Enhancing the quality and safety of healthcare is a priority measure for achieving the desired clinical outcomes and efficiencies. Providers should assess their care delivery systems for inefficiencies that increase the risk of healthcare-associated infections (HAIs). These unexpected but preventable adverse events are undesirable outcomes that develop in inpatient care settings and contribute to high morbidity and mortality among patients. HAIs also lengthen the duration of hospital stay and increase the overall cost of treatment. Evidence-based process-improvement initiatives can be implemented to enhance quality and safety outcomes. In this paper, a quality improvement initiative is proposed to decrease the incidence of catheter-associated urinary tract infection (CAUTI) in a hospital setting.
Problem or Issue in Practice or Organization
CAUTIs are among the most prevalent and costly but preventable HAIs. The condition accounts for 32% of all HAIs reported, and it is associated with a prolonged length of hospital stay of up to two days and high annual treatment costs of more than $450 million nationally (Centers for Disease Control and Prevention [CDC], 2020). As a result, the Centers for Medicare and Medicaid Services (CMS) considers CAUTI a quality indicator and imposes negative financial incentives on providers reporting higher rates. CAUTI is defined as a urinary tract infection developing within two days after the placement of an indwelling catheter (CDC, 2020). Among the complications linked with CAUTI are bacteremia and sepsis, which cause patient discomfort, lengthen hospital stays, and increase treatment costs. CAUTI is prevalent in inpatient units where urethral catheterization is required. Quality improvement is proposed for a 24-bed postoperative acute care setting reporting high CAUTI incidence in its intensive care unit.
Significance of Quality Improvement in Practice or Organization
The goal of this quality improvement initiative is to decrease the CAUTI risk and incidence in the facility’s intensive care unit due to inappropriate indwelling catheter use. The target facility recorded 5.6 CAUTI incidents per 1,000 catheter days in its intensive care unit (ICU) against a national benchmark of 1.07 (CDC, 2020). In an ICU setting, Foley catheter placement is indicated for surgical patients but inappropriate usage increases the risk of CAUTI (CDC, 2020). The hospital has recognized the need to reduce CAUTI rates in its ICU.
A CAUTI prevention bundle will be adopted to assess the need for catheter insertion, maintenance, and removal. According to Parker et al. (2017), although about 12% of inpatients require a Foley catheter at one point during their hospital stay, over 50% of the indications are inappropriate. The greatest risk of infection is associated with poor catheter maintenance. This quality improvement project will include an integrated maintenance bundle for preventing CAUTI in an ICU setting. It will entail five components: hand hygiene, ensuring a closed drainage system, routine aseptic perineal cleansing, unobstructed urine flow, and securing the device appropriately. The anticipated outcomes include lower CAUTI risk, reducing unnecessary antibiotic use, length of hospital stay, and costs. The need to increase federal reimbursement to this facility also underlie the quality improvement efforts. CMS no longer reimburses providers for specific infections acquired during a hospital stay, including preventable CAUTI cases (Parker et al., 2017). Thus, CAUTI prevention is needed at the facility to realize these goals.
Demonstration of Support From Previous Research
Studies have established an evidence base for appropriate catheter use to prevent CAUTI. Hand hygiene and cleaning a Foley catheter and urethral meatus under aseptic conditions (using chlorohexidine soap) have proved effective in reducing the CAUTI incidence during maintenance (Cao, Gong, Shan & Gao, 2018). The risk of complications, such as bacteremia, is decreased significantly using the aseptic technique. The findings of Cao et al.’s (2018) study also suggest that cleaning the tubing is a best practice during catheter maintenance. The device should remain sterile, sealed, and well secured at all times to avoid infection. An 83% reduction in the CAUTI rate was achieved after implementing a nurse-led protocol for Foley management and removal (Zurmehly, 2018). The bundle included custom procedures throughout the post-surgical recovery period.
Implementing a CAUTI bundle during catheter maintenance is associated with lower CAUTI incidence. Parker et al. (2017) adopted physician orders for device replacement, routine perineal cleansing, regular assessment of ongoing catheter need, and hand washing. Additionally, draining of the catheter bag at an interval of 8 hours and proper sealing of the tubes were implemented in the ICU unit. The facility was able to achieve a 38% decrease in catheter days for close to two years (Parker et al., 2017). The bundle has high efficacy in CAUTI prevention, as it includes a combined use of different interventions. The recommended guidelines for urinary catheter maintenance include ensuring a closed drainage system and unobstructed urine flow, securing the draining tube, and regular drainage bag emptying (Parker et al., 2017). Thus, using a bundle that includes multiple elements has been demonstrated to lower the CAUTI risk for recovering patients.
Steps Necessary to Implement Quality Improvement Initiative
The project will be implemented in an ICU unit to change procedures and processes to ensure favorable outcomes. The plan-do-study-act (PDSA) model will be adopted to guide the implementation of this initiative. The rationale for using PDSA is to test and improve on the change during the project. According to Hughes (2008), the plan portion of the model primarily involves identifying a specific problem that requires change and the individuals to be involved. It will entail seeking administrative approval from the unit manager, developing a two-week training for a few nurses at the ICU, and measuring outcomes (compliance with the catheter maintenance bundle).
In the next step, the target population will be trained on this protocol and engaged in best practices in preventing CAUTI in collaboration with the facility’s infection control team. The training will focus on the importance of the change process and elements of the catheter maintenance bundle, including cleansing. The reason for including an educational component is to improve the capacity and skills of staff nurses in this area. After two weeks, an audit will be done to assess compliance. In the study component of the model, the results of the review will be compared with baseline data to identify areas of improvement. Based on the outcome, the project will be rolled out in the unit to achieve a sustained decrease in CAUTI rates at the unit. An audit tool will be used to measure compliance, and the nurses will receive further training in areas of weakness that require further development.
Evaluation of Quality Improvement
Bi-weekly audits will indicate improvements in compliance with the catheter maintenance bundle from the baseline. The rate of compliance with each of the five bundle components per month will be measured and expressed as a mean value. Pairwise comparisons of monthly data will indicate if there is a significant change in percentage adherence during the project period. An increase in compliance with the bundle between any two months will be an indicator of the success of the project. A decrease in catheter utilization is an outcome metric of quality improvement that will be used to evaluate this initiative (Parker et al., 2017). It will imply that indications for the device and its prompt removal are observed as a way to avoid overutilization. Monthly data on the number of CAUTIs reported and length of stay (LOS) are other outcome metrics that will be used in this project. A decrease in CAUTI incidence and LOS over time will indicate improvement. Lastly, patient satisfaction surveys will be carried out at discharge and compared with baseline data to measure how inpatient experience improved due to this project.
Identification of Variables, Hypothesis Test, and Statistical Test
Data collected at baseline and after the project will be needed to prove the quality improvement initiative succeeded. Five variables will be measured: CAURI rates, percentage compliance with the maintenance bundle among staff nurses at the unit, Foley catheter utilization rates, length of hospital stay, and patient experience. A practice change is expected after implementing the project in the unit. A null hypothesis to be tested is that the quality improvement project will have no significant effect on CAUTI rates, compliance, catheter utilization, LOS, and patient satisfaction (p ≤ 0.05). Sample data on these variables will be analyzed to either accept or reject the hypothesis. The study will use t-tests and one-way analysis of variance for post hoc pairwise comparisons among means of outcome metrics.
Quality improvement seeks to enhance specific clinical processes or outcomes. The proposed initiative will entail implementing a urinary catheter maintenance bundle in an ICU unit using the PDSA steps. The expected outcome is reduced CAUTI risk and rate, decreased utilization rates, lower LOS, increased compliance, and higher patient satisfaction from the baseline. These variables will be measured to assess the success of the improvement efforts.
Cao, Y., Gong, Z., Shan, J., Gao, Y. (2018). Comparison of the preventive effect of urethral
cleaning versus disinfection for catheter-associated urinary tract infections in adults: A network meta-analysis. International Journal of Infectious Disease 76, 102–108.
Centers for Disease Control and Prevention. (2020). Urinary tract infection (catheter-associated urinary tract infection [CAUTI] and non-catheter-associated urinary tract infection [UTI]) events [PDF document]. Web.
Hughes, R. G. (2008). Patient safety and quality: An evidence-based handbook for nurses.
Rockville, MD: Agency for Healthcare Research and Quality. Parker, V., Giles, M., Graham, L., Suthers, M., Watts, W., O’Brien, T., & Searles, A. (2017).
Avoiding inappropriate urinary catheter use and catheter-associated urinary tract infection (CAUTI): A pre-post control intervention study. BMC Health Services Research, 17(1), 314.
Zurmehly, J. (2018). Implementing a nurse-driven protocol to reduce catheter-associated urinary tract infections in a long-term acute care hospital. The Journal of Continuing Education in Nursing, 49(8), 372-377.