¶ … Quality Improvement Program Needs Assessment and Quality Improvement Plan

Paula Stechschulte, PhD, RN

Quarter

This paper discusses the process of drafting a quality improvement plan at a community level medical facility, a plan that is aimed at reducing days under urinary catheter and also reducing the rates of infections associated with the said catheters. As a high rate of incidence of infection related to catheter usage is costly for the hospital, this implementation strategy is aimed both at reducing hospital costs and boosting patient health, safety and satisfaction. The requirement for this strategy is a level of nursing education, dedication and commitment that will necessitate training and a "go-live" session of implementation which can be stressful for workers and for patients as both adjust to change. The management directors will need to not only monitor progress using the Six Sigma method but also will need to effectively maintain levels of employee morale and support so that staff fatigue does not set in as a result of over-emphasis of the importance of monitoring catheters and implementing the overall strategy. The budget for the plan is estimated to be within the employable funds of the hospital but alternative fund raising measures are available should the hospital choose to manage the plan via different financial route. Consideration is given to appropriate leadership theories to serve as a guiding framework for implementation and a strategy is described that utilizes Emotional Intelligence, Social Intelligence and transparency in order to maintain a positive workplace environment and a quality culture.

Introduction

Catheter-associated urinary tract infection (CAUTI) is the most prevalent HAI (hospital acquired infections), responsible for up to 34% of all hospital acquired infections. Over half a million cases of CAUTI are reported every year in the U.S., leading to higher rates of mortality and morbidity and overuse of hospital resources. The condition is of a special concern especially among older patients, based on the revelations of inappropriate use of IUCs (Indwelling urinary catheters) among this vulnerable population. In spite of being the most common HAI, catheter-associated urinary tract infection has never been a focus of HAI control programs (Fink, et.al, 2012). A countrywide survey of infections among professionals involved in the control of hospital infections reported poor implementation of catheter-associated urinary tract infection prevention measures meant to reduce the number of catheter days such as the early removals of catheters and avoidance of indwelling urinary catheters. These reports are of concern, especially when considering different studies that recommend several evidence-based prevention practices, for instance, those suggested by the CDC (centers for disease control) in its 2010 evidence-based guidelines, towards significantly reducing the number of catheter-associated urinary tract infections. The 2010 CDC document makes over sixty recommendations specific to CAUTI. However, it must be said that the majority of these recommendations are backed with very little evidence.

The Guidelines released in 2009 by IDSA (Infectious Diseases Society of America) defines catheter-associated urinary tract infections (CAUTI) as the infections contracted by patients currently fitted with catheters in their urinary tracts or had been fitted with catheters in their urinary tracts within the last forty-eight hours. Also, according to the IDSA Guideline, the term urinary tract infection (UTI) by itself refers to a significant concentration of bacteria in a patient with signs or symptoms ascribable to the urinary tract and no other source. UTIs (Urinary Tract Infections) are the most prevalent hospital acquired infections accounting for almost forty percent of all adult nosocomial infections. It is also important to note that an overwhelming majority of UTIs (eighty percent) are caused by IUCs (Leithhauser, 2004).

According to Gorman (2011), between 15 and 25% of all hospitalized patients are fitted with short-term indwelling catheters. The day-to-day risk of contracting CAUTI is three to seven percent in an acute care environment. The IUCs are often placed for the wrong reasons and patients are often unaware of the presence of the medical equipments. As a result, the IUCs stay in the tract for lengthy durations. However, there is a significant variation of the reported rates of urinary tract infections among patients fitted with IUCs (Gorman, 2011).

Data from the CDC, through the NHSN (National Healthcare Safety Network) revealed that acute care settings reported rates of between 3 and 7.5 infections per a thousand catheter days. Another government agency, the CMS (Centers for Medicare and Medicaid Services), listed hospital-associated UTIs among the eight conditions for which health facilities will not be receiving any additional funds (Gorman, 2011). The...

The agency also lists catheter associated urinary tract infections as the second most prevalent cause of nosocomial blood infection.
Budgetary considerations are well within the means of the hospital and should present no difficulty for the implementation of this plan, as it is estimated that the total cost savings of reduced CAUTI cases will be approximately $150,000 per year, while the "go-live" stage of the implementation will require sufficient funding to meet the needs of supply levels (alternative types of catheters, beddings, waste removal) and a one-time purchase of a bladder scanner (approximately $10,000). These costs should be able to be absorbed by the hospital. If, however, there is some disagreement by upper management, a grant could be applied for with the state or an appeal to local donors could be made as is consistent with the hospital's mission over the years.

Risk considerations include patient safety, staff fatigue, proper education, oversight of the implementation, and maintenance of supply upkeep. These concerns will be mitigated through the application of Six Sigma as well as the appropriate utilization of management and leadership theories to guide the process, such as Knowledge leadership and Transformational leadership, including effective use of EI and transparency qualities.

The strategic plan includes educating both staff and patients on the positive impact of reducing catheter exposure as a means of controlling and reducing the rate of infection at the hospital. Training and monitoring will be implemented in order to guide the project and Six Sigma will employ a top-down approach that will include all levels of staff working together to fulfill the basic 4E's of implementation.

Definition of the problem

The stakeholders involved include the physicians, nurses, the hospital and the patient. As stated above the CMS has listed CAUTIs among the eight conditions for which health facilities will not be receiving any additional money (Gorman, 2011). The CMS guidelines also state that complications and risks associated with catheter-associated urinary tract infections as gram-negative bacteremia, chronic or acute pyelonephritis, epididymitis, prostatitis, periurethral abscess, and cystitis, which can cause death in up to 60% of the cases. A complication resulting from a catheter-associated urinary tract infection can increase the hospital stay of a patient by up to 0.4 days if it doesn't show any symptoms and 48 hours if it is symptomatic (Leithauser, 2004). Even though a lot of progress has been achieved in the prevention of catheter-associated urinary tract infections, there is still some way to go in addressing some of the unresolved issues surrounding the condition (Gorman, 2011). Efforts have to be focused on developing the best practices in IUC use and prevention of the condition. Research should also be done to investigate and document: which of the cases absolutely require the use of a catheter; after what time span should reassessments be done to check if a patient still needs to use an IUC; what alternative methods are available; and the best practices concerning catheter use. Attention should also be focused on the need to continuously reassess the healthcare gaps and also the retraining of staff when necessary. All these issues will be addressed in this plan.

Currently, there are two guidelines in place for catheter use. There is one by the CDC and another one by IDSA. The CDC published in 2009 highlights several recommendations for the prevention of CAUTIs. First, the guideline recommends the utilization of catheters only for appropriate cases. The CDC guidelines also recommend that the frequency of use and the duration of use of catheters should be kept at a minimum among all patients, particularly among patients from vulnerable communities such as the elderly, women and individuals with impaired immunity. Even though, the CDC guidelines recommend that catheters should be maintained in place for as long as it is necessary, the CDC suggests that the indwelling catheters fitted in individuals undergoing operations ought to be removed as soon as possible after the surgery is completed (Brusch, 2015). The utilizations of IUCs for treatment of incontinence ought to be avoided. One of the other important recommendations by the 2009 CDC guidelines is that nurses and physicians should avoid routinely utilizing systemic anti-microbials to prevent CAUTIs in patients in need of either long of even short-term catheterization. This is because the routine use of systemic anti-microbials has been shown to lead to more resistant bacterial strains.

The Guidelines released in 2009 by IDSA (Infectious Diseases Society…