Category: Infection

Introduction

New health problems are coming up today as time progresses and lifestyles of individuals in the society change. Before the end of the twentieth century, practitioners strictly relied on their knowledge and skills to solve medical related problems in their field. Due to increased complication of these conditions, clinicians find it hard to keep up with the emerging demand for new and improved skills (Melnyk & Fineout-Overholt, 2010, p. 167). As a result, practitioners around the world are adopting different methods to solve emerging problems. For example, most of them conduct randomized tests on patients. The development has raised concerns among stakeholders. Consequently, it has created the need for guidelines that would reduce the inappropriate variations in techniques used by these professionals. In addition, the guidelines are aimed at minimizing harm and optimizing health outcomes among patients receiving medical care (Melnyk & Fineout-Overholt, 2010, p. 186).

Surgical infection is not a major issue in medical practice if it is handled appropriately. It can be prevented using basic hygiene practices. However, it may become fatal when ignored. Research shows that about 5% of patients undergoing extra-abdominal surgery develop infections during recovery. The same happens to 20% of individuals undergoing intra-abdominal operations (Bratzler & Houck, 2005, p. 396).

The objective of this paper is to develop a detailed guideline for clinical practice in the context of surgical site infections. Students, physicians, nurses, patients, and management teams will find this paper beneficial to their practice and research.

Target Audience

The parties targeted by this guideline include:

• Patients undergoing surgery from around the world
• Clinicians involved in surgery
• Caregivers dealing with surgery patients

Stakeholders

Following are the stakeholders:

Bratzler D. and Houck P.

The two are the authors of “Antimicrobial Prophylaxis for Surgery: An Advisory Statement from the National Surgical Infection Prevention Project”.

Melnyk, B and Fineout-Overholt, E.

They are the authors of “Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice”.

Dellinger, E., Olsen, K, Perl, T., Auwaerter, P., Bolon, M., Fish, D., Napolitano, L., Sawyer, R., Slain, D., Steinberg, J., and Weinstein, R.

The scholars have authored an article titled “Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery”.

All stakeholders possess knowledge, skills, and experience in the medical field. In addition, they are recognized by their respective medical bodies in their regions.

Surgical Site Infections

The main function of the skin is to prevent entry of pathogens into human bodies. It is noted that chances of infection increase when the skin tears off or breaks. Surgical site infections (SSIs) refer to contamination of wounds obtained as a result of surgical procedure. According to Bratzler et al. (2013, p. 200), the infections are usually caused by bacteria. They result from contamination to the surgical wound. The pathogens that cause surgical site infections are usually from the body of the patient. When this happens, the resulting situation is referred to as endogenous infection. On its part, exogenous infections are rare. They occur as a result of contamination of the wound by pathogens from operating equipments. The pathogens may also access the wound during recovery (Berrios-Torres, 2009, p. 6). The major signs and symptoms associated with an infected surgical wound include fever, pain around the affected area, and pus. In addition, there is redness around the wound.

According to Melnyk and Fineout-Overholt (2010, p. 34), the risk for a site infection is determined by the type of surgical wound the patient has. In light of this, Berrios-Torres (2009, p. 5) notes that wounds are classified into different clusters.

Classification of Surgical Wounds

Clean wounds

They have a low risk of infection. The likelihood of an infection is usually 2% (Institute for Healthcare Improvement, 2012, p. 5). The wounds are strictly as a result of operation on the skin surface. They do not involve internal organs. In addition, they are not contaminated at the time of surgery. As a result, they do not get infected during recovery.

Clean-contaminated wounds

They are as a result of an operation conducted on an internal organ. In most cases, they do not display any contamination at the time of surgery. However, risk of getting infected during recovery stands at about 10% (Graham, Mancher, Wolman, Greenfield & Steinberg, 2011, p. 5).

Contaminated wounds

They result from an operation conducted on an internal organ. The secretions of this organ get into contact with the wound. The probability of obtaining a surgical site infection ranges from 13% to 20% (Graham et al., 2011, p. 4).

Dirty wounds

They are wounds that display a known infection during operation. They have a 40% risk of surgical site infection (Bratzler & Houck, 2005, p. 401).

Surgical Site Infections: Risk Factors

Smoking

Research shows that smokers are at a higher risk of developing surgical site infections compared to non-smokers. Smoke from the cigarette reduces the capacity of blood to carry oxygen. The situation leads to vasoconstrictive effects. Low concentration of oxygen interferes with the healing process of the wound (Bratzler & Houck, 2005, p. 399).

Obesity

After bleeding has been controlled in a wound, the inflammatory phase of the healing process begins. The process sets in with the movement of inflammatory cells into the wound area. It is followed by the infiltration of neutrophils, microphages, and lymphocytes (Graham et al., 2011, p. 9). The neutrophils act as clearing agents by removing microbes from the wound. As such, they are important in the wound healing process. The adipose tissue of obese persons is poorly vascularized. As a result, there is low blood supply. The situation means that there are few neutrophils in the wound. As a result, microbes accumulate, leading to infection.

Malnutrition

Human bodies require nutrients to build immunity against pathogens. Poor eating practices and lack of a proper diet deprives the body of these nutrients. The situation leads to a weak immune system. Ultimately, malnutrition increases the risk of wound infection (Bratzler et al., 2013, p. 204).

Recommendations to Avoid Surgical Site Infections

Patients and other stakeholders should take precautions to avert instances of surgical site infections. Preventive measures are broadly categorized into three phases. The three include preoperative, intraoperative, and postoperative phases.

Pre-Operative Measures

They include the precautions undertaken before the patient undergoes surgery. They include:

Shaving of hair

Hair on the operation site should not be shaved unless it interferes with surgery (Berrios-Torres, 2009, p. 14). If shaving occurs before surgery, it should be done using clippers and not a razor. Use of razors increases the risk of surgical site infections. The reason is that these tools can cause microscopic cuts and nicks on the skin (Institute for Healthcare Improvement, 2012, p. 7).

Administering antibacterial prophylaxis

The prophylaxis should not be administered during a clean wound surgery. The purpose of this intervention is to inhibit the accumulation of organisms during operation by manipulating levels of drugs in serum and tissues (Bratzler & Houck, 2005, p. 398). Prophylaxis should only be used during clean-contaminated and contaminated surgeries. It is used during clean surgeries only in cases of implants or operation on prosthesis (Bratzler et al., 2013, p. 203). It should be administered 1 hour before surgery and discontinued 24 hours after. However, at times, it extends to 48 hours, especially for heart patients (Institute for Healthcare Improvement, 2012, p. 6). The antibacterial should be administered 2 hours before operation in cases of fluoroquinolone or vancomycin (Berrios-Torres, 2009, p. 13).

Dressing

Both the patient and the operating team should be dressed in proper theater gear. They should not have any make-ups or jewelry (Graham et al., 2011, p. 5).

Intra-Operative Measures

Skin preparation

The skin should be disinfected just before the incision using an alcohol-based disinfectant. Povidone-iodine is commonly used by most practitioners.

Maintaining homeostasis

It is another important aspect of intra-operative procedures. The temperature of the patient should be stabilized during the operation (Bratzler & Houck, 2005, p. 401). Concentration of oxygen should also be maintained at 95% and above during surgery and recovery.

Closure methods

The method used in wound closure solely depends on the preferences of the surgeon. Research is still ongoing in relation to different closure strategies. In the past, materials used in the process included catgut and silk. However, modern surgeons prefer absorbable and non-absorbable polymers (Graham et al., 2011, p. 9). Some methods allow for faster closures compared to others. Regardless of the method used by the surgeon, efforts should be made to minimize risks of surgery site infection.

Post-Operative Measures

Wound Dressing

Surgical wounds should be dressed using sterile material for up to 48 hours after operation. When changing the dressing, an antiseptic should be used without directly touching the wound (Graham et al., 2011, p. 5).

Antibiotics

Administration of antibiotic prophylaxis should be discontinued 24 to 48 hours after surgery. In case surgical site infection occurs, tests should be done to determine the best antibiotic to use (Bratzler et al., 2013, p. 197).

Wounds Healing from Secondary Infection

A patient should consult a medical practitioner to get information on how to dress wounds that are healing from secondary infection. The patient should avoid using Eusol and gauze on such wounds.

Implementing the Guidelines

To effectively implement the recommendations, a fiduciary relationship should exist between a clinician and a patient. The clinician must take into consideration the patient’s best interests (Melnyk & Fineout-Overholt, 2010, p. 172). Consequently, a bond is established between the two parties. The link is strong enough for the clinician to mind the wellbeing of the patient.

Different jurisdictions adopt varying clinical practice guidelines. Some medical bodies would disapprove the recommendations outlined in this guideline. However, it is important to note that the recommendations are based the need for efficiency. In terms of cost, the suggestions mainly involve basic hygiene practices and care of surgical wounds. Most of the items needed are found in standard hospital stores. As such, no extra costs will be incurred in the process of adopting these guidelines. However, institutions should take into consideration implementation costs when working on these recommendations.

Conclusion

The early 1990s were characterized by variations in practice and failure to turn research evidence into practical applications. The situation led to the establishment of regulatory guidelines. The guidelines combine research with the need to observe patients’ values. Such interventions have changed the status of medical practice around the globe.

References

Berrios-Torres, S. (2009). Surgical site infection (SSI) toolkit: Activity C: ELC prevention collaboratives. Web.

Bratzler, D., & Houck, P. (2005). Antimicrobial prophylaxis for surgery: An advisory statement from the National Surgical Infection Prevention Project. American Journal of Surgery, 189(4), 395-404.

Bratzler, D., Dellinger, E., Olsen, K., Perl, T., Auwaerter, P., Bolon, M.,…Weinstein, R. (2013). Clinical practice guidelines for antimicrobial prophylaxis in surgery. American Journal of Health-System Pharmacy, 70(3), 195-283.

Graham, R., Mancher, M., Wolman, D., Greenfield, S., & Steinberg, E. (2011). Clinical practice guidelines we can trust. Web.

Institute for Healthcare Improvement. (2012). How-to guide: Prevent surgical site infections. Web.

Melnyk, B., & Fineout-Overholt, E. (2010). Evidence-based practice in nursing & healthcare: A guide to best practice (2nd ed.). Philadelphia, PA: Wolters Kluwer/Lippincott, Williams & Wilkins.

According to Moore, Day & Albers (2002) pathogenesis of Urinary Tract Infections (UTIs) is not a widely known infection. Current research has shown that most UTIs cases result when bacteria gains access to the bladder via the urethra. This is due to ascending infection, through a single gram-negative enteric bacterium some of which include Escherichia coli, Klebsiella, Proteus, Enterobacter, Pseudomonas, or Serratia. Research has shown that out of UTI cases by Enterobacteriaceae, about 80% of community-acquired infections are caused by Escherichia coli (Ronald & Toye, 2002). In addition, other gram-negative organisms, including Klebsiella, Proteus, Enterobacter, Pseudomonas, or Serratia, together represent 10 % of community-acquired infections. As a result, patients with recurrent infections are highly prone to these pathogens (Ronald & Toye, 2002). Similarly, Staphylococcus saprophyticus is the second most common cause of acute cystitis in young and sexually active females. On the other hand, Enrerococcus faecalis is a gram-positive pathogen in the elderly and in patients who have undergone genitourinary tract instrumentation (Ronald and Toye, 2002). In children, Enterobacteriaceae is the primary cause of UTI, while etiologic pathogens associated with diabetic patients are Klebsiella, Group B streptococci, Enterococcus and E coli. For patients with indwelling urethral catheters but not receiving antimicrobial agents, a different etiology exists for them because they are at the greatest risk of acquiring multiple resistant bacteria. For patients being treated with Cephalosporins infection due to E. faecalis has become more common nowadays (Ronald and Toye, 2002).

Although infection through the hematogenous is a rare occurrence, the ascending route is still the most rampant. Before the development of UTI, migration of uropathogens from the rectum to the vagina with urethral colonization occurs (Ronald and Toye, 2002). Consequently, a bacterial entry into the bladder is facilitated by sexual intercourse hence allowing the bacteria to proceed to the upper tract and kidneys. In contrast, a special zone within the urethra creates a natural barrier to the ascent of organisms colonized in the distal urethra and the bladder. Therefore, this interaction of the host defenses with bacteria determines the occurrence of the infection (Moore et al, 2002). The major host defense evident in the flushing effect of micturition is an elaborately normal urinary flow. The normal functioning of the ureterovesical junction coupled with inherent antibacterial properties of bladder mucin help in preventing infection.

Physiologically, the P fimbriae of E coli are a virulence determinant and permit their adherence to epithelial cells. While women with recurrent infections experience increased incidences of the Lewis blood-group non-secretor phenotype, females without vesicoureteral reflux have increased susceptibility to pyelonephritis due to the PI blood group. In response to infection with virulent bacteria, IL-6 and IL -8 cytokines are produced locally by epithelial cells. These cytokines not only produce acute-phase proteins but also act as a chemoattractant for neutrophils. Surprisingly, most women with complicated and recurrent infections have normal urinary tracts. Cases of interruption of the normal flow of urine such as obstruction, neurogenic bladder, or calculi result in residual urine and instrumentation, thereby increasing the incidents of infections. The findings of a recent study showed that the high incidence of UTI among women resulted from the shortness of the female urethra, which predisposes women to infection caused by bacteria from the vagina, perineum, rectum, or from a sexual partner (Harrington & Hooton, 2000).

In a positive light, recent advancements in molecular biology will highly facilitate the identification of new etiologic agents for UTI.

Heart surgery continues to be a salient operative procedure regardless of current technologies in coronary revascularization. At least 600,000 individuals undergo open heart surgery in the United States, every year (Haycock, 2005). Post surgery infections, though rare after open heart surgery, can have debilitating effects. However, among the nosocomial infections, surgical site infections (SSIs) occur more frequently than other types of infections. These SSIs occur within a span of 30 days after surgery. The infections can either be superficial, deep incisional infections or infections that affect organs or body spaces as shown in figure 1 below (Owens & Stoessel, 2008). Postsurgical wound care management is crucial in the prevention of postsurgical infections; hence, this paper aims at presenting a design of practice to prevent postsurgical infections.

Evidence-Based Practice

Discovery Research

Reference to the Acer Star Model that is shown below (Cooper, 2011), generating knowledge through literature search to identify ways of improving health care delivery with regard to postsurgical infection is the first step towards practice change. The knowledge that this paper seeks to discover is on surgical site infections, and a summary of evidence is obtained from various peer-reviewed articles.

Acer Star Model.

Evidence Summary

Post-surgical infections may stem from pre-surgery preparations; hence, the entire surgical procedure of handling the surgical site should be cautiously carried out. The CDC guidelines (Mangram, Horan, Pearson, Silver, & Jarvis, 1999) should be followed to the letter, but it is unclear whether these guidelines are cautiously and obediently followed. The facts summarized in this paper have been obtained from high quality reviews and research studies that have adopted experimental research designs.

Before Surgery

Preoperative patient and skin preparations

The first thing is to ensure that the patient’s general health condition is good, and he or she has no local infections. The patient should maintain a healthy nutritional status through healthy eating and should not use smoke and alcohol. Secondly, if need be, hair should be removed just before the operation by clipping and not by using the traditional shaving method with razors. The skin around the incision site should be thoroughly washed before disinfecting the incision area with chlorhexadine in alcohol (Owens & Stoessel, 2008). In the recent past, research indicates that 2% chlorhexidine in alcohol is very effective in reducing surgical site infections compared to the use of povidone iodide (Cabrera, 2010). It is, however, important to note that alcohol solutions are not ideal for damaged skin and neonates.

Administration of prophylactic antibiotics and monitoring

Prophylactic antibiotics should be administered to help attain bactericidal concentrations in the blood and tissues before the first incision. Monitoring of these bactericidal concentrations of the drug should be done throughout the surgery, and some hours after the surgery. The aim of giving this antibiotic is to help the patient cope with intraoperative contamination. The type of antibiotic is dependent on the pathogens associated with a particular procedure. It is not advisable to use vacomycin as a routine prophylaxis.

Control of blood glucose

Intensive insulin therapy is necessary at this point because hyperglycemia and insulin resistance are a major problem for severely sick patients, and especially those with a history of diabetes.

Personnel

Infected personnel should be treated to avoid cross-contamination, and they should perform surgical scrubs before putting on surgical wear.

Perioperative strategies

Surgical technique

A good surgical technique is that which ensures haemostatis is maintained, and devitalized tissue, foreign bodies and dead space are removed (Owens & Stoessel, 2008). The room where the operation is being conducted should be as sterile as possible; hence, the use of protective wears, such as, gloves, gowns, facemasks and sterile drapes. Flash sterilization is applied in cases where instruments are required for immediate use, such as when they unwittingly fall. A microbial sealant is recommended for use due to the presumption that endogenous bacteria remain despite the fact that proper procedures are followed. Various studies have shown that the microbial seal, a cyanoacrylate-based antimicrobial sealant, is associated with reduced surgical site infections (Dohmen, 2011).

Post Operation

Wound care management

The first 48 hours are very critical, and the wound should be protected using sterile dressing. However, there is usually a lot of variation in how wound care management is conducted after these hours due to lack of assented evidence. Therefore, this design will aim at gathering facts from different researches that indicate successful postsurgical results. After this time (48 hours), hand hygiene using alcohol has been associated with better results compared to the use of soap and water. Emphasis on alcohol-based hand rubs is due to the inconvenience of hand washing and the high non-adherence rate. Healthcare workers will only wash their hands when visibly soiled; thus as a means of infection control, alcohol-based rubs should be available always. Surveillance is also an important intervention offered after the first 48 hours in the case of closed surgery.

There is a lack of scientific evidence on effective strategies that could help to reduce post surgery infections. As a result of this, it is important for the health care team in the telemetry unit to deliberate about the existing CDC guidelines, and whether the unit abides by them, any gaps that need improvement and solutions to improve management of wound care at this point. The patient is educated on how to take care of the wound, and especially when being discharged. Hygiene is emphasized at this point since it is the only way to avoid infections.

Translation into Guidelines

This stage will entail identification of ways that will be used to relay information to the rest of the staff, and what will be required to do this. I will also identify the equipment that I know will be required to effect changes. I will be required to justify the need for these changes. I will develop a plan on how to introduce these changes without overwhelming the hospital system; thus, I will select the staff that will be trained. These will be the health care workers who are very knowledge and with adequate experience in the telemetry unit, so that cost-effectiveness is ensured while training.

Practice Integration

Train the Staff

Reduction of post surgical site infection in the telemetry unit will only be possible if the staff is well-informed; hence, training is imperative. The staff working in the telemetry unit will be educated on the evidence-based practices that have had a positive impact preventing postsurgical infections on the surgical site. The staff will be trained on all the aforementioned procedures, and caution will be emphasized in post surgery wound management where evidence is limited, and the guidelines seem to be the only source of reference. The health care workers selected for training will also present their views on additional tools and resources they feel are required in implementing the new changes. The health care providers will be cautioned about the usage of wrong terminologies to avoid confusion. Haycock’s et al. (2005) review indicates that despite a 100% clipping compliance, health workers used clipping and shaving interchangeably. In addition, the training will entail a review of the nursing code of ethics to enhance performance and cooperation among the staff. Due to limited evidence on reduction of surgical site infections after surgery, the CDC recommends documentation of both direct and indirect approaches to help obtain information on the occurrence of SSIs in relation to specific procedures (Mangram, Horan, Pearson, Silver, & Jarvis, 1999).

Soliciting Resources from the Management

I will have a meeting with the management of the hospital: the CEO, the director and the manager of the cardiac surgery department. During the meeting, I will make a presentation about post surgery site infections: occurrence in the telemetry unit, findings, prevailing gaps in the telemetry unit, and how these gaps can be addressed. Convincing the management team about the need for changes is very important because it holds the key to making the change in practice a reality. I will present the already outlined plan to guide in the implementation of changes and planning of finances.

Process, Outcome and Evaluation

Once the management agrees about the developed planned on how to improve management of post surgical site infections, the necessary equipment will be bought, and only trained staff will operate in the unit. In addition, the policy regarding surgery procedures in the telemetry unit will be modified. The novel procedures will be executed with caution and after one month, there will be an assessment of the trend in the occurrence of post surgical site infections.

References

Cabrera, R. H. (2010). Prevention of surgical-site infection, using a modified bundle. Rev esp cir ortop traumatol., 54(5), 265-271.

Cooper, C. (2011). Transforming health care through the use of evidence-based practice. Nursing Excellence, 1 (1). Web.

Dohmen, P M., Weymann, A., Holinski, S., Linneweber, J., Geyer, T., & Konertz, W. (2011). Use of antimicrobial skin sealant on the rate of surgical site infections after cardiac surgery. Surgical Infections, 12 (6), 475-481.

Haycock, C., Laser, C., Keuth, J., Montefour, K., Wilson, M., Austin, K., … Boyle, D. (2005). Implementing evidence-based practice findings to decrease postoperative sterna wound infections following open heart surgery. Journal of Cardiovascular Nursing, 20(5), 299-305.

Mangram, A. J., Horan, T. C., Pearson, M. L., Silver, L. C., & Jarvis, W. R. (1999). Guideline for prevention of surgical site infection, 1999. Infection Control and Hospital Epidemiology, 27, 97-134.

Owens, C. D., & Stoessel, K. (2008). Surgical site infections: epidemiology, microbiology and prevention. Journal of Hospital Infection, 70(S2), 3-10.

Introduction

General Notions

The Health of human beings has always been threatened by various diseases that develop and evolve together with the improvement of methods people find to fight them. Considering the relevant literature, one can find numerous pieces of evidence about the diseases and infections that attack almost any part of the human organism, and the urinary tract is not an exception. This part of the human body functioning is subject to numerous urinary tract infections (UTIs) that might have different causes, develop in a variety of ways, and be treated through the use of different clinical approaches (Mateucci, Walsh, and Pravikoff, 2009, p. 1; Jain et al., 2006, p. 233).

Clinical Issue Background

In more detail, urinary tract infections (UTIs) are observed rather often among countries and regions. According to Mateucci, Walsh, and Pravikoff (2009), alone in the USA specialists record the average of 1 million UTIs annually, and the major reasons for the bulk of these infections are the improperly carried out process of catheterization and its negative consequences for the human health conditions (p. 1). At the same time, Smith and Pravikoff (2009) consider catheterization as one of the basic ways to treat UTIs caused by urine retention or incontinence (p. 2). Given these seemingly opposite viewpoints, one cannot ignore the fact that UTIs are common health issues for intensive care unit (ICU) patients, and scholars like Elpern et al. (2009), Randolph et al. (2005, p. 20), and Jain et al. (2006, p. 234) connect this fact to the routine use of catheters, especially indwelling ones, in ICUs.

Research Question

Thus, the above introductory remarks and the background of the clinical issue under consideration allow seeing that UTIs are a serious health care problem of today, especially for ICU patients. Therefore, if such a problem exists and scholars like Beaver (2008), Volkar (2010), Mateucci, Walsh, and Pravikoff (2009), etc. admit this fact, one cannot ignore the need to find the solution to this problem. Based on this need, the research question of the current paper can be formulated:

• Q: How can catheter-associated urinary tract infections (UTIs) be prevented or treated in ICU patients?

Findings

Key Terms

Further on, for a better understanding of the topic and for being able to find the answers to the research question, it is necessary to define the key terms used in the area of urinary tract treatment, UTIs, and the specificity of these issues for ICU patients:

• A urinary catheter – Smith, and Pravikoff (2009) define it as “any tube system placed in the body to drain and collect urine from the bladder” (p. 2);
• A short-term catheter – a system placed into the body intermittently and removed as soon as it helps empty the bladder from urine (Mateucci, Walsh, and Pravikoff, 2009, p. 2);
• A long-term catheter (or indwelling catheter) – a system used permanently, mainly for patients suffering from urine, retention, incontinence, or both disorders combined (Mateucci, Walsh, and Pravikoff, 2009, p. 2);
• A urinary tract infection (UTI) – an infection that results from a critical illness or continued and improper use of catheters for treatment (Bagshaw and Laupland, 2006, p. 68); it is usually provoked by the introduction of bacteriuria and pyuria bacteria into the bladder through the urinary tract and urethra (Mateucci, Walsh, and Pravikoff, 2009, p. 3).
• A catheter-associated urinary tract infection (CAUTI) – the above-defined infection caused directly by or associated with the use of a catheter for treatment of urine retention, incontinence, or related issues (Prevention of catheter-associated urinary tract infections, 2008, p. 86).
• An intensive care unit (ICU) – a medical facility where patients with critical or urgent conditions are taken care of and treated; use of supportive devices is common for ICUs, and this is especially relevant for urinary tract issues where catheterization is a common practice (Elpern et al., 2009; Randolph et al., 2005, p. 19; Rosenthal et al., 2010).

Clinical Issue Details

Thus, after the key terms in the topic of CAUTIs in ICU patients are defined, it is now possible to explain the very clinical issue in detail. First of all, it should be stated clearly that a UTI is catheter-associated because it is observed in a patient during or after the process of catheterization being used for the treatment of his/her urine retention, incontinence, and other issues (Mateucci, Walsh, and Pravikoff, 2009, p. 1). CAUTI is only one of the catheter use complications, while the set of others includes bladder stones, hematuria, urethral injury, and even bladder cancer (Smith and Pravikoff, 2009, pp. 3 – 4).

According to Stockowski (2010), catheter-associated urinal tract infections amount to 40% of all so-called nosocomial infections, and the bulk of them is caused by the use of indwelling long-term catheters. At the same time, Stockowski (2010) considers UTI to be a minor disorder that has no serious consequences. This opinion is confronted by the views of Elpern et al. (2009), who list “sepsis, prolonged hospitalization, additional hospital costs, and mortality” among the major results of UTIs caused by prolonged improper use of urine catheters. The interesting fact is that regular interventions carried out during catheterization with indwelling devices can substantially reduce the risk and the actual occurrence of UTIs in ICU patients (Elpern et al., 2009).

Further on, it is proven empirically that the risk of a catheter-associated urinary tract infection grows by 5% with every day of urine catheter use. This approximate meaning is developed by Saint et al. (2010), who notice that the amount of bacteriuria and pyuria bacteria in the bladder increases by an average of 5% for every day of ICU urine catheterization. Finally, the groups of patients that are subject to the highest rates of UTIs’ risks are female and elderly patients, although the reasons for female patients to be more endangered by UTI risks than the male ones is still not considerably studied by scholars.

Accompanying risk factors for UTI development, in both male and female patients of all ages also include “Pre-existing chronic illness, malnutrition, diabetes, renal insufficiency, and insertion of the catheter outside the operating room or late in hospitalization” (Crosby, 2005).

Thus, the above-presented details on the catheter-associated urinary tract infections (CAUTI/UTI) in ICU patients allow formulating the major profile of the clinical issue in the following way:

1. Catheter-associated urinary tract infections in ICU patients develop during the procedures of catheterization;
2. The riskiest catheterization is the one that presupposes the use of the long-term indwelling catheters as it has a permanently growing risk of UTI’s development;
3. Patients in intensive care units (ICUs) are subjected to the highest risks of UTIs’ development as far as long-term indwelling catheterization is a routine procedure in such medical facilities for respective patients;
4. Female and elderly patients are the major risk groups for UTIs’ development;
5. Pre-existing health issues, malnutrition, untimely, and/or improper catheter insertion are the main UTI risk factors for all groups of patients without exceptions.

Discussion

Accordingly, the above-detailed discussion of catheter-associated UTIs and their causes for ICU patients allows developing the set of UTI prevention policies. The first point to address is the use of catheterization as such for health care purposes. As noted above in the Introduction section, catheterization is a source of numerous health care problems, but it is at the same time a method of treating urine retention, incontinence, and related issues. Therefore, specialists analyze the pros and cons of catheterization and often conclude that the use of antimicrobials can be a quite effective alternative, although fully applicable to symptomatic UTIs only (Nicolle, 2005, p. 635).

Further on, the high risk of using the long-term indwelling catheters for UTIs’ development is another serious issue associated with ICU patients’ protection from urinary problems. In brief, ICU patients are commonly exposed to indwelling catheterization on the regular basis, which results in 40% of ICU patients having UTIs (Stockowski, 2010). To solve this problem, two ways are seemingly the best nowadays. The first one is the use of properly designed indwelling catheters, while the second one is the use of regular interventions to monitor catheterization procedures.

In more detail, Mateucci, Walsh, and Pravikoff (2009) argue that the use of a catheter made out of a proper material that fits every specific patient might be a solution. Some patients are allergic to latex, and the use of catheters of this material can increase the UTI risk, while silicon, Teflon, and silver catheters reduce this risk by their antiseptic properties. One more approach to the issue is to use coated catheters that reduce bacteria adherence rates (Mateucci, Walsh, and Pravikoff, 2009, pp. 2 – 3). In addition to this, Elpern et al. (2009) argue that control over catheterization in ICUs should be exercised on the regular basis to ensure the proper design of the procedure and to reduce its UTI risk for ICU patients.

Another important point is the set of UTI risk groups and risk factors for ICU patients. Female and elderly patients are considered to be at the highest risk due to the peculiarities of the urinary system of the former and the weakening of the urinary systems and “host immune response” of the latter. Again, the ideas by Nicolle (2005) can be of great help for solving the issue, as the author insists on an individual approach to antimicrobials’ use that can weaken an already exhausted immunity of a patient with a developed UTI (p. 637).

Finally, scholars like Crosby (2005), Srinivasan et al. (2006), and Beaver (2008) stress the importance of an individualized approach to the overall procedure of urinary treatment at both pre-catheterization and post-catheterization stages. In more detail, should make sure to study the pre-existing peculiarities of every patient as well as his/her allergic reactions. The second point in this individualized approach is more generally applicable as far as it is all about providing timely, proper, and sterile catheterization to prevent or at least reduce, the risk of UTI development in ICU patients. Education and professional responsibility development are the two basic concepts for the effective development of the above-listed initiatives.

Concluding Remarks

Conclusions

Thus, the above discussion allows concluding that catheter-associated urinary tract disease (CAUTI/UTI) is one of the most serious health care issues of today amounting to 1 million annual occurrences alone in the USA. Improper catheterization accompanied by pre-existing conditions, malnutrition, and belonging to one of the two major risk groups, i. e. female and elderly patients, are all UTI-friendly factors. So, proper catheterization practices, educated medical staff, and professional responsibility are the qualities needed to fight UTIs.

Recommendations

Drawing from the above-presented arguments and support from relevant scholarly works, the following set of recommendations for the expected improvement of UTIs’ prevention and treatment can be formulated. Thus, to fight UTIs medical professionals should:

• Be educated, professionally qualified, and responsible;
• Try to prevent UTIs instead of fighting their consequences;
• If facing UTIs, use an individualized approach to every single patient;
• Study pre-existing conditions and allergic reactions of a patient;
• Use the equipment, i. e. urine catheters in this case, that fits the patients in every particular case.

References

Bagshaw, S. and Laupland, K. (2006). Sexually transmitted diseases and urinary tract infections: Epidemiology of intensive care unit-acquired urinary tract infections. Current Opinion in Infectious Diseases, 19(1), 67 – 71. Web.

Beaver, M. (2008). CMS Reimbursement Changes Put Spotlight on Prevention of Catheter-Related Infections. Web.

Crosby, C. (2005). Prevention of catheter-associated urinary tract infections. Retrieved April 28, 2010, from Healthcare Purchasing News: Web.

Elpern, E. et al. (2009). Reducing Use of Indwelling Urinary Catheters and Associated Urinary Tract Infections. Web.

Jain, M. et al. (2006). Quality improvement report: Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change. Quality Sage Health Care, 15, 232 – 239. Web.

Mateucci, R., Walsh, K., and Pravikoff, D. (2009). Urinary Catheter Use and Prevention of Infection. CINAHL Nursing Guide, 11(13), 1 – 9. Retrieved April 28, 2010, from CINAHL Information Systems Database.

Nicolle, L. (2005). Catheter-Related Urinary Tract Infection. Drugs and Aging, 22(8), 627 – 639. Web.

Prevention of catheter-associated urinary tract infections. (2008). In: Betsy Lehman Center for Patient Safety and Medical Error Reduction, JSI Research and Training Institute, Inc. Prevention and control of healthcare-associated infections in Massachusetts. Part 1: final recommendations of the Expert Panel (pp. 83-9). Boston (MA): Massachusetts Department of Public Health. Web.

Randolph, A. et al. (2005). Definitions of Specific Infections: Identification of central venous catheter-related infections in infants and children. Pediatric Critical Care Medicine, 6(3), 19 – 24. Web.

Rosenthal, V. et al. (2010). Device-Associated Nosocomial Infections in 55 Intensive Care Units of 8 Developing Countries. Web.

Saint, S. et al. (2010). Catheter-Associated Urinary Tract Infection and the Medicare Rule Changes. Web.

Smith, N. and Pravikoff, D. (2009). Urinary Catheter Insertion and Care. CINAHL Nursing Guide, 12(11), 1 – 13. Web.

Srinivasan, A. et al. (2006). A Prospective Trial of a Novel, Silicone-Based, Silver-Coated Foley Catheter for the Prevention of Nosocomial Urinary Tract Infections. Infection Control and Hospital Epidemiology, 27(1), 1. Web.

Stockowski, L. (2009). Preventing Catheter-Associated Urinary Tract Infections. Web.

Volkar, G. (2010). Urinary Catheter Infection Prevention. Web.

Problem Description

Incidences of nosocomial infections have been increasing in the ICU due to poor maintenance of hygiene in the use of medical devices such as syringes, catheters, and ventilators. Nosocomial infections in the ICU have a negative impact on the clinical interventions and nursing care that patients receive (Scales, 2011). Given that critical care nurses ensure that patients receive appropriate therapies and health care, the presence of nosocomial infections complicates the health conditions of the patients and consequently treatment requirements. Additionally, nosocomial infections increase the length of stay and the cost of medical care. According to Safdar and Abda (2008), “approximately 2 million patients each year in the United States acquire nosocomial infections, resulting in some 90,000 deaths and adding an estimated $4.5 to $5.7 billion per year to the costs of patient care” (p. 933). Hence, there is a need to educate critical care nurses on how to maintain hygiene when using medical devices that increase the risk of nosocomial infections.

The deficit in the application of evidence-based practices that are in tandem with current preventive measures is an issue that the hospital needs to address. As a baseline preventive measure, the critical care nurses in the hospital employ conventional practices such as hand hygiene, cleansing of catheter sites, and sterilization of the medical devices. Despite using these conventional interventions in the prevention and control of nosocomial infections, the incidence rates of the infections continue to remain high. In a study, Ding et al. (2009) find out that the rate of nosocomial infections in the ICU ranges from 22% to 32% depending on the clinical practices and nursing care that patients receive. Such figures are very high because they imply that about a third of patients in the ICU are at risk of losing their lives due to nosocomial infections. The increase in the incidences of nosocomial infections is attributable to the deprived hygienic conditions of the ICU, poor maintenance of catheters and ventilators, improper use of antiseptics, and lack of antiseptic-impregnated catheters (Kathleen et al., 2011). Thus, the hospital needs to upgrade preventive and control measures of nosocomial infections in the ICU.

Solution Description

The education of critical care nurses is an appropriate intervention for reducing incidence rates of nosocomial infections in the ICU. The rationale for using education as a proposed solution is that it facilitates the adoption and utilization of evidence-based practices (Chittick & Sherertz, 2010). Evidence-based practices are effective in the prevention and control of nosocomial infections in the ICU because they forestall medical errors due to the use of opinions and assumptions, which are quite misleading (Milstone, Passaretti, & Perl, 2008). Lack of evidence-based interventions in the prevention of nosocomial infections compels critical care nurses to employ outdated interventions, which are not only effective, but also increase morbidity and mortality rates associated with the nosocomial infections (Wilson, Wilde, Webb, Thompson, Harwood, Callan, & Gray, 2009). The education enables critical care nurses to update their knowledge and skills about current interventions for preventing nosocomial infections in the ICU. According to Mermel (2011), educational interventions have a significant impact on reducing the rates of nosocomial infections in the ICU. Hence, educational intervention supports the adoption and the use of evidence-based interventions in the prevention and control of nosocomial infections in the ICU.

Implementation Plan

The implementation plan of the educational program that aims at equipping critical care nurses with essential knowledge and skills derived from evidence-based practices consists of weekly seminars. As part of stakeholders, critical care nurses will be responsible for the implementation of the educational program. Critical care nurses will attend weekly seminars where they will receive updated preventive measures of nosocomial infections in the ICU. The educational program expects critical care nurses to apply the knowledge that will be gained during each seminar in preventing nosocomial infections. Since the nurse manager is in charge of the ICU, the manager will be responsible for initiating the educational program and overseeing the implementation of evidence-based practices gained during the seminar. Halm (2010) argues that the implementation of evidence-based practices requires leadership and administrative support. Thus, a managerial role is necessary for the implementation of the educational program. The seminar will ensure that critical care nurses gain preventive measures of nosocomial infections that are in tandem with current evidence-based practices.

Evaluation Plan

The use of surveys is one of the methods of evaluating the effectiveness of the educational program in reducing incidences of nosocomial infections and improving the quality of care in the ICU. The variables that the evaluation plan seeks to assess are knowledge, skills, and perceptions of critical care nurses, perceptions of patients, the prevalence of nosocomial infections, and the cost of treating nosocomial infections. The survey helps in gathering information regarding the perceptions of nurses about the implementation of the educational program and its impact on their knowledge and skills. Majid, Foo, and Mokhtar (2011) argue that perceptions, skills, and knowledge of nurses determine the effectiveness of adoption and utilization of evidence-based practices. The evaluation plan also surveys the perceptions of the ICU patients concerning the quality of care that they receive. In this view, a survey of nurses and patients before and after implementation of the educational program is necessary. Moreover, analysis of records, before and after implementation of the educational program, which shows the prevalence of nosocomial infections and cost associated with their treatment, is important in evaluating the effectiveness of the program in reducing nosocomial infections.

Dissemination Plan

The dissemination of the evaluation findings regarding the outcomes of the educational program focuses on aspects of the outcomes such as knowledge, skills, and perceptions of nurses, perception of patients, the prevalence of nosocomial infections, and the cost of treating nosocomial infections. Since the educational program aims at improving the competence of critical care nurses, dissemination of their knowledge, skills, and perceptions regarding the prevention of nosocomial infections is important in highlighting the impact of the educational program (Vandijck, Labeau, Vogelaers, & Blot, 2010). The perception of patients is critical information that requires dissemination. Satisfaction of patients normally signifies the nature of care and competence of nurses in the delivery of nursing care (Zavare, 2010). Thus, dissemination of patients’ perceptions is necessary so that nurses can understand how to deliver effective nursing care that meets the demands and expectations of patients. Given that the educational program aims at reducing the prevalence of nosocomial infections and consequently treatment of patients in the ICU, dissemination of the information regarding the extent of reduction in the prevalence of nosocomial infections and treatment cost is invaluable.

Annotated bibliography

Barsanti, M., & Woeltje, K. (2009). Infection prevention in the intensive care unit. Infectious Disease Clinics of North America, 23(3), 703-725.

The article emphasizes the impact of nosocomial infections on the economic, social, and psychological aspects of patients and families. Thus, to prevent the occurrence of nosocomial infections in the ICU, the article recommends minimization of risk factors, continual education of healthcare providers, and adoption of evidence-based practices.

Chittick, P., & Sherertz, R. (2010). Recognition and prevention of nosocomial vascular devices and related bloodstream infections in the intensive care unit. Critical Care Medicine, 38(8), 363-372.

The article reviews available tools that are integral in the prevention and diagnosis of nosocomial infections in the ICU. In this view, the article highlights that the use of antiseptic-impregnated catheters, hand hygiene, skin cleansing, catheter changes, catheter choice, and early diagnosis is central in the prevention of nosocomial infections.

Ding, et al. (2009). Retrospective analysis of nosocomial infections in the intensive care unit of a tertiary hospital in China during 2003 and 2007. BMC Infectious Diseases, 9(115), 1-109.

The article describes the experiences of patients with nosocomial infections through retrospective analysis. Since the experiences of patients are imperative in understanding the occurrence of nosocomial infections, the article declares that poor hygienic practices and a lack of evidence-based practices contribute significantly to the occurrence of nosocomial infections in the ICU.

Halm, M. (2010). ‘Inside Looking In’ or ‘Inside Looking Out’? How Leaders Shape cultures equipped for evidence-Based Practice. American Journal of Critical Care, 19(4), 375-378.

As leadership is critical in the implementation of evidence-based practices, the article comprehensively examines the role of leaders in the adoption and implementation of evidence-based practices in the healthcare system. Overall, the article suggests that healthcare leaders should help in shaping cultures that support the adoption and implementation of evidence-based practices.

Helder, O., Brug, J., Loonman, C., Goudoever, J., & Kornelisse, R. (2010). The impact of an education program on hand hygiene compliance and nosocomial infection incidence in an urban neonatal intensive care unit: An intervention study with before and after comparison. International Journal of Nursing Studies, 47(1). 1245-1252.

Hand hygiene is one of the interventions that are central in the prevention and control of nosocomial infections. The article assesses the impact of an educational program on the reduction of nosocomial infections in the neonatal ICU. Hence, the article recommends the use of hand hygiene in the prevention and control of nosocomial infections among babies in the ICU.

Kollef, M. (2008). SMART approaches for reducing nosocomial infections in the ICU. Chest, 134(2), 447-456.

Although evidence-based practices are available, critical care nurses do not apply them because they do not have essential knowledge and skills. In this view, the article outlines smart approaches such as hand hygiene, the use of antiseptic-impregnated devices, and the improvement of clinical practices. Therefore, the article emphasizes that new approaches are necessary to enhance preventive measures of nosocomial infections.

Kathleen, et al. (2011). Nurse-directed interventions to reduce catheter-associated urinary tract infections. American Journal of Infection Control, 30(1), 1-6.

Despite the fact that evidence-based guidelines are available, the article states that healthcare professionals do not follow them consistently. To establish the impact of evidence-based interventions, the study examines patients with catheter-related urinary tract infections. On this basis, the article establishes that compliance with guidelines leads to a decrease in catheter days and a reduction in the prevalence of nosocomial infections.

Majid, S., Foo, S., & Mokhtar, I. (2011). Adopting evidence-based practice in clinical decision-making: Nurses’ perceptions, knowledge, and barriers. Journal of Medical Library Association, 99(3), 229-236.

In the article, the authors claim that the adoption and implementation of evidence-based practices are dependent on perceptions, knowledge, and institutional barriers. To enhance the adoption and implementation of evidence-based practices, nurses and other healthcare providers should change their attitudes and perceptions, and improve their knowledge.

Mermel, L. (2011). What is the predominant source of the intravascular catheter Clinical Infectious Disease, 52(2), 211-212.

The article seeks to establish if intraluminal or extraluminal parts of the catheter are responsible for nosocomial infections. To establish the source of nosocomial infections, the article examines the extensive literature. Based on the literature, the article verifies that both intraluminal and extraluminal parts of the catheter are responsible for the occurrence of nosocomial infections.

Milstone, M., Passaretti, L., & Perl, M. (2008). Chlorhexidine: Expanding the armamentarium for infection control and prevention. Clinical Infectious Diseases, 46(2), 274-281.

Since chlorhexidine is a powerful antiseptic, the article reviews its uses and that of its derivatives in skin cleansing and impregnating syringes and catheters. The article attributes the occurrence of nosocomial infections to poor hygiene in the use of medical devices. As part of the findings, the article establishes that chlorhexidine and its derivatives are effective in the prevention of nosocomial infections.

Safdar, N., & Abda, C. (2008). Educational interventions for the prevention of healthcare-associated infection: A systematic review. Critical Care Medicine, 36(3), 933-940.

The authors hold that education is an effective intervention in preventing and controlling nosocomial infections. Despite the fact that evidence-based practices are in the literature, healthcare providers have not adopted and implemented them because they do not have relevant knowledge and skills. Therefore, the article supports the use of education as an intervention for improving the knowledge and skills of nurses so that they can apply evidence-based practices in the prevention of nosocomial infections.

Scales, K. (2011). Reducing infections associated with central venous access Nursing Standard, 25(36), 49-56.

The nature of clinical practices that nurses apply determines the occurrence of nosocomial infections. The article argues that poor hygienic conditions predispose patients to nosocomial infections. Hence, the article suggests the use of antiseptics and antiseptic-impregnated devices in the ICU to prevent and control the occurrence of nosocomial infections.

Vandijck, M., Labeau, O., Vogelaers, P. & Blot, I. (2010). Prevention of nosocomial infections in intensive care patients. Nursing in Critical Care, 15(5), 251-256.

The article stresses that ICU patients commonly experience nosocomial infections due to the unhygienic conditions of the ICU, outdated clinical practices, and invasive treatment procedures. In this view, the article affirms that maintenance of hygiene and the adoption of current clinical practices are effective in reducing the prevalence of nosocomial infections in the ICU.

Wilson, M., Wilde, M., Webb, M., Thompson, D., Harwood, J., Callan, L., & Gray, M. (2009). Nursing interventions to reduce the risk of catheter-associated urinary tract infections: Part 2: Staff education, monitoring, and care techniques. Journal of Wound, Ostomy, and Continence Nursing, 36(2), 137-154.

The article examines nursing interventions that are applicable in the prevention of urinary tract infections. Since the use of catheters predisposes patients to nosocomial infections, the article supports the use of evidence-based interventions. Hence, the article recommends the education of staff, constant monitoring of catheters, and the use of good insertion techniques as effective interventions for reducing the prevalence of nosocomial infections.

Zavare, M. (2010). Patient satisfaction: Evaluation nursing care for patients hospitalized with cancer in Tehran Teaching Hospitals, Iran. Global Journal of Health Science, 2(1), 117-126.

As different parameters of assessing the quality of nursing care exist, the article asserts that patient satisfaction is the best. Patient satisfaction is a reliable parameter because it assesses the quality of healthcare from the viewpoint of patients. In this view, the article recommends the assessment of the quality of healthcare using the perception of patients.

Conclusion

Nosocomial infections challenge the health care system because it threatens the lives of about a third of patients in the ICU and markedly increases medical costs. The major factor that contributes to the occurrence of nosocomial infections is poor hygiene in the use of medical devices such as catheters and syringes. Although the literature review shows that ample evidence-based practices exist, nurses do not apply them in the prevention and control of nosocomial infections because they do not have essential knowledge and skills. In this view, the project recommends the use of the educational program as an intervention of improving the knowledge and skills of nurses so that they prevent and control nosocomial infections effectively in accordance with the current evidence-based practices. In the implement the educational program, nurses will attend weekly seminars where they will learn evidence-based knowledge and skills, and then the program undergo an evaluation to determine its impact in enhancing nurses’ knowledge and skills, and in reducing incidences of nosocomial infections. Since the literature review supports the use of education in the prevention and control of nosocomial infections, the projects will disseminate the evaluation findings through publications and seminars.

References

Barsanti, M., & Woeltje, K. (2009). Infection prevention in the intensive care unit. Infectious Disease Clinics of North America, 23(3), 703-725.

Chittick, P., & Sherertz, R. (2010). Recognition and prevention of nosocomial vascular device and related bloodstream infections in the intensive care unit. Critical Care Medicine, 38(8), 363-372.

Ding, et al. (2009). Retrospective analysis of nosocomial infections in the intensive care unit of a tertiary hospital in China during 2003 and 2007. BMC Infectious Diseases, 9(115), 1-109.

Halm, M. (2010). ‘Inside Looking In’ or ‘Inside Looking Out’? How Leaders Shape cultures equipped for evidence-Based Practice. American Journal of Critical Care, 19(4), 375-378.

Helder, O., Brug, J., Loonman, C., Goudoever, J., & Kornelisse, R. (2010). The impact of an education program on hand hygiene compliance and nosocomial infection incidence in an urban neonatal intensive care unit: An intervention study with before and after comparison. International Journal of Nursing Studies, 47(1). 1245-1252.

Kollef, M. (2008). SMART approaches for reducing nosocomial infections in the ICU. Chest, 134(2), 447-456.

Kathleen, et al. (2011). Nurse-directed interventions to reduce catheter-associated urinary tract infections. American Journal of infection Control, 30(1), 1-6.

Majid, S., Foo, S., & Mokhtar, I. (2011). Adopting evidence-based practice in clinical decision-making: Nurses’ perceptions, knowledge, and barriers. Journal of Medical Library Association, 99(3), 229-236.

Mermel, L. (2011). What is the predominant source of the intravascular catheter infections. Clinical Infectious Disease, 52(2), 211-212.

Milstone, M., Passaretti, L., & Perl, M. (2008). Chlorhexidine: Expanding the armamentarium for infection control and prevention. Clinical Infectious Diseases, 46(2), 274-281.

Safdar, N., & Abda, C. (2008). Educational interventions for prevention of healthcare-associated infection: A systematic review. Critical Care Medicine, 36(3), 933-940.

Scales, K. (2011). Reducing infections associated with central venous access devices. Nursing Standard, 25(36), 49-56.

Vandijck, M., Labeau, O., Vogelaers, P. & Blot, I. (2010). Prevention of nosocomial infections in intensive care patients. Nursing in Critical Care, 15(5), 251–256.

Wilson, M., Wilde, M., Webb, M., Thompson, D., Harwood, J., Callan, L., & Gray, M. (2009). Nursing interventions to reduce the risk of catheter-associated urinary tract infections: Part 2: Staff education, monitoring, and care techniques. Journal of Wound, Ostomy, and Continence Nursing, 36(2), 137-154.

Zavare, M. (2010). Patient satisfaction: Evaluation nursing care for patients hospitalized with cancer in Tehran Teaching Hospitals, Iran. Global Journal of Health Science, 2(1), 117-126.

Introduction

The subject of infection prevention and control has received unprecedented attention over the last decades with the media and scientific literature equally contributing to this attention. Boyce et al. (2009, p. 12) report that media has reported on several occasions about the absence of hand hygiene and insufficient cleaning practices among health workers. The malpractice has amounted to carelessness. One of the infections that commonly pose a challenge to health workers is the Methicillin Resistant Staphylococcus Aureus (MRSA), which is one of those infections caused by multiple resistant bacteria. Research has shown that, with the application of intensive infection prevention programs in health institutions, a third to a quarter of all hospital-acquired infections could be prevented (Fraise & Bradley, 2009, p. 23). Adherence to these measures is a problem with research showing that health workers are unaware of the measures. They exhibit ignorance on the rationale behind the measures by projecting the problem to hygiene experts (Verhoeven et al. 2009). Several infection control practices are in place in all health institutions with specific measures being aimed at preventing MRSA infections. The role played by health workers especially the nursing staff cannot be overemphasised. However, much work is yet to be implemented. A multifaceted approach is therefore necessary to cut the spread of the infection. This essay is a critical review of the infection control practices in place for the microorganism. It analyses literature on the same in addition to making recommendations to the practice.

Pathogenesis

According to Gould and Brooker, “Staphylococcus aureus bacteria are Gram-positive cocci that are both coagulase and catalase positive, and have long been recognised as important pathogens in human disease” (2008, p. 81). The argument is true because bacteria can cause infection by both noninvasive and invasive methods thus affecting virtually all tissues of the body in human beings. Since bacteria are commonly found on the skin of healthy individuals, they may be inoculated through injury. However, with the introduction of penicillin in the 1940s, some strains of the bacteria were isolated after being found to be resistant to the antibiotic (Fraise, & Bradley, 2009, p. 27). With the introduction of methicillin, a group of the bacteria was also found to be resistant to the drug a year later in the hospital set up (Gould, & Brooker, 2008, p. 11). The bacteria were then referred to as MRSA based on the resistance. It has a rate of transmission that is greater than that of its Methicillin sensitive strain especially between health workers and patients (Gould, & Brooker, 2008, p. 11).

Verhoeven et al. claim that the infections by MRSA are mainly seen in patients who are frequently exposed to the hospital environment. The argument mainly points at patients with open wounds such as those who recently had surgery, dialysis, hospitalisation, or those who reside in a care facility such as nursing homes (2009, p. 16). Aside from this study, it is worth noting that the isolation of MRSA is not only on patients with exposure to a health facility, but can also occur in those without healthcare risk factors (Verhoeven et al. 2009). The isolated community-acquired MRSA and those that are hospital-acquired are different in the toxin profiles and in the number of beta lactam antibiotics to which the strains are resistant. However, infection with any strain of MRSA causes infections in individuals that are both expensive and difficult to treat. Hospitalisation is necessary in most cases.

Infection Control Practice in Work Area

In most of the health institutions all over the world, a standard procedure is used for infection prevention against MRSA. The main guidelines used are those that are laid down by the Centres for Disease Control and prevention (CDC). The personal work place is no different. However, there exist differences and alterations in the measures put in place especially in the workplace. The measures at the personal workplace can be grouped into those preventing transmission of bacteria and those that are standard precautions for the institution.

In the preventive standard precautions at the institution, an assumption is made that the body fluids and secretions contain microorganisms. The precautions are aimed at preventing inoculation. These precautions are therefore standard to all patients at the institution irrespective of the infective organism. They comprise “gowning, the use of gloves when handling patients, mask protection, hand hygiene, safe injections, and shielding of the face and eyes from exposure” (Gould, & Brooker, 2008, p. 12). Use of gloves is applied where the healthcare giver is at risk of coming into contact with bodily fluids such as blood and mucous from the patients when they need to practice safe injections.

In the same institution, gowning is used to prevent contamination of clothing by material that may be infectious more so in the operating theatres and in the general wards where a caregiver is always in contact with infectious materials. A combination of masks, goggles, and face shields is frequently used in the institution especially where a procedure being performed is likely to produce a splash. The same procedure is also used in the management of patients who may have one or more sites where there is a high likelihood of large bacterial colonisation and overgrowths in patients with tracheostomies.

Standard precautions are applied to almost all patients in the institutions. However, other patients require transmission-based precautions, which are additional measures that the hospital applies to prevent infections that are not necessarily prevented by the standard precautions. The precautions are more focused on the transmission routes for the infection. Gould and Brooker state that the interventional strategies that employ transmission-based precautions can either be airborne precautions, droplet precautions, or contract precautions (2008, p. 11). The strategies are utilised in the health institution of practice. However, as Fraise and Bradley state, contact precautions are necessary for patients with an established MRSA infection or colonisation (2009, p. 12). This suggestion should however be regarded as inaccurate, as the transmission of the bacteria is shown to be via many routes. Therefore, contact prevention is not enough for prevention. The findings by Baldwin et al are more accurate since they suggest the use of multiple transmission-based interventions for the prevention of MRSA infection (2010, p. 24). In the institution of contact precautions, the hospital is required to place the patient in a single room with the caregivers being required to gown and glove before any interaction with the patient or contaminated materials from the patient and his or her vicinity (Gould, & Brooker, 2008, p. 17). However, the institution has few of these rooms. At times, the best that can be done is to keep the patient in a room of two contrary to the rules.

Existing practices with their strengths and weaknesses

Many practices and measures have been put in place to counter the spread of infection caused by MRSA. These measures have stemmed from the extensive research that has been conducted on the topic with the various researchers having their own suggestions and findings. The practices are unique to the institutions in different parts of the world with some having universal application. Some of these have been documented to be effective in the prevention of infection with others showing no benefit to the same. It is therefore important to consider some of these practices with a critical evaluation of the effects that each has had on the spread of the MRSA infection.

Baldwin et al. (2010, p. 24) performed a study on the spread of MRSA in clinical settings with recommendations on measures to be implemented to curtail the same. Among the infection control measures that they researched was the use of hand and environmental hygiene (Baldwin et al. 2010, p. 24). Another method of prevention was the use of personal protective equipment. The group performed a randomised control trial on the efficacy of these measures in the prevention of the infection (Baldwin et al. 2010, p. 24). The prevalence of the MRSA associated infections and the bacteria were found to be reduced in the population where the measures were applied within a period of one year (Baldwin et al. 2010, p. 24). The study demonstrated that the use of hand washing is effective. However, the technique used for the same was not effectively demonstrated. The sample size used for the study was also not sufficient to generalise the results. Moreover, the sensitivity of the tests used to evaluate the microorganisms was not given. Therefore, the validity of the conclusions made is wanting.

Bassetti et al. (2009, p. 234) also conducted a study in Italy on the prevalence of MRSA in one of the health institutions. Their study focused on the use of medication to reduce the prevalence of MRSA. With the reduction in the use of cephalosporins and increase in the use of ciprofloxacin, the researchers observed a reduction in the MRSA (Bassetti et al. 2009, p. 234). They proved that one can use medication to eliminate MRSA in health institutions. However, one of the weaknesses in this interventional measure is the cost of the medication. The cost was not factored in during the research, and that health institutions may find it hard to treat the infection. Burkitt et al. (2010, p. 230) also conducted a similar study in the United States where patient screening and isolation were investigated as prevention methods in addition to the use of hand and personal hygiene. A limitation to hand hygiene is the use of alcohol-based hand sanitizers in the place of soap and water. Another limitation is that most of the people using the hand hygiene method of preventing the spread of infection were not consistent as reported by Burkitt et al. (2010, p. 332). They only washed at certain times. Some of the respondents also complained that the use of hand hygiene was associated with the bruising of the hands and damage to the skin by the soap they were using, which in turn deterred them from using the hand hygiene method.

Carboneau et al. performed a similar study on the prevention of MRSA infection with the inclusion of the utilisation of changes in physical structure, facilities, and equipment in addition to hand hygiene (2010, p. 234). The research reported a decrease in the cases of MRSA that were reported months after the interventions thus supporting both the use of hand hygiene and general hygiene measures (Carboneau et al. 2010, p. 234). However, the research does not document the prevalence of the MRSA in the community in which it was carried out. In addition, it postulates constant factors in the spread of the microorganisms. It also did not incorporate all the other methods of prevention of infection. An assumption was that there were no changes in these methods. An adjustment to the same research was made and carried out by Cheng et al. when they conducted their research in a different country, China, including patient isolation as a mode of prevention of the spread of the infection (2009, p. 289). Some of the other researchers on the use of hand hygiene in the prevention of MRSA spread over the past decade found the act of hand hygiene and use of patient isolation to be effective (Davis 2010: Fowler, et al. 2010: Gagné et al. 2010: Goodman et al. 2008).

Holder and Zellinger suggested an ambitious method of preventing the spread of MRSA by the use of chlorhexidine baths (2009, p. 512). This method is however expensive. Holder and Zellinger say, “The cost of the chlorhexidine cloths is greater than for the non-chlorhexidine” (p. 512). Therefore, it would prove to be less sustainable in most of the health institutions. The concentrations that are required for the effectiveness of the chemical were not defined. It is therefore erroneous to claim that all surfaces are infected with the bacteria before an effective method of determining this infection is developed. Patient isolation is also a measure that is suggested to be effective in the prevention of the spread of MRSA-related infection. Several researches have demonstrated its efficacy (Kho et al. 2008, Kurup et al. 2010). Some of the limitations of this method include the unavailability of space in most of the health facilities for the isolation of such patients with the isolation spaces being preserved for conditions perceived to be more life threatening.

Some other methods of infection prevention against the spread of MRSA have also been suggested. However, they have their weaknesses. One of these methods is the use of patient screening. O’Brien et al conducted a study on the effectiveness of the same on infection prevention (2008, p. 2456). The results of their study showed a reduction in the infection. They observed an “Overall decrease in the rate of MRSA acquisition in the pre-IT period compared with the post-IT period” (O’Brien et al. 2008, p. 2456) that was statistically significant to their research. The major weakness of the use of this method in the prevention of MRSA infection is that patient screening is expensive and that the tests used are not absolutely sensitive and specific. The method cannot therefore be used as the basic measure to prevent the infection. Therefore, it does not solve the problem.

Audits in Infection Prevention and Control

Infections associated with MRSA have a multifactorial origin. Prevention may be undertaken through the application of the strategies and measures highlighted above. Various policies, guidelines, and procedures for carrying out infection prevention and control exist. The existing practices are gauged and compared against these guidelines. Auditing allows the establishment of whether the healthcare workers or the infection prevention teams are compliant with the methods of prevention of infections (Gould, & Brooker, 2008, p. 11). In most of the instances, the results of the audit are used to improve the methods of prevention of the spread of MRSA. A health institution can carry out internal audits where the results are compared against the objectives set within the facility and against the external guidelines and standards.

An audit is usually carried out in the areas that are perceived to be important to the success of the preventive measures. According to Gould and Brooker, “An effective audit should include a description of the physical layout, review of traffic flow, protocols and policies, supplies and equipment, and observation of appropriate IPC practice” (2008, p. 11). An effective audit should be able to assess the knowledge of the team involved in the infection control. A report should be prepared with recommendations on the areas to be improved. However, in most of the health institutions with prevention strategies in place for MRSA, there exists no definitive audit process and or procedures in place. Most of the recommendations are not acted upon. The cost of carrying out an audit on the preventive measures is also reported to be high (Fraise, & Bradley, 2009, p. 28). Institutions are not willing to commit their resources towards the objective. In auditing the effects of infection prevention and control strategies, it is important to monitor the behavioural changes that are because of the measures. Some of them include hand washing. When this monitoring is done, auditors must then make recommendations based on the capabilities of the institution to make the recommended changes. For any intervention to be successful, it must be easy to implement, effective, and affordable for the institutions.

Effectiveness and respect for cultural values

Various authors and researchers have described the effectiveness of the measures described above with each stating his or her observations and inferences. In the isolation of patients, one of the drawbacks to the use of this method for infection prevention is that the healthcare givers often spend a little time in the isolation room examining the patient. As Fowler, et al report, “isolated patients are less likely to have their vital signs recorded, have fewer physician progress notes, are more likely to complain about their care, and are more likely to experience an adverse event” (2010, p. 233). This case is a challenge to the use of isolation as a means of preventing the spread of MRSA. It may be prevented trough educating the health care providers and promoting the use of hand hygiene.

The use of personal protective equipment is reported to be effective against the spread of MRSA. Gowning and mask protection are among the preferred methods. However, the compliance to the use of these items in the prevention of MRSA spread is inhibited by the amount of investing in the item that is required against the outcome. Some studies describing the effectiveness of these methods have found an overall reduction in the infection spread by about 17% (Fraise, & Bradley, 2009, p. 29). However, the studies do not take into consideration the methods of using the personal protective items, which may be significant contributing factors. Hand and environmental hygiene are reported to be the most effective in the prevention of the spread of MRSA infection with some studies quoting a significant reduction on the same (Fowler et al. 2010). Health workers especially nursing staff people are therefore encouraged to use hand hygiene whenever they encounter patients or their environs. Cleaning of patient environments should be carried out regularly.

Recommendations to improve practice

From the review of methods of infection, prevention and control applied for the case of MRSA, several recommendations are evident. The institutions wishing to control the microorganisms need to support the initiative by having administrative support directed towards the prevention of the spread. This strategy should then be focused on educating the staff and patients besides collaborating with bodies with the same intentions and provision of adequate funding. The institutions also need to develop policies directed towards the prevention of the spread of infection and or invest in education. The institutions should then encourage the use of personal protective items when handling patients. They should promote hand hygiene and provide the necessary equipment for this task. Some of the other measures that can be implemented include screening of patients and proper environmental hygiene.

Conclusion

In conclusion, Methicillin Resistant Staphylococcus Aureous (MRSA) continues to pose a challenge to the delivery of health services. Several methods of preventing the spread of the microorganism have been described with the efficacy of these methods being analysed by various authors and researchers. Health care workers should ensure that they put the right measures in place to prevent the spread of the microorganism, as the management of infections caused by it is costly to the health sector.

References

Baldwin, S, Gilpin, F, Tunney, M, Kearney, P, Crymble, L, Cardwell, C, & Hughes, M 2010, ‘Cluster randomised controlled trial of an infection controleducation and training intervention programme focusing on meticillin-resistant Staphylococcus aureus in nursing homes for older people’, Journal of Hospital Infection, vol. 76 no. 1, pp. 36-41.

Bassetti, M, Righi, E, Ansaldi, F, Molinari, P, Rebesco, B, McDermott, L, Fasce, R, Mussap, M, Icardi, G, Pallavicini, B, & Viscoli, C 2009, ‘Impact of limited cephalosporin use on prevalence of methicillin-resistant Staphylococcus aureus inthe intensive care unit’, Journal of Chemotherapy, vol. 21 no. 6, pp. 633-638.

Boyce, M, Havill, L, Dumigan, G, Golebiewske, M, Balogun, O, Risvani, R 2009, ‘Monitoring the effectiveness of hospital cleaning practices by use of an adenoisetriphosphate bioluminescence assay’, Infection Control and Hospital Epidemiology, vol. 30 no. 7, pp. 678-684.

Burkitt, H, Sinkowitz-Cochran, L, Obrosky, S, Cuerdon, T, Miller, J, Jain, R, Jernigan, A, & Fine, J 2010, ‘Survey of employee knowledge and attitudesbefore and after a multicenter Veterans’ Administration quality improvement initiative to reduce nosocomial methicillin-resistant Staphylococcus aureus infections’, American Journal of Infection Control, vol. 38 no. 4, pp. 274-282.

Carboneau, C, Benge, E, Jaco, T, & Robinson, M 2010, ‘A lean Six Sigma team increases hand hygiene compliance and reduces hospital-acquired MRSA infections by 51%’, Journal for healthcare quality: official publication of the National Association for Healthcare Quality, vol. 32 no. 4, pp. 61-70.

Cheng, C, Tai, M, Chan, M, Lau, Y, Chan, W, To, W, Li, S, Ho, L, & Yuen, Y 2009, ‘Sequential introduction of single room isolation and hand hygiene campaign in the control of methicillin-resistant Staphylococcus aureus in intensive care unit’, BMC Infectious Diseases, vol. 10 no. 1, p. 263.

Davis, R 2010, ‘Infection-free surgery: How to improve hand-hygiene compliance and eradicate methicillin-resistant Staphylococcus aureus from surgical wards’, Annals of the Royal College of Surgeons of England, vol. 92 no. 4, pp. 316-319.

Fowler, S, Webber, A, Cooper, S, Phimister, A, Price, K, Carter, Y, Kibbler, C, Simpson, H, & Stone, P 2010, ‘Successful use of feedback to improve antibiotic prescribing and reduce Clostridium difficile infection: a controlled interrupted time series’, Journal of Antimicrobial Chemotherapy, vol. 59 vol. 5, pp. 990-995.

Fraise, P & Bradley, C 2009, Ayliffe’s Control of healthcare-associated infection: Hodder Arnold, London.

Gagné, D, Bédard, G, & Maziade, J 2010, ‘Systematic patients’ hand disinfection: impact on meticillin-resistant Staphylococcus aureus infection rates in a community hospital’, Journal of Hospital Infection, vol. 75 no. 4, pp. 269-272.

Goodman, R, Platt, R, Bass, R, Onderdonk, B, Yokoe, S, & Huang, S 2008, ‘Impact of an environmental cleaning intervention on the presence of methicill in resistant Staphylococcus aureus and vancomycin-resistant enterococci on surfaces in intensive care unit rooms’, Infection Control and Hospital Epidemiology, vol. 29 no. 7, pp. 593-599.

Gould, D, & Brooker, C 2008, Infection Prevention and Control: Applied Microbiology for Healthcare, Palgrave Macmillan: UK.

Holder, C & Zellinger, M 2009, ‘Daily bathing with chlorhexidine in the ICU to prevent central line-associated bloodstream infections’, Journal of Clinical Outcomes Management, vol. 16 no. 11, pp. 509-513.

Kho, N, Dexter, R, Warvel, S, Belsito, W, Commiskey, M, Wilson, J, Hui, L, & McDonald, J 2008, ‘An effective computerised reminder for contact isolation of patients colonised or infected with resistant organisms’, International Journal of Medical Informatics, vol. 77 no. 3, pp. 194-198.

Kurup, A, Chlebicka, N, Tan, Y, Chen, X, Oon, L, Ling, A, Ling, L, & Hong, G 2010, ‘Active surveillance testing and decontamination strategies in intensive care units to reduce methicillin-resistant Staphylococcus aureus infections’, American Journal of Infection Control, vol. 38 no. 5, pp. 361-367.

O’Brien, M, Greenhouse, K, Schafer, J, Wheeler, A, Titus, A, Pontzer, E, O’Neill, M, & Wolf, D 2008, ‘Implementing and improving the efficiency of amethicillin-resistant Staphylococcus aureus active surveillance program using information technology’, American Journal of Infection Control, vol. 36 no. 3, p. 2456.

Verhoeven, F, Steehouder, F, Hendrix, G, & van Gemert-Pijnen, C 2009, ‘Factors affecting health care workers’ adoption of a website with infection control guidelines’, International Journal of Medical Informatics, vol. 78 no. 10, pp. 663-678.

Conjunctivitis is the inflammation of the conjunctiva. The aetiology of conjunctivitis may be a consequence of virus, bacteria, toxic agents, allergens and chemicals (Parcell et al. 2013). Viral conjunctivitis is the emerging form of conjunctivitis and refers to all conjunctiva inflammation processes that result from viral infections (Allergic Conjunctivitis 2010). Some viruses responsible for viral conjunctivitis include adenovirus, HIV, and poxvirus (Silverman 2014).

Adenoviruses are the most common cause of viral conjunctivitis and fall under the family of Adenoviridae (Scott 2014). Biological, social, economic and ecological factors have been instrumental in the reappearance of conjunctivitis (Scott 2014). The need for economic growth requires industrialisation, which significantly affects atmospheric conditions and increases conjunctivitis causing allergens (Kimura et al. 2009). Also, social factors, such as population density have attributed to recent increase in frequency of epidemics associated with conjunctivitis.

Transmission of conjunctivitis is by direct contact, faecal-to-oral transmission, waterborne, or air droplets. The pathological DNA is copied and reproduces within the host cell’s nucleus (Visscher, Hutnik & Thomas 2009). The pathological mRNA is processed in the nucleus and is converted in the cytoplasm. Converted proteins travel back to the nucleus, where new virions converge and subsequently disperse (Visscher, Hutnik & Thomas 2009).

Virus communication with the host cell may be hindered at various steps, which causes an abortive or incomplete sequence (Chennai’s medical history unveiled 2011). This involves the host’s inherent and adaptive immune system. In youths and adults, a higher prevalence of circulating counteracting antibodies supports extensive defence against adenovirus pathogens. Antibodies deactivate viruses by preventing interactions between the viruses and the host cell (Chennai’s medical history unveiled 2011). Antibodies also recognise viral antigens cells that have already been infected by the virus which may result in (ADCCs) or balance-arbitrated lysis (Parcell et al. 2013). The most significant antibody that is released upon when pathogens infect the conjunctiva is the IgA.

Individuals with conjunctivitis may present with a history of current exposure to a person with red eye at school, work, home, or other public places, or they can present with a history of current indications of an upper respiratory tract disease (Azari & Barney 2013). This eye infection is either bilateral or unilateral. Various organisms offer diverse symptoms thus numerous symptoms are possible. Some of the symptoms include external body sensation, ocular irritation, redness of the eyes, tearing, photophobia, and discharge. Other symptoms include malaise, nausea, fever, vesicular eruption, and in extreme cases acute haemorrhage (Silverman 2014).

Diagnosis is done through observation of clinical features. Conjunctivitis is a self-limiting disease and usually requires no medications. International agencies, such as The World Health Organisation (WHO) and the Centre for Disease Control (CDC) make efforts to manage infectious disease outbreaks (World Health Organisation 2014). The CDC and WHO in conjunction with immunisation programs in different countries and states, organise health education programs and immunisation programs against causative organisms at birth and other stages of life (Conjunctivitis (Pink Eye): prevention 2014).

References

Allergic Conjunctivitis 2010. Web.

Azari, A & Barney, P 2013, ‘Conjunctivitis: a systematic review of diagnosis and treatment’, Journal of the American Medical Association, vol. 310, pp. 1721–1729.

Chennai’s medical history unveiled 2011. Web.

Conjunctivitis (Pink Eye): prevention 2014. Web.

Kimura, R, Migita, H, Kadonosono, K, & Uchio, E. 2009, ‘Is it possible to detect the presence of adenovirus in conjunctiva before the onset of conjunctivitis?’, Acta Ophthalmol, vol. 87, pp. 44-47.

Parcell, J, Sharpe, G, Jones, B & Alexander, L. 2013, Conjunctivitis induced by a red bodied mite. Web.

Scott, U 2014, Viral Conjunctivitis. Web.

Silverman, A 2014, Acute Conjunctivitis. Web.

Visscher, L, Hutnik, M, & Thomas, M. 2009, ‘Evidence-based treatment of acute infective conjunctivitis: Breaking the cycle of antibiotic prescribing’, Canadian family physician, vol. 55, pp. 1071–1075.

World Health Organisation 2014, Emerging diseases. Web.

Importance Reporting the History of Dementia

Many patients residing in hospitals after being diagnosed with dementia are, usually, very vulnerable to other infections such as pneumonia and UTI. These illnesses take advantage of the weak immunity in the bodies of the patients since most of them are 81 years and above (Fortinash & Holoday-Worret, 2012). These illnesses are preventable and curable. In the case of this patient, reporting the history of the presence or absence of dementia helps the hospitalist establish the exact cause of pneumonia and UTI. This knowledge helps in eliminating these problems.

Implications of UTI Acquired in a Nursing Facility

UTI acquired in nursing facilities develops as a result of using contaminated catheters in the urethra. The micro-organisms on the catheters attack the urethra and infect it with UTI. Patients who suffer from this infection experience many problems. Such problems include urethral inflammations and fatal kidney problems (Fortinash & Holoday-Worret, 2012). In many cases, patients experience burning sensations when passing urine. Sometimes, the urine comes out as a cloudy and smelly fluid. Elderly men, usually, experience confusion and continence (Fortinash & Holoday-Worret, 2012).

Considerations during the Treatment of UTI

Medical experts need to be very careful during the treatment of hospital-acquired UTIs to prevent them from causing more problems or spreading to other patients (Hillard & Zitek, 2004). They should take the following precautions:

• They must sterilize all the instruments they use in treating UTI
• Doctors should treat UTIs while in their early stages of development to prevent them from developing into more serious problems
• Medical experts should be very keen when carrying out a diagnosis. Keenness helps determine the real cause of many illnesses. Hence, it reduces the chances of recurrence (Hillard & Zitek, 2004).

Necessary Measures

The nurse should look for other drugs that reduce the effects of haloperidol. Such drugs include carbamazepine, phenytoin, phenobarbital, and rifampin (Sikich, Hamer, Bashford, Sheitman & Lieberman, 2004). The nurse should then advise the patient to taper down the drug in small amounts since a sudden withdrawal may cause more serious implications for the patient. The patient should continue reducing the dosage until the prescriber advises her to withdraw completely (Hillard & Zitek, 2004).

Other Important Assessment Data

The nurse should look for more symptoms. Some of the commonest symptoms of the side effects of Haldol include:

• Irregular or fast heartbeats
• Stiffness in the throat and neck
• Blurred vision
• Loss of interest in sex
• Stiffness of the body muscles
• Prolonged erection
• Stomach problems
• Insomnia
• Uncontrolled body movements
• Prolonged headaches
• Difficulty in passing urine
• Skin rash
• A protruding tongue (Hillard & Zitek, 2004)

After the withdrawal, the patient may respond negatively if the withdrawal process did not follow the right procedure (Fortinash & Holoday-Worret, 2012). Therefore, the nurse should look for the following indications of a withdrawal syndrome after withdrawing the patient from the medication:

• Tremors in the body muscles and uncoordinated body movements
• Hallucinations
• Fresh psychotic problems
• Confusion.

References

Fortinash, K., & Holoday-Worret, P. (2012). Psychiatric mental health nursing. St. Louis, MO: Elsevier Mosby.

Hillard, J., & Zitek, B. (2004). Emergency psychiatry. New York: McGraw-Hill, Medical Professions Division.

Sikich, L., Hamer, R., Bashford, R., Sheitman, B., & Lieberman, J. (2004). A pilot study of risperidone, olanzapine, and haloperidol in psychotic youth: a double-blind, randomized, 8-week trial. Neuropsychopharmacology: Official Publication of The American College of Neuropsychopharmacology, 29(1), 133-145.

Need for a guideline and benefits

This guideline provides recommendations to reduce inappropriate prophylactic antibiotic prescription in pre and post-surgery and consequently reduce surgical site infection (SSI). There is an ever-increasing need to use antibiotics intelligently, especially due to the prevalence of more resistant organisms. It further addresses risk factors for surgical site infection, benefits, and risks of antibiotic prophylaxis, indicators for surgical antibiotic prophylaxis and finally recommend a suitable administration of intravenous prophylactic antibodies. As such, this guideline gives some procedures used in surgical prophylaxis to prevent SSI by using antibiotics.

Risk factor for surgical site infection

Microorganisms cause surgical site infections (SSIs). Some of the most common germs include staphylococcus, Streptococcus, and Pseudomonas. These pathogens spread through contact with caregivers, contaminated surgical instruments, through airborne microorganisms, or sometimes organisms already in the patient’s body spreading to the surgical wound.

SSI risk factors can be broadly classified into, host characteristics, operation environmental factors and microbial factors. For patients’ state, factors that increase peril include poor nutritional state, obesity, extreme age, smoking, existing infections, diabetes, bacterial colonization, and the use of immunosuppressive drugs. On the other hand, operation factors include insufficient preoperative skin preparation, inadequate instrument sterilization, the presence of foreign material in surgical sites, poor surgical technique, prolonged operation, antimicrobial prophylaxis, and postoperative hypothermia among others (Johns Hopkins Medicine 1). Microbial factors include virulence, contaminated inoculum, and nasal or skin carriage. In this guideline, the American Society of Anesthesiologists (ASA) comorbidities score is used. The higher the score level the higher the risk.

Surveillance and prediction of SSI factors play a crucial role in managing SSI. As such, stakeholders in surgery and SSI management have suggested and used varied risk indicators to improve surveillance accuracy. This guideline uses NNIS, which is based on stratification of SSI risks.

The NNIS risk index starts from 0-3 (based on the American Society of Anesthesiologists) and the risk increases with increasing risk score. Using the risk index, surgeons comprehend how comorbidity, wound class and operation time contribute to the risk defined by types of operative wound. Further, this guideline identifies the operations for which routine prophylaxis is evidence supported (Musmar, Baba and Owais).

Nonetheless, the surgeon assessment of risks and benefits will primarily inform their decision. As such, a surgeon can administer prophylaxis to patients contrary to the provision given by a clinical guideline. However, the surgeon must first be convinced that the SSI risk is prevalent. Additionally, the guideline recommends that the surgeons record their justifications and criteria used for risk assessment.

Benefits and risk of antibiotics

The severity of post elective surgery SSI consequences states the value of surgical antibiotic prophylaxis. For instance, properly administered prophylaxis drastically reduces long-term postoperative morbidity in patients with anastomosis of the colon or total hip replacement surgery. Nonetheless, prophylaxis only decreases short-term morbidity in most surgical operations.

Further, prophylaxis has the potential to shorten hospital stay. Although the length of hospital stay depends on the type of surgery, SSI increases it. Therefore, to prevent SSI and consequently, reduce the hospital stay, the use of antibiotic is necessary. Additionally, antibiotic prophylaxis has been linked to faster returns to normal work after discharge from hospitals. Finally, the use of antibiotics reduces post-surgical costs by reducing the care intensity (Pear 56-64).

However, misuse of antibiotics has adverse effects on surgical patients. First, optimal management may be compromised if surgical patients are wrongfully attributed to a penicillin allergy. Penicillin is among the most commonly used antibiotic prophylaxis. Therefore, its allergic manifestation plays a key role in antibiotic prophylaxis. As such, a patient’s history, especially their reaction penicillin antibiotic, is integral to allergy evaluation.

Second, a couple of antibiotics are associated with diarrhea. Nevertheless, ways of reducing the incidence of antibiotic-associated diarrhea (AAD) remain difficult in many research cases. In children, a single randomized controlled trial has linked the yeast Saccharomyces boulardi to 23% to 8% relative to placebo. However, S. boulardi treatment may increase fungaemia risk especially in patients with compromised immunity. Therefore, thorough research should be considered before administering S. boulardi. In adults, the use of active Lactobacillus, particularly from yoghurt has posted positive results (Scottish Intercollegiate Guidelines Network).

Third, there are general surges of antibiotic resistance in hospitals. Studies have shown that the more patients use antibiotics, the higher the chances of developing resistance. For instance, uncontrolled studies revealed that subsequent antibiotic treatment is faced with high risks of resistance. Exposure to a single dose of antibiotics such as ciprofloxacin is linked to a substantial increase in resistance in the subsequent treatments.

Fourth, administering antibiotics to surgical patients exposes them to risks of Clostridium difficile infections (CDI). The risk is amplified if patients are in with diarrhea and multiple risk factors. It is therefore imperative to note that CDI has been linked to a considerable number of deaths.

Administration of Surgical Antibiotic Prophylaxis

While a wide range of microorganisms may be responsible for surgical site infection, SSI normally results from a significantly small number of microorganisms. Nevertheless, the choice of antibiotic is imperative in preventing SSI (Scottish Intercollegiate Guidelines Network 24).

Choice of Surgical Antibiotic

• Antibiotic preferred should be effective against pathogens mostly related with wound infections after a given surgical procedure and against pathogens found in the part of the body for operation
• The choice of a suitable antibiotic for a given patient should consider comparative efficacy as well as potential adverse effects and allergies
• For a number of surgical procedures, both cefoxitin 2 g and cefazolin 1 g tend to be the most preferred antibiotic agents due to their long-lasting effects, effectiveness on pathogens common in operating environments, and their affordability
• It is recommended that patients allergic to penicillin should receive vancomycin or clindamycin
  • Patients not at risk for infection should receive clindamycin because of resistant-gram pathogens inferior to its more focused spectrum and generally fast infusion period
  • Vancomycin is not recommended for routine usages
  • Changes of surgical antibiotic prophylaxis regimen could be essential specifically in patients with pre-existing infections before surgery, fundamental length of hospital stay before surgery and past positive colonization
  • For patients already on drugs before the surgery, it is normally not necessary to provide other drugs for surgical prophylaxis, particularly if the administered antibiotic is considered effective, appropriate for the type of surgery intended and the timing is optimized compared to surgical time
  • It is necessary to consider the maximum doses for each patient, for instance, 2 g of cefazolin is recommended for patients weighing more than 80 kg

Dosage Selection

It is usually recognized as best practice that the needed dosage of antibiotic for prophylaxis is similar to that used for infection therapy. Only a single dose is considered adequate under most conditions.

Timing

• Surgical antibiotic infusion for surgical prophylaxis should be introduced within one hour before the surgical procedure (cases of cesarean procedures and oral administration are however exempted)
• For vancomycin, administration may start within two hours before the surgery because of extended periods of infusion and to ensure enough tissue levels at the period of the procedure
• All antibiotics for administration should be finished before the surgery because some studies have established that provision ‘as near to the period of surgery as possible may not be the best approach. It is therefore recommended that antibiotic should be administered between 15 minutes to one hour (Scottish Intercollegiate Guidelines Network).

Dosing and Timing of Antibiotic Prophylaxis.

Duration

• The precise optimal time of perioperative prophylaxis has not been determined. In addition, it is improbable that patients would get further health benefits through more doses once the wound has healed and post-operative antibiotic prophylaxis is not required.
• One prophylaxis dose with or without other intraoperative doses in extended surgical procedures is preferred. When prophylaxis is administered beyond the period of the procedure, then the use of antibiotics should cease within 24 hours unless clear indications are provided (NewYork-Presbyterian Hospital 1-8).
• More intraoperative doses may be necessary in extended surgical procedures at a given interval, preferably twice the half-life of the antibiotic. That is, redosing should occur one interval less than the usual practice.
• More intraoperative doses may not be necessary for surgical patients with prolonged cases of half-life of the drug, specifical patients with renal issues.
• It is not recommended to continue with the antibiotic prophylaxis until the removal of all drains and catheters.

Multiresistance Carriage (MRSA)

MRSA carriage could be a critical risk factor for surgical site infection. SSI is generally responsible for adverse health outcomes, specifically for patients undergoing high-risk surgeries. Hence, patients recognized to have MRSA should also have an intervention therapy before the high-risk procedure (Rochester General Health System 1-4).

Guidelines.

Surgical Antibiotic Prophylaxis Recommendations

The recommendations for these drugs are based on evidence obtained from clinical experiments on effectiveness of antibiotic prophylaxis in controlling cases of surgical site infection (Scottish Intercollegiate Guidelines Network 28).

It is recommended that antibiotic prophylaxis should only be administered when clear evidence of benefits have been established. Conversely, they should never be considered when efficacy outcomes are not known. It is imperative to recognize that there is a paucity of evidence demonstrating the efficacy of antibiotic prophylaxis in children (from birth to 16 years old) (Scottish Intercollegiate Guidelines Network 29). Hence, general principles noted in antibiotic prophylaxis for adults have been applied to guide applications of drugs in children. On this note, recommendations have been provided for surgical antibiotic prophylaxis.

• Antibiotic prophylaxis is effective in reducing cases morbidity, cost of hospitalization and is most likely to lessen the use of antibiotics
• It is recommended that antibiotic prophylaxis should be used for all patients. Nevertheless, there are exceptions, particularly when the use of prophylaxis would increase costs of hospitalization and dependence on antibiotics. Specific reasons for restriction of prophylaxis to certain ‘high risk’ patients should be provided alongside justification. In addition, it is important to maintain continuous documentation of the infection rates to determine variations between patients who receive antibiotic prophylaxis and others who do not. These strategies are useful to determine clinical effectiveness of surgical antibiotic prophylaxis particularly when no evidence is available (Scottish Intercollegiate Guidelines Network 31). Trials may have not been performed or outcomes have been obtained from a rather small negligible sample.
• It is not recommended to use surgical antibiotic prophylaxis when it has not been clinically proven effective, as well as when outcomes of infections are not deemed severe. This would reduce the use of antibiotic for minimal expected benefits.

Administration of antibiotic prophylaxis, notably administered by the parenteral intravenous route has traditionally proven reliable and efficient prophylaxis used to control surgical site infection in every type of surgery. It is important to administer surgical antibiotic prophylaxis intravenously. However, there are cases of oral administration. The rate of absorption may be used to determine the concentration of tissue and serum during oral administration. It is however important to note that little evidence is available to support the use of oral administration of antibiotic prophylaxis. In addition, it is difficult to determine the best time for administration because of the prevailing theater conditions.

It is not recommended to administer fluoroquinolones and cephalosporins because of potential to contribution to antibiotic resistance. Thus, patients identified as carrying MRSA should not receive these antibiotics because they may result in overgrowth of MRSA and increased rates of subsequent infections (Scottish Intercollegiate Guidelines Network 34). Minimal prophylactic antibiotic may be administered to control symptomatic risks of infections low.

Topical administration is used in high-risk surgeries particularly with gentamicin containing collagen fleeces after abdominal operations on rectal cancer to reduce possible wound infection after the procedure.

In some instances, for example, the administration of intranasal mupirocin to avert surgical site infections, are not consistent because of limited sample size, variations in clinical study designs, and different surgical groups. Such antibiotics may only be suitable for non-general surgical procedures such as orthopedic or cardiothoracic operations (Scottish Intercollegiate Guidelines Network 34).

Provision of Information and Support

It is generally important to provide information and support to patients, caregivers, families and the public on surgical antibiotic prophylaxis. This would ensure that they comprehend various approaches adopted to control infections or any other emerging issues. In addition, they would be more informed and take part in SSI control.

Works Cited

Johns Hopkins Medicine. Surgical Site Infections. n.d. Web.

Musmar, Samar MJ, Hiba Baba and Ala Owais. “Adherence to guidelines of antibiotic prophylactic use in surgery: a prospective cohort study in North West Bank, Palestine.” BMC Surgery 14 (2014): 69. Print.

NewYork-Presbyterian Hospital. Surgical Prophylaxis: Antibiotic Recommendations for Adult Patients. 2011. Web.

Pear, Suzanne M. Patient Risk Factors and Best Practice for Surgical Site Infection Prevention. 2007. Web.

Rochester General Health System. Surgical Prophylaxis Antibiotic Guidelines. 2012. Web.

Scottish Intercollegiate Guidelines Network. Antibiotic prophylaxis in surgery: A national clinical guideline. 2014. Web.

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.