Quality improvement program reducing Foley catheter days and CAUTIs

¶ … Quality Improvement Program at a Community Medical Center Designed to Reduce Foley Catheter Days and the Incidence of Catheter Associated Urinary Tract Infections (CAUTIs)

It is estimated by the United States Centers for Disease Control and Prevention (CDC) that about 2 million health care-associated infections take place every year. These infections bring about 99,000 deaths and roughly $40 billion in additional health care expenses. Shockingly, these statistics reveal that more deaths result from healthcare-associated infection (HAI) than the total combined deaths from Acquired Immuno-Disease syndrome (AIDS), breast cancer, and auto accidents. Given these facts, it is imperative to take note that majority of the HAIs are preventable.

The most common type of healthcare-associated infection is referred to as Catheter-Associated Urinary Tract Infections (CAUTI). Health problems which are associated with this HAI result in extended length of stay, patient distress (including pain and discomfort as well as emotional distress), increased health care expenses, and death. Every year, it is estimated that about 560,000 cases of CAUTI take place, resulting in increased and/or excess health care expenses as well as mortality (Anderson et al. 2007; Klevens et al. 2007). Tackling and reducing CAUTI is part of the nation's HAI initiative; the purpose is to save up to $35 billion in terms of health care expenses, comprising $10 billion set out for Medicare. In medical institutions, CAUTIs are the most prevalent kind of HAI in the United States and make up just about 35% of all such types of contaminations (Saint, 2000). According to Klevens et al. (2007), it is estimated that the United States (U.S.) incurs a cost of about $565 million for CAUTI and the resulting estimated annual death rate is 13,000 every year.

Preventing CAUTI

The systems of care, as well as those hospitals that have been most fruitful in attaining and sustaining reductions in infection rates, have generally employed a two-pronged method that makes use of the best clinical practices along with a change in culture. There are clear and comparatively straightforward scientific or practical interventions to reduce CAUTI. Nonetheless, wholly incorporating these best practices into standard procedures of operation appears to be problematic, and beset with difficulties and intricacies within the care setting. Making use of technical interventions to reduce CAUTI necessitates a concurrent and synchronized ethnic and/or adaptive method to generate a care environment that enables and boosts development (American Hospital Association, 2013).

Clinical CUSP (Comprehensive Unit-based Safety Program)

Systems of care, including hospitals, can attain pronounced change and positive impact by enhancing patient safety and quality care simply by instigating an organizational culture of safety. This organizational culture should also be entrenched in evidence-based technical interventions. A 'safety-oriented' organizational culture decreases mistakes and errors, and also improves the level of communication amid hospital personnel, workers, and patients (including their families). The Comprehensive Unit-based Safety Program (CUSP) model generates a fundamental basis or groundwork for medical doctors, nurses, other clinical care team members, and subsidiary divisions to function and operate together (AHRQ).The context for fighting CAUTI would consist of the following as a unit management viewpoint:

i. Bringing the team together

Each unit-based team focused on the improvement of safety ought to have an acknowledged team leader, members of different points-of-view, and a majority of members who offer direct care.

ii. Involving the Senior Executive

It is the role and work of the senior leader to talk about issue(s) dealing with safety that have been acknowledged by the unit teams and caregivers; this should focus on doing away with obstacles to enhancement.

iii. Comprehending the aspect of safety

The delivery of care is done through intricate systems and structures; input is required from the front-line caregivers to take into account safety flaws at the system level.

iv. Detect and learn from Shortcomings

This encompasses specific examples concerning what has happened within and around the unit that was deemed to be erroneous, or not 'best practice', and that would not be desired to occur repetitively. More so, it covers primary causes of CAUTI (and other issues) that can be taken into consideration to ensure safer care

v. Executing teamwork and tools for communication

Hands-on and everyday models for teamwork and tools for communication can be employed to take into account the issues that might hinder dangers to safety.

Aspects to consider prior to inserting the catheter

Prior to the insertion of an indwelling catheter, it is imperative to take into consideration whether these alternatives would be more suitable:

i. Bladder scanner to evaluate and provide confirmation of urinary retention prior to inserting the catheter in order to release urine (OHTAS)

ii. Bedside garments such as those of assisting continence, and provision of urinal with the purpose of managing incontinence iii. Straight catheter for one-time, irregular, or protracted emptying needs.

iv. External catheter, also referred to as condom catheter. This is suitable for obliging men devoid of any urinary retention or any form of impediment (Saint et al., 2006).

Technical Interventions for CAUTI Prevention

Evidence that is obtained clinically is employed to offer guidance for CAUTI prevention. The following are major steps which hospitals ought to concentrate on:

i. Suitable use of urinary catheter

The main components of the Appropriate Catheter Placement Intervention include:

1. The insertion of urinary catheters should only be for suitable indications. The evidence-based HICPAC/CDC Policy stipulates appropriate suggestions for urinary catheter insertion and use.

2. Take into consideration the different alternatives to in-dwelling urinary catheters; these include using bladder scanners to detect and supervise urinary retention, external catheters, and approaches to measuring output of urine that are non-invasive.

ii. Proper catheter insertion and maintenance

The main components of the Proper Insertion and Maintenance Intervention consist of:

1. Making sure that only well trained personnel who are certain of the appropriate method of sterile catheter insertion, as well as catheter maintenance, are handed these duties

2. Catheters should be inserted through use of hygienic methods and equipment that is sterile

3. Maintenance of a disinfected drainage system that is always closed

4. Ensure that the urinary drainage system is not disconnected to the catheter unless the latter ought to be irrigated physically due to hindrance and impediment.

iii. Timely removal of the catheter

The catheters ought to be removed as soon as possible. There should be daily monitoring and supervision of any patients using catheters. If by any chance, a suitable indication for catheter use is not existent anymore, then there should be the timely removal of the catheter. It is important for doctors and nurses to be wary of the indications for the use of urinary catheters; these medical professionals ought to repeatedly monitor and supervise patient need for a catheter. Doctors ought to quickly withdraw catheters that are not indicated or needed anymore; nurses assessing catheters and discovering no indication ought to communicate with the doctor to quickly discontinue or withdraw the catheter. One common reason for the improper and unfitting use of catheters is simply the lack of awareness and alertness amongst clinicians using catheters. In one research study, eighteen percent of medical students, twenty two percent of medical interns, twenty eight percent of medical residents, and thirty five percent of attending physicians did not observe or take into consideration that their patients had an indwelling catheter (Saint, Weiss and Amory J. K, et al., 2000).

iv. Training of Personnel

Make certain that only well-trained personnel, who are well informed about the proper method of sterilized catheter insertion, and its maintenance, are given the duty and accountability for placement or insertion of the urethral catheters. The following are materials which are required for inserting urethral catheters:

1. Sterile gloves

2. Underpads that are water absorbent

3. Aseptic drape

4. Forceps

5. Swabs for preparation

6. Antiseptic solution

7. Catheter

8. Tubing

9. Collecting bag

10. Aseptic water for inflating the balloon

11. Lubricating jelly

Plenty of the above mentioned supplies can be bought as kits which are already prepackaged. The catheters widely and largely differ in terms of design, size, as well as material. The most commonly used catheter is the Foley catheter. Others include the straight-tip as well as double-lumen catheters.

All the urethral catheters have to be placed under aseptic conditions at all times and while wearing gloves which are sterile. If a catheterization kit is being used, first off it has to be removed from its external packaging, and thereafter open the paper wrapping inside to create an aseptic field. In order to ensure that the gloves are not contaminated, the absorbent pad ought to be retrieved in a careful manner from the top of the kit with cleansed hands and thereafter placed underneath the buttocks of the patient with the plastic being side down. The gloves should then be put on and the greater pubic area and the abdomen of the patient covered with the drape. The content of the tray should be placed on an area that is sterile and on a bedside table that can be easily reached and the tray should be well organized. There are varying methods for the catheterization of female and male patients. For instance, two comprehensively referenced journal articles have been published in the New England Journal of Medicine detailing videos that have instructions on the catheterization of both males and females (Ortega, Sekhar and Song, 2008; Thomsen and Setnik, 2006).

Quality improvement

A culture of safety is employed by several nationwide quality improvement schemes focused on health care delivery in order to enhance patient safety. These projects make use of a robust and resilient safety culture with clinical or practical interventions that have already been proven to bring down the rate of health care associated infections. A good example of a nationwide project is the endeavor to get rid of and do away with catheter-associated urinary tract infections (CAUTI) by means of the On the CUSP: Stop CAUTI project. The systems of care, as well as hospitals that have been most fruitful in attaining and sustaining reductions in infection rates, have employed a two-pronged method that makes use of the best clinical practices with a change in culture. There are clear and comparatively straightforward scientific or practical interventions to reduce CAUTI. With sturdy safety cultures, systems of care and hospitals can shape and modify the detailed interventions for decreasing CAUTI rates. The whole process of quality improvement can be presented as a practice that is a self-governing or self-supervision improvement program, or as an evaluation undertaken by an external party (CFPC, 2011). It is important to develop an official quality improvement approach for guidance during the transformation process as the healthcare organization strives to become a patient-centered medical facility (Fontaine et al., 2014; Spenceley et al., 2013; Wagner et al., 2012; Wagner et al., 2014).

The following are some of the characteristics of an effective approach for quality improvement:

1. Has solid and involved leadership with proficiency in change management

2. Makes use of rapid-cycle methods of change to assess innovations and plans for change

3. Is reliant on unchanging performance measurement to pinpoint or ascertain prospects for improvement

4. Engages the personnel in the process of development and implementation

5. Routinely attains and makes use of patient experience information and data to notify improvement endeavors

6. The engagement of personnel in these activities offers a well-accepted and understood perspective on the prevailing processes and notions for change, and might make the changes be more acceptable (Wagner et al., 2014).

7. Involves patients and their families in an endeavor to make the practice be more receptive to the needs and inclinations of their clients.

8. Approaches to involve patients as well as families in current quality improvement endeavors consist of petitioning consistent reactions and responses through surveys, collecting additional information on patient standpoints through the creation of patient/family consultative assemblies, and welcoming separate patients and customer and patient establishments to add to quality improvement undertakings and events (Peikes, Genevro, Scholle, & Torda, 2011).

Cultural Interventions for CAUTI Prevention

A robust safety culture creates the conditions under which CAUTI reduction is possible. Both attaining and maintaining these reductions in CAUTI necessitate a healthcare setting that supports honest and clear communication, shared responsibility, and constant development. The behaviors intrinsic to a culture of safety facilitate the kinds of process improvements that will bring about prevention of infections. Development and improvement, in the long run, necessitates a culture that makes sure that the practical work will done effectively. One challenge that comes with these quality improvement practices is project fatigue. Health care systems have ascertained that the CUSP model works and functions very well with other change models, such as the IHI model and the Kotter Leading Change Model (American Hospital Association, 2013).

Effective Practice

The nationwide project dubbed On the CUSP: Stop CAUTI offers comprehensive tutoring and important data gathering support to unit teams constantly working to reduce CAUTI. By means of this support and mentoring, the involved hospitals have pinpointed numerous key lessons to positively decrease and prevent rates of CAUTI. These include:

1. Exhibit senior leadership dedication

2. Amass a varied and involved multidisciplinary group on each operation unit

3. Authorize front-line personnel

4. Make sure procedures for data collection and recording are recognized

5. Offer committed resources to the project

6. Involve personnel with patient stories

7. Communicate achievements primarily in the project in the long run

8. Create and supervise metrics to assess routine improvement determinations and results. Also make sure all personnel members have an understanding of the metrics for success

9. Make the most of health information technology that offers support to critical functions; for instance, performance measurement, alerts to providers, and constant reminders, computerized order entry (COE), and population management

10. For the quality improvement strategy to be effective, it is important that clinically significant and actionable metrics that are suitable to each exercise and public setting be carefully chosen (CFPC, 2011; Coleman et al., 2014; Martin, 2014).

Healthcare associated infections (HAI)

Procedurally, healthcare associated infections (HAI) are not dissimilar from the health concerns of attending to adult patients. Whereas CAUTI is acknowledged to be the primary basis of HAIs in adults, CAUTI occurrence rate and comparative importance in pediatrics is only now being recognized and proven. In pediatrics, the justification for catheter placement, catheter size, consideration of sterilization methods on insertion, and the dependence on a "package" approach for quality of care in handling the equipment, are all essential to preclude these infections. Nonetheless, children cannot be simply considered as lesser adults. Care providers to children, particularly in a hospital environment, ought to embrace the consideration that there are numerous extra issues and concerns that are associated distinctively with the age of their patients. Patients who are of any age face probable negative outcomes due to an indwelling catheter. These include shock, distress, rigidity, loss of self-respect, amplified antimicrobial use, and the making of pools for pathogens. Nevertheless, the extra worries explicitly intrinsic in the care of children consist of, but are not restricted to the following for the clinician's concern:

1. The age of the child and the use of developmentally suitable methods for appropriate care are vital considerations and ought to be taken into account in every aspect of the child's care. Additionally, it is not abnormal or developmentally unsuitable for young children to have issues with lack of urinary and/or bowel control. It is imperative to note that even youngsters who have attained self-restraint as a developmental breakthrough may relapse when met with sickness or hospitalization.

2. Considerations of family-centered care, cultural proficiency of the clinicians, and health literateness of the family can generate a more accommodating and cooperative patient understanding. Family-centered care, which is a prevalent focus in pediatric health care, prompts clinicians to study the child's specific uncertainties and conduct patterns. This is data best attained from a family-identified professional, comprising family members in the child's care, to the extent that they wish to play a part, and is a vital component in attaining the child's belief and collaboration (Stephan, Wachsmuth M, et al.,2006).