الفهرس 
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Abstract
Patients in the intensive care unit (ICU) are at a high risk for infections, which
can lead to higher morbidity, mortality, and medical costs. The overall infection rate
in critically ill patients is close to 40%, and it may even reach 50% or 60% in patients
who stay in the ICU for more than five days.
In the intensive care unit, catheter-associated urinary tract infections (CAUTIs)
are the most common healthcare-associated infection. A variety of measures,
including the proper use of an indwelling urinary catheter, are suggested in the
preventative recommendations for CAUTIs. Patients with stroke who are immobile,
have deterioration in consciousness, or have bladder problems frequently need to
have a catheter inserted. Between 12% and 31% of acute stroke patients in a recent
study had indwelling urinary catheters implanted while they were hospitalized.
The majority of urinary tract infections in the ICU occur after the installation of a
convenient, painful, frequently unwanted, and easily forgotten urine catheter, making
it one of the most prevalent hospital acquired infections. In the ICU, urinary catheters
are frequently used. Patients keep one in place to monitor urine flow or to treat
urinary retention and incontinence.
In order to decrease the incidence of CAUTIs and to provide effective and save
catheter care a short term urinary catheter care bundle was developed. A bundle is a
structured way of providing high quality care and improving patient’s outcomes: a
few, straightforward set of evidence-based practices that, when implemented reliably
and collectively, have been proven to improve quality of patient care. Implementation
of UCCBs has been shown to be efficient in decreasing the rate of CAUTIs and
decrease urinary catheterization rates. There for this study carried out to identify
barriers to implementation of a urinary catheter care bundle for critically ill patients
with cerebrovascular stroke in Health Affairs Directorate hospitals in Alexandria
governorate.
A convenient sample of 130 staff nurses who delivered direct patient care to
critically ill patients with cerebrovascular stroke having urinary catheter.
Two tools were used in the current study:
Tool one: Urinary catheter care bundle barriers questionnaire: This tool consists of
four parts.
Part I: Critical care nurses’ socio-Demographic data: It used to collect data
about the studied nurses’ age, gender, marital status, education level and years of
experiences in ICU.
Part II: Critical care nurses’ related barriers: This part includes barriers related to
nursing such as presence of nursing supervision during inserting urinary catheter,
years of experience in ICU, have knowledge about signs and symptoms of infection,
using aseptic technique during insertion and maintenance, attending workshop about
CAUTI prevention, awareness of the nurse about protocol and policy of CAUTI in the
unit, attending training program about UCCBs and having brochure and poster about
inserting urinary catheter.
Part III: Organization related barriers: This part includes barriers related to the
organization such as presence of policy about maintaining UCCBs, presence of
infection control team and link nurse in the unite all over 24 hours, presence of a checklist for inserting and maintaining UCCBs, presence of time plan for inserting
and removing of the urinary catheter.
Part IV: Environment related barriers: This part includes barriers related to the
environment such as adequate number of sinks according to the beds in the unit,
availability of antiseptic solutions for hand hygiene, tissue paper and water, presence
of urine bag holder in bed, availability of sterile equipment for each patient, necessary
material for urinary catheter care such as bladder scanner and close drainage system,
availability of urethral catheter kites and Presence of clean basin for each patient for
urethral meatus. Each barrier was documented as present or not present.
Tool two: Nurses’ knowledge about urinary catheter care bundle for critically ill
patients with cerebrovascular stroke questionnaire:
This tool is a multiple-choice question; it was used to assess nurses’ knowledge
about UCCBs for critically ill patients with cerebrovascular stroke. It contains one
correct answer, two wrong answer and one don’t know answer. It includes three parts.
Part I assesses nurses’ knowledge with cerebrovascular stroke disease, it includes 5
questions, part II assesses nurses’ knowledge about CAUTIs, it includes 5 questions,
part III assesses nurses’ specific knowledge about UCCBs component, it includes 10
questions. The nurse has chosen one answer from the four choices. Nurses’
response to each item varies between correct answer that scored with one and
wrong / don’t know answer that scored with zero. The total knowledge score
calculated and classified into following categories: - High level of knowledge ≥ 75 %,
Moderate level of knowledge ≥ 50% < 75% and Low level of knowledge < 50%.
The main findings of the current study were that:
Regarding UCCB implementation barriers among studied critical care nurses, it
was clear that the majority of UCCB implementation barriers were CCNs related
barriers in nature, followed by environmental related barriers and organizational
related barriers in nature. Barriers related to nurses such as absence of brochure and
poster regarding inserting a urinary catheter, lack of routine assessment and
evaluation of urinary catheter care and need, failure to avoid contact between the
urinary drainage tap and the container when emptying the drainage bag, and absence
of meatal care with soap and water prior to urinary catheter insertion.
Furthermore, organizational barriers such as not having a policy on replacing a
system if there is a break in asepsis, not having a time plan for inserting and
removing the urinary catheter, not having a checklist for inserting and maintaining
UCCBs, not having an infection control team or a link nurse on shift 24 hours a day,
and not having a policy in place to collect CAUTI-related data (urinary catheter
prevalence, appropriateness, and infection rates) in the unit, moreover, environmental
barriers such as the lack of necessary urinary catheter care materials such as a
bladder scanner and a close drainage system, the absence of a clean basin for each
patient for urethral meatus, the absence of sterile lubricant (gel) during urinary
catheter insertion, the absence of urethral catheter kits, and the absence of the
presence and wearing of a sterile gown during urinary catheter insertion.
Finally, it can be recommended that:
Based on the findings of the current study, the following recommendations are
suggested on educational level include: Incorporate urinary catheter care bundle into undergraduate curriculum, educate critical care nurses about care of urinary
catheters using bundle approach with continuous development courses to update
their knowledge regarding new evidence-based practice, foster nurses to attend
workshops about urinary catheter care bundle to clarify their further role in nursing
care, on administrative level include: Implement quality improvement strategies to
enhance appropriate use of indwelling catheters and reduce the risk of CAUTI based
on a facility risk assessment, monitor adherence to facility-based criteria for
acceptable indications for indwelling urinary catheter use and ensure that supplies
necessary for aseptic technique for catheter insertion are readily available.
Further studies are needed for developing educational programs to educate
healthcare providers about the care of urinary catheter, applying this study on a large
popularity sample to validate the results, developing nursing led protocols that
empower nursing staff to remove catheters based on predetermined criteria,
developing catheter restriction protocols to decrease catheter use and/ or CAUTI
rates, using catheter reminder interventions which include a daily checklist or verbal/
written reminder, a sticker reminder on the patient’ chart or catheter bag, or an
electronic reminder that a catheter is still in place. Regarding clinical practice
includes: Use observational checklist to observe healthcare providers during insertion
of urinary catheter, adequate and appropriate adherence with insertion and ongoing
UCCB practices for all staff all the time, availability of link nurse all over 24 hours to
monitor implementation of practices regarding UCCB. Finally regular staff meeting,
training and conference should be conducted to discuss barriers of UCCB
implementation, their categorization and their control.