ITS 72 - Engagement with Electronic Medical Record Documentation for Prevention of Catheter-associated Urinary Tract Infections

Background: Catheter-associated urinary tract infections (CAUTIs) present negative, and highly complex, consequences for patients and healthcare organizations. Following a literature review of current CAUTI prevention evidence-based practices (EBP), it was determined there was opportunity for development in professional nursing electronic medical record (EMR) documentation of indwelling urinary catheters (IUCs) to promote CAUTI prevention.

Methods: An interdisciplinary team, composed of Infection Prevention, Information Systems (IS), Nursing Education, and direct-care professional nurse (RN) members, reviewed and revised the EMR documentation of IUCs. The team identified EMR documentation fields for alignment with CAUTI prevention EBP and how to foster continued critical evaluation of IUC function by the RN completing EMR documentation. In October of 2020, the EMR revisions were implemented. RNs were educated on the updates electronically and through in-person on-boarding by colleagues with IS expertise.

Results: Five EBP-based novel documentation fields were created. Site Assessment included options to note potentially infectious changes at the IUC insertion site. Signs of Leakage promoted monitoring of drainage from the system. Urine Flow supported assessment of unobstructed passage of urine. The Concerns for Infection field, with multiple-selection options such as bladder discomfort and fever, was implemented to encourage detailed review of CAUTI-associated signs and symptoms. Previously present fields were revised. Indications was edited to include the current recommendations for IUC use. Catheter Secured was expanded to identify the devices available for preventing movement of the IUC within the urethra and bladder. Drainage System was clarified to include the type of urinary collection bag a patient had in place and to promote the practice of maintaining a closed system for CAUTI prevention. Two fields were removed as they were non-essential to RN IUC assessment.

Conclusions: Utilizing an interdisciplinary team’s EMR documentation review and revision to support RN evaluation of IUCs is one component of administrative infrastructure for CAUTI prevention.