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Preventing Catheter Associated Urinary Tract

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Preventing Catheter Associated Urinary Tract PREVENTING CATHETER ASSOCIATED URINARY TRACT INFECTIONS: IMPLEMENTATION OF A NURSE DRIVEN CATHETER REMOVAL PROTOCOL AND EDUCATION PROGRAM A Project Presented to the Faculty of California State University, Stanislaus In Partial Fulfillment of the Requirements for the Degree of Master of Science in Nursing By Jessica Fisher May 2015 CERTIFICATION OF APPROVAL PREVENTING CATHETER ASSOCIATED URINARY TRACT INFECTIONS: IMPLEMENTATION OF A NURSE DRIVEN CATHETER REMOVAL PROTOCOL AND EDUCATION PROGRAM by Jessica Fisher Signed Certification of Approval Page is On File with the University Library Dr. Debbie Tavernier EdD, MSN, RN Date Professor of Nursing Stephanie Lambert BSN, RN, CIC Date Infection Preventionist Evelyn Eubank MSN, RN, CIC Date Infection Preventionist © 2015 Jessica Fisher ALL RIGHTS RESERVED DEDICATION This project is dedicated to my husband, he is a stud muffin. iv ACKNOWLEDGEMENTS Thanks to all of the professional nurses in this world, who work tirelessly to improve the quality of healthcare we all deserve. Additionally, I would like to give a special thanks to Dr. Debbie Tavernier, Stephanie Lambert, Evelyn Eubank, and the entire faculty of the CSU Stanislaus Nursing Department. v TABLE OF CONTENTS PAGE Dedication ............................................................................................................... iv Acknowledgements ................................................................................................. v Abstract ................................................................................................................... vii Catheter Associated Urinary Tract Infections: A Priority for Prevention .............. 1 Review of Literature ............................................................................................... 4 Physician Reminder Projects ...................................................................... 5 Nurse-Driven Protocols for Removal of Foley Catheters ........................... 7 Alternatives to Catheterization ................................................................... 9 Catheter Maintenance ................................................................................. 12 Theoretical Framework ........................................................................................... 14 Application of Mezirow’s Transformative Learning Theory ..................... 15 Application of Peplau’s Nurse-Patient Relationship Theory ...................... 19 Summary of Theory Application ................................................................ 21 Methodology ........................................................................................................... 23 Project Development ................................................................................... 23 Discussion ................................................................................................... 33 Evaluation ............................................................................................................... 34 References ............................................................................................................... 38 Appendices A. Nurse-Driven Protocol ................................................................................ 44 B. Online Education: Part 1 ............................................................................. 46 C. Online Education: Part 2 ............................................................................. 68 D. Policy and Procedure .................................................................................. 75 E. Online Education: Part 3 ............................................................................. 86 F. Competency ................................................................................................ 97 G. Learner Pre-Assessment.............................................................................. 103 vi ABSTRACT The purpose of this project is to reduce the catheter associated urinary tract infection rates (CAUTI) in a 209 bed acute care facility located in California’s central valley. Catheter associated urinary tract infections are responsible for up 380,000 infections, 9,000 deaths and $451million in health care costs per year in the United States. It is also estimated that up to 50% of urinary catheters are used unnecessarily. Nursing driven discontinuation protocols are an effective means of decreasing catheter days and subsequently decreasing CAUTI rates. Each day a catheter remains in place the risk for infection increased by 7%. The CAUTI rates for the project facility have been ranked as the fourth worst in the state of California. To promote CAUTI prevention an online education module is introduced. The education module includes proper techniques for catheter insertion and maintenance, patient education strategies and the directions for using the nursing driven catheter discontinuation protocol. The online module is mandatory paid training. Nurses must complete a learner pre-test, assessment, and post-module competency. Supplemental education is provided for all staff during rounds and staff meetings using simulation and case studies. Education has also been provided for physician staff during unit rounding, online forum and presentation at physician meetings. Future CAUTI prevention strategies to enhance prevention at this facility will include policies and education to improve emergency department catheter utilization, critical care catheter utilization and nursing assistant education. vii CATHETER ASSOCIATED URINARY TRACT INFECTIONS: A PRIORITY FOR PREVENTION Illness causes a vulnerable state for many. It is because of this vulnerability, that people need the reassurance that healthcare will be delivered safely and efficiently. Unfortunately, the healthcare system does not always provide such reassurance. The groundbreaking report “To Err is Human” released in 2000 by the Institute of Medicine’s Committee (IOM) on Quality of Health Care in America revealed how health care system errors have contributed to increased morbidity and mortality rates, prompting the public’s demand for improvement in the quality of health care and legislative action. As outlined in this report a significant health care system failure that occurs is Hospital Acquired Infections (HAI). Although some progress has been made since the release of this report, HAI’s continue to occur. A multi-state point prevalence survey for 2011 found that one out of every 25 patients within the acute care setting had at least one HAI on any given day (Magill et al., 2014). The estimated total number of HAI is 721,000 with 75,000 deaths occurring during hospitalization (Magill et al., 2014). Urinary tract infections (UTI) are the most commonly reported HAIs in the United States, accounting for 32% of all infections (Weber et al., 2011). The biggest risk factor for acquiring a UTI is the presence of an indwelling urinary catheter (Weber et al., 2011). Each day an indwelling catheter is in place increases the risk of infection an estimated 3% to 7% (Lo et al., 2014). Urinary tract infections that occur 1 2 as a result of an indwelling urinary catheter are referred to as catheter associated urinary tract infections (CAUTI). Distinct epidemiological criteria for defining CAUTI are outlined by the Centers for Disease Control’s National Health Care Safety Network (NHSN). The NHSN is the nation’s largest database for tracking HAIs (Centers for Disease Control and Prevention, 2013). Not only does CAUTI cost lives, it also creates huge financial implications for the health care system. Federal initiatives affecting financial reimbursement related to CAUTI for hospitals receiving Medicare and Medicaid are the most significant of these financial implications. The Value Based Purchasing Program (VBP) was established in 2010 by the Affordable Care Act (ACA). The VBP was added to the Social Security Act 1886(o). Historically, hospitals would receive payment for a procedure or event for a given patient and would also have been reimbursed for a given amount to treat a urinary tract infection if the patient had acquired one. Currently, if a patient acquires a CAUTI during hospitalization, the reimbursement for the infection will not be paid leaving the hospital to absorb the cost of the infection as well as the associated cost of the length of stay associated with such an infection (Meddings et al. 2012). Attributable costs associated with CAUTI range from $758 to $1,006 (Zimlichman et al. 2013). Hospitals that perform well and have a CAUTI rate less than the national average are paid a higher reimbursement than the average or lower performers (U.S Department of Health and Human Services, 2012). Currently up to 1% of total reimbursement can be lost associated with poor 3 performance using the VBP, future initiatives will further reduce payment up to 2% (U.S. Department of Health and Human Services, 2012). Clearly, CAUTI is a matter of concern, and focus on prevention should be a high priority. Many methods of CAUTI prevention have been researched with attention to three focuses: insertion, maintenance, and discontinuation or prevention of insertion. These recommendations for prevention are summarized in The Association for Professionals in Infection Control and Epidemiology “Guide to Preventing Catheter-Associated Urinary Tract Infections” (Felix, Bellush, & Bor, 2014). This proposed CAUTI project focuses on infection prevention. The project involves educating registered nurses working
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