Background: Urinary catheters, vascular catheters, and wounds such as pressure injuries are often hidden from view under gowns and sheets – out of sight, out of mind – contributing to prolonged catheter use, infections, delayed interventions, and diagnostic errors for symptoms (e.g., fever, delirium) related to catheters and wounds. We developed and pilot tested a digital bedside “Patient Safety Display” of catheter and wound information to improve awareness by rounding providers (i.e., physicians, advanced practice providers (APPs)).

Methods: The display’s development was informed by clinical observations of provider rounds and nurse handoffs, interviews, and iterative prototype testing with clinicians in simulated cases using catheterized mannequins with wounds. The display (Figure 1) reported the presence and duration of urinary and vascular catheter use, urinary catheter indication, and wound presence and severity, from real-time mandatory nurse documentation in the electronic medical record. In a pilot study in a tertiary care medical-surgical step-down unit with 20 private rooms, including a pre-intervention period and a post-intervention period with 10 rooms without the display (control rooms) and 10 rooms with the display (intervention rooms), we surveyed individual providers by brief quantitative questionnaire directly after rounds to assess awareness of each of their patients’ catheters and wounds, compared to medical record documentation. We also assessed display utility and usability from post-intervention clinician interviews, with major themes identified using an adapted grounded theory approach.

Results: A total of 787 surveys (681 Medicine service with 89% response rate, 106 Surgery service with 47% response rate; 363 pre-intervention surveys, 424 post-intervention surveys) were completed involving 176 unique patients and 47 unique providers. Amongst all 787 patient encounters, 156 (19.8%) had a transurethral indwelling urinary catheter (Foley), 314 (39.9%) had a central venous catheter (CVC, including peripherally inserted central catheters (PICCs)), and 247 (31.4%) had at least one pressure injury. Figure 2 summarizes provider awareness of catheters and pressure injuries when present as assessed for patients in the pre-intervention and post-intervention periods. Responses from 13 post-intervention interviews with clinicians (4 attending physicians, 1 resident, 3 nurse practitioners, 2 physician assistants, and 3 nurses) yielded preliminary findings regarding the display’s benefits and limitations. Benefits reported by clinicians included: prompts discussion about catheters and skin, increases awareness of catheters and skin issues, and serves as a reminder to assess appropriateness of catheters. Limitations identified included: clinicians often did not notice the display, display less useful for attending physicians, and the display is repetitive to the electronic medical record.

Conclusions: In this pilot study of a new Patient Safety Display, although provider awareness of Foley catheters, CVCs, and pressure injuries appeared higher for patients in the intervention rooms compared to awareness as measured in the pre-intervention rooms and/or post-intervention control rooms, most of these comparisons did not meet statistical significance. Clinicians varied widely in their personal assessments of the display as a useful tool for improving awareness and prompting discussion about catheters and wounds.

IMAGE 1: Figure 1. Patient Safety Display

IMAGE 2: Figure 2. Results for Catheter and Pressure Injury Awareness