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Catheter-Associated Urinary Tract Infection
Assignment Instructions:For this assignment select a practice improvement issue within your organizational system and within the realm of your practice area. Using the grading rubric as a guide, develop a quality improvement plan to address the identified issue. The purpose of this paper is to demonstrate knowledge of the essential elements of quality improvement, with change theory as an underpinning for the process.Do not use a quality intervention plan that has already been implemented for this assignment; this should be a new plan for the organization with a clear measurable problem statement and a planned evidence-based intervention. Students are not expected to implement the plan; however, the process for implementation and evaluation is addressed as part of the planning process.
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Catheter-Associated Urinary Tract Infection
Hospitals face unprecedented challenges in their delivery of care to patients. Given their sensitive role, healthcare facilities must engage in continuous quality improvement (QI) through actions that improve care services and populations' health status. At X facility in Department 10, Catheter-Associated Urinary Tract Infections (CAUTIs) have contributed to adverse patient outcomes in the last five years. In most cases, care providers use catheters for inappropriate indications and sometimes forget that their patients have catheters, which leads to prolonged and unnecessary utilization. In this quality intervention plan, there is a focus on reducing CAUTIs in Department 10 by using Lewin's change theory as a theoretical foundation while relying on the fishbone cause/effect and the FADE model to guide interventions.
CAUTI is a common healthcare-associated infection. According to Taha et al. (2017), CAUTI is one of the leading causes of secondary bloodstream infection, leading to a high morbidity and mortality rate with approximately 13000 deaths annually. It also contributes to increased hospital stays by two to 4 days and increases healthcare costs by $1200 to $2400 per individual (Taha et al., 2017). The primary contributing factor to the high rate of CAUTI is the overreliance on indwelling urinary catheters. The most significant risk factor is the duration of urinary catheterization (Kramm, 2018). In Department 10, there were seven CAUTIs in 2020. Using the National Healthcare Safety Network Criteria, X's management calculates every departments' standardized infection rate (SIR). In 2020 (January to December), Department 10 had a 2.4 SIR, which means that seven patients had acquired a CAUTI. In that regard, the purpose/aim of this quality intervention plan is to reduce the number of CAUTI infections in Department 10 from seven in 2020 to two in 2021 by closely monitoring the duration of urinary catheterization, catheter placement, catheter management, and catheter removal.
Lewin's Change Theory
Change is an essential component in any healthcare facility or department. As a pioneer of group dynamics and organizational development, Kurt Lewin proposed the three-stage model of change, including the unfreezing, change, and unfreezing (Udod & Wagner, 2018). In Department 10, solving the menace of the high rate of CAUTIs requires guidance from Kurt's framework. The unfreezing stage occurred when X's management determined that Department 10 had a high catheter utilization rate (CAR) and SIR, leading to adverse patient outcomes. They realized and acknowledged that change is inevitable if the facility continues to promote positive care outcomes. In the change phase, change commences, and providers will lean how to follow new practices leading to efficient patient care. Change will have occurred in the final refreezing stage, and care providers will have mastered the new practices. The leadership at X facility will have the duty of sustaining the changes.
In all three stages, care providers must remain engaged, empowered, and committed for any effective change to occur. In the unfreezing phase, engaging care providers will help analyze and predict how they will react to change. In the unfreezing stage, leadership will empower the team by highlighting the problems of CAUTI and the benefits of reducing the SIR. According to Carthon et al. (2019), nurse engagement, empowerment, and commitment to projects lead to "reduced turnover, lower burnout, and high job satisfaction." Therefore, the team should be involved in every stage of the process.
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Fishbone Cause and Effect
The fishbone cause and effect is relevant in the analysis of the CAUTI issue in Department 10. The fishbone diagram acts as a graphical representation to identify, explore, and analyze causes and effects (Coccia, 2018). The risk factors for CAUTI include catheter maintenance, patient condition, catheter removal, and insertion. On catheter maintenance risk, the factors include a poor securement device and culturing technique, bag location, and peri care. On patient condition, patients at risk include the critically ill and those with impaired sensory perception. The catheter insertion risk comprises poor bladder scanning, lack of a straight line, and poor insertion technique (Parker et al., 2017). The catheter removal risk includes inadequate retention assessment and lack of a nurse-driven protocol. Increased awareness of the four areas is paramount to decreasing the catheter line days, leading to low CAUTI cases in Department 10. On the possible interventions, the team will focus on reducing the degree of risk among the four primary factors.
The Focus Analyze Develop Execute (FADE) Model
The FADE is a valuable approach in assessing and reducing CAUTI infections in Department 10 from seven in 2020 to two in 2021.
It is paramount to focus on patient conditions that expose them to a possible CAUTI to achieve the desired outcomes. One of the groups is the critically ill patients. According to Anggi et al. (2019), critically ill patients remain at risk for CAUTI due to the use of invasive equipment such as urine, vein, and artery catheters. The second group is those with an impaired sensory perception such as paralysis and neuropathy. According to Haugen (2018), patients with impaired sensory perception remain at high risk for developing device-related ulcers. A focus on these high-risk patients within the neurological unit (department 10) will reduce CAUTI.
An analysis of the current education level provided using a quality improvement (QI) survey tool to care providers on CAUTI is critical. However, based on previous analysis, it is unlikely that care providers have adequate education and training on catheter removal, insertion, and management. Therefore, the QI survey will only reflect the training and skills inadequacies of care providers within Department 10. The training will also be an important activity to increase the provider's awareness of the unit's high rate of CAUTI.
The first step in the development stage will be creating a rounding team. The team will play a critical role in educating care providers on catheter removal, insertion, and placement. They will also create a catheter removal and management algorithm. The rounding team will conduct daily rounds to evaluate the necessity and ensure that all providers adhere to the laid-out protocols while collecting relevant data. The collected data will be available to all care providers assigned to a patient and continuously reviewed in all shifts. Evidence shows that facilities have high rates of CAUTI due to the lack of awareness among clinicians of current catheter use in a patient (Gould et al., n.d). The developed strategies will help reduce CAUTI rates in the department by closely monitoring urinary catheterization duration.
The development phase strategies will lead to execution by encouraging nurses to embrace a nurse-driven protocol to remove indwelling and early urinary catheters. According to Tyson et al. (2020), a nurse-driven protocol leads to significant decreases in catheter utilization and CAUTI rates. A unique characteristic of the protocol is that a nurse does not require a physician to discontinue catheters.
The project will lead to significant savings for the hospital. At a 35.4% return on investment (ROI) and project earnings of 39,000, Department 10 will have promoted positive patient outcomes and saved the hospital the additional cost of taking care of CAUTI patients. The project will not involve hiring any additional staff but will compensate nurses for their daily rounds due to the additional duties not highlighted in their employment contract. The cost avoidance of managing five CAUTI patients is the financial goal of the project.
Structure, Process, and Outcome Measures
Department X has suitable structure measures. One of the most significant structure measures in the project includes the adequate staff to patient ratio. The staff can effectively reduce the rate of CAUTIs with the necessary education and resources. The process measures are the means to an end. On CAUTI, any extended use of indwelling catheters is a significant risk (DeVries et al., 2017). The care providers at Department 10 should ensure that they use catheters only in the presence of relevant indications and discontinue their use when no longer required. Therefore, the process measures include the number of catheters removed during standard routine rounds and the number of patients who have a catheter accurately placed based on Department 10s protocol. The outcome measures include standardized infection rate and catheter utilization rate within Department 10 compared to other departments.' A reduction of the rates indicates a successful program.
Qualitative and Quantitative Measures
The quantitative data to determine the effectiveness of the quality initiative includes the SIR and catheter utilization rate. The catheter utilization rate includes dividing the total catheter days by total patient-days multiplied by a hundred to provide a 'baseline catheter utilization rate.' The calculation for SIR involves evaluating the total number of observed infections with the number of predicted infections. Reducing the metrics suggests a successful program or a reduction of patients who acquire a CAUTI within the department.
A histogram and line graph will be the two most critical visual displays for the project. The histogram will depict the number of observable infections against predicted infections. The graph would be vital when comparing the rates for 2020 and 2021. The line graph will play a role in highlighting the line days or the average duration a patient stays with a catheter for the years 2020 and 2021. In both visual displays, the expected outcome is a reduction in observable infections and line days in 2021 compared to the previous period.
Undoubtedly, any healthcare-associated infection is a problem for any health facility, given providers' unique role to facilitate healing by providing relationship-centered care and evidence-based practice. It is expected that monitoring the number of catheters removed during standard routine rounds and the number of patients who have a catheter accurately placed based on Department 10s protocol (process outcomes) reduces the standardized infection rate and catheter utilization rate (outcome measures). Successful implementation of this quality intervention plan will reduce the number of CAUTI infections in Department 10 from seven in 2020 to two in 2021.
Anggi, A., Wijaya, D. W., & Ramayani, O. R. (2019). Risk Factors for Catheter-Associated Urinary Tract Infection and Uropathogen Bacterial Profile in the Intensive Care Unit in Hospitals in Medan, Indonesia. Open access Macedonian journal of medical sciences, 7(20), 3488. https://doi.org/10.3889/oamjms.2019.684
Carthon, J. M. B., Davis, L., Dierkes, A., Hatfield, L., Hedgeland, T., Holland, S., ... & Aiken, L. H. (2019). Association of nurse engagement and nurse staffing on patient safety. Journal of nursing care quality, 34(1), 40. https://doi.org/10.1097/NCQ.0000000000000334
Coccia, M. (2018). The Fishbone diagram to identify, systematize and analyze the sources of general purpose Technologies. Journal of Social and Administrative Sciences, 4(4), 291-303. https://doi.org/10.1453/jsas.v4i4.1518
DeVries, M., Lee, J., & Hoffman, L. (2019). Infection free midline catheter implementation at a community hospital (2 years). American journal of infection control, 47(9), 1118-1121. https://doi.org/10.1016/j.ajic.2019.03.001
Gould, C. V., Umscheid, C. A., & Agarwal, R. K. Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospital Units: Implementation Guide.
Haugen, V. (2018). Prevention of pressure ulcers due to medical devices. Perspectives, 10(3), 1-11.
Kramm, W. (2018). Catheter-Associated Urinary Tract Infection Reduction: A Quality Improvement Project.
Parker, V., Giles, M., Graham, L., Suthers, B., Watts, W., O'Brien, T., & Searles, A. (2017). Avoiding inappropriate urinary catheter use and catheter-associated urinary tract infection (CAUTI): a pre-post control intervention study. BMC health services research, 17(1), 1-9. https://doi.org/10.1186/s12913-017-2268-2
Taha, H., Raji, S. J., Khallaf, A., Hija, S. A., Mathew, R., Rashed, H., ... & Ellahham, S. (2017). Improving catheter associated urinary tract infection rates in the medical units. BMJ Open Quality, 6(1), u209593-w7966. http://dx.doi.org/10.1136/bmjquality.u209593.w7966
Tyson, A. F., Campbell, E. F., Spangler, L. R., Ross, S. W., Reinke, C. E., Passaretti, C. L., & Sing, R. F. (2020). Implementation of a nurse-driven protocol for catheter removal to decrease catheter-associated urinary tract infection rate in a surgical trauma ICU. Journal of intensive care medicine, 35(8), 738-744. http://dx.doi.org/10.1177/0885066618781304
Udod, S., & Wagner, J. (2018). Common Change Theories and Application to Different Nursing Situations. Leadership and Influencing Change in Nursing.
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