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Running head: CAUTI LEADERSHIP ANALYSIS STRATEGY 1

Leadership Analysis Strategy for the Prevention of


Catheter Associated Urinary Tract Infections: Foley Free Program
Nate Dixon, Amanda Mikula, Mary Nason, Bill Winowiecki, and Sara Young
Ferris State University

CAUTI LEADERSHIP ANALYSIS STRATEGY 2
Abstract
Catheter associated urinary tract infections (CAUTI) continue to be a problem especially in the
acute care setting. Increased length of hospital stay, reduced quality of patient care, and loss of
hospital reimbursement are all associated with CAUTI. The Foley-Free program outlines the
implementation of a nurse-driven protocol for the prevention of CAUTI through the development
of an interdisciplinary team. This nurse-driven strategy illustrates the steps needed to decrease
the use of indwelling urinary catheters and thus the incidence of CAUTI, causing improved
patient outcomes. Evaluation of these measures reflects evidence-based research and upholds
professional nursing standards of care.
Keywords: CAUTI, Foley-Free, evidence-based practice, acute care setting, patient
outcomes, nurse-driven protocol

CAUTI LEADERSHIP ANALYSIS STRATEGY 3

Leadership Analysis Strategy for the Prevention of Catheter Associated Urinary Tract Infections:
Foley Free Program
Catheter-associated urinary tract infections (CAUTI) are a common healthcare-associated
infection and a major concern for all healthcare workers. They cause an increased amount of
pain and discomfort, and lead to increased length of stay, cost, and mortality. Each year, more
than 13,000 deaths are associated with CAUTI (CDC, 2012), making it an important focus for
nursing interventions. CAUTI is defined as clinical symptoms and laboratory evidence of
urinary tract infection in a patient who has had a urethral catheter in place for more than two
days (Magers, 2013). In addition, reimbursement from Medicare and Medicaid is dependent
upon the absence of CAUTI.
Catheter Associated Urinary Tract Infection Prevention
Approximately 75% of urinary tract infections (UTI) acquired while in the hospital are
associated with urinary catheter use (CDC, 2012). The most significant risk factor for
developing a UTI is prolonged use of indwelling urinary catheters (CDC, 2012). CAUTI can
lead to complications such as cystitis, pyelonephritis, gram-negative bacteremia, prostatitis,
epididymitis, orchitis, endocarditis, vertebral osteomyelitis, septic arthritis, endophthalmitis, and
meningitis (CDC, 2012). CAUTI is the most common hospital acquired infection (HAI) (CDC,
2012).
Beginning in 2008, the Centers for Medicare and Medicaid Services (CMS) stopped
reimbursing hospitals for treatments specific to reasonably preventable hospital acquired
complications. The intention was to encourage hospitals to improve patient safety in addition to
reducing Medicare spending. CAUTIs are considered reasonably preventable and as such, no
additional payment is provided to hospitals for CAUTI-related treatment. Hospitals are required
CAUTI LEADERSHIP ANALYSIS STRATEGY 4
to report certain data about patients at the time of discharge (administrative discharge claims
data). This data can then be used to deny payment for specific complications (HAIs) in addition
to publicly reporting and comparing hospitals using their complication rates (Meddings et al.,
2012). Fortunately, the use of Foley-Free programs with nurse-driven protocols in acute-care
settings have been shown to significantly reduce catheter use and thus CAUTI (Mori, 2014).
Interdisciplinary Team
An interdisciplinary team is a group of healthcare workers that comes together with the
common goal to collaborate and improve patient health and well being (Yoder-Wise, 2011).
Utilization of an interdisciplinary team is crucial for the implementation of a Foley-Free
program. A team approach is necessary for creating an evidence-based nurse-driven protocol,
obtaining electronic data about the use of urinary catheters, determining dwell times and
prevalence rates of CAUTI, and evaluating outcomes and data after protocol initiation. This
interdisciplinary team is also responsible for hospital-wide education for the prevention of
CAUTI. It will consist of floor nurses, a charge nurse, a physician liaison, a quality
improvement representative, education services, a pharmacist, and an infectious disease
physician.
Since nursing is at the frontline of catheter care, this protocol will be nurse-driven and the
team will be nurse-led. The floor nurses will communicate the presence of an indwelling urinary
catheter at the end of each shift to the charge nurse and provide the reason for the continued need
for the catheter. The charge nurse will maintain a list of those on the unit with catheters as well
as insertion dates and reason for continued need. This list, in addition to the electronic medical
record, will provide data for quality improvement personnel to track the number of catheters is
use, reason for use, indwelling times, infection rates, and signs of active infection. If a CAUTI is
CAUTI LEADERSHIP ANALYSIS STRATEGY 5
suspected, the primary care provider, infectious disease doctor, and pharmacist will be notified
and further treatment discussed. Education staff will be responsible for maintaining evidence-
based protocols and ensuring that staff is educated and updated regarding any changes to the
protocol.
Data Collection Method
The collection of data is an important aspect in determining the incidence of CAUTI.
Quality improvement utilizes collected data to initiate changes in the protocol or provide
education where gaps in communication or skills are noticed. A study by Magers (2013),
utilized statistical software to collect data on the number of days a catheter was in place before
and after nurse-driven protocols were initiated in addition to collecting data on CAUTI rates.
Use of a computer program that is embedded within the nursing assessment that asks specific
questions regarding catheter use, insertion date, removal date, and reason for use can be utilized
by quality improvement to track data and trends. Additionally, the Agency for Healthcare
Research and Quality has funded the On the CUSP: Stop CAUTI initiative that provides data-
collection support for organizations striving to reduce CAUTI (AHRQ, 2014). The Foley-Free
program plans to utilize both forms of data collection to track trends in catheter use, CAUTI
rates, and to guide infection prevention efforts based on evidence-based nursing research.
Outcomes for CAUTI Initiatives
Outcomes in the prevention of CAUTI include indications for catheter use,
documentation, communication, and compliance each shift. Staff education and competency will
be provided and monitored twice a year to review the protocol and changes to policy. The goal
of the Foley Free program is to reduce the number of patients who receive indwelling catheters
by 25% in 90 days. For patients who meet the criteria for indwelling catheters, the goal is to
CAUTI LEADERSHIP ANALYSIS STRATEGY 6
reduce the number of dwelling days by 25% in 90 days. Multiple studies indicate that 21-56% of
urinary catheters are placed without appropriate indication (Meddings et al., 2014). The CDC
recommends catheter use only for: peri-operative for selected surgical procedures (with removal
within 24 hours), urine output monitoring in critically ill patients, management of urinary
retention or obstruction, assistance in pressure ulcer healing for those who are incontinent, end-
of-life care, or prolonged immobilization (Mori, 2014). Adherence to the recommended CDC
guidelines will be included in the Foley Free protocol, which will improve outcomes associated
with CAUTI.
Implementation Strategies
Evidence extensively studied by the CDCs Healthcare Infection Control Practices
Advisory Committee (HICPAC) and CMS strongly supports core strategies in the reduction of
CAUTIs (Magers, 2013). These basic strategies include the practice of good hygiene, use of
standard precautions, aseptic technique during catheter placement, use of high quality sterile
equipment, maintenance of a closed drainage system, unobstructed flow, and ensure drainage
bag remains below the level of the bladder (Magers, 2013). Making sure these basic core
strategies are implemented involves educating staff, team building, and encouragement for
successful outcomes. In-services will be held initially for all staff to review evidence-based
guidelines and a short quiz will administered.
Nursing will be the driving force behind the administration of the Foley-Free program.
Huddles at shift change led by the charge nurse will alert all staff of patients with catheters and
keep the focus on the importance of reducing CAUTI. Nursing documentation in the electronic
medical record will include a checklist explaining reasons for indwelling catheter use. If a
catheter is not indicated by one of the outlined reasons, it will be the nurses responsibility to
CAUTI LEADERSHIP ANALYSIS STRATEGY 7
notify the primary care doctor. If a catheter is indicated, use of a securement device will be
utilized to reduce bacterial contamination and irritation in addition to the recommended core
strategies outlined in the protocol. Quality improvement will track catheter use and CAUTI and
quarterly meetings with staff will display results of protocol adherence. Nursing is responsible
for initial placement and daily maintenance of catheters and therefore is ideally positioned in the
healthcare setting to initiate and execute protocols for catheter use and CAUTI prevention.
According to a study by Mori (2014), catheter usage was reduced to 27.7% from 37.6% and
CAUTI rate was reduced from 0.77% to 0.35% utilizing nurse-driven protocols. This
demonstrates higher quality of care and improved outcomes for hospitalized patients.
Evaluation
Hospitals are required to report instances of CAUTI monthly (Gould, Umscheid,
Agarwal, Kuntz, & Pegues, 2009). They must also follow the National Healthcare Safety
Network (NHSN) CAUTI protocol exactly and report complete and accurate data in a timely
manner. Nurse-driven quality improvement projects related to CAUTI must include a detailed
evaluation process such as the Plan-Do-Study-Act (PDSA) guidelines recommended by the
Agency for Healthcare Research and Quality (AHRQ). This cycle is a checklist and scientific
method used for action-oriented learning that plans the observation or data collection, does or
tests the action on a small scale, studies or analyzes data and results, and acts or refines changes
needed in the program (AHRQ, 2014).
Using a retrospective chart review, prevalence of catheter usage and dwell time will be
measured three months before and three months after implementation of the nurse-driven Foley-
Free protocol. Data will be collected using computerized patient records and databases to
retrieve patient demographic information, admitting diagnosis, age, and sex. Indwelling catheter
CAUTI LEADERSHIP ANALYSIS STRATEGY 8
usage will be tabulated monthly from nursing clinical documentation. The sum of catheter days
will be divided by the total patient days and multiplied by 100 for a percentage of catheter usage
for each month (Mori, 2014).
Unit specific CAUTI rates will be offered quarterly to nursing and other clinical staff.
Participating units will be requested to complete a Foley Free protocol assessment evaluating
three primary areas: adoption of Foley Free activities, implementation of CAUTI reduction steps,
and protocol barriers. The purpose of this tool is to keep patient safety the primary focus at both
the system and unit level (Gould et al., 2009).
Conclusion
Healthcare-associated infections are a significant cause of illness, death, and excessive
costs in all health care settings (Gould et al., 2009). Findings support the use of nurse-driven
quality improvement projects and protocols to decrease the incidence of CAUTI, and to improve
the quality of care for hospitalized patients (Mori, 2014). Use of interdisciplinary teams along
with a team building culture that strives for reduction in CAUTI as well as use of data collection
to drive improvements in protocol will reveal positive patient outcomes and reduce length of stay
in acute care settings. Essentially, the best scientific evidence should be the foundation of all
patient care and should not vary from clinician to clinician.
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References
Agency for Healthcare Research and Quality (AHRQ). (2014). Plan-do-study-act (PDSA) cycle.
Retrieved from http://www.innovations.ahrq.gov/content.aspx?id=2398
Centers for Disease Control and Prevention (CDC). (2012). Catheter-associated urinary tract
infections (CAUTI). Retrieved from: http://www.cdc.gov/HAI/ca_uti/uti.html
Gould, C.V., Umscheid, C.A., Agarwal, R.K., Kuntz, G., & Pegues, D.A. (2009). Healthcare
infection control practices advisory committee: Guideline for prevention of catheter-
associated urinary tract infections. Atlanta, GA: Centers for Disease Control and
Prevention.
Magers, T. (2013). Using evidence-based practice to reduce catheter-associated urinary tract
infections. American Journal of Nursing, 113, 34-42.
Meddings, J., Reichert, H., Rogers, M., Saint, S., Stephansky, J., & McMahon, L. (2012).
Impact of non-payment for hospital-acquired catheter-associated urinary tract infection:
A statewide analysis. Retrieved from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3652618
Meddings, J., Rogers, M., Krein, S.L., Fakih, M.G., Olmstead, R., & Saint, S. (2014). Reducing
unnecessary urinary catheter use and other strategies to prevent catheter-associated
urinary tract infection: An integrative review. British Medical Journal Quality & Safety,
23, 277-289. doi:10.1136/bmjqs-2012-001774
Mori, C. (2014). A-voiding catastrophe: Implementing a nurse-driven protocol. MEDSURG
Nursing, 23, 15-28.
Yoder-Wise, P. S. (2011). Leading and managing in nursing (5
th
ed.). St. Louis, MO: Elsevier
Mosby.

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