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Quality Improvement Plan

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Nursing Quality Indicators

As the largest healthcare workforce component, nurses are ethically bound to

measure, evaluate, enhance quality, and improve the practice. A nursing quality indicator is a

measure of a healthcare activity that can be used to plan, assess and monitor the quality of

care and care processes provided to a patient (1). According to the Joint Commission on

Accreditation of Healthcare Organization (US), quality indicators need to be sensitive,

specific, objective, valid and straightforward. Quality indicators are used to reduce healthcare

costs, improve patient outcomes, improve quality of care and strengthen the healthcare

system (1). Nursing quality indicators evaluate three sections of the healthcare triad:

structure, processes, and results. This case report will discuss catheter-associated urinary tract

infections (CAUTIs) as a nursing quality indicator within my hospital unit.

Catheter-Associated Urinary Tract Infections: A Nurse-Sensitive Indicator

Among hospitalized patients, nosocomial infections are the chief cause for increased

healthcare cost, increased antimicrobial resistance, lengthy hospital stays, morbidity, and

mortality (2). Many strides have been made in the area of patient safety and hygiene.

However, this has not seen an equal reduction in hospital-acquired infections (3). Nosocomial

infections cost our healthcare system an estimated $33 billion per annum and are responsible

for over 90,000 preventable deaths in the United States alone. Urinary tract infections are the

most common type of hospital-acquired infection, with more than 600,000 hospitalized

patients developing CAUTIs every year (3). CAUTIs are regarded as preventable as 3 in

every 4-hospital acquired UTIs can be attributed to improper use of indwelling urinary

catheters. The current data reports within my organization reveal the increasing prevalence of

CAUTI among all cases of reported nosocomial infections. Financial records also show that

my organization has faced substantial penalties from Medicare due to CAUTI rates higher

than the national benchmark. Currently, my organization lacks specific CAUTI prevention
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policies and is only guided by general infection control plans. In light of this background, it is

necessary to develop an interdisciplinary quality improvement plan to decrease catheter days

and the prevalence of catheter-associated urinary tract infections (CAUTIs).

Role of Healthcare Team

Reducing CAUTI rates requires collaboration and teamwork between

interdisciplinary teams to implement evidence-based policies and guidelines (4). Before

implementing this quality improvement plan, the healthcare leadership must show support for

the plan by providing resources necessary for its implementation. These resources include

prerequisite human resources, time, and financial funding. The hospital leadership is also

responsible for engaging and mobilizing all the different stakeholders and departments to

improve the vision. Each department's clinical needs are unique, and therefore their priorities

and perception of the prevention of CAUTI should be considered in the overall plan.

Excellence in leadership is demonstrated by promoting a culture of clinical excellence, a

cohesive workforce, and innovative strategies aimed at improving patient outcomes. Leaders

need to drive and be proactively involved in quality improvement initiatives (5). Resistance

and lack of support from the leadership will undermine this quality improvement initiative.

Various departmental heads will be responsible for providing leadership and

coordination, insights, monitoring, and evaluating the departments' implementation plan.

They will also serve as a conduit between various stakeholders and their departmental staff.

Departmental heads will also play a crucial role in technical assistance and education. This

quality improvement plan requires a paradigm shift within the healthcare teams, and this can

only be achieved via intense and continuous staff training. Drawing from their expertise, the

departmental heads will organize patient safety education programs and activities on

evidence-based practices for their staff. The departmental leads will also be responsible for

creating evidence-based policies and guidelines aimed at reducing CAUTI. To ensure the
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project's sustainability, continuous education and commitment from senior leadership are

critical (4).

My primary role in this quality improvement plan as a nurse is to deliver safe and

effective patient care. As a nursing team champion, my role includes inspiring and steering

the nursing team to the project vision. I will help educate the nursing team directly and

provide an example of good clinical practices to reduce CAUTI. As a frontline nurse, I will

ensure appropriate catheter insertion is done at all times. I will also ensure all CAUTI policies

and procedures are followed, and all catheter use assessments are done in good time. Due to

the complexity of this aspect of healthcare, there must be interdisciplinary teamwork between

patients, stakeholders, leaders, and healthcare workers.

Quality Improvement Plan

Among hospitalized patients, overuse of indwelling catheters is the most significant

risk factor for getting catheter-associated urinary tract infection (CAUTI). Older age and

female sex are also additional risk factors (6). Studies have revealed that the risk of acquiring

CAUTI increases by 5% for every extra day of indwelling catheter use (7). It has also been

reported that indwelling catheters have been inserted when not indicated, and healthcare

providers often forget that a patient has an overdue catheter inserted (7).

CAUTIs are caused when a catheter becomes a conduit for fungi or bacteria to enter

the urinary tract. Some of the most common ways infection occurs during catheterization

include during insertion of catheters, during a bowel movement, backflow of urine from

catheter bag, and catheter not being cleaned frequently (3). Currently, 25% of all hospitalized

patients will have an indwelling catheter placed during recovery. In a satisfaction survey

conducted by (2), 42% of catheterized patients reported the indwelling catheters as

uncomfortable, 48% reported them as painful, and 61% stated that their daily activities were

interrupted due to indwelling catheters.

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The biggest impediment to proper catheter use at my organization is non-compliance

to recommended evidence-based practices and infection prevention protocols. There are also

no CAUTI prevention guidelines and protocols that can be used across all hospital units.

Lack of collaboration between physicians and nurses exacerbates the situation even further.

For example, there are situations that nurses have reported that they have differed with the

physician’s instructions on placing a catheter. While physicians are mandated to make orders

to place or discontinue catheter use, the nurses should be empowered to make autonomous

decisions to remove catheters (6). Patients and their caregivers also seem to prefer indwelling

catheters over external catheters. This makes it difficult for the healthcare team to

recommend external catheters. There is the challenge of breaking old habits and culture

within the healthcare team on catheter use. This is probably the biggest hurdle to cross when

implementing this quality improvement project, as these habits are engrained in the staff’s

clinical practice.

There is no single solution to reduce CAUTI, and a multi-faceted approach to catheter

use and care must be followed (2). Considering that over 70% of CAUTIs are preventable if

prevention practices are followed, it is necessary to carry out a quality improvement project.

This quality improvement plan aims to reduce catheter-associated urinary tract

infection (CAUTI) rates and the duration of urinary catheterization in patients. The measure

of quality is the prevalence of catheter-associated urinary tract infection (CAUTI) and

catheterization duration. The appraisal concept is a 25% reduction in CAUTI rates per 1000

device days in the hospital.

Multidisciplinary taskforce

A multidisciplinary task force will be set up to steer this quality improvement project.

The team's main objectives are to educate frontline health workers on good clinical practices

and encourage accountability to enhance compliance with CAUTI prevention protocols. This
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task force will also develop evidence-based CAUTI prevention guidelines and protocols to be

followed by all departments.

Quality Improvement Plan Strategies

The first step is to conduct a gap assessment to analyze the current status of health

workers’ catheter education, appropriateness of indwelling catheters, and available guidelines

currently used in the catheterization process. This gap analysis will evaluate present urinary

catheter insertion, maintenance, and catheter removal protocols and practices in the hospital

unit.

A crucial component of quality improvement strategies to reduce CAUTIs is

educating patients, their caregivers, and the healthcare team (8). Quite often, patient’s

caretakers are responsible for the catherization process. The patients and their caregivers

should be educated on proper catheter insertion practices, techniques, maintenance of urinary

catheters, and signs to look out for in suspected CAUTI. The healthcare team should have a

checklist that guides them in the process of catheter insertion, a daily mechanism to evaluate

the continued use of catheters, protocols to encourage discontinuation of catheters, and

guidelines to assess the need for catheters (6).

The cornerstones of reducing CAUTIs can be summarized as appropriate use of

catheters, prompt removal of catheters, and proper insertion of urinary catheters (3). The

following measures are proposed to prevent the development of CAUTI in hospitalized

patients:  

1. Use catheters only when needed and leave them in place only when needed.

2. Minimize the use of urethral catheters only when beneficial medically. For patients with a

high risk of getting CAUTI, e.g., the elderly, only use urethral catheters when necessary

rather than routinely.

3. Post-operatively, remove the catheter within 24 hours unless continued use is necessary.
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4. In male patients, consider the use of external catheters or intermittent catheters.

5. Ensure all persons handling the patient are correctly and routinely trained on hand hygiene,

insertion technique, and catheter maintenance

6. Always use sterile equipment to ensure urine samples are obtained aseptically.

7. Setting up interventions such as reminders to staff to ensure that they do not forget the

removal of unnecessary catheters.

A complete evaluation of the hospital’s electronic health system will be carried out to

establish catheterization documentation procedures. Data records should be checked to ensure

proper documentation of catheter insertion, care, and discontinuation during this process. The

justification should be recorded in the system whenever urinary catheter use is continued

beyond stipulated guidelines. The records should include the patient’s biodata, indications for

catheter insertion, time and date of insertion, date and time of removal, reasons for the

extension, and removal criteria.

A continuous evaluation and assessment process will be established to evaluate all

healthcare staff's competence that handles patients' urinary catheters: transport team,

pharmacy department, assistive personnel, physiotherapists, and all nurses. This will include

defining audit compliance responsibilities and reporting. For example, all nurses will be

required to document catheter insertion and removal dates; all physicians note catheterization

indications, all nurse managers to compile weekly reports. Quality improvement meetings

should also be scheduled periodically to assess progress and receive feedback from the

healthcare team. Expected outcomes of these interventions include:

1. The number of patients contracting healthcare-associated infections will decrease to 1 out of

every ten hospitalized patients.

2. Patients' hospital stays will be reduced.

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3. The cost of hospitalization will also reduce as patients will be discharged early.

4. The economic burden of CAUTI on the healthcare system will reduce

Organizational features that influence the implementation

An organizational culture like openness and flexibility to innovation is a crucial

indicator of success, while lack of a learning culture is a significant hindrance to quality

improvement projects. In my hospital unit, the senior leadership has installed a culture of

learning, innovation, and positive staff initiation of projects.

Another essential feature for effective implementation is organizational leadership. In

my hospital unit, the senior leadership has created a high morale environment and is

committed to integrating acceptable clinical practices in everyday processes. Because of this,

I anticipate that the quality improvement project will be sustainable across the hospital

departments.

Another crucial component of implementing the quality improvement project is

networks and communication. My hospital unit has a culture of inter-organizational

collaborations. We expect to set up a close working collaboration with external teams to

support our staff during this project's implementation. Since this is a multidisciplinary

project, teamwork is paramount in its execution. Various communication channels will be set

up to facilitate implementation, including scheduled meetings, debriefings, bulletin boards,

and team ward rounds.

Resources such as finances, time, and human resources are pivotal to optimizing any

project. The leadership would be responsible for approval of resource allocation to this

project. If we do not secure these resources, then this project will not be successfully

implemented and sustained.

At the core of any change, the process is an appropriate audit and feedback

mechanism. To ensure this project's long-term sustainability, this will be set up to encourage
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monitoring and feedback from the team members responsible for the project implementation.

Perhaps the most notable feature necessary for this project is the presence of

champions across all departments. The presence of champions ensures that there are

advocates of change, training other staff, and monitoring adherence to new guidelines. Our

hospital unit will have nurses, physicians, and support staff champions to lead and be

accountable for the project implementation.

Conclusion

The best strategy for reducing nosocomial infections involves strict adherence to

multiple measures simultaneously (8). The above quality improvement plan is geared towards

guaranteeing good clinical practices and promoting patient safety. After implementing these

change strategies, it is crucial to develop monitoring and surveillance frameworks to ensure

sustainability. By following these evidence-based change strategies, patient care and

outcomes will be improved.

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References

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Associated Urinary Tract Infections Using Education, Continuum of Care, and Systemwide

Buy-In. Ochsner J. 2016;16(1):96–100.

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Catheter-Associated Urinary Tract Infection. Top Spinal Cord Inj Rehabil. 2019;25(3):228–

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