Patient and Family Engagement in Catheter-Associated Urinary Tract Infection (CAUTI) Prevention: A Systematic Review

Abstract

Background:

Catheter-associated urinary tract infections (CAUTI) are detrimental to health and are largely preventable with adherence to CAUTI prevention guidelines. Patient and family engagement in CAUTI prevention is often encouraged in these guidelines; however, little is known about how this engagement is operationalized in practice. A systematic review was conducted to synthesize the content, format, and outcomes of interventions that engage patients and/or families in CAUTI prevention.

Methods:

Two reviewers independently screened records from four databases up to March 2021 and searched reference lists of final articles. Included articles were primary research, tested an intervention, involved indwelling urinary catheters, and described at least one patient and/or family engagement method. Articles were appraised for quality using the Downs and Black checklist.

Results:

After 720 records were screened, 12 were included. Study quality ranged from good to poor, scoring lowest in internal validity. The most common formats of patient/family engagement were flyer/handout (83%) and verbal education (58%). Common content areas were urinary catheter care and maintenance strategies. Most study outcomes (83%) measured CAUTI rates, and half measured patient/family-related outcomes. Improvements were seen in at least one outcome across all studies, but less than half (42%) showed statistically significant results.

Conclusions:

We found that most interventions lacked sufficient detail on the content, delivery, and/or outcome measurement of patient/family engagement, which limits transferability. More high-quality, generalizable trials are warranted in this area. Future research should focus on integrating publicly available resources into practice that can be tested for comprehension and revised based on feedback from target audiences.

Catheter-associated urinary tract infections (CAUTI) are among the most common device-associated infections, which account for nearly 26% of all health care–associated infections (HAI). CAUTI occur when bacteria enter the body through an indwelling urinary catheter that is inserted into the bladder for purpose of draining urine.^1,2 CAUTI are associated with negative sequelae, including increased length of hospital stay, excess cost, morbidity, and mortality, leading to more than 8,000 deaths annually.^3,4 The risk for developing a CAUTI increases 3% to 7% with every additional catheter day in the hospital, and CAUTI are prevalent among patients with long-term indwelling urinary catheters in nursing homes and home care.^5–9 Notably, up to 70% of all CAUTI, or up to 380,000 infections per year, can be prevented with adherence to recommended practice guidelines.^10–12

Existing CAUTI-prevention guidelines recommend engaging patients and families in their care to prevent these infections.^13,14 Patient and family engagement is broadly defined as “patients, families, their representatives, and health professionals working in active partnership at various levels across the health care system…to improve health and health care.”¹⁵ Over the past decade, patient and family engagement has been recognized by national institutes as a key strategy to improve patient safety and prevent infections.^15–17 A growing body of evidence suggests that patients’ active engagement in care may result in improvements in the provision of care and patient outcomes. For instance, the implementation of patient and family engagement strategies such as patient-centered rounds and shared care plans have been associated with improved patient safety outcomes, reductions in adverse events, and increased patient satisfaction.^14,16,17 Additionally, large, randomized trials in the intensive care setting demonstrate that written materials and family education programs are associated with improved depression and anxiety symptoms and family members’ improved comprehension of the patient’s medical condition.^16,18,19

While multifaceted initiatives resulted in reductions in HAI, the Agency for Healthcare Research and Quality (AHRQ) highlights the need for additional patient engagement, mentioning that “patients’ choices often occur without the robust information they need, and this limitation constrains their efforts to be engaged in their own care.”²⁰ Additionally, AHRQ implemented a nationwide initiative called “On the CUSP: Stop CAUTI” that provides webinars, presentations, and guides on how to engage patients and families into care to prevent CAUTI.¹³ The National Patient Safety Foundation also disseminated a report, “Safety is Personal: Partnering with Patients and Families for the Safest Care,” which includes recommendations for providers to engage patients and families in infection prevention, and empowers patients to identify early signs and risk factors of infections.¹⁴

Despite guideline recommendations to engage patients and families in CAUTI prevention, little is known about the content, delivery, and outcomes of patient and family engagement strategies to prevent CAUTI. We conducted a systematic review to synthesize the literature on existing interventions that involve and evaluate patients and/or families in CAUTI prevention. Our specific research question was: What are the components and outcomes of efforts to engage the patient and/or family in the prevention of CAUTI?

METHODS

Theoretical Framework

This systematic review is guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and the Multidimensional Framework for Patient and Family Engagement in Health and Health Care.^15,21 The Multidimensional Framework for Patient and Family Engagement in Health and Health Care operationalizes patient and family engagement across three domains: direct care, organizational design and governance, and policy making. This review will identify interventions across the “direct care” domain as we were interested in the practical application of patients and families seeking and receiving health information and interacting with clinicians. The subsequent domains (organizational design and governance, and policy making) were not evaluated, as they are beyond the scope of this review because we are interested in experimental studies about clinical activities implemented at the point of care, and not indirectly as part of an organization or policy initiative. Across direct care, levels of engagement exist across a continuum which span from “consultation” (e.g., receiving information about a diagnosis), to “involvement” (e.g., patients are asked about preferences in treatment plan), and lastly to “partnership and shared leadership” (e.g., treatment decisions made based on patients’ preferences, medical evidence, and clinical judgment).¹⁵

Search Strategy

Two reviewers conducted a search for all peer-reviewed literature published up to March 2021, with no restrictions on the beginning date, using PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Embase. We searched ProQuest for conference proceedings and dissertations/theses. Reference lists of final articles were searched by hand. A medical librarian was consulted for feedback on the search and methods to ensure a comprehensive search strategy. Relevant key terms were searched relating to patients, families, and CAUTI (Appendix 1). Where applicable, all key terms were coupled with a corresponding database-specific search term using “OR” Boolean operators (e.g., “urinary catheter” OR “urinary catheters” [MeSH Terms]).

Selection Criteria

Articles were included if they had aspects of patient and/or family engagement in the context of CAUTI prevention using an experimental or quasi-experimental design. We defined patient and/or family engagement as a resource or interaction shared between the patient and/or family and a clinician intended to facilitate information sharing across the direct care continuum of engagement, such as through an educational flyer or participation in rounds. Study selection was not restricted by date, outcome measure (e.g., CAUTI incidence rates, patient satisfaction), or health care setting (e.g., inpatient, nursing home). Articles were excluded if they were not in English, did not include aspects of patient and family engagement in CAUTI prevention, or were limited to conference proceedings.

Two reviewers independently screened records for eligibility based on title/abstract, and then based on full-text articles using Covidence (online systematic review management software) to organize correspondence. One reviewer extracted key information from final articles using a standardized data-extraction form, which included key study elements—population type, location, sample size, study design, study length, study aim, and patient/family engagement-related and/or CAUTI-related outcomes. A reduced data extraction method was used to extract key elements from the studies,²² in which a second reviewer reviewed 25% of the extracted data for consistency. Main study characteristics were further verified during the quality appraisal process in duplicate.

Risk of Bias

The Downs and Black Checklist for Assessing Quality of Studies was used to appraise study quality.²³ The checklist includes four evaluative domains: reporting (11 points), external validity (3 points), internal validity (13 points), and power (1 point). The checklist also defines the following summed score ranges: excellent (24–28 points), good (19–23 points), fair (14–18 points), and poor (<14 points). Two reviewers performed quality appraisals independently and discussed discrepancies to consensus.

RESULTS

Search Results

A total of 836 records were identified. After removal of duplicates, 720 records were screened for inclusion. After title/abstract screening, we identified 60 articles for full-text review. After application of inclusion/exclusion criteria, 12 studies were included in this review. The results of screening are displayed in the PRISMA flow diagram in Figure 1.

Figure 1:

a) This flow diagram demonstrates the study screening process in accordance with PRISMA guidelines.²¹

Overall study characteristics are summarized in Table 1. Publication dates ranged from 1990 to 2019, study duration ranged from 5 months to 4 years, and sample sizes ranged from 45 to 12,962 patients. Out of 12 studies included in the final analysis, 9 were non-randomized, pretest-posttest, or posttest-only design.^24–32 The remaining three studies were randomized controlled trials.^33–35 In 7 studies, the patient and family engagement intervention was a component of a larger care initiative (i.e., a combination of interventions or care bundle that included at least one component of patient and family education or engagement).^{24,26–30,32} All studies were conducted in the United States with the exception of one study conducted in Taiwan.³³

Table 1.

Summary of Included Study Characteristics, Aims, Patient/Family Engagement Strategies, and Outcomes

Author (Year)	Population; Location; Sample size (N)	Study design; Study length; Level of engagement	Study aim	Description of patient/family engagement in CAUTI prevention	Patient/family-related outcomes	CAUTI-related outcomes
Elkbuli et al. (2018)24	Adult trauma inpatients US academic medical center N = 12,962	Single-site Pretest-posttest 2014–2017 (4 years) Consultation	Determine whether an implemented CAUTI prevention bundle would reduce CAUTI rates in trauma population over a 4-year study period.	RN and research investigator provide verbal education and handouts to patients, families and caregivers on catheter risks and CAUTI prevention before placement, during catheter care, and at discharge with a catheter.	N/A	CAUTI incidence rates per 1,000 days (%)*: Pre-intervention: 41 (1.34), Post-intervention: 8 (0.25); p < .001
Inman et al. (2013)25	Urology patients undergoing prostatectomy US academic medical center N=100	Single-site Pretest-posttest Dec 2009–Jan 2011 (2 years) Involvement	Determine the effect of standardized preoperative urinary catheter management education on patients’ level of anxiety following prostatectomy.	Intervention group of patients received a 1-hour RN-taught preoperative educational class and standard verbal postoperative education; control group only received verbal post-operative education.	Postoperative State Trait Anxiety Index (STAI) Score – Preoperative STAI Score Control: −4.9 Intervention: −9.6 p < .020	N/A
Joseph et al. (2018)26	Trauma ICU (TICU) US level 1 trauma center N=76	Single-site Pretest-posttest + post-test only survey Retrospective analysis: Oct 2013–Nov 2016 (3 years) Post-test survey: Apr–Nov 2016 (8 months) Involvement	Integrate a multidisciplinary checklist into rounds on one TICU and measure its effects on standard quality metrics and team-to-family communication.	Brief description of the daily goals of care in in layman’s terms called “Family Message” stated verbally on rounds (CAUTI prevention content not specified)	Family reported receipt of updates from team at 3 timepoints (n, %): (22, 73), (28, 93), (12, 75) Updates consistent with EMR (n, %): (17, 77), (24, 86), (12, 100) Family reported that updates were adequate (n, %): (51, 81)	CAUTI incidence rates per 1,000 days*: Preintervention: 8.13, Postintervention: 3.2 p = 0.2416
Lee et al. (2015)33	Patients from two surgical wards, Family caregivers (FCs) 500-bed teaching hospital in northern Taiwan N = 122 (61 patients, 61 FCs)	Single-site Randomized controlled trial Intervention length: 5 days Partnership and Shared Leadership	Evaluate the effects of a nurse–family partnership model on the self-efficacy of family caregivers and the incidence of CAUTI among patients.	Intervention group: nurse-family partnership intervention with 4-hour training course and educational session of CAUTI prevention Control group: routine care	Modified Caregiver Self-Efficacy Scale Score (SD) Intervention: 84.5(25.1) Control: 92.7 (23.1) p = 0.28	CAUTI incidencea: n (%) Intervention: 6 (20) Control: 12 (38.8) p = 0.079
Mody et al. (2017)27	Community-based nursing homes Nationwide (US) sample N = 404 (nursing homes)	Multisite Pretest-posttest Mar 2014–Aug 2016 (2.5 years) Consultation	To develop, implement, and evaluate a multicomponent technical and socio-adaptive bundle of interventions to reduce urinary catheter use and CAUTI.	Train family and nursing home residents on catheter care using available resources from Agency for Healthcare Research and Quality website	N/A	Adjusted CAUTI incidence rates per 1,000 days†: Pre-intervention: 6.42; Post-intervention: 3.33; p < .001
Oman et al. (2012)28	Patients from 2 medical/surgical units (pulmonary and general surgery) US Academic medical center N = 273 (pulmonary unit) N = 422 (surgery unit)	Single-site Pretest-posttest Jan 2009–Oct 2009 (10 months) Involvement	Evaluate the impact of a multifaceted, nurse-driven intervention incorporating evidence-based practice champions of change (nurses and certified nursing assistants) and patients and families to reduce CAUTI in hospitalized patients.	Developed educational materials with catheter care guidelines and encouraged patients and families to communicate with providers and question the necessity of the urinary catheter	N/A	CAUTI incidence rates per 1,000 days*: Pulmonary: Phase 1 (Baseline): 0.0 Phase 2: 0.0 Phase 3 (Post-intervention): 0.0 General Surgery: Phase 1 (Baseline): 1.9 Phase 2: 3.4 Phase 3 (Postintervention): 2.2 p values not reported
Purvis et al. (2014)29	Surgical inpatients US academic medical center N=89	Single-site Pretest-posttest May 2012–Feb 2013 (9 months) Consultation	Reduce the incidence of CAUTI across all inpatient units through education, practice changes, and evidence-based protocols.	Toolbox available in electronic health record with patient education material	N/A	CAUTI incidence rates per 1,000 days†: Pre-Intervention (2012): 4.2 Post-intervention (2013): 2.4 p values not reported
Roe et al. (1990)34	Adult community-dwelling patients discharged with urinary catheters 13 US health centers N=45	Multisite Randomized controlled trial Intervention length: 5 months Involvement	Test the effects of an educational program on patients’ knowledge and acceptance of urinary catheters.	Implemented an educational program comprising an information booklet, demonstration of catheter care, and provider visits/phone calls	Knowledge of catheters How catheter works (trial vs control): chi square = 9.77, p = 0.007 ID risks of catheter use (trial vs control): hi square = 17.37, p = 0.001 Acceptance of and coping with catheters No significant differences found between trial and control	N/A
Sarpong et al. (2017)30	Neurointensive care unit patients 14-bed US neurointensive care unit N = 144 (patient satisfaction surveys) N = 8,922 (total patient days)	Single-site Pretest-posttest 36 months Involvement	Evaluate the impact of newly appointed neurointensivists with the subsequent development of a neurocritical care team on quality metrics including patient and family satisfaction after discharge.	Families were encouraged to participate in daily rounds (CAUTI prevention content not specified)	Patient satisfaction (% increase) Physician/nurse consistency: 28.3, p = 0.025 Confidence/trust in physicians: 69.5, p < 0.0001 Physicians treated me with courtesy/respect: 78.3, p < 0.0001 Physician attentiveness: 46.4, p < 0.0001	CAUTI incidence, n (%)a: Pre-intervention: 16 (52) Post-intervention: 8 (34) p = 0.41
Spencer et al. (2019)31	Urologic oncology patients discharged with temporary urinary catheter after a short stay 620-bed US academic medical center N=60	Single-site Pretest-posttest Dec 2016–Feb 2017 (1 year, 1 month) Involvement	To reduce CAUTI through implementation of an educational program and improved scheduling processes for device removal.	Implemented a multifaceted pre-operative educational program for patients regarding catheter management at home and plan for follow-up appointment	N/A	CAUTI incidence (%)*: Preintervention: 12.5 Postintervention: 8 p = .69
Theobald et al. (2017)32	Medical inpatient veterans Acute medical unit in US hospital N=99	Single-site Pretest-posttest Dec 2012–Feb 2015 (2 years, 2 months) Consultation	Design and implement a multidisciplinary quality improvement program to reduce catheter use and CAUTI rates among a veteran population while simultaneously addressing persistent barriers to program success.	Implemented a social marketing campaign to explain catheter overuse and CAUTI risk through displays in patient rooms and public areas in the hospital.	N/A	CAUTI incidence rate per 1,000 days*: Preintervention: 3.53; Postintervention 0.70 p values not reported
Wilde et al. (2015)35	Community dwelling adult long-term urinary catheter users 2 US regions from 1 hospital and 1 home care agency N=202	Multisite Randomized controlled trial Jun 2009–Jun 2012 (3 years) Partnership and Shared Leadership	Determine the effectiveness of a self-management intervention in prevention of CAUTI, blockage, and accidental dislodgement.	Learning catheter self-management skills including diary tracking of symptoms and intake/output, educational booklet and goal setting during periodic RN home visits and phone calls	Catheter-related quality of lifec: (Control-intervention score, standard error): −2.03, 1.389 “not significant at p < 0.05”	CAUTI incidence rate per 1,000 days*: Experimental (baseline, postintervention): 6.93, 4.89 Control (baseline, postintervention): 5.50, 4.12 “not significant at p < 0.05”

CAUTI, catheter-associated urinary tract infection; RN, registered nurse;

^*CAUTI rates were analyzed at the patient-level.

^†CAUTI rates were analyzed at the hospital/nursing home-level.

^‡Higher scores indicate better quality of life; negative results favor the intervention group.

All studies focused on adult patients. Five studies took place in the medical/surgical inpatient setting.^{25,28,29,32,33} Three studies took place in an ICU or trauma unit.^24,26,30 Three studies were conducted in the outpatient/home care setting.^31,34,35 One study was conducted in nursing homes.²⁷

Five interventions (41%) focused on both patients and families as their target audience for interventions. These studies consisted of encouragement to participate in inpatient rounds and prompts to ask providers if the catheter is still necessary.^{24,26,28,30,32} Four studies (33%) focused on patients and their transition to or care in the home setting. They measured patient-related outcomes such as knowledge of catheters, self-management measures, and anxiety.^25,31,34,35 One study targeted patients’ family members and measured caregiver self-efficacy,³³ and two studies (17%) were unspecified as to whether patients and/or families were the target audiences.^29,32 Purvis et al. included patient education materials in an educational toolbox, but it is unclear whether families were also involved in this education.²⁹ Theobald et al. reports that posters were placed in the room to mitigate patient and family misconceptions of catheter use, but family-related outcomes were not captured.³²

Total quality appraisal scores ranged from 10 (poor) to 23 (good), with the lowest scoring area being internal validity, primarily due to a lack of blinding, randomization, and evidence of follow-up (Figure 2). Zero studies scored in the excellent category. Only two studies (17%) conducted a power analysis to determine the sample size; of these, one study did not reach its target power due to small sample size,³³ and the other did reach an adequate sample size at power of 0.8.³⁵

Figure 2:

This chart provides the results of the quality appraisal of the 12 included articles using the Downs and Black Checklist,¹⁴ showing the scores in each category and a total score with quality interpretation.

CAUTI-Prevention Content

Patient and family engagement content included four CAUTI-prevention areas (Table 2): (1) purpose of indwelling urinary catheter (structure and utility of a urinary catheter), (2) risks to indwelling urinary catheter use (potential negative sequelae of CAUTI [e.g., antibiotic resistance, extended hospital stay]), (3) symptoms of CAUTI (how to identify symptoms of infection [e.g., cloudy urine, pain]), and (4) care and maintenance, which included information about skincare/cleaning (cleaning the insertion site, hand hygiene, bathing recommendations), and/or urinary catheter maintenance (maintaining a closed system, proper bag positioning, bag changing/emptying procedures). Urinary catheter care and maintenance strategies were the most common information categories used in interventions to communicate CAUTI prevention to patients and families (n = 7, 58%).^{24,25,27,31,33–35} Studies that did not provide enough information about the intervention to determine the content delivered were categorized as ‘not specified.’

Table 2.

Content and Mechanisms to Engage Patients and/or Families in CAUTI Prevention

Author (Year)	CAUTI-prevention content provided to patient/family					Mechanisms to engage patient/family in CAUTI prevention
	Purpose of IUC	Detecting CAUTI	Risks of CAUTI	Skin care/cleaning	IUC/Bag Mgmt	NS	Flyer/Handout	Verbal Education	Class/Demo	Rounds/Q&A	Video
Elkbuli et al. (2018)24	X	X	-	X	-	-	X	X	-	-	-
Inman et al. (2013)25	-	X	-	X	X	-	X	X	X	-	X
Joseph et al. (2018)26	-	-	-	-	-	X	-	-	-	X	-
Lee et al. (2015)33,*	-	X	-	X	X	-	X	X	X	X	X
Mody et al. (2017)27	-	-	-	X	X	-	X	X	-	-	-
Oman et al. (2012)28	-	-	-	-	-	X	X	-	-	X	-
Purvis et al. (2014)29	-	-	-	-	-	X	X	-	-	-	-
Roe et al. (1990)34	X	-	X	-	X	-	X	X	X	-	-
Sarpong et al. (2017)30	-	-	-	-	-	X	-	-	-	X	-
Spencer et al. (2019)31	-	-	-	-	X	-	X	X	-	-	X
Theobald et al. (2017)32	-	-	X	-	-	-	X	-	-	-	-
Wilde et al. (2015)35,†	-	X	-	X	X	-	X	X	X	X	-

CAUTI, catheter-associated urinary tract infection; IUC, indwelling urinary catheter; Mgmt, management; NS, not specified; Q&A, question and answer.

^*In addition to Q&A, Lee et al. (2015) included nurse and family caregiver sessions to discuss goals and determine solutions and strategies to assist their family member with CAUTI-preventive measures.

^†In addition to Q&A, Wilde et al. (2015) included additional interactive components that involved diary tracking for symptoms and intake and output, and held periodic phone calls with a nurse to discuss symptoms and set goals.

Mechanisms to Engage the Patient/Family

Mechanisms to deliver CAUTI-prevention content to patients and/or families spanned 5 categories: flyers/handouts, verbal education, classes/demonstrations, rounds/question-and-answer (Q&A), and video/multimedia (Table 2). In a total of 10 studies (83%), flyer/handouts were used, which included a handbook of urinary catheter care guidelines, a poster display in the patient’s room, and educational brochures in English and Spanish.^{24,25,27–29,31–35} In 7 articles (58%), patients and/or families were engaged through verbal education from a health professional, which was paired with a flyer or handout.^{24,25,27,31,33–35} Some verbal communication engagement approaches included prompts to question the necessity of a urinary catheter, and one study encouraged patients not to pressure their providers for urinary catheters because it was perceived that patients in that setting sought a urinary catheter for symptom relief.³²

Five studies (42%) included rounds/Q&A, which encouraged patients and/or families to communicate verbally with their care team during daily rounds or through asking questions.^{26,28,30,33,35} In four studies (33%), classes/demonstrations were used to engage families in action-oriented tasks relating to catheter care.^25,33–35 Nurses hosted interactive sessions on managing urinary bag equipment and prompted discussions about caring for family members with urinary catheters.

Video included video demonstrations of urinary catheter cleaning, bag care, and hygiene procedures and were coupled with verbal education and flyer/handouts in two studies,^25,31 and with flyer/handouts, verbal education, and class/demo in one study.³³

Outcomes

Ten studies (83%) reported CAUTI rates as outcomes to prevention interventions.^24,26–33 Among these, two studies reported statistically significant reductions in CAUTI rates but did not measure patient/family related outcomes.^24,27

Six studies (50%) reported on patient/family-related outcomes, which measured pre-postoperative anxiety scores, patient satisfaction, caregiver self-efficacy, knowledge and acceptance of catheters, and quality of life.^{25,26,30,33–35} Of the six studies that reported patient/family related outcomes, three showed a statistically significant change in at least one measured outcome.^25,30,34 Namely, Inman et al. showed a statistically significant decrease in anxiety levels after attending pre- and postoperative educational classes on catheter management, and did not measure CAUTI rates.²⁵ Sarpong et al. demonstrated a statistically significant increase in satisfaction with physician/nurse consistency, trust in providers, and attentiveness after a multimodal intervention that involved patient participation in rounds, and CAUTI rates improved but were not significant.³⁰ Roe demonstrated a statistically significant increase in knowledge of how the catheter works and risks of catheter use after a multifaceted educational program, and also did not measure CAUTI rates.³⁴

Mapping of Interventions to the Multidimensional Framework for Patient and Family Engagement in Health and Health Care

The engagement of patients and families in CAUTI prevention spanned across the continuum of engagement specified by the Multidimensional Framework for Patient and Family Engagement in Health and Health Care.¹⁵ In four studies (33%), engagement was at the level of consultation, in which patients seek and/or receive health information about their condition with minimal to no interaction with a health care provider.^24,27,29,32 In six studies (50%), engagement was at the level of involvement, as patients were encouraged to participate in classes and engage in a discussion with a health care provider regarding their care. In these studies, patients were encouraged to participate in daily rounds and to question the necessity of the catheter.^{25,26,28,30,31,34} In two studies (17%), engagement was at the level of partnership and shared leadership, in which patients and families were considered partners in care, where they exchanged questions and information that influenced their care goals and/or plan of care.^33,35 More specifically, partnership was demonstrated in these studies through the use of periodic phone calls with a clinician for question-and-answer and goal-setting, symptom tracking and discussion, and through a nurse-family partnership intervention. These measured both CAUTI and patient-centered outcomes and showed improvements in both domains, but these improvements did not reach statistical significance due to small sample sizes and lack of power.

The studies that reached statistical significance represented involvement and consultation. The three studies that demonstrated significance in patient/family-related outcomes (e.g., lower anxiety, higher satisfaction, higher knowledge of urinary catheter care) used involvement to implement educational programs focused on CAUTI prevention teaching.^25,30,34 However, these studies did not measure CAUTI rates as outcomes. The two studies that showed statistical significance in reducing CAUTI rates were categorized as consultation, and the patient and family engagement components were parts of bundled interventions and were not measured separately for an effect.^24,27

DISCUSSION

In this systematic review of CAUTI prevention interventions that engage the patient and/or family, we found relatively few studies that examined the impact of patient and family engagement on CAUTI prevention. All studies showed improvements in CAUTI and/or patient/family-related outcomes.

Most approaches to engage patients/families in CAUTI prevention were integrated into a bundle of interventions, were formatted as flyer/handouts, and were often paired with verbal education. The content of tools varied, but most focused on catheter care and management and how to detect CAUTI. Most studies lacked sufficient detail regarding the origin or development of CAUTI prevention material, with only one study referencing the CAUTI prevention toolkit provided by AHRQ.^13,27 The combination of interventions is consistent with evidence-based guidelines that recommend multifaceted programs to address CAUTI, and the use of educational handouts likely facilitated dissemination efforts. The variation in focus areas likely reflects the diverse populations and needs of study clinical settings and patients, and generally fair to poor study design quality ratings likely reflect existing practical barriers to implementing large-scale initiatives in the inpatient setting.³⁶

Despite a general lack of statistically significant findings, all studies demonstrated decreases in CAUTI rates and/or improvements in patient and family-centered outcomes. CAUTI-prevention interventions that measured specific patient and family engagement outcomes such as anxiety levels, knowledge, and satisfaction represented most of the significant results.^25,30,34 Overall, interventions at the partnership and shared leadership level did not reach significance but did show improvements in both CAUTI rates and patient/family engagement outcomes. Interventions at the involvement level (e.g., participation in rounds) or consultation level (e.g., informational flyers) showed significance but were often bundled with other interventions and not evaluated for an individual effect. Although interventions at the involvement or consultation level are likely more practical to implement on a larger scale, additional research is needed to determine the differential impact of different patient engagement approaches on CAUTI.³⁷

Although the use of CAUTI-prevention bundles is recommended and combinations of interventions yield favorable results, we were unable to determine the fidelity to the patient-centered intervention (e.g., did the recipients comprehend the resource, were the recipients engaging in the recommended activity, and were providers delivering the resource effectively, if at all?).^38–41 Additionally, all studies using a handout/flyer were coupled with verbal education from a provider; however, they did not specify the extent to which the communication was delivered. This is an important consideration, especially when working with patients and families with limited English proficiency or low health literacy, where the level of comprehension would be difficult to ascertain without adequate reporting of results.⁴²

We found that many hospital interventions that scored poor to fair on quality appraisal assessments were conducted at the unit level because of targeted quality improvement efforts. While this addresses immediate issues, generalizability and scope were limited. Future clinical interventions should consider integrating a plan for larger (e.g., hospitalwide, statewide) implementation to encourage generalizability, or may adapt existing publicly available resources to address local needs (e.g., patient/family requests for a urinary catheter).^13,37 Additionally, future interventions should consider measuring patient-related outcomes in addition to CAUTI rates for a more holistic evaluation. Finally, to encourage further evaluation of patient and family engagement, future bundled interventions may consider integrating a methodologically rigorous plan to evaluate their components separately for individual effects on desired outcomes.⁴³

Limitations

This review has several limitations. Although we comprehensively searched three medical databases and gray literature, it is possible that we missed relevant articles. The wide range of study designs and outcome measures found in studies that fall under our definition of patient and family engagement and the limited information many studies provided about their interventions prevented us from distinguishing optimal approaches to patient/family engagement in CAUTI prevention. It is also possible that other interventions that may represent other definitions of patient and family engagement were not identified.

CONCLUSION

We found few studies to evaluate patient and family engagement in CAUTI prevention. Most engagement efforts consisted of educational flyers/handouts and concerned patients’ involvement in the management/care of their urinary catheter. All studies found patient and family engagement interventions were associated with improvements in CAUTI rates and/or patient- and family-related outcomes. Further research is needed to systematically develop and evaluate patient and family engagement approaches in CAUTI prevention to ensure that they achieve the goals of the engagement effort. Research should also take into consideration the comprehensibility of resources for the target audience, particularly among populations with limited English proficiency and low health literacy. Approaches may include the adaptation of existing, rigorously designed resources as well as the involvement of patients and families in the creation of the resources to engage patients/families in CAUTI prevention.

Appendix 1

Keywords in systematic review search and PubMed search strategy

Patient and Family Keywords	CAUTI Keywords
family families parent mother father guardian caregiver patient-centered family-centered “patient engagement” “family engagement” “patient and family engagement” “patient teaching” “family teaching” “patient education” “family education” patient-focused family-focused	“catheter-associated urinary tract infection” “urinary catheter” “foley catheter” CAUTI
PubMed Search Strategy ((family OR family [MeSH Terms] OR families OR parent OR parents [MeSH Terms] OR mother OR father OR guardian OR caregiver OR caregivers [MeSH Terms] OR “legal guardians” [MeSH Terms] OR patient-centered OR “patient-centered care” [MeSH Terms] OR family-centered OR (“patient engagement”) OR “patient participation” [MeSH Terms] OR (“family engagement”) or (“patient and family engagement”) OR (“patient teaching”) OR “patient education as topic”[MeSH Terms] OR (“family teaching”) OR (“patient education”) OR (“family education”) OR patient-focused OR family-focused)	AND (CAUTI OR “urinary catheter” OR “urinary catheters” [MeSH Terms] OR “catheter associated urinary tract infection” OR “foley catheter”))