Quality Improvement Project Healthcare Associated Infections

NURSING

Abstract

Healthcare-Associated Infections (HAI) are the ones that are caught by the patient when they are at the hospital for the treatment of another medical condition. One of the common infections is urinary tract infection, which majorly affects the urinary tract system and causes pain and distress for the patients for the rest of their lives. If no proper precautions are taken during catheter insertion, which is considered one of the leading causes of UTI, and no timely treatment is given to the patient, consequences could be severe.

The current project seeks to employ a quality improvement project by studying a similar retrospective project from literature. With the deployment of a PDSA cycle, need identification is made, and running a literature review and exploring the evidence-based practices for supporting the change. Further, the paper discusses the application of change theory and its various stages, selecting an inter-professional team for reviewing the area of change, tools and methods for data collection for the current status of change, data analysis procedures and their presentation in graphic forms, the establishment of measurable quality outcomes with the use of benchmark or nurse indicators, detailed account of change plan implementation for meeting the outcomes, estimation of the projected data collection and noting whether the achievement outcomes met the goals, and lastly, summarizing the change’s impact on nursing as well as patient outcomes. 

Nursing: Quality Improvement Project

For reducing patient events, it is crucial to have a continuous quality improvement in the healthcare industry so that cost-effective methods could be implemented for better patient outcomes, satisfaction, and healthcare sustainability. This paper aims at presenting a retrospective quality improvement project for healthcare-associated infections (HAI), specifically urinary tract infection, with the help of the PDSA model (plan, do, study, act). The changes that could be applied for its prevention and the strategy in which various participants would be involved are explained in the further sections of the paper.  

Identifying the Need for Change

Urinary tract infection (UTI) is one of the most common types of healthcare-acquired or associated infections from the hospitals that account for up to 75% of the urinary catheter usage (Center for Disease Control and Prevention, 2015). It is estimated that 15 to 25% of hospitalized patients have to use a catheter for any of their medical conditions, for which it should be considered that prolonged use must be avoided. 

The catheter-acquired UTI (CAUTI) is seen being prevalent in the patient who is either outside the intensive care units (ICU) that account for 70% or inside the ICUs, for which the percentage is 95% (Nicastri & Leone, 2021). The increment in CAUTI associated hospital charges and the hospital stay have surged up to four days, attributing to $876 inpatient cost. The daily rate of acquiring this infection ranges from 3% to 10% since there are high chances that 10% to 25% of the patients develop UTI symptoms during their stay at the hospital. 

Compared to other hospital-acquired infections, UTI has gained significantly less attention due to less awareness about the topic. Being one of the most prevalent infections among females, it is predicted that women’s body anatomy has more to do with the prevalence of this disease than shedding light on its actual reason (Huston, 2018). It is known that since women have a shorter urethra and bacteria do not have to travel a long way to enter the bladder to create an infection; women are more prone to developing this disease than men. Females are admitted to the hospitals for cesarean deliveries where they have to have a catheter attached to their urethra for the ease of urinating after the operation. Research suggested that women who were non-catheterized had less difficulty in voiding for the first time, took lesser time in voiding, had a lesser prevalence of UTI symptoms, and had lesser need of antibiotics for the prevention of developing any infection (Pandey et al., 2015) 

Literature Review and Evidence-Based Practices (EBP) to Support Change and Selecting the Solution

One of the leading causes of UTI is the use of an indwelling urethral catheter which is unavoidably used at the hospitals for patients who find difficulty either due to particular operations in mobilization and going to the washroom on their own for urination (Nicolle, 2008). Mostly, 5% of the patients that come to hospitals and use catheters have the average risk of developing UTI per day since 24 hours is compulsory if it has to be used. The associated adverse outcomes include genitourinary disturbance, urethral strictures, and patient immovability due to severe discomfort that they get in their bladder. 

With the extended usage, a biofilm is developed along the lines of the urethra. The bacteria and yeast easily settle and travel conveniently through the surface of the catheter. The prevention of the infection becomes even harder when biofilm is formed since the organisms travel with ease within the biofilm, and the host defenses then feel weak for providing the body the protection against the inevitable UTI. 

The suggested evidence-based practices (EBP) indicate that healthcare workers (HCWs) must be educated about the duration for which the catheters should be used, the anatomic outlet impediment, the tracking of amount and frequency of the need of urination for the patient daily, and detailed information about the type of surgeries that the patient undergoes after which catheter is to be used (Nicastri & Leone, 2021). Education about correct technique for its insertion and the care about prevention of possible infections should be considered so that complications and adverse events should be avoided. As a result, the frequency of re-admissions would also be prevented, further lessening the hospital costs incurred by the country’s economy (Babich et al., 2021). Care and maintenance in emptying the urine bag, keeping the bag above the flow but below the pelvis, avoiding the repeated change of catheters, and contemplating the use of anti-infective place when the use of catheters is for the patient who is at high risk of developing infections. Moreover, there are additional EBPs related to the prevention of UTI linked with the use of catheter such as the utilization of aseptic technique, using computer-generated reminders for stopping the catheter use upon the patients, documenting the procedures used for patient’s use of a catheter, and continuously monitoring the patient’s health condition and the frequency of urine so that removal of the catheter could be done earlier. 

For reducing the incidence of CAUTI, the American Journal of Nursing (AJN) disclosed a step-by-step approach for the healthcare workers teams for the adoption of the procedures to be implemented in Mississippi Hospital for Restorative Care and the duration of the patient’s stay where catheters were used could be made convenient (Magers, n.a.). The EBPs developed for this purpose included scrutinizing the need for supporting evidence-based practices in which need for strategies like appropriate hand hygiene, training of the healthcare workers for proper insertion of catheter and deployment of the aseptic technique, taking standard safety measures in which use of high-quality sterile equipment and ensuring the unobstructed flow of urine along with drainage bag level above the surface should be ascertained. The next steps include extensive research about the previously existing literature on the same topic and critically reviewing it asking clinically relevant questions, such as the effect of nursing-based practices in CAUTI prevention and how patient outcomes could be improved, etc. For an appropriate integration of EBPs, a team is to be formulated so that it does not become the sole responsibility of one department at the hospital to ensure that CAUTI is prevented. For this, EBPs state that team should comprise of nurse managers, nursing staff, medical doctors, staff from the infection control department, workers from the Quality Improvement (QI) or Performance Improvement (PI) department, and constant integration of information technology in all medical processes (Magers, n.a). Getting approval from top authorities of the medical institution for implementing the proposed change, specifically for the prevention of CAUTI, should be obtained to find data sources to be attained for comparisons with the benchmark and standard procedures. After having implemented the change, the outcomes should be evaluated, and the gaps should be identified. However, it remains mandatory for the nursing practice to share the successful EBP implementation rituals to further the positive results in preventing CAUTI. 

Adaptation of Change Theory as a Framework to the QI Project and Its Use in Implementation

Lewin’s Change Theory could be used as a framework for implementing the change for quality improvement in the healthcare industry so that urinary tract infection, one of the most persistent HAIs could be eliminated, and better patient outcomes and reduced re-admission could be reduced be certified. The framework has three major specifications: driving forces, restraining forces, and equilibrium (Raynaldo, 2020, p. 7). For this project, the driving forces would be the frequent incidence of urinary tract infections caused primarily by the use of a catheter. It is one of the most visible causes for the patient who comes to the hospitals to treat another medical condition. Still, due to severe physical inability to use the washroom, they have to have a catheter for discharging their urine in the urine bags. If the catheter is not properly sanitized or is used for a prolonged period, UTI is unavoidable. With the increasing number of patients coming back to the hospitals for UTI treatment, the hospital re-admissions due to UTI have eventually posed a huge economic burden on the country (Goldfield et al., 2008, p. 89). 

The restraining forces could be some of the stakeholders in the healthcare industry that might not support the change implementation. For example, the healthcare workers who are not sufficiently educated or trained about the use of catheters do not want to change the strategy of its usage. They might not be aware that aseptic technique and proper hand hygiene go a long way in UTI prevention and avoiding HAIs on a long-term basis. Other possible restraining forces could be hospital management for not wanting to incur costs for additional training of their workers or not having sufficient financial resources for the same purpose, thus being reluctant.  

Looking forward to the three steps in Lewin’s change theory, the unfreezing, change, and re-freezing stages play an integral part in change implementation (Manchester et al., 2014). Unfreezing stage, being the most intricate one, would require the hospital staff’s preparation and willingness to implement change since employees are important assets in the healthcare field. They need to be suitably equipped and should know about the benefits resulting from the quality improvement change. The second stage would require the actual implementation of evidence-based practices that should be implemented for accurate use of catheters and prevention of CAUTI in all of the patients coming to the hospitals for cures for further deterrence of re-admissions. Leadership should be strong enough to guide the change participants in the right direction and take them along as a team. The unified goals would help to process the change application for quality improvement. The third and last stage in Lewin’s change model, re-freezing, is about sustaining the newly changed strategies in hospital operations and making them a part of the organizational culture. Standard clinical practices should guide the future ways in which catheter usage would be applied, and UTI would be prohibited. 

Inter-Professional Team to Review the Area of Change

According to evidence-based practices and guide generated by Agency for Healthcare Research and Quality (AHRQ), the core team members for facilitating the quality improvement for the eradication of UTI resulting from the use of catheter can include administrative champion who would be responsible for endorsing the intervention aims and their consequences, highlighting the safety steps, rules and procedures, making sure that the staff has the required means and resources for the quality improvement change and for that, vigorously reviewing the records for meeting the set goals; team leader who would be in charge for keeping in check that every team member plays his or her part in completing their assigned duties, closely monitoring their daily progress so that meeting goals on a daily basis becomes easier, keeping a review of the supporting materials such as educational videos and constant reinforcement of the EBPs throughout the nursing departments; data coordinator who would have the duty of ensuring the coordination required among all the participants and departments for verifying the patient’s outcomes, particularly in long-term facilities (Agency for Healthcare Research and Quality, 2017).  

Tools and methods for data collection for measuring current status of change

Data collection would be done using the simple data collection planning presented by Institute for Healthcare Improvement (IHI) since it saves time and no additional costs are incurred. One of the best data collection methods via this tool is PDSA (plan, do study, act), for which the worksheet is available at IHI’s website. The following figure is the depiction of the data collection method through the PDSA method:

Figure 1: Data collection by using PDSA worksheet

In the ‘plan’ section, one of the evidence-based practices would be selected, for instance, using the aseptic method for inserting catheters accurately for preventing UTI among patients. The test would be conducted by implementing all the important stages of the aseptic method encompassing setting up the sterile field, carefully acting upon the hand hygiene before and after the catheter insertion, use of hygienic gloves and other useful materials for insertion, and using appropriate cleaning methods with lubricants and antiseptic liquids for ensuring clean insertion without contamination (Manojlovich, Martin & Carraway, 2017).

The ‘do,’ ‘study,’ and ‘act’ sections require simple markings of the checkboxes against simple questions so that estimation could be made whether the process should be carried out in the future if it is done successfully and proved fruitful in the prevention of UTI after catheter insertion. However, in the acting stage, the leadership plays an integral part in implementing the change for quality improvement. The leader must make sure about four aspects: all changes do not ensure improvement, and it is upon the leaders to carefully examine the activities that would facilitate the activities whose outcomes are targeted; secondly, the leader must keep in mind that specific changes can be implemented without any widespread efforts that can adjust to external environmental changes; third, the factors that have a large impact on the way the change will be implemented include environmental factors, convenience with which implementation is organized, making assessments about the resulting impact, the number of participants involved in the change system, organizational culture and its resilience for opposing primacies; fourth being the leaders themselves who want to implement change on a larger scale but should not emphasize on speeding the process (Hines, 2014).  

As mentioned in the paper’s first section, the daily rate of acquiring this infection is 3% to 10%; in the initial stages, the data collection could be done every week. The administrative champion would be the one who would collect the data for certifying that the staff carries out the evince-based procedures.  

Data Analysis in the Form of Charts

A line chart would be suitable for presenting the data for better data analysis purposes for ten weeks. Weeks would be taken on the x-axis, and the y-axis would indicate the time patient took for the first voiding without discomfort. The chart and its axis were set based on the research by Pandey et al. (2015) mentioned in the first section as it stated that the patients who were non-catheterized took lesser time in their first voiding and that too, without discomfort. 

Establishing Measurable Quality Outcomes

Based on the achievement outcome criteria that is set in the previous section for data analysis and chart formulation purpose, which is lesser discomfort and lesser tike taken in first voiding by the patient, the nurse-sensitive indicator is set as the measurable quality outcome and a benchmark for the change implementation and quality improvement in hospitals for lower UTI cases and re-admissions. By searching the National Database of Nursing Quality Indicators (NDNQI), the nosocomial infections that include CAUTI as well had no sub-indicators but had the outcome measures (Montalvo, 2007). It is inferred that the outcome measures set for this project, which is lesser voiding time for the first time and without discomfort, should be attributed to a successful, measurable quality outcome. 

Details about Implementation of Plan to Meet Outcomes

The plan implementation for meeting the outcomes, which is less discomfort and lesser time taken for the first voiding by the patients who have used catheter so that prevention of UTI could be confirmed and fewer re-admissions are witnessed, would be done based on the evidence-based practices specified in the earlier sections of the paper. Some of the salient points of EBPs include:

· Education of healthcare workers (HCWs) about the aseptic method is one of the critical steps used in the PDSA cycle, and measurable outcomes have been specified for this particular tool in the current quality improvement project. Hence, the focus here would be on the aseptic method for this project. 

· Training of the medical staff for care and maintenance during the aseptic method

· Constant monitoring over the step-by-step process of aseptic method inculcating arranging the sterile field, taking care of the hand hygiene steps before and after the catheter insertion, use of disinfected gloves and other useful materials for insertion, and using apt cleaning approaches with lubricants and antiseptic liquids for warranting clean inset without impurities. 

· Regularly and vigorously monitoring the patient’s health condition and the rate of urination so that removal of the catheter could be done earlier.

Estimation about Projected Data Collection for Evaluating the Implementation

The projected data collection would be to evaluate change implementation procedures and their effectiveness in using the aseptic method. The achievement outcomes are expected to meet the set goal, which is reducing CAUTI and re-admission of patients. Although limited data is available for the efficacy of this method in controlling CAUTI, it is still considered as the standard infection controlling method, including the use of sterile equipment, strictly taking care of hygiene by washing hands before and after insertion, and proper unobstructed urinary draining (Medinngs et al., 2014). Adherence to basic hygiene principles is mandatory in any department or treatment area of the healthcare industry. The general infection control principles are guided by proper hygiene maintenance, education of healthcare workers, hand cleanliness, and continual surveillance of the patient for observing any uneasiness or time taken for first voiding, which would support successful change implementation and quality improvement medical institute.