Constructing the Written Evidence-Based Proposal

Running head: EVIDENCE-BASED PROPOSAL Professional Research Project: Catheter-Associated Urinary Tract Infection (CAUTI) - Evidence-Based Proposal (Student`s Name) (Course Code/Number) (Name of Professor) (Date of Submission) Catheter-Associated Urinary Tract Infection (CAUTI): Evidence-Based Proposal Abstract Urinary catheterization is considered as one of the most standard procedures carried out in hospitals, especially in cases of surgeries and other medical interventions. However, because of different reasons attributable to neglect or breaks in sterility, urinary catheterization also becomes a source of nosocomial infection. Indeed, even though the insertion of urinary catheters is considered as a sterile procedure, breaks in the sterility of the catheter system may sometimes bring different types of infections to the patient. In relation, one of the most common forms of nosocomial infection acquired from urinary catheter insertion is CAUTI, which stands for Catheter- Associated Urinary Tract Infection. The rise in the cases of CAUTI has continued to alarm concerned officials and healthcare providers. Therefore, this paper presented an in-depth discussion of the problem on CAUTI. This paper has been divided into five main parts, each of which discussed an aspect of evidence-based practice: problem-identification, solution description, implementation of interventions, evaluation of implementation, and dissemination of findings or results. Thus, the first chapter presented an exploration of the problem on CAUTI, the second part provided a solution for the said problem, and the third section discussed a plan for implementation. Moreover, the fourth and fifth parts of the paper presented a plan for evaluation and a strategy for dissemination, respectively. Based on the evidences and literatures discussed, it was found that there is indeed a problem on CAUTI, especially with the negative impacts of the said disease, but that there are steps the healthcare provider can take in order to solve the said problem. Key Words: CAUTI, nosocomial infection, urinary catheterization Catheter-Associated Urinary Tract Infection (CAUTI): Evidence-Based Proposal 1.0 Problem Description Urinary catheterization is a treatment used to empty the bladder. Healthcare providers may recommend urinary catheterization for short or long-term use for patients experiencing urinary incontinence, urinary retention, surgery and other medical conditions. The occurrence for long-term use of urinary catheters can usually be observed in the intensive care unit (ICU). Because most of the patients in the ICU are unconscious and critically-ill, it is not uncommon for long-term use of urinary catheters to occur. Urinary catheterization is indicated for diagnostic or therapeutic purposes. Diagnostic use includes urine specimen collection, urine output monitoring and urinary tract imaging. The therapeutic use of urinary catheterization includes acute urinary retention, chronic obstruction, initiation of continuous bladder irrigation, intermittent decompression for neurogenic bladder, and hygienic care for bedridden patients ("Urinary Catheterization", n d). Nosocomial or hospital-acquired urinary tract infection (UTI) is a significant contributor in the prevalence in nosocomial infections (Bennet & Brachmann, 1986). The use of a urinary catheter is a major predisposing factor in the occurrence of nosocomial urinary tract infections (Alavaren, Lim, Antonio-Velmonte & Mendoza, 1993). Approximately 80% of nosocomial UTI is associated with the use of a urinary catheter (Mandell, Douglas, & Bennet, 1990). Knowing the risk factors for catheter-associated urinary tract infection (CAUTI) is one way to lessen its prevalence. The duration of catheter use is the major risk factor for the occurrence of CAUTI (APIC, 2008). The occurrence of CAUTI increases by 5% to 10% for each day that the catheter remains in place (Stokowski, 2009). Patients with a long-term catheter almost always develop CAUTI (Stokowski, 2009). Females are more prone than males (Alavaren, Lim, Antonio-Velmonte, & Mendoza, 1993). A females` short urethra makes for easy access of the bacteria from the outer part of the catheter. Elderly patients are more prone since they have a compromised immune system due to their age (Albright, n d). The urine collection bag is a pool for microorganisms that is why proper handling can help reduce the risk for infection (Infection Prevention Guideline, 2000). CAUTI is a most important concern for the caregiver because it entail numerous implications not only for the patient`s health status, but also for the hospital`s integrity and reputation. Indeed, the occurrence of any nosocomial infections reflects the level and quality of healthcare the patient is receiving (Minnesota Evidence-based Practice Center, 2007). Since the insertion of a urinary catheter should be done in a sterile technique, maintaining its sterility is dependent on the healthcare provider who is placing the catheter. Nosocomial UTI is a significant cause of mortality and morbidity (CDC, 1982). CAUTI is a very preventable condition according to the Centers for Medical Services and that is why the CMS has announced that they will no longer allow the reimbursement of healthcare institutions for care associated with preventable conditions such as CAUTI (Blodgett, 2009). CAUTI bring about an increase in extra expenses since it causes prolonged hospital stay, additional hospital costs and complication to the recovery of a critically-ill patient (Alavaren, Lim, Antonio-Velmonte, Mendoza, 1993; Stokowski, 2009). 2.0 Solution Description Although not all CAUTIs can be prevented (Stokowski, 2009), it is believed that a large part can be prevented with the proper handling of the catheter. The maintenance of the sterility in the process of placing a urinary catheter should be given more focus and monitored closely by nurses. The proposed solution to address the occurrence of CAUTI includes the following: (a) proper insertion and management techniques, (b) lessen unnecessary catheter use, (c) prompt removal of urinary catheters, (d) adequate availability of nurses, and (e) patient and nurse education (Stokowski, 2009). This solution can be more easily understood if it were to be applied to a certain cases. Thus, for easier explanation, the intended solution will be applied on the case of a hypothetical patient, who will be named Ms. William (pseudonym). Ms. William is a critically ill patient who has been in the ICU for almost a month. She was unconscious upon admission due to an occurrence of a stroke while she was at home. Upon admission to the ICU, an indwelling catheter was placed and has not been replaced since. P - Critically-ill patients in the intensive care unit I -- Intervention: Prolonged use of Foley catheter. Avoid unnecessary catheter placement and limit duration of catheter use. C - Decreased use of a catheter O - Outcome: Reduce the risk of catheter associated urinary tract infection and improve the patient outcome and decrease hospital cost and the length of stay. T - In a span of 1 month Therefore, given this PICOT format of the research topic, the proposed study will aim to address or answer the PICOT question: In the intensive care unit, does prolonged use of a catheter compared to the decreased use in critically-ill patients cause an increase in catheter associated urinary tract infection in a span of 1 month? 3.0 Implementation Plan The initial step in the implementation plan is to establish different committees that will focus on the proposal, implementation and evaluation process. The goal of the proposal committee is to obtain necessary approvals, support, and feedback from Nursing Management, the Chief Nurse, and other staff members of the institution, like pharmacists, dieticians, and others. Part of the committee`s goal is to make sure that any mission, views or objectives of the institution are not compromised. Presenting the proposal to the concerned health care providers can be done through electronic means but presenting a hard copy is a better and more formal approach. When the approvals have been obtained, the implementation group will begin their tasks. Still, to get the said approval, a thorough understanding of the current problem must be achieved. One of the traditional responsibilities of a nurse is urinary bladder catheterization. In the hospital setting, up to 31% of patients has a urinary catheter CITATION Nic05 \l 1033 (Nicolle, 2005). This commonality of catheterization does not ensure its safety. In relation to the issue of CAUTI, nurses play a major role. Maintaining the urinary catheters sterility and patency is their primary goal. Despite this, 80% of all urinary tract infections are associated with the insertion of a urinary catheter CITATION Ven07 \l 1033 (Venkatram, Grosu, Torchon, & Soni, 2007). Many factors can affect the risk for CAUTI like the process of insertion, the type catheter used, and the patient`s hygiene. However, all these factors can be influenced by the nurse. That is why nurses are the major contributors CITATION Pel09 \l 1033 (Pellowe, 2009) for this project. The unnecessary prolonged use of a urinary catheter is a major problem which increases the risk for CAUTI CITATION JMT09 \l 1033 (Barford & Coates, 2009). According to Foxley (2011), evidence shows that most cases of catheterizations are unjustified and exposes patients to significant risk for urinary tract infection. Appropriate indication for catheterization should be properly assessed before deciding to insert a catheter. The issue of aseptic and sterile technique is also important since catheterization is a very invasive procedure. Choosing of the proper type and size of catheter is also relevant to avoid further damage or injury to the patients which also increases the risk for infection CITATION Poi10 \l 1033 (Poisson, Johnston, & Josephson, Urinary Tract Infections Complicating Stroke, 2010)as well as the proper securing or anchoring of the catheter CITATION JMT09 \l 1033 (Barford & Coates, 2009). Maintaining a closed system is also important when a urinary catheter is already in place CITATION Pel09 \l 1033 (Pellowe, 2009). Proper patient hygiene especially for women is necessary to avoid any infection, even those not related to catheter insertion CITATION MND09 \l 1033 (Dudley & Barriere, 2009). The timely removal of the urinary catheter is also a vital factor in the risk for CAUTI CITATION Nic05 \l 1033 (Nicolle, 2005). Each of these problems involving the urinary catheter can be influenced by the nurse that is why focus on this project is on them. Thus, given the said problems, the following paragraphs will discuss in greater detail the solutions for the problem. This proposed solution includes providing detailed information for the health care practitioners as well as to the family on the proper process of catheterization. First and foremost, indication for catheter insertion should be assessed properly and thoroughly. Other options should be explored first before finally deciding to insert a catheter. According to Makic, VonRueden, Rauen & Chadwick (2011), clear indications for catheterization include the following: urinary retention or obstruction, alteration in volume status or blood pressure, need for accurate input and output where a patient cannot use a urinal or bedpan, emergency surgery, major trauma, urologic procedures, bladder irrigation, management for stage III or above pressure ulcers and comfort care for terminally ill patients. The health care practitioner, knowing these indications is the first step to prevent CAUTI. When there are no other options except to catheterize, the choice of catheter type and size is very important (Slater, 2011). Every health care facility must consider exploring other alternatives to indwelling urinary catheter like external catheters, intermittent catheterization or suprapubic catheters for selected patients when appropriate (Gould, Umscheld, Agarwald, Kuntz & Pegues, 2009). In relation to Urinary catheter size, according to Pratt & Pellowe (2010) and Gould et al. (2009), the smallest appropriate catheter gauge should be selected to allow free urinary outflow and to minimize bladder neck and urethral trauma. Larger catheters may cause leakage and increased pain; however they are useful after urologic advice (Madeo & Roadhouse, 2009). In relation to the balloon size of the indwelling catheter, a 10ml catheter balloon should be used for adults while a bigger size may be required for urologic patients (Pratt & Pellowe, 2010). The next factor to be considered in preventing CAUTI is to take note is the material of the catheter. There are two types of material used for catheters: latex and silicone CITATION Sai99 \l 1033 (Saint & Lipsky, 1999). Latex catheters coated with polytetraflouroethylene are said to reduce urethral irritation CITATION Nic05 \l 1033 (Nicolle, 2005). Hydrogel-coated latex cores become smoother upon insertion when it comes in contact with the moisture inside the urethra CITATION Ven07 \l 1033 (Venkatram, Grosu, Torchon, & Soni, 2007). A hydrogel-coated latex catheter is also resistant to bacterial colonization and encrustation. Silicone catheters have wider lumens that promote better drainage (Madeo & Roadhouse, 2009). However, it is quite stiff which can be uncomfortable. The most approved type of catheter is the silver alloy and hydrogel-coated catheters (Gentry & Cope, 2005; Kassler & Barnett, 2008; Seymour, 2006; Jenkinson, 2006; Scott, 2010). Catheterization is an aseptic procedure which requires sterile equipments. It is a fundamental skill learned by nurses (Makic et al., 2011). Suffice to say that catheterization requires trained and competent personnel for its insertion and maintenance (Gould et al., 2009; Pratt & Pellowe, 2010). The most primary step before catheter insertion is to perform hand hygiene. Equipments are then prepared, like sterile gloves, drapes, sponges, antiseptic solution and single-use lubricant pack (Gould et al., 2009). Meatal care is also part of proper catheter care. Research shows that the use of antiseptics cleansers, creams or lotions made no difference from the use of soap and water for perineal care to reduce CAUTIs. Some antiseptics may even increase the risk for irritating the urethral meatus (Makic et al., 2011). Proper securing of the catheter prevents urethral trauma or traction, erosion and accidental removal (Gould et al., 2009). Experts also suggest securing the outer part of the device to the upper thigh in females and abdomen in males (Makic et al., 2011). It may be through the use of adhesive tapes to prevent it from being dislodged when the patient moves. These techniques and methods will then be used for the actual implementation of interventions. Catheter maintenance involves keeping a closed drainage system which is central to the prevention of CAUTIs. This entails connecting the catheter to a sterile and sealed urinary drainage system. When an open system is used there is a 97 percent risk for infection which decreases significantly to 8%-15% when a sterile closed system is adopted (Madeo & Roadhouse, 2009). Breaking the closed system should be avoided to lessen the risk for infection CITATION Pel09 \l 1033 (Pellowe, 2009). These techniques and considerations will also be used in the implementation of care to prevent CAUTI. In addition, hand hygiene and wearing of a clean pair of gloves is done before handling any part of the catheter. An unobstructed urine flow is also important. It is vital to keep the catheter and tubing free from kinking to avoid obstructions. The collecting bag should be placed below the level of the bladder at all times but not resting on the floor. This minimizes reflux into the catheter and prevents retrograde urine flow (Makic et al., 2011). When emptying the collection bag use a separate and clean container (Gould et al., 2009). Regularly empty the collection bag which also prevents reflux and maintains urine flow. This is a simple and effective strategy to reduce CAUTIs when transporting a patient (Madeo & Roadhouse, 2009). When collecting a urine sample use the sample port using aseptic technique (Pratt & Pellowe, 2010). These things, among others, will be carried out as part of the actual implementation strategy. A good personal hygiene lessens the microorganisms that cause bacteriuria and infections (Dailly, 2011). It is also the nurses` duty to encourage the patient on proper hygiene. Meatal hygiene should be part of the patient`s daily routine. An increase in urethral secretions may occur due to irritation and form crusts around the meatus. It is recommended that gentle perineal hygiene be practiced using soap and water (Madeo & Roadhouse, 2009). High fluid intake of at least 2 liters per day brings about diuresis. This promotes increase urine production and voids the bacteria from the bladder, dilutes urine thus impairing bacterial growth and reduces the encrustation process (Dailly, 2009). Still, the implementation logistics includes when the plan will be implemented. In this specific plan, the implementation will be started as soon as the approvals have been obtained. Different committees are responsible for the proposal, implementation and evaluation processes. Sub-groups will be formed where needed. The action plan will be implemented to promote a smooth transition between changes. A committee will be appointed which will then be divided into sub groups. These sub-groups will be in charge of the meetings that will discuss and review the action plan implemented. The results of the meeting will be then be given to the committee. The necessary changes will be made by the committee in response to the feedback obtained. All committees and sub-groups are interrelated but all have different tasks. A major evaluation will be done by the committee in response to the reports made by the sub groups 1 month from the starting date. Different resources also have to be tapped to make the implementation possible. The resources required for the proposed plan include: 1 Nursing staff members All nursing staff members are required to participate in this program to promote an all-out change. Their role is of most importance to carry-out this implementation process. Each nurse manager from the different hospital stations is given the responsibility to educate and assess other nurses in their specific areas. 2 Educational materials This consists of prepared materials like power point presentation (Appendix A), handouts or posters that will be presented, posted or distributed to all participants. 3 Assessment tools This is comprised of questionnaires (Appendix B), pre/post-tests random spot checks to assess the participant`s knowledge. Rounds observation during the shifts by head nurses and doctors as well as charting can be other means for assessing the compliance of the nurses. Results of the evaluation can be posted on specific areas or given to the nurse managers. 4 Technology 5 Funds Funding or sponsorships for the different catheter (silver alloy-coated, hydrogel-coated) to be utilized in the implementation will be needed. Also, funds are needed for printing and producing educational materials, and for gathering and analyzing data. In all, implementation of this program requires team work and dedication from the committees and the nurses as well. Staff adherence to the implemented policies by the hospital on preventing CAUTI is very important to be carried out. The availability of evidence-based sources that backs-up this program gives incentive and added motivation to the participants. However, further research should still be pursued in relation to other options besides catheterization. 4.0 Evaluation Plan The determination of the success of interventions can only be achieved through the conduct of an evaluation. Indeed, Daniels (2004) stated that evaluation makes possible the understanding of the effectiveness of steps rendered in terms of the standards of the institution and evidence-based practice. 4.1Evaluation Methods The implementing team conducted as part of their shifts daily assessment procedures to ensure the sterility of the procedure, the materials used (including the catheter), and similar other aspects of care. In these daily rounds, nurses must also ensure that the placement and anchoring of catheters in patients, especially for those who are bedridden and comatose, is secure. Moreover, these rounds will also guarantee that the catheter system remains intact and sterile as much as possible. In addition, weekly discussions and seminar will be conducted for all the members of the healthcare team, so as to enable them to review and remember the sterile principles in catheterization. These seminars will also involve the discussion of possible alternatives to catheterization. Upon approval, these procedures became a standard operating procedure for the institution. Evaluation of these methods will be carried out through the comparison of discharge rates and statistics on nosocomial catheter-related urinary tract infections before and after the implementation of the interventions. 4.2Variables In the interventions developed for the institution, certain variables that affect or determine the outcomes have been found. One of the variables that are significant for evaluation is the census of patient conditions depicting the statistics of CAUTI and similar nosocomial infections. A decrease in this number would show if the interventions for the current problem were successful or not. In addition, the scores of the staff members would also show a difference in the knowledge or learning of the institution`s staff and nurses, especially if pre-tests and post-tests would be conducted for the nurses` seminars and information dissemination drives or endeavors. Also, the attitudes and perceptions of the individuals concerned (staff, patient, and significant others) with regards to the interventions can also serve as significant variables for evaluation. The dependent variable of the program will be the improvement in the patient statistics on CAUTI and in the knowledge or perception of nurses on CAUTI and nosocomial infections. On the other hand, the independent variable will involve the different interventions. More specifically, the interventions to be provided will serve as the independent variable since it will be the one manipulated, and this will then affect the dependent variable, which involves the patient`s health outcomes, and the nurses`/staffs` knowledge and observation of evidence-based practice. 4.3Assessment Tools to Evaluate Project Outcomes Certain tools for the evaluation of the effectiveness of the interventions can be utilized. Indeed, evaluation is a significant aspect of evidence-based practice CITATION Boh03 \l 1033 (Bohinc & Gradisar, 2003), since it lets the concerned parties know whether the interventions have been successful and helpful for both the patient and the staff of the institution. In relation, evaluation in evidence-based practice focuses on the knowledge, skills, attitude, and behaviors of the ones learning (nurses/staff), as well as the outcomes of the patient. It can also cover the reviews or feedbacks of the consumers of heath care services, especially focusing on the final status or condition of the patient upon discharge CITATION Sus02 \l 1033 (Hamer & Collinson, 2002). Thus, the different evaluation tools to be used are the following: questionnaire, daily-round checklist, catheter care bundle checklist, and CAUTI/nosocomial care examination sheets. The questionnaire, which will be presented in Appendix B, will measure the perceptions and level of satisfaction of the patient or his/her significant other with the care for CAUTI prevention given by the nurses in the hospital. The questionnaire will explore the opinions of the patients themselves CITATION Reb11 \l 1033 (Keele, 2011), or in the case of comatose patients, their support system, with regard to the measures involving the prevention of CAUTI. On the part of the medical staff, the questionnaire can be used as a form of pre-test to assess the level of knowledge of nurses, and to give the foundation for the learning needed by the hospital staff. Basing on these results, the nurses would then be educated on CAUTI and catheter-care. Also, the daily-round checklist, presented in Appendix C, will present a list of things and events that the nurse will check during each daily round in order to check that the CAUTI interventions were being carried out properly. From these daily assessments, areas needing further improvement can also be addressed more carefully. Moreover, the catheter care bundle checklist will also function very much like the daily-round checklist, only this time, assessment would focus solely on the processes involving the catheters and catheterization, from the preparation of materials, to the insertion of catheter, to its checking, to its removal, and even up to the care of the patient after catheterization. Finally, the CAUTI/nosocomial care examination sheets will assess the level of knowledge that the nurse has gained during the seminars. The said sheet could also show evaluators the degree of improvement that the nurses and the system have undergone over the time of implementation. Indeed, evaluation is a significant aspect of evidence-based practice. It is most especially vital in the determination of the success of interventions, and its results can also serve as powerful indicators for the improvement that the hospital has undergone. Thus, the intended interventions need to be evaluated carefully, and this will be done through the floating of questionnaires, administration of checklists, as well as examinations. 5.0 Dissemination Strategy Polit and Beck (2006) noted that dissemination is a part of the evidence-based practice where the findings of a study are communicated to concerned individuals so as to serve as a basis for change in practice. A plan for dissemination usually guarantees that the technique and knowledge gathered by the institution with regards to a nursing problem can be tested and applied by other institutions as well. In relation, different techniques are being used for information dissemination, including PowerPoint presentations, oral presentations, round table discussions, media broadcasts, posters, publications, and others. Some of these methods will then be utilized for the dissemination of the findings from the evaluation of the interventions for the problem of CAUTI. PowerPoint presentations can serve as effective media for relaying the findings of the interventions. Indeed, PowerPoint presentations provide a means of organizing data about the evidence-based practice, and it also allows for the inclusion of the presenter`s creativity in the whole process of dissemination. In a similar light...