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Introduction
Background
In the healthcare environment, patients usually acquire nosocomial infections. Nosocomial infections such as catheter-associated urinary tract infections (CAUTIs) are common among patients who have indwelling catheters in their urinary tract. The use of catheters among patients is a very delicate practice because it increases the susceptibility of a patient to infections. According to Greene, Marx, & Oriola (2008), CAUTIs ranks second as the cause of nosocomial infections because they contribute about 36% of nosocomial infections that occur in intensive care units or acute care hospitals. CAUTIs usually result in complications such as orchitis, epididymis, prostatitis, meningitis, endocarditis, and septic arthritis, which are common in the intensive care units. In addition, Greene, Marx, and Oriola (2008) reports that CAUTIs cause about 13,000 deaths annually besides prolonging the length of stay in hospital and increasing medical costs. Owing to increased medical costs, Centers for Medicare and Medicaid Services (CMS) have ruled that they will not compensate for the additional medical costs due to CAUTIs (Saint, Meddings, Calfee, Kowalski, & Krein, 2009). In this view, healthcare centers are struggling to improve the quality of medical services that they provide to patients to prevent the occurrence of CAUTIs. Therefore, this essay develops a quality improvement plan that targets reducing the prevalence of catheter-associated urinary tract infections in healthcare facilities.
Major Players of the Quality Improvement Plan
As a quality improvement plan is critical in a health care system, different healthcare organizations employ different strategies in preventing the occurrence of CAUTIs in healthcare environments. The Institute of Medicine is an important organization in health that advocates for the improvement of healthcare services to meet required quality and safety standards. In 2000, the Institute of Medicine conducted research, which established that nosocomial infections are part of medical errors that healthcare providers make as they deliver healthcare services. According to Greene, Marx, and Oriola (2008), the Institute of Medicine reports that adverse events associated with healthcare cause about 90,000 deaths, affect about 2 million of patients, and increase medical costs by approximately $6 billion. In its report, Institute of Medicine confirmed that medical errors are preventable if healthcare providers follow appropriate practices and standards that enhance quality of care and safety of patients. In this view, the Institute of Medicine challenged the Joint Commission to set standards and accredit healthcare centers so that they can provide quality and safe healthcare services to patients. Currently, the Joint Commission is formulating patient safety goals; among them is the reduction of nosocomial infections such as CAUTIs. Thus, the Institute of Medicine and the Joint Commission are important players in the implementation of a quality improvement plan.
Other important players are American Nurses Association (ANA), Institute for Healthcare Improvement, the Centers Medicare and Medicaid, and Agency for Healthcare Quality and Research. The American Nurses Association sets nurse-sensitive indicators that aim at improving the outcome of nursing care. Through nurse-sensitive indicators, American Nurses Association can measure quality of care by assessing patient outcomes. Patient outcomes in terms of prevention of CAUTIs are important nurse-sensitive indicators that enable nurses to measure the quality of their nursing care. Institute for Healthcare Improvement is an important player in the prevention of CAUTIs because it creates links with patients, nurses, and healthcare centers in improving quality of healthcare. Since insurance companies incur unnecessary medical costs due to nosocomial infections the Centers for Medicare and Medicaid is also an important player in the implementation of a quality improvement plan. Agency for Healthcare Quality and Research is a significant player because it sets guidelines that help in the prevention of CAUTIs. According to Agency for Healthcare Quality and Research (2009), its mandate is to update and expand guidelines that are critical in prevention of CAUTIs. In this view, a combined effort of various players is necessary to improve quality of healthcare services and prevent the occurrence of CAUTIs.
The Rationale and Supportive Data
The quality improvement plan is an integral component of the health care system since it creates goals and objectives that are essential in the improvement of healthcare practices. Poor quality of healthcare practices usually results in the development of CAUTIs among patients who have indwelling catheters. In this case, the purpose of the quality improvement plan is to enhance quality of healthcare services with the objective of reducing prevalence of CAUTIs in a healthcare environment such as acute care hospitals. According to Saint, Meddings, Calfee, Kowalski, and Krein (2009), Centers for Medicare and Medicaid Services recommends application of evidenced-based practices in prevention of catheter-associated infections to reduce medical costs and reduce occurrence of preventable deaths in hospitals. To aid healthcare centers prevent CAUTIs, the quality improvement plan is necessary. The quality improvement plan outlines the goals and objectives that are measurable using certain outcomes. Therefore, healthcare centers should develop the quality improvement plan for them to follow guidelines that help in the prevention of CAUTIs.
Reduction of nosocomial infections is one of the goals found in National Patient Safety Goals (NPSGs) that the Joint Commission uses in accrediting hospitals. The Joint Commission notes that poor hygienic practices in the healthcare environment predispose patients to nosocomial infections. Cather-related bloodstream infections, surgical site infections, and CAUTIs are some of the nosocomial infections that are common in the healthcare environment. Center for Disease Control and Prevention (CDC) in conjunction with the World Health Organization (WHO) have developed hand hygiene guidelines and protocols that aid in prevention of nosocomial infections. Hence, the Joint Commission (2013) requires healthcare providers to comply with hand hygiene guidelines as recommended by CDC and WHO. Moreover, the goal recommends the use of evidence-based practices such as impregnation of catheters while following standard protocols. Thus, the goal of preventing CAUTIs ensures that the hospital accreditation program considers the use of evidence-based practices in prevention of nosocomial infections.
Prevention of healthcare-associated infections such CAUTIs is a complex issue in the healthcare system because it attracts different players in the health care system such as the Institute of Medicine. The Institute of Medicine holds that adverse events cause about 90,000 deaths, affect about 2 million of patients, and increase medical costs by approximately $6 billion (Greene, Marx, and Oriola, 2008). These statistics indicate that CAUTIs among other nosocomial infections pose significant challenge to not only the health care system and patients, but also to insurance companies such as Medicare and Medicaid. The extensive impact of CAUTIs calls for the development of quality improvement plan to reduce the prevalence of CAUTIs and alleviate their impacts on health care system, patients, and insurance companies. The health care system of the United States in conjunction with the Joint Commission and Agency for Healthcare Research and Quality has developed goals and quality indicators that healthcare centers should strive adopt.
The National Issue
Catheter-Associated Urinary Tract Infections (CAUTIs)
In the United States, CAUTIs is the most nosocomial infection that the healthcare system is struggling to eradicate in healthcare centers. Saint, Meddings, Calfee, Kowalski, and Krein (2009) state that, “urinary catheter use is common, with approximately one in every five patients admitted to an acute care hospital receiving an indwelling catheter” (p. 878). This means that about 20% of the patients who have indwelling catheters acquire CAUTIs. The figure of 20% is quite high for it implies that a healthcare center endangers the lives of some patients instead of saving them. As practices that healthcare providers follow when inserting catheters and maintaining them is prone to CAUTIs, healthcare providers need to take appropriate precautions. Quality improvement plan targets nurses because they have a direct responsibility of inserting and maintaining catheters. Different healthcare centers employ various practices, and thus explains why there is variation in the prevalence of CAUTIs.
CAUTIs are important nationally because they cause death, increase recovery period of patients, and increase medical costs. According to Greene, Marx, and Oriola (2008), CAUTIs are the dominant nosocomial infection because they contributes about 36% of the infections in the acute care environment. Thus, it implies that patients who are in the acute care environment with indwelling catheters are likely to acquire CAUTIs when compared to other nosocomial infections. Moreover, Greene, Marx, and Oriola (2008) estimate that, “more than 30 million Foley Catheters are inserted annually in the United States, and these catheterization procedures probably contribute to 1 million CAUTIs” (p. 9). Increased catheterization of patients due to severity of diseases and related complications of care has contributed the occurrence of increased prevalence of CAUTIs in various healthcare centers. The rate of catheterization varies from about 7% to 25% in an acute care environment depending on the conditions of the patients. Hence, as the use of catheters is indispensable, nurses should adopt evidence-based practices that enhance quality of care and prevent CAUTIs.
Impacts of CAUTIs
One of the major impacts of catheters is that it increases mortality rates of patients who are in acute care centers who use urinary catheters. The use of urinary catheters predisposes patients to CAUTIs because urinary catheters create routes that allow pathogens to enter into the body. In a healthcare environment, patients are susceptible to both endogenous and exogenous pathogens such as viruses, fungi, bacteria, and protozoa. The endogenous pathogens are present on mucosal surfaces such as the gastrointestinal tract, and respiratory tract, while exogenous pathogens are present on surfaces such as patient room, bed, medical equipment, and medications. In this view, urinary catheters create routes for these pathogens to enter into the human body and cause CAUTIs and other nosocomial infections. Conway and Larson (2012) state that CAUTIs cause about 13,000 deaths annually and increase morbidity among millions of patients who use catheters. Hence, CAUTIs are dominant nosocomial infections that threaten the lives of many patients, particularly in acute care centers.
In addition to increasing mortality and morbidity rates of patients in healthcare centers, CAUTIs increase medical costs. When patients acquire CAUTIs, they require additional medications to treat these infections. Moreover, the length of stay in hospital increases, thus inflating medical bills. According to Centers for Medicare and Medicaid, “12,185 CAUTIs, costing $44,043/hospital stay, occurred in fiscal year 2007” (Greene, Marx, & Oriola, 2008, p. 6). Such a high medical costs have made the Centers for Medicare and Medicaid to protest and change their legislations to disallow them from paying medical costs associated with CAUTIs. Owing to this development, healthcare centers have to bear the medical burden that emanates from CAUTIs. Therefore, the Centers for Medicare and Medicaid have compelled healthcare centers to improve the quality of healthcare services that they provide to patients and consequently prevent the occurrence of CAUTIs.
Nurse-Sensitive Indicators
Nurse-sensitive indicators are important in assessing the quality and safety of care that nurses provide in the healthcare facilities. Structure of nursing care is the first part of nurse-sensitive indicators. The structure of nursing care examines the educational level of nurses, their skills, and their number in a healthcare center. Healthcare centers with sufficient number of qualified and skilled nurses have the potential to provide quality and safe healthcare services to patients without endangering their lives. Patient outcome is a critical health indicator that depicts the quality of care, which patients receive in a healthcare environment. The second part of the nurse-sensitive indicators is process indicators. These indicators comprise of intervention, assessment, and the satisfaction level of job. The third part of the nurse-sensitive indicators consists of patient outcomes. Patient outcomes significantly reflect quality of healthcare services that patients receive. In this case, the prevalence of nosocomial infections such as CAUTIs reflects the quality of healthcare that patients receive. Conway and Larson (2012) attribute the increasing of CAUTIs among various healthcare centers to poor clinical practices. Thus, healthcare centers should apply nurse-sensitive indicators in assessing quality of healthcare services that nurses provide to patients.
Given that the delivery of healthcare services is a complex practice, nurse-sensitive indicators have evolved with time. In the past, nursing practice had its basis on medical knowledge, which health experts received and passed from one generation to another as a medical tradition. In contrast, modern nursing practices rely on the evidence-based practices. According to the Joint Commission (2013), application of evidence-based practices in prevention of CAUTIs is one of the goals outlined by National Patient Safety Goals. Evidence-based practices are effective practices because they rely on valid and accurate evidences that have a scientific basis. The health care system also recommends application of the evidence-based practices in healthcare centers to increase the quality of healthcare and safety of patients. Therefore, American Nurses Association continues to update new nurse-sensitive indicators depending on the emergence of new evidence-based practices.
Clinical Practice Guidelines
As a national issue, CAUTIs threaten the lives of many patients and increase medical costs. CAUTIs have compelled the health care system to develop clinical practice guidelines that nurses must follow. The first guideline focuses on the appropriate use of urinary catheters. According to Agency for Healthcare Research and Quality (2009), nurses should “minimize urinary catheter use and duration of use in all patients, particularly those at higher risk CAUTIs or mortality from catheterization such as women, the elderly, and patients with impaired immunity” (p. 5). This guideline seeks to prevent the routine use of catheters among all patients irrespective of their conditions and predisposition to CAUTIs. Proper insertion of catheters is the second guideline, which requires nurses to maintain high standards of hygiene during insertion to prevent contamination of the catheters and insertion sites. To maintain high standards of hygiene, the guideline recommends the use of sterile gloves, sponges, drape, and antiseptics to ensure that catheter site is aseptic.
The third guideline recommends for the maintenance of catheters to prevent the occurrence of CAUTIs. Conway and Larson (2012) argue that indwelling catheters should have a sterile drainage system that is not obstructive. In maintaining the indwelling catheters, nurses should empty urine regularly while preserving the hygienic conditions of catheters. The fourth guideline deals with the development of quality improvement programs. Agency for Healthcare Research and Quality (2009) states that quality improvement programs aims at promoting correct utilization of catheters, maintenance of catheters, and compliance with hygienic practices. The fifth guideline focuses on the administrative infrastructure. For evidence-based practices are effective in prevention of CAUTIs, their implementation requires administrative infrastructure. Surveillance is the sixth guideline that monitors the occurrence and prevalence of CAUTIs. Regular surveillance of CAUTIs enhances their prevention in a healthcare environment.
Evidence-Base Sources
Appropriate Use of Urinary Catheters
The use of catheters predisposes patients to CAUTIs. An increase in the use of catheters in the health care system has led to a concomitant increase in the prevalence of CAUTIs among patients. Hence, research has shown that the appropriate use of catheters among patients can significantly reduce the prevalence of CAUTIs and improve quality of healthcare that patients receive (Saint, Meddings, Calfee, Kowalski, & Krein, 2009). To reduce CAUTIs through appropriate use of urinary catheters, healthcare providers should assess the conditions of patients and determine the necessity of using catheters. Agency for Healthcare Research and Quality (2009) recommends healthcare providers to “minimize urinary catheter use and duration of use in all patients, particularly those at higher risk of catheter-associated urinary tract infections or mortality from catheterization such as women, the elderly, and patients with impaired immunity.
Proper Insertion of Catheters
Insertion of urinary catheters determines the occurrence of CAUTIs. Normally, insertion of catheters creates routes through which exogenous and endogenous pathogens can enter into the body and cause CAUTIs and other nosocomial infections. Available evidence shows that the method of insertion and hygienic conditions determine the occurrence of nosocomial infections. Saint, Meddings, Calfee, Kowalski, and Krein (2009) assert that use of sterile catheters, aseptic techniques of insertion, and maintenance of a high standard of hygiene in the insertion of urinary catheters is essential in prevention of CAUTIs. The insertion practices should be aseptic to prevent pathogens from gaining entry into the body via urinary catheters and their sites of insertion. In this view, healthcare providers should ensure that they maintain aseptic conditions during and after insertion of catheters.
Maintenance of Urinary Catheters
After insertion of catheters, their maintenance is necessary to prevent pathogens from entering into the body and causing CAUTIs. Indwelling urinary catheters are very delicate because they can easily cause CAUTIs if hygienic conditions of the patient and environment are poor. Since urinary catheters are prone to damage, Agency for Healthcare Research and Quality (2009) states that, “if breaks in aseptic technique, disconnection, or leakage occur, replace catheter and collecting system using aseptic technique and sterile environment” (p. 7). Moreover, regular changing of indwelling catheters and prompt emptying of the urinary bags forms part of the maintenance practices, which are central in the prevention of CAUTIs? Even if insertion of catheters is aseptic, poor maintenance creates circumstances that allow pathogens to enter into the body and cause CAUTIs.
Surveillance
Surveillance of CAUTIs is necessary so that healthcare providers can take appropriate intervention in time to prevent the occurrence of further complications. Early detection of CAUTIs enables the application of appropriate intervention before the infections become complicated and difficult to treat. As CAUTIs are common in critical care environments, routine screening of patients is critical so that healthcare providers can take appropriate interventions in the treatment and management of CAUTIs (Conway, & Larson, 2012). Healthcare centers that perform surveillance of CAUTIs can significantly reduce their prevalence in acute care environments as they can halt their progression and spread among patients due to transmission. The lack of surveillance and poor hygiene practices usually encourage the transmission of infections from one patient to another, and eventually to all patients in a given unit. Thus, surveillance is an essential component of a quality improvement plan.
Training of Nurses and Other Healthcare Providers
Healthcare providers play a central role in prevention of CAUTIs and associated nosocomial infections, as their clinical practices determine the extent to which they predispose patients to the infections. Although clinical care nurses have appropriate knowledge and skills, there is a need for them to update their knowledge and skills in response to the development of new evidence-based practices that are effective in prevention of CAUTIs. Conway and Larson (2012) assert that clinical care nurses can contribute directly to the prevention of CAUTIs by monitoring patients, complying with guidelines and protocols, and applying evidence-based practices in acute care environment.
Quality Improvement Plan
Since the quality of healthcare practices determines the occurrence of CAUTIs, healthcare centers need to perform quality improvement plan. The use of quality improvement plan in the prevention of CAUTIs is effective because it provides guidelines, standards, and protocols that healthcare providers need to adhere to prevent occurrence of nosocomial infections. According to Agency for Healthcare Research and Quality (2009), use of alert systems, adherence to protocol and guidelines, and education of patients in areas of the quality improvement plan to aid in prevention of CAUTIs. Alert systems enable healthcare providers to assess the use of catheters, while protocols and guidelines enable them to apply evidence-based practices that are effective in prevention of CAUTIs. Education of healthcare providers enables them to acquire new knowledge and skills, which are critical in prevention of CAUTIs.
Work Plan
Appropriate Use of Urinary Catheters
The first objective of the quality improvement plan is to enhance the appropriate use of urinary catheters by the nurses in the acute care environment. Clinical care nurses should acquire knowledge and skills that enable them to assess the necessity of urinary catheters and identify patients who are at risk of acquiring CAUTIs. To enhance the appropriate use of urinary catheters, nurses need to:-
- Reduce the use of urinary catheters and shorten the duration of indwelling catheters among patients.
- Use urinary catheters as a necessity rather than as a routine practice among operative patients.
- Have a preference of using external catheters rather than indwelling urinary catheters.
The stakeholders that would help in the promotion of appropriate use of catheters are the Joint Commission, American Nurses Association, Agency for Healthcare Research and Quality, and Institute of Medicine. These stakeholders could help in the development quality indicators, guidelines, and protocols that entail the use of urinary catheters. Therefore, to improve the use of urinary catheters, healthcare centers should provide clear guidelines and protocols as resources that help nurses prevent CAUTIs.
Proper Insertion of Urinary Catheters
The second objective of a quality improvement plan is the proper insertion of urinary catheters by following strict hygienic practices. In this objective, nurses should adhere to the following steps:
- Maintain hand hygiene before and after inserting urinary catheters.
- Use sterile urinary catheters and observe the appropriate technique of aseptic insertion.
- Firmly secure urinary catheters after inserting them to prevent them from coming out or causing urethral traction.
- Apply intermittent catheterization at regular intervals if indwelling urinary catheters are not effective.
Since the insertion of urinary catheters is a delicate procedure, the Joint Commission in conjunction with the Agency for Healthcare Quality and Research should formulate guidelines and protocols that outline the process of inserting CAUTIs. Additionally, American Nurses Association is a significant stakeholder since it formulates nurse-sensitive indicators. In this case, successful insertion of urinary catheters reflects patient outcomes. Essential resources for the implementation of this objective are sterile urinary catheters, gloves, antiseptic solution, and appropriate urinary catheters. Moreover, portable ultrasound device is necessary in performing intermittent catheterization. Hence, proper insertion of urinary catheters is a measurable objective in the quality improvement plan.
Maintenance of Urinary Catheters
The third objective of the quality improvement plan is to improve maintenance of urinary catheters. Maintenance of catheters is a measurable objective because it entails the following practices:-
- Nurses should empty urinary bag regularly to prevent urine from flowing back into the bladder.
- Check for breakages or disconnection of the urinary catheter system.
- Nurses should also maintain urinary catheters under sterile conditions.
- The urinary bag must always be below the level of the bladder to allow urine to flow freely.
- During manipulation of urinary catheters and urinary system, nurses must wear gloves and protecting gown.
- Change urinary catheters routinely to prevent CAUTIs.
To ensure that healthcare centers improve maintenance of urinary catheters according to the above guidelines, the Joint Commission and American Nurses Association are major stakeholders that formulate guidelines and protocols essential in improving practices of maintaining urinary catheters. In addition, Agency for Healthcare Quality and Research is an important stakeholder because it creates quality indicators, which are applicable in maintenance of urinary catheters. Besides guidelines and protocols, improvement of catheter maintenance requires the use of ultrasound device to assess the flow of urine.
Education of Nurses
Education of nurses is the fourth objective of a quality improvement plan. Education of nurses regarding evidence-based practices enhances their knowledge and skills in the prevention of CAUTIs. Essentially, nurses should gain knowledge and skills in the following areas:-
- Assessment of patients for appropriate use of urinary catheters
- Aseptic techniques of inserting urinary catheters
- Maintenance of urinary catheters by changing, emptying of urinary bags, and diagnosis of CAUTIs
- Application of evidence-based practices
- Methods of preventing CAUTIs
To educate nurses, educational programs are necessary. The Institute of Healthcare Improvement is an important stakeholder that helps in the designing and implementing educational program to train nurses and equip them with essential knowledge and skills. Moreover, American Nurses Association is also another stakeholder that aids in the education of nurses. Therefore, the necessary resources are reading materials, seminars, PowerPoint presentations, charts, and medical experts.
Surveillance
Surveillance is the fifth objective of the quality improvement. Surveillance is critical because it is part of the control measures that are applicable in control and prevention of infectious diseases. Hence, the capacity of nurses to survey CAUTIs determines their ability to control and prevent CAUTIs in an acute care environment. In this case, nurses should attain the following knowledge and skills:-
- Perform surveillance regularly to assess potential of CAUTIs occurring in a given care unit
- Diagnose patients for the presence of CAUTIs pathogens
- Identify patients who are susceptible to CAUTIs and isolate them from others patients
- Keep records that show the prevalence of CAUTIs over a given period of time
- Identify risk factors that predispose patients to CAUTIs
Surveillance of CAUTIs helps in early diagnosis and prevention the infections before they cause further complications. The important stakeholders are Institute of Medicine, Center for Disease Control and Prevention, and the Agency for Healthcare Quality and Research. These stakeholders design surveillance protocols and guidelines that enhance accuracy of surveillance data. For effective surveillance, well-equipped laboratory with diagnosing tools is essential. Moreover, databases, data analysis software, and data analysts are required to analyze surveillance data and present important information.
Conclusion
CAUTIs pose a significant challenge to health care system because it causes deaths and increase medical costs. In the United States, CAUTIs represent about 36% of nosocomial infections and cause approximately 13,000 deaths yearly. Moreover, CAUTIs increase medical cost by approximately6 billion dollars annually. Owing to the impact of CAUTIs on the health care system, stakeholders such as the Joint Commission, Institute of Medicine, American Nurses Association, the Center for Medicare and Medicaid, Institute for Healthcare Improvement, Center for Disease Control and Prevention and Agency for Healthcare Quality and Research have developed guidelines and standards that are applicable in reducing the prevalence of CAUTIs. Therefore, quality improvement plan focused on the appropriate use of catheters, proper insertion, maintenance, education of nurses, and surveillance of CAUTIs.
References
Agency for Healthcare Research and Quality (2009). Guidelines for Prevention of Catheter-Associated Urinary Tract Infections. Web.
Conway, L., & Larson, E. (2012). Guidelines to Prevent Catheter-Associated Urinary Tract Infections 1980 to 2010. Heart Lung, 41(3), 271-283.
Greene, L., Marx, J., & Oriola, S. (2008). Guide to the Elimination of Catheter-Associated Urinary Tract Infections (CAUTIs). Washington: APIC Publisher.
Joint Commission (2013). National Patient Safety Goals Effective January 1, 2013: Hospital Accreditation Program.
Saint, S., Meddings, J., Calfee, D., Kowalski, C., & Krein, S. (2009). Catheter-Associated Urinary Tract Infections and the Medicare Rule Changes. Annals of Internal Medicine, 150(12), 877-884.
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