Interventions to reduce urinary catheter use: it worked for them, but will it work for us?

To cite: Meddings J. BMJ Qual Saf 2013;22:967–971. In most hospitals, four steps are required to remove a urinary catheter: the physician recognises the patient has a catheter in place; the physician realises the catheter is no longer necessary; the order is written to remove the catheter; and the nurse removes the catheter. Interventions to prompt removal of unnecessary urinary catheters by expediting these steps are primarily of two types: ‘reminders’ which function to simply remind that a urinary catheter is in place and should be removed if unnecessary and ‘stop orders’ which prompt nurses or physicians to remove catheters based on criteria, such as 24– 48 h after surgery 7 or when the patient no longer meets other clinical criteria. These interventions can be implemented using a range of technology, as complex as a computer-generated reminder or stop order 13–15 initiated with each catheter order, or as simple as printed postprocedure order sets 7 with stop orders, sticker reminders on charts 4 or catheter bags, a mandatory daily verbal reminder from nurses to physicians of catheterised patients, or as a reminder on a checklist 17 18 used daily on rounds. These interventions can be directed at either physicians 13 14 or nurses, with nurse-directed interventions ranging from requiring nurses to remind physicians to order catheter removal 17–20 to nurse-empowered stop orders 21 22 enabling nurses to remove catheters that do not meet appropriate criteria, without requiring an additional physician order. Consequently, there are many options to consider when designing an intervention to facilitate removal of unnecessary catheters, with success demonstrated using all of these options. The article by Janzen et al in this issue of the journal describes an intervention aimed at expediting the process of catheter removal by increasing physician awareness through educational sessions and requiring daily review of catheter necessity, with nurses encouraged to remind physicians to remove catheters. With a significant decrease in catheterisation duration, catheter-associated urinary tract infections (CAUTIs), and even length of stay, readers may be inspired to try similar strategies for their own hospitals with high expectations. But will it work as well? Unfortunately, not all types of urinary catheter reminders (or stop orders) are equally effective. The success of reminders and stop orders in reducing urinary catheter use depends upon the environment in which they are deployed. Because both physicians and nurses have preferences (which may conflict) regarding urinary catheter use and removal, the success of interventions to reduce catheter use depends on how concerns and challenges that arise are addressed, and whether reducing catheter use is seen as a common goal for the team of physicians and nurses, or as a lowpriority recommendation approached with resistance or indifference. Thus, whether the environment promotes respectful communication and problem solving versus turf battles and accountability wars will influence the impact of interventions for reducing urinary catheter use. Because removing catheters requires changes in longstanding caregiver habits, perhaps the most important ‘environment’ influencing the success of a reminder intervention is the pre-existing behaviour and communication patterns of the physicians and nurses. In other words, how much change is required in the routine workflow of the physicians and nurses for the intervention to succeed? For example, Janzen et al describe what sounds like a simple intervention to increase physician awareness of unnecessary catheters by educational sessions, posters, and encouraging nurses to remind physicians to remove the catheters—all of which could be expected EDITORIAL