Improving Patient Safety and Quality Paper

Improving Patient Safety and Quality Paper

Introduction

UTIs are among the commonest HAIs (healthcare-associated infections) that account for approximately 36% of all HAIs and CAUTIs account for the majority of HAIs. The risk of CAUTIs increases with an increase in the period of catheterization and this generates significant healthcare costs, care burden, discomfort, patient distress, and embarrassment. CAUTIs are the most preventable HAIs that save potential costs.  Parker et al (2017) estimate that annually there are 380, 600 additional hospital-beds that are utilized due to HAIs, the majority being CAUTIs where each CAUTI incurs between $1200-$4700. It is for this reason that prevention of HAIs has emerged as a major focal point for improving the safety and quality of healthcare delivery among hospitalized patients as evidenced by the CMS (Center for Medicaid and Medicare Services) decision not to reimburse hospitals for additional costs incurred for the care of patients who develop specific preventable infections during admission. Improving Patient Safety and Quality Paper

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CMS selected CAUTIs as the first choice for non-payment since it is the most common HAI in the US and a reasonably preventable condition. A major premise that underlies the CMS policy is the existence of multimodal prevention strategies and evidence-based practices that hospitals can implement to decrease the rates of CAUTIs. A component common in the prevention of CAUTI is using a nurse-driven catheter protocol which has been addressed in the USA with the AHRQ safety program for decreasing CAUTIs in hospitals and allows nurses to practice efficiently and autonomously. It also promotes prompt removal of UCs (urinary catheters) leading to a reduction in the incidences of CAUTIs, device days, risk, and mortality of CAUTIs. According to Parker et al (2017), this ultimately improves patient outcomes and reduces the financial burden of patients and healthcare systems. This paper outlines the implementation of a quality improvement project for the prevention of CAUTIs in the author’s healthcare organization using a nurse-driven IUCP (indwelling urinary catheter protocol). It provides a review of literature, analysis of causes, change model, benchmark to measure expected outcomes, and implementation timeline.

 Problem Statement

TIRR Memorial Herman is a research and rehabilitation hospital that provides rehabilitation care to patients with neurologic illnesses, traumatic brain injury, and spinal injury in Houston, Texas. It ranks among the best rehabilitation hospitals in the US to an extent that it earned a Gold Seal of Approval which symbolizes quality and reflects its commitment to provide effective, efficient, quality, and safe care to patients. Although the institution has recently been recognized as a national leader in research and rehabilitative services, it seeks to continuously improve patient care and health outcomes.

Recently, the organization through its leadership launched a project for the prevention of CAUTIs. This project saw a drastic decline in the incidences of CAUTIs from 9.5 to 2 per 1000 device days in three months. The success of the aforementioned project was influenced by improvement in care and education, and collaboration between nurse educators and leaders of the CAUTIs taskforce. However, TIRR still records below benchmarks for catheter maintenance which includes care for indwelling urinary catheters with regards to the use of gloves and hand hygiene, care for the drainage bag, use of bath basins, and leg bags. As a result, the organization still records slightly lower incidences of CAUTIs that affect its financial performance, incurs additional costs, and prolong the duration of hospitalization. Improving Patient Safety and Quality Paper

Literature Review

Umer et al (2016) conducted a study whose purpose was to decrease the postoperative UTIs rates. The background of the study was based on high mortality and morbidity, and increased hospitalization costs of CAUTIs. The researchers implemented an indwelling catheter protocol to guide the use, removal, and maintenance of indwelling catheters based on the guidelines provided by CMS. Before implementing the protocol, Umer et al (2016) focused on a wide range of measures such as staff education, modifying existing systems for compliance, and performing audits of different patient care areas on the utilization of catheters before protocol implementation. The researchers collected data from 3873 participants through postdischarge interviews with patients and chart reviews. Initially, Umer et al (2016) diagnosed (N=1404), 2,6% (36) patients with CAUTIs while after intervention, (N=2469), 1.5% (38) patients were diagnosed with a CAUTI. This was a 1.1% reduction in CAUTI rates post-intervention (P < .028). This decrease translated to approximately $81,840 to $320,540 annual savings. They concluded that a multifaceted approach comprising of changes in existing processes and staff education reflect practices in the best care with significant potential to decrease the postoperative incidences of CAUTIs. This finding is similar to that of Wooller et al (2018) of increased effectiveness of a SafetyLEAP program in detecting and reducing safety incidents in healthcare settings.

Wooller et al (2018) acknowledge in their study that, despite the common use of urinary catheters, they are linked to significant adverse health events like UTIs, delirium, and discomfort. Their study described the use of a program called SafetyLEAP to drive efforts in improvement, particularly in decreasing CAUTI in medical wards. They conducted pre and post-intervention studies using the prevalence of urine catheters as the primary outcome. The initial audit comprised of n = 534 patients, while the QI project comprised of n=1601 patients (Wooller et al., 2018). During the intervention, n=379 had a urinary catheter. There was a 97.4% adherence to the SafetyLEAP program. Post-intervention, the daily prevalence of catheter points reduced from 22%-13%. Post-program implementation, the utilization ratio of urinary catheters were reduced from 0.14-0.12.

Burrington (2019) refers to increased healthcare costs that accompany HAIs particularly CAUTIs and non-reimbursements by Medicare and Medicaid. The researchers particularly acknowledge that 31% of inpatients require indwelling catheters at a point during the hospital stay and the risk of a CAUTI increase daily. The primary outcomes of the study were increased mortality, morbidity, and bloodstream infections (Wooller et al., 2018). The researchers concluded that a nurse-driven protocol empowers nurses to make clinical decisions to prevent CAUTIs.

Hamilton (2018) et al highlight CAUTIs are a major cause of preventable HAIs and acknowledge the use of nurse-driven protocols to decrease CAUTIs. They conducted a study whose purpose was to implement a protocol to prevent CAUTIs in the med-surge unit of an adult acute care setting. Through a convenience sample of 28 nurses and a quantitative research design, Hamilton (2018) delivered an educational intervention on the prevention of CAUTIs based on regulatory agencies guidelines. The survey was administered as a short survey on the prevention of CAUTIs pre and post-implementation.  The findings were statistically significant revealing an improvement in nurses’ perceptions and knowledge on CAUTIs post-intervention (p < .001 to p < .043). Besides, there was also a decrease in the urine catheter days about patient days (z = 5.562, p < 0.001). Hamilton (2018) concluded that implementing a nurse-driven IUCP improves the perception and knowledge of nurses on the prevention of CAUTIs. This intervention empowers nurses to manage indwelling urinary catheters better and reduce CAUTIs incidences in hospitals.

Campbell (2020) acknowledge CAUTIs acquired in acute care settings as an issue of public health significance. They further highlight the number of days of indwelling catheters as the most significant determinant of CAUTIs. The primary purpose of this quantitative quality improvement study was to determine the relation that existed between a nurse-driven IUC days and removal. The researchers used the Tanners clinical judgment model and Lewin’s change theory as the theoretical frameworks. They analyzed data from EHRs from a convenience sample (n=110) for four weeks pre and post-implementation and found a decrease in IUC days by nine days. Although this finding was not statistically significant, (p=.224), Campbell (2020) concluded and recommended that, since a nurse-driven IUC protocol reduces IUC device days and improves patient outcomes, it should maximally be utilized in clinical settings to decrease the risk of CAUTIs in clinical settings.

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The objective of the study by Fisher (2015) was to decrease the rates of CAUTIs in an acute care setting that was located in the central valley in California. The researchers acknowledged CAUTIs as an issue of public health significance that accounts for more than 300,000 infections, $451 million in healthcare-related costs, and 9000 deaths annually in the US. The researchers recommend the use of nurse-driven discontinuation protocols as an efficient and effective means to reduce CAUTI rates and IUC days (Fisher, 2015). The protocol is comprised of educating staff during staff and rounding meetings. The researchers also recommended the use of policies, and continuous education to prevent CAUTIs among patients hospitalized in the critical care and emergency department. The findings of this study are similar to that of Eckert-Davis (2017) who found that the use of a nurse-driven IUCP promoted a decrease of CAUTIs from seven to five before and after implementation. They also noted a decrease in IUC days and CAUTI rates (p = 0.5736) by 29%. Even though this finding was not statistically significant, given that it influenced a decrease in CAUTIs, it is clinically significant. Eckert-Davis (2017) concluded that implementing a nurse-driven IUCP can be a useful tool in reducing CAUTIs.  Johnson et al (2016) found several factors that increase the success of a nurse-driven protocol such as multidisciplinary collaboration between healthcare staff, and transformational leadership which facilitate transformative change and guarantees structural sustainability and stability. Improving Patient Safety and Quality Paper

According to Helber-Cassady (2015), chronically ill patients living in long term healthcare settings and use urinary catheters during admission which increases the risk of HAIs particularly CAUTIs. CAUTIs increase healthcare costs, mortality, and CAUTIs whose major risk factors are the duration and use of urinary catheters. Their study purposed to establish whether implementing a UC protocol decreases the UC days, risk, and rates of CAUTIs. The researchers performed the study in two long-term care facilities whereby, the hospital’s leadership team received an online synchronous education followed by the implementation of a urinary catheter protocol (Helber-Cassady, 2015). Generally, they found a decrease in urine catheter days to 2382 from 2846 (16.3%). The rates of CAUTIs reduced to 2.52 from 6.32(60%) decrease.  This was a 3.81 absolute risk reduction of infections per 1000 catheter days. The finding had a statistical significance of (z= 1.82, p<0.03) and revealed that an evidence-based UCP could decrease CAUTI rates and catheter days.

Analysis of Causes

The major factor that contributes to the below benchmarks for catheter maintenance in the author’s healthcare organization is nursing staff non-compliance with catheter maintenance protocols. The catheter maintenance protocols outline the nursing care standards and professional expectations of nurses when caring for patients with an indwelling urinary catheter. It provides nursing staff with an objective standard to evaluate care, and ensure consistency when caring for patients with urinary catheters. These standards provide all nurses with vital information to deliver and evaluate quality care. Although the organization’s policy requires that all nurses must comply with the care guidelines outlined in the protocol, most nurses are non-compliant. This is partly due to lack of adequate knowledge on the best practices of catheter maintenance and care, dos and don’ts of catheter care and maintenance, and lack of well-defined roles and responsibilities among unit-based team members.

Interventions to Address Quality Improvement Initiative

The primary intervention to address the proposed quality improvement initiative was using a nurse driven UC protocol. Literature review findings revealed that the use of a nurse-driven IUCP is a highly effective method for decreasing the use of catheters, and promoting nurse’s compliance with currently existing CAUTI prevention guidelines.  The protocol comprises of a broad range of CAUTI prevention measures with regards to cleansing protocols and charting. The protocol describes the strategies of preventing CAUTI in the following ways:

• Early engagement with unit-based champions (chief medical officer, disease physician, epidemiologist, or urologist)
• Educating and training nursing staff (dos and don’ts of catheter care and maintenance, IUC best care practices)
• Use of cleansing protocols and charting (hand hygiene and use of gloves, care of the drainage bag, performing bath basins and leg bags, dos and don’ts of IUC) Improving Patient Safety and Quality Paper

Use of gloves and hand hygiene

• hand hygiene and wearing gloves before
  • drainage system access
  • Urine sample collection
  • drainage bag emptying
• Removing gloves and performing hand hygiene immediately after
  • drainage system access
  • Handling an indwelling catheter
  • urine sample collection
  • drainage bag emptying

Care of the Drainage Bag

• only emptied by a trained staff
• follow the instructions for use as provided by the manufacturer
• regularly empty the drainage bag
• ensure the drainage bag and catheter tubing are stabilized (Gould, Umscheid & Agarwal, 2020)
• ensure the drainage bag is kept below the bladder level as well as off the floor
• during daily activities, consider where to place the patient’s drainage
  • Walker
  • Bed

Performing Bath Basins and Leg Bags

Bath Basins

• After every bathing procedure, clean and disinfect basins

• When not in use maintain basins dry and clean and store an upside-down to prevent airborne contamination Gould, Umscheid & Agarwal, 2020)

• In case of damage, replace damaged basins
• Display patient identifier

Leg Bags

• At times, patients prefer leg bags that improve dignity and mobility
• Promptly change and maintain leg bag care

• The leg straps and bag should be rinsed and dried promptly, wiped downwards during care baths, do not allow long skin-to-skin contact with dump materials (Gould, Umscheid & Agarwal, 2020)

Do’s and Don’ts of IUC

Do’s

• Perform peri-care using soap and water
•  Avoid obstruction and kinking of tubing and catheter
• When using leg bags and collection bags for urine, maintain closed catheter systems
• Replace disconnected urine collection bags and catheters
• Ensure containers for collecting urine have the patient identifier date
• Disinfect the port sampling before sample collection.

Don’ts

• Routinely change drainage bags and catheters
• Routinely administer prophylactic antimicrobials on routine
• Clean the periurethral area with an antiseptic with a catheter in situ
• Vigorously clean the periurethral area
• Use antimicrobials to irrigate the bladder
• Instill drainage bags with antimicrobial solutions and antiseptics
• Screen for asymptomatic bacteriuria
• Contaminate the outlet valve of the catheter while emptying the collection bag.

Change Model to Implement the Project

To attain a decrease in the rates of CAUTIs, compliance with the CAUTIs intervention bundle, and increase nurses’ understanding of the essence of change in care, the author will use Lewin’s theory of change to implement the project. It involves the following three stages: unfreezing, moving, and refreezing (Hussain et al 2018). The unfreezing phase involves the identification of a problem and the need for change. In the author’s healthcare organization, reducing the incidences of CAUTIs has emerged as a significant health issue associated with additional medical costs and prolonged hospitalization (Hussain et al 2018). The moving stage will involve the implementation of the proposed change while the refreezing stage will set the implemented change as the new organizational culture. Improving Patient Safety and Quality Paper

Benchmarks to Measure Expected Outcomes

This project will focus on internal benchmarks, particularly outcome indicators that identify best practices within the organization and compare present and past practice outcomes over time. The main outcome indicators will be catheter days, CAUTI incidences, and compliance with IUC cleansing protocols. A decrease in catheter days, reduction in CAUTI incidences, and increased compliance to IUC cleansing protocols evidenced by chart audits will correspond to a decrease in CAUTI risks and CAUTI incidences.

References

Burrington, S. (2019). Nurse-Driven Protocol to Reduce Urinary Catheter Infections: A Quality Improvement Project.

Campbell, B. J. (2020). Improving Patient Outcomes through Implementation of a Nurse-Directed Protocol for Urinary Catheter Removal (Doctoral dissertation, Grand Canyon University).

Eckert-Davis, L. (2017). The Impact of a Nurse-Driven Foley Catheter Removal Protocol on Catheter-Associated Urinary Tract Rates in Critical Care Areas.

Fisher, J. (2015). Preventing catheter-associated urinary tract infections: implementation of a nurse drove catheter removal protocol and education program (Doctoral dissertation).

Hamilton, E. (2018). Nurse-Driven Protocol to Reduce Catheter-Associated Urinary Tract Infections.

Helber-Cassady, B. (2015). The Impact of an Evidence-Based Practice Protocol on Catheter-Associated Urinary Tract Infections and Urinary Catheter Days.

Johnson, P., Gilman, A., Lintner, A., & Buckner, E. (2016). Nurse-Driven Catheter-Associated Urinary Tract Infection Reduction Process and Protocol. Critical Care Nursing Quarterly, 39(4), 352-362.

Mawoneke, J. (2017). A Quality Improvement Nurse-Led Initiative to Decrease the Rate of Catheter-Associated Urinary Tract Infections at a Long-Term Acute Care Hospital.

Umer, A. F. F. A. N., Shapiro, D. S., Hughes, C. H. R. I. S., Ross-Richardson, C. Y. N. T. H. I. A., & Ellner, S. C. O. T. T. (2016). The use of an indwelling catheter protocol to reduce rates of postoperative urinary tract infections. Conn Med, 80(4), 197-203.

Improving Patient Safety and Quality Paper