Houdini Protocol: A Nurse-Driven Practice Change Research Papers Example

Patient Care Description

At the Spartanburg Regional Healthcare System, current policies in regards to urinary catheterization state that there must be an approved indication for insertion. The indications are I & O monitoring at hourly or every two-hour intervals; acute exacerbations of chronic heart failure where diuretic therapy requires I & O monitoring; comfort care during terminal illness; incontinence with perineal, ischial, or sacral Stage III or IV pressure ulcers; urologic surgery; surgical need; chronic urinary retention; diagnostic purposes; and others that must be specified. The patient must be assessed daily to determine if there is still an acceptable indication justifying continued catheterization in order to prevent unnecessary Foley occurrence (UFO). If not, the nurse must ask the physician if the catheter can be removed. If a nurse works the night shift and the assessment shows there is no indication but cannot reach the physician, he or she can leave a pink communication form on the patient’s chart to request for a stop order.

The Need for Change

Catheter associated urinary tract infection (CAUTI) is a possible complication of catheterization. It is the second most commonly reported nosocomial infection and may lead to pyelonephritis, septic arthritis, endocarditis, and bacteremia among others (CDC, 2015). CAUTI causes unnecessary suffering to patients, prolongs hospitalization, increases the costs of healthcare, and may lead to death. A key risk factor in the occurrence of CAUTI is prolonged catheterization. Hence, the intent of the Spartanburg Medical Center’s policy is to address this risk by decreasing the occurrence and duration of catheterization.
However, the current policy often causes delays in the removal of catheters when there is no longer a valid indication for it. The role of the nurse is to assess the patient, document the information, and relay a request to discontinue the catheter. However, noncompliance or failing to perform these tasks is one cause of delay. Because the physician has to give the order to do so, the lack of timely stop orders inadvertently prolongs catheterization. While the hospital’s CAUTI incidence per 1,000 urinary catheterization days have gone down since the policy was implemented, zero CAUTI remains an elusive goal. Further practice improvements are necessary to achieve sustained reductions in the CAUTI rate and require the greater empowerment of nurses in designing better systems of catheter discontinuation.

Rationale and Decision-Making

The current policy was the result of a physician-led multidisciplinary quality improvement initiative through the infection control committee led by an infectious disease specialist. Represented were the disciplines and sub-disciplines of medicine, surgery, nursing, microbiology, central sterilization services, environmental services, risk management, and quality control. It was the committee who, as early as 2009, assessed the trends and current CAUTI rate, conducted a rapid cycle analysis to determine the contributory factors, and planned and implemented the current policy. The rationale for instituting the policy was the PPACA and its mandate to improve the quality of health as well as the value-based purchasing system established by the CMS.
The decision makers decided to implement the current policy as it was based on research evidence. Guidelines from the CDC, the Surgical Care Improvement Project (SCIP), and other evidence-based sources were employed. Adopting EBP increased the probability of safe, effective, and cost-efficient interventions. In keeping with the principle of multidisciplinary care, the role of concerned disciplines in the prevention of CAUTI was established. Coordination between the nurse and physician in decisions to remove a catheter was regarded as necessary in promoting awareness of the issue and joint accountability.

Recommendation for Practice Change

A primary nursing practice issue that needs to be addressed is compliance with patient assessment for possible urinary catheter removal while the patient care issue is timely urinary catheter removal. A common reason for noncompliance was that the nurses simply forgot to include catheter indication assessment when they provided care related to activities of daily living. Clearly, a tool is needed to promote greater awareness of the relationship between CAUTI and prolonged catheterization and the impact of compliance to indication assessment on patient outcomes. The tool must also link catheter removal with post-catheter removal care.
The HOUDINI criteria are an appropriate tool in enhancing staff compliance and timely catheter removal. The term “Houdini” refers to Harry Houdini (1874-1926), an American magician and escape artist who performed disappearing acts (The Library of Congress, n.d.). The HOUDINI protocol was developed by nurses at BJC Healthcare System in Missouri (Trovillion et al., 2011). It was pilot tested by nurses in an acute care hospital in England. The protocol’s “tagline” was “make that urinary catheter disappear” (Adams et al., 2012, p.44). The reference to Harry Houdini was one way of making the protocol easier to remember and thus more likely to be performed, i.e. assessing the patient can make the urinary catheter disappear and in the process, so will the risk for CAUTI.
HOUDINI is an acronym of the acceptable indications or criteria for keeping a urinary catheter in place as shown in Figure 1. The acronym can conveniently be displayed as posters, reminders on the carts or in patient rooms, or given as handheld cards to remind individual nurses. It differs from the current policy at Spartanburg as it does not specifically refer to I & O monitoring in CHF and surgical/operative need. The former is subsumed in Intake & Output which is “I” in the acronym. The latter is more appropriately managed using SCIP guidelines. HOUDINI also includes hematuria and immobility that are not in the current policy while the current policy specifies diagnostic need as an indication but is not added in HOUDINI. The HOUDINI criteria are supported by a literature review of available evidence.
Figure 1. HOUDINI Criteria for Continuing a Urinary Catheter
The HOUDINI criteria can be integrated into a protocol to streamline care. Daily, the nurse must include in her assessment an evaluation of the continuing need for the urinary catheter using the HOUDINI criteria. If one of the indications exists for the patient, the nurse should perform catheter care. If none of the indications exist, however, the nurse must discontinue the urinary catheter and perform post-urinary catheter care to promote voiding. There is no need to ask the physician for a stop order and wait for it unless there is an order to do so. Thus, the HOUDINI protocol can improve compliance through steps that are both easy to remember and follow.
Implementation of the HOUDINI in hospitals within the BJC Healthcare System resulted in a 2.8% to 7.5% reduction in urinary catheter utilization in 5 of the hospitals compared to baseline (Trovillion et al., 2011). There were no significant improvements in 2 of the hospitals, but this was attributed to low rates of staff compliance estimated to be only 20%. The intervention further facilitated communication with physicians regarding the issue of urinary catheters wherein there was support for the use of the protocol because it resulted in less interruption in the workflow. It was also clarified that physicians could write specific orders for the urinary catheter if the protocol did not apply to the patient.
The pilot study by Adams et al. (2012) in three wards - elderly care, respiratory medicine, and gastroenterology - validated the findings of Trovillion et al. (2011). The pilot demonstrated a 17-percent decline in the duration of usage of urinary catheters compared to baseline. Compared with a control group, the intervention group also demonstrated a 70-percent decline in laboratory-confirmed Escherichia coli in urine samples. The HOUDINI was further found to be highly acceptable to the staff who found the intervention easy to implement as it did not require time-consuming paperwork. At the same time, it was not focused on finding out what nurses did wrong but instead assisted nurses to do what needed to be done. The results facilitated the adoption of the HOUDINI by different trusts in the UK National Health Service since 2013.

Relevant and Credible Sources

The following studies support the HOUDINI criteria or protocol and can be used to inform the decision for practice change:
1. Adams, D., Bucior, H., Day, G., & Rimmer, J. (2012). HOUDINI: Make that urinary catheter disappear – nurse-led protocol. Journal of Infection Prevention, 13(2), 44-46. doi: 10.1177/1757177412436818.
2. BJC Healthcare Infection Prevention and Epidemiology Consortium (2012). Prevention of catheter-associated urinary tract infections. Retrieved from http://www.bjclearn.org/courseware/CAUTI/Prevention%20of%20CAUTI%20Module% 202012.pdf
3. Prayle, H., Thompson, M., Lancaster, S., Molyneux, R., & Tsang, J. (2014). Early removal of urinary catheters in patients with hip fracture using the HOUDINI checklist. Age and Ageing, 43(Suppl 1), i8-i11. doi:10.1093/ageing/afu036.35.
4. Tiger Institute for Health Innovation (2014). Reducing CAUTI infection rates. Retrieved from http://www.tiger-institute.org/2014/reducing-cauti-infection-rates/
5. Trovillion, E.W., Skyles, J.M., Hopkins-Broyles, D., Recktenwald, A., Faulkner, K., Rogers, A.D., Woeltje, K.F. (2011). Development of a nurse-driven protocol to remove urinary catheters. Society for Healthcare Epidemiology of America (SHEA) 2011 Annual Scientific Meeting presentations. Retrieved from https://shea.confex.com/shea/2011/webprogram/Paper4451.html

Clinical Implications of Practice Change

A reduction in catheter utilization and the risk to CAUTI support increased patient safety and are the most important clinical implications of practice change. The health system-wide implementation of the HOUDINI at BJC and the pilot study in the UK show that it is an effective intervention with statistically significant reductions in utilization ranging from 2.8% to 17% and a lower detection rate of CAUTI-associated bacteria in the urine (Adams et al., 2012; Trovillion et al., 2011). Implementation among patients with hip fracture effectively increased the number of catheters removed within a week following insertion from 45% to 82% (Prayle et al., 2014). The adoption of the protocol at the Missouri University Health Care also led to a 5% reduction in the rate of catheter utilization in the ICU and a 2% reduction in rate in non-ICU settings (Tiger Institute, 2014). While the studies did not employ CAUTI incidence rate as an outcome given that factors related to the insertion and care of the catheter also influence this indicator, reduced risk is expected to contribute to lower incidence rates. Better care would translate to shorter stays in the hospital, lower health care cost, and less harm to patients.

Organizational Implications of Practice Change

The practice change implies changes in systems and processes. Providing staff education will be necessary to improve knowledge and skills related to the HOUDINI protocol (Adams et al., 2012; Prayle et al., 2014; Tiger Institute, 2014; Trovillion et al., 2011). Reminders such as posters, hand-held cards, and notices have to be produced and installed in prominent places or distributed to the staff (Adams et al., 2012; Trovillion et al., 2011). A committee or project team has to be formed or assigned the task of planning, implementing, and evaluating the intervention with collaboration between different disciplines (Adams et al., 2012; BJC Healthcare, 2012; Tiger Institute, 2014). Surveillance systems including may need to be improved to promote data collection on catheter utilization for research as well as project monitoring and evaluation (BJC Healthcare, 2012; Prayle et al., 2014). A budget will also need to be allocated for the project.
While there is a cost to adopting the protocol, it helps reduce health care costs (Adams et al., 2012; BJC Healthcare, 2012; Tiger Institute, 2014) which can translate into annual savings for Spartanburg Healthcare. Hence, the benefit is a more efficient use of resources. At the same time, improvements in CAUTI rates permit the organization to qualify for incentive payments within the CMS’ value-based purchasing program. Incentives are tied to significant improvements in care. Enhancing safety through CAUTI prevention will further assist Spartanburg Healthcare in realizing its mission of providing excellent care. Further, the organization can continue to be competitive in the industry where consumers now consider quality indicators in their choice of where to seek health care. Lastly, the collective experience of implementing practice change improves the capability of the organization’s human resources.

Involving Key Stakeholders

The primary stakeholders in the practice change are physicians and nurses. A collaborative approach to planning and implementation will ensure their participation. Collaboration fosters common ownership of the initiative as each discipline is able to contribute to the design and implementation (Bankston & Glazer, 2013). Ownership, in turn, fosters commitment to successful practice change. In regards to eliciting the compliance of staff nurses, providing opportunities for them to participate in decision-making related to the practice change promotes buy-in. This is because they fully understand the need for the change and how it can improve direct care practice. With participation such as through meetings and discussions, concerns can be raised and addressed that enhances acceptance of the practice change.

Specific Barriers and Overcoming Them

There are several possible barriers to practice change. One is the lack of management support that can result in lukewarm acceptance especially from other disciplines. However, a culture of safety is in the process of being established in the organization with a stronger role being given to quality improvement personnel. Evidence-based practice and quality improvement are consistent with this culture. Research and quality improvement activities have data collection as a common ground. Surveillance data before, during, and after change implementation can be analyzed within a quasi-experimental approach, specifically the before-and-after design. Meanwhile, research and EBP have the HOUDINI intervention as common ground. As such, research activities can be integrated with the current safety culture. Nurses can write down a proposal for the study for presentation to leadership to obtain permission and formalize their support.
Another barrier is job dissatisfaction of staff nurses primarily due to inadequate staffing. Initially, resistance might be strong if the practice change is perceived as another paperwork burden or another task that needs extensive learning and mastery. Related to this is the hiring of agency nurses who may not be familiar with the HOUDINI protocol. To overcome these barriers, the staff will be encouraged to participate in the planning and implementation. For instance, implementation at the unit level will be left to the unit staff. They will be empowered to make decisions as they see fit in relation to staffing issues specific to their context but will be guaranteed support from the project team or committee members if needed.

Change Implementation

It is important to have a framework for the change process as relevant models have empirical support and thus can serve as guides in implementing change. Probably because of journal space constraints, the studies mentioned above did not include a discussion on framework. One applicable theory, however, is Kurt Lewin’s change theory which posits that change is a linear process consisting of the stages of unfreezing, moving, and refreezing (Mitchell, 2013).
Unfreezing is the stage wherein the need for change is communicated to stakeholders. Change is commonly an uncomfortable period for the staff because it means modifying usual ways of thinking and doing that have become their comfort zone (Mitchell, 2013). Hence, resistance is an expected reaction, but if the rationale for the change is clear and supported in actual practice, buy-in will be easy to obtain. Staff education was a change strategy of the BJC Health Care System (2012), Prayle et al. (2014), the Tiger Institute (2014), and Trovillion et al. (2011) in the implementation of HOUDINI. A practice review comparing current practices with best practices in the literature was also done and presented as basis for the change (BJC Health Care System, 2012). On the other hand, Adams et al. (2012) employed ward meetings to raise awareness of CAUTI utilization and how the HOUDINI helps resolve the issue.
Another strategy in promoting change is employing the plan-do-study-act (PDSA) cycle (Adams et al., 2012). By implementing change in a small scale such as a pilot and then studying the outcomes as well as improving the project before full-scale implementation, evidence that the intervention will result in expected outcomes will help convince the staff to support it. Another useful framework is Carl Roger’s diffusion of innovations theory (Kaminski, 2014). The nurses involved in the pilot study and who have direct experience in using the HOUDINI protocol and seeing its benefits can act as champions or opinion leaders who can facilitate the diffusion of the new practice to the staff in other units.
In addition, physicians who have received communication in regards to the removal of a patient’s urinary catheter and knew the protocol is working as described in the planning phase will most likely promote its benefits among peers (Trovillion et al., 2012). Change is subsequently implemented during the moving stage. Adams et al. (2012) and Trovillion et al. (2011) reported the development of policies to enforce the new practice. Protocols were also formulated to standardize the HOUDINI. In the study by Adams et al. (2012), visual reminders in the workplace were also installed to promote the change. Frequent communication with the nursing staff regarding practice change and feedback was also reported by the Tiger Institute of Healthcare Innovation (2014).
Last, the refreezing stage entails sustaining adherence to the new practice so that it becomes the new norm (Mitchell, 2013). The Tiger Institute (2014) used a reward system to sustain staff compliance with the practice change. Surveillance systems and periodic communication of outcomes assisted in refreezing. For instance, Adams et al. (2012) collected monthly data on urinary catheterization prevalence while Trovillion et al. (2011) also collected monthly data on urinary catheter utilization and ratios. Presenting these numbers as trending data communicates progress and continually motivates the staff to further improve practice to achieve even better outcomes.
The Tiger Institute (2014) included EMR adjustments with practice change. Specific to the Spartanburg Healthcare System, technology can also be used to also support the implementation of change. The HOUDINI assessment criteria can be integrated as a checklist so that during documentation, the nurse only needs to check the appropriate indication or no indication depending on patient assessment. The protocol can further be built into the documentation system. Only after using the criteria can a nurse proceed to the documentation of either continuing catheter care or catheter removal. In so doing, the protocol is both complied with and properly documented. Staff training should include the changes in the electronic documentation system.

References

Adams, D., Bucior, H., Day, G., & Rimmer, J. (2012). HOUDINI: Make that urinary catheter disappear – nurse-led protocol. Journal of Infection Prevention, 13(2), 44-46. doi: 10.1177/1757177412436818.
Bankston, K., & Glazer, G. (2013). Interprofessional collaboration: What’s taking so long? Online Journal of Issues in Nursing, 19(1). Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/ OJIN/Columns/Legislative/Interprofessional-Collaboration.html
BJC Healthcare Infection Prevention and Epidemiology Consortium (2012). Prevention of catheter-associated urinary tract infections. Retrieved from http://www.bjclearn.org/courseware/CAUTI/Prevention%20of%20CAUTI%20Module% 202012.pdf
Kaminski, J. (2014). Diffusion of innovation theory. Canadian Journal of Nursing Informatics, 9(1-2). Retrieved from http://cjni.net/journal/?p=1444
Mitchell, G. (2013). Selecting the best theory to implement planned change. Nursing Management, 20(1), 32-37. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23705547
Prayle, H., Thompson, M., Lancaster, S., Molyneux, R., & Tsang, J. (2014). Early removal of urinary catheters in patients with hip fracture using the HOUDINI checklist. Age and Ageing, 43(Suppl 1), i8-i11. doi:10.1093/ageing/afu036.35.
The Library of Congress (n.d.). Harry Houdini collection. Retrieved from http://www.loc.gov/rr/rarebook/coll/122.html
Tiger Institute for Health Innovation (2014). Reducing CAUTI infection rates. Retrieved from http://www.tiger-institute.org/2014/reducing-cauti-infection-rates/
Trovillion, E.W., Skyles, J.M., Hopkins-Broyles, D., Recktenwald, A., Faulkner, K., Rogers, A.D., Woeltje, K.F. (2011). Development of a nurse-driven protocol to remove urinary catheters. Society for Healthcare Epidemiology of America (SHEA) 2011 Annual Scientific Meeting presentations. Retrieved from https://shea.confex.com/shea/2011/webprogram/Paper4451.html