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1 Critical Appraisal of Evidence-Based Literature Student’s Name Institution Course Number and Name Professor’s Name Date

2 Introduction According to Li et a. (2018), the primary objective of health services is to promoted the patient’s quality of life. However, today, modern facilities face many problems such as patient falls and medication errors. Instead of enhancing their quality of life, medical errors and falls increases their medical problems. The PICOT question: In the Acute care setting (P), how does the implementation of a nurse-driven indwelling catheter removal protocol (I), help reduce CAUTI (C) rates from 1.25/1000 catheter days to less than the benchmark of 0.69/1000 catheter- days (O) over three months (T)? The indwelling urinary catheter is an integral part of numerous medical practices. Catheter associated urinary tract infection (CAUTI) accounts for about 40 percent of all institutionally acquired infections. CAUTI ranges from asymptomatic bacteremic urinary tract infection to a serious symptomatic urinary tract infection. Therefore, the primary aim of this study is to address the link between nurse-driven indwelling catheter removal protocol and the risk of CAUTI that affect the population of patients in the acute care setting through proposed interventions. Critical Appraisal Tool With an ever-increasing tally of issued systematic reviews of researches on healthcare intervention, systematic reviews are prone to biases. For this reason, users need to differentiate high-quality reviews. Numerous frameworks have been established to assess different scenarios of systematic reviews. Most of the developed frameworks are complex and suit researchers involved in advanced levels of study. This article uses the Caldwell et al. (2005) framework due to its ability to validate and ensure the objective approach to this process. Furthermore, this critique framework help users conduct a comprehensive critical appraisal of randomized and non-randomized trials and can address qualitative and quantitative research within one list of

3 PICOT questions. Lastly, I chose to use this framework because its bases its findings and decisions on real-world observational evidence. Annotative Bibliography Durant, D. J. (2017). Nurse-driven protocols and the prevention of catheter-associated urinary tract infections: A systematic review. American Journal of Infection Control , 45 (12), 1331–1341. https://doi.org/10.1016/j.ajic.2017.07.020 This section presents a critical appraisal of the article “Nurse-driven protocols and the prevention of catheter-associated urinary tract infections: A systematic review." by Durant. The article was issued, in 2017, in the American Journal of Infection Control. A critical appraisal tool developed by Caldwell et al. (2005) will be employed to assess the quality of the researchers' purpose, methods, design, and findings for this appraisal. The article outlines the findings of a qualitative study on nurse-driven protocols and the prevention of catheter-associated urinary tract infections, and how these impacts indwelling- urinary catheter utilization and CAUTI rates. The purpose of this research is presented within the abstract and highlighted in the introduction. The research employed a systematic review of studies published in the United States since 2006. The systematic review was conducted in line with the Institute of Medicine, which demonstrates its suitability and significance to likely produce relevant information required to realize the viewpoint of nurses on the impact of catheter-associated urinary tract infections on indwelling-urinary catheter utilization and CAUTI rates. Generally, the approach is good, and it can be concluded that the researcher would be able to realize the participants' viewpoints.

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4 The researcher employed a searching strategy known as PRISMA guidelines (Selçuk, 2019). The researcher searched through PubMed, Google Scholar, Cochrane, Scopus, and Web of Science to allocate records published since 2006. This design and research strategy were appropriate. One limitation demonstrated by the Author is the lack of clarification of how the articles included was synthesized. Unfortunately, the research in their study does not indicate how the data was synthesized and thus leaves a gap in which the user has no conceptualization of inclusion and exclusion criteria. Tyson, A. F., Campbell, E. F., Spangler, L. R., Ross, S. W., Reinke, C. E., Passaretti, C. L., & Sing, R. F. (2020). Implementation of a nurse-driven protocol for catheter removal to decrease catheter-associated urinary tract infection rate in a surgical trauma ICU. Journal of intensive care medicine , 35 (8), 738-744. This segment illustrates the critical appraisal of Tyson et al.'s article" Implementation of a Nurse-Driven Protocol for Catheter Removal to Decrease Catheter-Associated Urinary Tract Infection Rate in a Surgical Trauma ICU."This study aimed to acknowledge that early eradication of urinary catheters can be a successful approach to preventing catheter-associated urinary tract infection (CAUTI). This review equally employs a critical appraisal tool developed by Caldwell et al. (2005) to assess researchers' purpose, methods, design, and findings. The research aimed to discover whether the nurse-directed catheter removal protocol would significantly reduce catheter-associated urinary tract infection (CAUTI) and catheter utilization, which is usually experienced in a surgical trauma intensive care unit (STICU). Therefore, the study's goal was precise and was clearly stated in the abstract section.

5 The study enacted a retrospective and unit extermination based on applying a multichannel CAUTI prevention bundle in the STICU of a huge tertiary care center. The researchers compared data gathered from a 15-month intervention period with that from a 19- month historical control during the study. Consequently, a comparison of post-intervention and pre-intervention in dwelling CAUTI and catheter utilization rates was conducted. This was a cohort study following a multimodal CAUTI prevention bundle implementation in the STICU of a large tertiary care center. The research compared data from 19-month historical control with a 15-month intervention period. Therefore, the data collection used is appropriate since data comparison will enable the researcher to understand the lived experience in-depth. According to the article, there was a significant reduction in Catheter utilization from around 0.78 during the preintervention period to around 0.70 in the postintervention period upon implementing the nurse-driven protocol. The research discovered that it is indeed possible that the application of the nurse-driven protocol to eradicate urinary catheters at the early stages of life to prevent multimodal CAUTI can lead to a massive reduction in CAUTI and catheter utilization rates. DePuccio, M. J., Gaughan, A. A., Sova, L. N., MacEwan, S. R., Walker, D. M., Gregory, M. E., ... & McAlearney, A. S. (2020). An examination of the barriers to and facilitators of implementing nurse-driven protocols to remove indwelling urinary catheters in acute care hospitals. The Joint Commission Journal on Quality and Patient Safety , 46 (12), 691-698.

6 This part consists of a critical appraisal of the article" An Examination of the Barriers to and Facilitators of Implementing Nurse-Driven Protocols to Remove Indwelling Urinary Catheters in Acute Care Hospitals," published on September 2 nd , 2020. This review equally employs a critical appraisal tool developed by Caldwell et al. (2005) to assess researchers' purpose, methods, design, and findings. The article aimed to comprehend the facilitators and barriers of applying Urinary catheter nurse-driven protocols (UCNDPs) in critical care medical facilities. The article acknowledged that as much as Urinary catheter nurse-driven protocols (UCNDPs) might be crucial in the eradication of indwelling urinary catheters (IUCs), which is significant in the prevention of (CAUTIs), they are still being used inconsistently. The researcher incorporated the interview method to grasp an ideal comprehension of the experiences of medicinal officials on implementation, application, and foresing the use of Urinary catheter nurse-driven protocols (UCNDPs). Therefore, to gather better information, the researchers interviewed approximately 449 frontline staff members, including executives, nurses, and physicians from the top 17 medical facilities based in the United States. In addition, the article incorporated a semi-structured interview that composed questions concerning policies and management practices concerning the enactment of a UNDP. The study employed numerous data collection instruments. The primary data collection method was through semi-structured interviews using a questionnaire. Using an open-ended questionnaire was appropriate for this research as it gives participants freedom and space to answer as much detail as possible. However, the research failed to demonstrate the technique or question used within the interviews. Furthermore, there is an ethical and methodological gap as participants

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7 desired to avoid negative consequences. The article recommends that as much as UCNDPs are essential in the reduction and prevention of CAUTIs, medical facilities should take charge in supporting their implementation and application by designing skills that care team colleagues can implement whenever the individual patients meet the set conditions for removal. In addition, the research indicated that most medical institutions face three core obstacles in the implementation and application of UCNDPs. The barriers include nurse deference to physicians, miscommunication about IUC removal, and physician push-back. Haley, T. M. (2018). CAUTI reduction was observed during developing a nurse-driven protocol for foley catheter removal. American Journal of Infection Control , 46 (6), S58. This article entails" CAUTI Reduction Observed During Development of Nurse Driven Protocol for Foley Catheter Removal," and Haley, T. M in 2018 wrote it. This review equally employs a critical appraisal tool developed by Caldwell et al. (2005) to improve the quality of researchers' purpose, methods, design, and findings. The article aimed to illustrate the significant changes in terms of reductions seen in Catheter-Associated Urinary Tract Infections (CAUTI). This was due to the invention and implementation of the Nurse Driven Protocol for Foley Catheter Removal. The study enacted a systematic review of studies published in the United States since 2006. The systematic review was implemented according to the Institute of Medicine, which demonstrates its suitability and significance to likely produce relevant information required to realize the viewpoint of nurses on the impact of catheter-associated urinary tract infections on indwelling-urinary catheter utilization and CAUTI rates

8 The research design is appropriately discussed and justified in this research study. The researcher employed semi-structured interviews, which is supported as an approach. However, I believe the use of semi-structured interviews matches the research objectives as it enables obtaining a detailed narrative from each patient with coverage of critical concepts. Therefore, despite not presenting details of the semi-structured interview process in the main body, they are recorded in the appendix section. The article indicates that the various CAUTI reduction techniques, custom insertion kits, compliance with a catheter insertion bundle, and other options for indwelling catheters have significantly displayed pleasing results. According to the article, there has been a substantial reduction in CAUTI by approximately 83% in 2017 from the previous year. This massive shift is due to incorporation Urinary catheter nurse-driven protocols (UCNDPs). Reif, L., & Reif, L. A. (2021). Enhancing the Effectiveness of a Nurse-Driven Indwelling Urinary Catheter Removal Protocol through the Implementation of a Decision Support Initiative. This section entails a critical appraisal of the article "Enhancing the Effectiveness of a Nurse-Driven Indwelling Urinary Catheter Removal Protocol through the Implementation of a Decision Support Initiative." Reif, L., & Reif. For this appraisal, a critical appraisal tool developed by Caldwell et al. (2005) will be employed to assess the quality of the researchers' purpose, methods, design, and findings. The article aimed at determining whether the enaction of an evidence-based initiative that entails decision support tool and educational program can be used to enhance the productiveness

9 of medical facilities' already surviving urinary catheter eradication procedure by upgrading the nurses' abilities to incorporate the knowledge gained into practice. As a result, there will be easier and earlier eradication of irrelevant in-built urinary catheters than independently using the urinary catheter removal protocol. The study incorporated Durant’s systematic review of the literature (2017) to discover whether the nurse-driven catheter eradication protocols pose the capacity to reduce or prevent catheter-associated urinary tract infection (CAUTI). The researcher conducted a qualitative research study in a vast advancement care section to assess barriers to the prompt eradication of in-built catheters. However, the research design lacks clarity and concurrence on suitable reasons to maintain an in-built catheter, albeit with a list of appropriate indications. The article project recommends vital decrease in catheter utilization, Catheter-Associated Urinary Tract Infections. It further points out an acceleration in awareness and comprehension in nursing and the administration of strategies to enhance maintenance of a built-in catheter. On the flip side, there is a potential generalization of the decision support tool used in the project to escort the unique disease and situations found in the neuroscience ICU population. Proposed Intervention According to Wanat et al. (2020), CAUTI are common preventable. Employing healthcare professional behaviors such as mitigating unsignificant use of Catheter may help reduce CAUTI. This study proposes six intervention strategies. These includes;  Developing checklist for admission and discharge of patients to wards  Informing patients and relatives about merits and demerits of Catheters

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10  Developing and setting specific guidelines or viable and sustainable use of catheters  Campaigning and promoting the alternative to catheter use.  Standardizing countrywide computer-based documentation.  Implementing the use of bladder scanners Conclusion Lastly, this analysis believes that despite the few weaknesses demonstrated in the selected systematic reviews, the articles provide more valuable and appropriate information for nurses, students and researchers interested in CAUTI. Nonetheless, this critical appraisal analysis finds, the systematic reviews lack in-depth findings that practitioners, students and researchers can base their assessment on whether or not the findings articulate a potent account of precision.

11 References DePuccio, M. J., Gaughan, A. A., Sova, L. N., MacEwan, S. R., Walker, D. M., Gregory, M. E., ... & McAlearney, A. S. (2020). An examination of the barriers to and facilitators of implementing nurse-driven protocols to remove indwelling urinary catheters in acute care hospitals. The Joint Commission Journal on Quality and Patient Safety , 46 (12), 691-698. Durant, D. J. (2017). Nurse-driven protocols and the prevention of catheter-associated urinary tract infections: A systematic review. American Journal of Infection Control , 45 (12), 1331–1341. https://doi.org/10.1016/j.ajic.2017.07.020 Haley, T. M. (2018). CAUTI reduction was observed while developing a nurse-driven protocol for foley catheter removal. American Journal of Infection Control , 46 (6), S58. Li, S. A., Jeffs, L., Barwick, M., & Stevens, B. (2018). Organizational contextual features that influence the implementation of evidence-based practices across healthcare settings: a systematic integrative review. Systematic reviews , 7 (1), 1-19. Reif, L., & Reif, L. A. (2021). Enhancing the Effectiveness of a Nurse-Driven Indwelling Urinary Catheter Removal Protocol through the Implementation of a Decision Support Initiative. Shelton, R. C., Cooper, B. R., & Stirman, S. W. (2018). The sustainability of evidence-based interventions and practices in public health and health care. Annual review of public health , 39 , 55-76.

12 Tyson, A. F., Campbell, E. F., Spangler, L. R., Ross, S. W., Reinke, C. E., Passaretti, C. L., & Sing, R. F. (2020). Implementation of a nurse-driven protocol for catheter removal to decrease catheter-associated urinary tract infection rate in a surgical trauma ICU. Journal of intensive care medicine , 35 (8), 738-744. Wanat, M., Borek, A. J., Atkins, L., Sallis, A., Ashiru-Oredope, D., Beech, E., ... & Tonkin-Crine, S. (2020). Optimising interventions for catheter-associated urinary tract infections (CAUTI) in primary, secondary and care home settings. Antibiotics , 9 (7), 419.

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