| Objective:To summarize the best evidence for the prevention of catheter-associated urinary tract infection(CAUTI)in adult patients in ICU,analyze the obstacles to the implementation of CAUTI prevention evidence compliance by ICU nurses,and evaluate the effect of transformation strategy on improving nurses ’ compliance.Methods:This study was comprised of three parts:Part Ⅰ: Evidence Summary.A approach of evidence-based summary was taken with computer searches of electronic databases,guidelines websites,professional associations.All evidence on the prevention of catheter-associated urinary tract infections in adult ICU patients,including guidelines,evidence summaries,expert consensus and systematic reviews.Three researchers used AGREE II to evaluate the literature quality of the guidelines,and two researchers used the literature quality evaluation criteria of the Australian JBI evidence-based health care center to evaluate the literature quality of other types of research.After two researchers independently extracted and translated the evidence,they were reviewed by experts.Finally,according to the corresponding principles,the evidence of the same content,complementary content,conflict content and independent content were summarized and sorted out.Part Ⅱ: Analyze barriers and construction of translational strategies.First,Clinical applicability evaluation of the extracted evidence was carried out in the form of an expert panel meeting to form review indicators.An interrupted time series design was used to review the current status of compliance with the best evidence of CAUTI prevention implemented by nurses in the emergency intensive care unit(EICU)and neurology intensive care unit(NICU)of a tertiary care hospital in Yunnan Province from June to August 2022,with a 15-day node and data collected from 1 to 6 nodes to identify the gap between clinical practice and the best evidence.Next,the current status of nurses’ knowledge,attitudes,and behaviors was understood based on(i)distribution of the Catheter-Associated Urinary Tract Infection Prevention Knowledge and Belief Behavior Scale to nurses;and(ii)semi-structured interviews with nurses based on the review data to collect possible difficulties and concerns of nurses’ adherence to the evidence from the nurses’ perspective and to summarize the factors that are barriers to nurses’ implementation of the evidence for CAUTI prevention.Finally,the Evidence-Based Nursing Practice Readiness Assessment Scale was distributed to nurses to understand the readiness of the ward to implement evidence-based nursing practice and to further refine the barrier factors.An expert panel meeting was used to construct a translation strategy in the form of a translation plan by synthesizing the pre-collated barrier factors and the results of the readiness of the ward to carry out evidence-based nursing practice.Part Ⅲ: Evidence introduction and effect evaluation.According to the interrupted time series design,nurses in the emergency intensive care unit and neurology intensive care unit,patients admitted to the emergency intensive care unit and neurology intensive care unit from June to August 2022 were used as the control group,and data on nurses’ compliance rate with evidence of CAUTI prevention implemented at 1 to 6 nodes and patients’ length of indwelling catheter and CAUTI rate were used as baseline data;and patients in the emergency intensive care unit and neurology intensive care unit from November 2022 to January2023 emergency intensive care unit and neurology intensive care unit nurses,patients admitted to the emergency intensive care unit and neurology intensive care unit as the intervention group,and data on nurses’ compliance rate for implementing CAUTI prevention evidence at 7 to 12 nodes and patients’ length of indwelling catheter and CAUTI rate were collected for comparison with baseline data.The intervention group implemented the conversion program on the basis of the control group,focusing on the feedback of the review index data with lower compliance rate before the implementation of the conversion program and implementing the process intervention.Finally,the difference in the mean nurse adherence rate before and after the implementation of the program was evaluated,and the nurse adherence rate at each node after the implementation of the program was compared to the baseline with the nurse adherence rate at node 6 and compared to the previous node to evaluate the change in nurse adherence rate after the implementation of the program.Second,the impact of this evidence-based nursing practice on the system level,patient level,and practitioner level was evaluated.Results:Results of Part Ⅰ: Evidence summary results.A total of 15 publications,including6 evidence-based guidelines,2 expert consensus,and 7 systematic reviews were included in this study,and 37 pieces of evidence were extracted,and the evidence themes were further refined and organized into eight areas including indications for retention assessment,catheter retention,catheter maintenance,catheter removal,tissue management,feedback,urine specimen collection,and others.Results of the Part Ⅱ: Analysis of barriers.Thirteen experts applied the FAME strategy to evaluate the clinical applicability of 37 pieces of evidence and finally formed 22 review indicators for the 23 pieces of evidence to be included in clinical translation,including 18 at the health care worker level,1 for the commissioner of the Office of Sensory Control,and 3 at the system level.After implementation of the status review,the adherence rate was 0% for 1 review indicator(indicator 21)at the system level,0% for 3 review indicators(indicators 1,9,and 11)at the healthcare professional level,and 7.89% to 98.75% for 5 review indicators(indicators 2,4,10,15,and 16).The adherence rate for the remaining review indicators was 100%.After administering the questionnaire to 55 nurses,it was found that the nurses scored low on the knowledge dimension,with knowledge(indications for indwelling catheters)at only 58.18% and knowledge(strategies for CAUTI prevention)at 69.18%,and the attitude and behavior scores were moderate.After in-depth interviews with 12 nurses,six themes were extracted including lack of knowledge,serious stereotypical thinking,increased workload,inadequate human resources,lack of decision-making power,restricted space,and lack of confidence in the effectiveness of the reform.The evidence-based team first combined the questionnaire and qualitative interviews to brainstorm around the 7 review indicators with low adherence rates in the status quo review and analyzed 16 barrier factors,and secondly,combined with the evidence-based nursing practice readiness survey,a total of 17 barrier factors were obtained to develop 17 transformation strategies under the guidance of experts.The evidence-based team formed the transformation strategies into a transformation plan by brainstorming method.Results of the Part Ⅲ: Compliance improvement.The control group included 210 patients and 55 nurses;the intervention group included 228 patients and 55 nurses.There was no significant difference in baseline data between the two groups(P>0.05),and there was no change in nurses before and after the implementation of the program.During the implementation of the program,two process interventions were conducted on nodes 8 and 10 for the review indicators with low compliance rates.As of node12,22 review indicators except indicator 16(compliance rate was 25%),the compliance rate of other review indicators was>90%.There was a statistically significant difference in the average compliance rate of nurses before and after the implementation of the program(P<0.05).Among them,with node 6 as the baseline,the compliance rate of index 1 increased from 0 % to 96.67 %,the compliance rate of index 9 increased from 0 % to 100 %,the compliance rate of index 10 increased from9.09 % to 92.59 %,the compliance rate of index 11 increased from 0 % to 100 %,and the compliance rate of index 15 increased from 4.54 % to 98.77 %.The compliance rate of indicators 1 and 9 at the end of the 8th node has been significantly improved,compared with the previous node(node 7),the difference was statistically significant(P<0.01);index 10 and index 15 showed a significant increase in compliance rate after the end of the 9th node,and the difference was statistically significant compared with the 8th node(P<0.01).Through evidence-based nursing practice,the changes are as follows : at the system level,the department updates the routine in time,improves various operational procedures,establishes a regulatory feedback mechanism,and rationally allocates human resources;at the patient level,the catheter indwelling time and CAUTI rate in the intervention group were lower than those in the control group.Compared with before the implementation of the program,the difference in catheter indwelling time was statistically significant(P<0.05).At the practitioner level,the nurses ’ awareness rate of CAUTI retention indications and prevention strategy knowledge was improved,and the difference was statistically significant(P<0.05).The scores of the organizational environment sub-scale and the promotion factor sub-scale in the evidence-based nursing practice preparation were higher than before,and the difference was statistically significant(P< 0.05).Conclusions:1.The evidence summarized in this study is mainly based on severe patients,which is highly consistent with the situation of clinical transformation of evidence in the later stage.The content of 37 pieces of evidence extracted and integrated by evidence-based method is comprehensive,which can provide a comprehensive management basis for CAUTI prevention.2.Based on the gap between clinical practice and evidence,this study takes nurses as the main body,and combines questionnaire survey and semi-structured interview analysis to obtain 17 obstacle factors.The transformation strategy for the construction of obstacle factors is targeted around the problem of nurse feedback.3.Through the implementation of evidence transformation and application,the compliance rate of nurses has been improved,while promoting the improvement of relevant processes and mechanisms at the system level,improving patient outcomes,improving nurses ’ mastery of relevant knowledge,and further standardizing the clinical practice of catheter-related urinary tract infection prevention. |
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