Two of the most prevalent and costly healthcare-associated infections (HAIs) are catheter-associated urinary tract infections (CAUTIs) and central-line–associated bloodstream infections (CLABSIs). 1,Reference Klevens, Edwards and Richards2 When indwelling urinary catheters (ie, Foley catheters) and central-line devices are correctly inserted, properly maintained, and promptly removed, CAUTIs and CLABSIs can be avoided. Reference Gould, Umscheid, Agarwal, Kuntz and Pegues3,4 Although healthcare providers are viewed as responsible for preventing HAIs, the role of patients in infection prevention has also been recognized. Reference Berger, Flickinger, Pfoh, Martinez and Dy5–Reference Fernandes Agreli, Murphy and Creedon7 Empowering patients to participate in patient safety initiatives requires that patients are educated about the risks to their safety and the actions they can take to mitigate those risks. Reference McGuckin and Govednik8
Patient education resources for the prevention of CAUTIs and CLABSIs are available from the Society for Healthcare Epidemiology of America 9–11 as well as the Centers for Disease Control and Prevention. 12,13 However, the need to improve patient education related to the prevention of CAUTIs and CLABSIs is highlighted by studies that have revealed that many patients are unaware of the risks of infection associated with indwelling urinary catheters and central lines. Reference Safdar, Codispoti, Purvis and Knobloch14,Reference Anderson, Ottum, Zerbel, Sethi and Safdar15 Furthermore, there is little current evidence of standardized efforts to educate patients about CAUTIs and CLABSIs, and there is a lack of information from the perspective of hospital leaders and staff about how this education is delivered, what challenges are encountered when delivering patient education, and what opportunities exist for improving patient education. We sought to understand the perspectives of hospital leaders and staff about how patient education is currently utilized to engage patients in the prevention of CAUTIs and CLABSIs to inform the development and implementation of patient education to help prevent these HAIs.
Methods
Study design
We visited 18 US hospitals from September 2017 to November 2019 as a part of a study exploring the role of management practices in the prevention of CAUTIs and CLABSIs. Reference McAlearney, Hefner and Sieck16 Hospitals were selected using a purposive sampling approach that aimed to recruit hospitals with a variety of organizational characteristics (Table 1).
Hospital Study Site Characteristics
Note. CAUTI, catheter-associated urinary tract infection; CLABSI, central-line–associated bloodstream infection.
a Hospital size is indicated by number of hospital beds: small, <300; medium, 300–499; large, 500–899; extra-large, ≥900.
b Hospital performance is indicated relative to the national average according to standardized infection ratios reported by the Centers for Medicare and Medicaid Services’ Hospital Compare data.
Data collection
In total, 471 key informants were interviewed across all hospitals (Table 1). Key informants included administrative leaders (eg, C-suite leaders, n = 51), clinical leaders (eg, clinical directors and managers, n = 137), infection prevention and quality (eg, infection preventionists, directors and managers of quality improvement, n = 102), and frontline staff (eg, nurses and physicians, n = 181). Key informants at each hospital were identified by a site contact who helped ensure that all key informant roles were represented.
We used a semistructured interview guide to ask key informants about their perspectives on management practices to prevent CAUTIs and CLABSIs. This interview guide included questions about systematic education surrounding infection prevention practices (see the interview guide in the Appendix online). Most interviews were conducted in person, one on one, or in small groups, and they lasted an average of 28 minutes. Interviews were audio recorded, transcribed, and deidentified for analysis. The Ohio State University approved this study, and all key informants provided verbal informed consent.
Data analysis
A deductive-dominant thematic analysis was used to categorize themes within the interview transcripts. Reference Armat, Assarroudi, Rad, Sharifi and Heydari17–Reference Miles and Huberman19 Three members of the research team used a preliminary coding dictionary to code a small sample of interviews. Reference Crabtree and Miller20 The preliminary coding dictionary was iteratively revised to accommodate emergent codes and evolving code definitions, and a finalized coding dictionary was then applied to all interview transcripts. Systematic education was one theme identified in the transcripts through our deductive analysis. Through inductive analysis involving the constant comparative method, Reference Glaser and Strauss21,Reference Constas22 we categorized key informants’ perspectives on patient education. ATLAS.ti qualitative analysis software (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany) was used to support this analysis.
Results
Analysis of interview transcripts revealed several topics around patient education for the prevention of CAUTIs and CLABSIs: (1) types of resources used for patient education, (2) methods of educating patients, (3) content of patient education, (4) challenges to patient education, and (5) opportunities to improve patient education.
Patient education resources for prevention of CAUTIs and CLABSIs
Interviewees identified a number of resources for providing patient education about infection prevention (Table 2). These included offering paper resources, such as booklets, packets, and handouts; posted resources, such as signs and posters; and electronic resources, such as the electronic medical record (EMR), patient portals, or the internet.
Patient Education Resources for Prevention of CAUTIs and CLABSIs
Note. CAUTI, catheter-associated urinary tract infection; CLABSI, central-line–associated bloodstream infection; EMR, electronic medical record.
Patient education methods for prevention of CAUTIs and CLABSIs
Interviewees also identified a number of methods by which patient education regarding infection prevention was delivered including at the point of care (eg, during patient care tasks), during clinician rounding, at admission, or at discharge (Table 3).
Patient Education Methods for Prevention of CAUTIs and CLABSIs
Note. CAUTI, catheter-associated urinary tract infection; CLABSI, central-line–associated bloodstream infection.
Patient education content for prevention of CAUTIs and CLABSIs
Interviewees discussed 4 types of patient education topics that were focused on the prevention of CAUTIs and CLABSIs: (1) risks of indwelling urinary catheters and central lines, (2) necessity of hand hygiene, (3) importance of maintenance care for indwelling urinary catheters and central lines, and (4) support to speak up (Table 4).
Patient Education Content for Prevention of CAUTIs and CLABSIs
Note. CAUTI, catheter-associated urinary tract infection; CLABSI, central-line–associated bloodstream infection.
First, interviewees recognized the importance of communicating to patients the risk of infection associated with indwelling urinary catheters or central lines. This education could occur at the time the device was inserted, or it could be reiterated once a patient had a device in place. Interviewees noted the need to educate patients about the importance of removing the device to lower the patient’s chance of infection. This was particularly important because having an indwelling urinary catheter or central line could be perceived by the patient to be a convenience. As one frontline staff interviewee noted, “One of the biggest things I can see about the Foley, it’ll be get the Foley out. You’re trying to educate the patient because, you know, some people will say, ‘Oh, you know the Foley can come out.’ ‘Oh, leave it in, it’s easier.’ So, we do education–there are the risks for infection, and things like that.”
Second, interviewees mentioned patient education about hand hygiene and its role in preventing CLABSIs and CAUTIs. Interviewees mentioned educating patients specifically to wash their hands in relation to touching their devices. As one clinician leader interviewee described, patients would be given the message, “…You have a central line, this is what you should expect. Everybody washes their hands. You wash your hands. You don’t touch it. Same thing with a catheter and, you know, appropriate hygiene care for yourself while you have it.”
Interviewees also recognized the need to educate patients about the importance of the maintenance care they would receive for their devices to help prevent infections. Education surrounding care of central lines was perceived as particularly important because some patients would try to decline this care. One administrative leader interviewee gave this example: “…What we were finding was that the patients were just declining their chlorhexidine [gluconate] baths because, you know, they don’t like it. It’s sticky, …‘No thanks, I do not need that today.’ ”
Supporting patients and encouraging them to speak up when they saw something of concern was another topic of education that interviewees noted. First, interviewees stressed education to support patients speaking up when care providers did not perform proper hand hygiene. Patients were also educated to speak up about the maintenance of their devices. As one frontline manager described, “When we’re rounding on the various bundles, I know that we talk to the patients and let them know what they should be seeing. When someone touches your central line, they should be scrubbing that hub before … We even have little signs hanging in the rooms with a little rubber ducky saying, ‘Scrub the hub.’ …We talk openly with them about what they should expect to see, and they’re free to call it out if they don’t see it to protect themselves.” Lastly, some interviewees discussed encouraging patients to speak up about the removal of their devices, and one clinical leader interviewee gave this example: “… Ask every day. Tell the patient [to] ask, ‘Do I have to have it?’ ”
Challenges to patient education for prevention of CAUTIs and CLABSIs
When discussing patient education for the prevention of CAUTIs and CLABSIs, interviewees emphasized 2 challenges: (1) lack of patient education targeted toward CAUTI and CLABSI prevention and (2) nonstandardized patient education. With respect to a lack of targeted education, some interviewees noted that they were not aware of any patient education for infection prevention; others were aware of general infection prevention education but not of education specific to the prevention of CAUTIs or CLABSIs. With respect to a lack of standardized patient education, one clinical leader explained, “…There is no such thing as a patient with a central line or a Foley, if we are about to place those devices, that we re-educated in a standardized way.” Inconsistency across units in the hospital was also noted as a challenge to delivering standardized education to the patient. One quality leader discussed this challenge with regard to creating patient awareness about the need for their central line hub to be scrubbed for the recommended 15 seconds: “1-2-3 count with me, which is a scrub-the-hub thing, and it really is an engaging of the patient and the family and that process and empowering them to assume that that is going to happen and to intervene… The challenge to that is that it has to roll out at the same time to anyone who would access this line. Another hospital who had done this said our big challenge was yes, we teach this in the inpatient unit and then they go to the outpatient infusion and they go, ‘Wait a second, you didn’t count with me,’ and the person who accesses the line says, ‘What are you talking about?’ So, we have to make sure that everybody knows the plan and that we are consistent in that.”
Opportunities to improve patient education for prevention of CAUTIs and CLABSIs
Finally, interviewees discussed opportunities that could improve patient education for the prevention of CAUTIs and CLABSIs, including (1) use of the EMR to alert clinicians about the need to provide patients with education and (2) involvement of patients and family members in the development of educational materials. Interviewees mentioned that patient education was often documented in the EMR, but they also provided examples of how the EMR could alert providers to the need for patient education. One interviewee described the use of grouped orders in the EMR that would alert the nurse to provide education to the patient if they were at risk of developing a CAUTI or CLABSI. In another example, the EMR could help coordinate education between providers. As one frontline staff interviewee explained, the EMR helped alert providers about the need for education when a patient refused the recommended care for their central line: “So, it is now built into [the EMR] if a patient refuses to use CHG [chlorhexidine gluconate] wipes it will notify the MD [physician] or the APP [advanced practice provider] and the idea or expectation is that they will follow up and provide additional education or the same education to the patient about the importance of that practice.”
Interviewees also discussed opportunities for involving patients and families in the creation of education materials. As one administrative leader explained, “When somebody has any type of line, then teaching and training is going on, from scrub the hub, to hand hygiene, and so forth. We made patients and families part of that strategy many years ago when we actually had them refine our patient and family education related to any signage we make that has to do with that, using our patient family advisors.”
Discussion
The key informants in our study identified a variety of educational resources and methods of delivering patient education that were a part of their hospital’s efforts to educate patients about infection prevention. Furthermore, key informants described important educational topics for the prevention of CAUTIs and CLABSIs, including risk of infection, hand hygiene, necessity of device maintenance, and speaking up about handwashing, device maintenance, and device removal. In addressing these topics, key informants noted particular instances in which patient education could be especially impactful, for example, when explaining the importance of device removal to patients who perceived their device as a convenience or when convincing patients of the importance of maintenance care for their device when patients resisted this care.
Our interviewees identified the lack of standardized education about CAUTIs and CLABSIs as a major challenge to providing patient education for infection prevention. Providing standardized education may be especially important to address patient behaviors that go against infection prevention practices such as patient resistance to device removal or maintenance care. Furthermore, delivering a unified message with patient education initiatives may also be critical to create an environment of psychological safety in which patients feel comfortable playing an active role in their care. Reference Bell and Martinez23 For example, although patients express interest in being involved in patient safety efforts, many may not be comfortable speaking up to their healthcare providers about concerns related to their care and safety. Reference Görig, Dittmann, Kramer, Heidecke, Diedrich and Hübner24,Reference Fisher, Smith, Gallagher, Huang, Borton and Mazor25 Empowering patients to speak up therefore requires the creation of an environment in which the expectation for patients to speak up is consistently made clear. Reference Fernandes Agreli, Murphy and Creedon7,Reference Bell and Martinez23
Interviewees also discussed opportunities to improve patient education, including the use of the EMR and patient and family advisory groups. Developing standardized policies to use the EMR to consistently deliver patient education could help ensure that patients are educated about their individual needs Reference Volk and Obeid26 and could help overcome inconsistencies in the use of the EMR for patient education that are already evident in the literature. Reference Cook, Castrogiovanni and David27,Reference Shipman, Lake, Van Der Volgen and Doman28 Furthermore, patient and family advisory groups may be particularly helpful in reviewing education materials because some of these materials for CAUTI and CLABSI prevention have been found to be difficult to understand and navigate. Reference Park and Seale29,Reference Zellmer, Zimdars and Safdar30
Evidence in the literature supports initiatives to educate patients with the goal of decreasing HAIs. Patient education may reduce the risk of HAIs, for example, by reducing unnecessary device use Reference McHugh, Corrigan and Dimitrov31 or by increasing compliance with device maintenance. Reference Vanhoozer, Lovern Bs and Masroor32 Furthermore, some patient education initiatives to improve clinical maintenance of indwelling urinary catheters and central lines have been associated with reduced CLABSI Reference DeLa Cruz, Caillouet and Guerrero33,Reference Møller, Borregaard, Tvede and Adamsen34 and CAUTI rates. Reference Spencer, Flynn Makic and Shaw35 Efforts to enhance the effective delivery of patient education may therefore have the potential to improve patient safety outcomes.
Some limitations should be considered when interpreting the results of this study. First, the topic of patient education was not the sole focus of the data collected as a part of this study; it is possible that additional perspectives could be revealed in a study focused solely on this research topic. Second, we did not consider patient perspectives in this study. Future studies should incorporate patient perspectives to understand the needs and preferences of patients and to ensure that educational content is meaningful and delivered effectively. Input from patients through patient and family advisory groups may be a particularly powerful tool to learn about patient perspectives that may be unique to individual hospital settings. Finally, we did not evaluate the impact of patient education on infection prevention outcomes. Further work will be necessary to understand how to best implement patient education initiatives for CAUTI and CLABSI prevention and to evaluate the impact of these initiatives on the reduction of HAIs.
Acknowledgments
The authors would like to thank Lindsey Sova, Jaclyn Volney, Toby Weinert, Jeanette Gardner, Natalie Gaines, Caroline Sugar, and Meg Suttle, all affiliated with the authors’ institution, for their assistance with this project. The authors would also like to express their gratitude to the key informants and hospitals that participated in this study. The views expressed in this manuscript are those of the authors; the Agency for Healthcare Research and Quality (AHRQ) had no involvement in the execution of this research or the preparation of this manuscript.
Financial support
This research was supported by a grant from AHRQ (Grant# R01HS024958).
Conflicts of interest
All authors report no conflicts of interest relevant to this article.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/ice.2021.271
