Abstract

The purpose of this literature review is to answer the following question: In patients

requiring indwelling urinary catheterization, does the presence of a secondary nurse observing

sterile technique reduce the incidence of CAUTIs? To answer this question we compared eight

studies focusing on implementing two-person catheter insertion in different units across various

hospitals. Our results showed that implementation of a protocol involving two RN insertion

decreases the prevalence of CAUTIs in the inpatient setting. However, this could be result of

other confounding factors. Therefore, hospitals should look into changing their current Foley

catheter policies to help decrease their costs and improve patient outcomes.

Introduction

According to the ​American Journal of Infection Control​, researchers found that catheter

associated urinary tract infections (CAUTIs) account for 34% of all health care associated

infection in the United States (Fink et al., 2012). CAUTIs are preventable infections caused by

pathogens, such as​ ​Escherichia coli,​ that enter the urethra upon insertion of a urinary catheter.

Indications for urinary catheterization include strict measurement of urine output, lengthy

surgical procedures, end of life care, and to allow for the healing of open sacral wounds. The

insertion of a Foley catheter is a sterile procedure, typically performed by one nurse. Due to the

prevalence of CAUTIs, several hospitals have begun implementing protocols that make catheter

insertions a two person procedure. In this two-person procedure, one nurse is responsible for

catheter insertion and the other nurse is responsible for observing sterile technique. Since

CAUTIs are preventable infections, hospitals are held liable and pay out of pocket for any

associated complications and the increased length of stay. The purpose of this literature review
is to answer the following question: In patients requiring indwelling urinary catheterization,

does the presence of a secondary nurse observing sterile technique reduce the incidence of

CAUTIs?

Synthesis of the Literature

Throughout our literature review, we noticed several similarities between the eight

articles selected. First, the articles used in this review were primarily qualitative or case-control

studies, which are ranked lower on the level of evidence pyramid, either level IV, VI, or

unranked. Furthermore, the settings in which the studies took place were primarily the

emergency department and the ICU. A common theme noted in the literature review is that

implementation of a nurse driven protocol for indwelling urinary catheterizations was associated

with a decrease in the total number of CAUTIs in the selected setting. While the research does

not show that the mere presence of two RNs during catheter insertion is what reduced the

incidence of CAUTIs, it does show that increasing awareness about the indications for Foleys

and facilitating quick removal of catheters is a factor contributing to the reduction in CAUTIs.

According to the ​Journal of Clinical Outcomes Management​, the pre- two nurse catheter

insertion CAUTI rate was 6.9 CAUTIs/ 1000 catheters, compared to the post-intervention rate of

1.7 CAUTIs/ 1000 catheters (Rhone et al., 2017). This resulted in a 75% reduction in CAUTI

incidence. Additionally, Belizario, in ​Nursing2015,​ found that the pre- two-RN insertion CAUTI

rate was 6.70 CAUTIs/ 1000 catheter days, and the post-intervention rate was 1.6 CAUTIs/ 1000

catheter days (Belizario, 2015). Furthermore, we noted that nurses are integral in the prevention

of CAUTIs and driving quality improvement projects designed to implement best practice for

indwelling catheter insertion. In fact, “A-voiding catastrophe: Implementing a nurse-driven

protocol” by Mori noted findings that supported the use of nurse-driven protocol to decrease the

use and duration of urinary catheters (2014). An article of the ​American Journal of Infection

Control​ noted that nurses were the most frequently reported indwelling urinary catheter inserters

(Fink et al., 2012), while an article from the ​Journal of Nursing Administration​ found that nurses

are best equipped to examine catheter insertion and to identify areas for improvement, and that

nurses need to be empowered to address these areas for improvement for CAUTI prevention

(Carter et al., 2016).

A major difference noted in the articles is what interventions were included in each

indwelling urinary catheter protocol. For example, the Foley protocol used in “Preventing

Catheter-Associated Urinary Tract Infection” only involved two-RN insertion (Belizario, 2015).

In the study published by the ​Journal of Clinical Outcomes Management, t​ he unit implemented

“technical and socioadaptive changes focused on prevention of insertion-related CAUTIs in the

ED” (Rhone et al., 2017). This protocol included two RNs insertion, a pre procedure safety

time-out, and an overview of proper technique. Maxwell’s research in the ​Canadian Journal of

Infection Control ​included perineal care every 4 hours, CHG to Foley every shift, two RNs for

insertion and nurse driven Foley removal into their catheter bundle (2018).

One major limitation, noticed in the review of the literature, was the lack of

differentiation between CAUTIs arising from improper insertion technique as compared to

maintenance related infections (Rhone et al., 2017). An additional limitation is that units are

often understaffed and cannot meet the demands of a two RN protocol ​(Galiczewski & Shurpin,

2017).

Conclusion
 The goal of the literature review was to answer the following question: I​n patients

requiring indwelling urinary catheterization, does the presence of a secondary nurse observing

sterile technique reduce the incidence of CAUTIs? Following the review, it is evident that

implementation of a protocol involving two RN insertion decreases the prevalence of CAUTIs in

the inpatient setting. While it cannot be concluded that the two RN insertion protocol alone is

what decreased the CAUTI rates, it is clear that reviewing the insertion protocol in all aspects

helps to lower the CAUTI rate.

Recommendations

Education is critical in the prevention of CAUTIs. As lifelong learners, nurses must be

aware of the detriment CAUTIs have placed on the healthcare system and its patients. One

recommendation for practice is the implementation of regular education on the toll that CAUTIs

take on both the hospital and the patients. For the hospital, insurance companies will not pay for

extra hospital resources used on account of the patient’s prolonged hospital stay. For the patient,

a nosocomial infection increases his or her stay, increases the need for medications and

additional treatment, and adds trauma related to the stay, hindering trust in the healthcare system.

Regular education to the entire staff on ways to prevent CAUTIs and how new implementation

methods are being adhered to will further encourage nursing staff to help to reduce the incidence

of CAUTIs. Training at the time of hire in aseptic technique and explaining the importance of

two-RN Foley insertion will further encourage nurses to begin their practice with the ideals of

the cruciality of CAUTIs.

Another recommendation for practice would be to train certified nurse assistants (CNAs)

to effectively observe sterile technique and to successfully identify breaches in sterile technique.
This will help to counteract the problem of understaffing that proves to be a barrier to two-RN

insertion as well as making more of the hospital staff aware of the importance of CAUTI

prevention and the need for the presence of two RNs as urinary catheters are inserted. The

understaffing issue can also be counteracted by delegating certain tasks to CNAs so that the

nurse may be present for Foley catheter insertion. Direct observation by trained personnel has

proved to allow immediate constructive feedback to the inserter, which will facilitate awareness

of needs for improvements and will allow widespread teamwork and collaboration (Galiczewski

& Shurpin, 2017).

Finally, implementation of nurse-driven protocols as well as bundles of care for urinary

catheter insertion will contribute to a decrease in the unnecessary use of Foley catheters and,

therefore, the incidence of CAUTIs. This protocol can include the presence of two nurses at the

bedside during insertion. These protocols would be most effective when a nurse leader is in

charge of its implementation, as these are the people who are most respected on the unit by other

nurses. This can also include a checklist for the observant nurse as part of a nurse-driven

protocol for both insertion and removal of a catheter to ensure patient safety (Krein et al., 2013).

These checklists should be a bright color, making them easy to find. According to an article by

Journal of Nursing Administration, “​ nurses will be more engaged in CAUTI prevention

programs if: urinary catheters are framed as a possible source of patient harm; nurses are

empowered to address areas for improvement in CAUTI prevention; there is a culture of

teamwork facilitating interdisciplinary communication about the appropriateness of and

alternatives to urinary catheters; nurses are held accountable for CAUTIs” (Carter et al., 2016).

This article emphasizes the role of the registered nurse in overall practice change.
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