Children in the pediatric intensive care unit often can't tell nurses how their bodies are reacting to treatment or medicines, either because they cannot speak, are in and out of consciousness, or because everything feels so strange and scary. Instead, nurses rely on clear, accurate measurements, with urine output one key to understanding what's going on inside the patient's body. This has often meant using a urinary catheter.
Maybe too often, says Johns Hopkins University School of Nursing DNP student Judy Ascenzi, who points to an increase in catheter-related urinary tract infections in children as evidence that "sometimes less is best."
Ascenzi is part of a team of Johns Hopkins nurse and physician leaders looking at best practices for when a catheter is the right call for a seriously ill child, how long one can or should be used, and how to prevent it from leading to a potentially deadly urinary tract infection. Ascenzi says she became fascinated with the catheter-infection link during her work studying intubation and bloodstream-infection links in critically ill children. In the pediatric ICU, she says, she was surprised to see that "there were so many kids with urinary catheters." Why? It was just done that way. The ICU culture prescribed it. That was a red flag.
The statistics are out there on catheter associated urinary tract infections (CAUTIs) in adults--after five days on a catheter, a patient's risk of urinary tract infections begins to multiply; an estimated 32 percent of all healthcare associated infections can be blamed on catheters; catheters can be a breeding ground for antibiotic-resistant strains of bacteria. But "nobody talked about the kids."
The team, which includes the School of Nursing DNP Director, Mary Terhaar, DNSc, CNS, RN and faculty member Joanne Silbert-Flagg, DNP, CPNP, and Marlene Miller, MD, MSc of Johns Hopkins Children's Center, determined the answer was to try to "bundle" accepted best practices. It worked with pediatric ICU nurses to make those practices automatic (things "that every caregiver performs 100 percent of the time every day on every single patient"), and observed whether CAUTIs declined. The team might not know for sure exactly which best practice was the reason, a process that would take a much longer time, but could say that this bundle helps reduce infections, so the safety of patients could be increased in the meantime.
"The care a nurse provides in the ICU is complex," Ascenzi says, stressing that procedures and not people should be faulted when caregivers fail to do the right things, like being lulled by the convenience of a catheter and accidentally opening the door to an infection that could significantly compromise a fragile child. "We're multitasking. It is easy to forget the simple things because we become so focused on the high-tech things."
One simple thing, she says, is considering diapers instead of catheterization, which usually involves inserting a tube through the urethra to the bladder. "We're asking nurses to be a little creative--working to get people to realize that there are other avenues to measure urine output that do not rely on a catheter." There is a scale, for instance, that measures the weight of a dry diaper vs. one that is wet, down to the cubic centimeter. It can be as accurate a gauge as a catheter bag, she says, acknowledging that diapering young patients isn't a revolutionary idea. "Diapering is routine in less sick patients," Ascenzi says, "but getting people to accept that it is OK in really sick kids has been the challenge."
Hand-washing and extra-careful handling of catheters, lines, and specimen bags (every time, every day, every patient) are other small tasks that can be lost in translation--or transition, as staff turnover is a big part of any working environment. "If this sounds a bit obsessive, it's meant to be. That's one lesson I've learned: Good care is a given, all the time," Ascenzi says.
So far the team's efforts show promise. "I haven't gotten all of the data analyzed yet, but I can tell you anecdotally that we've had improvement," she says. "And we are seeing buy-in."
That would take one very large bundle of worry off the minds of the parents in the waiting room.
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