CAUTI Prevention: A Nursing Quality Improvement Project

Introduction and Need for Change

For reducing patient adverse events, continuous quality improvement in the healthcare industry is essential so that cost-effective methods can be implemented for better patient outcomes, satisfaction, and healthcare sustainability. This paper presents a retrospective quality improvement (QI) project focused on healthcare-associated infections (HAI), specifically urinary tract infection (UTI), using the PDSA model (Plan, Do, Study, Act). The changes that could be applied for UTI prevention and the strategy by which various participants would be involved are explained in the sections that follow.

Urinary tract infection (UTI) is one of the most common types of healthcare-associated infections, accounting for up to 75% of urinary catheter usage (Centers for Disease Control and Prevention, 2015). It is estimated that 15 to 25% of hospitalized patients must use a catheter for one or more medical conditions, and prolonged use should therefore be avoided.

Catheter-associated UTI (CAUTI) is prevalent among patients both outside the intensive care units (ICU), where it accounts for 70% of cases, and inside the ICU, where the proportion rises to 95% (Nicastri & Leone, 2021). The increment in CAUTI-associated hospital charges and extended hospital stays has surged by up to four days, attributing to $876 in additional inpatient costs. The daily rate of acquiring this infection ranges from 3% to 10%, since there are high chances that 10% to 25% of patients develop UTI symptoms during their hospital stay.

Literature Review and Evidence-Based Practices

Compared to other hospital-acquired infections, UTI has received significantly less attention due to limited awareness about the topic. Being one of the most prevalent infections among females, it is predicted that women's anatomy contributes more to the prevalence of this disease than is commonly acknowledged (Huston, 2018). Because women have a shorter urethra, bacteria do not have to travel far to reach the bladder and create an infection, making women more prone to developing this disease than men. Females admitted to hospitals for cesarean deliveries, for instance, typically have a catheter attached to their urethra to ease urination after the operation. Research suggests that non-catheterized women experienced less difficulty voiding for the first time, took less time to void, had a lower prevalence of UTI symptoms, and required fewer antibiotics for infection prevention (Pandey et al., 2015).

One of the leading causes of UTI is the use of an indwelling urethral catheter, which is unavoidably used in hospitals for patients who have difficulty mobilizing or using the restroom independently due to particular operations (Nicolle, 2008). On average, 5% of patients who use catheters in hospitals face a daily risk of developing UTI, since catheter use beyond 24 hours is often unavoidable. Associated adverse outcomes include genitourinary disturbance, urethral strictures, and patient immobility due to the severe discomfort experienced in the bladder.

With extended catheter usage, a biofilm develops along the urethra. Bacteria and yeast settle and travel easily through the catheter surface. Prevention of infection becomes even more difficult once biofilm has formed, as organisms move freely within it and the host's defenses are weakened, making UTI increasingly difficult to avoid.

Evidence-based practices (EBP) indicate that healthcare workers (HCWs) must be educated about appropriate catheter duration, anatomic outlet impediments, tracking the amount and frequency of a patient's urination daily, and detailed information about the types of surgeries after which catheter use is required (Nicastri & Leone, 2021). Education about the correct insertion technique and infection prevention should be prioritized so that complications and adverse events are avoided. As a result, the frequency of re-admissions would be reduced, further lessening hospital costs (Babich et al., 2021). Additional recommended practices include proper care and maintenance in emptying the urine bag, keeping the bag above the flow but below the pelvis, avoiding repeated catheter changes, and considering anti-infective options when catheter use is necessary for high-risk patients. Further EBPs related to CAUTI prevention include the use of aseptic technique, computer-generated reminders for discontinuing catheter use, documenting catheter-related procedures, and continuously monitoring the patient's health and urination frequency to allow for earlier catheter removal.

For reducing the incidence of CAUTI, the American Journal of Nursing (AJN) disclosed a step-by-step approach for healthcare worker teams to adopt procedures in hospitals that make restorative care and catheter-related hospital stays more manageable (Magers, n.d.). The EBPs developed for this purpose included scrutinizing the need for supporting evidence-based practices, appropriate hand hygiene, training healthcare workers in proper catheter insertion and aseptic technique, taking standard safety measures (including the use of high-quality sterile equipment and ensuring unobstructed urine flow), and maintaining the drainage bag at the correct level. Additional steps include conducting extensive reviews of existing literature, asking clinically relevant questions — such as how nursing-based practices affect CAUTI prevention and patient outcomes — and forming an interprofessional team so that CAUTI prevention does not rest solely on one hospital department. According to this framework, the team should include nurse managers, nursing staff, medical doctors, infection control personnel, workers from the Quality Improvement (QI) or Performance Improvement (PI) department, and continuous integration of information technology into medical processes (Magers, n.d.). Approval from institutional authorities should be obtained to access data sources for comparison with benchmarks. After implementing the change, outcomes should be evaluated, and gaps should be identified. It remains mandatory in nursing practice to share successful EBP implementation results in order to advance CAUTI prevention efforts.

Change Theory Framework

Lewin's Change Theory can serve as a framework for implementing quality improvement in the healthcare industry so that urinary tract infection — one of the most persistent HAIs — can be eliminated, and better patient outcomes with reduced re-admissions can be assured. The framework has three major components: driving forces, restraining forces, and equilibrium (Raynaldo, 2020, p. 7). For this project, the driving forces are the frequent incidence of urinary tract infections caused primarily by catheter use. Patients who come to the hospital for treatment of another medical condition may find themselves physically unable to use the restroom and are therefore dependent on a catheter. If the catheter is not properly sanitized or is used for a prolonged period, UTI is nearly unavoidable. With the increasing number of patients returning to hospitals for UTI treatment, re-admissions due to UTI have posed a significant economic burden (Goldfield et al., 2008, p. 89).

The restraining forces may include stakeholders in the healthcare industry who do not support change implementation. For example, healthcare workers who are insufficiently educated or trained in catheter use may resist changing their practices. They may not be aware that aseptic technique and proper hand hygiene are critical to long-term UTI and HAI prevention. Other possible restraining forces include hospital management unwilling to incur the costs of additional training or lacking sufficient financial resources for that purpose.

Lewin's change theory operates through three stages: unfreezing, change, and re-freezing (Manchester et al., 2014). The unfreezing stage, being the most complex, requires preparing and motivating hospital staff to implement change, since employees are critical assets in the healthcare field. They need to be properly equipped and made aware of the benefits resulting from the quality improvement change. The second stage involves the actual implementation of evidence-based practices for accurate catheter use and CAUTI prevention across all patient groups, aimed at reducing re-admissions. Strong leadership is essential to guide change participants in the right direction and foster a unified team approach. The third and final stage — re-freezing — involves sustaining the newly adopted strategies within hospital operations and embedding them into organizational culture. Standard clinical practices should guide future approaches to catheter use, ensuring that UTI prevention becomes a lasting institutional norm.

Conclusion: Impact on Nursing and Patient Outcomes

HAI conditions can affect patient re-admissions, which implies that the patient discharge process should be transparent and effective to ensure patient well-being and the guaranteed absence of HAIs, specifically CAUTI. The nursing outcomes would be reflected in a reduction in the nursing staff workload once successful change implementation has been achieved, since there would be fewer re-admissions and fewer patients requiring ongoing care. There would be minimized nurse burnout and greater job engagement, doubling the productivity of the medical staff and the hospital as a whole. On the other hand, patient outcomes are far-reaching, since the frequency of patient re-admission would serve as the greatest and most definitive indicator of the success of the implemented change. Patients would experience less discomfort during urination, as the difficulties often associated with first voiding after catheter use are predicted to diminish following the adoption of the aseptic method for quality improvement.