Perceptions of a Nurse-Driven Urinary Catheter Removal Protocol in a Hospital Setting.

PURPOSE/AIMS: The purpose of this study was to examine the feasibility and acceptability of a nurse-driven catheter removal protocol among nurses in a hospital setting. DESIGN: A mixed-methods design was used. A modified version of the Abbreviated Acceptability Rating Profile was used in this study, along with 3 open-ended questions. METHODS: Staff nurses assigned to care for nonpregnant, cognitively intact adults with a short-term Foley catheter were asked to apply a nurse-driven catheter removal protocol on the enrolled patient every 12 hours. They were asked to complete a modified version of the Abbreviated Acceptability Rating Profile and open-ended questionnaire each time they used the protocol. RESULTS: A total of 13 questionnaires were completed (52% completion rate). Nurses reported that the nurse-driven catheter removal protocol was highly acceptable in intensive care units and intermediate care units, but not in medical-surgical units. Nurses felt that the protocol should be effective in preventing catheter-associated urinary tract infection, that they would be willing to use the protocol with their loved ones, and that overall, the protocol was helpful for their patient. However, they did not feel that their patient's risk for catheter-associated urinary tract infection was high enough to warrant using the protocol. Barriers to using the protocol as planned included encrustation, inconvenient times of day, unawareness, and a desire to follow orders and current institutional policies. CONCLUSION: Findings from this study generally support the acceptability of the nurse-driven catheter removal protocol, particularly in higher-acuity units. Recommendations are provided to help clinical nurse specialists support adherence to these protocols.

Co-administration of multiple intravenous medicines: Intensive care nurses' views and perspectives.

BACKGROUND: Co-administration of multiple intravenous (IV) medicines down the same lumen of an IV catheter is often necessary in the intensive care unit (ICU) while ensuring medicine compatibility. AIMS AND OBJECTIVES: This study explores ICU nurses' views on the everyday practice surrounding co-administration of multiple IV medicines down the same lumen. DESIGN: Qualitative study using focus group interviews. METHODS: Three focus groups were conducted with 20 ICU nurses across two hospitals in the Thames Valley Critical Care Network, England. Participants' experience of co-administration down the same lumen and means of assessing compatibility were explored. All focus groups were recorded, transcribed verbatim, and analysed using thematic analysis. Functional Resonance Analysis Method was used to provide a visual representation of the co-administration process. RESULTS: Two key themes were identified as essential during the process of co-administration, namely, venous access and resources. Most nurses described insufficient venous access and lack of compatibility data for commonly used medicines (eg, analgesics and antibiotics) as particular challenges. Strategies such as obtaining additional venous access, prioritizing infusions, and swapping line of infusion were used to manage IV administration problems where medicines were incompatible, or of unknown or variable compatibility. CONCLUSIONS: Nurses use several workarounds to manage commonly encountered medication compatibility problems that may lead to delays in therapy. Organizations should review and tailor compatibility resources towards commonly administered medicines using an interdisciplinary approach. Developing a clinical decision-making pathway to minimise variability while promoting safe co-administration practice should be prioritised. RELEVANCE TO CLINICAL PRACTICE: This study highlights several ways ICU nurses are able to manage challenges associated with co-administration and the need for the development of a more robust and comprehensive compatibility resource that is relevant to everyday practice through collaboration between nurses and pharmacists.

Implementing Clinical Practice Guidelines for Replacing Peripheral Intravenous Catheters.

BACKGROUND: A community hospital policy of routinely replacing peripheral intravenous catheters (PIVCs) needed updating to the clinical practice guideline (CPG) of clinically indicated replacement. METHODS: Guided by Lean principles, a clinical nurse leader (CNL) led a quality improvement small test of change on a 38-bed medical unit. The impact of the CPG was evaluated using quality, safety, and workflow measures. RESULTS: Nurses managed 469 inpatients, receiving 1033 PIVCs. Routine PIVC replacement declined from 34% to 3% (P < .001). PIVC dwell time ranged from 4 to 20 days and did not increase phlebitis (P = .41) or catheter-related bloodstream infections. Nurses attributed the improvements in workflow (P = .01) and the quality of patient care (94%) to the updated PIVC guideline. CONCLUSIONS: Clinically-indicated PIVC replacement reduced unnecessary catheter insertions, maintained patient safety, improved efficiency, and is being implemented hospital-wide. This project highlights and advances the CNL role in transforming healthcare.

Implementation of a Nurse-Driven Protocol for Catheter Removal to Decrease Catheter-Associated Urinary Tract Infection Rate in a Surgical Trauma ICU.

INTRODUCTION: Early removal of urinary catheters is an effective strategy for catheter-associated urinary tract infection (CAUTI) prevention. We hypothesized that a nurse-directed catheter removal protocol would result in decreased catheter utilization and CAUTI rates in a surgical trauma intensive care unit (STICU). METHODS: We performed a retrospective, cohort study following implementation of a multimodal CAUTI prevention bundle in the STICU of a large tertiary care center. Data from a 19-month historical control were compared to data from a 15-month intervention period. Pre- and postintervention indwelling catheter utilization and CAUTI rates were compared. RESULTS: Catheter utilization decreased significantly with implementation of the nurse-driven protocol from 0.78 in the preintervention period to 0.70 in the postintervention period (P < .05). As a result of the bundle, the CAUTI rate declined significantly, from 5.1 to 2.0 infections per 1000 catheter-days in the pre- vs postimplementation period (Incident Rate Ratio [IRR]: 0.38, 95% confidence interval: 0.21-0.65). CONCLUSIONS: Implementation of a nurse-driven protocol for early urinary catheter removal as part of a multimodal CAUTI intervention strategy can result in measurable decreases in both catheter utilization and CAUTI rates.

Nurses' decision-making about intravenous administration set replacement: A qualitative study.

AIMS AND OBJECTIVES: To explore nurses' decision-making regarding intravenous administration set replacement for vascular access device infusions in paediatric and adult clinical settings. BACKGROUND: Intravenous administration sets are routinely replaced at regular intervals in clinical practice with the goal of preventing catheter-related bloodstream infection; however, emerging evidence is challenging traditional hang-time durations. Nurses' perceptions and contextual factors affecting decision-making for administration set replacement have not been assessed previously. DESIGN: Qualitative study using focus groups with contextualism methodology and inductive analysis. METHOD: During November-December 2016, eight semi-structured focus groups were conducted with 38 nurses at two metropolitan hospitals in Queensland, Australia. Interviews were audio-recorded and transcribed. Two authors independently reviewed transcripts and extracted significant statements using Braun and Clarke's 7-step method of thematic analysis. The COREQ checklist provided a framework to report the study methods, context, findings, analysis and interpretation. RESULTS: Five key themes emerged from the analysis: (a) infection prevention, (b) physical safety, (c) patient preference, (d) clinical knowledge and beliefs, and (e) workload. Administration set replacement can be a complex task, particularly when patients have multiple infusions and incompatible medications. Nurses drew on perceptions of patient preference, as well as previous experience, knowledge of peer experts and local policies, to aid their decisions. CONCLUSIONS: Nurses use clinical reasoning to balance patient safety and preferences with competing workplace demands when undertaking administration set replacement. Nurses rely on previous experience, hospital and medication manufacturer policies, and peer experts to guide their practice. RELEVANCE TO CLINICAL PRACTICE: Nurses at times deviate from clinical guidelines in the interests of patient acuity, nurses' experience and workload. The findings of this study indicate nurses also balance considerations of patient preference and safety with these competing demands.

Removing epidural catheters: A guide for nurses.

Short-term epidural analgesia is effective for postoperative pain, procedural pain, trauma pain, and labor pain. This article describes the skills, procedures, and nursing care required for removing a short-term, temporary epidural catheter.

Cervical Spine Collar Removal by Emergency Room Nurses: A Quality Improvement Project.

INTRODUCTION: The Canadian C-Spine Rule (CCR) is a clinical decision aid to facilitate the safe removal of cervical collars in the alert, orientated, low-risk adult trauma patient. Few health care settings have assessed initiatives to train charge nurses to use the CCR. This practice improvement project conducted in a secondary trauma center in Canada aimed to (1) train charge nurses of the emergency room to use the CCR, (2) monitor its use throughout the project period, and (3) compare the assessments of the charge nurses with those of emergency physicians. METHODS: The project began with the creation of an interdisciplinary team. Clinical guidelines were established by the interdisciplinary project team. Nine charge nurses of the emergency room were then trained to use the CCR (3 on each 8-hour shift). The use of the CCR was monitored throughout the project period, from June 1 to October 5, 2016. RESULTS: The 3 aims of this practice improvement project were attained successfully. Over a 5-month period, 114 patients were assessed with the CCR. Charge nurses removed the cervical collars for 54 of 114 patients (47%). A perfect agreement rate (114 of 114 patients, 100%) was attained between the assessments of the nurses and those of physicians. DISCUSSION: This project shows that the charge nurses of a secondary trauma center can use the CCR safely on alert, orientated, and low-risk adult trauma patients as demonstrated by the agreement in the assessments of emergency room nurses and physicians.

Optimising peripheral venous catheter usage in the general inpatient ward: a prospective observational study.

AIMS AND OBJECTIVES: To evaluate current practices in managing peripheral venous catheters through catheter lifespan, reasons for removal and identifying potential predictors of catheter complications. BACKGROUND: Peripheral venous catheter insertion is a common minimally invasive procedure performed during patient admission. Current routine replacement of catheters may not be required in the light of recent evidence. DESIGN: A prospective observational study was carried out in April 2013. METHODS: One hundred patients were selected by systematic sampling. Ward nurses with support from three research nurses collected data for two weeks, ceasing earlier if patient no longer required venous catheters, was discharged, passed on or was transferred to a nongeneral ward setting. Analysis for potential predictors was carried out using random-effects model. RESULTS: A total of 218 catheters were sampled, with a median catheter lifespan of 2·0 days. Half the catheters were removed because of complications with only 13 catheter removals due to phlebitis (grade 1+) in the first three days. Percentage of catheters removed due to complications also decreased as indwelling time increased. Twenty-three catheters (8·3%) could also have been saved as they were rendered 'not required/discharge' on day 1. Only insertion on the outer forearm was found to be associated with the likelihood of developing venous catheter complications. CONCLUSIONS: Phlebitis rates in our setting are comparable to other published studies with all phlebitis cases occurring before the third day. The median catheter lifespan of two days is shorter than routine three-day replacement, which warrants an urgent review of current insertion and maintenance practices in our local setting. RELEVANCE TO CLINICAL PRACTICE: Changing practice from routine replacement to clinically indicated has benefits to nurses and patients in terms of manpower time and costs. However, an effort to maximise peripheral catheter lifespan is necessary through daily vigilant catheter care and regular audits of practices.

Managing the weaning of a temporary tracheostomy.

The second article of this four-part series on tracheostomy care describes the process of weaning patients off a tracheostomy, decannulation of the tube and aftercare. The role of the multidisciplinary team is discussed, as well as the importance of psychological care of patients who may be anxious about their ability to breathe without a tube.

Can emergency nurses safely and accurately remove cervical spine collars in low risk adult trauma patients: An integrative review.

BACKGROUND: Well validated clinical decision rules exist to facilitate the safe removal of collars in the alert, orientated, low risk adult trauma patient, however this practice is traditionally conducted by medical staff. The aim of this review is to synthesise current evidence to determine the efficacy of emergency nurses in safely and accurately removing cervical spine collars using cervical spine rules, in alert, orientated, low risk trauma adult patients. METHODS: A multi-method search strategy was used to find primary research studies followed by a rigorous screening and quality appraisal process. Data from included articles were extracted, grouped and synthesised. RESULTS: Nine quantitative research articles resulted in four key findings: the inter-rater reliability between nurses and doctors clearing the cervical spine was high (kappa range (0.61-0.80)); nurses can safely implement the cervical spine clinical decision rule; use of a cervical spine clinical decision rule decreases the time patients are immobilised and; nurses felt confident applying a cervical spine clinical decision rule. CONCLUSION: Appropriately trained emergency nurses can safely apply cervical spine rules to alert, orientated, low risk adult trauma patients. Implementation of nurses clearing cervical spines should include training and ongoing monitoring.

Are retrievable vena cava filters placed in trauma patients really retrievable?

PURPOSE: Concerns have arisen regarding the use of retrievable inferior vena cava filters (rIVCFs) in trauma patients due to increasing reports of low retrieval rates. We hypothesized that complete follow-up with a dedicated trauma nurse practitioner would be associated with a higher rate of retrievability. This study was undertaken to determine the rate of retrievability of rIVCFs placed in a Canadian Lead Trauma Centre, and to compare the rate of retrievability in our trauma population to our non-trauma patients. METHODS: We performed a retrospective cohort study of all patients with rIVCF placed between Jan 1 2000 and June 30 2014. Data were collected on demographics, indication for filter placement, retrieval status, and reasons for non-retrieval. Comparison was made between trauma patients and non-trauma patients. RESULTS: A total of 374 rIVCFs were placed (61 in trauma patients and 313 in non-trauma patients) and follow-up was complete for the entire cohort. Filter retrieval was achieved in 86.9 % of trauma patients. Reasons for non-retrieval were technical in two patients, and death before retrieval in six patients. Retrieval was successful in 48.9 % of non-trauma patients. CONCLUSIONS: This study demonstrates that rIVCFs can be successfully retrieved amongst trauma patients. We demonstrated a higher rate of successful retrieval amongst trauma patients than non-trauma patients in our institution. Careful patient follow-up may play a role in successful retrieval of rIVCFs.

A Nurse-Driven Protocol for Removal of Indwelling Urinary Catheters Across a Multi-Hospital Academic Healthcare System.

Catheter-associated urinary tract infections (CAUTIs) are one of the most common hospital-acquired infections in the United States. Because of persistently high CAUTI rates despite evidence-based interventions, we designed and implemented a performance improvement nurse-driven removal protocol for indwelling urinary catheters. Post-implementation, both catheter utilization and CAUTIs decreased significantly at the one hospital with the highest baseline rates; at the two hospitals with low baseline rates, the impact of the protocol varied. This project highlights important steps in developing and implementing a nurse-driven removal protocol across a multi-hospital academic healthcare system.

[The assessment of the effectiveness of long vs standard-length catheters in reducing complications: a randomized controlled trial]. / Valutazione dell'efficacia dei dispositivi venosi periferici a cannula lunga vs quelli di lunghezza standard nella riduzione delle complicanze: studio clinico randomizzato controllato.

INTRODUCTION: From 30 to 80% of hospitalized patients is inserted a peripheral venous catheter (PVC). The PVC may be associated to several infective and non infective complications. AIMS: To assess whether a long-length vs standard-length PCV reduces the incidence of CRCs; to assess the patients' preferences and costs. METHODS: Randomized clinical trial on 211 patients (339 cannulas) admitted to an emergency medical and surgical wards. Patients were included if >18 years and prescribed a PVC. After the randomization the PVC were inspected daily, until removal. RESULTS: 186 complications occurred with the standard CVPs vs 16 with the midline, per 1000 catheter days; 47 phlebitis were observed in patients with standard PVCs vs none in those with midline; also infiltrations (66 vs 2 per 1000 catheter days), asymptomatic thromboses (34 vs 7 per 1000 catheter days), occlusions and accidental removals were greatly reduced. The higher cost of midline is counterbalanced by the complications prevented. In addition midline patients referred less limitations (96% vs 50.7%) and an higher satisfaction (91.9% vs 53.7%). CONCLUSIONS: The midline catheters radically reduce PVC associated complications, are preferred by patients and the higher costs should be weighted against the complications avoided.

Transvenous Lead Extraction for Cardiac Implantable Electronic Devices.

This article illustrates the important role that lead extraction plays in the management of patients with cardiac implantable electronic devices. Individualized care of the patient is paramount when considering lead management strategies. The critical care nurse must have a comprehensive understanding of the indications, procedural considerations, and preprocedural and postprocedural care for patients undergoing lead extraction procedures, thereby improving patient safety and maximizing patient outcomes.

Evaluation of a Nurse-Driven Protocol to Remove Urinary Catheters: Nurses' Perceptions.

This article describes nurses' perceptions of the effect of a nurse-driven protocol in a Magnet-designated hospital. Post-protocol implementation data indicate improved job ease and positive patient feedback following protocol implementation. Younger or less-experienced nurses were likely to use the protocol.