Introduction
Catheter-associated urinary tract infection (CAUTI) remains one of the most significant health problems in acute care facilities. According to the recent statistical estimations, the daily risk of developing CAUTIs is nearly 7 percent, and it increases depending on the length of catheterization (Amine, Helal, & Bakr, 2014). Researchers indicate that the given health issue poses a topical problem to health practitioners and the overall healthcare system as it is associated with a high level of mortality and morbidity in patients, and puts an extra financial burden on hospitals.
CAUTI can be regarded as both a barrier to the maintenance of patient safety and the outcome of an ineffective care environment. At the same time, the topicality of the given study is defined by the fact that the majority of CAUTI cases are preventable, and the reduced incidence rate can be achieved through the enforcement of prevention practices among health providers and the education of nurses regarding the problem of patient safety. According to the National Council of State Boards of Nursing (NCSBN, 2016), safety and infection control is one of the primary client needs and functions in the nursing profession. In accordance with the knowledge content noted in the NCLEX-RN subcategories, a nurse should be skillful in incident prevention and emergency response, aware of safety regulations related to the use of equipment, standards, and principles of problem management (NCSBN, 2016). Based on this, the main purpose of the paper is the investigation of the recent research findings related to the selected clinical issue and examination of the evidence which will be subsequently used for the design of a CAUTI prevention plan.
Importance
According to Nicolle (2014), CAUTI is “the source for about 20% of episodes of health-care acquired bacteremia in acute care facilities” (p. 1). Catheterization significantly increases the risk of the transfer of bacteria to the urinary tract and the consequent development of symptomatic infection. Although the presence of bacteria transferred via catheters in the organism remains asymptomatic in the majority of the acute care cases, such adverse outcome of CAUTI as bacteremia, i.e., the secondary bloodstream infection, occurs in 3 percent of patients with the given health problem (Nicolle, 2014). The researcher also identifies a few other types of CAUTI-related morbidity. They include catheter obstruction, bladder urolithiasis, purulent urethritis, gland abscesses, prostatitis, mechanical traumas, nonbacterial inflammation, immobility, etc. (Nicolle, 2014). In case the clinical issue remains unresolved, CAUTI may contribute to the increase in the length of the patient stay at the hospital or death.
Patient Population
Since bacteriuria inevitably occurs after a few weeks of catheterization, any hospitalized patient who receives urinary catheters throughout the stay at the facility is prone to the development of CAUTI. However, Nicolle (2014) states that the rate of incidence is higher for females and people of advanced age.
When speaking of potential impacts of cultural values held by diverse patients in the selected group, they may likely only affect the course of CAUTI treatment, e.g., if a person refuses to intake antibiotics due to specific health care beliefs, and so on. Nevertheless, researchers suggest that the best solution for the given health problem is the avoidance of the unnecessary application of catheters (Meddings, Krein, Fakih, Olmsted, & Saint, 2013). Therefore, it is mainly related to nursing practice and the specialists’ compliance with monitoring and intervention protocols. Thus, the cultural values held by nurses, as well as the overall organizational culture, maybe attributive to the success of the prevention strategy to a greater extent than patients’ beliefs. If a nurse is not sufficiently aware of the safety protection techniques and does not follow the basic hygiene practices, her or his incompetence may negatively affect the patient outcome. Thus, the level of nurses’ knowledge and healthcare literacy may likely have a stronger influence on the course of the intervention.
Proposed Solution
According to Meddings et al. (2013), and Nicolle (2014), the aim of an effective CAUTI prevention strategy is the limitation of the unwanted use of invasive devices. Therefore, the researchers suggest implementing two primary types of intervention: the regulation of the unnecessary placement of catheters, and the timely removal of unnecessary catheters (Meddings et al., 2013).
A number of recent studies point out that the development of protocols for the management of urinary retention in hospitalized patients, regular reporting system and analysis of the use of indwelling urinary catheters, as well as its unfavorable effects on patients may be efficient in reducing CAUTIs (Dy, Major-Joynes, Pegues, & Bradway, 2016). Thus, hospitals should design organization-wide strategies to identify and remove catheters when they are not necessary. Moreover, Dy et al. (2016) state that nurse-directed interventions are essential to comprehensive prevention endeavors.
According to Fink et al. (2012), one of the most common practices aimed at the prevention of CAUTIs is the implementation of systems for catheters removal. The results of their extensive study carried out on the sample of 75 acute care hospitals reveal the given practice is performed in 56% of the surveyed settings. The evidence provided by Tenke, Mezei, Bőde, and Köves (2017) demonstrates that the removal of catheters as early as possible and the avoidance of catheterization are the most effective prevention methods. The researchers state that the consideration of the device material and surface properties is essential for intervention success, e.g., chlorhexidine/silver sulfadiazine-impregnated catheters may avert infections. Additionally, it is recommended to pay attention to hygiene regulations (Tenke et al., 2017).
Overall, the implementation of catheter removal protocols is correlated with the overall CAUTI rate decrease. For instance, Dy et al. (2016) found that CAUTI incidence per 1.000 days may be reduced by up to 28 percent. Moreover, the study demonstrates that the education of care providers on patient assessment, placement, management, and early removal of catheters increased nurses’ commitment to the administration of removal protocols and resulted in improved their decision-making skills.
Protecting patients and self from infections is one of the primary ethical obligations of every nurse. However, due to some organizational issues, e.g., staffing and heavy workloads, nurses may not always regard patient safety as a priority. Thus, an organization-wide enforcement strategy is required. The intervention plan must aim to provide the nursing team with an appropriate environment, knowledge, and support to implement hygiene practices and monitor catheterized patients in a regular manner. To achieve better results, it is important to remove the competing ethical and professional duties which may challenge nurses’ shift towards desirable behavior. Nicolle (2014) claims that the overall success of the intervention program largely depends on such organizational factors as the existence of relevant policies for catheter indications and infection control, staffing, the level of staff education and competence, access to necessary clinical supplies, information technology, etc. Therefore, before the realization of the actual intervention, the hospital should evaluate the organizational strengths and weaknesses and fill the identified gaps. In this way, it will be possible to eliminate potential ethical issues and improve patient protection capability.
Goals
The recommended intervention program includes the design of catheter removal decision support instrument, continual nurse supervision, and submission of catheterization documentation/reports. Consistently with the removal protocol guidelines, nurses will assess patients’ conditions, needs for catheterization, and the overall time of catheterization every day and remove the devices when required. Since education and awareness are essential to the adoption of protocols (Dy et al., 2016), prior to the plan implementation, nurses will be educated by the project leader and through self-learning both online and offline.
The short-term objective of this project is the reduction of catheter use, while the long-term goal is the decreased rate of CAUTIs in the hospital. The best way to measure the first objective is the direct observation of nurses’ performance. Other surveillance methods may include self-reports, automated monitoring systems, and so on. The data collected via self-reports, personal interviews, and group meetings will also allow the identification of factors that interfere with nurses’ adherence to protocols. The long-term outcomes of the intervention plan will be measured by using statistical analysis. The documents and reports on patient conditions, demographic backgrounds, time of catheterization, and removal, etc. composed by nurses during the intervention period will serve as the source of the necessary data.
Barriers
Staffing ratios, as well as other organizational problems, may affect the success of the plan implementation (Dy et al., 2016). High workloads and low levels of nurse staffing are the major proximal causes of patient neglect. Thus, inadequate work structure may be correlated with high CAUTI rates. To improve the intervention outcomes, hospital management should balance patient-to-nurse staffing ratios and decrease the risk for nurses’ burnout. In this way, a favorable environment for high-quality care will be created and, moreover, the level of staff motivation and commitment will be increased.
Another barrier is poorly developed nurses’ skills in aseptic techniques and inadequate hand hygiene. Although the suggested intervention program is mainly focused on the time of catheterization, health protection practices play a major role in the overall success of CAUTI prevention efforts. Proper hand hygiene, the use of sterile materials, compliance with the standardized contact guidelines, and environmental controls are associated with the decreased risk of transmission of pathogens. For this reason, it can be recommended to re-educate nurses on aseptic and clean techniques before the implementation of the intervention plan. Secondly, charge nurses and supervisors should continually observe how nurses keep up with hygiene regulations and standards.
Benefits
The CAUTI prevention strategy mainly benefits patients with chronic indwelling catheters because bacteriuria in these patients is unavoidable. According to Tenke et al. (2017), antibiotic treatment of asymptomatic bacteriuria does not result in the decrease of CAUTI but only increases the organisms’ resistance. Thus, by removing catheters when the condition of a patient allows it, it is possible to reduce the risk for CAUTI development, avoid unnecessary exposure to medicines, decrease morbidity and discomfort associated with CAUTIs.
When speaking of the benefits for the nursing profession, the suggested plan largely contributes to the development of nurses’ competence and awareness. It is possible to say that individual RN’s professional performance reflects the nursing profession as a whole and affects its public image. Thus, by improving the CAUTI prevention skills of staff members, hospitals and health providers may advance the whole of the profession and, in this way, enhance nurses’ self-efficacy and the overall quality of healthcare.
Participants and Interdisciplinary Approach
An inter-professional team comprised of physicians, nurses, nurse managers, clinical nurse specialists, etc. is needed to develop and implement the plan and required intervention protocols. Along with nurses, physicians may play one of the major roles in the intervention process because usually they are considered to be responsible for the decisions to maintain indwelling catheters, while nurses frequently remain unaware of why patients have them (Kolonoski, Stanley, & Anderson, 2012). Thus, by including physicians into the process of the protocol development, and combining their clinical expertise with nurses’ understanding of patients’ needs, it will be possible to identify the efficiency criteria and authority in decision making which each party will have in the CAUTI prevention program, e.g., nurses should provide medical justification for the catheter removal to physicians, the device insertion should require the physician’s order, and so on. Additionally, in the study by Dy et al. (2016), the representatives of the Clinical Information Systems and Center for Evidence-Based Practice (SCEBP) department were included in the interdisciplinary team. The SCEBP members may instruct the hospital personnel on the issues related to information technology use, electronic data collection, data management, and so on. Therefore, their participation may significantly reduce the administrative workload of the involved health providers and, in this way, resulting in greater time availability, confidence, and overall intervention success.
Conclusion
Urinary tract infections remain one of the most topical health issues and the most common type of care-associated infections. The condition is detrimental to patients’ health. It causes significant morbidity and, in some severe cases, leads to fatal outcomes. The fact that the majority of CAUTIs develop after the insertion of the convenient yet frequently unnecessary catheters, which are then become easily forgotten by the clinical staff members, indicates that a significant number of adverse cases are preventable. Therefore, the major purpose of the prevention plan is the limitation of unnecessary catheterization, as well as the early removal of catheters. It is suggested that since the factor of time is correlated with the risk for CAUTI occurrence, by controlling the length of the catheter use (or simply avoiding it), it will be possible to prevent infection and decrease CAUTI rates within the hospital.
The selected clinical issue negatively affects hospitals, clinical personnel, and patients. Over a million CAUTIs are reported per year, and each case is associated with an average additional cost of over $670 (Meddings et al. 2013). Nowadays, the enormous amounts of additional costs become a burden for many healthcare organizations because, since 2008, Medicaid and Medicare do not provide hospitals with reimbursements for catheter-related complications. Without public health insurance coverage, many patients suffering from CAUTIs fail to pay their medical bills and, as a result, the number of outstanding revenues grows. Therefore, the prevention plan may help to improve the financial performance of hospitals. Along with this, the suggested strategy will foster a greater level of nurses’ awareness and improved professional performance. Moreover, in the long run, not only the standardized approach to CAUTI prevention may cause a decrease in infection rates, but also the development of professional confidence in nurses and greater time efficiency. Lastly, the plan is beneficial for patients, especially those who are associated with the increased risk for CAUTI occurrence (i.e., women of advanced age and patients with chronic indwelling catheters). The avoidance and removal of catheters can lead to better patient outcomes, reduce discomfort, and eliminate the issue of catheter-related immobility.
References
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Dy, S., Major-Joynes, B., Pegues, D., & Bradway, C. (2016). A nurse-driven protocol for removal of indwelling urinary catheters across a multi-hospital academic healthcare system. Urologic Nursing, 36(5), 243-249. Web.
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Kolonoski, P., Stanley, K., & Anderson, K. (2012). An interdisciplinary approach toward reducing the incidence of catheter-associated urinary tract infections in a post-acute facility. American Journal of Infection Control, 40(5). Web.
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Tenke, P., Mezei, T., Bőde, I., & Köves, B. (2017). Catheter-associated Urinary Tract Infections. European Urology Supplements, 16(4), 138-143. Web.