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Abstract
When applied to healthcare environments, quality improvement (QI) is an important
process used in ensuring the safety and quality care of patients. Steps involved in quality
improvement include identifying a need to be addressed, assembling an interdisciplinary team,
collecting data on the current status, establishing measurable outcomes and quality indicators,
selecting and implementing a plan, and collecting data to evaluate results. These six steps of QI
are used to address high incidence rates of catheter-associated urinary tract infections (CAUTI)
in healthcare setting. The desired end-results of quality improvement, is an improved healthcare
environment that leads to better outcomes for patients.
from supervisory staff, risk management, and quality management are included in the
interdisciplinary team.
Data collection method
Data will be obtained from the hospitals laboratory database, and by collecting risk
management data regarding the incidence of CAUTI infections per nursing unit. To determine
the incidence of CAUTIs, the team will analyze the number of urinary catheter days and compare
them to the number of patient days. The team will then cross reference this data to the incidence
of CAUTI infections per 1000 patient days. A chart review form will be created and utilized for
all organism positive urinalysis (UA) data (see Appendix). Once all data has been collected via
the laboratory data base for the last fiscal quarter, patient charts will be reviewed to determine
whether they fit the inclusion criteria.
The criteria for inclusion in this study will be: positive UA following hospital admission
with concurrent use of urinary indwelling catheter, as well as recent discontinuance of an
indwelling urinary catheter with and without a diagnosis of secondary bloodstream infection.
Data related to uncompensated hospital costs occurred as a result of these infections will also be
obtained and analyzed.
A measure of relationship between the use of urinary indwelling catheters and CAUTI
data sets will be analyzed using the Spearman Rho correlational procedure. Information
regarding secondary bloodstream infections as well as other complications due to the CAUTI
will also be gathered and analyzed using the Spearman Rho correlational procedure. Information
related to the costs of CAUTI and associated illnesses will be analyzed using measures of central
tendency.
reach 100 percent completion by the end of the quarter. Finally, the rates of CAUTI will be
reduced by 40 percent by the end of the next fiscal year.
Strategies for implementation
Using the ADKAR method, the first step to implementing change in this area, is to
provide awareness to the need for change (Varkey & Antonio, 2010, p. 269). Kotters 8 step
model in conjunction with ADKAR breaks the first step of creating awareness into 4 more
detailed steps (Varkey & Antonio, 2010). Therefore, in creating awareness of the needed change,
the team will first increase the urgency for change, then build a team for implementation which
will work together to construct the vision, then communicate the change to the facility (Varkey
& Antonio, 2010, p. 269).
In the particular case of creating awareness of the needed change among the facility, it
would be ideal to start by providing statistical information regarding the facilitys incidence rates
of CAUTI, the increased cost for the facility, and the morbidity and mortality rates for the
consumers at the facility. Another measure that would increase the awareness of need for the
change as well as the sense of urgency would be to relay to the staff the facilitys budget and
what it would mean for the staff if the incidence rates continued (i.e. hiring freezes, layoffs, etc.).
This would relay to the staff the significance of how this problem can affect them personally.
After increasing the desire to make the change, ADKAR requires increasing
knowledge on how to change, and the ability to implement new skills and behaviors,
(Varkey & Antonio, 2010, p. 269). These three steps encompass the next phase of Kotters 8 step
model, to empower the staff in making the needed change (Varkey & Antonio, 2010, p. 269).
Kotters 8 step model adds two additional steps to this phase in which management will create
short term goals, and be persistent in making the necessary changes (Varkey & Antonio,
2010, p. 269).
To empower staff to make the needed change, educational seminars and continuing
education units will be created, on appropriate use of urinary catheters, hand hygiene, and
catheter care. To build on this education, managers can supervise staff while performing catheterrelated tasks during performance evaluations to determine competency. These educational
opportunities will serve to educate staff on the appropriate use of catheters as well as determining
situations where bladder training programs should be implemented as well as the use of
intermittent straight catheterization in an effort to reduce the occurrence of CAUTI. This
education, implementation, and evaluation procedure will also fulfill the criteria for creating
short-term goals and being persistent in making the change.
In the final phase for implementing change according to ADKAR, the team must provide
reinforcement to retain the change once it had been made, which runs concurrently with
Kotters last step, making the change permanent, (Varkey & Antonio, 2010, p. 269). In this
case, making the change permanent will include continued use of the Urinary Catheter
Questionnaire, (see Appendix A) to gather statistics and data related to catheter care and
incidence of infection. Providing updates to staff as well as updates related to the budget
improvements will help them to see how the change has positively affected their patients,
employer, and themselves. This will provide the continuation of the change by increasing the
staff willingness to participate and train new staff appropriately.
Evaluation
Clinical staff learning related to proper use and indications for Foley insertion will be
tested following the learning modules. In addition, there will be continued monitoring of the
occurrence of CAUTI and associated complications by means of the online form required for all
catheter insertions as seen in Appendix A. This form will serve to collect any relevant data
related to the appropriateness of catheterization, catheter days, secondary complications, and
other relevant data to the study. The Independent-T test will be utilized to determine
effectiveness of the interventions listed in decrease the incidence of CAUTI and its associated
complications.
Conclusion
The Centers for Disease Control (CDC) (2015) estimates approximately 13,000 deaths
annually, related to UTIs (p. 1). Academy of Nursing (AAN, 2014) states, CAUTIs are
responsible for an annual increase of $131 million in U.S. healthcare costs, (p. 1). By creating
QI teams consisting of members from a variety of health-care related fields, valuable information
and techniques can be implemented for improving patient outcomes and reducing the occurrence
of CAUTI within the hospital setting using the ADKAR model of change in conjunction with
Kotters 8 step model. After collecting and analyzing the data, evidenced-based interventions and
educational requirements will be implemented. The main goal of the QI process is to improve
documentation, reduce unnecessary use of indwelling urinary catheters, and reduce the instance
of CAUTI and secondary complications by at least 40 percent by the end of the next fiscal year.
This will serve to improve patient outcomes and satisfaction, and reduce the amount of
unreimbursed hospital expenditures related to HAIs.
References
American Academy of Nursing. (2014). American academy of nursing, choosing wisely: Urinary
catheters. Retrieved from https://aan.memberclicks.net/assets/images/ChoosingWisely/urinary%20catheters%20-%20aacn%20critcare%20%207%2014%20final.pdf
Centers for Disease Control. (2015). Catheter-associated urinary tract infections (CAUTI).
Retrieved from http://www.cdc.gov/HAI/ca_uti/uti.html
Centers for Disease Control. (2015). Urinary tract infection (catheter-associated urinary tract
infection [CAUTI] and non-catheter-associated urinary tract infection [UTI]) and other
urinary system infection (USI) events. Retrieved from
http://www.cdc.gov/nhsn/PDFs/pscManual/7pscCAUTIcurrent.pdf
Fink, R., Gilmartin, H., Richard, A., Capezuti, E., Boltz, M., & Wald, H. (2012). Indwelling
urinary catheter management and catheter-associated urinary tract infection prevention
practices in Nurses improving care for healthsystem elders hospitals. American Journal
of Infection Control, 1-6. http://dx.doi.org/10.1016/j.ajic.2011.09.017
Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner & Suddarths
textbook of medical-surgical nursing (12th ed.). Philadelphia, PA: Wolters Kluwer
Health/Lippincott Williams & Wilkins.
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Varkey, P., & Antonio, K. (2010). Change management for effective quality improvement: A
primer. American Journal of Medical Quality, 25, 268-273.
http://dx.doi.org/10.1177/1062860610361625
Yoder-Wise, P. S. (2015). Leading and managing in nursing (6th ed.). St. Louise, MO: Elsevier.
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Appendix A
Original Date:
Dates Revised:
Name
Room:
Date of insertion:
DOB:
Date of discontinuance:
UTI
Endocar
ditis
prostatitis
orchitits
bacteremia
pyleonephritis
osteomyelitis
OTHER:
meninigitis
cystitis
Catheter Days
DAYS THIS INSERTION
Prescribed drugs
Name the Drug
Allergies to medications
Name the Drug
PRIOR INSERTIONS
Strength
Reaction
Frequency Taken
12
CHECKLIST
Does this patient have a catheter inserted?
Yes
No
Yes
No
Is this a reinsertion?
Yes
No
Yes
No
Yes
No
Surgery: C-section
Surgery: Abdominal
Surgery: Pelvic
Surgery: Cardiac
Surgery: Other prolonged