Quality Improvement Interventions to Reduce Catheter-associated Urinary Tract Infection

Introduction

Infections within the hospitals are a common challenge facing many healthcare facilities, especially the surgical units. Hospital-acquired catheter-associated urinary tract infections (CAUTIs) are prevalent and treatment comes at high cost. In the United States alone, over 500,000 CAUTIs are recorded annually, which represent 30% of infection associated cases (Kathleen et al., 2014). CAUTIs are the highest source of bacterial infection and the major cause of bacterial infections. Its prevalent has been associated with excessive use of urinary catheterization. This research adopted a multifaceted approach through a pre/post-intervention design to determine the impact of nurse-driven evidence-based intervention of change among patients, Registered Nurse (RNs), and certified nursing assistants [CNAs]), and patient families in management of hospitalized patients (Kathleen et al., 2014). Quality improvement is essential to ensure safe care of patients in the surgical units.

Patient Case

Mr. Robin was admitted to the surgical unit following diagnosis of urinary problems. The Registered Nurse recommended catheter to the patients with a recommendation that the patient was to be under keen observation and the bag to be replaced as regularly as possible. Before the night shift, the patient was shifted to the empty corner bed, upon his request. During the shift, the nurses forgot to check the patientís catheter. When the new nurse arrived, she noticed that Mr. Robin was the last to be attended to and paid no particular attention to his catheter. Mr. Robin spent the entire night with no attendance. In the morning, the nurse who attended the patient noticed that Mr. Robinís urine was flowing backward to his bladder, the nurse also realized the bag was full of urine, a sign that it had not been emptied for several hours. The patient seemed to be in pain. A physician came to Mr. Robinís aid and established slight bacterial infection, but with no much damage. The catheter was replaced and Mr. Robin continued with his treatment. This was one of the many near miss situations.

Data Collection and Intervention

Data was collected in three phases. The phases included baseline data collection in the surgical units, house-wide intervention (second data collection), and intervention directed at the study units. The third intervention became the last data collection point. The first phase was dependent on data collected from surgical inpatients. The second intervention relied on present medical policies and evidenced based practices. Information was collected upon.

Errors were established on the mode of replacement of silver alloy-coated catheters with latex and nonlatex catheters, standardization and proper securement of devices and the point of stocking, and the level of provision of metered drainage bags in insertion kit in the care areas. Education interventions was lacking among rehabilitation therapists, radiology staff, and transport staff. During intervention, the specific education areas included emptying and replacement of urinary catheter bags prior to therapy, transportation, and radiologic examinations. Education need to be conducted based on the results from the best practice outcomes. The goals are to ensure an error free intervention setting (Wilson, Wilde &Webb, 2009). The education should be continuous.

The third phase intervention phase targeting the surgical inpatients. The phase should be conducted in stages, and with diverse groups. The first stage can involve a sixty-minute learning session undertaken by nurse scientists and educators to analyze a journal on risk factors associated with indwelling catheters plus possible intervention approach (Lo E, 2008). Among the areas of concern are discussion sessions of the problem and developing a patient-centered nursing approach and coming up with competency-based learning of instrumental applications. Other stages include enhancing bedside commodes, promoting ostvoid residuals through purchasing new bladders, determining effective use of TRIP fliers, managing catheter rounds among nurses, and coming up with a holistic care among nurses, patients, and their families (Wilson, Wilde &Webb, 2009). The areas should be covered by all the nursing staff.

Stakeholders Involvement

The entire intervention involved various groups. Among the parties involved included the nurses (RNs and CNAs), The Quality Intervention Team, nurse managers, educators, nursing staff, patients, families, policy makers, The study framework involve recruitment of multidisciplinary team, which included clinical, scientists, educators , physicians (for hospitalists and infectious disease), clinical informatics representatives, transport personnel, rehabilitation therapists, central supply, infection control preventionists, and healthcare government representatives (Kathleen, Mary, Regina, Nicolle, Teresa, Tarah & Heidi, 2014). This is to ensure the entire hospital process in improved.

While Mr. Robin was the patient of concern, sample group was important for the three-phase data collection, which included data collection in the surgical units, house-wide intervention (second data collection), and intervention directed at the study units. The study adopted both patient and nurse centered approach to ensure a holistic intervention approach. While patients were the center of the intervention, nursing staff, (RNs and CNAs) were core in the study since they are the major health care implementers. In any care intervention, the family is a vital part of treatments. Family members form an integral part of healthcare decision-making, as well as, source of emotional and financial support to the patients.

Healthcare organization management are charged with ensuring proper and effective facility management, human resource development, improvement of structures, process, and outcome. The hospital management team initiates change implementation. As a result, the team is a pillar in any form of an intervention program. Nurses play an integral part in the implementation of evidence-based practices. Based on the article, nurses are the immediate providers of patient-centered care. As a result, they are core members in developing an intervention plan. Nursing educators are vital in managing therapeutic changes. They help nurses inculcate the new values. As change implementers, educators help set the pace for the new nursing practices to curtail the dangers associated with an infectious catheter (Wilson, Wilde &Webb, 2009). For a comprehensive change, all parties must be involved.

Rigor of Development

The research is evidenced based quality improvement intervention. It utilized current peer-reviewed materials within the study objective. The study framework involved recruitment of multidisciplinary team, which included clinical, scientists, educators, physicians (for hospitalists and infectious disease), clinical informatics representatives, transport personnel, rehabilitation therapists, central supply, and infection control preventionists. Evidence was examined through an exhaustive literature review. A systematic literature analysis was undertaken and graphical illustrations developed (Kathleen, Mary, Regina, Nicolle, Teresa, Tarah & Heidi, 2014). The therapeutic products are effectively defined and analyzed. Among these included IUC material, skits, drainage bags, and sizes. Catheter securement devices, such as urinals and bedpan, bladder scanners, commodes, plus alternatives including condom catheters, and incontinence pads. Several outcome indicators were also adopted, these included catheter-days/hospital days, CAUTIs/1,000 catheter-days, and postoperative catheter-days/patient (Kathleen, Mary, Regina, Nicolle, Teresa, Tarah & Heidi, 2014). Effective quality rigor will ensure improvement of safe practices.

Data collection procedure was systematic across the three study phases. In Phase 1, IUC duration and CAUTI data were collected from surgical inpatients to determine infection prevalence. In Phase 2, evidence based materials were utilized to come up with up-to-date policy and education approaches. Extensive literature materials were analyzed in this part of the study. Phase 3 relied on evidenced-based data to come up with the most appropriate intervention approach (Wilson, Wilde &Webb, 2009). While Mr. Robin was the subject of study, an elaborate data collection was important for rigor development.

Various forms of data was collected during the study. CAUTI data was based daily records from ICU catheterizations. CAUTIs were recorded, calculated, and tracked by nurses on duty. Quarterly tracking for baseline and post intervention interventions were taken into considerations. CAUTIs were reported based on per 1000 absolute catheter-days for enrolled patients. The study demographic information included patient age, gender, surgical procedure, and hospital length of stay (LOS). The information collected from patientís medical record abstraction (Kathleen, Mary, Regina, Nicolle, Teresa, Tarah & Heidi, 2014). The data was further validated by literature findings.

Recommendations

The study presented several deficiencies. It adopted pre/post-intervention approach. As a result, the intervention of the team affected CAUTI rates observed and the catheter duration. In a normal program, no form of interference should occur in the study universe. In most hospitals, there are many acute surgical units; as a result, consideration of the two units may influence the overall study outcome. It is clear that more assumptions are made based on the few selected data collection points. It is recommended that for validity and accuracy purposes, more units should be considered for future studies. The number of CAUTIs for the study was below the required level. The confidence interval, on the other hand, was relatively large. The relatively low number of CAUTIs and large intervals makes difficult to determine targeted intervention outcome effectively. For studies with small sample population, the level of confidence should be low. Future studies should focus on ensuring large sample population that easily represents the entire world of study. The level of confidence should be in line with the sample population size. The manual data abstraction is an ineffective method of tracking information. The data collection for this project demanded real-time approaches. This could not be effectively be achieved by the current by the present system. For effective evaluation of the intervention, electronic data management system should be put in place for ease of capturing real-time data (Kathleen, Mary, Regina, Nicolle, Teresa, Tarah & Heidi, 2014).

The study focus was to on the management of IUC to curb CAUTIs, to come up with a comprehensive human resource management strategy, and modes of mobilizing other resources for effective managed care. Despite its success in tackling many areas, it failed to underscore bladder catheters direct insertion and removal modes. It is recommended that future studies should effectively address management of bladder catheters. Finally, the evidence provided in the study are inconclusive. Future researches should be geared towards collecting and analyzing more evidenced based materials.†

Implementation

While creating new strategies are essential in CAUTIs management, the interventions presented in this study involve many stakeholders. As a result, change management will be the major barrier to implementing the study findings (Lo E, 2008). Managing change in a diverse environment is often associated with conflicts, especially with improper management and poor change management plan (Wald & Kramer, 2011). Effective communication is essential in ensuring the change process takes place.

Cost considerations will hugely affect the implementation of the project. For smooth running of the project, a lot of financials is demanded for procurement of the products, outsourcing experts, and ensuring properly equipped units (Wilson, Wilde &Webb, 2009). The cost of running the plan over a duration of time might not be economical in the short run. As a result, implementing the intervention calls for financial injection from diverse sources, which might not be easy.

Conclusion

Care centers can benefit from properly implemented quality system. The case of Mr. Robin is among the many near miss cases, often in hospitals. To mitigate such cases, hospitals rigorous quality improvement policies which are supported with data from the critical units. Evidenced based approach provide the best solution to tackling healthcare challenges. With the identified changes and recommendations, the quality of catheter administration will be improved.

References

Kathleen S., FAEN, Mary B., Regina F., Nicolle S., Teresa H., Tarah K., & Heidi W. (2014). Nurse-directed interventions to reduce catheter-associated urinary tract infections. American Journal of Infection Control. PDF (attached)

Lo E et al.(2008).† Strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiol. 29(Suppl ††† 1):S41-50

Wald HL & Kramer AM. (2011). Feasibility of audit and feedback to reduce postoperative urinary catheter duration. J Hosp Med 2011; 6:183-9.

Willson M, Wilde M, Webb ML, et al. (2009). Nursing interventions to reduce the risk of catheter-associated urinary tract infection: part 2: staff education, monitoring, and care techniques. J Wound Ostomy Continence. Nurs 2009;36:137-54.