Review Interventions to minimise the initial use of indwelling urinary catheters in acute care: A systematic review Catherine Murphy *, Mandy Fader, Jacqui Prieto Faculty of Health Sciences, University of Southampton, United Kingdom What is already known about the topic? There are risks associated with the use of indwelling urinary catheters (IUCs), in particular they are the cause of approximately 80% of urinary tract infections in acute care. International Journal of Nursing Studies 51 (2014) 4–13 A R T I C L E I N F O Article history: Received 21 March 2012 Received in revised form 13 December 2012 Accepted 13 December 2012 Keywords: Catheter-associated urinary tract infection Inappropriate use Infection prevention Systematic review Urinary catheterisation A B S T R A C T Background: Indwelling urinary catheters (IUC) are the primary cause of urinary tract infection in acute care. Current research aimed at reducing the use of IUCs in acute care has focused on the prompt removal of catheters already placed. This paper evaluates attempts to minimise the initial placement of IUCs. Objectives: To evaluate systematically the evidence of the effectiveness of interventions to minimise the initial placement of IUCs in adults in acute care. Design: Studies incorporating an intervention to reduce the initial placement of IUCs in an acute care environment in patients aged 18 and over that reported on the incidence of IUC placement were included in the review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist has been used as a tool to guide the structure of the review. Data sources: MEDLINE, CINAHL, EMBASE, National Health Service Centre for Review and Dissemination and Cochrane Library. Review methods: A systematic review to identify and synthesise research reporting on the impact on interventions to minimise the use of IUCs in acute care published up to July 2011. Results: 2689 studies were scanned for eligibility. Only eight studies were found that reported any change (increase or decrease) in the level of initial placement of IUCs as a result of an intervention in acute care. Of the eight, six had an uncontrolled before–after design. Seven demonstrated a reduction in the initial use of IUCs post-intervention. There was insufficient evidence to support or rule out the effectiveness of interventions due to the small number of studies, limitations in study design and variation in clinical environments. Notably, each study listed the indications considered to be acceptable uses of an IUC and there was substantial variation between the lists of indications. Conclusions: More work is needed to establish when the initial placement of an IUC is appropriate in order to better understand when IUCs are overused and inform the development of methodologically robust research on the potential of interventions to minimise the initial placement of IUCs. ß 2012 Elsevier Ltd. All rights reserved. * Corresponding author. E-mail address: [email protected](C. Murphy). Contents lists available at SciVerse ScienceDirect International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns 0020-7489/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijnurstu.2012.12.007
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terventions to minimise the initial use of indwelling urinary catheters acute care: A systematic review
therine Murphy *, Mandy Fader, Jacqui Prieto
ulty of Health Sciences, University of Southampton, United Kingdom
What is already known about the topic?
� There are risks associated with the use of indwellingurinary catheters (IUCs), in particular they are the causeof approximately 80% of urinary tract infections in acutecare.
R T I C L E I N F O
icle history:
ceived 21 March 2012
ceived in revised form 13 December 2012
cepted 13 December 2012
ywords:
theter-associated urinary tract infection
ppropriate use
ection prevention
stematic review
inary catheterisation
A B S T R A C T
Background: Indwelling urinary catheters (IUC) are the primary cause of urinary tract
infection in acute care. Current research aimed at reducing the use of IUCs in acute care has
focused on the prompt removal of catheters already placed. This paper evaluates attempts
to minimise the initial placement of IUCs.
Objectives: To evaluate systematically the evidence of the effectiveness of interventions to
minimise the initial placement of IUCs in adults in acute care.
Design: Studies incorporating an intervention to reduce the initial placement of IUCs in an
acute care environment in patients aged 18 and over that reported on the incidence of IUC
placement were included in the review. The Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) checklist has been used as a tool to guide the
structure of the review.
Data sources: MEDLINE, CINAHL, EMBASE, National Health Service Centre for Review and
Dissemination and Cochrane Library.
Review methods: A systematic review to identify and synthesise research reporting on the
impact on interventions to minimise the use of IUCs in acute care published up to July
2011.
Results: 2689 studies were scanned for eligibility. Only eight studies were found that
reported any change (increase or decrease) in the level of initial placement of IUCs as a
result of an intervention in acute care. Of the eight, six had an uncontrolled before–after
design. Seven demonstrated a reduction in the initial use of IUCs post-intervention.
There was insufficient evidence to support or rule out the effectiveness of interventions
due to the small number of studies, limitations in study design and variation in
clinical environments. Notably, each study listed the indications considered to be
acceptable uses of an IUC and there was substantial variation between the lists of
indications.
Conclusions: More work is needed to establish when the initial placement of an IUC is
appropriate in order to better understand when IUCs are overused and inform the
development of methodologically robust research on the potential of interventions to
C. Murphy et al. / International Journal of Nursing Studies 51 (2014) 4–13 5
Over-use of IUCs within acute care has been identified asa problem. Interventions to reduce the duration of use ofIUCs (e.g. reminder systems) have been found to beeffective.
What this paper adds
This is the first review to systematically evaluate theevidence on interventions to minimise the initialplacement of IUCs.
There is no robust evidence for any particular interven-tion to reduce the initial placement of IUCs.
There is a lack of agreement regarding indications forappropriate use of IUCs in acute care.
. Introduction
Alongside other healthcare-associated infections, therofile of catheter associated urinary tract infectionsAUTIs) has risen in recent years. Catheter insertion
ccounts for around 16% of all healthcare-associatedfections in the UK (National Audit Office, 2009). Over
ne hundred million urinary catheters are used annuallyround the world (Nasr, 2010) and up to 25% of patients ineneral hospitals have an indwelling urinary catheter (IUC)serted at some point during their stay (Hooton et al.,
010). The financial burden to healthcare is difficult tostablish, but it has been estimated that the cost of CAUTI
the UK National Health Service could be as much as £99illion per year (Davenport and Keeley, 2005) at an
stimated cost per CAUTI episode of £1968 (Ward et al.,010).
Furthermore, the potential harm caused by IUCs todividuals can be substantial. Urinary tract infectionsTI) are estimated to cause one death per 1000 episodes
f catheterisation (Gokula et al., 2004). CAUTIs are aading cause of secondary nosocomial bloodstreamfections, with around 17% of hospital-acquired bacter-
emia being traced to a urinary source (Weinstein et al.,997). Moreover, CAUTIs contribute to the excessive use ofntimicrobial agents with the potential to lead tontimicrobial resistance. Of particular concern is the rise
antimicrobial-resistant Gram-negative organismsicolle et al., 2005). Additionally, the Royal College of
ursing (2008) warns of other risks associated withoutine catheterisation such as reduced patient interactionom the reduced need to change pads and assist withileting, potentially increasing the risk of pressure ulcers.
There has been a recent shift towards viewing CAUTIs asreventable adverse incidents. In 2008, the Centers foredicare and Medicaid Services in the USA announcedat they would no longer continue to compensate
ospitals for the costs of hospital-acquired UTIs as theyerceived them to be reasonably preventable (U.S.A.epartment of Health and Human Services, 2008). In theK, the Department of Health has the reduction of CAUTIss one of its key patient safety goals, aiming to halve theumber of hospital-associated CAUTIs in 2 years (Patientafety First, 2011).
Although the need to minimise use of IUCs is widelyccepted, there is a significant body of literature reporting
their continued overuse in acute care (Gokula et al., 2007;Tiwari et al., 2011). Overuse occurs when a device is inplace without an appropriate indication. There are twoways of reducing IUC use: firstly by minimising the initialplacement of IUCs, secondly by reducing the duration ofeach catheterisation. The majority of research aimed atminimising IUC use has focused on limiting the duration ofcatheterisation and there is evidence that interventions inthis area can achieve positive outcomes. A systematicreview and meta-analysis of the efficacy of remindersystems to prompt the removal of unnecessary IUCs toreduce CAUTI concluded that reminders can be effective inreducing the rate of CAUTI (Meddings et al., 2010).Reducing the initial placement of IUCs has received lessattention and, as yet, there are no published systematicreviews of the efficacy of interventions aimed at mini-mising initial placement. This review aims to address thisknowledge gap.
2. Methods
2.1. Aim
This review sought to answer the question, ‘‘Whatevidence is there for the effectiveness of interventions tominimise the initial use of IUCs in acute care?’’
2.2. Design
A systematic review was undertaken in order toaccurately identify, evaluate and summarise the findingsof all relevant studies. To aid the complete and transparentreporting of this systematic review, the Preferred Report-ing Items for Systematic Reviews and Meta-Analyses(PRISMA) checklist has been used as a tool to guide thestructure of the review.
2.2.1. Tools
Three tools were used to assist in evaluating andsummarising the eligible studies. The results from the useof the tools are provided in supplementary data. The firsttool was the Cochrane Effective Practice and Organisationof Care (EPOC) Group data extraction checklist (2002). Itprovides a well-established tool for obtaining data frommultiple study designs (Centre of Reviews and Dissemina-tion, 2009) and it broadly follows the PICOS (population,intervention, comparison, outcome, study design) formatappropriate to this review. The second tool was theCochrane Collaboration’s tool for assessing risk of bias(2011), designed to detect selection, performance, attri-tion, detection and reporting bias. Finally, the Standards forQuality Improvement Reporting Excellence checklist forquality improvement reporting (SQUIRE) was chosen as itprovides a framework for assessing the standards ofreporting in variety of study designs.
2.3. Search strategy
A comprehensive search strategy was used on electro-nic databases (MEDLINE, CINAHL, EMBASE, NationalHealth Service Centre for Review and Dissemination,
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C. Murphy et al. / International Journal of Nursing Studies 51 (2014) 4–136
chrane Library) from inception of the databases to July11. Additionally, the reference lists of all studiescluded and the reference lists of infection controlidelines were consulted. Keywords used to search thetabases were combinations of ‘‘ur* catheter*’’ andrinary tract infection.’’ A combination of Medical Subjectadings (MeSH) and text words were used to search
EDLINE. The MeSH subject headings were ‘‘urinarytheterisation/utilisation’’ and ‘‘urinary tract infection/evention and control.’’To be included in the review studies had to incorporateo elements; firstly, an intervention to reduce the initial
acement of IUCs in an acute care environment in patientsed 18 and over and, secondly, they had to report on thecidence of IUC placement pre and post intervention. Itas correctly anticipated that a small number of studiesould be eligible for this review. It was therefore decided
include uncontrolled studies. Papers not written in theglish language were excluded. In order to assessgibility, the titles of the studies found were initiallyanned with full text retrieved for any studies thattentially met the stated criteria.
Results
. Study selection
A flow chart of the selection of eligible studies is given Fig. 1.
The titles of studies initially identified (N = 2689) wereanned for eligibility. 2567 of these were excludedcause they did not meet the inclusion criteria for thisview. The full text of the remaining 122 studies wassessed, 59 were rejected as the study was not related toe overuse of IUCs, four were rejected as they were not inute care and 51 were rejected because, although related
the overuse of IUCs, the incidence of placement of IUCsas not provided as an outcome. Only eight studiesported on the impact of an intervention to reduce the use
IUCs in acute care and its impact on the incidence of IUCacement.
Commonly, studies excluded for not reporting on thecidence of IUCs pre and post intervention either reportedtheter days for the patient population or frequency of
CAUTI per 1000 catheter days, thus making the studiesineligible for this review. This is discussed in Section 5.2.
3.2. Study characteristics
An alphabetical overview of the eligible studies isprovided in Table 1. Relative risk relating to IUC use wascalculated by dividing the post-intervention number bythe pre-intervention number to provide a simple overviewof the results of the studies.
3.2.1. Study design
All but two of the eight studies had an uncontrolledbefore–after intervention design. Danchaivijitr et al.(1992) conducted a randomised controlled experiment,with cluster randomisation at ward level. Stephan et al.(2006) carried out a controlled before–after study, withorthopaedic surgery patients assigned to the interventiongroup and abdominal surgery patients acting as thecontrol.
Three of the papers (Topal et al., 2005; Patrizzi et al.,2009; Voss, 2009) stated that their studies were part of alocal quality improvement or patient safety project ratherthan formal research studies. Distinguishing betweenresearch and quality improvement projects (QIPs) is notalways clear cut and there is often overlap between themethods used. Cosco et al. (2007) established three criteriato help to differentiate: the study’s purpose, the degree ofgeneralizability possible and the risks associated with thestudy. The impact that this variation has on this review andexpanding the knowledge base surrounding IUC use isconsidered in Section 5.
3.2.2. Sample size
Total sample size in terms of number of patients wasgiven in all of the studies and ranged from 182 (Voss, 2009)to 16,959 (Danchaivijitr et al., 1992). The duration of datacollection, including follow-up period, varied from 8 weeks(Voss, 2009) to 2 years (Topal et al., 2005; Stephan et al.,2006).
3.2.3. Setting
All but one study took place at a single hospital site.Danchaivijitr et al. (1992) collected data from 13 randomly
Records identified through elec tron ic
databa ses= 268 9
Records ex cluded :•Not related t o IUC s = 1358•Not a study = 149•Not acute care = 89•Not related to initial place ment of IUC s = 97 1
Full-text articles asses sed for eli gibili ty= 12 2
Full text article exc luded :•Not related t o ove ruse of IUC s = 59•Not acute care = 4•Inc idence of initial IUC place ment no t prov ide d = 51
Stud ies included = 8
Fig. 1. Flow diagram of studies identified.
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elected hospitals in Thailand and was one of the onlyree studies not set in the USA, the other two were
lappendel and Weber (1999) in the Netherlands andtephan et al. (2006) in Switzerland. Three of the studiesok place in an emergency department (Fakih et al., 2010;okula et al., 2007; Patrizzi et al., 2009), two in surgicalnits (Stephan et al., 2006; Slappendel and Weber, 1999),
o within medical wards (Topal et al., 2005; Voss, 2009)nd one both medical and surgical wards (Danchaivijitrt al., 1992).
.2.4. Intervention
The EPOC Data Extraction form was used to evaluatend summarise the interventions. All but one (Danchai-ijitr et al., 1992) of the eight studies used multifacetedterventions that included two or more methods (see
ection 3.4 for further details) aimed at implementing aeduction in the initial placement of IUCs in the definedetting by changing clinical practice.
3.2.5. Outcome measurement
All studies reported the number of initial IUC place-ments post-intervention compared to the pre-interventionfigure. The baseline and post-intervention data werecollected from patients’ notes (either paper or electronic)or from hospital billing data.
3.3. Quality appraisal
3.3.1. Methodological quality
Six of the studies had an uncontrolled before and afterdesign which can provide a pragmatic option for individualsettings to gauge the impact of the introduction of qualityimprovement policy. However, due to their intrinsicallyweak methodological nature, the use of uncontrolledstudies is not recommended to assess the efficacy ofinterventions (Eccles et al., 2003).
The risk of bias was assessed using the CochraneCollaboration tool. The study undertaken by Danchaivijitr
C. Murphy et al. / International Journal of Nursing Studies 51 (2014) 4–138
al. (1992) was the only randomised controlled experi-ent, with cluster randomisation taking place at wardel. The method of allocation and concealment ofocation were not fully reported, therefore the risk ofas is unclear. The only controlled before and after studytephan et al., 2006) did not state how the allocation ofe surgical department as the control and the other as the
tervention group was undertaken. In all studies, data wasllected from a set number of consecutive patients orm all patients within a set time frame.With the exception of Danchaivijitr et al. (1992), all of
e studies had an element of clinician education withineir interventions. Therefore, performance bias mightve been a significant source of bias in these sevendies. None of the studies stated whether the clinicians
ere aware of the data collection periods or if the aims ofe study were made explicit. However, particularly for theality improvement projects, the nature of the interven-ns suggests that clinicians would be aware of thejectives and that the use of IUCs would be monitored,us increasing the risk of bias.As data was collected from standard medical records
omputer or paper based) or hospital billing records inl of the studies there is arguably little room fornfusion as to whether or not an IUC has been placed.wever, knowledge that the intervention had taken
ace could have influenced measurement since in alludies it appears that the researchers who wereplementing the interventions were also involved inllecting the data and assessing the outcome and wereerefore not blinded. Fakih et al. (2010) and Voss (2009)entified the risk of bias caused by missing/inaccurateta due to retrospective data gathering from notes as aitation.Three of the studies in this review identified potential
urces of bias within their own studies not specificallycluded in the risk of bias tool. Potential confoundersentified included variation in commitment to infectionntrol by physicians and variation in clinicians’ skillstephan et al., 2006), variation in physician preferencegarding the use of protocols (Voss, 2009), the presence ofsenior clinician on ward rounds (Voss, 2009), variations
unit based culture (Gokula et al., 2007; Stephan et al.,06; Voss, 2009) and the potential for pre and posttervention populations to have varying demographic andnical factors (Gokula et al., 2007).
.2. Reporting quality
Using the SQUIRE guidelines reveals that the report-g standard of the eight studies was variable, since noneported fully on more than half the relevant criteria.e local background to the studies was poorly reported.ly two of the studies reported on the local nature and
verity of the problem being addressed, both of whichere QI studies (Slappendel and Weber, 1999; Patrizzi al., 2009). There is a lack of detail on why theterventions were chosen and why the authors believede interventions worked or did not work. There werew reports of attempts to understand which elements multi-component interventions worked and at whichvel.
3.4. Intervention characteristics
The most common form of intervention was education,with all except two studies (Danchaivijitr et al., 1992;Slappendel and Weber, 1999) including some kind ofclinician education. There was a wide variation of methodsused within this category from one-to-one nurse educationby a clinical nurse specialist, to changes in protocols andguidelines.
The other methods of change used were the introduc-tion of bladder scanners (Patrizzi et al., 2009; Slappendeland Weber, 1999; Topal et al., 2005), the introduction oradaptation of IUC guidelines (Gokula et al., 2007;Slappendel and Weber, 1999; Stephan et al., 2006; Voss,2009), indication checklist reminders (Danchaivijitr et al.,1992; Fakih et al., 2010; Gokula et al., 2007; Patrizzi et al.,2009), removal of IUC kits from bedsides (Patrizzi et al.,2009), feedback on IUC usage (Patrizzi et al., 2009) andintroduction of physician’s IUC ‘‘champion’’ (Fakih et al.,2010).
All but one of the studies (Danchaivijitr et al., 1992) hadmulti-component interventions. Although none of thestudies directly compared efficacy of different componentsof interventions or combinations of components ofinterventions, some studies noted the importance ofcombining different mechanisms. Topal et al. (2005)identified the importance of merging increased awarenessof the risks of catheterisation with directives to avoidunnecessary use in order to achieve cultural change.According to Patrizzi et al. (2009), practice change wasdependent upon addressing a combination of educational,behavioural and cultural factors. Gokula et al. (2007)believe that combining education and reminder methodswas vital to their success, commenting that Danchaivijitret al.’s (1992) use of reminders alone reduced the recordedinappropriate use of catheters, but not the number ofcatheters used. Fakih et al. (2010) commented on theimportance of the designated change leader in enforcingcompliance with the education and reminder systemaspects of the intervention. Stephan et al. (2006) noted,that ‘‘feedback of performance and results’’ was only madeavailable after the intervention but that this might havebeen critical in ensuring a sustained effect.
Most interventions were aimed at changing thebehaviour of both physicians and nurses. However, in 2(Danchaivijitr et al., 1992; Fakih et al., 2010) theintervention was aimed at physicians only. Despite thefocus on physicians, both of these studies commentedupon the influence of nurses over the decision tocatheterise. Fakih et al. (2010) commented that in orderto address inappropriate IUC use, indications must be usedby both emergency physicians and nurses. The interven-tion in Patrizzi et al.’s (2009) study was designed by andaimed predominately at nurses. However, collaborationand communication with physician colleagues was notedas important to support the change in practice.
Several of the studies discussed the importance ofaddressing individual clinicians’ beliefs, cultural normsand organisational barriers in changing practice. Topalet al. (2005, p. 126) stated, ‘‘The power of collaborationamong physicians and nurses played a vital role in our
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uccess. We recognised that the 40-year culture ofdwelling catheter use was an interdisciplinary norm
nd that the norm was likely motivated differently foroctors and nurses.’’ Patrizzi et al. (2009, p. 539) observedat ‘‘Collaboration, communication and teamwork
etween the two units were major factors in the projectsuccess’’ and with reference to the routine placement of
Cs, ‘‘This almost ritualistic behaviour was difficult tohange because of it enculturation into standard EDursing practice.’’ Fakih et al. (2010, p. 339) reported that,Recognising the factors that lead nursing to inappropriatelacement of IUCs may help us target the noncomplianceith UC indications.’’
Whichever method of implementation was used, all ofe studies used a checklist of accepted indications for
lacing an IUC as part of their intervention, either duringducation sessions, as part of new guidelines or in the formf a reminder checklist. A summary of the indicationriteria used by the studies is provided in Table 2. Theethod of compiling a list of acceptable criteria varied
etween the studies. Topal et al. (2005) and Patrizzi et al.009) used existing guidelines. Voss (2009), Gokula et al.007), Fakih et al. (2010) and Stephan et al. (2006)
eveloped the lists locally. Danchaivijitr et al. (1992) andlappendel and Weber (1999) did not state the method ofevelopment.
There was substantial variation between the lists ofdications that each study considered to be appropriate
easons to place an IUC (see Table 2). In some studies thisas related to the specific patient group (e.g. Stephan et al.,
2006) or the intervention being tested (e.g. Slappendel andWeber, 1999). The levels of acceptance and adoption of theindication checklists also varied widely. Topal et al. (2005)found that 14.8% of placements post-intervention did notmeet the stated criteria and Voss (2009) reported that theappropriate use of IUCs fell from 57.1% to 53.8% with theintroduction of the indications. Gokula et al. (2007) foundthat appropriateness of use increased from 37% at baselineto 51% following the intervention. However only 12% ofIUCs placed had a completed indication sheet and 60% ofclinicians stated that they would not wish to routinely usethe indication sheet. Danchaivijitr et al. (1992) reportedthat on 96.5% of IUC placements prescribers used theindication sheet and that overall it was seen as highlyaccepted. It was found that the indication sheet reducedcatheter use recorded as inappropriate (27% down to14.3%) but not the actual number of catheters used, whichrose slightly. Fakih et al. (2010) noted that over half of theIUCs were placed without physicians orders and of thatnumber around half did not fit any of the indications. Theauthors of that study believed that this might reflect adifference in what physicians and nurses judged appro-priate indications for IUC use.
4. Review of evidence
The forest plot in Fig. 2 provides a summary of theimpact of the interventions. Seven out of the eight studiesdemonstrated a reduction in the initial use of IUCs post-intervention. Overall, it can tentatively be proposed that
able 2
ummary of stated indications to place an IUC.
Indication Danchaivijitr
et al. (1992)
Fakih
et al.
(2010)
Gokula
et al.
(2007)
Patrizzi
et al.
(2009)
Slappendel
and Weber
(1999)
Stephan
et al.
(2006)
Topal
et al.
(2005)
Voss
(2009)
Acute urinary retention (no use of bladder
scanner stated)
x x x x
Acute urinary retention (with use of bladder scanner) x x
Need for urinary output monitoring/haemodynamic
instability
x x x x x
Postoperative requirements x
Urinary incontinence and skin breakdown x x x x x
Emergency surgery x x
End-of-life care x x x x
Aggressive treatment with diuretic medications
or fluids
x
Pre-operative incontinence of urine x
A need to measure output accurately in an
uncooperative patient (e.g. intoxication)
x
Bladder irrigation x x
History of chronic catheterisation or difficult
to catheterise
x
Injury to urethra x
Unresponsive x
Evaluation of ectopic pregnancy x
Acute mental status changes with agitations x
Intubated x
Uncleared spinal radiographs in female patients only x
Deep sedation x
Interventions with foreseen duration of surgery >5 h x
Total hip replacement and age >75 years, an ASA
class of 3+ or obesity
x
Total knee and age >80 years or obese x
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C. Murphy et al. / International Journal of Nursing Studies 51 (2014) 4–1310
terventions aimed at reducing the number of IUCs beingaced in acute care are likely to have a positive effect.wever, caution should be used when interpreting the
sults from non-RCT studies and studies using a pre-test,st-test design are inherently biased in favour of thetervention. Two of the studies (Gokula et al., 2007;trizzi et al., 2009) reported the post-interventionmber of IUCs placed reduced to a quarter or less ofe base level. Three of the other studies (Slappendel andeber, 1999; Topal et al., 2005; Voss, 2009) reportedductions to around half of the pre-intervention level.kih et al. (2010) and Stephan et al. (2006) reported lessbstantial falls in use. It is worth noting that the twontrolled studies (Danchaivijitr et al., 1992; Stephan et al.,06) included in this review had the least positive results,
ith an increase in IUC use in Danchaivijitr et al.’s (1992)dy.It is difficult to draw any conclusions about the efficacy
individual methods of intervention. Examining theficacy of the interventions is made complex by the range
methods used, different clinical environments and theriation in study design. Although all but one of thedies reported a reduction in the initial placement of
Cs, the uncontrolled pre and post-test design of 6 of thedies is weak and the efficacy of the intervention is
erefore unknown. The only randomised controlled trialanchaivijitr et al., 1992) was poorly reported. Further-ore, any impact interventions have on practice might beort lived. Only two studies (Gokula et al., 2007; Topal
al., 2005) reported IUC use for more than a 6-monthriod.
Discussion
A number of key observations can be made from thedings.Firstly, based on the evidence available, although it
pears that the interventions implemented do improvenical practice, it is impossible to draw any strongnclusions about the efficacy of individual interventions
combinations of interventions due to the study designs,
the variation in clinical environments and the paucity ofnumber of studies. Reviews of implementation strategieshave consistently demonstrated considerable variation inthe success of similar interventions (Eccles et al., 2005) andthis is echoed here. However, some broad observations canbe made. Clinician education was the most commonintervention component, with only two studies notincluding it (Danchaivijitr et al., 1992; Slappendel andWeber, 1999). Danchaivijitr et al.’s (1992) intervention ofusing clinical reminders alone was not effective. However,the other studies that implemented interventions with twoor more components saw positive results. This correspondswith the findings of systematic reviews of interventions toimplement change in clinical practice that have reportedmultifaceted interventions to be more effective (Boaz et al.,2011; Grol and Grimshaw, 2003).
Most of the studies combined a practical/resourcebased component (for example, the introduction of bladderscanners or indication checklists) with an educationalcomponent (Fakih et al., 2010; Gokula et al., 2007; Patrizziet al., 2009; Slappendel and Weber, 1999; Topal et al.,2005). Of the three that did not (Danchaivijitr et al., 1992;Stephan et al., 2006; Voss, 2009), two (Danchaivijitr et al.,1992; Stephan et al., 2006) had the least positive results.However, these were also the only two studies that used acontrol group, therefore it is difficult to draw anyconclusions about the benefits of combining these twocomponents.
The need to change the culture surrounding the initialplacement of IUCs was considered as an important factorby many of the studies. Two key issues were highlighted;firstly the importance of collaboration and communicationbetween colleagues (Fakih et al., 2010; Topal et al., 2005;Patrizzi et al., 2009) and, secondly, the need to addressritualized practice (Patrizzi et al., 2009; Topal et al., 2005;Stephan et al., 2006). There is little literature addressingthe culture of IUC use in acute care and this is an importantarea for further research.
Secondly, when exploring the eligible studies, it isimportant to note their initial purpose. Three of the studiesincluded in this review were categorised as local quality
. 2. This forest plot summarises studies that have used either uncontrolled pre and post-test, or controlled trial designs to test interventions to minimise
initial placement of IUCs.
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C. Murphy et al. / International Journal of Nursing Studies 51 (2014) 4–13 11
provement projects, thus providing further confirma-on that such studies have the potential to provide aignificant contribution towards efforts to improve patientxperience and outcomes (Sales, 2009). However, this alsoighlights the importance of achieving a high level ofethodological and reporting quality in local QIPs as well
s formal research studies. Despite their local nature,mall-scale projects have the potential to generate under-tanding that can help to develop knowledge that can bepplied further afield (Harvey and Wensing, 2003).ombining more formal research studies and local projectsrings both the benefits and challenges of differentxperiences in diverse contexts, using varying methodol-gies and reporting standards. Additionally, the QIPs arekely to inflate any intervention effects and theirombined use as evidence must therefore be treated withaution. There was little variation between the methodo-gical quality and reporting standards of the studiesentified as quality improvement projects and thoseentified as research. This is partly due to the limitedethodology and reporting standards of the research inis area.Given the increasing pressure to minimise the use of
Cs, future local quality improvement projects shouldeek to articulate a clear description of aims, context andtervention. The use of a tool such as SQUIRE toprove reporting standards might improve the trans-
rability of the knowledge gained from these studies tother locations. There is a particular lack of reporting onhe specific local problem of the overuse of IUCs in all ofhe studies and without this information it is difficult tonderstand how any intervention works. Calls for theigh quality and consistent reporting of interventions to
prove healthcare have been increasing in recent yearsMichie et al., 2009). The need for a standardised,omprehensive approach to reporting is clear. Whereystematic reviews of interventions have found
provements in healthcare outcomes there is oftenttle explanation of which mechanisms result in thehange and how the processes are taking place (Michiet al., 2009). None of the studies in this review referredo a theoretical model or previous diagnostic work toiscover barriers to change or address cultural normsnd individual beliefs regarding the use of IUCs whenesigning interventions. Eccles et al. (2005) note the
portance of working with theories to understand bothhe processes that underlie clinical practices and howhange in care practices can be effected. They note thathe lack of theoretical framework to guide the selectionf implementation methods may limit the success ofrojects.
Finally, this review highlights the wide variation in theontent and reported acceptability of the ‘indications foratheter placement’ lists used in reviewed studies. In turn,
ese disparities highlight the complexity of defining IUCveruse and raise questions regarding the evaluation andeasurement of overuse. It might be expected that
ariation would occur between studies with medical orurgical settings, but even within these two groups there isttle consensus on what is an acceptable indication for IUCse. Even with similar indications, there is variation in
detail. For example, when using an IUC to manage urinaryincontinence where skin integrity is at risk the statementsvary: Gokula et al. (2007) state ‘‘Urinary incontinenceposing a risk to the patient (e.g. major skin breakdown orprotection of nearby operative site)’’, Patrizzi et al. (2009)state ‘‘Incontinence with skin breakdown,’’ Voss (2009)states ‘‘Wound care management with incontinence’’ andTopal et al. (2005) state ‘‘Urinary incontinence with opensacral or perineal wounds.’’
All of these indications are open to interpretation by theclinician and would potentially lead to inconsistent use ofthe indication guidelines within individual settings,inhibiting the wider standardisation of IUC use indicationchecklists. For example, there is variation between thestudies in the definition of urine output monitoring. Topalet al. (2005) state ‘‘Urinary output monitoring if patientwas unable to collect,’’ Gokula et al. (2007) state ‘‘A need tomeasure output accurately in an uncooperative patient(e.g. intoxication)’’ and Danchaivijitr et al. (1992) ‘‘Record-ing hourly urine output.’’ Again, these statements are opento clinician interpretation.
5.1. Limitations
This review sought to assess the body of evidence forthe efficacy of interventions to minimise the initial use ofIUCs in acute care. Findings were limited by quality issues(both methodological and reporting quality) and theheterogeneous characteristics of the studies included.Furthermore, the impact of the interventions variesenormously as would be expected when comparing, forexample, an intervention introducing the routine use ofbladder scanners with an intervention to introduce the useof an indication sheet. The search terms and eligibilitycriteria used by this review did not specify clinical area andallowed this heterogeneity.
There were few studies eligible for this review. Themain reason many studies were excluded was that they didnot report the impact of an intervention on the level ofinitial IUC placement. Instead, many studies reportedchange in rates of CAUTI. The focus on reducing CAUTIrates rather than the overall use of IUCs might explain whythe reduction in initial placement has received lessattention than the prompt removal of IUCs already insitu. Fakih et al. (2012) used a simulation model tocompare 100 hypothetical interventions to reduce the rateof CAUTI, analysing the impact on the frequently usedCAUTI rate (CAUTI per 1000 catheter days) and theirproposed ‘‘population CAUTI rate’’ (CAUTIs per 10,000patient days). They concluded that, when evaluating theeffect of a CAUTI reducing intervention, the measureshould include the risk to all patients receiving care in thehospital. The adoption of this approach might lead to agreater focus on the initial inappropriate use of cathetersrather than reducing infection rates in those patients whoare catheterised.
The lack of clarity on when the benefits of using an IUCoutweigh the risks makes evaluating the overuse of IUCsdifficult. What is considered an acceptable justification forplacing an IUC in one setting might not in another whichcomplicates comparisons between studies.
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C. Murphy et al. / International Journal of Nursing Studies 51 (2014) 4–1312
Finally, only one reviewer completed data extractiond assessed the quality of the research studies found.
. Implications for policy, practice and research
This is the first systematic review of evidence on anportant clinical quality issue. The evidence found is not
bust enough to determine the effectiveness of anytervention to minimise the overuse of IUCs or make anycommendation for QIP strategies.
However, this work does highlight that qualityprovement interventions designed to minimise the
itial placement of IUCs would benefit from work toderstand pre-intervention the local culture of use ande causes of overuse. Additionally, it has been made clearat, if a list of indicators for appropriate IUC initialacement is used to guide practice, it should beambiguous and appropriate to the setting. Currentlye evidence is weak, but it might also be beneficial tombine both an educational component and a practical/source based component within the intervention.
There are deep-rooted questions that need to beswered before the efficacy of interventions can beaximised. There is a need for greater understanding ofhen the placement of an IUC is necessary, whatnstitutes IUC overuse and the eventual development at of consistent, evidence based, setting-appropriate,nician-friendly indicators for the initial placement of
IUC. To inform this work, it would be beneficial toplore how and why clinicians make decisions in a realorld context.
Conclusion
Understanding of interventions to reduce the initialacement of IUCs is poor. Furthermore, there is a lack ofnsensus as to when the initial placement of an IUC ispropriate. More work is needed to establish what thepropriate indications for IUC placement are in order torify the definition of IUC overuse and develop robust
search on the potential of interventions to reduceeruse.
nflict of interest
None declared.
nding
None declared.
hical approval
None declared.
pendix A. Supplementary data
Supplementary data associated with this article can beund, in the online version, at http://dx.doi.org/10.1016/nurstu.2012.12.007.
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