Essay: Healthcare-associated infections (HAI)

Healthcare-associated infections (HAI) are a significant threat to patient safety and carry a substantial financial burden. (Kennedy, Greene, Saint, 2013) CDC  provides national leadership in surveillance, investigations of the outbreak, laboratory research, and prevention efforts for healthcare-associated infections. The knowledge gained through these activities to detect infections and develop new strategies to prevent healthcare-associated infections. The health action by CDC and other healthcare partners has led to the dramatic improvements in clinical practice and the ongoing development of evidence-based infection control guidance and prevention. (CDC,2009) Among the associated healthcare infections, catheter-associated urinary tract infections (CAUTIs) are the most prevalent despite our preventive efforts. A patient has a 3%-7% increased risk of acquiring a catheter-associated urinary tract infection (CAUTI) each day the indwelling urinary catheter remains. ( Safdar, N. et al. ,2009) CAUTI complications may include prostatitis, epididymitis, and orchitis in males, and cystitis, pyelonephritis, gram-negative bacteremia, endocarditis, osteomyelitis, meningitis, septic arthritis, endophthalmitis in patients. CAUTI complications can cause discomfort to the patient, prolonged hospital stay, and increased cost and mortality.( Murad, Auerbach, 2012). It is also associated with 13,000 UTI deaths. As CAUTI was known to be one of the top five influential factors in the publicly reported hospital quality scores, our healthcare facility studied the infection data for more visibility to determine the elements that were contributing to CAUTIs to decrease the number of CAUTI and other HAI permanently. (Gonzales, Ghaferi, 2014)  I found an article that talks about the evidence-based practice utilization of  CAUTI prevention compliance bundle in CINAHL. (Marra et al., 2011 ) It is a quasi-experimental prospective, quality improvement study which shares similarities to randomized controlled trial but lacks the element of randomization to treatment or control.  (Dinardo, 2008) The study involves multiple interventions with the aim of reducing the incidence of CAUTI in the ICU and step-down units. The time element was between June 2005 and December 2007 (phase 1) and between January 2008 and July 2010 (phase 2). In phase 1, Centers for Disease Control and Prevention‒recommended evidence-based practices were introduced. (CDC, 2015) And in phase 2, the Institute for Healthcare Improvement’s bladder bundle for all ICU and SDU patients requiring urinary catheters were instituted to promote and improve compliance with these practices and aside from continuous bedside performance monitoring. (Berwick, D. et al., 2006)
The results showed a statistically significant reduction in the occurrence of CAUTI in the ICU. The result of the study was that 6 per 1,000 catheter-days (95% confidence interval [CI] ) before the intervention to 5.0 per 1,000 catheter days (95% CI) (P, .001) after the intervention. (Marra, et al. 2011)
The interventions in the SDUs resulted in the reduction of CAUTI, from 15.3 per 1,000 catheter-days (95% CI) before the intervention to 12.9 per 1,000 catheter-days (95% CI) after the intervention (P 5 .014). (Marra, et al. 2011)
The findings of the study suggest that reducing CAUTI rates in the ICU setting is a complicated process requiring multiple performance measures and interventions that if performed correctly will result in overall CAUTI rate reduction. The same criteria can be applied to SDU settings as well.
In the healthcare facility where I’m currently employed, clinical and quality staff were engaged in the compliance with CAUTI prevention best practices. As a result, our healthcare facility has achieved sustainable and constant developments. We are currently celebrating a great reduction in hospital-acquired infections by 40%. With regards to CAUTI, there is a 50.2 % relative decrease in the  CAUTI standardized infection ratio (SIR). If you are to translate it to some patients, this means that there will be 37 fewer cases of patients with CAUTI  than anticipated. Because of consistent clinical and quality staff commitment to the catheter insertion bundle, there was a 6.7 % relative change and improvement in insertion bundle compliance. Compliance to the maintenance bundle improved significantly with nearly a three-fold increase in the percentage of patients receiving the maintenance bundle.
How did our facility reduce CAUTIs with evidence-based prevention?
Healthcare-associated infections (HAI) are a common, expensive and potentially deadly occurrence. (Hooton et al., 2010) Catheter-associated urinary tract infections (CAUTI) account for a significant cause of hospital-acquired infections. (CDC, 2009) Our healthcare system made an effort and looked at the reduction of CAUTIs as an opportunity to improve quality outcomes and reduce costs. Evidence-based practice guidelines were made accessible to inform all staffs the prevention activities that would lead to a reduction in CAUTIs. The challenge lies in ensuring compliance with the guidelines in the complex healthcare environment. To ensure the consistent reduction in CAUTI’s,  our facility implemented and increased a system-wide compliance with CDC’s CAUTI maintenance bundle. The following elements were consistently monitored namely documentation of the daily need for the catheter; catheter securement; ensuring that the tamper-evidence seal is intact; urometer or urine bag below bladder level; urine bag is not touching the floor; and dependent loop compliance. (CDC,2009) There was also a setback when CAUTI prevention effort was thwarted by executives focusing on the results rather than process metrics. Process metrics involved factors that impacted infection rates, such as insertion or maintenance of the indwelling urinary catheter. The CAUTI prevention strategy was eventually changed when the system understood that change would happen if it shifts focus to monitoring and measuring CAUTI prevention process metrics such as insertion and maintenance bundle compliance and to engage providers and nursing staff in the change in culture. Our hospital made CAUTI reduction in its top priority. The system understood that everyone particularly clinician ordering practices and care processes contribute to infection risks,  The health system formed an interdisciplinary CAUTI team with a clear goal of achieving a Standardized Infection Ratio (SIR) of less than 1 and 80% compliance with insertion and maintenance bundle components. Team members included urologists, physicians, registered nurses, infection control specialists, quality improvement professionals, and laboratory staff. Physician advisors and nurse champions advocated for change within the nursing department along with other interdisciplinary team members. Nurse champions and doctors gave expert guidance for developing policy, decision support algorithms, and care procedures. To facilitate improvement, our facility defined standard work and process metrics for insertion and maintenance of indwelling urinary catheters. The protocols described the roles and responsibilities of everyone involved particularly the executive leaders, quality control leaders, nursing staff, clinical educators, safety coaches, and laboratory staff in preventing CAUTIs. The entire interdisciplinary team developed a CAUTI toolkit to ensure access to the standard workflow and evidence-based guidelines for indwelling urinary catheters. The toolkit serves all frontline staff with easy access to all CAUTI prevention information in our charting system that includes goals, catheter insertion criteria, policy, and procedures.
The collaborative efforts of all departments resulted in evidence-based guidelines with standard workflow for indwelling urinary catheters, including the insertion bundle, maintenance bundle.
Algorithms were available for inability to void, measurement of post-void residual and postoperative urinary retention.All catheter insertion and catheter management in the EHR. There is an algorithm that gives an alternative to indwelling urinary catheters. There are algorithms for discontinuing catheters present on admission, we inserted in the emergency department and those inserted in the OR. Initial improvement efforts were focused on prompt discontinuation of indwelling urinary catheters. There was a CAUTI application that provides infection prevention specialists, clinical and operational directors, and quality improvements staff an easy visualization of various process metrics, supporting the monitoring of catheter days, insertion bundle compliance, and maintenance bundle compliance.The data gathered helps the health system study the unit, service, or patient level when analyzing performance. The data acquired provides our facility the power to review the effectiveness of quality improvement interventions and provide feedback to nursing staff and providers. Nurses are committed to applying best practice interventions for patients, minimizing the use of urinary catheters and discontinuing indwelling urinary catheters when appropriate.Physician assistants provide further help and support to the nursing staff by delivering education and share the changes with physician peers through presentations.To ensure that patients were not catheterized more often than necessary, additional bladder scanner equipment was purchased which allows the nursing staff to assess the volume of urine in the bladder before catheterization, decreasing unnecessary catheterization.The standard organizational workflows and evidence-based guidelines for indwelling urinary catheters outlined in the CAUTI toolkit helped in dramatically reducing the cases of CAUTI in our facility.  The setback was when no standard process metrics were enforced, and a team was appointed to manually audit the CAUTI rates because the executives just focused on rates and occurrence instead of analyzing the process metrics.
As an advanced nurse practitioner in the future, I would like to enforce the use of guidelines derived from research, and other high-quality sources of evidence to successfully improve patient outcomes. I would like to empower myself and other nurses in performing nurse-driven interventions, combined with system-wide product changes, and patient and family involvement in effectively strategize efforts to reduce CAUTI and other nosocomial infections.