Center for Disease Control and Prevention Discussion

Center for Disease Control and Prevention Discussion

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Sonya Hash
Week 4 Initial Blog Post Sonya Hash
COLLAPSE

Blog Post Week 4

Discuss the Practice Problem

The current practice problem has been correctly defined at the suburban community acute care hospital is an increasing number of catheter-associated urinary tract infections (CAUTIs). The CAUTI rate for fiscal year to date is 2.73/ 1000, greater than the organizational target of 1.70 / 1000 catheter days. Despite previous prevention efforts, CAUTI rate continue to increase. Center for Disease Control and Prevention Discussion

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There has been discussion at the hospital that some root causes (practice gaps) may include IUCs are remaining in place longer than is clinically necessary with initial report of causes being that nurses donâ€t feel comfortable removing them, are concerned they will “get in trouble, or there is no order to follow for removal (Blodgett & Sheets, 2021). Some nurses report not feeling comfortable to removing the catheter with consulting a provider, despite the order for nurse -directed removal. Some nurses also feel they will be causing unnecessary discomfort to the patient if they remove the catheter, but later have to reinsert it or straight catheterize the patient for retention. During chart review justification for IUC initiation or continuation do not appear to meet the standard criteria. Notes stating that the IUC will be maintained “until patient is better” or “because they arenâ€t moving much”. When patients are transferred out of the intensive care unit, the IUC is often not evaluated for potential removal, when there is opportunity to do so.  Center for Disease Control and Prevention Discussion There may be additional opportunities to use external urine collection devices instead of the IUC that are not currently utilized. The post void residual (PVR) is not documented in the EMR in the same location, making chart review during voiding trials more difficult. There is currently no hard stop for a maximum duration of an IUC, such as having to renew the order and justify continuation every 24 hours. There is a perceived opportunity to have a more rigorous review of the necessity of IUC continuation during daily rounds. Patients are not necessarily educated on the risks of having a catheter inserted and continued. Center for Disease Control and Prevention Discussion

Another concern is that urine specimens are being sent for urinalysis with reflex to culture from catheters that have been indwelling > 24 hours, and may cause false positive CAUTI results (due to catheter-associated asymptomatic bacteriuria). Reduction of false positive results could decrease unnecessary patient complications/ outcomes and healthcare costs from overtreatment/ complication of unnecessary treatment. Reduction of catheter use is known to reduce CAUTI incidence. Other contributing factors may also include the order not being entered as nurse-directed when appropriate. Center for Disease Control and Prevention Discussion

Explain Whether the Practice Focused Questioned was Refined and Why

The PICOT practice focused question to facilitate the literature search to guide improvement was revised and narrowed at this time to be “What are the best interventions to improve compliance with an IUC nurse driven removal protocol by adult acute care inpatient nurses”. The question “What are the best interventions to improve compliance with permitting/ facilitating timely removal of IUCs by physicians and advanced practitioners in adult acute care inpatient setting”? was removed from the proposed search at this time, as the focus will be narrowed to nursing at this time. Center for Disease Control and Prevention Discussion After discussing with stakeholders, it appears that the first area of opportunity will be empowering / reminding nursing staff to remove the catheter as soon as possible, prevent specimens being sent that can be contaminated/colonized from a catheter, and look for alternatives to inserting the catheter (using external devices) when possible.

What is Currently Working and What Has Not Worked Center for Disease Control and Prevention Discussion

The nurse directed protocol removal protocol has been implemented at the organization but it is not consistently adhered to. Pericare wipes specifically for patients with an IUC are available, but not always used correctly despite education. The EMR has order sets for nurse vs provider driven removal, but it is not always entered correctly. Other gaps are noted in the previous section.

What Changes Could Be Implemented to Address the Problem Center for Disease Control and Prevention Discussion

Leadership strategies for this would include using a change model framework such as Kurt Lewinâ€s change model which consists of “unfreezing” (motivating change, creating a vision), “movement” (developing political support and managing the transition), and “refreezing” (sustaining momentum and implementation of change). Leaders have to understand current state, desired future state, and design a way to get there, and motivating others to make the change happen. Additional leadership strategies include being a transformational leader vs a transactional leader. It is essential to involve those that are effected by the change in the planning of the change, to share knowledge and communicate effectively throughout the process, as well as clearly defining the resources necessary, and ensuring political support (Hussain et al., 2018). Center for Disease Control and Prevention Discussion

Are These Changes Supported by Evidence?

The desired changes to empower / encourage nurses to adhere to the nurse directed removal protocol, removing the IUC as soon as possible, and looking for alternatives to IUC use are all also supported by evidence (Center for Disease Control and Prevention, 2015, November 5; Schiessler et al., 2019; Tyson et al., 2018), as well as not culturing from a catheter that has been in place more than 24 hours (Frontera et al., 2021). Center for Disease Control and Prevention Discussion

References

Blodgett, T. J., & Sheets, C. (2021). Perceptions of a nurse-driven urinary catheter removal protocol in a hospital setting. Clinical Nurse Specialist, 35(2), 73-79. https://doi.org/10.1097/nur.0000000000000579 Center for Disease Control and Prevention Discussion

Center for Disease Control and Prevention. (2015, November 5). Catheter-associated urinary tract infections (CAUTI). https://www.cdc.gov/infectioncontrol/guidelines/cauti/index.html#anchor_1552413639

Frontera, J. A., Wang, E., Phillips, M., Radford, M., Sterling, S., Delorenzo, K., Saxena, A., Yaghi, S., Zhou, T., Kahn, D. E., Lord, A. S., & Weisstuch, J. (2021). Protocolized Urine Sampling is Associated with Reduced Catheter-associated Urinary Tract Infections: A Pre- and Postintervention Study. Clin Infect Dis, 73(9), e2690-e2696. https://doi.org/10.1093/cid/ciaa1152

Hussain, S. T., Lei, S., Akram, T., Haider, M. J., Hussain, S. H., & Ali, M. (2018). Kurt Lewin’s change model: A critical review of the role of leadership and employee involvement in organizational change. Journal of Innovation & Knowledge, 3(3), 123-127. https://doi.org/https://doi.org/10.1016/j.jik.2016.07.002

Schiessler, M. M., Darwin, L. M., Phipps, A. R., Hegemann, L. R., Heybrock, B. S., & Macfadyen, A. J. (2019). Don’t Have a Doubt, Get the Catheter Out: A Nurse-Driven CAUTI Prevention Protocol. Pediatr Qual Saf, 4(4), e183. https://doi.org/10.1097/pq9.0000000000000183 Center for Disease Control and Prevention Discussion

Tyson, A. F., Campbell, E. F., Spangler, L. R., Ross, S. W., Reinke, C. E., Passaretti, C. L., & Sing, R. F. (2018). Implementation of a Nurse-Driven Protocol for Catheter Removal to Decrease Catheter-Associated Urinary Tract Infection Rate in a Surgical Trauma ICU. Journal of Intensive Care Medicine, 35(8), 7 Center for Disease Control and Prevention Discussion