Hospitals and patients
The hospitals were visited a total of 791 times; 16,495 patients were admitted to the participating wards. The number of patients with a urethral catheter was 3335. Of them 392 patients could not be included, because they were too ill, were nursed in isolation or temporarily absent for examinations or surgery. Of the included patients 483 (16%) were admitted to the intensive care or coronary care unit, 652 (22%) to an internal medicine ward, 1325 (45%) to a surgery ward and 483 (16%) to a neurology ward.
Since time series analysis revealed no significant trends in outcome measures over time before the intervention (data not shown), data from each hospital gathered during the multiple visits before the start of the intervention were combined. The same was the case for data gathered during the visits after the intervention (data not shown). Excluding visits made during the 4-month period of actual intervention activities in the hospitals did not change the results (data not shown). Data from group A and B were merged because no significant differences were found between the groups (data not shown).
Each hospital developed its own implementation strategy (table ). Looking back the activities can be categorized into three types. The first is revision of existing protocols and materials used for catheterization, as was done by seven hospitals. The second category is education and providing information by oral (9 hospitals) or written (8 hospitals) instructions, by posters (6 hospitals), pocket cards (3 hospitals) or holding a competition (1 hospital). The third category is changing daily practice by paying attention explicitly to catheterized patients during the daily work meetings (6 hospitals), putting a reminder on the patient's record (4 hospitals), a fixed stop order for removal of the catheter (1 hospital), introducing a bladder scan (2 hospitals) or involving a specially trained nurse (2 hospitals).
Intervention activities per hospital
Before the implementation activities on the wards started there were 1149 catheterized patients. After the interventions had been started there were 1794 patients.
The average prevalences of urethral catheters before and after the interventions are shown in table for each hospital per ward type. For intensive care and coronary care units the prevalence increased after intervention. On the neurology and internal medicine wards the prevalence decreased although it was not statistically significant. The largest, statistically significant decrease was observed for the surgery wards (table ).
Average catheter prevalence (%) per ward type before and after intervention.
Comparison of catheter prevalence and duration of catheter before and after intervention.
Alternatives for urethral catheterization
The use of alternatives for urethral catheterization such as condom catheters and diapers fluctuated considerably. The prevalence was 12.5% (95% CI 11.7 - 13.3) before and 11% (95% CI 10.4 - 11.6) after the interventions.
Duration of catheterization
The average durations of catheterization before and after the interventions are shown in table for each hospital per ward type. The average duration of catheterization decreased for all ward types. On intensive care and coronary care units and neurology wards the decreases were small and statistically insignificant. Larger and statistically significant decreases were seen on the internal medicine wards and surgery wards (table ). In total, per 100 catheterized patients 460 (95% CI 162 - 761) catheter days were eliminated by the intervention.
Average duration of catheter in days per ward type before and after intervention.
Indications for catheterization
Surgery and monitoring of urine production were the most common indications for catheterization; 60% on the day of insertion and 50% on the day of inclusion in the study. The third most frequent category was unknown reason for catheterization. On the day of insertion this was the case for one-fifth of the catheters and on the study day for almost two-fifth of the cases. Before the intervention 64% of the catheters were inserted for a correct reason, on the day of inclusion this was the case for 50%. After the intervention the percentage of correct indications increased to 74% on the day of insertion and 67% on the day of inclusion (p < 0.0001).
Urinary tract infections
Clinical signs and symptoms observed among the patients were fever (27%), pus along the catheter (3%), pain in the bladder region (5%), abdominal pain (2%), and pain in the renal region (0.5%). Symptomatic urinary tract infection was present in 12.6% of the patients before the intervention and in 12.7% after the intervention. Ninety-five percent of the patients with symptomatic urinary tract infections had bacteriuria besides symptoms. Asymptomatic urinary tract infection was diagnosed in 37.4% of the patients before intervention and in 38.3% after intervention.
The mean costs of the implementation programme per hospital were € 2638, including the implementation expert, and € 1993 without the implementation expert. The costs per hospital varied from € 1023 to € 3763.
The costs of insertion of an indwelling catheter were calculated as € 28, removal of the catheter as € 3 and daily care as € 3. Costs of catheterization per 100 hospitalized patients are summarized in Table . In eight of the 10 hospitals costs of bladder catheterization per 100 patients were less after the intervention than before. The mean amount saved was € 537 per 100 hospitalized patients.