Fever, Hyperglycemia, and Swallowing Management in Stroke Unit and Non-Stroke-Unit European Hospitals: A Quality in Acute Stroke Care (QASC) Europe Substudy.

ABSTRACT: BACKGROUND: Stroke unit care reduces patient morbidity and mortality. The Quality in Acute Stroke Care Europe Study achieved significant large-scale translation of nurse-initiated protocols to manage Fever, hyperglycemia (Sugar), and Swallowing (FeSS) in 64 hospitals across 17 European countries. However, not all hospitals had stroke units. Our study aimed to compare FeSS protocol adherence in stroke unit versus non-stroke-unit hospitals. METHODS: An observational study using Quality in Acute Stroke Care Europe Study postimplementation data was undertaken. Hospitals were categorized using 4 evidence-based characteristics for defining a stroke unit, collected from an organizational survey of participating hospitals. Differences in FeSS Protocol adherence between stroke unit and non-stroke-unit hospitals were investigated using mixed-effects logistic regression, adjusting for age, sex, and National Institutes of Health Stroke Scale. RESULTS: Of the 56 hospitals from 16 countries providing organizational data, 34 (61%) met all 4 stroke unit characteristics, contributing data for 1825 of 2871 patients (64%) (stroke unit hospitals). Of the remaining 22 hospitals (39%), 17 (77%) met 3 of the 4 stroke unit characteristics (non-stroke-unit hospitals). There were no differences between hospitals with a stroke unit and those without for postimplementation adherence to fever (49% stroke unit vs 57% non-stroke unit; odds ratio [OR], 0.400; 95% confidence interval [CI], 0.087-1.844; P = .240), hyperglycemia (50% stroke unit vs 57% non-stroke unit; OR, 0.403; 95% CI, 0.087-1.856; P = .243), swallowing (75% stroke unit vs 60% non-stroke unit; OR, 1.702; 95% CI, 0.643-4.502; P = .284), or overall FeSS Protocol adherence (36% stroke unit vs 36% non-stroke unit; OR, 0.466; 95% CI, 0.106-2.043; P = .311). CONCLUSION: Our results demonstrate that the nurse-initiated FeSS Protocols can be implemented by hospitals regardless of stroke unit status. This is noteworthy because hospitals without stroke unit resources that care for acute stroke patients can potentially implement these protocols. Further effort is needed to ensure better adherence to the FeSS Protocols.

How registry data are used to inform activities for stroke care quality improvement across 55 countries: A cross-sectional survey of Registry of Stroke Care Quality (RES-Q) hospitals.

BACKGROUND AND PURPOSE: The Registry of Stroke Care Quality (RES-Q) is a worldwide quality improvement data platform that captures performance and quality measures, enabling standardized comparisons of hospital care. The aim of this study was to determine if, and how, RES-Q data are used to influence stroke quality improvement and identify the support and educational needs of clinicians using RES-Q data to improve stroke care. METHODS: A cross-sectional self-administered online survey was administered (October 2021-February 2022). Participants were RES-Q hospital local coordinators responsible for stroke data collection. Descriptive statistics are presented. RESULTS: Surveys were sent to 1463 hospitals in 74 countries; responses were received from 358 hospitals in 55 countries (response rate 25%). RES-Q data were used "always" or "often" to: develop quality improvement initiatives (n = 213, 60%); track stroke care quality over time (n = 207, 58%); improve local practice (n = 191, 53%); and benchmark against evidence-based policies, procedures and/or guidelines to identify practice gaps (n = 179, 50%). Formal training in the use of RES-Q tools and data were the most frequent support needs identified by respondents (n = 165, 46%). Over half "strongly agreed" or "agreed" that to support clinical practice change, education is needed on: (i) using data to identify evidence-practice gaps (n = 259, 72%) and change clinical practice (n = 263, 74%), and (ii) quality improvement science and methods (n = 255, 71%). CONCLUSION: RES-Q data are used for monitoring stroke care performance. However, to facilitate their optimal use, effective quality improvement methods are needed. Educating staff in quality improvement science may develop competency and improve use of data in practice.

The role of stroke nurses in thrombolysis administration in Australia and the United Kingdom: A cross-sectional survey of current practice.

BACKGROUND: The role of stroke nurses in patient selection and administration of recombinant tissue plasminogen activator (rt-PA) for acute ischaemic stroke is evolving. OBJECTIVES: To compare differences in stroke nurses' practices related to rt-PA administration in Australia and the United Kingdom (UK) and to examine whether these differences influence rt-PA treatment rates. METHODS: A cross-sectional, self-administered questionnaire administered to a lead stroke clinician from hospitals known to provide rt-PA for acute ischaemic stroke. Chi-square tests were used to analyse between-country differences in ten pre-specified rt-PA practices. Non-parametric equality of medians test was used to assess within-country differences for likelihood of undertaking practices and association with rt-PA treatment rates. Reporting followed STROBE checklist. RESULTS: Response rate 68%; (Australia: 74% [n = 63/85]; UK: 65% [n = 93/144]). There were significant differences between countries for 7/10 practices. UK nurses were more likely to: request CT scan; screen patient for rt-PA suitability; gain informed consent; use telemedicine to assess, diagnose or treat; assist in the decision for rt-PA with Emergency Department physician or neurologist; and undergo training in rt-PA administration. Reported median hospital rt-PA treatment rates were 12% in the UK and 7.8% in Australia: (7.8%). In Australia, there was an association between higher treatment rates and nurses involvement in 5/10 practices; read and interpret CT scans; screen patient for rt-PA suitability; gain informed consent; assess suitability for rt-PA with neurologist/stroke physician; undergo training in rt-PA administration. There was no relationship between UK treatment rates and likelihood of a stroke nurse to undertake any of the ten rt-PA practices. CONCLUSION: Stroke nurses' active role in rt-PA administration can improve rt-PA treatment rates. Models of care that broaden stroke nurses' scope of practice to maximise rt-PA treatment rates for ischaemic stroke patients are needed. RELEVANCE TO CLINICAL PRACTICE: This study demonstrates that UK and Australian nurses play an important role in thrombolysis practices; however, they are underused. Formalising and extending the role of stroke nurses in rt-PA administration could potentially increase thrombolysis rates with clinical benefits for patients.

Are clinicians using routinely collected data to drive practice improvement? A cross-sectional survey.

BACKGROUND: Clinical registry participation is a measure of healthcare quality. Limited knowledge exists on Australian hospitals' participation in clinical registries and whether this registry data informs quality improvement initiatives. OBJECTIVE: To identify participation in clinical registries, determine if registry data inform quality improvement initiatives, and identify registry participation enablers and clinicians' educational needs to improve use of registry data to drive practice change. METHODS: A self-administered survey was distributed to staff coordinating registries in seven hospitals in New South Wales, Australia. Eligible registries were international-, national- and state-based clinical, condition-/disease-specific and device/product registries. RESULTS: Response rate was 70% (97/139). Sixty-two (64%) respondents contributed data to 46 eligible registries. Registry reports were most often received by nurses (61%) and infrequently by hospital executives (8.4%). Less than half used registry data 'always' or 'often' to influence practice improvement (48%) and care pathways (49%). Protected time for data collection (87%) and benchmarking (79%) were 'very likely' or 'likely' to promote continued participation. Over half 'strongly agreed' or 'agreed' that clinical practice improvement training (79%) and evidence-practice gap identification (77%) would optimize use of registry data. CONCLUSIONS: Registry data are generally only visible to local speciality units and not routinely used to inform quality improvement. Centralized on-going registry funding, accessible and transparent integrated information systems combined with data informed improvement science education could be first steps to promote quality data-driven clinical improvement initiatives.

Effectiveness of meatal cleaning in the prevention of catheter-associated urinary tract infections and bacteriuria: an updated systematic review and meta-analysis.

OBJECTIVE: A systematic review on meatal cleaning prior to urinary catheterisation and post catheterisation and reduces the risk catheter-associated urinary tract infections (CAUTIs) and bacteriuria was published in 2017, with further studies undertaken since this time. The objective of this paper is to present an updated systematic review on the effectiveness of antiseptic cleaning of the meatal area for the prevention of CAUTIs and bacteriuria in patients who receive a urinary catheter. DESIGN: Systematic review. DATA SOURCES: Electronic databases Cochrane Library, PubMed, Embase, The Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline and Academic Search Complete were searched from 1 January 2016 and 29 February 2020. ELIGIBILITY CRITERIA: Randomised controlled trials (RCTs) and quasi-experimental studies evaluating the use of antiseptic, antibacterial or non-medicated agents for cleaning the meatal, periurethral or perineal areas before indwelling catheter insertion or intermittent catheterisation or during routine meatal care. DATA EXTRACTION AND SYNTHESIS: Data were extracted using the Cochrane Collaboration's data collection form for RCTs and non-RCTs. Data were extracted by one researcher and then checked for accuracy by a second researcher. RESULTS: A total of 18 studies were included. Some potential benefit of using antiseptics, compared with non-antiseptics for meatal cleaning to prevent bacteriuria and or CAUTI was identified (OR 0.84, 95% CI 0.69 to 1.02; p=0.071). Antiseptics (chlorhexidine or povidine-iodine) may be of value for meatal cleaning on the incidence of CAUTI, compared with comparator agents (saline, soap or antimicrobial cloths) (OR=0.65, 95% CI 0.42 to 0.99; p=0.047). CONCLUSION: There is emerging evidence of the role of some specific antiseptics (chlorhexidine) prior to urinary catheterisation, in reducing CAUTIs, and some potential benefit to the role of antiseptics more generally in reducing bacteriuria. PROSPERO REGISTRATION NUMBER: CRD42015023741.

Can emergency nurses safely and effectively insert fascia iliaca blocks in patients with a fractured neck of femur? A prospective cohort study in an Australian emergency department.

AIMS AND OBJECTIVES: To compare the effectiveness and safety of ultrasound-guided fascia iliaca block (FIB) insertion in patients with fractured neck of femur by trained emergency nurses with insertion by doctors. BACKGROUND: The FIB is an effective and safe form of analgesia for patients with hip fracture presenting to the emergency department (ED). While it has traditionally been inserted by medical doctors, no evidence exists comparing the effectiveness and safety of FIB insertion by nurses compared with doctors. DESIGN: A prospective cohort study. METHODS: The study was conducted in an Australian metropolitan ED. Patients admitted to the ED with suspected or confirmed fractured neck of femur had a FIB inserted under ultrasound guidance by either a trained emergency nurse or doctor. A retrospective medical record audit was undertaken of consecutive ED patients presenting between January 2013-December 2017. Reporting of this study followed the Strengthening the Reporting of Observational Studies in Epidemiology guidelines for cohort studies. RESULTS: Of the 472 patients eligible for a FIB, 322 (68%) had one inserted. A majority were inserted by doctors (n = 207, 64.3%) with 22.4% (n = 72) by nurses and in 13.3% (n = 43) of patients the clinician was not documented. There were no differences between the nurse-inserted and doctor-inserted groups for mean pain scores 1 hr post-FIB insertion; clinically significant reduction (≥30%) in pain score 1 hr post-FIB insertion; pain score 4 hr post-FIB insertion; delirium incidence; opioid use post-FIB insertion; or time to FIB insertion. No adverse events were identified in either group. CONCLUSION: Insertion of FIBs by trained emergency nurses is as effective and safe as insertion by doctors in patients with fractured neck of femur in the ED. Senior emergency nurses should routinely be inserting FIB as a form of analgesia for patients with hip fracture. RELEVANCE TO CLINICAL PRACTICE: Our study showed trained emergency nurses can safely and effectively insert fascia iliaca blocks in patients with hip fractures. Pain was significantly reduced in a majority of patients with no reported complications. Emergency nurses should be trained to insert fascia iliaca blocks in patients with hip fractures.

The frequency of urinary tract infections and the value of antiseptics in community-dwelling people who undertake intermittent urinary catheterization: A systematic review.

BACKGROUND: This systematic review had 2 aims. First to identify the incidence of urinary tract infection (UTI) and bacteriuria in people undertaking intermittent catheterization (IC), second to determine the effectiveness of antiseptic cleaning of the meatal area prior to IC in reducing the incidence of UTI and bacteriuria. METHODS: A systematic review was conducted. Medline and the Cumulative Index to Nursing and Allied Health Literature electronic databases were systematically searched between January 1, 1990 and January 31, 2020, to identify studies that reported either the incidence of UTI or bacteriuria or the impact of using antiseptics for meatal cleaning prior to IC on incidence of these same outcomes. RESULTS: Twenty-five articles were identified for the first aim, 2 articles for the second. The proportion of participants experiencing ≥1 UTIs per year ranged from 15.4% to 86.6%. Synthesis of these studies suggest a combined incidence of 44.2% (95%CI 40.2%-48.5%) of participants having ≥1 UTIs per year. One of the 2 studies exploring the benefit of antiseptics in reducing UTI suggest some potential benefit of using chlorhexidine in reducing UTIs. Both studies have significant limitations, making interpretation difficult. CONCLUSIONS: A large proportion of people undertaking IC in the community have UTIs each year. Evidence on the role of antiseptics in the prevention of UTI for people who undertake IC remains unclear.

Measuring organizational context in Australian emergency departments and its impact on stroke care and patient outcomes.

BACKGROUND: Emergency departments (ED) are challenging environments but critical for early management of patients with stroke. PURPOSE: To identify how context affects the provision of stroke care in 26 Australian EDs. METHOD: Nurses perceptions of ED context was assessed with the Alberta Context Tool. Medical records were audited for quality of stroke care and patient outcomes. FINDINGS: Collectively, emergency nurses (n = 558) rated context positively with several nurse and hospital characteristics impacting these ratings. Despite these positive ratings, regression analysis showed no significant differences in the quality of stroke care (n = 1591 patients) and death or dependency (n = 1165 patients) for patients in EDs with high or low rated context. DISCUSSION: Future assessments of ED context may need to examine contextual factors beyond the scope of the Alberta Context Tool which may play an important role for the understanding of stroke care and patient outcomes in EDs.

Process evaluation of an implementation trial to improve the triage, treatment and transfer of stroke patients in emergency departments (T3 trial): a qualitative study.

BACKGROUND: The implementation of evidence-based protocols for stroke management in the emergency department (ED) for the appropriate triage, administration of tissue plasminogen activator to eligible patients, management of fever, hyperglycaemia and swallowing, and prompt transfer to a stroke unit were evaluated in an Australian cluster-randomised trial (T3 trial) conducted at 26 emergency departments. There was no reduction in 90-day death or dependency nor improved processes of ED care. We conducted an a priori planned process influential factors that impacted upon protocol uptake. METHODS: Qualitative face-to-face interviews were conducted with purposively selected ED and stroke clinicians from two high- and two low-performing intervention sites about their views on factors that influenced protocol uptake. All Trial State Co-ordinators (n = 3) who supported the implementation at the 13 intervention sites were also interviewed. Data were analysed thematically using normalisation process theory as a sensitising framework to understand key findings, and compared and contrasted between interviewee groups. RESULTS: Twenty-five ED and stroke clinicians, and three Trial State Co-ordinators were interviewed. Three major themes represented key influences on evidence uptake: (i) Readiness to change: reflected strategies to mobilise and engage clinical teams to foster cognitive participation and collective action; (ii) Fidelity to the protocols: reflected that beliefs about the evidence underpinning the protocols impeded the development of a shared understanding about the applicability of the protocols in the ED context (coherence); and (iii) Boundaries of care: reflected that appraisal (reflexive monitoring) by ED and stroke teams about their respective boundaries of clinical practice impeded uptake of the protocols. CONCLUSIONS: Despite initial high 'buy-in' from clinicians, a theoretically informed and comprehensive implementation strategy was unable to overcome system and clinician level barriers. Initiatives to drive change and integrate protocols rested largely with senior nurses who had to overcome contextual factors that fell outside their control, including low medical engagement, beliefs about the supporting evidence and perceptions of professional boundaries. To maximise uptake of evidence and adherence to intervention fidelity in complex clinical settings such as ED cost-effective strategies are needed to overcome these barriers. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ( ACTRN12614000939695 ).

Chlorhexidine versus saline in reducing the risk of catheter associated urinary tract infection: A cost-effectiveness analysis.

BACKGROUND: Catheter associated urinary tract infections are one of the most common infections acquired in hospital. A recent randomised control study demonstrated the benefit of using chlorhexidine (0.1%) for meatal cleaning prior to urinary catheter insertion, by reducing both catheter associated asymptomatic bacteriuria and infection. These findings raise the important question of whether a decision to switch from saline to chlorhexidine was likely to be cost-effective. The aim of this paper was to evaluate the cost-effectiveness of adopting routine use of chlorhexidine for meatal cleaning prior to urinary catheter insertion METHODS: The outcomes of this cost-effectiveness study are changes to health service costs in $AUD and changes to quality adjusted life years from a decision to adopt 0.1% chlorhexidine for meatal cleaning prior to urinary catheter insertion as compared to saline. Effectiveness outcomes for this study were taken from a 32 week stepped wedge randomised controlled study conducted in three Australian hospitals. RESULTS: The changes in health costs from switching from saline to 0.1% chlorhexidine per 100,000 catheterisations would save hospitals AUD$387,909 per 100,000 catherisations, prevent 70 cases of catheter associated urinary tract infections, release 282 bed days and provide a small improvement in health benefits of 1.43 quality adjusted life years. Using a maximum willingness to pay for a marginal quality adjusted life year threshold of AUD$28,000 per 100,000 catherisations, suggests that adopting chlorhexidine would be cost effective and potentially cost-saving. CONCLUSION: The findings from our work provide evidence to health system administrators and those responsible for drafting catheter associated urinary tract infections prevention guidelines that investing in switching from saline to chlorhexidine is not only clinically effective but also a sensible decision in the context of allocating finite healthcare resources.

Chlorhexidine for meatal cleaning in reducing catheter-associated urinary tract infections: a multicentre stepped-wedge randomised controlled trial.

BACKGROUND: Evidence for the benefits of antiseptic meatal cleaning in reducing catheter-associated urinary tract infection (UTI) is inconclusive. We assessed the efficacy of 0·1% chlorhexidine solution compared with normal saline for meatal cleaning before urinary catheter insertion in reducing the incidence of catheter-associated asymptomatic bacteriuria and UTI. METHODS: A cross-sectional, stepped-wedge, open-label, randomised controlled trial was undertaken in Australian hospitals. Eligible hospitals were Australian public and private hospitals, with an intensive care unit and more than 30 000 hospital admissions per year. Hospitals were randomly assigned to an intervention crossover date using a computer-generated randomisation system. Crossover dates occurred every 8 weeks; during the first 8 weeks of the study, no hospitals were exposed to the intervention (control phase), after which each hospital sequentially crossed over from the control to the intervention every 8 weeks. Patients requiring a urinary cathetwer were potentially eligible for inclusion in this hospital-wide study. Participants were excluded if they were younger than 2 years, had a medical reason preventing the use of the chlorhexidine, had the catheter inserted in theatre, did not have the catheter insertion date documented, required in-and-out or suprapubic catheterisation, had symptoms and signs suggestive of UTI at the time of catheter insertion, or were currently undergoing treatment for UTI. The intervention was the use of 0·1% chlorhexidine solution for meatal cleaning before urinary catheterisation with 0·9% normal saline used in the control phase. Masking of hospitals was not possible because it was not feasible to mask staff administering the intervention. The co-primary outcomes were the number of cases of catheter-associated asymptomatic bacteriuria and UTI per 100 catheter-days and were assessed within 7 days of catheter insertion in the intention-to-treat population. This trial is registered with Australian New Zealand Clinical Trials Registry, number ACTRN12617000373370. FINDINGS: 21 hospitals were assessed for eligibility between Jan 5, 2017, and May 1, 2017; of these, three were successfully enrolled and randomised to one of three intervention crossover dates. 1642 participants in these hospitals were included in the study between Aug 1, 2017, and March 12, 2018, 697 (42%) in the control phase and 945 (58%) in the intervention period. In the control period, 13 catheter-associated UTI and 29 catheter-associated asymptomatic bacteriuria events in 2889 catheter-days (0·45 catheter-associated UTI cases and 1·00 catheter-associated asymptomatic bacteriuria cases per 100 catheter-days) were recorded compared with four catheter-associated UTI and 16 catheter-associated asymptomatic bacteriuria events in 2338 catheter-days (0·17 catheter-associated UTI cases and 0·68 catheter-associated asymptomatic bacteriuria cases per 100 catheter-days) during the intervention period. The intervention was associated with a 74% reduction in the incidence of catheter-associated asymptomatic bacteriuria (incident rate ratio 0·26, 95% CI 0·08-0·86, p=0·026), and a 94% decrease in the incidence of catheter-associated UTI (0·06, 95% CI 0·01-0·32, p=0·00080). There were no reported adverse events. INTERPRETATION: The use of chlorhexidine solution for meatal cleaning before catheter insertion decreased the incidence of catheter-associated asymptomatic bacteriuria and UTI and has the potential to improve patient safety. FUNDING: HCF Research Foundation.

Reducing urinary catheter use using an electronic reminder system in hospitalized patients: A randomized stepped-wedge trial.

OBJECTIVE: To determine the effectiveness and ease of use of an electronic reminder device in reducing urinary catheterization duration. DESIGN: A randomized controlled trial with a cross-sectional anonymous online survey and focus group. SETTING: Ten wards in an Australian hospital. PARTICIPANTS: All hospitalized patients with a urinary catheter. INTERVENTION: An electronic reminder system, the CATH TAG, applied to urinary catheter bags to prompt removal of urinary catheters. OUTCOMES: Catheterization duration and perceptions of nurses about the ease of use. METHODS: A Cox proportional hazards model was used to assess the rate of removal of catheters. A phenomenological approach underpinned data collection and analysis methods associated with the focus group. RESULTS: In total, 1,167 patients with a urinary catheter were included. The mean durations in control and intervention phases were 5.51 days (95% confidence interval [CI], 4.9-6.2) and 5.08 days (95% CI, 4.6-5.6), respectively. For patients who had a CATH TAG applied, the hazard ratio (HR) was 1.02 (95% CI, 0.91-1.14; P = .75). A subgroup analysis excluded patients in an intensive care unit (ICU), and the use of the CATH TAG was associated with a 23% decrease in the mean, from 5.00 days (95% CI, 4.44-5.56) to 3.84 days (95% CI, 3.47-4.21). Overall, 82 nurses completed a survey and 5 nurses participated in a focus group. Responses regarding the device were largely positive, and benefits for patient care were identified. CONCLUSION: The CATH TAG did not reduce the duration of catheterization, but potential benefits in patients outside the ICU were identified. Electronic reminders may be useful to aid prompt removal of urinary catheters in the non-ICU hospital setting.

Incidence of single-drug resistant, multidrug-resistant and extensively drug-resistant Escherichia coli urinary tract infections: An Australian laboratory-based retrospective study.

OBJECTIVES: The aim of this study was to evaluate the incidence of single-drug resistant, multidrug-resistant (MDR), extensively drug-resistant (XDR) and pandrug-resistant (PDR) Escherichia coli urinary tract infections (UTIs) in a sample of Australian Capital Territory (ACT) residents. METHODS: Laboratory-based retrospective data from all ACT residents whose urine samples were processed from January 2009 to December 2013 at ACT Pathology were utilised. Multivariate logistic regression models were constructed to determine the associations of age, sex, urine sample source and socioeconomic status with risk of resistant infections. RESULTS: A total of 146 915 urine samples from 57 837 ACT residents were identified over 5 years. The mean±standard deviation age of residents at first sample submitted was 48±26years, and 64.4% were female. The 5-year incidence of single-drug resistant E. coli UTI was high for ampicillin, trimethoprim and cefazolin (6.8%, 3.5% and 1.9%, respectively). No PDR E. coli UTI was detected. Five-year incidences of MDR and XDR E. coli UTIs were 1.9% and 0.2%, respectively, which is low in comparison with international rates. Female sex and age ≥38 years were significantly associated with single-drug and multidrug resistance. The risk of single-drug resistance was significantly higher in samples from after-hours general practice (GP) clinics compared with hospitals, office-hours GP clinics, and community and specialist health services (adjusted odds ratio=2.6, 95% confidence interval 2.2-3.1). CONCLUSIONS: These findings have significant implications for antimicrobial prescribing given the identified risk factors for the detection of resistance, especially in patients attending after-hours GP clinics.

Reducing urinary catheter use: a protocol for a mixed methods evaluation of an electronic reminder system in hospitalised patients in Australia.

INTRODUCTION: Despite advances in infection prevention and control, catheter-associated urinary tract infections (CAUTIs) are common and remain problematic. Prolonged urinary catheterisation is the main risk factor for development of CAUTIs; hence, interventions that target early catheter removal warrant investigation. The study's objectives are to examine the efficacy of an electronic reminder system, the CATH TAG, in reducing urinary catheter use (device utilisation ratio) and to determine the effect of the CATH TAG on nurses' ability to deliver patient care. METHODS AND ANALYSIS: This study uses a mixed methods approach in which both quantitative and qualitative data will be collected. A stepped wedge randomised controlled design in which wards provide before and after observations will be undertaken in one large Australian hospital over 24 weeks. The intervention is the use of the CATH TAG. Eligible hospital wards will receive the intervention and act as their own control, with analysis undertaken of the change within each ward using data collected in control and intervention periods. An online survey will be administered to nurses on study completion, and a focus group for nurses will be conducted 2 months after study completion. The primary outcomes are the urinary catheter device utilisation ratio and perceptions of nurses about ease of use of the CATH TAG. Secondary outcomes include a reduced number of cases of catheter-associated asymptomatic bacteriuria, a reduced number of urinary catheters inserted per 100 patient admissions, perceptions of nurses regarding effectiveness of the CATH TAG, changes in ownership/interest by patients in catheter management, as well as possible barriers to successful implementation of the CATH TAG. ETHICS AND DISSEMINATION: Approval has been obtained from the Human Research Ethics Committees of Avondale College of Higher Education (2017:15) and Queensland Health (HREC17QTHS19). Results will be disseminated via peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER: ACTRN12617001191381 (Pre-results).

CATHETER ASSOCIATED URINARY TRACT INFECTIONS (CAUTIS): A RESEARCH UPDATE.

Infections associated with indwelling urinary catheters (IDCs) are one of the most frequently reported healthcare associated infections (Elvy and Colville 2009). Approximately 26% of patients in Australian hospitals receive a catheter while on admission (Gardner et al 2014).

Reducing catheter-associated urinary tract infections in hospitals: study protocol for a multi-site randomised controlled study.

INTRODUCTION: Despite advances in infection prevention and control, catheter-associated urinary tract infections (CAUTIs) are common and remain problematic. A number of measures can be taken to reduce the risk of CAUTI in hospitals. Appropriate urinary catheter insertion procedures are one such method. Reducing bacterial colonisation around the meatal or urethral area has the potential to reduce CAUTI risk. However, evidence about the best antiseptic solutions for meatal cleaning is mixed, resulting in conflicting recommendations in guidelines internationally. This paper presents the protocol for a study to evaluate the effectiveness (objective 1) and cost-effectiveness (objective 2) of using chlorhexidine in meatal cleaning prior to catheter insertion, in reducing catheter-associated asymptomatic bacteriuria and CAUTI. METHODS AND ANALYSIS: A stepped wedge randomised controlled trial will be undertaken in three large Australian hospitals over a 32-week period. The intervention in this study is the use of chlorhexidine (0.1%) solution for meatal cleaning prior to catheter insertion. During the first 8 weeks of the study, no hospital will receive the intervention. After 8 weeks, one hospital will cross over to the intervention with the other two participating hospitals crossing over to the intervention at 8-week intervals respectively based on randomisation. All sites complete the trial at the same time in 2018. The primary outcomes for objective 1 (effectiveness) are the number of cases of CAUTI and catheter-associated asymptomatic bacteriuria per 100 catheter days will be analysed separately using Poisson regression. The primary outcome for objective 2 (cost-effectiveness) is the changes in costs relative to health benefits (incremental cost-effectiveness ratio) from adoption of the intervention. DISSEMINATION: Results will be disseminated via peer-reviewed journals and presentations at relevant conferences.A dissemination plan it being developed. Results will be published in the peer review literature, presented at relevant conferences and communicated via professional networks. ETHICS: Ethics approval has been obtained. TRIAL REGISTRATION NUMBER: 12617000373370, approved 13/03/2017. Protocol version 1.1.

Meatal cleaning with antiseptics for the prevention of catheter-associated urinary tract infections: A discussion paper.

Urinary tract infections related to indwelling urinary catheters, known as catheter-associated urinary tract infections (CAUTI), are largely preventable healthcare-associated infections (HAI). Healthcare-associated infections including CAUTI are associated with prolonged hospital stay, increased resistance of microorganisms to antimicrobials, increased morbidity and mortality as well as additional financial burden on health care systems, patients and their families. While the optimal aim for patients and the health care system is to prevent CAUTI using measures such as reducing unnecessary placement and early removal of urinary catheters, there is evidence that cleaning of the meatal or peri-urethral area with antiseptic prior to catheter insertion and care of this area while the catheter is insitu has the potential to reduce CAUTI. Evidence suggests that meatal cleaning with antiseptics while the catheter is insitu is non-beneficial in reducing CAUTI but current international and Australian guidelines for infection control professionals identifies that the benefit of antiseptic solution versus non-antiseptic solution for meatal or peri-urethral cleaning before urinary catheter insertion remains unresolved. This discussion paper therefore focuses primarily on antiseptic meatal cleaning prior to urinary catheter insertion in preventing CAUTI. Using evidence from a recently published systematic review and meta-analysis of the literature, this paper discusses the scope of the problem and limitations in the evidence regarding the effectiveness of antiseptics for preventing CAUTI and finally, proposes a way forward through the undertaking of a rigorously conducted randomised controlled trial aimed at evaluating the effectiveness and cost-effectiveness of antiseptic meatal cleaning for prevention of CAUTI.

Five-Year Antimicrobial Resistance Patterns of Urinary Escherichia coli at an Australian Tertiary Hospital: Time Series Analyses of Prevalence Data.

This study describes the antimicrobial resistance temporal trends and seasonal variation of Escherichia coli (E. coli) urinary tract infections (UTIs) over five years, from 2009 to 2013, and compares prevalence of resistance in hospital- and community-acquired E. coli UTI. A cross sectional study of E. coli UTIs from patients attending a tertiary referral hospital in Canberra, Australia was undertaken. Time series analysis was performed to illustrate resistance trends. Only the first positive E. coli UTI per patient per year was included in the analysis. A total of 15,022 positive cultures from 8724 patients were identified. Results are based on 5333 first E. coli UTIs, from 4732 patients, of which 84.2% were community-acquired. Five-year hospital and community resistance rates were highest for ampicillin (41.9%) and trimethoprim (20.7%). Resistance was lowest for meropenem (0.0%), nitrofurantoin (2.7%), piperacillin-tazobactam (2.9%) and ciprofloxacin (6.5%). Resistance to amoxycillin-clavulanate, cefazolin, gentamicin and piperacillin-tazobactam were significantly higher in hospital- compared to community-acquired UTIs (9.3% versus 6.2%; 15.4% versus 9.7%; 5.2% versus 3.7% and 5.2% versus 2.5%, respectively). Trend analysis showed significant increases in resistance over five years for amoxycillin-clavulanate, trimethoprim, ciprofloxacin, nitrofurantoin, trimethoprim-sulphamethoxazole, cefazolin, ceftriaxone and gentamicin (P<0.05, for all) with seasonal pattern observed for trimethoprim resistance (augmented Dickey-Fuller statistic = 4.136; P = 0.006). An association between ciprofloxacin resistance, cefazolin resistance and ceftriaxone resistance with older age was noted. Given the relatively high resistance rates for ampicillin and trimethoprim, these antimicrobials should be reconsidered for empirical treatment of UTIs in this patient population. Our findings have important implications for UTI treatment based on setting of acquisition.