, RN, CNE MSN Program Director Note: The program director must submit this form and paper. Date 1 Educating ICU Nurses on External Catheter Usage to Prevent CAUTIs Maylyn Larson, BSN, RN, MSN Student Annie Taylor Dee School of Nursing Weber State University MSN Project 2 Abstract Purposes/Aims: Catheter-Associated Urinary Tract Infection (CAUTI) is one of the most problematic hospital-acquired infections among ICU patients. Lack of knowledge about CAUTI prevention and the importance of using external urinary catheters and other alternatives contributed to the increase in CAUTIs. The MSN project aims to educate the ICU nursing staff about the importance of CAUTI prevention and the use of external urinary catheters, which will decrease the use of indwelling Foley catheters and CAUTI rates. Rationale/Background: Catheter-associated urinary Tract Infections (CAUTIS) are among the most common hospital-acquired infections that lead to poor-quality health outcomes, increased hospital costs, morbidity, and mortality. Research demonstrated that unnecessary use and length of indwelling Foley catheter placement contributed to CAUTIs. Using external urinary catheters as an alternative to indwelling Foley catheter placement can significantly decrease CAUTIs. Nurses’ lack of knowledge in preventing CAUTI and how to use external urinary catheters and other alternatives might have contributed to high CAUTI rates; however, educating nurses may significantly improve this issue. Methods: A literature review was conducted to understand better CAUTI prevention strategies and the benefits of external urinary catheters in decreasing CAUTI rates. This MSN project used the Evidence-based Practice Change Model as a foundation for the steps taken with this project. Various types of deliverables were used, such as PowerPoint presentations, handouts of catheter assessment tools, diagrams of urine management protocol, brochures of different types of external urinary catheters and alternatives, posters, bulletin board displays, pre-and postevaluation survey, and an in-service training, for educating ICU nursing staff. 3 Results: The staff educated on CAUTI prevention and the use of external urinary catheters consisted of forty nurses and ten patient care technicians (PCT) in the ICU. After implementing this MSN project, 99% of the ICU nurses (50% pre-evaluation) improved their knowledge about the importance of using external urinary catheters and CAUTI prevention. The technicians also improved their knowledge by 85% compared to 40% pre-evaluation. The utilization rate of indwelling Foley catheters dropped to 20% post-implementation compared to 80% preimplementation over the course of six months. Utilization of the external urinary catheters and other alternatives increased to 80%. Overall, CAUTI rates in the ICU decreased from six to one. Conclusions: Educating ICU nursing staff about the importance of CAUTI prevention and the use of external urinary catheters and other alternatives has a significant impact on preventing CAUTIs, decreasing the use of indwelling urinary catheters, and increasing the utilization of external urinary catheters. This MSN project helped nurses become more knowledgeable about using various types of external urinary catheters and other alternatives, leading to better health outcomes for patients in the ICU. Keywords: CAUTI prevention, external urinary catheters, indwelling Foley catheters, nurse education, hospital-acquired infections, and Evidence-Based Practice Change Model. 4 Educating ICU Nurses on External Catheter Usage to Prevent CAUTIs Catheter-associated urinary tract infections (CAUTIs) are prevalent hospital-acquired infections that lead to bacteremia, increased hospital costs, duration of stay, and mortality (Monday et al., 2021). The main risk factors of CAUTIs in the ICU are the presence of an indwelling Foley catheter and the duration of urinary bladder exposures to the organism (Barchitta et al., 2021). Over 80% of all intensive care patients with indwelling urinary catheters are treated for catheter-associated urinary tract infections during their hospital stay (Assadi, 2018). Nearly 98% of urinary tract infections in the ICU were associated with the presence of a urinary catheter (Barchitta et al., 2021). Research found that 65% - 70% of CAUTIs are preventable (Van Decker et al., 2021). An external catheter is one potential infection control method (Garcia, 2023). The external catheter is a urine containment device that fits over or adheres to the genitalia of the patient, and it is attached to a urinary drainage bag or container (Meddings, 2023). External urinary catheters are an alternative method of urinary drainage utilized in some patients to prevent CAUTIs. An essential CAUTI prevention method and a way to reduce the use of urinary catheters is to educate the nurses on external catheter usage. Research showed that educating nurses on external urinary catheters improved knowledge and increased usage, which can reduce the rates of CAUTIs (Seyhan & Ozbas, 2017; Wills-Lee & Dunleavy, 2023). According to the current ICU manager, nurses in the ICU are not educated on utilizing the external catheter because patients in the ICU are critically ill, and the culture that has been taught is that internal urinary catheters are utilized for any critically ill patient (ICU Manager, personal communication, 2023. 5 Statement of Problem ICU patients are vulnerable and at high risk for urinary catheter infections because of the severity of their illnesses that lead to indwelling Foley catheter placement (Born & Levinson, 2019). Evidence showed that indwelling Foley catheters are often inserted in hospitalized patients, sometimes unnecessarily (Born & Levinson, 2019). The Intensive Care unit involved in this MSN project has an increased use of indwelling Foley catheters (1.3%) and decreased utilization of external catheters, such as female Pure Wick, male Pure Wick, condom catheter, and other external methods (ICU Manager, personal communication, 2023). Approximately 560,000 patients developed UTIs annually from hospital stays, and threequarters of these patients are associated with urinary catheters (AHRQ, 2023a). In addition, the Agency for Healthcare Research and Quality (AHRQ) explained that nearly half of patients with urinary catheters do not have a valid indication for placement (2023). AHRQ explained that the ICU has two main challenges with catheter usage: first, potential catheter overuse, and second, critically ill patients in the ICU are not well-defined, and patients may not require a Foley catheter (AHRQ, 2023a). There are some barriers to nurses not utilizing external urinary catheters, such as workload, understaffing, physician variability in indwelling urinary catheter practices by diagnosis, nursing variability in urinary catheter placement technique, and poor documentation of nurses (Huang et al., 2023). Therefore, to address this problem, the purpose of this MSN project is to educate ICU nurses on external catheter usage to decrease internal catheter utilization and, therefore, decrease the incidence of CAUTIs. This project goal will be accomplished by reviewing and examining the current literature to determine the scope of CAUTI problems and the effectiveness of external catheter use, find evidence-based practices on CAUTI prevention, determine the barriers to 6 external catheter usage, then develop and implement an educational program for ICU nurses on external catheter usage. Significance of the Project Lack of education about external urinary catheters and the barriers to using them leads to increased use of indwelling Foley catheters and less awareness of CAUTI prevention (Oleson et al., n.d.). This MSN project is significant because it fills a gap in ICU nursing practice while giving the administration a better understanding of CAUTI rates and nursing barriers to implementing external catheters in the ICU setting. A project of this type can help nurses develop knowledge of CAUTI prevention by avoiding indwelling Foley catheter placement and utilizing more external catheters. Providing education on urine collection devices can increase the nurses’ confidence in choosing and implementing appropriate nursing interventions, such as utilizing external urinary catheter devices in their practice (Oleson et al., n.d.). In addition, this project benefits patients by increasing safety and reducing healthcareassociated infections, which results in decreased costs and shorter lengths of stay. Educational programs are necessary to decrease unnecessary catheter use and promote team collaboration and engagement in the ICU (Snyder et al., 2020). The overall benefit of using external methods to indwelling urinary catheters is decreasing infection rates in the ICU. This project explores the importance of educating ICU nurses about external catheter usage and its patient benefits. A current literature review was conducted to examine the extent of the problem. Review of the Literature A literature review was conducted to explore current research regarding catheterassociated urinary tract infection prevention and the need for ICU nurses’ education about using external urinary catheters. Research showed that using external catheters in an ICU significantly 7 reduced CAUTIs (Goris et al., 2020; Zavodnick et al., 2021). In the ICU setting, different external catheters can be utilized, such as condom catheters, female PureWick external catheters, Male PureWick external catheters, incontinence pads, male and female urinals, bedpans, commodes, and intermittent straight catheterization (Meddings, 2023.). Educating the nurses about the importance of external catheters will help nurses use external catheters appropriately and efficiently. Nurses’ education is essential to improve their knowledge of evidence-based practices to decrease the risk of urinary tract infections (Olatunji, 2019). Regular education is crucial in the reduction of CAUTI (Wills-Lee & Dunleavy, 2023). The PICOT question driving the literature review of this MSN project is: Does educating ICU RNs (P) on external catheter usage (I), compared to no education (C), increase utilization of external catheters to maintain lower or zero rates of CAUTIs (O) within six months (T). The Evidence-Based Practice Change Model was chosen as the framework for implementing this MSN project, and it will be discussed in the next section. Framework The Change model or theory that will guide this project is the Model for Evidence-Based Practice Change (Melnyk & Fine-Overholt, 2019, pp. 395-398). The model aligns with this project because it has the principles of quality improvement (QI) and the six steps that focus on improving patient outcomes (Melnyk & Fine-Overholt, 2019). The six steps include assessing the need for change in practice, locating the best evidence, critically analyzing the evidence, designing practice change, implementing and evaluating change in practice, and integrating and maintaining change in practice (Melnyk &Fine-Overholt, 2019). The Evidence-based practice change (EBP) model is an excellent guide for educating nurses to use external catheters to prevent catheter-associated urinary infections. 8 Using the six steps of the change model as a guide, the first step is assessing the need for change in practice and then evaluating the causes of why there is low external catheter usage in the ICU unit. The next step of the model is to locate the best evidence on the topic of external catheter usage and educate RNs in the ICU setting. It is vital to find quality evidence that is valid, reliable, and applicable to make important clinical decisions on this project (FineoutOverholt, 2019). The third step is to analyze the evidence critically. Analyzing the evidence to help convince and promote a practice change, like transitioning to external catheter usage, is essential. After analyzing the evidence, the next Change model step involves designing a practice change. The design process will be based on the evidence and will utilize best practices in educating the ICU nurses on external catheter usage to decrease CAUTIs. The final step of the Change model involves implementing and evaluating the change in practice. This step will closely monitor unit CAUTIs and the RN education process results. Evaluation findings will drive future implementation of external catheter usage to decrease infection rates. Using the Evidence-Based Practice Change model for this MSN project is essential because it provides tools and resources to implement the education program. The following section will discuss the strengths and limitations of the Model for Evidence-Based Practice Change. Strengths and Limitations Using the Model for Evidence-Based Practice Change in the ICU has several strengths and limitations. Strengths of the model include integrating the best available evidence and clinical expertise, transforming evidence into clinical practice, and promoting positive outcomes for patients (Dusin et al., 2023). In addition, the EBP model effectively creates a supportive practice environment (Duff et al., 2020). Educating nurses about using external catheters will help nurses adapt and integrate the knowledge learned from this project into practice. 9 Implementing the EBP model will help improve evidence-based care reliability and consistency (Duff et al., 2020). The Evidence-Based Practice Change model has some limitations that hinder decisionmaking and can reduce project outcomes (CEBMA, 2019). The limitation of the EBP model is that sometimes there is an unavailability of best evidence, and the clinical environment can involve rapid changes. These limitations lead to scientific and experiential evidence limitations, and practitioners must develop new skills in appraising new evidence (CEBMA, 2019). However, despite a few limitations, the Evidence-Based Practice Model is a reliable framework to guide this MSN project successfully. The following sections will further discuss the different literature analyses of this project. Analysis of Literature This literature review aims to explore the current literature regarding CAUTI prevention techniques and explore education and barriers to implementing the practice change in an ICU setting. The PICOT question for this MSN project was used to drive the literature review search strategies: Does educating ICU RNs (P) on external catheter usage (I), compared to no education (C), increase utilization of external catheters to maintain lower or zero rates of CAUTIs (O) within six months (T), helped to drive the focus of the project literature review. Search Strategies A literature search was conducted using Cochrane Library, Ovid, Google Scholar, Weber State University’s Stewart Library’s OneSearch and Advanced Search, PubMed, CINAHL, CDC, and AHRQ websites to identify the current evidence. The literature review articles included in this project are current from 2017 to 2023. The keywords used in searching a literature review are external catheters, catheter-associated urinary tract infections, healthcare- 10 associated infections, nursing education on alternative methods to indwelling urinary catheters, evidence-based practice model, CAUTI prevention techniques, how to reduce CAUTI rates, female external urinary catheter, male external urinary catheter, quality improvement, quality measurement, ICU education on external catheters, and barriers in implementing CAUTI prevention using external catheters in the ICU. A combination of keywords is also used to get relevant information. Some information can be found directly on the CDC and AHRQ websites. Synthesis of the Literature The literature review for this MSN project resulted in three themes found in the search. The first theme is catheter-associated urinary tract infections (Menegueti et al., 2019; Narula et al., 2019; Olatunji, 2019; Snyder et al., 2020; Werneburg, 2022; Van Decker et al., 2021). The second theme is external catheter usage (Dublynn & Episcopia, 2019; Garcia, 2023; Goris et al., 2020; Monday et al., 2021; Reeths & Merkatoris, 2020; Warren et al., 2021; Zavodnick et al., 2020). The third theme is educating ICU nurses on using external catheters (Benny et al., 2020; Herbert et al., 2023; Meddings, 2023; Mong & Ramoo, 2021; Oleson et al., n.d.; Seyhan & Ozbas, 2017; Wills-Lee & Dunleavy, 2023). Further discussion on these themes can be found in the following sections. Catheter-Associated Urinary Tract Infections Catheter-associated urinary tract infection is the most common infection acquired in the hospital that causes severe healthcare burden, increased rate of antibiotic resistance, and decreased patient outcomes (Menegueti et al., 2019; Narula et al., 2019; Olatunji, 2019; Werneburg, 2022; Zavodnick et al., 2020). Research reported that CAUTI cases in US acute care hospitals are alarming and primarily caused by indwelling Foley catheters (IHI, 2023; LeticaKriegel et al., 2019; Van Decker et al., 2021). There were approximately 93,000 cases of CAUTI 11 incidents in 2011 and over 13,000 deaths each year (Letica-Kriegel et al., 2019; Zavodnick et al., 2029). Globally, CAUTI is one of the most prevalent healthcare-related illnesses and can lead to more severe complications such as sepsis, pyelonephritis, bacteremia, and endocarditis (LeticaKriegel et al., 2019; Rubi et al., 2022; Werneburg, 2022). CAUTI in ICU Setting The intensive care unit or critical care unit is where critically ill patients receive intensive therapies, including strict monitoring of the urine output. Research showed that ICU patients are at high risk for CAUTI because of frequent indwelling urinary catheter usage (Edwardson & Cairns, 2019; Sampathkumar, 2017). The duration of indwelling catheter use is a significant factor in developing UTI and bacteremia (Anggi et al., 2019; Monday et al., 2021). Other factors that lead to UTI and bacteriemia include the severity of illness, immunocompromised, fecal incontinence, poor nutrition, and female gender (Anggie et al., 2019). However, the successful intervention for CAUTIs is prevention, increased use of external catheters, early removal of urinary catheters, and reduced indwelling Foley catheter usage (Edwardson & Cairns, 2019; Sampathkumar, 2017; Zavodnick et al., 2020). External Catheters Usage Several research studies proved that utilizing external catheters and avoiding the placement of indwelling Foley urinary catheters prevent or reduce CAUTIs (CDC, 2023; Cleveland Clinic, 2023; Dublynn & Episcopia, 2019; Garcia, 2023; Goris et al., 2020). Extended Foley catheter use is expected in the ICU due to prolonged hospital stays but can be a substantial risk factor for CAUTI development (Reeths & Merkatoris, 2020; Snyder et al., 2020). The primary method to prevent CAUTIs is to avoid using indwelling urinary catheters (Born & Levinson, 2019; Dublynn & Episcopia, 2019; Goris et al., 2020). 12 According to research, the reduction of indwelling urinary catheter utilization rates resulted after implementing a female external catheter (Dublynn & Episcopia, 2019; Goris et al., 2020). Goris et al. (2020) and Dublynn and Episcopia (2019) explained that using female external urinary catheters may improve patient outcomes and increase hospital rating and reimbursement. In addition, using female external urinary catheters may decrease CAUTI rates (Dublynn & Episcopia, 2019). ICU patients benefited from using external urinary catheters by reducing the risk of CAUTIs and increasing safety and comfort (Menegueti et al., 2019; Warren et al., 2020). The Cleveland Clinic (2023) website enumerated the benefits of external catheters, such as fewer CAUTIs than indwelling Foley catheters, less damage to the urethras, can be used by patients at home, and are more comfortable than indwelling catheters. Benefits of External Catheter Usage An external urinary device is an alternative bladder management device that minimizes utilizing indwelling Foley catheters (Beeson et al., 2023; Goris, 2023). It is beneficial in the ICU because it reduces patient harm and urinary catheter days (Beeson et al., 2023; Monday et al., 2021). Significant benefits of external catheter usage are decreased rates of CAUTI and internal catheter utilization (Garcia, 2023; Goris, 2023; Herbert et al., 2023; Monday et al., 2021; Warren et al., 2020; Zavodnick et al., 2020). External catheters reduce skin breakdown from urinary incontinence, measure urinary output, manage urinary incontinence, decrease bacteremia, and lower the incidence of UTIs (CDC, 2023; Cleveland Clinic, 2023; Van Decker et al., 2021; Warren et al., 2020). The lower incidence of CAUTIs is directly linked to improved patient outcomes, decreased mortality and morbidity, and increased reimbursement to the hospital. Barriers to Utilizing External Urinary Catheters in the ICU 13 The research demonstrated that a better understanding of the barriers to utilizing external urinary catheters will help patient infection outcomes and advocate for policy improvement (Herbert et al., 2023). The Centers for Disease Control and Prevention (CDC) (2023) showed that the barriers to alternative methods of indwelling Foley catheters included time, the perception that patients need a Foley catheter for intake and output monitoring, reluctance, lack of physician support, lack of available supplies, and lack of knowledge related to urinary catheter use complications. Additional barriers to reducing CAUTI in the ICU are leadership methods, unit cultural beliefs, clinical knowledge, and lack of resources (AHRQ, 2022). A nurse-driven protocol and a supportive culture are essential to overcome the barriers to preventing CAUTIs and increase the utilization of external urinary catheters (AHRQ2022; CDC, 2023). Educating nurses on available alternatives, involving the multidisciplinary team in implementing and evaluating internal dwelling catheter alternatives, ensuring the correct usage of alternative methods, and developing champions to coach and mentor are potential ways to improve CAUTI rates (AHRQ, 2022). Educating ICU Nurses on Using External Catheters Educating nursing staff is one method that can decrease CAUTI incidence in the ICU setting. Research demonstrated that educating staff and using a protocol for indwelling Foley catheter management reduces CAUTIs and catheter utilization rates (Assadi, 2018; Seyhan & Ozbas, 2017; Van Decker et al., 2021;). Research showed that daily reminders and communication on catheter necessity and employing the external urine collection device reduced indwelling Foley catheter standard utilization rates (Reeths & Merkatoris, 2020; Werneburg, 2022). In addition, the ability to use the knowledge to prevent CAUTIs can lead to a positive impact on patient outcomes (Narula et al., 2019; Assadi, 2018). 14 Significant factors to influence correct nursing practice are the nurses’ knowledge and positive attitude toward preventing catheter-associated urinary tract infections (Mong et al., 2022). Educating and training all healthcare workers, especially nurses and doctors, on the proper protocol can reduce CAUTI incidence (Benny et al., 2020; Wills-Lee & Dunleavy, 2023). Benny et al. (2020) further explained that education is a significant health-promotive tool. Healthcare workers, especially nurses, play the primary role in urinary catheter care and must be provided additional knowledge in CAUTI prevention (Mong & Ramoo, 2021; Wills-Lee & Dunleavy, 2023). Continued support and education are effective strategies to combat CAUTI (Dublynn & Episcopia, 2019; Werneburg, 2022). Summary of Literature Review Findings and Application to the Project Understanding the impact of catheter-associated urinary tract infections globally and in acute-care hospitals in the United States is crucial. The review of the current literature conducted for this MSN project identified the first theme, which is catheter-associated urinary tract infections. Catheter-associated urinary tract infections significantly contributed to prolonged hospital stays, increased healthcare costs, poorer quality patient outcomes, and death (Menegueti et al., 2019; Narula et al., 2019; Olatunji, 2019; Van Decker et al., 2021; Werneburg, 2022; Zavodnick et al., 2020). The leading cause of CAUTI is the placement of indwelling Foley catheters and prolonged use (IHI, 2023; Letica-Kriegel et al., 2019; Van Decker et al., 2021). Several studies showed that ICU patients are at high risk for getting CAUTIs because of frequent placement of indwelling urinary catheters (Edwardson & Cairns, 2019; Sampathkumar, 2017). However, research demonstrated that using external catheters and other care bundles can reduce CAUTIs (Edwardson & Cairns, 2019; Sampathkumar, 2017; Zavodnick et al., 2020). 15 The results of the literature review showed that preventing CAUTIs can be successful if indwelling Foley catheter usage is reduced and there is increased use of alternative methods such as external urinary catheters (CDC, 2023; Cleveland Clinic, 2023; Dublynn & Episcopia, 2019; Garcia, 2023; Goris et al., 2020). Identifying and understanding the benefits and barriers to utilizing alternative methods to indwelling urinary catheters is crucial in preventing CAUTIs (AHRQ, 2022; CDC, 2023; Garcia, 2023; Goris, 2023; Herbert et al., 2023; Monday et al., 2021; Warren et al., 2020; Zavodnick et al., 2020). According to the CDC (2023), It is essential to find specific ways to overcome the barriers to utilizing external urinary catheters so that they are used more often in the ICU. One method to overcome barriers to using external urinary catheters is by educating ICU nurses on the use of external catheters and the effects of this on CAUTIs (Assadi, 2018; Seyhan & Ozbas, 2017; Van Decker et al., 2021). Knowledge of preventing CAUTI and attitudes toward using external urinary catheters are significant factors in reducing CAUTI and indwelling urinary catheters (Benny et al., 2020; Mong et al., 2022; Wills-Lee & Dunleavy, 2023). The literature showed that nurses play a crucial role in urinary catheter care and prevention of CAUTIs (Mong & Ramoo, 2021; Wills-Lee & Dunleavy, 2023). The evidence-based articles used in the literature review will serve as a resource and guide in planning, designing, implementing, evaluating, and maintaining the proposed initiative of this MSN project. Project Plan and Implementation This MSN project aims to reduce catheter-associated urinary tract infections in the ICU by using external urinary catheters. The project goal will be accomplished by educating the ICU nurses on the importance of utilizing external urinary catheters and how to use these alternative methods to indwelling Foley catheters. 16 Plan and Implementation Process The model of Evidence-Based Practice Change will be used as a framework for implementing and evaluating this MSN project (Melnyk & Fineout-Overholt, 2019). Implementation of this project will require support from the unit manager, critical care director, critical care educator, physicians, staff nurses, techs, CNAs, infection control director, clinical nurse coordinators, charge nurses, patients, families, and the project coordinator of this MSN project. The first steps of initiating this project include a meeting with the ICU manager, critical care director, and the project coordinator during the first week to discuss the project plan and the distribution of the pre-evaluation questionnaire to the nursing staff in the second week. After getting approval from the ICU manager and critical care director, questionnaires will be distributed to the staff the following week, and their answers will be collected for analysis. During the third week, a meeting will be held with a team consisting of the ICU manager, critical care educator, clinical nurse coordinators, charge nurses, infection control director, physicians, and the project coordinator to discuss the dissemination of the project deliverables to gain support from these stakeholders (Melnyk & Fineout-Overholt, 2019). This meeting will present the importance of this project, the results of the pre-evaluation of the nurse’s knowledge about CAUTIs, the use of external urinary catheters, the audit of the daily utilization of indwelling Foley catheters in the ICU, and the process of disseminating the deliverables. The meeting will consist of open discussion and feedback from the various stakeholders. Once approved, the project will be presented using the PowerPoint deliverable to the unit charge nurses, clinical nurse coordinators, ICU staff nurses, techs, and CNAs on week four. In 17 addition, brochures with different external urinary catheters, handouts, urine management diagrams, and urinary assessment tools will be distributed and discussed. A week after the first staff meeting, a poster on CAUTI prevention highlighting the external urinary catheters will be placed in the ICU breakroom with at least five trivia questions to be answered by nurses, techs, and CNAs to gain participation in reading the poster presentation. Two winners who answered the questions will win prizes. The poster of different types of external urinary catheters will be posted in a common unit area for four weeks. The poster will show information on various types of external urinary catheters and CAUTI prevention each week. In-service training on different types of external catheters will be provided to both day and night-shift nurses the following week. The in-service training lasts three weeks (week 9 to week 11) to accommodate all nursing staff. The product representatives of different external urinary catheters will educate nurses on using these products properly and answer questions. In week twelve, at the end of the in-service training, all nursing staff must take a pass-off skills exam for competency. A monthly audit of the utilization of external urinary catheters and indwelling urinary catheters will be performed. The expected timeline for monitoring and auditing will be three months. After three months, a post-evaluation will be given to the nursing staff. All stakeholders will meet to update the project results and how to continue implementing this project in week 32. In this meeting, there will be an open discussion on the pros and cons of the external urinary methods used. Interdisciplinary Team 18 The healthcare professionals contributing to this project are the ICU Manager, Critical Care Director, project coordinator, clinical nurse coordinators, charge nurses, infection control directors, ICU physician lead, critical care educator, ICU staff nurses, certified nursing assistants, techs, product representatives from different companies, patients, and families. This team will significantly impact working together to decrease CAUTIs by increasing the use of external urinary catheters instead of indwelling Foley catheters. Working together will effectively manage better patient outcomes (Rosen et al., 2018). An interdisciplinary team approach will significantly increase the use of external urinary catheters, decrease indwelling Foley catheter use, and decrease CAUTIs (Nalbandian et al., 2022). ICU nurses will significantly contribute to this project's improvement by adequately assessing whether the patient needs an indwelling Foley catheter or an external catheter. ICU Manager and Critical Care Director The ICU Manager and Critical Care Director’s support significantly impact the implementation of this project and its potential success. They must approve this project with the buy-in from the administrators and establish a budget for the implementation expenses. They have a significant influence on the team because they are the leaders of the ICU Unit. As part of their daily safety huddle meeting, they collect the number of Foley catheters and encourage nurses to evaluate the early removal of the Foley catheters and replace them with external urinary catheters. During the first week, the project coordinator will meet the ICU manager and critical care director to discuss the MSN project plan and the distribution of the pre-evaluation questionnaires to the ICU nursing staff. After getting their approval, pre-evaluation questionnaires will be distributed to the ICU nursing staff. Project Coordinator 19 The project coordinator is responsible for planning and implementing this project. The project coordinator will meet with the stakeholders and convince them of the benefits of this project to combat CAUTIs, reduce indwelling Foley catheter use, and increase the use of external urinary catheters. The project lead will then present the deliverables at different times after getting approval from the stakeholders. She is also responsible for collecting the data and results of implementing this project, such as monthly audits of external urinary catheter placements, indwelling Foley catheter placements, and pre-and post-evaluation questionnaires to the nursing staff. She must coordinate with the ICU manager and critical care educator to invite medical device representatives from different companies for in-service training on external urinary catheters and other alternative methods for the ICU nursing staff. Clinical Nurse Coordinators and Charge-Nurses The clinical nurse coordinators and nurse charges, both night and day shifts, will help ensure this project initiative is implemented successfully. They will help monitor the nurses using the external urinary catheters instead of placing indwelling Foley catheters. They are the primary resource or guides to help nurses use the urinary assessment tool and urine management graph in selecting the appropriate urinary catheter. They will also help nurses evaluate for early removal of indwelling urinary catheters. Infection Control Director The infection control director will help monitor for CAUTIs by analyzing the utilization of indwelling Foley catheters versus the utilization rate of external urinary catheters. Close coordination with the infection control director is essential because she audits the total performance of the hospital sepsis rating. The data collected by the infection control director 20 related to his project will be posted on the bulletin board for everybody’s awareness and education. ICU Physician Lead An ICU physician lead is an integral part of the success of this project. The physician lead will deliver the message to his team of ICU doctors. The ICU doctors will discuss the early removal of the indwelling Foley catheters and replace them with external urinary catheters. The physician will put an order in Meditech to remove the Foley catheter and place an external urinary catheter. Critical Care Educator The critical care educator is one of the stakeholders who approved the implementation of this MSN project. He is also one of the consultants who gives ideas and suggestions on implementing this project. He will help educate nurses on using external urinary catheters. The project lead will also coordinate with him to invite the external urinary catheter representatives. The critical care educator can assist in making this project a success and help encourage nurses to participate in completing the deliverables. ICU Staff Nurses The ICU nursing staff are the ones carrying out the implementation of this project. They will answer the pre- and post-survey evaluation questionnaires to determine their knowledge about external urinary catheters and CAUTI prevention. The project coordinator will present this project to the ICU nursing staff and other stakeholders during a staff meeting in week four. They will receive education and training on using external urinary catheters to prevent CAUTIs and reduce unnecessary indwelling Foley catheter placement. They will read the weekly bulletin board, which displays different education on external urinary catheters, and participate in the 21 weekly quiz. They will receive prizes if their names are drawn on the weekly raffle. The nurses will utilize the urine management diagram and urinary assessment tool to determine whether the patient needs an external or indwelling urinary catheter. They will attend in-service training as scheduled (see Appendix F for schedules) and take the skills pass-off during week twelve. Certified Nursing Assistants and Techs The Certified Nursing Assistants (CNAs) and Techs are one of the stakeholders and are part of the ICU team. They are responsible for providing peri and urinary catheter care daily. They helped nurses determine what kind of urinary catheters could be placed or if a patient does not need a urinary catheter. CNAs and Techs will be educated on the importance of using external urinary catheters and how to use them properly. They will participate in the implementation of all deliverables. A separate pre- and post-evaluation survey specific to CNAs and techs will be given to determine their knowledge about CAUTI prevention and the importance of external urinary catheters. Medical Device Representatives Medical device representatives from different companies will be invited to educate and train nurses on various types of external urinary catheters and alternative methods to indwelling Foley catheters. Medical device representatives will present products to healthcare staff, including ICU nurses, CNAs, and technicians. The in-service training will take about three weeks to complete. The fourth week will be the pass-off skills of the staff. The project coordinator will work closely with the critical care educator and the medical device representatives during this four-week period of in-service training. Patients and Families 22 The patients and families are essential stakeholders. The patients are the primary recipients and beneficiaries of this project. The patients and families will receive education from the nursing staff about peri care, Foley care, the benefits of early removal of Foley catheters, and the use of external urinary catheters. The nursing staff will provide them with brochures of different external urinary catheters. Description and Development of Project Deliverables This MSN project will be presented using seven deliverables. The seven deliverables to be used are the following: (1) a PowerPoint presentation regarding the importance of utilizing external urinary catheters and CAUTI preventions, (2) urinary catheter assessment tool (step 1), (3) a urine management diagram protocol (step 2), (4) brochures of different types of external urinary catheters with description, (5) posters of different types of external urinary catheters to be displayed on the bulletin board and education corner, (6) pre and post-survey details for the ICU nursing staff’s understanding regarding the importance of external urinary catheter use and CAUTI preventions, and (7) in-service training of ICU nursing staff on how to use the external urinary catheters. The following sections will explain all seven deliverables and discuss the importance of external urinary catheters in preventing Catheter-Associated Urinary Infections (CAUTIS). PowerPoint Presentation of the Importance of External Urinary Catheters The first deliverable is the PowerPoint presentation on the importance of external urinary catheters, which will be presented during the staff meeting (see Appendix A). These PowerPoint slides will be presented to the stakeholders of this MSN project, such as the ICU nurses, CNAs, Techs, ICU managers, Critical Care director, ICU physician head, infection control director, educator, clinical nurse coordinators, and ICU nurse charges. The PowerPoint will highlight the 23 benefits and importance of utilizing external urinary catheters to prevent CAUTIS. Indwelling Foley catheters should only be placed when appropriate and if they meet the criteria of Foley catheter placement. It will also discuss the proper assessment of the necessity of an indwelling Foley catheter. The PowerPoint is an interactive presentation requiring full participation from the stakeholders. Urinary assessment tool, Diagram of Urine Management, and Brochures of different types of External Urinary Catheters The second, third, and fourth deliverables will be the urinary catheter indication assessment tool, urine management protocol, and brochure of different types of external urinary catheters to be distributed to the stakeholders (see Appendix B and C). The urinary catheter indication assessment tool (see Appendix B) will show the indications of the necessity of the indwelling Foley catheter placement, such as bladder obstruction, proven retention in the last 48 hours using a bladder scan measurement and straight catheterization four times consecutively, hourly urine volume used to provide treatment, per nephrologist or urologist, patient with epidural medication per physician’s order, stage three to four that cannot be kept clear of urinary incontinence, unstable pelvic or spinal fracture, peri operative with the emphasis to remove on postoperative day two, and neurologic bladder. The tool is answerable with either a yes or no. If the answer is yes, then it is an indication of an indwelling Foley catheter. If the answer is no, then alternative urinary management should be utilized. The urine management protocol (see Appendix B & C) is the second step in assessing and selecting the appropriate urinary catheter or alternative methods. The brochure (Appendix D) will also show the different types of external urinary catheters, their importance, and how to use 24 them. All these three deliverables will be utilized by the nursing staff daily and be placed on the patient’s chart as a quick reference. Posters of the Different Types of External Urinary Catheters This fifth deliverable displays posters of different types of external urinary catheters (Appendix D). The poster will depict how each external urinary catheter will be used. The posters will be placed on the nurses’ breakroom education billboard and in the ICU education corner. It will serve as an accessible resource for nurses on how to use these non-invasive external urinary catheter devices. In addition, the poster will serve as a reminder to provide patients with safe and quality care. There will be a poster every week for a month showing different external urinary catheters and CAUTI prevention information. Some trivia questions will be included, and nurses and techs will have a chance to win prizes at the end of the week. Examples of prizes are tollgate passes, twisted sugar cookie gift certificates, and other items. Pre- and Post-Survey of the Nurses’ Knowledge of the External Urinary Catheters The sixth deliverable is the pre-and post-survey details for the nursing staff's understanding of the importance of using external urinary catheters and how to use them (see Appendix E). The pre-survey will be administered before the implementation of this MSN project. The data for presurvey results will be used to present this project. The post-survey will be administered postimplementation. ICU registered nurses and techs will take the pre- and post-survey questionnaires. The Techs will have a pre-and post-survey specific to them. In-service Training of the Different Types of External Urinary Catheters This last deliverable is the in-service training of the different types of external urinary catheters (see Appendix G). The company’s representatives will demonstrate the proper use of the different types of external urinary catheters. During the in-service training, questions will be 25 answered. The in-service training will be done twice weekly on both day and night shifts (from week 9 to week 11). On week 12, there will be a skills pass-off for all ICU nurses, CNAs, and techs. This skills pass-off will test the competency of the nursing staff. Timeline This MSN project's timeline (please see Appendix H) is approximately six months for approval and implementation. To begin this project, during week one, the project coordinator will meet with the ICU manager and critical care director at their office to discuss the project plan, implementation, and deliverables. In week two, the project coordinator will distribute the pre-evaluation questionnaires to the ICU nurses, CNAs, and techs. After the ICU staff answers the questionnaires, the project lead will collect and analyze the results. In week three, an hourlong presentation will be scheduled with the ICU manager, critical care director, ICU physician head, infection director, critical care educator, clinical nurse coordinators, charge nurses, and the project coordinator. This presentation is about the importance of using external urinary catheters to prevent CAUTI, minimizing indwelling Foley catheter placement, and using the urinary catheter assessment tools and graphs in assessing the patient before deciding on the appropriate urinary catheters. The result of the pre-evaluation will also be discussed during the presentation. PowerPoint presentations, brochures, handouts, and posters will be provided. Open discussions will be part of the meeting. In week 4, the final presentation to the nursing staff, techs, and CNAs will be in the conference room. The exact deliverables will be presented to the staff during this meeting. From week five to week eight, posters of different external urinary catheters and quizzes will be posted weekly. In weeks nine, ten, and eleven, in-service training will be held to accommodate both day and night shift staff. In week twelve, there will be a skills pass-off for all ICU nursing staff (nurses, CNAs, and Techs) for competency. 26 For the next three months, the CNC and charge nurses will continue to educate, encourage, and help the nursing staff implement the project. At the end of every month for the three-month period, the project lead will evaluate the progress by auditing how many external and Foley catheters are used monthly. In addition, data will be collected from the infection control director for the standard utilization rates and monthly CAUTIs. Following the completion of the project, a post-evaluation questionnaire will be given to the nursing staff, and a final staff meeting will be held to discuss the results and lessons learned during the project process. Project Evaluation Evaluating a project is significant in determining if it meets its objectives and assessing its effectiveness, efficiency, impact, and sustainability (ILO.org, n.d.). Furthermore, evaluation is essential to ensure that resources used in disseminating the project deliverables are utilized efficiently (NICH, 2022). Three measures will be used to evaluate the effectiveness of this MSN project. The first measure is a pre-evaluation survey (see Appendix F) for nurses, which will be conducted before the implementation of this project. In addition, the CNAs and techs will also have a separate survey questionnaire specific to their role. The pre-survey evaluation measures the knowledge and skills of the ICU staff on CAUTI prevention and how to utilize external urinary catheters and other alternatives. The pre-and post-evaluation surveys include similar questions that evaluate knowledge about CAUTI prevention, utilization of external urinary catheters, and skills in using the various types of external urinary devices. Nurses, CNAs, and Techs will complete the surveys. The results of this survey will be used during the presentation to the project stakeholders, and findings will be compared to the results of the post-evaluation survey. 27 To increase the knowledge and skills of the nurses, techs, and CNAs, they will attend the in-service training provided and take a pass-off skills exam at the end of the three scheduled inservice events. This hands-on exam will evaluate staff skills using different types of external urinary catheters and other alternative devices for Indwelling urinary catheters. A post-evaluation of knowledge and skills will be administered at the end of six months. Results from the postsurvey will be closely monitored, and changes will be made to the project as needed. In addition, a monthly audit will be conducted during the project to evaluate an increase in the utilization of external urinary catheters and a reduction in indwelling Foley catheter utilization. The data will be obtained from the ICU daily census, chart audits, and from the infection control director. The results of this audit will be compared to the data from the audit conducted before the implementation of this project. Charge nurses and clinical nurse coordinators will update the ICU census daily if the patient’s indwelling Foley catheters are removed and replaced with external urinary catheters or if patients were placed with external urinary catheters. To implement this project successfully, the clinical nurse coordinators and charge nurses will encourage and educate the nurses during huddle time and have daily reminders to use the external urinary devices before utilizing the unnecessary placement of indwelling Foley catheters. The nurses who use external urinary catheters will be recognized and appreciated every shift and staff meeting to encourage them to do their best to prevent CAUTIs. After six months of project implementation, the project outcomes will be shared with the management team. The results of the post-survey evaluation data will be reported, and changes to the project will be made based on evaluation feedback. Monthly external urinary catheter and 28 CAUTI rate audits will be conducted, and results will be shared with the ICU staff to motivate them to prevent CAUTI and follow the proper utilization of external urinary catheters. Ethical Considerations This section discusses the different ethical considerations in implementing this project. Before implementing this project, ethical considerations should be taken to minimize patient harm, enhance privacy, and prevent potential burdens on staff (Hunt et al., 2021). ICU patients are at high risk for CAUTI due to immunosuppression, the severity of the illness, increased age, and frailty (Blot et al., 2022). Research indicated that nurses' knowledge, attitudes, and behaviors positively impact the prevention and control of CAUTIs (Benny et al., 2020; Huang et al., 2023). Therefore, in presenting this project, ethical considerations should be considered, such as respect for patients’ and families’ rights and confidentiality, as well as considering the staff’s various styles of learning, attitude, culture, language, and abilities. To protect staff privacy, anonymity will be maintained for those staff who participated in the pre-and post-survey evaluation. Staff are encouraged to answer the questions with sincerity and honesty to get an accurate result in the survey evaluation. Participation in deliverables will be voluntary and not mandatory, but they are strongly encouraged to participate in improving ICU patients' health outcomes. The privacy of patients, families, and caregivers is confidential during the audits to avoid violating the HIPPA policy. Patients and patients’ families will be educated on the importance of CAUTI prevention and the use of external urinary catheters, but they have the right to refuse for ethical reasons. A patient can refuse placement depending on the reason for needing external urinary catheters or other alternatives to indwelling Foley catheters. 29 Another important ethical consideration is preventing harm to patients due to the early removal of indwelling urinary catheters or placement of a wrong urinary catheter for a very ill patient. To avoid this ethical problem, staff will consult with the physician and discuss the appropriate urinary catheter or if a patient qualifies for an early removal of the urinary catheter. A physician order should be placed on Meditech as legal documentation. In addition, staff must follow the urinary assessment checklist tool and urinary management protocol as ordered. The project coordinator may face ethical considerations due to the study's location being the project coordinator's workplace. The project coordinator will maintain impartiality to ensure personal biases do not affect the decision processes, development, dissemination, and evaluation. Personal biases and favoritism can create misrepresentation, negative perception, and misjudgment of the situation, resulting in negative results (Flyvbjerg, 2021). Self-awareness and overcoming personal biases are essential to create a better outcome for the project (Switalski, 2022). Ethical considerations are vital in the implementation of this MSN project. It is essential to inspect all ethical considerations because they can affect the outcomes of this MSN project. Ethical considerations are important in ensuring the project is executed correctly and ethically. Maintaining integrity and accountability by following the objectives rather than personal gains or biases is crucial. Discussion A comprehensive education of ICU staff on the importance of utilizing external urinary catheters and other alternatives to indwelling Foley catheters is crucial in preventing CAUTIs (Benny et al., 2020; Born & Levinson, 2019; CDC, 2023; Dublynn & Episcopia, 2019; & Goris et al., 2020). In addition, educating the ICU staff on how to use external urinary catheters and 30 other alternatives to indwelling Foley catheters will help improve the CAUTI rates, decrease the use of indwelling Foley catheters, and increase the use of external urinary catheters (Born & Levinson, 2019). This MSN project will be implemented at the local medical center in their 14bed ICU with about fifty ICU staff members. The end goal of this MSN project is to increase the knowledge and confidence of the ICU nursing staff using external urinary catheters and other alternatives to prevent CAUTIs and reduce the use of indwelling Foley catheters as much as possible. The following sections will discuss the evidence-based solutions for dissemination, benefits, implications, recommendations, and conclusions. Evidence-based Solutions for Dissemination After implementing this project, the results will be disseminated in several ways. The following data will be gathered and analyzed: staff pre-survey evaluation, post-survey evaluation, and chart audits of CAUTI rates, placement of indwelling urinary catheters, utilization of external urinary catheters, and other alternatives. The data results will be shared with the nursing leadership team for evaluation and discussion if this project has a potential for continuation. The survey information and the data on CAUTI rates and utilizations of urinary catheters will help the nursing leaders, education, and quality improvement, whether this project is valuable, and will make changes to improve the project's objectives. Once the nursing leadership team approves the project, the coordinator will present the results to the ICU stakeholders during the staff meeting. Finally, the coordinator will present and discuss this MSN project using a poster presentation to Weber State University Annie Taylor Dee School of Nursing faculty and peers. If this project's findings are significant, then it will be submitted for journal publication. Significance to Advanced Nursing Practice 31 This MSN project can benefit nurses, CNAs, techs, and ICU patients they care for who are at high risk for CAUTIs by providing nurses with comprehensive education on the importance of preventing CAUTIs and using external urinary catheters and other alternatives through several deliverables. Research suggested that nurses understanding, attitudes, and knowledge are crucial to CAUTI prevention (Olatunji, 2019; Oleson et al., n.d.; Syehan & Ozbas, 2017; Van Decker et al., 2022; Warren et al., 2021; & Zavodnick et al., 2020). Educating nurses on CAUTI prevention has a significant impact on reducing CAUTI rate (Menegueti et al., 2019). ICU patients are at high risk for CAUTIs because they are severely ill, have extended hospital stays, and have weakened immune systems (Barchitta et al., 2021; Blot et al., 2022; Edwardson & Cairns, 2018). Providing the nurses with comprehensive education, urinary management tools, availability of external urinary devices, and other alternatives to indwelling Foley catheters will increase ICU nursing staff knowledge and skills, then will help decrease CAUTI rates and increase positive health outcomes for patients (Blot et al., 2022; Edwardson & Cairns, 2018; & Zavodnick et al., 2020). Implications This MSN project has identified several strengths and limitations. The strengths of this project include various educational methods, handouts, brochures, evaluation surveys, and frameworks. Having different types of educational materials enables staff to engage, learn deeply, and enhance their understanding of delivering content in different ways with different types of learning styles (University of Adelaide, 2017). This project has several deliverables to meet the different learning styles, including PowerPoint presentations, handouts, brochures, diagrams, posters, and in-service training. This project will use quantitative and qualitative 32 evaluation methods through surveys and chart audits. This project uses the Evidence-Based Practice Change model as a framework for this project (Melnyk & Fineout-Overholt, 2019). Several limitations were identified in the implementation of this project, such as sample size, staff buy-in, and barriers. The sample is small because this project will be implemented only in an ICU with about 50 nursing staff. Staff buy-in may be a barrier due to resistance, attitudes towards change, and inadequate knowledge about the importance of CAUTI prevention and External urinary catheters. Comprehensive educational information on the importance of CAUTI prevention, how to use the various types of external urinary catheters and alternative methods will be provided to counteract some of these barriers. Voluntary participation will foster buy-in but encourage staff participation to benefit patients' better health outcomes. The availability of external urinary representatives from different companies can be a barrier. Coordinating with the ICU manager, critical care director, and educator will help invite representatives from different companies to provide in-service training. Implementing this project can decrease CAUTIs because it will improve the knowledge of the ICU nursing staff in CAUTI prevention and increase competency in applying different types of external urinary catheters and other alternatives. Recommendations Recommendations such as using external urinary catheters and other alternatives are essential to improve and address any information gaps related to this project. Several literature reviews illustrated extensive research on CAUTI prevention, but few research studies on external urinary catheters and alternative methods for preventing CAUTIs (Benny et al., 2020; Goris et al., 2020). Therefore, the project lead should conduct further research to determine the effectiveness and benefits of external urinary catheters in preventing CAUTI rates. This study 33 would be beneficial if implemented in all units in the hospital, giving the study a bigger sample size. In addition, contacting different manufacturing companies of external urinary catheters and other alternatives would be beneficial in introducing new and effective products. Another recommendation is acquiring support from other hospital unit managers, directors, and administrators in implementing this project hospital-wide, which could provide successful results. Collaborating with other teams on this project could successfully improve patient outcomes (Huang et al., 2023; Letica-Kriegel et al., 2019; Menegueti et al., 2019; Mong & Ramoo, 2021). The findings of this MSN project can help guide efforts for larger external urinary catheter projects and CAUTI reduction studies in the future. Conclusions The presence of indwelling urinary catheters puts the patients in the ICU at high risk for CAUTIs or Catheter-Associated Urinary Tract Infections. In addition, these patients have compromised immune systems and severe illness, which lead to severe health complications, extended hospital stays, increased hospital costs, and increased morbidity and mortality (Monday et al., 2021). Numerous studies showed that CAUTIs are preventable using external urinary catheters and other alternative methods effectively (Garcia, 2023; Van Decker et al., 2021). Educating the ICU nurses and patient care technicians on the importance of utilizing external urinary catheters and other alternative methods may prevent catheter-associated urinary tract infections and reduce indwelling Foley catheter placement. Educating the patients and families will play a significant part in preventing CAUTIs. 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PubMed Central. 14, 109-133. https://doi.org/10.2147/RRU.S273663 Wills-Lee, S., & Dunleavy, S. (2023). To what extent is education for urinary catheter insertion and management offered to registered nurses in the United Kingdom? International Journal of Urological Nursing. 1–11. https://doi.org/10.1111/ijun.12364 Zavodnick, J., Harley, C., Zabriskie, K., & Brahmbhatt, Y. (2020). Effect of a female external urinary catheter on incidence of catheter-associated urinary tract infection. National Library of Medicine. 12(10), e11113. https://doi: 10.7759/cureus.11113 41 Appendix A The project coordinator will present a PowerPoint Presentation on the importance of CAUTI prevention and utilizing external urinary catheters to the stakeholders, such as the ICU manager, critical care director, clinical nurse coordinators, critical care educator, charge nurses, ICU physician lead, infection control director, ICU nursing staff, and nursing assistants or technicians. Good morning, everyone! Welcome to my presentation about CAUTI Prevention. This presentation highlights the importance of external urinary catheters and other alternative devices in preventing CAUTIs. 42 These are the objectives of this presentation. 43 What does the CAUTI/CAUTIs acronym stand for? What do you know about CAUTIs? Why is it important to prevent CAUTIs? 44 Major threats to patient safety and the most common hospital-acquired infections or HAIs worldwide (Mong & Ramoo, 2021). It can lead to bacteremia, extended hospital stays, healthcare costs, morbidity, and mortality (Monday et al., 2021). A significant risk factor for CAUTI is using an indwelling Foley catheter (Reeths & Merkatoris, 2020). 45 Divide the participants into three groups and discuss these questions. The first group leader will present the answer to question number 1. Second group leader will answer the question number 2, and the third group leader will answer the question number 3. 46 HCA Foley catheter Standard Utilization Rate (SUR) is <1% ORMC ICU SUR is 1.3% ORMC ICU has the highest Foley Catheter utilization among UTAH HCA hospitals. For two years, we have been free from CAUTIs. - but we need to maintain a zero or low rate There is an increase in the use of indwelling Foley catheters. 47 Audit results: From January 2023 to December 2023 (ICU Daily Census, 2023). Monthly Average Indwelling Foley Catheter Utilization rate is 75% - 80% Ambulatory patients had an average of 23% Alternative methods or external urinary catheter utilization only <1% 48 Divide the participants into 3 groups, and each group will discuss these questions. Then, each group will present their answers to these two questions. Examples of Barriers to Utilizing External Urinary Catheters: Lack of awareness Habits/ convenience Attitude towards the external catheters Not being comfortable with new devices Anatomy of the patient’s genitalia Leaking external catheter devices Hectic schedules Heavy workload No CNAs or Techs Difficulty with nurses and physicians’ engagement Patient and family’s request for indwelling catheter placement Lack of knowledge related to infections or complications of Foley use. Nursing reluctance Perception that patient needs a Foley catheter for accurate I&Os Physician’s variability in foley catheter orders 49 Discuss the factors that influence CAUTI prevention. Ask the participants about their thoughts on each factor. 50 Discuss the different types of external urinary catheters and other alternatives available in the ICU. Show these items and educate the stakeholders on how to use these devices. 51 Discuss the suggested interventions and show the present ICU tools to be utilized as well. 52 Open discussion: Any questions and comments? 53 Discuss the conclusions of this presentation. 54 Show the references of this presentation to give credit to the authors. 55 Thank you very much for your participation. 56 Appendix B Handout of Urinary Catheter Assessment Tool and Diagram of Urine Management The tool will be placed in every patient’s chart to guide nurses in selecting the appropriate urinary catheter. Step 1: ICU Urinary Catheter Indication Assessment Tool Indications of Indwelling Foley Catheters (Check Yes if your patient has the following issues, and check No if it is not an issue) Bladder Obstruction Proven retention in the last 48 hours (measured by a bladder scanner or with a straight catheterization x4) Hourly urine volume used to provide treatment Per Nephrologist or Urologist's order Epidural and with physician’s order Stage III to IV that cannot be kept clear of urinary incontinence Unstable pelvic or spinal fracture Peri Op- emphasis to remove on post-op day 2 considering other complications Any YES answer can be an indication for a Foley catheter. Any NO answer, utilize alternative urinary management. Yes No 57 Appendix C Handout of Urinary Catheter Assessment Tools and Diagram of Urine Management 58 Appendix D Brochure of Different Types of External Urinary Catheters with Description https://create.piktochart.com/beta/teams/30292891/saved/63036727 59 Appendix E Posters of Different Types of External Urinary Catheters will be displayed on nurses’ breakroom bulletin board and ICU Education Corner https://create.piktochart.com/beta/teams/30292891/saved/62943866 60 Appendix E Example of Bulletin Board Display 61 Appendix F Pre- and Post-Survey Evaluation Pre- and Post-Survey Evaluation Questionnaire for ICU Nurses 1. How long have you been a nurse? Please check your answer. o Less than a year o 1-2 years o 3-5 years o 6-10 years o 11-15 years o 16 years or above 2. How long have you been a nurse in the ICU? Please check your answer. o Less than a year o 1-2 years o 3-5 years o 6-10 years o 11-15 years o 16 years or above 3. Please circle the number that best describes your response to each question. Questionnaires None A Somewhat Moderately Very at all little Much 1. Do you know about Catheter1 2 3 4 5 Associated Urinary Infections (CAUTIs)? 2. Do you know about CAUTI 1 2 3 4 5 prevention techniques 3. How knowledgeable are you 1 2 3 4 5 about the indications of external urinary catheters? 4. How knowledgeable are you 1 2 3 4 5 about the indications of Indwelling Foley catheters? 5. How comfortable are you using 1 2 3 4 5 the external urinary catheters? 62 6. Are you interested in learning how to use external urinary catheters? 7. How comfortable are you using the external urinary catheters? 8. How willing are you to advocate for the patient to use the external urinary catheters? 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 4. On a scale of 1-5, how comfortable are you using the following external urinary catheters and alternative methods to indwelling Foley catheters? (1 being not comfortable and 5 being extremely comfortable. External Urinary Catheters and Alternative Methods Condom Catheter Female PureWick Male PureWick QuickChange Wrap Male Urinal Female urinal Bedpans Bedside Commode Female Incontinence Pouch Brief or adult diaper Chucks Bladder Scanner Straight Catheterization Not A Moderately Comfortable Extremely comfortable little Comfortable 1 1 1 1 2 2 2 2 3 3 3 3 4 4 4 4 5 5 5 5 1 1 1 1 2 2 2 2 3 3 3 3 4 4 4 4 5 5 5 5 1 2 3 4 5 1 2 3 4 5 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5 63 Appendix F Pre- and Post-Survey Evaluation Pre- and Post-Evaluation Questionnaire for CNAs or Patient Care Technicians (PCT) 5. How long have you been a CNA or a Tech? Please check your answer. 6. o Less than a year o 1-2 years o 3-5 years o 6-10 years o 11-15 years o 16 years or above How long have you been a CAN or Tech in the ICU? Please check your answer. o Less than a year o 1-2 years o 3-5 years o 6-10 years o 11-15 years o 16 years or above 7. Please circle the number that best describes your response to each question. Questionnaires None A Somewhat Moderately at all little 1. Do you know about Catheter1 2 3 4 Associated Urinary Infections (CAUTIs)? 2. Do you know about CAUTI 1 2 3 4 prevention techniques 3. How knowledgeable are you about 1 2 3 4 the indications of external urinary catheters? 4. How knowledgeable are you about 1 2 3 4 the indications of Indwelling Foley catheters? 5. How comfortable are you using the 1 2 3 4 external urinary catheters? 6. Are you interested in learning how to 1 2 3 4 use external urinary catheters? Very Much 5 5 5 5 5 5 64 7. How comfortable are you using the external urinary catheters? 8. How willing are you to advocate for the patient to use the external urinary catheters? 1 2 3 4 5 1 2 3 4 5 8. On a scale of 1-5, how comfortable are you caring for a patient with the following external urinary catheters and alternative methods to indwelling Foley catheters? (1 being not comfortable and five being extremely comfortable. External Urinary Catheters and Alternative Methods Condom Catheter Female PureWick Male PureWick QuickChange Wrap Male Urinal Female urinal Bedpans Bedside Commode Female Incontinence Pouch Brief or adult diaper Chucks Bladder Scanner Straight Catheterization Not A comfortable little Moderately Comfortable Extremely Comfortable 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 1 1 1 1 2 2 2 2 3 3 3 3 4 4 4 4 5 5 5 5 65 Appendix G In-service Trainings The project coordinator will invite representatives from companies that manufacture external urinary catheters to demonstrate to the staff the proper use of external catheters and other alternative urinary management methods. The representatives will teach different external urinary catheters and alternative methods within three weeks. Each nurse will have a checklist of different external urinary catheters and alternative methods to be signed off by each representative when participating in the in-service training. In-Service Training Schedules for Nurses and CNAs or Techs Activities Time Day-shift Time Night-Shift Week 9 – Daily In-service 1300 – 1700 1900 - 2200 Week 10 – Daily In-service 1300 – 1700 1900 - 2200 Week 11 – Daily In-service 1300 – 1700 1900 - 2200 Week 12 - Pass-off skills week 1300 – 1700 1900 - 2200 66 Appendix G Timeline 67 68 69