QSEN Change

Project
Urinary Catheter Complications

Project Overview:
The QSEN competency area of focus:
Implementing evidence based practice (EBP).
Nurses must demonstrating knowledge of basic
scientific methods and processes by adhering to
the Institutional Review Board (IRB) guidelines and
valuing the concept of EBP as integral to
determining best clinical practice for better patient
outcomes.
Other applicable QSEN competencies include safety
and quality improvement.

Case Study:

A 68-y/o male, admitted to hospital

Hx of hypothyroidism, hypertension, seizures, cerebrovascular attack with hemiplegia,
dysphagia, vascular dementia, speech disorder, benign hypertrophy of prostate with urinary
retention, and monocular blindness
NKA.
The PT required total care for ADLs.
Bolus feedings through a gastrostomy tube, occasional suctioning of his tracheostomy.
He was incontinent of bowel and bladder. He was alert and oriented to person and place.
A nursing assistant reported that the patient had not voided all day. He did not show any signs of distention
or discomfort. A catheter was ordered and prior to placement, the patient voided. The RN reported this to
the charge nurse, who informed the RN to proceed with the catheter insertion. The RN did so, but the
procedure did not produce any urine. Since the patient had just voided, the RN assumed the patient's
bladder was empty. Two hours later, the patient began to complain of discomfort. The RN attempted to
irrigate the catheter but met resistance.The charge nurse was called to assess the situation. A blood clot
was found in the tubing and the catheter was replaced with a three way catheter. This catheter was
misplaced and lead to severe distention of the bladder, loss of blood, and the patient was placed at risk for
complications (UTI, urosepsis, and bladder rupture).

Key problem: Complications associated with urinary

catheters from not following EBP and unit protocols.

Fishbone Diagram

Significance of Problem
-

Urinary catheters place patients at risks for complications such as UTI,

urosepsis, bladder rupture, urethra trauma, and blood loss. It has been
associated with a greater risk of bacteraemia, or sepsis and death.
CAUTIs account for approximately 35%-40% of all HAIs in the U.S.
Every day an indwelling catheter remains in place, the risk for infection
increases 3%-5%.
CAUTI complications include discomfort, cystitis, pyelonephritis, prostatitis.
Nearly 13,000 deaths occur annually as direct result of complications
associated with CAUTIs.

Contributing factors:
Unnecessary placement
Not removed when no longer needed
Not following sterile techniques
Not following unit protocol
Not performing a bladder scan
Improper placement (missing the bladder)

Development of a Solution: Literature

Review
Oman et al. (2012) implemented 60 minute education on CAUTI
prevention to a Med/Surg unit for two months and found that
CAUTIs, improper insertion of catheters, and catheter days
significantly decreased and the unit saved approx. $52,000.
Quinn (2015) describes the implementation of a simple 8 point
Question the Foley technique that was nurse driven. The practice
change reduced the CAUTI incidences within the first year with
continued reductions in subsequent years.
Strouse (2015) reports in a systematic review, that studies revealed

Literature Review (cont.)

Mavin and Mills (2015) describe a QI approach to the
implementation of CAUTI prevention strategies of the Scottish
Patient Safety Programme acute adult safety program.
This work included introducing UUC insertion and maintenance bundles and
collecting process and outcome data to show improvements made.
Findings:
CAUTI rates were relatively low/ better outcomes & patient experience.
Additional measures to reduce rates:
Reduction in UC placement.
Using alternative continence products/devices (female slipper pans, urosheaths, male penile pouches, intermittent self catheterization, bladder

Our Project
Recruit a multidisciplinary team at a local hospital Med/Surg Unit
Collect and examine data from hospital database about prevalence of CAUTIs and the
hospitals current policies on catheter insertion
Conduct a pre-test on the recruited multidisciplinary team to determine their level of
knowledge and competence on urinary catheter insertion/care
Interventions:
Conducted from May 1,2016- June 1, 2016
Implement Streamlined Evidence-Based RN Tool: Catheter Associated Urinary Tract
Infection (CAUTI) Prevention
Implement Question the Foley Criteria
Conduct 60 minute education sessions once a week for two months which will
include
Discussion of the scope of the problem
Reviewing EBP techniques for prevention of catheter infections
Competency based training and evaluation for catheter placement and
monitoring
Charge Nurse catheter care rounds

Development of a Solution: The Change

Resources of time:
CAUTI/Catheter Training for nursing staff (Approximately eight 60 minute educational sessions
for two months)
Fiscal resources:

Stakeholders:
Internal:
Nursing staff
Unit staff (management, housekeeping and nursing managers)
External:
The PATIENT and FAMILIES
The community
Marketing Strategies:
Educating the nursing staff regarding data about prevalence of CAUTI rates
Provide nursing contact hours for completing training

Change Theory
The inclusion of front line staff in planning groups and key decision
making processes promotes a feeling of empowerment that helps
to overcome their resistance to the change and enables them to
understand the importance of the project and how it will
beneficially affect client care. (http://cjni.net/journal/?p=2888)
Unfreezing:
Include key stakeholders in the process of decision making
Present to stakeholders and the recruited multidisciplinary team the
data of the prevalence of CAUTIs in their hospital
Restraining forces: unwilling to change; this is the way we have always
done it; lack of experience
Driving forces: adequate funding, management support, will reduce

Change Theory: The Change

The period of change in which our interventions
would take place
Help facilitate the multidisciplinary team to adapt to
and transition to these new interventions

Change Theory: Refreezing

Reinforce the change by providing ongoing support
and evaluation leading to stabilization
Encourage charge nurse and hospital administration
to support the nursing team in continuing to
perform these new interventions

Obstacles to Change
Nurses not wanting to change old habits
Healthcare providers wanting to place urinary catheters for
their own convenience (Inappropriate catheter use/ nurse
burnout)
Nurse/patient ratio out of proportion leading them to being
rushed
Nurses not participating in continuing education and
training
Lack of knowledge about evidence-based practice

Evaluation: How will change be measured?

Data collection:
Number
Number
Number
Number

of
of
of
of

catheters inserted in one month,

insertions where all EBP and unit protocol were followed,
insertions resulting in complications, and
catheterizations that met criteria for insertion

Rate of occurrence can be compared between pre- implementation and postimplementation of the changes made.
Post test given to staff to evaluate knowledge of catheter competence
All variables were summarized using descriptive statistics appropriate for the level of
measurement.
Statistical analyses were conducted to compare the differences between the
baseline and the post intervention
Alpha was set at .05.

Evaluation Tools

http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/Improving-YourPractice/ANA-CAUTI-Prevention-Tool/ANA-CAUTI-Prevention-Tool.pdf

Results: What could happen?

Positive: The Med/Surg unit would have decreased number of CAUTIs,
successful adaptation to the new intervention tools, and the staffs
knowledge/competence on catheter care/insertion would improve,
reduce inappropriate catheter use and facilitate prompt removal.
Negative: no change in numbers of CAUTIs, resistance to new
intervention tools, and no change in staff knowledge/competence on
catheter care/insertion
Effectiveness of our plan will depend on the increase of decrease of
CAUTIs

Results: What could happen?

What could facilitate change: Hospital and hospital cooperation,

frontline buy in
What could inhibit change: Resistance from staff, Hospital indifference
Alternative approaches:
A statewide program in Michigan focused on educating clinicians about
appropriate urinary catheter indications and included daily assessment
of continued catheter need during nursing rounds.
Effective strategies to reduce inappropriate catheter use and facilitate
prompt removal include use of electronic order sets, criteria-based
catheter orders, electronic reminders, nurse driven catheter removal
protocols, and daily nurse-physician catheter rounds.

References
American Nurses Association. (2016). CAUTI prevention tool. Retrieved from
http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/Improving-Your-Practice/ANA-CAUTI-Prevention-Tool/AN
A-CAUTI-Prevention-Tool.pdf

Fakih MG, Watson SR, Greene MT, et al. Reducing inappropriate urinary catheter use: a statewide effort. Arch
Intern Med 2012;172:255260.
Mavin, C., & Mills, G. (2015). Using quality improvement methods to prevent catheter-associated UTI. British
Journal of Nursing, 24S22-S28 5p. doi:10.12968/bjon.2015.24.Sup18.S22
Newman, D. K., Strauss, R., Abraham, L., & Major-Joynes, B. (2015). Unseen perils of urinary catheters. US
Department of Health and Human Services. Retrieved from https://psnet.ahrq.gov/webmm/case/352/
Oman, K. S., Makic, M. B. F., Fink, R., Schraeder, N., Hulett, T., Keech, T., & Wald, H. (2012). Nurse-directed
interventions to reduce catheter-associated urinary tract infections. American journal of infection
control,40(6), 548-553.
Quinn, P. (2015). Chasing Zero: A Nurse-Driven Process For Catheter-Associated Urinary Tract Infection
Reduction in a Community Hospital. Nursing Economics, 33(6), 320-325 6p.
Strouse, A.C. (2015). Appraising the Literature on Bathing Practices and Catheter-Associated Urinary Tract
Infection Prevention. Urologic Nursing, 35(1), 11-17 7p. doi: 10.7257/1053-816X.2015.35.1.11