QSEN ChangeProject Urinary Catheter Complications Project Overview: The QSEN competency area of focus: Implementing evidence based practice (EBP). Nurses must demonstrating knowledge of basic scientific methods and processes by adhering to the Institutional Review Board (IRB) guidelines and valuing the concept of EBP as integral to determining best clinical practice for better patient outcomes. Other applicable QSEN competencies include safety and quality improvement. Case Study: ○ ○ A 68-y/o male, admitted to hospital Hx of hypothyroidism, hypertension, seizures, cerebrovascular attack with hemiplegia, dysphagia, vascular dementia, speech disorder, benign hypertrophy of prostate with urinary retention, and monocular blindness ○ NKA. ○ The PT required total care for ADLs. ○ Bolus feedings through a gastrostomy tube, occasional suctioning of his tracheostomy. ○ He was incontinent of bowel and bladder. He was alert and oriented to person and place. A nursing assistant reported that the patient had not voided all day. He did not show any signs of distention or discomfort. A catheter was ordered and prior to placement, the patient voided. The RN reported this to the charge nurse, who informed the RN to proceed with the catheter insertion. The RN did so, but the procedure did not produce any urine. Since the patient had just voided, the RN assumed the patient's bladder was empty. Two hours later, the patient began to complain of discomfort. The RN attempted to irrigate the catheter but met resistance.The charge nurse was called to assess the situation. A blood clot was found in the tubing and the catheter was replaced with a three way catheter. This catheter was misplaced and lead to severe distention of the bladder, loss of blood, and the patient was placed at risk for complications (UTI, urosepsis, and bladder rupture). Key problem: Complications associated with urinary catheters from not following EBP and unit protocols. Fishbone Diagram Significance of Problem - Urinary catheters place patients at risks for complications such as UTI, urosepsis, bladder rupture, urethra trauma, and blood loss. It has been associated with a greater risk of bacteraemia, or sepsis and death. CAUTIs account for approximately 35%-40% of all HAIs in the U.S. Every day an indwelling catheter remains in place, the risk for infection increases 3%-5%. CAUTI complications include discomfort, cystitis, pyelonephritis, prostatitis. Nearly 13,000 deaths occur annually as direct result of complications associated with CAUTIs. Contributing factors: Unnecessary placement Not removed when no longer needed Not following sterile techniques Not following unit protocol Not performing a bladder scan Improper placement (missing the bladder) Development of a Solution: Literature Review Oman et al. (2012) implemented 60 minute education on CAUTI prevention to a Med/Surg unit for two months and found that CAUTIs, improper insertion of catheters, and catheter days significantly decreased and the unit saved approx. $52,000. Quinn (2015) describes the implementation of a simple 8 point Question the Foley technique that was nurse driven. The practice change reduced the CAUTI incidences within the first year with continued reductions in subsequent years. Strouse (2015) reports in a systematic review, that studies revealed Literature Review (cont.) Mavin and Mills (2015) describe a QI approach to the implementation of CAUTI prevention strategies of the Scottish Patient Safety Programme acute adult safety program. This work included introducing UUC insertion and maintenance bundles and collecting process and outcome data to show improvements made. Findings: CAUTI rates were relatively low/ better outcomes & patient experience. Additional measures to reduce rates: Reduction in UC placement. Using alternative continence products/devices (female slipper pans, urosheaths, male penile pouches, intermittent self catheterization, bladder Our Project Recruit a multidisciplinary team at a local hospital Med/Surg Unit Collect and examine data from hospital database about prevalence of CAUTI’s and the hospital’s current policies on catheter insertion Conduct a pre-test on the recruited multidisciplinary team to determine their level of knowledge and competence on urinary catheter insertion/care Interventions: Conducted from May 1,2016- June 1, 2016 Implement “Streamlined Evidence-Based RN Tool: Catheter Associated Urinary Tract Infection (CAUTI) Prevention” Implement “Question the Foley Criteria” Conduct 60 minute education sessions once a week for two months which will include Discussion of the scope of the problem Reviewing EBP techniques for prevention of catheter infections Competency based training and evaluation for catheter placement and monitoring Charge Nurse catheter care rounds Development of a Solution: The Change Resources of time: CAUTI/Catheter Training for nursing staff (Approximately eight 60 minute educational sessions for two months) Fiscal resources: Stakeholders: Internal: Nursing staff Unit staff (management, housekeeping and nursing managers) External: The PATIENT and FAMILIES The community Marketing Strategies: Educating the nursing staff regarding data about prevalence of CAUTI rates Provide nursing contact hours for completing training Change Theory ● “The inclusion of front line staff in planning groups and key decision – making processes promotes a feeling of empowerment that helps to overcome their resistance to the change and enables them to understand the importance of the project and how it will beneficially affect client care.” (http://cjni.net/journal/?p=2888) ● Unfreezing: ○ Include key stakeholders in the process of decision making ○ Present to stakeholders and the recruited multidisciplinary team the data of the prevalence of CAUTI’s in their hospital ○ Restraining forces: unwilling to change; “this is the way we have always done it”; lack of experience ○ Driving forces: adequate funding, management support, will reduce Change Theory: The Change The period of change in which our interventions would take place Help facilitate the multidisciplinary team to adapt to and transition to these new interventions Change Theory: Refreezing Reinforce the change by providing ongoing support and evaluation leading to stabilization Encourage charge nurse and hospital administration to support the nursing team in continuing to perform these new interventions Obstacles to Change ○ Nurses not wanting to change old habits ○ Healthcare providers wanting to place urinary catheters for their own convenience (Inappropriate catheter use/ nurse burnout) ○ Nurse/patient ratio out of proportion leading them to being rushed ○ Nurses not participating in continuing education and training ○ Lack of knowledge about evidence-based practice Evaluation: How will change be measured? ★ Data collection: ■ Number ■ Number ■ Number ■ Number of of of of catheters inserted in one month, insertions where all EBP and unit protocol were followed, insertions resulting in complications, and catheterizations that met criteria for insertion ★ Rate of occurrence can be compared between pre- implementation and postimplementation of the changes made. ★ Post test given to staff to evaluate knowledge of catheter competence ★ All variables were summarized using descriptive statistics appropriate for the level of measurement. ○ Statistical analyses were conducted to compare the differences between the baseline and the post intervention ○ Alpha was set at .05. Evaluation Tools http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/Improving-YourPractice/ANA-CAUTI-Prevention-Tool/ANA-CAUTI-Prevention-Tool.pdf Results: What could happen? Positive: The Med/Surg unit would have decreased number of CAUTIs, successful adaptation to the new intervention tools, and the staff’s knowledge/competence on catheter care/insertion would improve, reduce inappropriate catheter use and facilitate prompt removal. Negative: no change in numbers of CAUTIs, resistance to new intervention tools, and no change in staff knowledge/competence on catheter care/insertion Effectiveness of our plan will depend on the increase of decrease of CAUTIs Results: What could happen? What could facilitate change: Hospital and hospital cooperation, frontline “buy in” What could inhibit change: Resistance from staff, Hospital indifference Alternative approaches: A statewide program in Michigan focused on educating clinicians about appropriate urinary catheter indications and included daily assessment of continued catheter need during nursing rounds. Effective strategies to reduce inappropriate catheter use and facilitate prompt removal include use of electronic order sets, criteria-based catheter orders, electronic reminders, nurse driven catheter removal protocols, and daily nurse-physician catheter rounds. References American Nurses Association. (2016). CAUTI prevention tool. Retrieved from http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/Improving-Your-Practice/ANA-CAUTI-Prevention-Tool/AN A-CAUTI-Prevention-Tool.pdf Fakih MG, Watson SR, Greene MT, et al. Reducing inappropriate urinary catheter use: a statewide effort. Arch Intern Med 2012;172:255–260. Mavin, C., & Mills, G. (2015). Using quality improvement methods to prevent catheter-associated UTI. British Journal of Nursing, 24S22-S28 5p. doi:10.12968/bjon.2015.24.Sup18.S22 Newman, D. K., Strauss, R., Abraham, L., & Major-Joynes, B. (2015). Unseen perils of urinary catheters. US Department of Health and Human Services. Retrieved from https://psnet.ahrq.gov/webmm/case/352/ 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. Quinn, P. (2015). Chasing Zero: A Nurse-Driven Process For Catheter-Associated Urinary Tract Infection Reduction in a Community Hospital. Nursing Economics, 33(6), 320-325 6p. Strouse, A.C. (2015). Appraising the Literature on Bathing Practices and Catheter-Associated Urinary Tract Infection Prevention. Urologic Nursing, 35(1), 11-17 7p. doi: 10.7257/1053-816X.2015.35.1.11