In this week’s Discussion, you shared your experiences with health  care practice problems as a consumer and/or as a practitioner. Now,  consider your current practice setting and think about something  specific and relevant to your practice setting that you would like to  see improved or changed. Interview a key leader in your practice setting  who can confirm that your practice problem is one that should be  addressed to enhance delivery or performance in the field. It is  important to remember from the beginning that your practice problem must  be measurable, and that you identify data that  suggests a problem exists, and although this comes up more specifically  in Week 2, it is important to consider this from the start.

This will be the problem discussed in your Practice Experience Project, Capstone Paper, and Storyboard.

By Day 4

Identify a measurable patient-centered practice problem related to  quality or safety and relevant to your practice setting that you will  also focus on in your Capstone Paper, and post a brief description of  the problem and an explanation of why you selected it. Explain how the  conversation you had with the key leader in your practice setting  impacted your decision to address this particular practice problem. Be  sure to support your practice problem with the literature that indicates  the relevance of this problem for nursing practice. Provide evidence  from your practice area and describe the data that is available.

You will not be collecting any data during the practice experience  project; you will use data already available to you in your workplace  or other practice setting. Think about the different kinds of data that  is shared with you in your work area. For example, data may include  patient satisfaction scores, medication error rates, fall, CLABSI or  CAUTI rates. Analyzing the data available to you is how you will  identify that a quality problem exists. Data identifies potential areas  for improvement, and monitors the effectiveness of any changes. It  is important to obtain baseline data before beginning a quality  improvement project and to analyze results during and at the end of a  projec

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Week 6 Assignment: EBP Change Process form

ACE Star Model of Knowledge Transformation

Follow Nurse Daniel as your process mentor in the weekly Illustration section of the lesson.

Name: __________Lishan Brown___________

Star Point 1: Discovery (Identify topic and practice issue)

Identify the topic and the nursing practice issue related to this topic. (This MUST involve a nursing practice issue.)

The topic is hospital acquired infections. The nursing practice issue is catheter associated urinary tract infections and the high incidence on an acute rehabilitation unit.

Briefly describe your rationale for your topic selection. Include the scope of the issue/problem.

The nursing practice issue I would like to investigate is healthcare associated infections (HAI), particularly catheter associated urinary tract infection (CAUTI). CAUTI is very important to investigate because I believe HAI’s can be decreased, if not prevented. Being that nurses are educated on the possible causes or symptoms of HAI’s, we can be more proactive in our treatment plans. If a patient falls, that can be an unpredictable event but HAI’s are more so predictable. With CAUTI, making sure that the perineal area is cleaned on a regular, consistent basis is important. Providing proper interventions to not keep an indwelling catheter in longer than necessary is also important.

Urinary tract infections are one of the most common hospital acquired infections. At least 80% of urinary tract infections an be attributed to an indwelling urinary catheter. There are approximately 13,000 annual deaths associated with catheter associated urinary tract infections (CAUTI). CAUTIs can lengthen hospital stays, increase morbidity and mortality, and raise healthcare costs.

Star Point 2: Summary (Evidence to support need for a change)

Describe the practice problem in your own words and formulate your PICOT question.

The practice problem is members of the healthcare team are not properly cleaning the perineal area of patients who have indwelling catheters and indwelling catheters are placed for unnecessary longer periods of time.

PICOT question- In (P) patients with an indwelling catheter on an acute rehabilitation unit, does (I) cleansing the perineal area every eight-hour period compared to (C) routine daily cleansing of the perineal area (O) decrease the catheter associated urinary tract infection with patients over a (T) six month period?

List the systematic review chosen from the Cochrane Database of Systematic Reviews from the Chamberlain library. Type the complete APA reference for the systematic review selected.

Interventions to improve professional adherence to guidelines for prevention of device‐related infections.

Reference

Flodgren  G, Conterno  LO, Mayhew  A, Omar  O, Pereira  CR, Shepperd  S. Interventions to improve professional adherence to guidelines for prevention of device‐related infections. Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.: CD006559. DOI: 10.1002/14651858.CD006559.pub2.

List and briefly describe other sources used for data and information. List any other optional scholarly source used as a supplement to the systematic review in APA format.

In my search for evidence, I found an article about nurse-driven CAUTI prevention. This evidence is relevant to my PICOT because I would like to find a way to decrease or eliminate the instances of CAUTI in a hospital setting. The article gives a history of prevalence of CAUTI then goes into costs related to CAUTI. The article also mentions ways of preventing CAUTI. The article also discusses an algorithm used to decrease the prevalence of CAUTI.

I also found an article about the causes of CAUTI and how to properly clean the perineal area as an educational tool.

Reference

Russell, J. A., Leming-Lee, T. ‘Susie,’ & Watters, R. (2019). Implementation of a Nurse-Driven CAUTI Prevention Algorithm. Nursing Clinics of North America, 54(1), 81–96.

https://doi-org.chamberlainuniversity.idm.oclc.org/10.1016/j.cnur.2018.11.001

Memorial Sloan Kettering Cancer Center (2018). Caring for Your Urinary (Foley®) Catheter. Retrieved from https://www.mskcc.org/cancer-care/patient-education/caring-your-urinary-foley-catheter

Briefly summarize the main findings (in your own words) from the systematic review and the strength of the evidence.

The main findings from the systemic review were that there weren’t sufficient evidence to properly corroborate the research. The trials were too small and there was inadequate reporting of information. Because the findings were too small, it was difficult to determine which intervention would be optimal in CAUTI care. The strength of the evidence was weak for the change process.

Outline one or two evidence-based solutions you will consider for the trial project.

An evidence-based solution would be the CAUTI Prevention Tool by the American Nurses Association. This streamlined evidence-based tool is used to reduce CAUTI by fewer catheters being used, timely removal, and insertion, maintenance and post removal care.

Reference

American Nurses Association (2009). Streamlined Evidence-Based RN Tool: Catheter Associated Urinary Tract Infection (CAUTI) Prevention. Retrieved from

https://www.nursingworld.org/~4aede8/globalassets/practiceandpolicy/innovation–evidence/clinical-practice-material/cauti-prevention-tool/anacautipreventiontool-final-19dec2014

Star Point 3: Translation (Action Plan)

Identify care standards, practice guidelines, or protocols that may be in place to support your intervention planning (These may come from your organization or from the other sources listed in your Summary section in Star Point 2).

Care standards for urinary catheter care would be proper education to staff and those in use of the indwelling catheter (importance of infection prevention, symptoms of urinary tract infection, proper care of an indwelling catheter).

Provide written criteria for the necessity of an indwelling catheter by using the CAUTI Prevention tool.

Following procedures for the insertion and maintenance of an indwelling catheter (proper handwashing, use of aseptic techniques for insertion an removal of catheter, securing the tubing and drainage bag, maintaining sterility, replacement of supplies).

Having proper documentation of insertion, maintenance and removal.

Reference

The Joint Commission (2017). Requirements for the Catheter-Associated Urinary Tract Infections (CAUTI) National Patient Safety Goal for Hospitals. Retrieved from

https://www.jointcommission.org/assets/1/6/R3_Cauti_HAP

List your stakeholders (by title and not names; include yourself) and describe their roles and responsibilities in the change process (no more than 5).

Nurse Leader- the person leading the trial, responsible for ensuring the success of the project and day to day intricacies of the project.

Nurse Manager

– Person overseeing the trial to ensure the nurse leader and provide assistance as necessary.

Unit Nurses- team members who are assisting in carrying out the change process and day to day bedside care with patients with indwelling catheters.

Patient- consents to a clinical trial and helping to identify symptoms of CAUTI.

What specifically is your nursing role in the change process? Other nursing roles?

My nursing role in the change process is to be at the forefront of change process. As the nurse leader, I would want to ensure that all supplies, education, proper documentation is in place throughout the trial to ensure effectiveness. Unit nurses are responsible the placement of an indwelling catheter, the daily care management, and the removal of the indwelling catheter. Nurses are also responsible for specimen collection. Nurses are also the main person to diagnose a patient who is suspected of CAUTI.

List your stakeholders by position titles (charge nurse, pharmacist, etc.).-Why are the members chosen (stakeholders) important to your project?

MD- Doctor of Medicine

DO- Doctor of Osteopathic Medicine

Nurse Educator

RN- Registered Nurse/ Unit Nurse

CNA- Certified Nursing Assistant

Nurse Manager

These members are important to the project because they are all a part of the team who is essentially caring for a patient with an indwelling urinary catheter. They are important in making necessary changes to decrease the incidents of catheter associated urinary tract infection. It all begins with proper education right down to actually caring for the patient who has an indwelling catheter. The MD/DO are responsible for ordering the indwelling catheter for the patient. Unit nurses and CNA’s are important in the day to day care of the indwelling catheter. The nurse manager is important in making sure policies are followed for the change process and provide additional assistance if necessary.

What type of cost analysis will be needed prior to a trial? Who needs to be involved with this?

The type of cost analysis which would be needed prior to a trial would be a cost effectiveness analysis. A cost effectiveness analysis is a method of analyzing the cost and health outcome of an intervention. The finance department would need to be involved in this portion of the change process. This is necessary to see how much funds can be allocated to the project for additional resources. It is also important to know the initial cost to the hospital for CAUTI’s compared to after the completion of the trial to see if there was an improvement. Having the quality control department involved ensures policy and procedures are being followed as well.

Reference

Jamison DT, Breman JG, Measham AR, et al., editors. Priorities in Health. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2006. Chapter 3, Cost-Effectiveness Analysis. Available from: https://www.ncbi.nlm.nih.gov/books/NBK10253/

Star Point 4: (Implementation)

Describe the process for gaining permission to plan and begin a trial. Is there a specific group, committee, or nurse leaders involved?

The process of gaining permission to plan and begin a trial first begins with management of the hospital. One cannot perform a trial without the permission of management. There also needs to be the onboarding of the finance department to see how much resources can be allocated to the project. Quality assurance is important for ensuring policy and procedures are being followed. There also needs to be permission from other nurses on the unit for their cooperation. Having signed permission from patients are also important to begin the trial. Patients need to be aware of what they are getting into and if they would cooperate or not.

Describe the plan for educating the staff about the change process trial and how they will be impacted or asked to participate.

First, coordination with a nurse educator is important in order for them to educate staff members on the change process. Nurse educators can educate staff members of the proper way of preventing CAUTI and an ongoing refresher course throughout the trial period. Educators could be available for all shifts throughout the day in order for convenience to the staff. Educators can come to the unit to educate for added convenience. Online educational learning exercises would be an also added benefit.

Outline the implementation timeline for the change process (start time/end time, what steps are to occur along the timeline).

The implementation timeline for the change process would be over a six-month period. This would include the education of staff members on proper catheter care and documentation. Also included in this timeline would be the trial of patients who have consented to be a part of the change process.

List the measurable outcomes based on the PICOT. How will these be measured?

The measurable outcomes based on the PICOT would be the number of CAUTI incidents over a six-month period. This can be measured by the incident reports for CAUTI, the necessary medications needed to treat CAUTI and also the number of indwelling catheterizations utilized on the unit.

What forms, if any, might be used for recording purposes during the pilot change process. Describe.

Forms that may be used for recording purposes would be documentation of education and refresher for staff members. Consent forms from patients detailing the intention of the trial would be important. Staff would be required to document each time perineal care was given or any catheter care to the patient. Staff would also be given a self-assessment on their readiness and understanding of catheter care in order to effectively care for the population of patients with indwelling catheters.

What resources are available to staff (include yourself) during the change pilot?

Resources that would be available to staff during the pilot would be extra catheter care supplies, such as Foley catheter bags, tubing, stat locks, perineal soap, etc. Educational resources for staff and patients on recognizing CAUTI, ways of preventing CAUTI and general care for an indwelling catheter.

Will there be meetings of certain stakeholders throughout the trial? If so, who and when will they meet?

Meetings throughout the trial will be held with stakeholders on the progress of the trial and if any necessary changes need to be made. Meetings will be held weekly during the first month and twice per month for the remainder of the trial. All stakeholders would be invited to the meetings to get a progress of is happening during the trial. Opinions can be shared on what could be effective or changes that can be made to make the trial a success.

Star Point 5: (Evaluation)

How will you report the outcomes of the trial?

Reporting of the outcomes will be posted throughout the staff rooms on the unit in the form of a data report. A meeting at the end of the trial will also be held to discuss how effective the trial was or wasn’t. The data from the report can then be given to management to consider further implementation or recommendations.

What would be the next steps for the use of the change process information?

Using the information from the trial, ongoing changes can continue to be made regarding CAUTI using the takeaway from the trial. After seeing what worked and what didn’t, staff can adapt what was successful and build on that information and make progress in decreasing the incidents of CAUTI on the unit.

2.2019 Update. DLP

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Catheter-Associated Urinary Tract Infections (CAUTI)

Walden University

Leadership Competencies in Nursing and Healthcare

NURS-4220-5

Catheter-Associated Urinary Tract Infections (CAUTI)

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).

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.

Literature review

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).

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).

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).

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.

References

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

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

Scanlon, K. A. (2017). Saving Lives and Reducing Harm: A CAUTI Reduction Program. Nursing Economic$, 35(3), 134-141.

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. 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

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Spath, P. (2013).  Introduction to healthcare quality management (2nd ed.).  Chicago, IL: Health Administration Press.