Running head: CAUTI PREVENTION 1

Safety Performance Improvement Paper: Catheter Associated Urinary Tract Infection Prevention

Manatshitu Mubiayi, Rachel Neal, Sandra Nelson, Taylor Neuburg, and Olivia Nogaki

Old Dominion University

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Safety Performance Improvement Paper: Catheter Associated Urinary Tract Infection Prevention

Catheter associated urinary tract infections (CAUTIs) are a major safety risk to patients

and one of the most common complications in healthcare. CAUTIs are developed from bacteria

being introduced to the urinary tract through Foley catheter use. CAUTIs are associated with

increased length of hospital stays, patient discomfort, increased health care costs, and mortality

(Centers for Disease Control, 2018). To prevent incidents that put patients at risk, The Joint

Commission (TJC) sets national patient safety goals annually. CAUTI prevention through using

evidence-based practice guidelines is a current TJC 2018 patient safety goal. TJC uses evidence-

based practice to develop standards and guidelines for hospital practice nationwide. Even though

hospitals have access to the TJC guidelines, CAUTIs still occur. The TJC guidelines need to be

followed by all nurses and hospital providers to decrease rates of CAUTIs and improve patient

outcomes.

CAUTI and Evidence Based Practice

CAUTIs are a major safety risk to patients and can be prevented through implementation

of evidence-based practice. Basic practice recommendations for preventing CAUTIs include the

provision of adequate infrastructure for CAUTI prevention, performing CAUTI surveillance,

providing education and training, and ensuring appropriate management of indwelling catheters

(Pashnik, Creta, & Alberti, 2017). It is important to use evidence-based practice bundles to

ensure the best possible care is provided to patients. TJC developed guidelines for Foley catheter

using evidence-based practice and suggests following the evidence-based practice CAUTI

prevention care bundle developed by The Centers for Disease Control (CDC).

The CDC guidelines include recommendations for appropriate urinary catheter use,

proper techniques for urinary catheter insertion, and proper techniques for urinary catheter
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maintenance. Implementing the CDC’s CAUTI care bundle in the form of a checklist has been

proven to decrease the number of CAUTI cases and improve patient safety outcomes (Centers

for Disease Control and Prevention, 2018). Prior to implementing the CAUTI care bundle, it is

important to understand the recommended guidelines to provide the best possible care to patients

and reduce rates of CAUTIs.

Appropriate Catheter Use

Foley catheters put patients at risk for infections and it is critical that they are only used

in critical situations where the benefits outweigh the associated risks. Urinary catheters should

only be utilized under specific circumstances outlined by the CDC. The CDC recommends only

using catheters for acute urinary retention, to improve comfort in end of life care, in critically ill

patients for accurate hourly measurement of intake and output, and specific surgical procedures

to assist in healing of open sacral or perineal wounds in incontinent patients, and in

circumstances of prolonged immobilization (Agarwal et al., 2009). Catheters should be removed

as soon as possible. The risk of patients acquiring a CAUTI increases by 3% - 5% each day the

catheter remains in the bladder (Pashnik, Creta, & Alberti, 2017). It is also recommended that

nurses use critical thinking to assess the need for Foley catheters daily. Nurses assessing for daily

Foley catheter need and advocating for earliest possible removal is formally known as nurse-

initiated removal (Magers, 2013). Nurse initiated removal and daily assessment for need with the

care team are critical to the decrease the rates of CAUTIs.

Insertion Practices

Proper catheter insertion practices are necessary to reduce the rates of CAUTIs. The CDC

recommends strict hand hygiene before and after the procedure, using two nurses for the

insertion process, using strict sterile technique, and to assess for urine flow before balloon
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inflation (Agarwal et al, 2009). Sterile insertion is key in not introducing harmful bacteria to the

urinary tract.

Recommended Catheter Maintenance

While the catheter is in place, it is important to use the CDC guidelines for catheter

maintenance. Best practices for CAUTI prevention include: daily perineal cleaning, keeping the

tamper seal intact, keeping the drainage bag less than half full, keeping the drainage bag below

the level of the bladder and not touching the floor, ensuring there is unobstructed flow from the

drainage tubing to the bag, and making sure the tubing is secured to the patient’s leg with a

catheter secure device (Agarwal et al., 2009). The guidelines need to be followed to decrease

patient’s risk of acquiring a CAUTI.

Plan for Change

Even though hospitals use the CDC guidelines for policy development, the rates of

CAUTIs are still high. To improve patient safety and decrease the number of CAUTIs, an

evidence-based practice bundle checklist will be implemented in an acute care hospital for a six-

month period. It is hypothesized that the number of CAUTI occurrences will decrease with the

initiation of strict following of the CAUTI bundle checklist.

Prior to the implementation of the The ANA’s Streamlined Evidence-Based RN Tool,

the number of CAUTIs will be calculated during a six-month period. All nurses and managers

will be required to attend a mandatory inservice on CAUTI prevention. The hospital will use one

of the CDC’s recommended education tools to provide consistency in the delivery of information

provided to all the nurses and administrators in the acute care hospital. The focus of the

education session should be the nurses understanding the patient safety issue of CAUTIs, how

CAUTIs occur, what the bundle checklist is, how the bundle checklist will be implemented, and
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be able to demonstrate proper Foley catheter insertion recommended by CDC guidelines. At the

end of the teaching session, each nurse will demonstrate accurate insertion of a Foley catheter

following CDC guidelines and will be able to verbalize understanding of how utilize the

checklist.

CAUTI Bundle Checklist

The CDC specifically recommends the use of The American Nurses Association’s

(ANA) Streamlined Evidence-Based RN Tool: Catheter Associated Urinary Tract Infection

Prevention (American Nurses Association, 2015). The tool outlines the CDC’s evidence-based

recommendations for appropriate urinary catheter use, proper techniques for urinary catheter

insertion, and proper techniques for urinary catheter maintenance and organizes them into a

checklist format. The ANA’s Streamlined Evidence-Based RN Tool (Appendix A) will be

utilized by every nurse at the beginning of the shift for every patient that has a Foley catheter and

during every new Foley catheter insertion. At the end of the shift, the checklist will be reviewed

with the oncoming nurse, and the oncoming nurse will prepare their own personal checklist

assessment. The assessments will be kept in the patient folder and will follow the national

guidelines for patient confidentiality. The assessments will be reviewed by the unit manager

weekly. There will be a monthly safety meeting with all the managers, supervisors, and infection

control officers in the hospital to discuss progress and any adjustments that need to be made.

After the six-month period, the number of hospital CAUTIs will be totaled. It is estimated that

the number of CAUTIs will decrease after the strict implementation of the CAUTI prevention

bundle. For data collection, six months data reports will be obtained from each unit after they

have been referred to the infection control manager. Over the six-month period, there will be

recordings of the number of catheters used per day along with CAUTI incidents by the nursing
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staff. To facilitate identification of time periods, the length of time documentations will be for

daily and monthly up to the sixth month of data collection.

The catheters per day ratio will be defined by the total catheter inserted or currently in

use per day to the total length of the patient’s stay on the unit. The CAUTI rates will be

calculated by the number of CAUTI cases over a month period and that number will be then

divided by the number of catheter-days over that same period and multiplying the quotient by

182.5 catheter-days equaling a six-month period. The resulting six months’ worth of data will be

compiled into one excel spreadsheet for the project team to access. At the end of the data

collection period, the hospital's infection control managers will share this data with the project

team after removing patient names.

Data Analysis

This research will utilize quantitative data analysis through descriptive statistical data.

Data reports will be gathered after they have been reviewed by infection control and leadership.

The collected data will consist of daily usage of catheters per unit along with semiannual CAUTI

cases. The nursing staff of each unit will provide monthly summations of which of their patients

had Foley catheter insertions. The resulting ratio of daily to monthly catheter usage will then be

compared to the number of CAUTI cases of the same time period. This will allow for unit trend

comparisons among acute care units.

Support and Opposition to Change

During the change process, there are going to be individuals that support the change

process and individuals that go against the change. Providing someone insight into the same

problem with another set of eyes can provoke change, and nurses who do not comply with the
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protocol will need remediation which is the best opportunity to achieve this. Nurses are one of

the biggest factors in the success of the patient CAUTI safety checklist implementation.

Leadership is key to the change process. “A leader employs specific behaviors and

strategies to influence individuals and groups to attain goals” (Sullivan, 2017, p. 57). Leading by

example will in turn, push fellow nurses to make the changes needed. Tools to help initiate

change include communicating openly and honestly with those who oppose change, maintaining

support and confidence in staff, emphasizing importance and positive outcomes, and finding

solutions to obstacles during resistance to change (Sullivan, 2017). It is important to understand

how to support and encourage nurses that are in favor of the change and how to motivate and

coach nurses that are in opposition to the change.

Methods to Gain Supporters

During the change process, it is important that reform is achievable. The following four

steps would be effective in gaining supporters: engaging, educating, executing and evaluating

(Felix, Bellush & Bor, 2014, p.46). Engaging starts by actively seeking out unit leaders and

management and determine which units are engaged and if others need greater involvement.

Nurse managers should think of creative ways to encourage and reinforce nurses and units that

are positively incorporating the CAUTI bundle checklist. Nurse managers and leaders should

clarify that CAUTI prevention is a high priority in the hospital’s safety program and demonstrate

this through their actions and words (Felix, Bellush & Bor, 2014, p.46). CAUTI rates are the

most effective way to see which units are being compliant with the CAUTI bundle checklist and

which units need coaching and encouraging. Education is important to ensure everyone is

motivated and on the same page.

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Evaluation is key in the CAUTI checklist implementation. Unit leaders and management

should take the time to evaluate the performance from healthcare providers with the

implementation of prevention against CAUTI (Felix, Bellush & Bor, 2014, p.47 ). The APIC’s

CUSP Learn From Defects Tool Worksheet (Appendix B) utilized by every nurse at the end of

each month prior to the monthly safety meeting. The worksheet should be reviewed by unit

leaders to see what success and failures have come from utilizing the program.

Managing Resistance to Change

In Sullivan (2017), “Resistance to change is to be expected, and it can be a stimulant as

well as a force to overcome” (p.73). One-on-one conversations with any nurses who may not

seem receptive or confident with this new process is beneficial. This may lead to a demo/return

demo opportunity which is a useful teaching tool. Coaching and teaching with demonstrations

will take place for those who make mistakes during the check-off process. Ir noncompliance

occurs, written formal warnings will need to be addressed and filed with Human Resources.

Another method to manage resistance occurs when collected and analyzed data is shared

with nurses on the unit. After applying the new standardized protocol of Foley management,

insertion/removal, and indications, management will have the opportunity to audit nursing efforts

and results. By auditing, management can launch control points and provide feedback

mechanisms to gauge its advancement and achievement. “Successful leaders inspire and

empower others, generate excitement, and individualize their approach to differences in people”

(Sullivan, 2017, p.57). Positive reinforcement could include a unit gathering as a reward for

positive outcomes from the CAUTI care bundle implementation. Change is inevitable within the

hospital, it is key to keep patient safety at our focus and adapt accordingly to changes needed to

meet our goals.

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Change Theory: Lippitt

Lippitt’s theory is a seven-step extended process of Lewin’s theory. The focus is less on

the evolution of change and more emphasis is placed on the role and responsibility of the change

agent. The seven steps are: (1) Become aware of the need for change and diagnose the problem;

(2) Assess the motivation and capacity for change by developing a relationship between the

system and change agent; (3) Assess the change agent’s resources and its motivation; (4) Choose

progressive change objects by setting goals for change and action plan for achievement; (5)

Select the role of the change agent and implement the change; (6) Maintain the change and

stabilization; and (7) Gradually terminate the helping relationships (Sullivan, 2018, p. 62).

The manner in which this theory could be applied to prepare for change and to implement

the change process is, once the change agent has been identified, an assessment of the unit staff’s

motivation for change has to occur. The theory emphasizes participation during the change

process. Communication skills, rapport building, and problem-solving strategies are key

components of the different phases.

Feedback Mechanisms and Evaluation Process

The most efficient way to provide feedback would be for unit managers to report the

number of days without a CAUTI incident on their unit at every shift meeting. Since attendance

is mandatory at these shift meetings, it ensures that each staff member is aware and up to speed

of the floor’s progress at decreasing CAUTI occurrences.

The only way to determine if the CAUTI prevention program was successful with

certainty is to compare the number of CAUTIs after the intervention to the number of CAUTIs

prior to the intervention. A drop in number of incidents would imply that the CAUTI bundle

checklist was effective in improving patient safety CAUTI outcomes.

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Stabilizing the Change

Stabilizing change requires continuous support and effort from everyone. Observing

actual results and measurable outcomes are critical in the longevity and success of any program.

After the six-month period, it is important to revisit and discuss the importance of the program,

review what procedures need to be revised, explain any concerns or failed techniques, and adjust

goals accordingly (Felix, Bellush & Bor, 2014, p.48). Revaluating provides the opportunity to

reinforce positive behaviors and a means to improve areas of weakness. Skill labs and monthly

huddles can be implemented to help refresh individuals that are unsure of their techniques,

clarify any confusion, and share the revised goals of the program to staff (Felix, Bellush & Bor,

2014, p.48). Improper technique and procedures can be identified and addressed.

Leadership’s Role and Key Players

Management must take an active role in locating any opportunity for CAUTI prevention.

Nurse managers should make frequent rounds and be present during at least one Foley catheter

insertion of each RN per shift to observe skills and offer feedback. Consistent follow-ups and

open communication allow for the opportunity to reduce the rate of infection as well as improve

quality of care. Nurse managers are responsible for summation reports to submit to upper

management regarding number of insertions witnessed, breaks of sterile field or improper

technique, improvements, and coaching provided during the monthly safety meeting.

Conclusion

CAUTIs continue to threaten patient safety regardless of standing hospital best-practice

policies. TJC sets standards for nursing practice and creates annual national patient safety goals.

The goal to reduce CAUTIs in a hospital setting can be achieved through CAUTI Care Bundle

implementation, inservice training, review of policy, and consistent follow up. Implementation
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of the CAUTI prevention checklist is a measure to improve quality of care and aids in improving

overall patient safety outcomes. By planning change within our Foley catheter policies and

implementing the goal to reduce CAUTIs, nursing staff are able to standardize care and promote

a safer environment for patients.

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Honor Code

“I pledge to support the Honor System of Old Dominion University. I will refrain from any form

of academic dishonesty or deception, such as cheating or plagiarism. I am aware that as a

member of the academic community, it is my responsibility to turn in all suspected violators of

the Honor Code. I will report to a hearing if summoned.”

Name (Print): Manatshitu Mubiayi, Rachel Neal, Sandra Nelson, Taylor Neuburg, and Olivia

Nogaki

Signature: Manatshitu Mubiayi, Rachel Neal, Sandra Nelson, Taylor Neuburg, and Olivia

Nogaki (Electronic Signature)

Date: 07/25/2018
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References

Agarwal, R. K., Gould, C. V., Kuntz, G., Pegues, D. A., & Umscheid, C. A. (2009). Guideline

for prevention of catheter-associated urinary tract infections 2009. Atlanta, GA: Centers

for Disease Control and Prevention.

American Nurses Association (2015). Streamlined evidence-based RN tool: Catheter associated

urinary tract infection (CAUTI) prevention. Retrieved from

http://nursingworld.org/ANA-CAUTI-Prevention-Tool

Centers for Disease Control and Prevention (CDC). (2018). Retrieved from https://www.cdc.gov/

ECRI Institute. (2016). National study supports care bundles to reduce CAUTI rates and

unnecessary catheter use. Retrieved from https://www.ecri.org/components/HRCAlerts/.

Felix, K., Bellush, M. J., & Bor, B. (2014). APIC implementation guide: Guide to preventing

catheter-associated urinary tract infections. Retrieved from

http://apic.org/Resource_/EliminationGuideForm/0ff6ae59-0a3a-4640-97b5-

eee38b8bed5b/File/CAUTI_06.pdf

Magers, T. L. (2013). Using evidence-based practice to reduce catheter-associated urinary tract

infections. AJN, American Journal of Nursing, 113(6), 34-42.

Pashnik, B., Creta, A., & Alberti, L. (2017). Effectiveness of a nurse-led initiative, peer-to-peer

teaching, on organizational CAUTI rates and related costs. Journal of Nursing Care

Quality, 32(4), 324-330.

Sullivan, E. J. (2018). Effective leadership and management in nursing (9th ed.). Boston, MA:

Pearson Education.
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Appendix A
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Appendix B
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