running head: apa typing template -...

Running head: CHANGE AGENT 1

Change Agent: Implementing CAUTI Protocols

Michele L. Chong

DeSales University

CHANGE AGENT: IMPLEMENTING CAUTI PROTOCOLS

Catheter associated urinary tract infections (CAUTI) are preventable events that with

proper interventions can be reduced in number by great amounts. One of the Joint Commissions

2011 National Patient Safety Goals was to implement strategies in hospitals to reduce the

number of events related to this rising nosocomial infection. Despite efforts by the Centers for

Disease Control and Prevention (CDC), the Centers for Medicare and Medicaid Services (CMS),

and hospitals nationwide CAUTI’s remain the number one nosocomial infection in the United

States. Managerial involvement and staff compliance have been identified as major issues related

to overcoming these preventable events. Proper protocols and interventions need to become a

part of every healthcare organizations mission in the fight against CAUTI’s.

Today’s patients have many comorbidities which hinder the overall plan of care and

successful healthy outcome of treatments provided. Complications of hospital acquired

infections or nosocomial infections only add another element which increases the complexity of

patient care. The American Association of Critical Care Nurses (2011) reports that urinary tract

infections (UTI’s) are the most common nosocomial infection, accounting for up to 40 percent of

the infections reported by acute care hospitals. Up to 80 percent of UTI’s are associated with the

presence of an indwelling catheter. These statistics are astounding considering the fact that a

catheter associated urinary tract infection (CAUTI) is reasonably preventable. In an effort to

reduce CAUTI’s the Centers for Medicare and Medicaid Services (CMS) have implemented a

pay for performance plan that holds hospitals financially accountable for CAUTI’s incurred

during hospitalization” (Bernard, Hunter & Moore, 2012). “Mandatory reporting legislation is

aimed at getting healthcare facilities to make changes to reduce infection (Reed & Kemmerly,

2009). Hospitals will not obtain reimbursement dollars from CMS for any treatments, diagnostic

procedures and test, and increased length of stay associated with CAUTI’s. This patient safety

2


quality initiative requires acute care hospitals to report CAUTI’s based on a certain criteria. If a

patient has had a urinary catheter in place for more than two days and have contracted a UTI as

shown by a positive urine culture of > 105 colony forming units /ml with no more than two

species of microorganisms with or without symptoms associated the hospital is then accountable

(CDC, 2014). The CDC estimates that the average CAUTI costs $1,006 per event (Scott, 2009).

Annually over 450,000 patients contract this nosocomial infection placing a $450 million dollar

bill to the financial healthcare system. This financial burden to hospitals is costly and so many

initiatives to prevent CAUTI’s have been put into action across all hospitals nationwide.

The manager sees several problems on the unit, but one issues stands out because of its

implication to patient safety. There has been a steady 10 percent increase in the number of

catheter associated urinary tract infections (CAUTI) over the last three years on the unit. Since

January 2012 hospital inpatient quality reporting requirements provided by the Centers for

Medicare and Medicaid Services (CMS) mandate the reporting of all CAUTI’s (Bernard et. al.,

2012). In an effort to comply with the new mandate of reporting nosocomial infections the

organization hired a nurse specially trained in infection prevention one year ago. The infectious

disease nurse has implemented several training sessions over the last year and sterile placement

of an indwelling urinary catheter has always been a part of the annual mandatory training on the

unit. Administration is also concerned about these statistics because of the non-reimbursed

expenses accrued over the last several years in relation to the pay for performance mandate by

CMS. The nurse manager realizes that this is a serious problem effecting all members of the

organization including floor staff and patients. The characteristics of the unit provide a serious

challenge to resolving this issue. The unit is an 18 -bed long-term acute care unit where the

average hospital stay or diagnosis related groups (DRG) are 25 days. A prolonged hospitalization

3


increases the probability of attaining a nosocomial infection. The patient population consists

mainly of ventilator dependent respiratory failure and severe wound management patients

requiring long term intravenous (IV) antibiotics. Incontinent patients with sacral or other severe

wounds require an indwelling catheter in order to allow for healing and to prevent infection in

the wound. Ventilator dependent patients are almost always at risk for congestive heart failure

and other fluid retaining disorders requiring the aggressive use of diuretics and therefore a need

for accurate assessment of output from an indwelling urinary catheter. Over 90 percent of all

patients on the unit are admitted from intensive care units (ICU). “ICU’s typically use indwelling

catheters because of the need to accurately and frequently document urinary output” (Elpern et.

al., 2009). A large percent of patients being admitted already have an indwelling catheter in place

and frequently the insertion date goes unreported by the admitting nurse.

The nurse manager has viewed several issues that are directly related to the contraction of

CAUTI’s. One major issue is the number of patients that have an indwelling catheter in place. As

stated the majority of this patient population is admitted from an ICU where there may at the

time be an indication for the monitoring of the patient’s output, but moving to this level of care

may no longer require such monitoring. “Among all risk factors, increased duration of

catheterization is the greatest for development of a urinary tract infection (Elpern et. al., 2009).

A physicians order must be obtained to discontinue the use of an indwelling catheter. This poses

a great challenge for many because although the physician may not be directly affected by the

non-reimbursement of CAUTI’s, they are indirectly affected due to the reduction in overall costs

incurred by the hospital which has an impact on budgeting for physicians. Some physicians,

although educated about the prevalence of CAUTI’s struggle to weigh the pros and cons related

4


to patient care and the accurate monitoring tool catheters provide. Therefore making the

physicians an active participant in the initiative to remove unnecessary foley catheters is crucial.

Nurse driven protocols have been proven to be effective in the reduction of CAUTI’s,

most specifically in their actions of actively seeking the removal of the catheter. “Simply put,

patients without urinary catheters do not develop CAUTI. Yet, studies show that between 21 and

63 percent of urinary catheters are placed in patients who do not have an appropriate indication

and therefore may not even need a catheter (Meddings et. al., 2013). Nurse driven initiatives for

the prevention of CAUTI’s include daily documentation of an appropriate indication, date of

insertion with reminder to change catheter every 30 days on the chart as well as on the catheter

bag itself, removal of foley catheter upon admission without a physician’s order if there is no

indication to keep the foley catheter and daily initiatives by nurses to ask for the removal of the

foley as soon as the indication no longer exists. “Acceptable indicators are acute urinary

retention or obstruction, preoperatively for select surgeries, assistance in the healing of sacral

and perianal wounds, hospice/comfort care, required immobilization for trauma or surgery, and

chronic catheter upon admission” (Meddings et. al., 2013).

Another unit related issue is proper cleansing and care of the catheter. Proper cleansing

and catheter care is essential in maintaining the sterility of the urinary catheter. Techniques for

cleaning include one directional wiping from the point of insertion site towards the drainage bag

as well as the use of single clean cloths for each wipe. Evidence based practice suggest that

cleansing with a 2% chlorhexidine gluconate solution (CHG) is effective in the removal of

microorganisms that cause CAUTI’s. “Chlorhexidine gluconate reduces bacterial colony counts

nine fold and provides prolonged skin antisepsis actively fighting against fungi and gram-

positive and gram-negative bacteria including Methicillin-Resistant Staphylococcus aureus,

5


vancomyacin-resistant Enterococci, Pseudomonas aeruginosa, and other multi-drug resistant

pathogens” (Graling and Vasaly, 2013). The solution along with proper technique should be

done after bathing, after each episode of bowel incontinence and whenever visible soiling of the

catheter is assessed. Some studies suggest that after a soap and water bath the patient be wiped

with 2% chlorhexidine gluconate solution cloths on all areas of the body with the exception of

exposed wounds or areas of compromised skin integrity. One study conducted at the Baptist

Memorial Hospital in New Mexico found that by implementing a lower abdominal and bilateral

lower extremity daily bath with 2% chlorhexidine gluconate solution wipes there was a 63%

reduction in the number of CAUTI’s (Soto, 2014).

Evidenced-based practice also shows that using a silver alloy tip catheter can reduce the

number of microorganisms that can survive on the surface of the catheter therefore preventing

CAUTI’s. Beattie (2014) conducted a literature review of silver alloy impregnated catheters and

found the evidence favorable for use over the non-silver alloy catheters. The product functions

by reducing biofilm formation and/or reducing colonization of bacteria by releasing silver ions

into the urinary tract (Beattie, 2014). Currently the unit uses standardized indwelling catheter kits

complete with all items necessary for sterile insertion.

The problem of an increased number of CAUTI’s can be analyzed using Marquis and

Huston’s managerial decision making model (2015). The first step is to set objectives or

outcomes. Objective one is to reduce the number of indwelling catheters on the unit. Objective

two is to implement new evidence-based practice guided protocols to reduce the number of

CAUTI events. Objective three is to promote awareness and motivation for continual compliance

with the new implemented protocols. Objective four is to decrease the number of CAUTI events

6


by 25 percent in one year. Objective five is cost efficiency of implemented decision. Objective 6

is time efficiency of implemented decision.

The second step in the managerial decision making model is to identify all available

options or alternatives (Marquis and Huston, 2015). There are several possible alternatives to

address these objectives. Alternative one: Implement a nurse driven protocol by providing staff

with education. Alternative two: Implement a daily bathing with 2 percent chlorhexidine

gluconate solution protocol. Alternative three: Change the product to silver alloy impregnated

indwelling foley catheters. Alternative four: Hire a specialist to oversee the implementation of all

new protocols.

The next step is to analyze each alternative as shown in the consequence table below

(Table 1). A consequence table allows for fair comparison between alternatives and assists in

eliminating undesirable choices (Marquis and Huston, 2015). The objectives are listed in order of

significance with objective one being the most important and objective 6 being the least

important.

Objectives Alt #1 Alt #2 Alt #3 Alt #4

#1: Decrease the number of CAUTI events X X X

#2: Reduce the number of catheters X X

#3 Implement EBP protocols X X X

#4 Promote motivation for compliance X

#5 Cost efficiency X

#6 Time efficiency X X X

Consequence Table 1

The next step is to make a decision based on the analytical review of comparing and

contrasting the alternatives. Alternative four is the only option that does not meet the number one

7


objective of decreasing the number of CAUTI’s so therefore it is eliminated as an option.

Alternative two and three meet the same objectives both alternatives have to do with the adding

or modification of current supplies used. They are both evidence-based, proven materials to fight

against microorganisms that can adhere to indwelling catheters causing infection. Another

positive aspect of these interventions is that they are time efficient changes that can take effect

immediately. Using a silver alloy catheter possess minimal education because the actual skill set

is the same. Only an introduction to the product needs to take place. The implementation of using

2% chlorhexidine gluconate wipe for bathing will take a small amount of time to educate staff

mainly because both registered nurses (RN) and unlicensed assistant personnel (UAP) will need

to be educated. The skill set or level of the implementation of this protocol is minimal and can be

easily determined by a return demonstration of the act.

The downside of this intervention are the costs associated with it. The cost of the silver

alloy catheter is $5 more than the standard catheter package currently used in the unit. The

addition of the 2% chlorhexidine gluconate solution is $2.75 per bottle. If using incremental

budgeting the calculation of the added expense of using the silver alloy catheter can be

determined. “Incremental budgeting uses the current years expenses and multiplies that by the

inflation rate or the consumer price index” (Marquis and Huston, 2015). If 197 catheters were

used last year it would be reasonable to assume the same number of catheters or less will be used

in the within the next fiscal year. This would mean an estimated $1000 additional annual

expense.

Adding the 2% chlorhexidine gluconate solution to the supplies list would be best

accounted for with a flexible budgeting plan. “Flexible budgets flex up and down over the year

depending on volume as a result of changes in census and needs” (Marquis and Huston, 2015). If

8


on average the 30 day census is equal to 80% occupancy rate of the 18 bed unit, then the average

daily patient census is equal to 14.4 patients. Daily bathing is required for each patient on the

unit. By multiplying the daily census rate by the 365 calendar days in one year the estimated cost

of 2% chlorhexidine bathing intervention is $5,256. That is a total of $6,256 for the

implementation of both of these evidence based practices. The costs associated with the

implementation of these interventions can be offset by the cost reduction by the decreased

number of CAUTI events. “The average CAUTI event including treatment and increased length

of hospital stay costs $1000 (CDC, 2009). In this view point the cost efficiency objective could

be added to the list of pros.

Alternative one is to implement a nurse driven protocol for the removal of indwelling

catheters. This initiative is evidence-based, would reduce the number of catheters therefore

reducing the number of CAUTI events and is cost efficient. Besides the initial expense of

educating staff there is minimal to no cost associated with this intervention. However time is an

issue. Whenever there is a new protocol that incorporates several different aspects it takes time to

implement as part of a normal daily routine. Therefore it is expected to take a period of six

months to one year for this to be a fully self-sustaining initiative by RN’s. It will take continual

training and ongoing evaluation and adjustment until all obstacles are overcome.

The major obstacle to overcome will be the compliance of the staff. Adding an extra step

to their daily tasks can be daunting. Therefore it would be necessary to implement this protocol

with education including rationales and evidence-based practice. Marquis and Huston (2015)

state that an effective tool used in the healthcare setting is the SWOT analysis because it allows

strategic planners to identify those issues most likely to impact a future situation and then

develop an appropriate plan of action.

9


The first step in SWOT is awareness of strengths (Marquis and Huston, 2015). Strengths

of the unit include a high percentage of staff being bachelorette prepared, low turnover and have

worked with each other for an extended period of time, comradery, teamwork, several quality

leaders within the group and a positive overall motivating force. Other strengths are that the

initiative is evidence-based and is centered on best patient outcomes.

The second step in SWOT is awareness of weaknesses” (Marquis and Huston, 2015).

One weakness of the group is the generational diversity. This will prove to be challenging

because of different learning needs. “Older nurse often learn best in a different manner than do

new graduates and respond well to sharing anecdotal case histories (Marquis and Huston, 2015).

Another weakness of the group is the introduction of new management. The previous manager

was employed for seven years and was well like so it would not be abnormal for there to be some

resistance to change. Other weaknesses include the time away from patient care with additional

duties and documentation that need to be completed as well as the fact that both the RNs and

physicians need to “buy into” this program.

The third step is to identify external conditions that promote achievement of

organizational goals (Marquis and Huston, 2015). Having the best interest of the patient as the

core rational for the nurse driven catheter removal protocol is appealing to healthcare workers.

Also giving the employees the autonomy of enacting this protocol provides them with a sense of

value and job satisfaction.

The fourth step is to identify external conditions that threaten or challenge the

achievement of this goal (Marquis and Huston, 2015). Some nurses may feel burdened by the

additional responsibilities and quit, others may just find less satisfaction in their job due to extra

duties therefore demotivating them and decreasing their productivity. The education and learning

10


curves needed to overcome based on the cultural diversity of the staff may also prove

challenging. A major external negative force would be the slow process of its implementation

into policy with possible rejection by administration.

Overall the initiation of several objectives has been identified as being a positive

effective decision based on Marquis and Huston’s managerial decision model (2015).

Implementation of its components proves challenging in the manner of education and staff

compliance. The use of different learning and motivational theories should be incorporated into

the plan of action.

The use of adult learning theory and social learning theory can be utilized in this

situation. The adult learning theory suggests that adults need to learn the rationale behind the

reason for education before they are open-minded enough to accept learning. It is then that they

are self-directed and motivated enough to learn because they see the problem that learning solves

(Marquis and Huston, 2015). Given that the implementation of new protocols takes time and has

a learning curve for not only staff but the management implementing the protocol, it would be

appropriate to include the social learning theory. Social learning theory suggests that we learn

from our interactions with others in a social context where people learn from direct experience

and observation (Marquis and Huston, 2015). This is going to be very important in the learning

process of all interventions. For example, several UAP’s have noticed that the patients normally

complain of the CHG wipes being cold. From experience or observation of others it seems to be

best practice to saturate the chlorhexidine solution in warm water just prior to application. It is

observations and learning curves like those of social learning that will aid in the success

implementation of these interventions.

11


These interventions are only productive if the staff is willing to do them. “We often

forget that the only way to achieve our goals is through the people who work with us (Marquis

and Huston, 2015). To deter the issue of compliance the manager must express a sense of need

and promote a positive motivating climate during these times of change. Herzberg’s motivation-

hygiene theory suggests that people can be motivated by the work itself because motivators are

present in the work which gives them the desire to work (Marquis and Huston, 2015). One

important factor of Herzberg’s motivation-hygiene theory is that the manager is responsible for

building and maintaining hygiene factors. Hygiene factors are those external factors that are not

necessary to motivate the employee, but are necessary to maintain because they can lead to

dissatisfaction in a job (Marquis and Huston, 2015). Examples of such would be excessive

supervision of the nurse driven protocol and threatened job security if company policy or

adherent to protocol is not met. By placing the responsibility on the RNs and UAPs gives them a

sense of achievement, advancement, and self-recognition that Herzberg believes are true

motivators.

It would be helpful to appoint a staff committee made of RNs and UAPs and if possible a

physician to oversee the new protocols and get immediate feedback from core staff. Using this

type of evaluation tool can really assess the plans successes and failures and will shorten the

length of time issues of the plan will be resolved. Other tools used to assess the new protocols

would be education based. Every RN and UAP should be able to demonstrate proper CHG

bathing of patients and wiping of catheters. Every RN should be able to state the approved

indications for the use of an indwelling catheter as well as demonstrate sterile technique when

inserting a foley catheter. These evaluation should be done shortly after education has been

provided and then every six months to ensure competency levels. Another evaluation tool that

12


will be utilized are chart audits for compliancy with documentation of catheter insertion and

removal, as well as the completion of the daily checklist that provides information such as

indication, date of insertion, and type and size of catheter. Chart audits should be completed

weekly in order to ensure compliance as well as gather the needed data to control the program.

Frequent evaluation of each intervention is necessary to the success of the program. By doing so

obstacles and challenges can be discovered and therefore the plan of action can be changed to

meet the units’ needs.

The initiation of daily 2% chlorhexidine baths and the use of silver alloy impregnated

catheters along with a strong motivating nurse driven catheter removal program will prove to

reduce the infection rates of CAUTI’s on the unit. There are going to be challenges that the

manager cannot foresee related to structure, process and outcome of the protocol and will need to

be revised throughout its initiation. Herzberg’s motivation-hygiene theory, social learning and

adult learning theories will provide the manager with the needed information behind preventing

and resolving situations that may arise out of these change. It is important for the manager to

promote a healthy motivating climate as well as develop interpersonal relations with the staff.

This type of unit, a long-term acute care, proves to be challenging in the prevention of CAUTI’s

because of the prolonged average DRG and the patient population which mainly requires

indwelling catheters. The prevention of CAUTI has undoubtedly been a hospital based epidemic

for far too long and these evidenced-based initiatives should prove to challenge the manager’s

dilemma of increasing CAUTI rates.

13


References

Beattie, M. (2014). Potential use of silver-alloy urinary catheters for reducing infection rates.

International Hospital Equipment and Solutions Magazine Online Electronic Database.

Retrieved from http://www.ihe-online.com/magazine/index.html

Bernard, M.S., Hunter, K.F., & Moore, K.N. (2012). A review of strategies to decrease the

duration of indwelling urethral catheters and potentially reduce the incidence of catheter

associated urinary tract infections. Urologic Nurisng, 32(1), 29-37.

Center for Disease Control and Prevention (2014). Catheter-associated urinary tract infection

(CAUTI) event. Guidelines for Prevention of Catheter-associated Urinary Tract

Infections: Patient Safety Monthly Reporting Plan. Retrieved from http://www.cdc.gov/

nhsn/pdfs/pscmanual/7psccauticurrent.pdf

Elpern, E.H., Killeen, K., Ketchem, A., Wiley, A., Patel, G., and Lateef, O. (2009). Reducing use

of indwelling catheters and associated urinary tract infections. American Journal of

Critical Care, 18(6), 535-541.

Graling, P.R. & Vasaly, F.W. (2013). Effectiveness of 2% chg cloth bathing for reducing surgical

site infections. Journal of Association of PeriOperative Registered Nurse, 97(5), 547-

551.

Joint Commission. (2011). Infection control standards FAQ details: Surveillance Requirements

for CAUTI: R report issue 2 CAUTI. Retrieved from http://www.jointcommission.org/

topics/ hai_cauti.aspx

14


Marquis, B. L., & Huston, C. J. (2015). Leadership roles and management functions in nursing:

Theory and application (8th ed.). Philadelphia, PA: Lippincott, Williams, and Wilkin

Meddings, J., Krein, S.L., Fakih, M.G., Olmsted, R.N., & Saint, S. (2013). Reducing

unnecessary urinary catheter use and other strategies to prevent catheter associated

urinary tract infection: Brief update review in making healthcare safer. National Center

for Biotechnology Information: National Institute of Health Evidence Reports and

Technology Assessments 211. Retrieved from http://www.ncbi.nlm.nih.gov/books/

NBK133354/

Reed, D. & Kemmerly, R.A. (2009). Infection control and prevention: A review of hospital-

acquired infections and economic implications. Ochsner Journal, 9(1), 27-31.

Scott, R.D. (2009). The direct medical costs of healthcare associated infections in us hospitals

and the benefits of prevention. Centers for Disease Control and Prevention, National-

Public Health Institute’s Hospital Acquired Infections. Retrieved from http://www.cdc.

gov /hai/pdfs/hai/scott_costpaper.pdf

Soto, S. M. (2014). Importance of Biofilms in Urinary Tract Infections: New Therapeutic

Approaches. Advances in Biology, 20(14) Article ID 543974. doi:10.1155/2014/543974

15

running head: apa typing template -...

Documents