Catheter-Associated Urinary Tract Infections
The healthcare system must provide safe and quality care to all patients. For years, hospitals nationwide have struggled with healthcare-associated infections (HAIs). Since HAIs are considered preventable events in a hospital setting the Centers for Medicare and Medicaid Services (CMS) established reimbursement changes and hospitals are focusing more on patient safety practices and improving processes to have better patient outcomes (Thornlow & Merwin, 2009). According to The Centers for Disease Control and Prevention (CDC, 2017), approximately seventy-five percent of hospital-acquired urinary tract infections are associated with a urinary catheter with a prolonged use being the most critical risk factor for developing a CAUTI. Also, CAUTIs can cause an overabundance of complications included but not limited to gram-negative bacteremia, sepsis, and mortality (Skanlon, 2017). In a long-term acute care hospital (LTACH), prolonged and unnecessary use of indwelling urinary catheters is interrelated with a higher risk of catheter-associated urinary tract infections (CAUTI) and extended lengths of stay (LOS) (Felix, 2016). The purpose of this paper is to reduce the usage of indwelling catheter days and decrease CAUTI rates from 2.48 to below the target rate of 1.71 by utilizing prevention practices in a 72-bed long-term acute care hospital emphasizing on the assurance of a continuous improvement process. This proposal consists of implementing alternatives before deciding to insert an indwelling catheter, utilizing maintenance bundles, and daily assessment of the necessity of the catheter. All these interventions are aiming at preventing and decreasing catheter-associated urinary tract infections (CAUTIs). Catheter-Associated Urinary Tract Infections
The role of nurses in the prevention of CAUTIs is critical; we are the frontline of patient care and safety. Although, sometimes we encounter situations where a CAUTI occurs, the quality of care we provide to our patients reflects by the interventions we take to prevent our patients from getting an infection. Every action we make while providing care for a patient is an essential step in the quality of their care. Most patients admitted into long-term acute care have wounds or infections that require long-term antibiotics. These patients come in from acute care hospitals, and in the majority of the cases patients already have an indwelling urinary catheter, however, there are situations where the patient doesn’t come with an indwelling catheter, and nurses get orders to place one on admission. Finding alternatives to either discontinue or insert a foley is an essential part of the daily nursing assessment and on the hospitalization of these patients. Important factors to consider while assessing the patient are mobility, cognitive status, gender, and wounds.
In 2009, The Centers for Disease Control and Prevention created guidelines for prevention of catheter-associated urinary tract infections including recommendations to use external catheters in cooperative male patients without urinary retention or bladder outlet obstruction, intermittent catheterization in patients with spinal cord injury and with bladder emptying dysfunction. Although there is not much literature on any alternative external devices to use with females, intermittent catheterization, frequent perineal care for incontinent patients and the use of bedpans are still adequate alternatives to an indwelling catheter. The use of external continent devices (ECD) in men such as condom catheters also known as Texas catheters is an alternative to the insertion of indwelling catheters for indications such as cognitive dysfunction due to acute or chronic illness and men with neurogenic bladder dysfunction (Gray, Skinner, & Kaler, 2016). Catheter-Associated Urinary Tract Infections
Implementation of catheter maintenance bundles is a fundamental piece in the prevention of CAUTIs. Bundles are a group of interventions. Unfortunately, many times staff are not aware of the existence of bundles. Therefore, education on the concept is a critical piece of implementation. A CAUTI bundle includes interventions such as appropriate catheter use, utilization of aseptic technique during catheter insertion, a closed drainage system, and removal of the catheter as soon as possible. (Meddings, Rogers, Krein, Fakih, Olmsted, & Saint, 2014). Appropriate indications for the use of an indwelling catheter include relief for patients with acute urinary retention or bladder outlet obstruction, accurate measurements of urinary output in critically ill patients, preoperatively for select surgeries, for incontinent patients with open sacral or perineal wounds and to assist in wound healing, patients requiring prolonged immobilization, and comfort for patients at end of life care (CDC, 2016). Utilization of aseptic technique during catheter insertion is a crucial step in preventing infection. In most cases, a Registered Nurse of a Licensed Vocational Nurse insert the catheter; consequently, policy and procedures, unit guidelines, skill checks, nursing competencies, random audits, and continuing education should be promoted (McNeill, 2017). Catheter-Associated Urinary Tract Infections
The maintenance of urinary catheters starts with the insertion of the catheter. Staff must perform hand hygiene and use gloves anytime the catheter or tubing is manipulated. Securement of the catheter with a stat-lock to the patient’s leg helps prevent pulling. A closed-draining system must be maintained to avoid the entrance of germs. The bag should be below the patient’s bladder and off the floor and emptied before it’s three-quarters full by using a container for patient use only and not allowing the spigot touch the container. Daily meatal care is necessary to reduce chances of infection (McNeill, 2017). Removing the catheter as soon as possible is vital in the bundle to prevent CAUTIs. The longer a catheter is in place, the higher risk for a patient to acquire an infection. Research has shown the risk of developing bacteriuria on catheterized patients as high as 3% to 10% per day and close to 100% after the catheter has been in place for 30 days (McNeill, 2017).
Daily assessment for the continuance of a catheter should be nurse-driven and supported by charge nurses, physicians, and infection control interventionists. In the United States, the statistics are alarming, approximately five million catheters are placed annually, and 50% of the patients do not meet appropriate criteria, and 40% of physicians are unaware of their patients have a urinary catheter in place (Mori, 2014). Advocating for patient’s safety is vital, prevention is the key in reducing CAUTIs, and this can be accomplished not only by limiting foley catheter insertions but by early removal of such devices (Yatim, Wong, Ling, Tan, Tan, & Hockenberry, 2016). Daily ongoing catheter needs assessments, and reminder protocols for early removal of catheters have proven effectiveness in reducing CAUTIs (Mori, 2014).
Quality Improvement Process and PDSA
The quality improvement (QI) process occurs when performance problems are identified. There is no standard definition of quality; quality is a feature of a product or service (Spath, 2013). Because performance problems affect the quality of service provided, actions must be taken to identify and resolve the issue that is causing a decrease in performance (Spath, 2013). To improve a performance problem, an analysis of measurable collected data needs to occur to find the gaps in performance. Once the data is analyzed, a plan for necessary changes develops, interventions are tested, implemented, and measured again to check the effectiveness of the project. Throughout the years, healthcare and other industries have used different systematic performance improvement models that have been created assisting in the delivery of a high-quality performance level (Spath, 2013). Catheter-Associated Urinary Tract Infections
The process improvement model that will be used to reduce catheter-associated urinary tract infection (CAUTI) is the Plan-Do-Study-Act-Cycle. As described by Spath (2013), currently the PDSA is the most recognized process improvement known. The PDSA model guarantees continuous improvement by repeating the cycle allowing the improvement team to learn from failures and successes assisting them to plan for the next process change. The long-term acute care hospital where I currently work is a 72-bed facility of which eight beds are ICU. Most of the patients admitted to this facility come in from acute care hospitals to wean off the ventilator, long-term antibiotic treatment, wound care, and hyperbaric oxygen treatments. Their length of stay ranges from 25 to 28 days. Time is crucial in the prevention of CAUTIs for these patients, the more days they have a catheter in place the higher chances of them acquiring a CAUTI.
Centers for Disease Control and Prevention. (2017). Catheter-associated Urinary Tract Infections (CAUTI). Retrieved from https://www.cdc.gov/hai/ca_uti/uti.html
Thornlow, D. K., & Merwin, E. (2009). Managing to improve quality: The relationship between accreditation standards, safety practices, and patient outcomes. Health Care Management Review, 34(3), 262–272. doi: 10.1097/HMR.0b013e3181a16bce Catheter-Associated Urinary Tract Infections
Gray, M., Skinner, C., & Kaler, W. (2016). External Collection Devices as an Alternative to the Indwelling Urinary Catheter. Journal of Wound, Ostomy and Continence Nursing, 43(4), 413. doi:10.1097/won.0000000000000251
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Centers for Disease Control and Prevention. (2016). Catheter-Associated Urinary Tract Infections (CAUTI). Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009). Retrieved from https://www.cdc.gov/infectioncontrol/guidelines/cauti/index.html
Meddings, J., Rogers, M. A. M., Krein, S. L., Fakih, M. G., Olmsted, R. N., & Saint, S. (2014). Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: An integrative review. BMJ Quality & Safety, 23(4), 277. Catheter-Associated Urinary Tract Infections doi:http://dx.doi.org.ezp.waldenulibrary.org/10.1136/bmjqs-2012-001774
Corley, L. (2015). INSPIRING CHANGE. CAUTI awakenings. Nursing, 45(1), 20-21. doi:10.1097/01.NURSE.00004589373.65995.89
McNeill, L. (2017). Back to Basics: How Evidence-Based Nursing Practice Can Prevent Catheter-Associated Urinary Tract Infections. Urologic Nursing, 37(4), 204-206. doi:10.7257/1053-816X.2017.37.4.204
Spath, P. (2013). Introduction to healthcare quality management (2nd ed.). Chicago, IL: Health Administration Press Catheter-Associated Urinary Tract Infections
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