Running head: LEADERSHIP STRATEGY ANALYSIS QUALITY IMPROVEMENT

Leadership Strategy Analysis: Quality Improvement to Prevent CAUTIs

Niccole Colthorp, Sarah Knoll, Jessica Olcheske, & Sonja Wroblewski
NURS 440
November 2, 2014

LEADERSHIP STRATEGY ANALYSIS QUALITY IMPROVEMENT

Leadership Strategy Analysis: Quality Improvement to Prevent CAUTIs

According to Yoder-Wise, the goals of the quality improvement process team is to
analyze and evaluate care to decrease the risk of adverse patient events and to make appropriate
changes (Yoder-Wise, 2011, Chapter 20). To make effective changes, the team must take into
account current research revealing best practices, collect data, and consider the experiences of
healthcare providers pertaining to practice situations and barriers (Oman et al., 2012). The end
result of utilizing such a systematic approach is enhanced health and safety, health cost savings,
and greater patient satisfaction (Yoder-Wise, 2011, Chapter 20). The purpose of this paper is to
perform a clinical review to show how the leadership strategy of proper delegation of catheter
care by nurses can decrease the prevalence of catheter associated urinary tract infections
(CAUTIs) and, thus, enhance health outcomes for patients and control hospital cost. The clinical
review will involve the identification of the need for change, input from the appropriate team of
healthcare workers, a design to review the problem, an establishment of goals for improvement,
strategies to implement change, and a review of the success of the goals.
Clinical Need
Problem
According to the Centers for Disease Control and Prevention (CDC), 15% of the
infections acquired in the hospitals are in the urinary tract, and almost all of them result from the
use of urinary catheters (CDC, 2014). Some health risks associated with catheter use include
discomfort for the patient and a risk of conditions such as cystitis, pyelonephritis, endocarditis,
and vertebral osteomyelitis. Yearly 13,000 people die from CAUTIs. CAUTIs also lead to
increased health care cost from increased hospital stay to manage complications (CDC, 2014).
CAUTIs are associated with improper emptying of the Foley bag causing urine backup, not

LEADERSHIP STRATEGY ANALYSIS QUALITY IMPROVEMENT

removing catheters in a timely manner, underutilizing the bladder scanner, using catheters
inappropriately, and inadequately performing peri-care (Oman et al., 2011).
Research
Understanding Urinary Tract Infections identifies that the risk of developing UTIs
increases with the following: obstruction anywhere in the urinary tract, enlarged prostate,
presence of an indwelling catheter, infection with resistant microorganisms, poorly controlled
diabetes, older age, and impaired immune function (Casey, 2014, p. 21). Prevention strategies
include reduction rate of catheterization and use of aseptic technique utilizing sterile equipment
and an antiseptic for peri-urethral cleansing. It is important to remember that catheterized
patients require frequent follow up, catheter care, and maintenance of collection devices in order
to prevent the spread of bacteria.
Engaging Health Care Workers to Prevent Catheter-associated Urinary Tract Infection
and Avert Patient Harm identifies the indications for catheterizations which includes the
following: acute urinary retention or bladder outlet obstruction, accurate measurements of
urinary output in critically ill patients, peri-operative use for selected surgical procedures such as
incontinence patients needing assist in healing of open sacral or perineal wounds, prolonged
immobilization requirement, and improved comfort for end-of-life care (Fakih et al, 2014, p.
S225). Often, in healthcare, catheter placement is used incorrectly for convenience in caring for
incontinent patients. To reduce catheter harm, the first step is to prevent placement of any
urinary catheter that would not be of medical benefit to the patient. Aseptic insertion and proper
maintenance reduces the risk of introducing organisms into the bladder which will delay the
occurrence of bacteriuria. Removal of the catheter when it is no longer medically needed

LEADERSHIP STRATEGY ANALYSIS QUALITY IMPROVEMENT

reduces the risk of infection. Preventing reinsertion of indwelling catheters can be accomplished
by bladder scanning to assess need and intermittent catheterization (Fakih et al, 2014, p. S225).
Nurse-directed Catheter Removal Protocols to Prevent Catheter-associated Urinary
Tract Infection: Strategies for Implementation looks at shifting responsibility for reducing health
care associated infections (HAIs) from the infection control professionals to the multidisciplinary
patient care team. CAUTIs represent 28% of all HAI cases (Hebden, 2014, p. 670). Patients at
greatest risk for CAUTIs are those with prolonged catheter use. Reports show that the sooner
catheters are discontinued, the more drastically rates of catheter related urinary tract infections
decline. To further assist in CAUTI prevention, nurses need to be continually educated on
prevention techniques as well as current guidelines and standards for catheter placement and use.
Interdisciplinary Team: Role in Reducing CAUTIs
A disciplinary team has been assembled to provide input in ways to reduce CAUTIs, to
discuss reasons for the issue, and to monitor the progress of implemented strategies to reduce
CAUTIs. This team consists of a registered nurse, a physician, a nursing assistant, and a nurse
manager. According to Yoder-Wise, planning utilizing a multidisciplinary approach is needed
for quality in healthcare (Yoder-Wise, 2011, p. 648). To understand the purpose of each team
members inclusion on the team, one must understand each members role in CAUTI prevention.
Registered Nurse
The role of the registered nurse in preventing CAUTIs is to perform a daily catheter
assessment, to educate other staff on making catheter assessments a routine task, and to evaluate
and implement solutions to prevent infections or complications from catheter use. In addition,
the nurse is responsible for evaluating and implementing solutions to prevent infection or
complications from catheter use (Fakih et al, 2014).

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Doctor
The doctor is in charge of deciding if a catheter is appropriate for the patient, and how
long the catheter must be in place. The doctor must give an order to the nurse for the placement
and discontinuation of the catheter. The doctor may also have to empower and train the nurses to
make the decision about removal of the catheter if an order is not needed. (Fakih et al, 2014).
Nursing Assistant
Nursing assistants can help to prevent CAUTIs by performing routine perineal care on
patients that have catheters. They can also remove catheters when a nurse delegates the task to
them. Nursing assistants can help to decrease the prevalence of CAUTIs by being proactive
when caring for patients with catheters. They can act as a resource to remind the nurse to
discontinue the catheter. They can also use a bladder scanner when delegated to them by the RN
to check for urinary retention to assist the nurse in assessing whether or not a catheter is required.
Nurse Manager
The nurse managers role is to ensure that the nurses are following guidelines regarding
catheters. The nurse manager can help to prevent CAUTIs by checking with the nurses daily to
see which patients have catheters that can be removed. It is also the nurse managers duty to
follow up with the RNs and aides to ensure catheter care is performed regularly.
Data Collection Method
The purpose of collecting data is to show proof without bias that interventions are needed
to improve quality. Data collection is also a useful tool for management to use in making
decisions about care strategies because it provides an objective statistical analysis of the problem
(Yoder-Wise, 2011, p. 394-395). The team will utilize several approaches to examine the need
for change. To show prevalence of the problem, the team will use a similar data collection

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method as in the article by Oman et al. The team will collect data from electronic medical
records on medical-surgical units to track patients with catheters, to track the length of time the
catheters stay in, and to compare CAUTI rates after interventions; every four months the team
will conduct a review of the trends (Oman et al., 2012, p. 550). To analyze trends over time, the
team will utilize a line graph (Yoder-Wise, 2011, p. 396). To view the rate of CAUTIs over
time, the dependent variable will be the number of CAUTIs in a given month, and the
independent variable will be the number of months. To view the impact that removing catheters
at a certain time has on length of hospital stay, the dependent variable will be the rate per
catheter day and the independent variable will be the days in the hospital. Another data
collection method the team will utilize is gathering qualitative data from a questionnaire. The
questionnaire will be use to show the extent the leadership strategy of delegation is utilized on
the units. For instance, the questionnaire will determine whether or not the RNs follow up on the
frequency of peri-care, the use of the bladder scanner, the assistants ability to perform bladder
scanning, the frequency that catheters are emptied, and whether assistants leave catheters in past
the time to be taken out and for incontinence management. Lastly, the team will use a fishbone
diagram which is a tool used to get to the root of a problem. It looks at several effects that are
responsible for causing a problem to help one see clearly the aspects contributing to a problem
(University Alliance, 2014). Appendix B shows a fishbone diagram outlining improper
delegation and CAUTIs.
Outcomes
Yoder-wise points out that delegation is one in authority sharing activities with other
individuals who have appropriate knowledge to accomplish the work, however the delegator is
accountable and responsible for the outcomes (Yoder-Wise, 2014, p. 522). Proper delegation of

LEADERSHIP STRATEGY ANALYSIS QUALITY IMPROVEMENT

care centered on catheter management will lead to the following patient outcomes: decreased risk
of developing a urinary tract infection, fewer days in the hospital accruing cost from a CAUTI,
and increased satisfaction because the patient will not have to experience unnecessary pain and
discomfort from a CAUTI. The team will set the following delegation goals to reduce CAUTIs
and to enhance patient outcomes:
Reduction in hospitals stay per medical surgical patient requiring a catheter by one
day per week over four months by nurses ensuring nursing assistants perform catheter
care at least once per shift. Generally accepted national funding for the direct costs of
CAUTIs is $750 per episode which is way under the coverage needed to cover the cost
hospitals require to care for these patients (Parry, Grant, & Sestovic, 2013, p. 1180). On
average, patients spend 6.3 days in the hospital after a diagnosis of a catheter associated urinary
tract infection. With the average cost of $1700 per day of hospitalization this could run a bill of
nearly $11,000.00 that is not reimbursed (Hu et al, 2013, p. 306).
The RN will remove or delegate to the nursing assistant to remove the catheter as
soon as the patient no longer requires or meets criteria for catheterization. Nursing
protocols for catheter removal greatly decreases the duration of use for indwelling catheters as
well as the incidence of CAUTIs, and, as a result, there is a reduction in the rate of hospital
stays and costs. This reduction will also improve patient satisfaction scores due to reduction in
discomfort and pain (Mori, 2014, p. 25).
The RN will ensure each shift that nursing assistants are assisting in toileting
patients with mobility issues every two hours, and the RN will not use a catheter to manage
incontinence. Michigan was part of a nationwide initiative to reduce CAUTIs that resulted in a
25% reduction of them by using a bladder bundle that promotes daily evaluation of catheter

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need, promotes use of tools such as the bladder scanner to prevent catheterization, and promotes
evaluation and feedback on catheter use to ensure appropriate use of them (Fakih et al., 2014).
Implementation Strategies
The nurse may delegate to the nursing assistant the task such as performing peri-care,
emptying the catheter bag, keeping the catheter bag patent, bladder scanning, and removing the
catheter, however if delegation is to be effective several steps need to be followed. A crucial
step in improving delegation is for the nurse to use the right communication and direction. The
right communication and direction refers to clearly and concisely communicating the delegated
task. Poor communication between the RN and the nursing assistant can lead to poor quality of
care and outcomes for the patients. Another important step in improving delegation is
establishing trust between the RN and the nursing assistant. Mutual trust in a relationship
develops and grows stronger over time and leads to better communication (Anthony & Vidal,
2010). The RN may assist the nursing assistant with the tasks, set a timeframe with the nursing
assistant to complete the task, and be mindful not to delegate too many tasks at once. The RN is
the one who is held accountable for the tasks to be completed properly and in a timely manner.
Lastly, the doctor and nurse managers role in improving delegation is to follow up with the
patient and RN to oversee that proper care is being provided to the patient. These team members
also consult with the RN for any changes or questions they may have. If a task is not being done
or is being done improperly, the doctor may meet with the nurse manager to discuss any
concerns. The nurse manager is then responsible for following up with the issue and discussing
it with the RN, nursing assistant, and/or patient.
Evaluation

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According to Yoder-Wise, when implementing a plan, a team must continue to gather

and evaluate the data and document that the outcomes are being met; if the outcomes are not
being met, revisions to the implementation of the plan are needed (Yoder-Wise, 2014, Chapter
20). Some indicators of success will be line graphs showing a decrease in hospital length of stay
of patients with catheters, high patient satisfaction scores on surveys from patients who had
catheters, and a large decrease in yearly CAUTI rates also shown on line graphs. Other quality
indicators are documentation showing improved incidence of catheters removed on time,
increased rates of the bladder scanner being used to assess retention, and increased frequency of
peri-care performed.
Conclusion
While delegation of tasks continues to be a necessary role in nursing, it is important that
the RN who is delegating tasks can pass appropriately work onto support staff and feel confident
that correct technique is used to implore patient safety. Catheter related urinary tract infections
continue to be a primary concern in the hospital setting. By avoiding unnecessary placement of
catheters, engaging in good maintenance care of catheters, and promptly removing catheters,
nursing and support staff can help to reduce the growing number for CAUTIs reported each
year, reduce health care costs incurred from extended hospital stays related to the treatment of
CAUTI, and prevent patient dissatisfaction from the pain of a CAUTI.

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References
Anthony, M. K., & Vidal, K. (2010). Mindful communication: A novel approach to improving
delegation and increasing patient safety. The Online Journal of Issues in Nursing, 15(2).
doi: 10.3912/OJIN.Vol15No2Man02
Casey, G. (2014). Understanding urinary tract infections. Kai Tiaki Nursing New Zealand, 20(5),
20-23. Retrieved from
http://www.thefreelibrary.com/Understanding+urinary+tract+infections.-a0372093617
Center for Disease Control. (2014). Catheter- associated urinary tract infection (CAUTI) event.
Device Associated Module. Retrieved from
http://www.cdc.gov/nhsn/pdfs/pscmanual/7psccauticurrent.pdf
Fakih, M. G., Krein, S. L., Edson, B., Watson, S. R., Battles, J. B., & Saint, S. (2014). Engaging
health care workers to prevent catheter-associated urinary tract infection and avert patient
harm. American Journal of Infection Control, 42(10), S223-S229.
doi:10.1016/j.ajic.2014.03.355
Hebden, J. N. (2014). Nurse-directed catheter removal protocols to prevent catheter-associated
urinary tract infection: Strategies for implementation. American Journal of Infection
Control, 42(6), 670. doi:10.1016/j.ajic.2014.02.005
Hu, B., Tao, L., Rosenthal, V. D., Liu, K., Yun, Y., Suo, Y., & ... Saunders, C. L. (2013).
Device-associated infection rates, device use, length of stay, and mortality in intensive
care units of 4 Chinese hospitals: International nosocomial control consortium findings.
American Journal of Infection Control, 41(4), 301-306. doi:10.1016/j.ajic.2012.03.037
Mori, C. (2014). A-voiding catastrophe: Implementing a nurse-driven protocol. MEDSURG
Nursing, 23(1), 15-28. Retrieved from CINAHL.

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Oman, K. S., Makic, M.B.F., Fink, R., Schraeder, N., Hulett, T., Keech, T., & Wald, H. (2012).
Nurse directed interventions to reduce catheter-associated urinary tract infections.
American Journal of Infection Control, 40(6), 548-553. doi: 10.1016/j.ajic.2011.07.018
Parry, M. F., Grant, B., & Sestovic, M. (2013). Successful reduction in catheter-associated
urinary tract infections: Focus on nurse-directed catheter removal. American Journal of
Infection Control, 41(12), 1178-1181. doi:10.1016/j.ajic.2013.03.296
University Alliance. (2014). What is a fishbone diagram? Retrieved from
http://www.notredameonline.com/resources/business-administration/what-is-a-fishbonediagram/#.VD3RGPldW2g
Yoder-Wise (2011). Leading & Managing in Nursing (5th ed). St. Louis, MO: Saunders.

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Appendix A
Acknowledgements
The contributions to this paper were completed by the team members in the following manner:

Sonja: provided a detailed outline for the entire paper, wrote the introduction, wrote the clinical
need (problem), wrote the first paragraph under interdisciplinary team introducing the team,
wrote the data collection method, constructed the fishbone diagram, edited the paper for content,
grammar, spelling, and APA, and added sources to the reference page.

Jessica: wrote the interdisciplinary team section for the doctor and registered nurse, wrote the
evaluation section, provided some APA editing, and added sources to the reference page.

Niccole: wrote the interdisciplinary team section for nursing assistant and nurse manager, wrote
the implementation strategies section, provided some editing for grammar, APA and spelling,
and added sources to the reference page.

Sarah: created the APA template for the paper, wrote the clinical need (research), wrote the
outcomes, wrote the conclusion, provided some editing for grammar, APA, and spelling, and
added sources to the reference page.

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Appendix B

CONTRIBUTORS OF CATHETER ASSOCIATED URINARY TRACT INFECTIONS: LACK OF FOLLOW

THROUGH ON CARE TASKS
IMPROPER CARE OF FOLEY BAG

TTASKS T

INADEQUATE PERI-CARE

PERTAINING TO DELEGATION
Positioning
bag to high
Allowing bag to be
kinked
Not emptied every
shift and/or
allowed to overfill

Not performing
peri-care per
shift
Not cleansing
around
catheter well
during pericare or after
fecal
incontinence

Leaving in too long

Using as a method of for

incontinence control
and not toileting
Not bladder scanning
to justify removal

INAPPROPRIATE USE OF
CATHETERS

CAUTI