Catheter associated urinary tract infections: research proposal and clinical outcomes

Research Proposal for Catheter Associated Urinary Tract Infections

Catheter Associated Urinary Tract Infections (CAUTI) affects timely reimbursement and prolongs patient stays in the healthcare facility. Many hospitals strive for ways to reduce CAUTIs and take specific medical measures to aid patients in recovery from the same and avoid recurrence of the cases of CAUTIs. These deliberate measures ensure so they can have better patient outcomes and improve patient care. This also improves the reimbursement received from insurance providers.

Research question

The research seeks to investigate the effect of frequent CAUTI education, among the in-hospital patients with indwelling urinary catheter, conducted over six months.

Background and Significance of the Problem

It is common medical knowledge that urinary catheters have the potential to cause urinary tract infections, known as catheter-associated urinary tract infections (CAUTIs). Indwelling catheters are a part of many plans of care, specifically for emergent and critical care patients within the hospital setting. According to the CDC, more than 12% of acute care infections are caused by CAUTI. They further report that 12%–16% of acute care patients require indwelling catheter during their hospital stay (Shaver et al., 2018).

Statement of the Problem and Purpose of the Study

The purpose of this study is to investigate the effect of frequent CAUTI education, among the in-hospital patients with indwelling urinary catheter, conducted over six months. Bearing that, as CDC postulates, there are as many as 16% of acute care patients that require indwelling catheters, there is urgent need in the medical practice to ensure that the indwelling catheters are beneficial to the patients and not causing more harm or infections. The 12% infection rate caused by the indwelling catheters is too high hence the urgent need for multifaceted approach in curbing the infections.

This proposed research is grounded on the premises that the prevention of CAUTI is not absolutely upon the medics within the hospital but greatly lies on the reliability of the in-hospital patients to take care of themselves and implement the medical directions given to them by the nurses, hence the CAUTI education for such patients. Once the intervention as will be explained herein is implemented, the UTI cases and their severity among the research participants will be observed and the new data compared to the pretest outcomes in order to see if there is significant difference after the intervention and also to seek if the difference can be directly associated to the education among the intervention patients.

Education is an effective way to address gaps in knowledge; nurse educators or clinical nurse specialists are the primary educators for these innovations. Providing data to clinical staff specific to CAUTI data from their unit/facility and then educating on ways to reduce the knowledge gaps could be an effective way to reduce CAUTI in acute care patients. CAUTI reduction programs with evidence based protocol driven guidelines which are educated to the staff are also effective to help reduce CAUTI. There is also financial savings that can be considered with the reduction in CAUTI (Scanlon, 2017). The education will be nurse driven but patient focused in nature. Here, the nurse will strive to impart the requisite knowledge of what CAUTI is and the care and caution that the patient needs to take in order to avoid the infection as long asthey are still with the indwelling urinary catheter. The patient will be educated on the dry bag concept and why it is important for their health, this will be followed up frequently among the intervention patients as will be discussed herein. The patients will also be educated on the perineal care practices, the maintenance and insertion techniques so that the patients can effectively manage their indwelling catheters within or outside the hospital setting.

Literature Review

In Carr (2017), they review CAUTI prevention with a nursing intervention bundle (CAUTI bundle) that all hospitals likely adopt. The bundle would be based on standardized, evidenced based practice and allow for consistent care and maintenance of indwelling catheters.Part of this bundle would include medical record review of those who have an indwelling urinary catheter and daily assessment by nursing and the physician to determine medical necessity the catheter. For those patients with a catheter, Foley care every eight hours and as needed aseptic cleaning. Other interventions in these bundles include hand hygiene, leg strap in place for management of catheter tubing and avoiding kinks in the tubing.

Fletcher (2016), conducted qualitative semi-structured interviews and observations at four sites: 3 academic medical centers and 1 Veterans Affairs. The research focused on the importance of the CAUTI Guide to Patient Safety (GPS) in the CAUTI prevention activities among some units in different hospitals. Participants from 2 units within 4 hospitals were included in the research. The researchers collaborated with nursing staff and interviewed nurse managers with specific questions after completing the CAUTI guide to patient safety (GPS). Based on results they debriefed the nursing staff discussing CAUTI preventative initiatives. Nursing staff was agreeable that the CAUTI GPS was an effective tool. The limitations for this study were the small hospital sample size. The results of the study included steps to engage physicians and encourage sharing of data about unit-level performance trends and goals. Another finding was that the GPS may be used to foster discussion among stakeholders to encourage CAUTI identification and implementation of treatment and prevention strategies for further improvement.

Peter (2018) evaluates the effectiveness of clinical practice guidelines on maintenance of indwelling catheters among an experimental and control group using a pre and posttest using evaluative approach was measured in this study. The objective of the research was to assess the insertion practice of the indwelling urinary catheter and asses the maintenance practice of the indwelling catheter. This was a quasi experimental non- equivalent control group pre test and post test design used over a period of one year. Demographic data were collected from nurses and patients. The present study showed that clinical practice guidelines regarding CAUTI were effective in participants to improve their practice of infection control and reduce the occurrence of CAUTI in the hospitals. This research conclusions show the need to support clinical nurses and the need for nurse education to help with implementation and monitoring of infection prevention and control standards. Their demographic and quantitative data has value to look at the demographics of the types of RNs used in this study.

Safdar (2016) presents a qualitative study to assess patient perspectives of indwelling urinary catheters using a semi-structured interview. Results were that patient awareness and engagement about indwelling urinary catheters and the potential risk for CAUTI could be improved in the hospital setting. Suggestions included implementing educational programs incorporating patient preferences for both health care workers and patients. This can increase the involvement of a patient in their care and awareness about the risk of CAUTI. The study found that 75% of patients perceived that they had not received adequate education about indwelling urinary catheter consequences. All patients surveyed felt that alternative methods of excretion were not discussed, and 65% of patients felt that they had not received adequate information on the risks of CAUTI due to an indwelling urinary catheter. Limitations of this study are the small sample size, but the qualitative information provided an opportunity for improvement in discussing indwelling catheters with their patients.

Scanlon (2017) used quantitative data collection to measure the success of their healthcare systems program by measuring the standardized infection ratio, incidence, and the number of catheter days of a healthcare system. The research was also to show quality improvement focusing on developing best practices and transferring them across the healthcare organization. The benefits of this study show the decrease in catheter days and also the reduction in the number of CAUTIs. The primary goal and objective of this study was to reduce hospital ICU catheter days by 25% within 12 months and 50% within 18 months of implementation.

Shaver (2018) discusses the fact that indwelling catheters are a part of many care of plans, specifically for emergent and critical care patients. According to the CDC, more than 12% of acute care infections are caused by CAUTI. They further report that 12%–16% of acute care patients require an indwelling catheter during their hospital stay. They performed education and developed “Best Practice Champions”while using a skills checklist. These super users worked one-on-one clinical nurses to reinforce appropriate Foley catheter insertion and maintenance techniques.

Research Questions, Hypothesis, and Variables

There are several considerations for research questions in this proposal. According to Melnyk & Fineout-Overholt (2015), “Research questions are directional and bring with them a sense of expectation of what will be found in the literature” (Melnyk & Fineout-Overholt, 2015, Pp 37). Questions posed should be considered based on literature review. Review questions to be answered may include the following; what is included in the catheter bundle; what is the CAUTI GPS and does it engage physicians and nursing staff to collaborate; are nurse educators helpful with implementation and monitoring of infection prevention and control standards; are patients involved in their plan of care as it relates to indwelling urinary catheters and vigilant to reduce their on CAUTI; does education on CAUTI bundles and GPS help reduce the risk of CAUTI and show a quantitative decrease in the amount of CAUTIs prior to the implantation of increased education involvement; is the use of a best practice checklist with the use of “Best Practice Champions” beneficial and assist educators in reduction of CAUTI. All these questions can help lead to the PICOT question identified.

My hypothesis is based on the fact that any time nurse educators provide frequent rounding on any subject you would expect a quantitative change in what can be measured. Based on the research done by Scanlon (2017), nurse educators are assisting with quality improvement and would focus on assuring best practices with CAUTI prevention (Scanlon, 2017). This study assist in my hypothesis that the CAUTI rate would be reduced with frequent education and quality assurance reviewed with staff by nurse educators.

There are some variables that must be considered with this study. We must first look at the baseline infection rate currently and then compare this to results during and after the education has been provided to the staff. One example of a reduction program by Peter, Devi &Nayak, 2018, is developing a CAUTI guide to patient safety (GPS) which was developed to assess CAUTI prevention activities. Some of these are nurse driven guidelines and engaging physicians on the need to reduce foley insertions and promote early catheter removal (Peter, Devi &Nayak, 2018). One way to reduce variability is by “maintaining consistent study conditions for all participants”this can help controlpotential confounding variables” (Melnyk&Fineout-Overholt, 2015, p. 464).

Theoretical Framework

Overview and Guiding Propositions

The research theory for this study would be a quantitative research design since there will be number of patients who will be involved in the research and their results tabulated in an excel tracking sheet and the number compared to the pre-test results.

Application of Theory to Study Focus

The qualitative research approach will be the best in this particular case since the only reflection of the efficiency of the intervention will be the reduction in the numbers of in-hospital patients with CAUTI. If the numbers before the intervention are similar to those after the intervention, then the qualitative theory will render the intervention null.

Methodology

Sample/setting

There will be use of 60 participants, 30 of whom will be in the intervention wing and another 30 in the control wing. The inclusion criteria for the participants will be that they must be in-hospital patients who part of their treatment involve indwelling catheter. The participants must also be hospitalized for at least 14 days to facilitate observation on the progress and tabulation of final results. The participant must be willing out of free will to participate in the research.

Sampling strategy

The researcher will get in liaison with the nurses in charge for reference of the patients who are scheduled for the indwelling catheter or those who already have it attached. The researchers will then contact the patient for possible inclusion in the research. Upon consent the patient will be included in the research. This will go on for 60 patients from whom random sampling will be done and 30 patients allocated the control and another 30 allocated control arm. Since the research will go on for six months, a period over which some patients will have been discharged and others admitted into the hospital, the sampling and allocation of the arms will take the snowball format. It will e continuous as the patients come in. The allocation of each patient into control or intervention will take the simple toss of a coin with the head being intervention and the tail being the control. The inclusion criteria will still be taken into account.

Research design

The research will be split into two sections;

Section I

This will take the form of literature review as a preamble and then there will be intervention and control groups set up. There will be extensive literature review particularly on the number of CAUTI and related infections within the targeted hospital. These numbers will help inform the research on the trend and the ratios of the in-hospital patients who suffered CAUTI prior to the research implementation. This will be a pre-test assessment that will be very instrumental in making conclusions after the implementation of the research. The numbers will be noted and the related graphs drawn showing the CAUTI victims against the patients who went through the intensive care with indwelling catheters but did not suffer CAUTI.

Section II

This will be the section where the intervention and the control arm of the research participants will be put to use. Of greater interest herein is the intervention arm, here the 30 participants in the intervention wing will be put through a series of education on CAUTI and how to avoid infections once they have the catheter. They will be well equipped to actively participate in the sanitation and healthy handling of the catheter. The nurses will be central in giving this education. There will also be active tracking of the intervention arm participants with the aim of ensuring they implement the care that they were taught. The adherence to the care and the standards that were set for the intervention will be strictly noted and continuous education to the care of the indwelling catheter will be done.

Once the patient has been in the hospital for at least two weeks, there will be a medical review to see if the patient will have developed CAUTI or not. The research will be done over six months and the results tabulated in a designated excel sheet.
On the other hand, the control arm participants will not be denied any services that are standard care of the hospital, but will not be subjected to the rigorous education by the research team, nor will they be followed up for adherence to the standards of the intervention.

Extraneous variables

Being a medical research, there are bound to be extraneous variables that may redirect or influence the outcome of particular participants. There are possibilities of other infections intervening and setting off a series of infections not occasioned by the urinal catheter but closely associated with it. There are also bound to be infections not detected before enrolment into the research only to be more pronounced after the enrolments. There will be possibilities of patients to be moved to other health care facilities within less than two weeks after enrolment into the research with the catheter already in place.
Instruments

There will be use of questionnaires to gather information about what the patents know of CAUTI before they are enrolled into the research. There will also be the use of training material, data collection score sheets, excel software for data entry and analysis.

Data analysis

The number of infections on both arms will be tabulated in different tables and over the month the trend graphs will be developed every two weeks. This will help in showing the trajectory of the research in terms of percentage of infections in both arms hence continuous monitoring of the research questions and the hypothesis. The final data will be tabulated and the final figures put on the comparison graphs in terms of six separate months so that a trend is seen across the research period.

Ethical issues

Medical researches often present unique challenges, especially the ethical challenges. There will be caution to ensure that the research is done in line with medical ethics that puts life first. There will be full disclosure of information and consent of the patient sought before enrolling into the research. There will be adherence to the guidelines of the hospital and continuous monitoring to ensure the research does not in any way compromise the health of the participant negatively or the medication process and timing.

Limitations of the study

The research limitations goes to the extent of numbers since the indwelling urinary catheter is not a common medical intervention, getting large numbers for the research purposes will always be a challenge. The willingness of the patients to participate in the research is also an eminent limitation since most patients feel they have already enough pain and would rather not strain further in participating in a research.

Implication of the practice

Once the results are generate and conclusive figures obtained, it is possible that the outcome will help positively inform and develop the care for patients with indwelling urinary catheters through involving the patients in their own care.

References

Carr, A. N. (2017). CAUTI prevention: Streaming quality care in a Progressive Care Unit.
MEDSURG Nursing, 26(5), 306-323.

Fletcher, K. E., Tyszka, J. T., Harrod, M., Fowler, K. E., Saint, S., &Krein, S. L. (2016). Major
Article: Qualitative validation of the CAUTI Guide to patient safety assessment tool.
AJIC: American Journal of Infection Control, 441102-1109. doi:10.1016/j.ajic.2016.03.051

Melnyk, B. M., &Fineout-Overholt, E. (2015). Evidence-based practice in nursing and
healthcare: a guide to best practice. Philadelphia, [PA] : Wolters Kluwer Health, [2015].

Peter, S., Devi, E. S., &Nayak, S. G. (2018). Effectiveness of clinical practice guidelines on
prevention of catheter-associated urinary tract infections in selected hospitals. Journal Of
Krishna Institute of Medical Sciences (JKIMSU), 7(1), 55-66.

Safdar, N., Codispoti, N., Purvis, S., &Knobloch, M. J. (2016). Patient perspectives on
indwelling urinary catheter use in the hospital. American Journal of Infection
Control, 44(3), e23-e24. doi:10.1016/j.ajic.2015.10.011

Scanlon, K. A. (2017). Saving lives and reducing harm: A CAUTI reduction program. Nursing
Economic$, 35(3), 134-141

Shaver, B., Eyerly-Webb, S. A., Gibney, Z., Silverman, L., Pineda, C., & Solomon, R. J. (2018).
Trauma and intensive care nursing knowledge and attitude of Foley catheter insertion and
maintenance. Journal of Trauma Nursing, 25(1), 66-72.
doi:10.1097/JTN.000000000000034