Chlorhexidine wipes for catheter care

BENCHMARK- CAPSTONE PROJECT CHANGE PROPOSAL 2

BENCHMARK- CAPSTONE PROJECT CHANGE PROPOSAL 13

Running head: BENCHMARK- CAPSTONE PROJECT CHANGE PROPOSAL 1

Preventing Catheter-Associated Urinary Tract Infections

The United States of America in known for its advanced medical practices and equipment, however, hospital-associated infections (HAIs) have a tremendous impact to the healthcare system. According to Healthy People 2020, Healthcare-associated Infections (HAIs) are related to increasing cost of health care in the United States as well as mortality and morbidity. These types of infections are preventable. Indwelling catheters count for about 80% of urinary tract infections (CDC, 2013). As healthcare professionals and adhering to the principle of nonmaleficence, we are obligated to make efforts to implement strategies to avoid any risks to harm patients. Proper assessment of patients regarding indwelling catheter insertion need, maintenance and care requires the collaboration of the entire interdisciplinary team. Evidenced-based practices (EBPs) have found a relationship between chlorhexidine (CHG) wipes usage and CAUTI reduction. This project’s goal is to provide safe-centered patient care in prevention of CAUTI through utilizing CAUTI Surveillance Bundle and implementing new interventions such as daily Chlorohexidine Gluconate (CHG) bathing for patients with Foley catheter. The author of this proposal will be providing an in-depth investigation into the background problem, discussion of the implementation of CHG wipes instead of regular wipes for perineal care for CAUTI prevention, as well as presenting evidence-based research reviews that support the project and potential barriers to success.

Background

Even though, measures to decrease the incidence of HAIs is the priority of many healthcare organizations, acute care facilities reported 54,500 cases of CAUTIs in the U.S in 2012, which represents a 3 percent fold increase from 2009 (Knudson, para. 1, 2014). Factors associated with the prevalence of CAUTIs is the inappropriate use of indwelling catheters, in addition to improper insertion techniques, and inadequate and poor catheter maintenance (Strouse, 2015). Preventing CAUTI by employing CHG wipes for perineal care has been proven to be effective. By using CHG wipes for perineal care the colonization of bacterial could be eliminated. One key reason for CAUTI is the overgrowth of bacteria that invade the lower urinary tract. CHG wipes have an antiseptic component that inhibits the growth of bacteria in the body (Flores-Mireles, Walker, Caparon, & Hultgren, 2015). The integration of best practices, patient involvement, and ongoing education and training for the nursing and medical staff in CAUTI prevention is imperative.

Problem Statement

The problem at hand is the difficulty that this author’s facility is experiencing in reducing the rates of urinary tract infections (UTIs) despite the implementation of indwell-catheter care bundles. The most common and costly healthcare related infection that prolongs the length of

stay and comorbidity is catheter-associated urinary tract infections (CAUTI). Furthermore, it is

one of those conditions that the Center for Medicaid and Medicare Service (CMS) no longer

reimburses the extra cost of treatment if a patient develops it during hospitalization (CMS, 2012).

Regardless of how hard many organizations put energy to reduce CAUTIs; the U.S. Department

of Health and Human Services indicates CAUTIs rate has increased by 9% between 2010 and

2013 (AHRQ’s, 2008). With all the penalties from CMS and continued effort from hospitals to

implement the best practices to reduce CAUTIs, Foley catheter use and Catheter-associated

Urinary Tract Infections continue to grow (CDC, 2010). Improving the adherence to healthcare policies and procedures in order to help prevent CAUTI needs further revision (see Appendix A). The evidence-based proposal arose from the clinical question in relation to the use of CHG wipes in comparison to regular wipes to decrease bacterial colonization in the external catheter and thereby reducing the incidence of CAUTI. One of safety goals set forth by the Joint Commission, is the reduction in the incidence of CAUTI (The Joint Commission, 2015).

Purpose of Proposal

The project’s purpose is to create consciousness of the devastating health complications associated with CAUTI. This project aims to reduce CAUTI occurrence and the process begins the moment the patient is admitted with orders to insert a urinary catheter, and the process ends with discontinuation of the urinary catheter. By working on the process, we expect to achieve the following:

· Prevent and decrease Catheter-associated Urinary Tract Infections

· Reduce indwelling catheter days

· Improve patients’ outcome, quality of care, and safety

· Decrease CAUTI and urosepsis

· Cut MDRO’s and C. diff that result from antibiotic treatment

· Reduce length of stay (LOS) and readmission

· Decrease cost

· Improve patient satisfaction

CAUTI is not a benign infection. It is important to work on this project because every

patient deserves to receive quality care that is safe, cost effective and is evidenced based.

After reviewing several research articles pertaining to CAUTI prevention, it was concluded by many of the researches that CHG wipe usage help reduce CAUTI rates. The proposed changed would also comply with the EBP guidelines of the American Association of Critical-Care Nurses (AACN, 2017), which support the use of CHG wipes for reduction of bacterial colonization and multi-drug resistant organisms. Lastly, a key objective to this evidence-based proposal for practice is to improve patient outcomes and safe lives.

PICOT Question

As discussed thus far, preventing CAUTIs by utilizing CHG wipes vs regular wipes for perineal care during a patient’s hospitalization was the motive. Considering the environment, engagement, attitude, and culture of the nursing staff was also a determining factor to the change proposal. Upon this author’s decision on the EBP proposal, a thoughtful analysis was conducted on whether independent and dependent variables could be measurable and achievable. The project implementation as a quality improvement initiative is targeted to improve the quality of care delivered to patients (U.S. Department of Health and Human Services, n.d.). To help prevent the incidence of CAUTI, the following components where identified: In adult hospitalized patients with indwelling urinary catheters (P), how does the use of chlorhexidine-impregnated wipes for perineal cleansing(I) compare to regular wipes (C) affect/reduce the incidence of catheter-associated urinary tract infections rates (O) during the time of hospitalization (T).

Literature Research Strategy

As hospitals seek to find measures to prevent the incidence of CAUTI, the strategy of this implementation is to determine if by using CHG wipes for perineal care, the rates of CAUTI could decrease. In order to gather evidence to support the change proposal, multiple search engines were utilized. Searches were conducted through databases such as PudMed, Ovid, CINAHL complete, and accredited nursing journals. The use of filters was utilized to guarantee current and accredited peer review articles. To obtain information specific to the issue of discussion, search words such as, CAUTI, chlorhexidine wipes, CAUTI prevention, infection control measures, and hospital-acquired infections were used. The AACN website was also accessed to search for the most current and up- to- date guidelines pertaining to SICU area. Supporting evidence was analyzed by utilizing a literature review table that helped compared, evaluate, and differentiate between distinct research methods, settings, and sample size studied. Additionally, Google search was used to locate information regarding CMS guidelines and Healthy People 2020 initiatives.

Literature Evaluation

The literature reviewed provided a detailed comparison of research questions and sample populations relevant to the project. The evidence gathered from the peer-reviewed articles undoubtedly supports the implementation of CHG wipe use for perineal care for CAUTI prevention. When CHG wipes were utilized for patient bathing the incidence of HAI was reduced. One of the several articles that supported to use of CHG wipes was the one conducted by Cassir et al. (2015) that found CHG daily cleansing related to a reduced incidence rate of HAI caused by gram-negative bacteria, highlighting the role of the transient gram-negative bacteria in skin colonization in the pathogenesis of HAI. As any other EBP implementation, reduction of CAUTI will require the collaboration of nursing staff, infection control nurse, risk management, and physicians. Although research provides supporting evidence on the use of CHG wipes for CAUTI prevention, this does not substitute the basic principle of good hand hygiene.” Hand hygiene (HH) is an inexpensive and practical measure, it is the cornerstone of nosocomial infection (NI) control” (Martínez-Reséndez, et al., 2014).

Change Theory

Implementing change in the healthcare industry requires a solid foundation in order to achieve success. This author finds the Kurt Lewin three stage change model to be appropriate for CAUTI prevention proposal by employing CHG wipes for perineal care. The Kurt Lewin’s change model is composed of the unfreezing, moving and refreezing stages. The unfreezing stage is providing a rational for change, the moving stage provides information for the need of change, and lastly the refreezing stage is the implementation or reinforcement of the process for change (Rainio, 2009). This model can be broken down to the nursing staff as follows: The unfreezing stage will be the introduction to EBP research and rationale for using CHG wipes for perineal care; the moving stage will focus on the nurses using the new implementation for perineal care, it is also the stage were barriers get addressed, and the refreeze stage will be the evaluation of the EBP proposal success with the aimed of decreasing CAUTI by using the CHG wipes (Rainio, 2009). Regardless of any model utilized, communication and consistency will play a key factor in educating the nurses of the benefits of CHG wipes and mainly patient harm prevention.

Proposal for Implementation and Outcome Measures

The proposal for the use of CHG wipes for perineal care to prevent CAUTI and overall HAI was discussed with the Director of Surgical Services. The conversation brought up key points regarding the effects of CAUTI to Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores and most importantly the impact of reimbursement from CMS. According to Galiczewski (2016), he cites “CAUTIs are considered preventable and its incidence has reached almost two million cases per year. CMMS in the U.S. has deemed CAUTI a “never event”, limiting government funded reimbursement” (para. 3). Another proposed implementation for the success of this author’s EBP proposal includes continuing in -service nursing education and training as well as a thorough quality improvement CAUTI prevention bundle (see Appendix B for CAUTI bundle). By requiring compliance with indwell catheter care bundles and CHG wipes for perineal care, it is expected to see a decrease of bacterial colonization and subsequently CAUTI prevention. Evaluating the EBP proposal and measuring the outcomes is the concluding step to determine if the implementation was effective and successful. The methods that could be utilized to measure outcomes are; data collection and recording on CAUTI incidences in the hospital, assessment of post-intervention CAUTI rates in the facility, and a readiness inventory tool to assess the nurse’s confidence level (Stevens, Puga & Low, 2012). Charge nurses will be expected to assess the nurses’ catheter insertion techniques and maintenance compliance. The final and most important step will be evaluating the patient’s comfort and care provided during perineal care with CHG wipe usage by means of surveys. The survey will additionally assess on the patient’s knowledge on the use of CHG wipes for CAUTI prevention and if education was provided by the nursing staff regarding reasons, care, and complication of indwell catheters.

Potential Barriers to Implementation and Solutions

Catheter associated urinary tract infections are preventable and should be treated with the seriousness it deserves. However, the evidence-based researched provided this author with insight of what some of the possible barriers would be during the EBP implementation. One key barrier is the lack of nurse driven catheter removal protocols, poor staff engagement and adherence to policies and procedures, the need to further the nursing staff knowledge regarding catheter need, insertion techniques, maintenance and care.

In the instance that the implementation could become obscured, some of the solutions to the implementation could be; revision of plan proposal, re-training staff on the proper use and aseptic insertion techniques, and guidelines on using CHG wipes for perineal care (see Appendix C). Furthermore, leadership and risk management will be consulted and assignation of CAUTI prevention champions will be endorsed. Obtaining the staff’s feedback throughout the implementation will also be measured.

Conclusion

Exercising basic nursing care and advocating for patients can ultimately lead to positive change in patient outcomes. Reviewing institutional policy and procedures and current evidence based research assisted in the development of a tool that helps guide and remind nurses of proper

indications and maintenance of urinary catheters. Implementing training and education for

nursing staff and ancillary staff on proper maintenance of urinary catheters and CHG bathing

supports an efficient change for this project. Lewin’s Change Model and Plan-Do-Study-Act

(PDSA) Improvement Model was incorporated as theoretical frameworks for implementing,

reinforcing, and preserving changes for this project. As a CNL student, I have learned a great

deal from this experience. I’ve learned this journey is a rocky road and need shared

accountability between the leadership, providers, nursing and other ancillary staff. I’ve also

learned:

· CAUTI prevention is a culture change and needs constant attention.

· Not to be afraid to refine the process

· Not to give up

· To continue talking to front line regarding obstacles and removing them

· To keep talking about patient and WHY we are doing this work!

· To focus on patient safety all the time

· To include all providers in education

· Respectful communication is a MUST!

This project’s result is not just CAUTI prevention; it is cost reduction, decrease length of stay,

fall reduction, and delirium prevention. Continuing nursing education and training will allow for nurses to grow within their organization and to practice to their full scope of practice. The nursing workforce is ready to help Americans achieve a healthy lifestyle and to increase patient satisfaction in every encounter.

References

Afonso, E., Llauradó, M., & Gallart, E. (2013). The value of chlorhexidine gluconate wipes and prepacked washcloths to prevent the spread of pathogens—A systematic review. Australian Critical Care, 26158-166. doi: 10.1016/j.aucc.2013.05.001

American Association of Critical-Care Nurses. ([AACN], 2017). AACN issues new protocols for bathing patients. Retrieved from https://www.nurse.com/blog/2013/04/21/aacn-issues-new-protocols-for-bathing-patients/

Cassir, N., Thomas, G., Hraiech, S., Brunet, J., Fournier, P., La Scola, B., & Papazian, L. (2015). Major article: Chlorhexidine daily bathing: Impact on health care–associated infections caused by gram-negative bacteria

Flores-Mireles, A. L., Walker, J., Caparon, M., Hultgren, S. (2015). Urinary tract infections: Epidemiology, mechanisms of infection and treatment options. Retrieved from http://www.nature.com/nrmicro/journal/v13/n5/fig_tab/nrmicro3432_F4.html

Galiczewski, J. M. (2016). Review: Interventions for the prevention of catheter associated urinary tract infections in intensive care units: An integrative review. Intensive & Critical Care Nursing, 321-11. doi: 10.1016/j.iccn.2015.08.007

Gesmundo, M. (2016). Enhancing nurses’ knowledge on catheter-associated urinary tract infection (CAUTI) prevention. Kai Tiaki Nursing Research, 7(1), 32-40.

Knudson, L. (2014). CAUTI prevention requires improved practices and policies. AORN Journal, 100(1), C1. doi:10.1016/S0001-2092(14)00377-9

Martínez-Reséndez, M. F., Garza-González, E., Mendoza-Olazaran, S., Herrera-Guerra, A., Rodríguez-López, J. M., Pérez-Rodriguez, E., & ... Camacho-Ortiz, A. (2014). Major article: Impact of daily chlorhexidine baths and hand hygiene compliance on nosocomial infection rates in critically ill patients. AJIC: American Journal of Infection Control, 42713-717. doi: 10.1016/j.ajic.2014.03.354

Rainio, K. (2009). Kurt Lewin’s Dynamical Psychology Revisited and Revised. Dynamical Psychology: An International, Interdisciplinary Journal of Complex Mental Processes, 1-20.

Stevens, K.R., Puga, F., & Low, V. (2012). The ACE-ERI: An instrument to measure EBP readiness in student and clinical populations. Retrieved from: www.acestar.uthscsa.edu/institute/su12/documents/ace/8%20The%20ACE-ERI%20%20Instrument%20to%20Benchmark.pdf

Strouse, A. C. (2015). Appraising the literature on bathing practices and catheter-associated urinary tract infection prevention. Urologic Nursing, 35(1), 11-17. doi:10.7257/1053-816X.2015.35.1.11

The Joint Commission. (2015). Hospital: 2015 National Patient Safety Goals. Retrieved from http://www.jointcommission.org/standards_information/npsgs.aspx

U.S. Department of Health and Human Services, n.d. Guidance on Institutional Review Board Review of Clinical Trial Websites. Retrieved from http://www.hhs.gov/ohrp/policy/clinicaltrials.html

Appendix A

Revision of policies and procedures for CAUTI reduction Analysis

One of the most common HAI, CAUTI is considered a preventable complication of a patient’s hospital stay. The healthcare industry is expected to report any urinary tract infection related to indwelling catheter insertions. The widespread use of catheters is related to the increase rate of CAUTIs. Knudson (2014) cites “one in 333 indwelling urinary catheters will cause infection and an estimated 1.5 infections occur per 1,000 catheter days.” Improvements to the healthcare infrastructure requires for a revision on the adherence to CAUTI reduction policies and procedures.

The nursing staff need to be re-evaluated in their understanding of catheter insertion, maintenance and care. “The CDC -guideline for prevention of catheter-associated urinary tract infections” emphasizes using urinary catheters only as necessary, rather than routinely.” (Knudson, 2014). This analysis finally concluded that “data from 1,653 ICUs found that the presence of CAUTI prevention policies ranged from 27 to 68 percent and adherence to the policies ranged from 6 to 27 percent.” (Knudson, para. 3., 2014). Clearly, this study highlights the necessity for implementation of and adherence to evidence-based practices related to CAUTI prevention.

Appendix B

CAUTI Bundle by Gesmundo, N. (2015) Review

CAUTI

(Image retrieved from htps://lopes.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=119345448&site=eds-live&scope=site)

Appendix C

Universal ICU Decolonization Protocol for CHG Bathing- (Agency of Healthcare Research and Quality)

Poster for Universal ICU Decolonization Protocol for CHG Bathing. Drawings depict the front and back of a person, with numbers that correspond to use of chlorhexidine gluconate (CHG) cloths below the jawline only. Text is below the image.

(Image retrieved from https://www.ahrq.gov/professionals/systems/hospital/universal_icu_decolonization/universal-icu-ape3.html)