Nurses’ Adherence to the Portuguese Standard to Prevent Catheter-Associated Urinary Tract Infections (CAUTIs): An Observational Study

Round 1

Reviewer 1 Report

First of all, I want to take this opportunity to thank you for the opportunity to review this manuscript, of which I will present my opinion below.

Introduction

Presents the research topic adequately, briefly presenting, in addition to the background of the problem, both the health and regulatory context in which it is developed.

Methods

Most of the subsections are explained satisfactorily, although I think it should be better explained how the bundle and criteria compliances were calculated. Otherwise, it is not easy to understand the results presented.

Table 1 indicates that one of the data sources is nursing feedback, but at no time is it explained what type of information is collected, if they are closed responses to a checklist-type questionnaire, or if more extensive responses are collected whose analysis requires qualitative techniques, for example.

Results

The number of people with a bladder catheter whose insertion and management were evaluated and the mean insertion time should be clarified. It seems to be understood that only 9 probes have been placed in this period, giving rise to 198 observations.

Therefore, it is unclear how there is such a disparity in the number of observations of each of the criteria, nor is it understood where the rates of adherence to each of the criteria shown as a result appear. It does not seem easy to understand how the results presented in this section are reached.

The same footer appears in Tables 2 and 4; however, the superscript to which it refers only appears in Table 4.

Discussion

Although it justifies and compares the results obtained in this work with similar studies, I consider it quite limited since comparisons could be made with many other works that analyze the proper performance of specific standard techniques in our daily practice. Perhaps this inconsistency is determined by the fact that the results do not seem very clear either.

Neither has it been studied in depth whether there was any differential characteristic in the study population in which the research was carried out that would justify the low adherence to the standards: level of knowledge, available materials...

Even so, I find it very interesting that it is proposed as a starting point for developing an educational intervention for nursing professionals to improve their care practice.

Overall impression

 

I believe that the manuscript requires changes, especially in clarifying certain aspects of the methodology and presenting the results, which are sometimes quite incomprehensible.

Author Response

Introduction

Presents the research topic adequately, briefly presenting, in addition to the background of the problem, both the health and regulatory context in which it is developed.

 

Thank you.

 

Methods

Most of the subsections are explained satisfactorily, although I think it should be better explained how the bundle and criteria compliances were calculated. Otherwise, it is not easy to understand the results presented. 

 

Thanks for the suggestion. We have added information that we believe helps us better understand how bundle membership was calculated (lines: 118–122). We also standardized the use of the terms adhesion and compliance, adopting the term adherence throughout the manuscript.

 

Table 1 indicates that one of the data sources is nursing feedback, but at no time is it explained what type of information is collected, if they are closed responses to a checklist-type questionnaire, or if more extensive responses are collected whose analysis requires qualitative techniques, for example.

 

Thanks for the suggestion. We add this information in Table 1.

 

Results 

The number of people with a bladder catheter whose insertion and management were evaluated, and the mean insertion time should be clarified. It seems to be understood that only 9 probes have been placed in this period, giving rise to 198 observations.

Therefore, it is unclear how there is such a disparity in the number of observations of each of the criteria, nor is it understood where the rates of adherence to each of the criteria shown as a result appear. It does not seem easy to understand how the results presented in this section are reached.

 

Thank you for sharing this observation with us. Re-reading the manuscript after your comment, we agree that it is not clear and even that we should make adjustments in the calculation of adherence to each of the urinary catheter maintenance criteria, due to the fact explained in lines 140–142. Therefore, to calculate adherence to the maintenance criteria, only the 51 moments in which it was possible to observe all the sub-criteria of all the criteria were considered. This led to the alteration of Table 4, with new rates of adherence to each of the catheter maintenance criteria, but did not alter the rate of adherence to the bundle.

 

The same footer appears in Tables 2 and 4; however, the superscript to which it refers only appears in Table 4.

 

Thanks for this reminder. It is clearer to put only the superscript in Table 1.

 

Discussion

Although it justifies and compares the results obtained in this work with similar studies, I consider it quite limited since comparisons could be made with many other works that analyze the proper performance of specific standard techniques in our daily practice. Perhaps this inconsistency is determined by the fact that the results do not seem very clear either.

 

Thanks for this comment. We hope that the changes made to the methods section and the results section will make our discussion more coherent.

 

Neither has it been studied in depth whether there was any differential characteristic in the study population in which the research was carried out that would justify the low adherence to the standards: level of knowledge, available materials...

 

This study did not seek to know the characteristics of the nurses that justified the low adherence to the criteria, either of introduction or maintenance of the urinary catheter, we only wanted to identify the practices as a starting point of a continuous improvement project. Following this study, the results will be presented to the nurses and a focus group will be held to identify barriers and facilitators to the implementation of good practices, individual and organizational, in the scope of care for people with urinary catheters.

 

Even so, I find it very interesting that it is proposed as a starting point for developing an educational intervention for nursing professionals to improve their care practice.

 

Thank you. Our goal is to make nurses aware of safer practices and thus improve care.

 

Reviewer 2 Report

The study considered adherence to Portuguese government protocols. The finding of non-compliance is important. However, it is more important to analyze the reasons for this. Also, to what extent deviation from protocol determines the quality of nursing care. A multivariate analysis of whether there are certain nurses who violate the protocol more often, and what the relationship is with the age and professional experience of the nurses, was not performed. In addition, it would be useful to include a survey on the reasons that the nurses consider important for the deviation from the protocol

Author Response

Dear reviewer,

we want to thank you for the time available to review our article and have helped us improve our manuscript with your reflections and suggestions.

The finding of non-compliance is important. However, it is more important to analyze the reasons for this.

We completely agree on the importance of analysing the reasons for non-compliance. After analysing the data from this study, the results were presented to all nurses and a focus group was conducted to identify the reasons for this (non-)compliance and identify strategies to improve care. We add this information to the manuscript.

We are analysing the data collected in the focus group to be published soon. We add this information to the manuscript.

Thank you for this reflection.

What extent deviation from protocol determines the quality of nursing care.

This study is part of an action research, so it is essential to make a base line. The focus of this study was not to identify to what extent (non-)compliance determines the quality of care. We did not have this concern because the bundle was built based on scientific evidence and the experts considered that these interventions, when carried out as a whole, improve the results.

A multivariate analysis of whether there are certain nurses who violate the protocol more often, and what the relationship is with the age and professional experience of the nurses, was not performed.

In fact, it would be very interesting for us to be able to do the analysis you suggest. When we outlined this study, the goal was to have a base line to evaluate the impact of implementing a formative intervention. The instruments created do not allow the analysis it suggests, but we will take this suggestion into account in our next studies.

We hope we have responded to your comments and suggestions. Thank you again for your willingness to read the manuscript and make comments and suggestions.

Reviewer 3 Report

When writing your article, it's important to consider how it will be received by healthcare professionals. To make your case for adopting new approaches more convincing, it might be helpful to show the direct impact on reducing infections like CAUTI. One way to do this is by reporting the incidence of CAUTI before and during the study period. By comparing these numbers, you can clearly perceive the difference in incidence and demonstrate how the new approach is making a positive impact on patient outcomes. This kind of data can be very compelling for healthcare professionals, who are always looking for ways to improve patient care and outcomes.

Author Response

Dear reviewer, we want to thank you for taking the time to read our manuscript and give your suggestion. 

We fully agree with the importance of showing the impact of practises on the reduction of CAUTI. 

The hospital where this study was conducted does not monitor CAUTI. For this reason, we chose to monitor the number of catheter days for 1000 days of hospitalisation, which is also a good indicator. The evidence holds that the longer the permanence of the catheter, the greater the probability of developing a CAUTI. This indicator will be used, replacing the CAUTI rate, to evaluate the impact of the educational intervention of the action research in which this research falls. 

Aware of the importance of CAUTI monitoring, we held a meeting with the hospital's infection control committee to try to find mechanisms to do this monitoring. 

Thank you for your reflection.

Round 2

Reviewer 1 Report

The changes introduced in the manuscript have responded to the suggestions proposed by the reviewer. I consider that the manuscript can be accepted for publication in this new form.

Reviewer 2 Report

Thank you for your changes in the manuscript.